Tomorrows regular customers stamping out tobacco use in the middle east and africa

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and Africa

A report from the Economist Intelligence Unit

Supported by

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Tomorrow’s regular customers? Stamping out tobacco use in the Middle East and Africa is a research

paper written by the Economist Intelligence Unit and sponsored by Pfizer The author is Jason Sumner and the editor is Katherine Shields Vanessa Barchfield also contributed to the report The findings are based on more than 40 interviews with experts from government, academia, NGOs and the tobacco industry in the Middle East, Africa and elsewhere We would like to thank the Economist Intelligence Unit’s extensive network of country analysts for organising and conducting most of these interviews We would also like to thank our sponsors and the experts who participated in the interviews for their time and valuable insight The views in this report are those of the authors, and do not necessarily represent the views of, and should not be attributed to, Pfizer

October 2009

Preface

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In much of the Western world, smoking is in retreat After peaking in the post-second world war

era, tobacco consumption has been in steady decline since the 1970s, halving in many countries

as the evidence around nicotine’s detrimental health effects swelled Over the decades, incremental tax hikes, advertising bans and public awareness campaigns—among other policies—have led to a seismic shift in public attitudes towards smoking Governments, wary of the future burden that a next generation of smokers could add to the already mounting healthcare costs associated with retiring baby boomers and obesity-related illness, have been pushing forward ever-tighter tobacco controls, and more expansive public awareness and cessation programmes

Acceptance is growing France has earned praise for a national ban on public smoking enacted in

2007 that has been both well accepted and well enforced, countering the romantic popular notion that cigarettes are as inseparable from French life as red wine and cafes In the US, home to many of the Big Tobacco producers and where adult smoking rates have already fallen from 37% to 20% in the last 40 years, Congress recently gave broad powers to the government to regulate tobacco products, and will force cigarette makers to disclose ingredients and place prominent warnings on packaging, among other reforms

Yet in the developing world, governments are only starting to wake up to the tobacco problem According to the World Health Organisation (WHO), the developing world’s share of total smokers climbed from just over 40% in 1970 to 70% by 2005

By 2030, the WHO forecasts that 80% of tobacco-related deaths will be in low- to middle-income countries For developing-world countries that aim to emerge as major economic players, the future social and financial penalties of rampant tobacco consumption could be crippling Preventable, early deaths first and foremost cause unnecessary suffering at an individual level At a macroeconomic level, premature mortality among those who would otherwise be healthy saps national productivity The Centers for Disease Control (CDC) in the US reckons that lives shortened by tobacco consumption cost the country US$97bn per year The European Union calculates yearly productivity losses in Europe at between €69.8bn and €86bn

Soon—and in many countries the impact is already being felt—governments grappling with expanding welfare costs as their populations age will have to add the burden of treating smoking-

Introduction and key findings

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related diseases such as cancer, heart disease and respiratory disease Health ministers throughout the emerging world understand the risks, but progress on anti-smoking policies has been sluggish because of the addictive nature of nicotine and politicians’ understandable reluctance to turn their backs on the revenue and jobs provided by the tobacco industry

This report focuses on one portion of the developing world—the Middle East and Africa (MEA)—which has become a key battleground in the struggle over government policy and public attitudes Although the region can lay claim to adult smoking rates mostly on par or lower than those of many Western and developing nations, expanding populations mean that even if rates were to stay relatively steady, the absolute numbers of smokers would still rise

The MEA region also poses other deeply entrenched challenges These include rising youth smoking rates, particularly among girls, a prevailing culture of acceptance around tobacco, especially the water pipe, widespread governmental ambivalence and a strong tobacco industry lobby But charities and other non-governmental organisations (NGOs) have gained a foothold in recent years They often work

on a shoestring, but are increasingly supported with much-needed financial lifelines from rich Western philanthropists

