摘要：Objectives. We estimated smoking-attributable mortality, assessed the impact of past smoking on recent mortality, and computed expected future losses in life expectancy caused by past and current smoking behavior in Latin America and the Caribbean. Methods. We used a regression-based procedure to estimate smoking-attributable mortality and information for 6 countries (Argentina, Brazil, Chile, Cuba, Mexico, and Uruguay) for the years 1980 through 2009 contained in the Latin American Mortality Database (LAMBdA). These countries jointly comprise more than two thirds of the adult population in Latin America and the Caribbean and have the region’s highest rates of smoking prevalence. Results. During the last 10 years, the impact of smoking was equivalent to losses in male (aged ≥ 50 years) life expectancy of about 2 to 6 years. These effects are likely to increase, particularly for females, both in the study countries and in those that joined the epidemic at later dates. Conclusions. Unless innovations in the detection and treatment of chronic diseases are introduced soon, continued gains in adult survival in Latin America and the Caribbean region may slow down considerably. Continuous progress in the remarkable mortality decline in Latin America and the Caribbean region 1 may be difficult to sustain. This possibility is foreshadowed in a recent report showing that cancers of the respiratory tract, particularly lung cancers, are among the 3 most important forms of cancer in the region and are primary causes of adult mortality. 2 It is known that these chronic illnesses are closely connected to smoking, but less is known about the actual contribution of past smoking on current and future adult mortality in these countries. It could well be that, if pervasive enough, past (and future) smoking behavior trumps long-term trends in adult mortality. In response to the increasing vigilance and massive public health campaigns against tobacco consumption that began in the United States after the mid-1960s, the tobacco industry initiated an aggressive program to open new markets in Europe, Asia, and Latin America. 3–5 A number of sociodemographic factors contributed to the higher numbers of potential smokers in Latin America and the Caribbean region beginning in the 1950s: the explosive growth in the populations of adolescents and young adults, who are at highest risk for smoking initiation; the spread of an urban lifestyle and the accelerated growth of cities; greater access to education; and the entry of women into the labor market. 6,7 Increasing cigarette affordability, 8–10 widespread legislative maneuvers, 6,11–13 and a sophisticated publicity machine 8,12–14 contributed to a massive market expansion for tobacco in all forms and cigarettes in particular. As a result, cigarette consumption increased first in countries in the vanguard of mortality decline (Argentina, Uruguay, Cuba, and Chile) and then in Mexico, Brazil, Colombia, Costa Rica, and Panama. 3,15 Countries with higher mortality, such as, Peru, Ecuador, Bolivia, Paraguay, and Guatemala, still have low levels of smoking, but some of them (e.g., Bolivia) are catching up rapidly. The spread of smoking is known in public health circles as the “smoking epidemic”—a term we adopt here. 16,17 According to a useful typology, 18 countries in Latin America and the Caribbean span a broad range of experiences in the smoking epidemic, from those in the late stages (Argentina, