TOBACCO AND TRANSITION: UNDERSTANDING THE IMPACT OF TRANSITION ON TOBACCO USE AND CONTROL IN THE FORMER SOVIET UNION ________________________________________________ Dr Anna BC Gilmore Thesis submitted for the degree of Doctor of Philosophy of the University of London 2005 London School of Hygiene and Tropical Medicine ABSTRACT The collapse of the Soviet Union in 1991 and its transfer from a command to a market economy precipitated immense change changes in the region’s tobacco industry. Most notable were the rapid and unregulated entry of the multinational and transnational tobacco companies (TTCs) and the privatisation of previously state owned tobacco industries. The impact of investment liberalisation and privatisation of state owned tobacco companies on patterns of tobacco use and tobacco control has not previously been studied, timely, accurate data on smoking patterns in the former Soviet Union are scarce and there has been no formal research on TTC activities there. This thesis capitalises on the unique social experiment provided by the Soviet Union’s transformation to address these research gaps through a combination of data and methodologies: analysis of routine and ad hoc data on investments and consumption; survey data on patterns and determinants of smoking behaviour in the region; and internal tobacco industry documents. The importance of this work is underlined by the fact that tobacco industry privatisation continues to be promoted by international actors who have seemingly given no consideration to its potential impacts, and that tobacco control policies are most effective when informed by accurate data on patterns and determinants of smoking and by information on industry tactics and actions. The thesis finds that between 1992 and 2000 the TTCs made significant investments in ten countries of the region. These investments have exponentially increased cigarette production rates and fuelled cigarette consumption without favourably influencing trade figures. Smoking prevalence rates in men remain amongst the highest in the world, with rates over 60% recorded in three of the eight countries surveyed. Smoking rates in women are far lower, but their pattern appears to reflect TTC activity. Tobacco industry documents outline the major negative influence TTCs have had on tobacco control. The thesis concludes that investment liberalisation and tobacco industry privatisation pose major threats to public health and makes recommendations for action. 2 TABLE OF CONTENTS ABSTRACT........................................................................................................................................................... 2 TABLE OF CONTENTS....................................................................................................................................... 3 LIST OF TABLES ................................................................................................................................................. 8 LIST OF FIGURES................................................................................................................................................ 9 LIST OF ABBREVIATIONS AND DEFINITIONS...........................................................................................10 Abbreviations ................................................................................................................................................... 10 Definitions ........................................................................................................................................................ 12 STATEMENT...................................................................................................................................................... 13 ACKNOWLEDGEMENTS ................................................................................................................................. 14 CHAPTER 1 Introduction, background, aims and objectives............................................................................ 16 SECTION A INTRODUCTION .............................................................................................................. 16 THESIS OUTLINE .......................................................................................................................................... 19 SECTION B BACKGROUND ................................................................................................................ 20 PART 1: THE FORMER SOVIET UNION..................................................................................................... 20 1.1 The history of the Soviet Union............................................................................................................. 20 1.2 The collapse of the Soviet Union........................................................................................................... 20 1.3 The fifteen Newly Independent States (NIS)......................................................................................... 21 1.4 Economic transition ............................................................................................................................... 23 1.4.1 The scale and speed of reform and privatisation .............................................................................. 25 1.4.2 Outcomes........................................................................................................................................... 26 1.4.3 A retrospective analysis – gathering the evidence on privatisation.................................................. 28 1.4.4 Further evidence from CEE/FSU...................................................................................................... 29 1.4.5 Success or failure? ............................................................................................................................ 30 1.5 Health impacts of transition................................................................................................................... 31 PART 2: THE TOBACCO INDUSTRY.......................................................................................................... 37 2.1 The Soviet Tobacco industry ................................................................................................................. 37 2.2 Transition and entry of the tobacco transnationals................................................................................. 39 2.3 The history of the international tobacco industry and its global expansion ........................................... 42 2.4 What can be learnt from the TTC’s previous expansion to new markets?............................................. 44 2.4.1 TTC expansion to Latin America ...................................................................................................... 45 2.4.2 TTC expanstion to Asia ..................................................................................................................... 46 2.4.3 Impacts of TTC entry to Latin America and Asia.............................................................................. 48 2.4.5 Globalisation of production .............................................................................................................. 50 2.5 The global shift in tobacco related disease patterns............................................................................... 53 PART 3: SMOKING IN THE FSU .................................................................................................................. 54 3.1 Measuring tobacco use: tobacco consumption and smoking prevalence ............................................... 54 3.2 Consumption and smoking habits.......................................................................................................... 54 3.3 Smoking Prevalence – adults ................................................................................................................. 54 3.4 Smoking prevalence - youth .................................................................................................................. 78 3.5 Smoking amongst doctors...................................................................................................................... 84 PART 4: THE HEALTH IMPACT OF TOBACCO ........................................................................................ 85 4.1 Chronic disease...................................................................................................................................... 85 4.2 Dose response ........................................................................................................................................ 87 4.3 Delay in health impact ........................................................................................................................... 87 4.4 The tobacco epidemic ............................................................................................................................ 88 4.5 Impacts of tobacco in non-western populations..................................................................................... 91 4.6 Health impacts of tobacco in the FSU ................................................................................................... 93 4.7 Gender differences in mortality ........................................................................................................... 108 4.8 Lifestyles and health promotion in the USSR/FSU ............................................................................