“There is a change in mentality in our region Ministries of health are working with the WHO and other NGOs—bringing together all the people working on tobacco control,” says Dr Jean-Pierre Baptiste, a regional adviser with the WHO’s Tobacco Free Initiative in Algeria He is one of more than 40 experts from government, academia, NGOs and the tobacco industry interviewed for this report But are their efforts enough? In this paper, we investigate the progress that has been made, the challenges that remain, what lessons can be drawn from successful policies elsewhere and how the landscape could look in a decade or two We examine ten major markets in-depth—four in North Africa: Egypt, Algeria, Morocco and Tunisia; two in Sub-Saharan Africa: Nigeria and South Africa; and four in the Middle East: Lebanon, Jordan, Saudi Arabia and the United Arab Emirates (UAE) The key findings

of the report are highlighted below

Youth smoking rates look dangerously high…and are rising

In most MEA countries, while smoking rates among adults appear generally to have held steady in the last ten years, youth rates are rising In Lebanon, which has one of the worst youth smoking rates in the region, two-thirds of boys and more than one-half of girls between 13 and 15 years of age smoke some form of tobacco, at least double the rates for Lebanese men and women Campaigners are duly worried because most lifelong smokers start before they turn the age of 18

In North Africa and the Middle East, the water pipe has become ubiquitous

Seen as trendy and traditional, the water pipe has surged in popularity in the past decade, and this factor more than any other is believed to account for the rise in tobacco consumption among children Variously known as hookah, nargile or shisha, the water pipe can deliver a hit many times more powerful than a cigarette, yet there is a widespread belief that it is less harmful than other types of tobacco Some parents encourage their children to smoke the pipe and it is increasingly popular with young women, who smoke it in cafes in more liberal cultures and at home behind closed doors in more conservative countries

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Governments rarely speak with one voice

In general, anti-tobacco policies are weak and contradictory Even countries that are seen as leaders in the region, such as Egypt, see infighting between ministers Finance departments point to the revenue and jobs generated by the tobacco industry, while health ministers argue that the long-term costs of caring for tobacco-related illnesses far outweigh any short-term benefits

Bans are sometimes strict on paper, but rarely in practice

Smoking restrictions vary throughout MEA, but with a few exceptions the laws are poorly enforced Advertising bans have been more successful, with a handful of countries receiving good scores from the WHO for both the completeness of their laws and strict enforcement Regional co-ordination is poor, however Television ads are forbidden in Jordan, but its neighbour, Lebanon, has no restrictions, so Jordanian children are treated to a bevy of cigarette ads via Lebanese satellite

NGOs punch above their weight

To the extent that governments have taken action, it is often due to the influence of NGOs Dr Judith Longstaff Mackay, a senior adviser at the World Lung Foundation, a charity, says in the past ten years there has been a “professionalisation of tobacco control” in MEA They focus on influencing governments and public attitudes with awareness campaigns, training and assistance for doctors, and lobbying for smoke-free zones, often one city at a time In Nigeria, campaigners cheered when, in

2008, after much pressure, the capital city of Abuja was made a smoke-free zone

Better data are needed to support awareness campaigns, acceptance and enforcement

Even on the most optimistic projections, a combination of prevalence trends and population growth means that in two decades there are likely to be several million more people smoking in MEA than there are today Whether this depressing trajectory proves true will depend on the success or failure of anti-smoking campaigners and their allies in the health ministries Yet success in the West in pushing down prevalence rates from the high 60% range to one-third of those rates today gives campaigners hope for MEA With many efforts just getting off the ground, public awareness is beginning to grow To keep up the pressure, anti-tobacco groups require consistent data on smoking rates and trends, and more hard evidence on the effects of the culturally acceptable water pipe

