Comparing smoking and smoking cessation process in the Republic of Karelia, Russia and North Karelia, Finland

Smoking and alcohol use among women in Russia: Dual risk for prenatal exposure

Alcohol consumption during pregnancy can produce adverse outcomes; maternal smoking compounds this risk. We examined prevalence of smoking and associations between smoking and alcohol use in Russian women of childbearing age (N = 648). Smoking was reported by 35% of nonpregnant and 14% of pregnant women. Smoking prevalence was higher (45%) among at-risk drinkers and those at risk for an alcohol-exposed pregnancy (AEP). In a multivariate model, smoking status and city of residence significantly predicted AEP risk. Pregnant women in urban locations were more likely to smoke. Smoking and alcohol misuse often co-occur among Russian women, presenting risk for dual prenatal exposure.

Misclassification of smoking habits: An updated review of the literature

BACKGROUND

Misclassification of smoking habits leads to underestimation of true relationships between diseases and active smoking, and overestimation of true relationships with passive smoking. Information on misclassification rates can be obtained from studies using cotinine as a marker.

AIM

To estimate overall misclassification rates based on a review and meta-analysis of the available evidence, and to investigate how misclassification rates depend on other factors.

METHODS

We searched for studies using cotinine as a marker which involved at least 200 participants and which provided information on high cotinine levels in self-reported non-, never, or ex-smokers or on low levels in self-reported smokers. We estimated overall misclassification rates weighted on sample size and investigated heterogeneity by various study characteristics. Misclassification rates were calculated for two cotinine cut points to distinguish smokers and non-smokers, the higher cut point intended to distinguish regular smoking.

RESULTS

After avoiding double counting, 226 reports provided 294 results from 205 studies. A total of 115 results were from North America, 128 from Europe, 25 from Asia and 26 from other countries. A study on 6.2 million life insurance applicants was considered separately. Based on the lower cut point, true current smokers represented 4.96% (95% CI 4.32-5.60%) of reported non-smokers, 3.00% (2.45-3.54%) of reported never smokers, and 10.92% (9.23-12.61%) of reported ex-smokers. As percentages of true current smokers, non-, never and ex-smokers formed, respectively, 14.50% (12.36-16.65%), 5.70% (3.20-8.20%), and 8.93% (6.57-11.29%). Reported current smokers represented 3.65% (2.84-4.45%) of true non-smokers. There was considerable heterogeneity between misclassification rates. Rates of claiming never smoking were very high in Asian women smokers, the individual studies reporting rates of 12.5%, 22.4%, 33.3%, 54.2% and 66.3%. False claims of quitting were relatively high in pregnant women, in diseased individuals who may recently have been advised to quit, and in studies considering cigarette smoking rather than any smoking. False claims of smoking were higher in younger populations. Misclassification rates were higher in more recently published studies. There was no clear evidence that rates varied by the body fluid used for the cotinine analysis, the assay method used, or whether the respondent was aware their statements would be validated by cotinine - though here many studies did not provide relevant information. There was only limited evidence that rates were lower in studies classified as being of good quality, based on the extent to which other sources of nicotine were accounted for.

CONCLUSION

It is important for epidemiologists to consider the possibility of bias due to misclassification of smoking habits, especially in circumstances where rates are likely to be high. The evidence of higher rates in more recent studies suggests that the extent of misclassification bias in studies relating passive smoking to smoking-related disease may have been underestimated.

Determinants of daily smoking in Estonia, Latvia, Lithuania, and Finland in 1994—2002

Aims: To investigate time trends in the smoking prevalence and the sociodemographic and psychosocial background of smoking in the Baltic countries in comparison with Finland during 1994—2002. Methods: Differences in daily smoking according to age, education, urbanization, and psychological distress in the Baltic countries and Finland were studied using postal surveys in 1994, 1996, 1998, 2000, and 2002 among adults (20—64 years old) in Estonia (n=6,271), Latvia (n=6,106), Lithuania (n=9,824), and Finland (n=15,764). Results: In 1994, 1996, 1998, 2000, and 2002 the prevalence of smoking in Estonia, Latvia, Lithuania, and Finland was 47%, 54%, 46%, and 29% among men, and 21%, 19%, 11%, and 19% among women, respectively. Smoking increased among Lithuanian women from 6% in 1994 to 13% in 2002, but decreased among Estonian men and women. Smoking was generally more common among younger individuals, the less educated, and people with distress in all four countries. The odds ratios for smoking for those with low education compared with those with high education were 2.18 (1.69—2.81), 3.32 (2.55—4.31), 2.20 (1.79—2.70) and 2.80 (2.40—3.27) in men, and 1.90 (1.42—2.52). 3.09 (2.28—4.18), 0.86 (0.59—1.26), and 3.00 (2.53—3.55) in women, in Estonia, Latvia, Lithuania, and Finland, respectively. There were indications of increasing educational differences in Latvian men. Smoking was less common among rural women in all countries except Estonia. Conclusions: Estonia, Latvia, and Finland show characteristics of the ``mature'' phase of a smoking epidemic, and smoking may not increase in these countries. In Lithuanian women smoking may increase. Smoking may be increasingly unequally distributed in the future in all the studied countries.

Adolescents' Attitudes on Smoking Are Related to Experimentation with Smoking, Daily Smoking and Best Friends' Smoking in Two Karelias in Finland and in Russia

PURPOSE

Becoming a smoker usually starts during adolescence and is a dynamic process involving experimentation before the establishment of daily smoking. It has been suggested that adolescents who smoke differ from those who do not in their attitudes to smoking. The purpose of this study was to find out whether attitudes related to smoking legislation and restrictions, social pressures in smoking and image of smokers are associated with smoking experimentation, daily smoking and best friends' smoking.

METHOD

The data were gathered with a self-administered questionnaire in North Karelia, Eastern Finland and in the Pitkyaranta district, Republic of Karelia, Russia. The respondents were 15-year-old 9th grade pupils in local schools. In Pitkyaranta, the data analyses covered pupils in all eight schools in the area (n = 179). In North Karelia, the data analyses comprised of selected eight schools (n = 601). Data were analysed with exploratory factor analysis.

RESULTS

The models revealed that attitudes related to restrictions and social pressure were significantly associated with experimenting with smoking [OR (95 % CI) 7.923 (5.787-10.847)], daily smoking [OR (95 % CI) 9.575 (6.727-13.628)] and the likelihood of best friends' smoking [OR (95 % CI) 3.154 (2.579-3.858)]. The stronger the young peoples' attitudes and opinions, for example, towards restrictions and with more difficulties in refusing smoking, the higher the likelihood for smoking experimentations, daily smoking as well as the likelihood for their best friends' smoking. The country and factor interactions were not associated with smoking experimentations, daily smoking or best friends' smoking.

CONCLUSION

Regardless of cultural background, adolescents who smoke have more positive attitudes to smoking, and perceive more social support for smoking, than do adolescents who do not smoke. The study stresses the similarity of the results in both Karelia's despite the enormous differences in culture, economy and public policy.

Research priorities for FCTC Articles 20, 21, and 22: surveillance/evaluation and information exchange

INTRODUCTION

Framework Convention on Tobacco Control (FCTC) Articles 20, 21, and 22 call for strong monitoring and reporting of tobacco use and factors influencing use and disease (Articles 20 and 21) and for collaboration among the Parties and relevant organizations to share resources, knowledge, and expertise on all relevant tobacco control strategies (Article 22).

METHODS

This paper provides background information and discusses research strategies that would strengthen these efforts and better inform the parties. By necessity, Articles 20 and 21 are discussed separately from Article 22, although 1 example that relates to both 20/21 and 22 is discussed at the end.

RESULTS

Twelve important research opportunities on surveillance and evaluation are recognized, along with 4 on collaboration. The authors believe that the 6 most important areas for research would study (a) possible underreporting of tobacco use among certain demographic groups in some countries, (b) measures of industry activities, (c) optimal sampling strategies, (d) sentinel surveillance, (e) networks of tobacco companies and their partners as they promote tobacco use and interfere with implementation of the FCTC, and (f) network/relationship factors that impact diffusion of knowledge and decision making on the implementation of the FCTC. In addition, we call for a review process of existing surveillance and evaluation strategies to coordinate activities to make optimal use of existing resources. This activity would involve networking as prescribed in Article 22.

CONCLUSIONS

Studies and activities such as these would facilitate control of the tobacco epidemic.

Smoking differences between employees in faculties of the University of Tartu, Estonia, and changes during the country's transition

Background

A previous study found marked differences in smoking between employees in various university faculties in Tartu, Estonia, soon after the disruption of communism. The present study was conducted to see whether such differences still exist and how the patterns had changed during the country's first transitional decade.

