8 96
from health professionals
to quit or at
least
reduce
intensity
of
smoking.
3.1.3.
Socioeconomic
status
and
smoking
Increases
in smoking prevalence
in both men and women
in
high-income
countries
started mainly
in
higher
socioeco-
nomic
groups
[37,38]. Over
time, high
smoking prevalence
shifted
to
lower
socioeconomic
groups
as
evidence
about
the
health
effects
of
smoking
emerged
in
the
1950s
and
early 1960s
[38].
In
the United States,
for example,
smoking
prevalence
in
1940 was
36%
in
those with
less
than
a
high
school education and 40%
in people with education
levels of
college
and
above
[38];
the
corresponding
rates were
35%
and
13%
in
2009–2010
[39] .Similar
patterns
of
smoking
prevalence
by
socioeconomic
status
have
been
reported
in
LMICs
[40–42].
When
specific
ethnic
groups
show
high
smoking prevalence,
it
is
likely because
they are dispropor-
tionately
represented
in
lower
socioeconomic
groups
[16,43].
3.2.
Regional
patterns
of
tobacco
smoking
3.2.1.
Africa
Updated
information
on
tobacco
smoking
in
Africa
is
limited
[44],
but
similar
to
other
LMICs,
in
Africa
smoking
is
substantially more
common
among
men
than
women
( Table 1). The slight decrease
in prevalence of daily smoking
from
1980
to
2012
( Fig. 2)
was
chiefly
prominent
in
countries
in which
the
tobacco epidemic
started earlier and
had
relatively
higher
smoking
rates
(eg,
South
Africa,
Lesotho,
Madagascar,
and
Algeria)
[24].
In
parallel
with
rapidly growing
incomes, which often make cigarettes more
affordable
[45],
and without major
tobacco
control
inter-
ventions,
it
has
been
projected
that
the
prevalence
of
current
smoking will
increase
from
15.8%
in 2010
to
21.9%
in
2030
in
the
WHO
African
region
(Africa
excluding
Djibouti,
Egypt,
Libya,
Morocco,
Somalia,
Sudan,
and
Tunisia)
if
current
trends
continue
[46].
Most
of
this
increase
is
expected
to
be
among men.
The
consequences of
the
tobacco
epidemic
in Africa will
be
exacerbated
by
rapid
population
growth,
which,
although
slowing,
is
among
the
highest
in
the
world.
By
current
trends,
the
estimated
population
of
Africa
will
increase
from 1.2 billion
in 2015
to 1.7 billion
in 2030 and
to
4.2 billion
(or
40%
of
the world’s population)
in 2100, with
the
highest
increase
in
East
Africa
and
West
Africa
[47]. Without
appropriate
tobacco
control
policies,
includ-
ing
prevention
strategies
across
the
continent,
Africa will
lose many millions
of
lives
in
this
century
due
to
tobacco
smoking
[45].
3.2.2.
The
Americas
Smoking
prevalence
in
Canada
and
the
United
States
has
decreased
from
>
55%
in men
in
the
1950s
and
>
35%
in
women
in
the 1970s
and 1980s
[4,48]to
<
20%
in men
and
<
15%
in women
in
2012
( Table 1). Also,
the
daily
smoking
prevalence
decreased
by
approximately
60%
in
both men
and
women
in
Mexico
from
1980
to
2012
[24].
Several
Caribbean, Central American, and South American countries
have
reduced
smoking
rates,
though
to
a
lesser degree
and
chiefly
in
men.
However,
there
has
been
no
significant
change
in male
smoking
in a
few
countries,
including Chile,
Costa
Rica,
Jamaica,
Peru,
and
Suriname
[24].
Smoking
is
generally
less
prevalent
in
Central
America
than
in
South
America,
particularly
among women.
The
smoking
preva-
lence
in many
South
American
countries
is
approximately
20–30%
in
men
and
10–20%
in
women
[6] .The
highest
smoking
prevalence
in
South
America
is
in
Chile:
44.2%
in
men
and
37.1%
in women
in
2010
( Table 1).
3.2.3.
Asia
Approximately
60%
of
the
world’s
current
smokers
in
2010
through
2012
lived
in
three
Asian
countries:
China
(317
million
smokers),
India
(122
million
smokers),
and
Indonesia
(115 million
smokers)
[49].
Chinese men
smoke
one
in every
three cigarettes
smoked worldwide
[2].
In only
a
few Asian
countries
(eg, Kazakhstan,
Lebanon, and Nepal)
is
the
smoking
prevalence
in
women
>
10%
( Table 1).
In
contrast,
smoking
is
quite
common
among Asian men.
The
male
smoking
prevalence
is
>
40%
in western
parts
of
the
Middle
East
(eg,
Lebanon,
Jordan,
and Kuwait)
but
is
lower
(15–30%)
in other West Asian countries
(eg,
Iran, Qatar, and
Oman)
and
adjacent
countries
in
South
Asia
and
Central
Asia
(eg,
India,
Pakistan,
and
Uzbekistan). Moving
toward
the
north
and
east,
this
rate
increases
to
>
40%
in
other
South
Asian
and
Central
Asian
countries
(eg,
Bangladesh,
Kazakhstan,
Kyrgyzstan,
and Nepal).
Smoking
prevalence
in men
is
extremely
high
in many
East
Asian
and
Southeast
Asian
countries.
The
current
smoking
prevalence
among men
in 2010–2011 was
67%
in
Indonesia and 53%
in China
( Table 1). Some countries
in East
Asia
and
Southeast Asia
have
been
able
to
reduce
smoking
rates. For example, male smoking rates halved
in Hong Kong
(China),
Japan,
and Singapore
from 1980
to 2012
[50]. Nev-
ertheless, many
other
countries
need
to
implement more
effective
tobacco
control
policies
to
attain
similar
goals.
With
current
high
smoking
rates
in
this
highly
populated
region,
smoking will
be
the main
cause
of morbidity
and
mortality
for
several
decades.
Current
trends
suggest
that
smoking
will
kill
>
50 million
people
between
2012
and
2050
in
China
alone
[51].
3.2.4.
Europe
Smoking
rates
have
substantially
decreased
in
several
countries
in Western Europe
and Northern Europe, notably
in
the United Kingdom and
the Nordic countries
[24].
In
the
United Kingdom,
smoking
rates dropped
from
>
80%
in men
in
1950
and
approximately
40%
in women
in
1970
[52]to
approximately
20%
in
both
sexes
in
2012
( Table 1).
Although
smoking
rates
have
also
started
to
decrease
in
many other European countries,
the
rates are
still very high
in
Eastern
Europe
and
Southern
Europe
( Table 1).
The
tobacco
epidemic
started much
earlier
in Western
Europe
than
in Eastern Europe. Following an earlier decline
in male
smoking
prevalence,
tobacco-related mortality
in
men
is
decreasing
in
several Western
European
countries
[53]. A decline
in
smoking-related mortality
in women has
begun
in
countries
with
decreases
in
female
smoking,
E U R O P E A N
U R O L O G Y
F O C U S
1
( 2 0 1 5
)
3 – 1 6
8