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Evaluating the progress of anti-smoking campaigns starts with good data How many people

smoke? Who smokes? How often? How do rates compare with a decade or two decades ago? In the developed world, surveys tracking this sort of information are commonplace In MEA, comparable data that measure trends across time are frustratingly difficult to come by Moreover, prevalence surveys are usually based on individuals reporting their own tobacco consumption, which the experts interviewed

by the Economist Intelligence Unit for this paper say underestimates the reality This factor is especially relevant among women in MEA, who often find it culturally difficult to own up to smoking The figures that do exist, however, give campaigners reason to believe that smoking rates among adults are holding relatively steady, and may have already peaked in some countries Yet the same studies show that the incidence of smoking among children in the region is alarmingly high and—although robust data on trends are spotty—most experts we interviewed believe the rate is rising

First the not-as-bad news—adult prevalence

The average percentage of adult male smokers in the ten countries examined in this paper is 32%, according to a 2008 WHO report*, which is the most up-to-date, comprehensive source for smoking prevalence in 135 countries Although the fact that an average of one in three men smoke some form of tobacco cannot be considered good news, this level remains below some Western countries, where anti-smoking campaigns are more firmly established In the US, for example, one-quarter of men are smokers

In France, Germany and the UK, the rate is just over one in three In Japan, 44% of adult men are smokers.The average prevalence rate among women in the ten countries in our sample is 5%, well below the rates for many Western countries For example, one-third of British women smoke, as do one-quarter of French and German women In the US, the figure is one in five The experts we interviewed believe that the WHO numbers for women are under-reported, and they also express concern that the water pipe is becoming more popular among women But even if the numbers were mistaken by as much as 10%, as some experts believe, they would still come in under those for Western nations

Campaigners are by no means complacent, because even if rates stay steady population growth means there could be millions more smokers in 20 years’ time But the adult prevalence figures suggest that if they are successful in implementing the kinds of anti-tobacco measures that have become routine in Western countries, they could make a significant further dent in the figures

Youth smokers: Don’t get them started

* World Health Organisation,

WHO Report on the Global

Tobacco Epidemic, 2008: The

MPOWER package.

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High and rising—youth prevalence

The chilling wisdom contained in an oft-cited passage from a 30-year-old Philip Morris internal document still holds true today: “Today’s teenager is tomorrow’s regular customer, and the overwhelming majority of smokers first begin to smoke while still in their teens.”

Official data and anecdotal evidence suggest that if youth trends in MEA remain unchecked, tobacco companies can count on a steady flow of regular customers in the coming decades

“Young people want to be like Europeans,” says Dr Wided Hizem Ben Ayoub, an epidemiologist and smoking cessation specialist at the Salah Azaiez Cancer Institute in Tunisia “They see smoking as a sign of independence, especially young women So we have to do a lot of work among young people.”

According to the WHO, the average prevalence rate is 26% for boys between the ages of 13 and 15 years in the nine countries in our sample (there are no comparable figures for Algeria) The figure is 18% for girls (excluding Algeria and Saudi Arabia) In Lebanon, the problem is particularly acute, with 65.8% of boys smoking, double the rate among Lebanese men; and 54% of girls, which is nine times the rate for women By contrast, the smoking rate among 11-15-year-olds in England (excluding Scotland, Wales and Northern Ireland) is 6%, according to John Tilley of the tobacco policy team in the

UK Department of Health, citing a 2008 National Health Service study

The WHO report only records smoking rates for those between 13 and 15 years, but the experts we interviewed say that the problem starts much earlier in most countries In Algeria, for example, the WHO declined to publish a figure for youth prevalence, citing a lack of comparable survey data Yet Dr Mokhtar Hamdi-Cherif, professor of epidemiology and preventative medicine at the University of Setif

in Algeria and prominent anti-smoking campaigner, cites a 2007 survey that suggested that one-half of

Adult and youth smoking prevalence in selected countries

(%)

Source: WHO Report on the Global Tobacco Epidemic, 2008: The MPOWER package, World Health Organisation.

