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Smoking Prevalence and Features
in an Uruguayan Population

Bianco, Eduardo; Senra, Hugo;
Nieto, Fernando; Sandoya, Edgardo;
Schettini, Carlos; Bianchi, Manuel

Asociación Española Primera de Socorros Mutuos (AEPSM), Montevideo, Uruguay

SUMMARY
Introduction: In Uruguay few studies on smoking prevalence and features have been performed. However, Uruguay was set as one of the latinoamerican countries with higher prevalence (35 to 40%). In 1993, the Cancer Prevention National Program, realized a national survey, and his results showed that 22.3% Uruguayan people older than 14 years old were smokers.
Objectives: To investigate prospectively, in a population of Montevideo, the smoking prevalence, sexual and gender distribution, educational level, health care consultation and associated risks factors.
Material and Methods: In 1995, a random sample of 2650 adults was selected among 190 000 people covered by AEPSM. In June 1998, when the study had finished, we had recruited 2070 (78%).
Results: Showed that 23% were smokers, 15% former smokers and 62% non smokers; 27% of male and 20% of female were smokers.
Gender and age distribution (Table 1):

Discussion: Data were similar to 1993 study, but women showed an increasing smoking prevalence .Women showed lower rates of former smoker at any age. Never smokers prevalence is higher at lower educational levels. Current smokers had lowest medical consultation rates (46%). Current smokers prevalence of hypertension (27%), diabetes (4,7%), dyslipidemia (13,5%) were lower. Regarding overweight prevalence, the study showed 27% in former smokers and 21% in current smokers.
Conclusions: Men have mostly experienced and had a higher prevalence than women, but are also more frequently quitters. It is probably that women smoking prevalence is increasing as well in others underdeveloped countries. People with lower educational levels are the ones who have experienced the least, it is essential to implement necessary measures to prevent the spread to this sociocultural group.

 

BACKGROUND
   Smoking has been defined by World Health Organization (WHO) as the main cause of anticipated and preventable death (1). Determining smoking prevalence and evolution in time, in the different countries, is a fundamental health marker. Uruguay has been one of the Latin-American countries considered as heavy smokers, with a smoking prevalence between 35-40% (2). Since 1993, after the survey performed by Uruguayan Statistics an Census Bureau, it was stated that only 22,3 %, of the population older than 14 years, smoked, in the urban Uruguay (3).

OBJECTIVES
   The aim of this study is analyzing the features of smoking population regarding its prevalence, gender and age distribution, educational level, frequency of medical visit and associated risk factors.

MATERIAL AND METHODS
  The Asociación Española Primera de Socorros Mutuos (A.E.P.S.M.) is a non profitable prepaid medical institution, situated in Montevideo, Uruguay, with over 190.000 members, who represented a percentage over 10% of the whole population in the capital city. This study, which is secondary to the one performed on Hypertension, was planned and carried out by the Cardiology Department. In October 1995, a selected sample of 2650 people older than 19, with no top of limits, distributed in six age groups, was randomized. The subjects were invited to participate by phone and/or letter. By the end of the study in 1998, 2070 (78%) had already been recruited. The data were obtained by interviews performed by nurses and physician. No smoking biologic convalidation was determined. Three population were defined to be studied: 1) Current smokers: those individuals who have been smoked in the last 6 months, 2) Former smokers: those who having smoked daily in the past, have not smoked in the last 6 months) Never smokers: Those who have never smoked.

    The educational level was determined based on the numbers of years of studies, grouping as follows: 0-6 years, 7-12 years and over 12 years . Besides, patients were questioned about their medical consultation in the last 6 months, and about their risks factors, such as hypertension, diabetes, and dislipidemy.

    In order to evaluate the body mass index the height and weight were evaluated, to study overweight (BMI 25 to 29) and obesity (BMI <30).

RESULTS
   2070 participants were admitted to the study, 799 male (38%) and 1271 (62%) female.