Methods

All employees at the University of Tartu (UT) were surveyed for smoking habits by means of a questionnaire in 1992 and 2003. The present paper is based on respondents whose faculty or workplace was known (1390 people in 1992, 1790 in 2003). Smoking differences were assessed in terms of regression-based adjusted figures.

Results

While 20% of the male employees smoked daily in 1992, 13% did so in 2003, the figures for females being 10% and 7%, respectively. The prevalence of men's daily smoking varied between faculties and other workplaces in the range 4-30% in 1992, and 0-24% in 2003, with corresponding ranges of 3-21% and 0-10% among females. Men in the medical faculty in both surveys, and those in the faculty of philosophy in the second survey showed higher rates than men in most other faculties, as did women in the faculty of law in the first survey and those in the faculty of philosophy in the second. The figures were usually low in the faculties of sports & exercise, physics & chemistry and mathematics. The sex pattern was reversed in the faculty of law and also in that of economics, where the women smoked more than the men.

Conclusions

Even in this low-smoking academic community, wide smoking differences existed between the faculties and other workplaces. Faculties where physical or mental performance is of prime importance are leading the way towards a smoke-free community, while men in the faculty of philosophy and, paradoxically, men in the medical faculty are lagging behind. The reversed sex ratio in the faculties of law and economics may indicate women's intensified drive for equality in this transitional society. We assume that different professional cultures may introduce variations in smoking patterns, thereby modifying the course of the smoking epidemic.

Nicotine dependence may link the 15q25 locus to lung cancer risk

The nicotinic 15q25 locus has been implicated in lung cancer risk, with an odds ratio of approximately 1.3. The same locus is associated with nicotine dependence due to cigarette smoking and with smoking-associated chronic obstructive pulmonary disease, which is a risk factor for lung cancer. Our meta-analysis of reported studies shows that this locus was not associated with lung cancer risk in >1000 never-smoker cases and >1800 controls. Review of exposure-response data for lung cancer risk showed that less than a half-cigarette per day may confer the same risk of lung cancer as that conferred by the 15q25 locus. Given the lack of effect in never-smokers and the known common and variable underreporting of smoking habit in studies on smoking-associated diseases, we cannot exclude that the association between the 15q25 locus and lung cancer risk is indirect, deriving from association of the same locus with smoking habit. Since nicotine is not carcinogenic, available data do not provide plausibility of the association between the nicotinic 15q25 locus and lung cancer pathogenesis. Thus, a direct link between the 15q25 locus and lung cancer risk has yet to be established.

The social and economic determinants of smoking in Moscow, Russia

BACKGROUND

Despite a high prevalence of smoking for decades, recent research has documented an increase in the rates of both male and female smoking in post-Soviet Russia. As yet, however, little research has taken place on smoking at the subnational level. The current study addresses this deficit by examining smoking in Moscow -- the city that has been at the forefront of the entry into the Russian market of transnational tobacco corporations (TTCs) in the transition period.

METHODS

Data were obtained from the Moscow Health Survey 2004 -- a stratified random sample of 1190 people representative of Moscow's larger population. Information was obtained about subjects' smoking habits and age of smoking initiation.

RESULTS

The prevalence of smoking was high among both men (55.5%) and women (26.9%), with significantly higher rates in the younger age groups. There was also a high prevalence of smoking initiation before age 15 years, especially in the youngest women (18-30 years). Logistic regression analysis showed that respondents' age, binge drinking, locus of control and economic situation were important determinants of smoking.

CONCLUSIONS

Although lifestyle factors seem to underpin the generally high levels of smoking, other things, such as its high prevalence in the younger generations and the factors associated with smoking (locus of control), nevertheless suggest that the TTCs may have played an important role in the spread of smoking in transitional Russia's changing social environment.

The accuracy of self-reported smoking: a systematic review of the relationship between self-reported and cotinine-assessed smoking status

INTRODUCTION

Smoking is a leading cause of premature mortality and preventable morbidity. Surveillance is most often based on self-reported data, but studies have shown that self-reports tend to underestimate smoking status.

METHODS

This study systematically reviewed the literature to measure the concordance between self-reported smoking status and smoking status determined through measures of cotinine in biological fluids. Four electronic databases were searched to identify observational and experimental studies on adult populations over the age of 18 years.