Note Data in this chart include the WHO's age-standardised estimates to a 95% confidence interval, for the purposes of comparison across countries Men and women are defined as adults over the age of 15 years old Youth smoking rates are for children between the ages of 13 years old and 15 years old The above chart identifies the adult prevalence rate for "current smoking" which is defined by the WHO as "smoking at the time of the survey, including daily and non- daily smoking." The rates reflect "smoking any form of tobacco including cigarettes, cigars, pipes, bidis, etc." Youth figures include those who "consumed any smokeless or smoked tobacco product at least once during the last 30 days prior to the survey".

0 10 20 30 40 50 60 70

United Arab Emirates Tunisia

South Africa Saudi Arabia

Nigeria Morocco

Lebanon Jordan

Egypt Algeria

Men Boys (13-15) Women Girls (13-15)

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Smoke in the water

Throughout the Middle East and North Africa, experts point to one common denominator that explains why tobacco use is rising among children and young women—the widespread acceptance and popularity of the water pipe Known as shisha, nargile or rengila, the water pipe is seen as less harmful, even though one session with the pipe can deliver many times the impact of a single cigarette, according to some experts

“It is a social activity in the evening or at the weekend,” says Dr Hani Algouhmani, the Eastern Mediterranean regional director for the Framework Convention on Tobacco Control, a treaty binding signatories to a number of anti-tobacco measures “It’s traditional, but it is also fashionable If you

Convincing adolescents: Combating youth smoking

in Jordan

The WHO estimates that nearly 63% of men and 10% of women use

tobacco in Jordan, giving it the highest tobacco prevalence rate

in the Middle East Moreover, with close to one-third of adolescent

boys and one-quarter of adolescent girls smoking cigarettes or

water pipes, Jordan’s smokers appear to be starting earlier than

almost anywhere else in the region (only Lebanon has a higher

youth tobacco prevalence, according to national surveys) “What

scares me most is that the age at which they start smoking is

getting increasingly younger,” says Mawya Zawawi Hammad,

general manager of Lina Creative Development (LCD), an NGO that

targets Jordanian youth in anti-tobacco media campaigns “You see

youngsters 9 to 10 years old starting to smoke.”

Jordan’s adolescents begin smoking, Ms Hammad says, by

following the examples of their adult role models “Their parents,

their teachers, their popular friends, rock stars—everyone smokes

It is considered to be a cool thing If you don’t smoke, you feel

socially excluded.”

According to the American Cancer Society, almost 90% of adult

smokers started at or before 19 years of age, making age the crucial

link in a lifelong chain of addiction

In order to break this trend, LCD, along with other NGOs, the Jordanian Ministry of Health and the WHO, tailors school campaigns specifically for children and teenagers—ideally to intervene before they start smoking and create smoke-free schools Young children are taught the hazards of tobacco through interactive games and puzzles, while programmes for teenagers include testing of CO2 levels in the blood and counselling on how to stop smoking “Many former youth smokers become advocates against tobacco This is the most effective way to change habits, to have youth delivering the message to other youth,” Ms Hammad says

Also at the forefront of the fight to end youth tobacco use in Jordan is enforcement of existing legislation Until now, people have smoked anywhere despite a ban on smoking in public places since 1977 Vendors and retailers have sold tobacco to under-age adolescents with impunity “Children have had easy access to tobacco Even young kids can go to a small corner shop and buy cigarettes,” confirms Ms Hammad But pressure is mounting to fine smokers caught lighting up in public places (including schools, hospitals and government buildings) and people caught selling tobacco products to minors

Despite some slow progress, cigarette smoking and the use of water pipes remain widespread, if not culturally sanctioned, in Jordan While the ultimate goal is eradication of both youth and adult tobacco use,

Ms Hammad acknowledges, “we still have a long way to go”

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have a party you have to have a water pipe.”