    Out of the total patients, 1296 (62%) never smoked, 305 (15%) were former smoker and 469 (23%) were current smokers. Of the 799 men, 396 (50%) said that they had never smoked, 185 (23%) were former smokers and 218 (27%) were current smokers. Among the women, 900 (71%) never smoked, 120 (9%) were former smokers y 251 (20%) were current smokers. (Table 1)

    Age mean: All studied patients: 49,9; Never smoked: 51,0; Former smokers: 54,3; Current smokers: 44,0. Men: All studied patients: 48,9; Never Smokers : 48,1; Former Smokers: 56,5; Current Smokers: 43,8. Women: All studied patients: 50,6; Never Smokers: 52,3; Former Smokers: 51,0; Current Smokers: 44,1

    If they are considered in 3 groups: young adults(20-39 years), adults (40-59), older adults (over 60) we find that: (Table 2)

    Distribution according to educational level:
    Data were obtained form 1250 of 1271 women and 790 of 799 men. (Table 3)

   Medical consultation: As for medical consultation in the last 6 months, data were obtained from 2044 of the 2070 participants. Never smokers: 780 de 1281 (59%); Former smokers: 185 de 303 (61%); Current smokers: 212 de 240 (46%).

   In relation with other risk factors we find:
1) Hypertension: 760 of 2070 (36.7%) were hypertensive patients. Never smokers: 499 of 1293 (38,6%); Former smokers: 32 of 305 (43,3%); Current smokers: 129 of 467 (27,6%).
2) Diabetes: 117 of 2070 (5,7%), were diabetics. Never smokers: 28 of 1291 (6,0%); Former smokers: 17 of 304 (5,6%); Current smokers: 22 of 467 (4,7%).
3) Dyslipidemia: 345 of 2070 (16,7%), were dyslipemics: Never smokers: 220 of 1286 (17,1%); Former smokers: 62 of 301 (20,6%); Current smokers: 63 of 406 (13,5%).
4) Overweight/Obesity:
a) Overweight (BMI 25 to 29) 854 of 2057 (41,5%). Never smokers: 489 of 1290 (38 %); Former smokers: 117 of 303 (39 %); Current smokers: 129 of 467 (36 %). b) Obesity (BMI 30 or over) 478 of 2057 (23,2%)--Never smokers: 297 of 1290 (23%); Former smokers: 82 of 303 (27 %); Current smokers: 99 of 464 (21 %).

DISCUSSION
   Data analysis shows that 23% are current smokers, with 15% of Former Smokers and 62% of participants who have never smoked. These figures are similar to those of the 1993 Home Survey in which a prevalence of 24% of current smokers, 14% of Former Smokers and 62% of Non smokers was found, in population of Montevideo (3). Current smokers population is younger than former smokers and never smokers (age mean: 44, 51 and 54,3 years, respectively). In relation with gender influence: Regarding men, 50% said that they had never smoked, 23% were former smoker and 27% current smoker. As for women, 71% said they had never smoked, 9% were former smokers and 20% were current smokers. This data has been observed in other countries at similar stage of the tobacco epidemic (4). The percentage of women who have never consumed tobacco is higher than men (71% vs. 50%). Among men, the prevalence of former smoker is higher (23% vs. 9%).

   Throw the information obtained, it is very clear the difference existing between men and women, related to the stage of tobacco epidemic, regarding consumption and if we consider lung cancer rates evolution, in men and women, from Lung Cancer National Program. Men seem to have reached the top consumption, starting the declination fase. Whereas women are in the firsts fase of the second stage, with an increasing consumption and very few quitters. If we consider the results of the Home Survey in 1993, we find that smoking prevalences between men and women are different. At the moment the survey was performed, in Montevideo there was a 32% of men smokers and 17% of women, with prevalence of former smoker of 21% in men and 8% in women. Though two different populations are considered, according to this information, we can concluded that men consumption declines and women consumption increases, with very few quitters. Going back to our population, the analysis according to age and gender groups, suggest: 1) Never smokers: The highest percentage are reach in the group over 70 years, with 76%. Obviously, the situation in this group may be due to the lower number of smokers alive (8%). Regarding gender, in never smokers there is so far, a wide predominance of women in all groups. 2) Former smokers: Considering the whole population, the highest prevalence is found in the decade of 60-69 years (20%) and the least in the decade 20-29 (40%). According to gender differences, in men top of cessation is observed in the decade of 60-69 (38%) whereas in women is in the decade of 30-39 years. 3) As for smokers, the highest prevalence (32%) is found in the ages 30-39 y 40-49. When consider differences according to gender we observed that high consumption in men coincides with the decades mentioned above, where there is a 37% of smokers. Women reach the top (32%) in the span of 30-39 years.

    When we compare young , adults and older adults, we find that:
   *The highest percentage (73%) of never smokers is found in older adults, coinciding with the lowest prevalence of current smokers (8%), which confirms the theory that very few current smokers are alive over 60 years.
   * As former smokers, the lowest prevalence is found in the young adults (10%), being the same in women and men. The older the age, the more former smokers, being 15% in adults an 19% in older adults, but such increment is mainly due to men that register 24% in adults and 37% in older adults. Whereas cessation rates in women are still low: 10% in young adults, 10% in adults and 9% in older adults.
   *Regarding smokers there is a similar prevalence in young adults and adults (30% and 28%) but it is very low in older adults (8%). In relation to gender there is no remarkable differences between young adults and adults men (35% and 32%) and women (27% y 25%). But there is a clear female prevalence in older adults ( men 12% and women 26%). When the educational level is considered related to tobacco consumption, we find that: The prevalence of never smoker is higher in the population with a lower educational level, being 57% for those who reach secondary school level and 50% for those who reach the highest level. Regarding the former smokers there is a similar prevalence between low and middle educational groups ( 17% and 16%), being their lowest level in the highest educational level (12%). Besides the highest prevalence of current smokers is nowadays in the people who reach the secondary educational level (27%) and the lowest in the group with primary. Usually, the onset of the tobacco epidemic is usually in the highest sociocultural groups, shifting later to lower levels, the percentage recorded in our survey seem to show the same situation. We should be aware of this fact to take the right and effective measures (such as increasing tobacco prices), to prevent the spread to the lower levels. In relation with health control either consulting a physician or not in the last 6 months, we observed that even if the smokers are the ones who had the fewest consultation, at least 46% had one in this period. This turns out to be very important since the physician may intervene in their behavior and encourage the patient to try quitting. According to international surveys (5) almost 70% of smokers consultate a physician in the previous year. Never smokers and former smokers showed similar percentages: 59% and 61% respectively. When associated risk factors are considered, current smokers prevalence of hypertension is 27%, diabetes 4,7%, Dyslipidemia 13,5%, which is lower than the one observed in former smokers and never smoker. This is clearly understandable, since that current smoking group belong to the younger population, and the diagnosis of any of the disease mentioned above can make the smoker consider quitting, increasing the population of former smokers. Tobacco consumption together with any of those factors, means a very high cardiovascular risk, and spots the consumer in a high risk smoker.

   When the whole population is considered we find that: 36,7% are aware they are hypertensive, from which 65,7% are never smokers and 17% current smokers. As for the diabetic (5,7% of the population), 66,7% are never smokers , 18% former smokers and 18,3% current smokers. That is to say that almost one of 5 diabetic smokes, and 50% of the ones that once smoked, have given up. About 16,7% are known dyslipemic, from which 63.6% are never smokers, 18% former smokers and 18.3% current smokers.

    Regarding overweight and obesity: 64,7% of the population have an exceeding in the Body Mass Index (BMI), being 41.5% to overweight and 23.2 % to obesity. There is no significance difference in overweight between former smokers in relation with current smoker (27% vs. 21% respectively).

CONCLUSIONS
   1) It was men who have mostly experienced and who nowadays had a higher prevalence than women, but they are also more frequently quitters.

   2) Although this population cannot easily be compared with the 1993 survey, female consumption would be s increasing in our country as well as in the other underdeveloped countries, and quitting is not being considered.

   3) People with the lowest educational level are the ones who have experienced the least, and nowadays also with the least consumption. It is essential to implement the necessary measures to prevent the spread to this socio cultural group.

   4) The prevalence of associated risks factors is lower in smoking population .


REFERENCES

1. Tabaquismo: Una amenaza constante para la salud. Organización Panamericana de la Salud (OPS), 1997, 40 p.OPS Comunicación para la Salud Nº 12.

2. Country Collaborator's report, Uruguay. OPS. Silva Sosa,R. 1990.

3. Investigación Sociolaboral del Tabaquismo en el Uruguay urbano. Carámbula, J; Ronco, A. Programa Nacional del Cáncer de Pulmón. Dirección General de la Salud. MSP,1993.

4. Guidelines for controlling and monitoring the tobacco epidemic. WHO, Geneva, 1998.

5. Treating tobacco use and dependence. US Department of Health and Human Services. Public Health Service,June 2000.

 

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2nd Virtual Congress of Cardiology

Dr. Florencio Garófalo
Steering Committee
President
Dr. Raúl Bretal
Scientific Committee
President
Dr. Armando Pacher
Technical Committee - CETIFAC
President
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