RESULTS

Searching identified 67 studies that met the eligibility criteria and examined the relationship between self-reported smoking and smoking confirmed by cotinine measurement. Overall, the data show trends of underestimation when smoking prevalence is based on self-report and varying sensitivity levels for self-reported estimates depending on the population studied and the medium in which the biological sample is measured. Sensitivity values were consistently higher when cotinine was measured in saliva instead of urine or blood. Meta-analysis was not appropriate because of the substantial heterogeneity among the cutpoints used to define smokers and the poor reporting on outcomes of interest.

DISCUSSION

Further research in this field would benefit from the standardization of cutpoints to define current smokers and the implementation of standard reporting guidelines to enhance comparability across studies. Accurate estimation of smoking status is important as data from population studies such as those included in this review are used to generate regional and national estimates of smoking status and in turn are used to allocate resources and set health priorities.

Trends in the prevalence of smoking in Russia during the transition to a market economy

BACKGROUND

Changes in smoking, particularly an increase in women, were predicted to follow the aggressive campaigns of multinational tobacco companies in transitional Russia. However, such changes have not yet been demonstrated unequivocally.

OBJECTIVE

To examine smoking trends by gender, education and area of residence.

METHODS

Data from 10 rounds of the Russia Longitudinal Monitoring Survey (1992-2003), consisting of more than 3000 men and 4000 women in each round, were used. The mean reported ages of first smoking in current smokers were compared between 10-year birth cohorts.

RESULTS

Between 1992 and 2003, smoking prevalence doubled among women from 6.9% (95% CI 6.3% to 7.6%) to 14.8% (13.9% to 15.7%) and increased among men from 57.4% (95% CI 56.0% to 58.8%) to 62.6% (61.1% to 64.1%). In both sexes, the rise was significantly greater in the least educated, markedly so in women (a doubling vs a 1.5-fold rise in the most educated). Although prevalence of smoking among women was considerably higher in Moscow and St Petersburg than in rural areas, the dramatic threefold increase in prevalence in rural women was significantly greater than in the main cities (36%, p<0.001). The mean age of first smoking was significantly lower in women born after 1960, but in men it was stable between cohorts.

CONCLUSIONS

For the first time, it has been shown unequivocally that smoking among women increased markedly during the transition to a market economy in Russia. The already high prevalence of smoking among men has continued to rise. These changes are likely to reflect the activity of the tobacco industry and provide further evidence of the harms of privatisation. Effective tobacco control policies are urgently needed.

Influence of household demographic and socio-economic factors on household expenditure on tobacco in six New Independent States

Background

To identify demographic and socio-economic factors that are associated with household expenditure on tobacco in Azerbaijan, Georgia, Kazakhstan, Kyrgyzstan, Russian Federation, and Tajikistan.

Methods

Secondary analysis of the data available through the World Bank Living Standards Monitoring Survey conducted in aforementioned countries in 1995–2000. The role of different variables (e.g. mean age of household members, household area of residence, household size, share of adult males, share of members with high education) in determining household expenditure on tobacco (defined as tobacco expenditure share out of total monthly HH consumption) was assessed by using multiple regression analysis.

Results

Significant differences were found between mean expenditure on tobacco between rich and poor – in absolute terms the rich spend significantly more compared with the poor. Poor households devote significantly higher shares of their monthly HH consumption for tobacco products. Shares of adult males were significantly associated with the share of household consumption devoted for tobacco. There was a significant negative association between shares of persons with tertiary education within the HH and shares of monthly household consumption devoted for tobacco products. The correlation between household expenditures on tobacco and alcohol was found to be positive, rather weak, but statistically significant.

Conclusion

Given the high levels of poverty and high rates of smoking in the New Independent States, these findings have important policy implications. They indicate that the impact and opportunity costs of smoking on household finances are more significant for the poor than for the rich. Any reductions in smoking prevalence within poor households could have a positive economic impact.

Parental smoking behaviour and effects of tobacco smoke on children's health in Finland and Russia

BACKGROUND

There is little information on potential differences in smoking behaviour of parents between Finland and Russia and on the effects of environmental tobacco smoke (ETS) exposure on allergic and respiratory diseases among Finnish and Russian children. The aim of the study was to compare the smoking behaviour of parents and school children and to assess the relations of tobacco smoke exposure during pregnancy and childhood with occurrence of allergic diseases and respiratory infections among school children.