Dr Monique Chaaya, a professor at the American University of Beirut, says that up to 60% of year-olds in the Middle East have tried the water pipe “It’s becoming an epidemic,” she says, claiming that between 1999 and 2007 water pipe usage in the Middle East rose by 200% among women and 60% among men

16-19-Efforts to stop the spread of water pipes are just beginning In general, anti-water pipe policies lag behind other anti-tobacco programmes, largely because the water pipe is culturally acceptable Water pipes fall under the bans on public smoking, but they are rarely enforced Children are often encouraged to smoke by their parents, and although doctors in the region might advise on the health risks of smoking, they are not as adamant about the risks of pipe smoking

“We are doing a lot of research on water pipes, the smoke and its composition,” confirms Dr Chaaya

“We have to come up with evidence, and we have to convince the public of the dangers We don’t want

to have to wait for another big global study The more we talk about it, the more it will filter through to policymakers.”

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In 2007, Egypt adopted landmark legislation that outlawed the sale of tobacco to minors, banned

smoking from indoor areas and added 10% to the cost of cigarettes The experts we interviewed say the government is a leader in the region “For a lot of the Middle East region, Egypt is a point of reference,” says Armando Peruga, Geneva-based programme manager for the WHO’s Tobacco Free Initiative

And yet, according to one official we spoke to in Egypt, the finance and health ministries are at odds over tobacco policy, and the result is often paralysis Other ministries are disposed to anti-tobacco policies, but they have more pressing priorities, this official notes The government’s cross-ministry anti-tobacco committee has convened only once in the past 18 months “The government is not yet fully committed,” he says

This kind of ambivalence on the part of elected officials is rife throughout MEA On the one side are the finance ministers, who focus on the jobs and revenue that depend on tobacco The tobacco industry, whose lobbyists often have the ear of finance ministries, emphasise the jobs that would be lost if the industry were hobbled One tobacco industry representative in Nigeria claims that about 5,000 people are directly employed by tobacco companies in Nigeria, in addition to about 1,000 farmers who rely on the industry for their livelihoods He calculates that further indirect employment, such as jobs in distribution, stocking and retailing, account for over 1 million people in Nigeria

On the other side are the health ministers, who emphasise the long-term consequences to the nation’s health, and, incidentally, its finances, since governments are ultimately responsible for dealing with a wave of smoking-related chronic diseases In 2007, in papers filed for a suit against BAT, Phillip Morris and the Tobacco Institute, the Nigerian government estimated there were more than 9,527 tobacco-related cases in state-run hospitals during the year Moreover, a survey of 26 state-run hospitals showed that two people die each day from tobacco-related illnesses It estimated that the state spends N216,000 (US$1,457) on each case of tobacco-related diseases and the individual spends another N70,000 (US$472)

The problem is multiplied in countries where the government either owns or controls tobacco manufacturing In Tunisia, government manufacturing translates into 17,000 jobs One official we spoke to acknowledges the brutal truth: “The government will lose money if Tunisians smoke less.”

Government action: Giving with one hand, taking away with the other

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It seems paradoxical—governments selling cigarettes while attempting to ban them at the same time Our experts say the issue is more complicated “It’s always a debate,” says Mr Peruga “On the one hand, it’s a source of revenue; on the other, because the tobacco companies are government-owned, they are usually more responsive to tobacco control policy It has pros and cons.”

The best tools, blunted

Three of the most effective policies for reversing prevalence trends are advertising bans, smoke-free public places and price hikes, with price increases having proved particularly effective in discouraging youth smoking All three policies create what Dr Rima Nakkash, a professor at the American University

of Beirut, calls an enabling environment for tobacco control “You can’t change behaviour unless you have an enabling environment,” she says “Knowledge is not sufficient for people to change their behaviour We are aware of a lot of doctors who know that smoking is bad for you, and still smoke.”South Africa is a prime example of the positive effects of public policy The WHO report lauds the country as a success story Prevalence rates dropped after strict bans were enforced, and the organisation says that after taxes were increased by 250% during the 1990s, consumption fell by 5-7% for every 10% increase in the price of cigarettes