METHODS

We conducted a population-based cross-sectional study in the neighbour towns across the border of Imatra in Finland and Svetogorsk in Russia. The study population consisted of 512 Finnish and 581 Russian school children aged 7-16 years (response rate 79%).

RESULTS

Children's tobacco smoke exposure differed markedly between Finland and Russia. The risk of asthma was particularly related to high maternal smoking exposure during pregnancy (adjusted OR 3.51, 95% CI 1.00-12.3), infancy (3.34, 1.23-9.07) and currently (3.27, 1.26-8.48), and the risk of common cold was related to high combined parental smoking during infancy (1.83, 1.06-3.17) in Finnish children. Among Russian children allergic conjunctivitis was related to maternal smoking during infancy (4.53, 1.49-13.8) and currently (2.82, 1.07-7.44).

CONCLUSIONS

Smoking behaviour of parents and ETS exposure during childhood differed markedly between Finland and Russia. Asthma was particularly increased in relation to high exposure to maternal smoking in Finland. The results suggest that more efforts should be directed to reducing tobacco smoke exposure of children in both Finland and Russia. (250 words).

Speculation about Options for Teen Tobacco Use Cessation in the Russian Federation

This paper summarizes prevalence and consequences, recent policies, prevention and cessation efforts, recent developmental work (focus groups), and speculation about the current status of cigarette smoking in the Russian Federation. Unique aspects of modern Russian society are suggested as leading to relatively high prevalence internationally of smoking among Russian males. Similar factors may lead to deflated smoking cessation attempt and quit rates. We believe that the future of tobacco control in Russia is close, but that it will involve raising the prices of tobacco products, enforcing no tobacco use policies among minors, ratification of the Framework Convention on Tobacco Control (FCTC) and implementation of evidenced-based tobacco use prevention and cessation programs.

Changes in smoking prevalence in Russia, 1996-2004

OBJECTIVES

In Russia, smoking prevalence has historically been high in men and relatively low in women. Female smoking prevalence is predicted to rise but assessment of changes has been limited by the lack of comparable data. Changes in the prevalence of smoking in Russia between 1996 and 2004, and whether theses changes differed by sociodemographic groups, were investigated.

DESIGN

Repeated national interview surveys in 1996 (731 men and 868 women) and 2004 (727 men and 864 women) aged 18 years or more.

MAIN OUTCOME MEASURE

Prevalence of current smoking.

RESULTS

The age standardised prevalence of smoking in 1996 and 2004 was 61% and 63%, respectively in men and 15% and 16%, respectively in women (both p values > 0.4). In men, the prevalence of smoking seemed to decline in those with university education (from 51% to 40%, p = 0.085). Among women, smoking appeared to increase in those with university education (from 10% to 17%, p = 0.071) and low levels of self-reported material deprivation (from 11% to 18%, p = 0.053). There was a pronounced increase in prevalence among women living in villages (from 8% to 14%, p = 0.049); the strong urban/rural gradient seen in 1996 became considerably weaker by 2004.

CONCLUSIONS

Overall smoking prevalence in both men and women in Russia remained stable between 1996 and 2004 but, given the sample size, a moderate increase in female smoking cannot be ruled out. In men, smoking increased among the least educated and declined in the most educated. In women the opposite appeared to occur, in addition to an increase in smoking in rural areas. More long term monitoring of smoking patterns in Russia, especially among women, using sufficiently large surveys, is required.

Determinants of smoking in eight countries of the former Soviet Union: results from the living conditions, lifestyles and health study

AIMS

To provide accurate and timely data on the determinants of smoking in countries of the former Soviet Union in order to facilitate the development of effective tobacco control policies in the region. Such data are urgently needed given the absence of accurate comparative data in the region and the recent changes experienced.

DESIGN

Cross-sectional surveys using standardized methods and representative samples of the adult population in eight former Soviet Union countries conducted as part of the EU-Copernicus Project Living Conditions, Lifestyle, and Health study.

SETTING

Armenia, Belarus, Georgia, Kazakhstan, Kyrgyzstan, Moldova, Russia and Ukraine.

PARTICIPANTS

A total of 18 428 adults aged 18 plus; response rates 71-88%.

MEASUREMENTS

The association of smoking with demographic and socio-economic factors was investigated using multiple logistic regression analyses, stratifying by gender.

FINDINGS

Age was a strong determinant of smoking in both genders, with elderly individuals being less likely to smoke. Men who were more socially disadvantaged (less educated, poorer economic situation and/or less social support) were more likely to smoke. In women, living in larger urban areas was the strongest predictor of smoking. Divorced, separated or widowed women were also more likely to smoke than married women. Muslim respondents smoked less frequently compared with other respondents.

CONCLUSIONS

Smoking is a major public health issue in the FSU particularly affecting socially vulnerable men and young women living in urbanized areas. These high-risk groups should be targeted in future smoking prevention and cessation strategies in the region.

Prevalence of smoking in 8 countries of the former Soviet Union: results from the living conditions, lifestyles and health study

OBJECTIVES

We sought to provide comparative data on smoking habits in countries of the former Soviet Union.

METHODS

We conducted cross-sectional surveys in 8 former Soviet countries with representative national samples of the population 18 years or older.

RESULTS

Smoking rates varied among men, from 43.3% to 65.3% among the countries examined. Results showed that smoking among women remains uncommon in Armenia, Georgia, Kyrgyzstan, and Moldova (rates of 2.4%-6.3%). In Belarus, Ukraine, Kazakhstan, and Russia, rates were higher (9.3%-15.5%). Men start smoking at significantly younger ages than women, smoke more cigarettes per day, and are more likely to be nicotine dependent.

CONCLUSIONS

Smoking rates among men in these countries have been high for some time and remain among the highest in the world. Smoking rates among women have increased from previous years and appear to reflect transnational tobacco company activity.

Housing conditions, perceived stress, smoking, and alcohol: determinants of fetal growth in Northwest Russia

BACKGROUND

Social determinants of health have become important in countries of the former Soviet Union during the time of transition.

AIM

This article estimates the influence of living conditions, smoking, alcohol, and maternal stress on fetal growth indices in an urban Russian setting.

METHODS

All pregnant women registered at antenatal care centres in Severodvinsk (Northwest Russia) and their infants comprised the study base (n = 1399). Multivariate linear regression analysis was applied to quantify the effects of the studied factors on birth weight and the ponderal index (PI) adjusted for maternal education, age, occupation, marital status, parity, pre-pregnancy weight, paternal employment, gestational age, and others.

RESULTS

Infants of smoking mothers were 126 g lighter compared with non-smokers [95% confidence interval (CI): -198; -54]. On average, birth weight decreased 27 g per cigarette smoked during pregnancy. Living in shared apartments, living in crowded housing situations, and perceived stress were associated significantly with birth weight loss: -89 g (95% CI: -153; -25), -82 g (95% CI: -136; -28), and -61 g (95% CI: -116; -7), respectively. A positive association between maternal alcohol consumption and birth weight was found. Living with parents was associated positively with both birthweight and PI. Infants whose fathers consumed more than 100 ml of absolute alcohol per week were thinner at birth compared with those of non-drinking and moderate drinking fathers.

CONCLUSIONS

Poor housing conditions, maternal stress, smoking, and alcohol consumption are independent determinants of fetal growth in Northwest Russia.

A multilevel analysis of tobacco use and tobacco consumption levels in France: are there any combination risk groups?

BACKGROUND

Both the predictors for tobacco use and the determinants of the amounts of tobacco consumed by smokers should be taken into account when designing prevention programmes.

METHODS

Using a sample of 12,948 individuals representative of the French population in 1999, multilevel models were used to carry out a comparative investigation for the predictors of tobacco use and the determinants of the amount of tobacco consumed by smokers.

RESULTS

At the individual level, a combination of risks (higher risk of smoking and larger amounts of tobacco consumed by smokers) was found for males, for individuals with a low level of education and for divorcees. At the level of the area of residence, both the risk of smoking (odds ratio 1.07, 95% confidence interval: 1.01-1.12 for an increase by one standard deviation) and the amount of tobacco consumed among smokers (percentage variation +4%, 95% confidence interval: 0% - +8%) increased with the gross domestic product per capita.

CONCLUSION

This study justifies the combined use, in such analyses, of consumption levels for smokers in addition to the risk of smoking, in order to identify the profiles with the highest risk. It was possible to identify various groups with both a high risk of tobacco use and a high level of consumption among smokers, on the basis of individual (male, divorced or less educated) and environmental (living in a high GDP area) factors. The prevention efforts should thus be focused on such groups.