Among the ten countries in our sample, three—Jordan, South Africa and the UAE—have “complete” advertising bans, according to the WHO, which encompass all national television and radio, local magazines and newspapers, billboard and outdoor advertising, and at the point of sale Enforcing the legislation is often far from complete, however The WHO, for example, gives both the UAE and South Africa a score of 7 out of 10 for enforcement, which means that, in practice, tobacco advertisements

Influence on a shoestring

When governments have acted, it has often been in response

to pressure applied by charities and other non-governmental

organisations (NGOs), and their influence throughout the region is

growing “Our objectives are twofold—to pressure governments to put

laws into place that regulate tobacco companies and to raise public

awareness,” says Akinbode Oluwafemi, programme manager and head

of the tobacco control campaign at Friends of the Earth Nigeria

NGOs have employed a range of tactics to achieve these ends In

Jordan, the Lina Creative Development Group runs school awareness

campaigns about the risks of tobacco use, while the American

Cancer Society programme for a smoke-free environment in Tunisia

focuses on training, assistance and workshops for doctors and

state and private companies “We raise public awareness about the

dangers of tobacco use on a local level, by getting involved with

people and communities,” explains Dr Ayoub, co-ordinator of the

American Cancer Society’s efforts in Tunisia

Anti-tobacco proponents in Nigeria had a tantalising taste

of victory last year when the federal government designated the

capital city of Abuja a smoke-free zone “This was a great success for organisations working in the area of tobacco control, and symbolically very important since Abuja is considered the centre of our country,” says Mr Oluwafemi “Now we are working towards a national anti-smoking law.”

Often run on shoestring budgets and staffed by volunteers, NGOs’ struggle against tobacco companies is a modern-day David and Goliath tale But support from the international community, such as the commitment in 2008 of the Bloomberg and Gates foundations of US$500m to support global anti-smoking efforts, is giving NGOs a much-needed boost “We are beginning to see more support for anti-tobacco efforts in the continent,” confirms Mr Oluwafemi, “although there is still a great need for funds in many countries.” (Mr Oluwafemi’s organisation won a US$100,000 grant from the Bloomberg foundation earlier this year.)

“There is now a career path for tobacco control in low- and middle-income countries, in the WHO and NGOs,” adds Dr Mackay

of the World Lung Foundation “Before, hospital medicine was seen as more exciting than prevention and public health I have received death threats from smokers’ rights groups It’s certainly not boring.”

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frequently find their way into newspapers and onto the air waves, despite the legal embargoes

Only Jordan has a complete advertising ban and scores a perfect 10 on the WHO’s enforcement scale

“I think Jordan is a regional leader in this regard,” says Dr Hiba Ayoub, head of the tobacco control unit at the Jordanian Ministry of Health “Laws banning advertising are strictly enforced, with heavy sanctions involved Car races in Amman used to be sponsored by Marlboro, but no longer You will never find a billboard or an advertisement in local newspapers.”

Jordan is a bright spot for advertising bans But in most countries in MEA, the ambivalence within governments leads to contradictory policies Bans are enacted but not well enforced, and taxes are levied but not at levels high enough to have a serious impact on prevalence In the meantime, regional policy remains scattered

“There is a lack of enthusiasm by the [Saudi Arabian] government,” says one doctor and expert we spoke to in Riyadh “They passed a smoking ban but it isn’t enforced There is a lack of will.”

Smoking in public is common throughout MEA and second-hand smoke wafts freely through hospitals, schools and restaurants None of the countries we examined had more than moderate policies in place, and several had no policies at all Even the countries with strict bans on the books, such as Egypt and Morocco, fail to enforce them adequately Jordan, which cracks down so effectively

on advertising, has what the WHO describes as a “minimal” policy and is given a score of 4 out of 10 on

Status of taxes, cigarette prices, advertising bans, smoke-free legislation, health warnings and cessation programmes in selected countries

and enforcement

Smoke-free environments and enforcement

Health warnings

Cessation programmes

United Arab Emirates $.36 Data not available Complete: 7 Moderate: 3 No policy Moderate Note: The prices of cigarettes in the above table are based on the price of a 20-pack of the most widely consumed brand in US dollars at

purchasing power parity in 2006 Tax rates do not reflect any changes subsequent to publication of the WHO mpower report Advertising bans, smoke-free environments, health warnings and cessation programme policies were rated on a four-point scale: no policy, minimal policy, moderate policy and complete policy The scores for the level of enforcement of advertising bans and smoke-free environments were measured

on a scale from 0 to 10 by the WHO.

Source: WHO Report on the Global Tobacco Epidemic, 2008: The MPOWER package, World Health Organisation.

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enforcement Algeria’s ban is not enforced anywhere, adds Dr Hamdi-Cherif of the University of Setif

“The only place in Algeria where people don’t smoke is on planes,” he says

Experts acknowledge that public support for smoking bans, which is so crucial to their success

in Western countries, is far from all-encompassing in MEA Compounding the problem is the social disparity between those charged with enforcing the bans and those who are flouting the rules It would

be inconceivable in many countries, for example, for a poorly paid mall security guard, who is often an immigrant, to approach nationals about refraining from lighting up

The latest comparable figures for cigarette pricing and taxes, measured in 2006 at US dollar parity, range from a low of 50 US cents for a pack of 20 cigarettes in Lebanon to a high of US$5.15 per pack in South Africa and US$5.32 in Morocco According to the WHO, tax rates are highest in Egypt, at 58%, and lowest in Nigeria, at 28% Generally, however, in most countries smoking remains affordable and accessible Cigarette taxes, which do so much to fight teen smoking, are undermined by cheap local brands, cigarettes sold by the stick, as well as smuggling and black markets In Saudi Arabia, according to the WHO, the price of a 20-pack of a leading international brand sells for about US$1.65—unacceptable according to a Saudi Arabian doctor we spoke to for the report “The price is dirt cheap,”

he says “That is what promotes smoking among high school boys and girls It’s as cheap as a cup of coffee or a sandwich.”

He also points the finger at regional agreements that he believes provide an excuse for inaction Tobacco taxes require the agreement of all six nations of the Gulf Co-operation Council (GCC) “If one country votes against an increase in the price of tobacco, the price is not increased,” he says

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Even if the most optimistic projections for smoking rates and population growth in MEA are

accepted, it is likely that there will be several million more smokers in the region by 2030 specific estimates for the resulting healthcare burden are thin on the ground, but data in the West suggests the bill could be staggering In the US, for example, according to the Centers for Disease Control, each adult smoker currently accounts for US$1,623 of extra medical spending per year Research by the British Heart Foundation found that treating smoking-related diseases costs the UK’s National Health Service (NHS) £5bn per year, amounting to about 5% of the entire NHS budget Whereas in China, a study conducted by the China Centre for Economic Research estimated that the tab for treating Chinese smokers was Rmb166.6bn (US$24.4bn) or about 1% of the country’s GDP

Region-All of the ten countries we examined for this report face challenging demographics Even in countries with relatively low adult prevalence rates, such as Nigeria, youth smoking and population growth are driving up absolute numbers From a public health perspective, it is clear that smoking rates, especially among children, cannot simply remain flat; they must come down

Clearing the air:

Outlook and future challenges

Number of smokers in selected countries, with all other factors remaining equal: 2010 and 2030

(m)

Sources: United Nations Population Division; World Health Organisation; Economist Intelligence Unit.

2010 2030

0 2 4 6 8 10 12 14 16 18

United Arab Emirates Tunisia

South Africa Saudi Arabia

Nigeria Morocco

Lebanon Jordan

Egypt Algeria

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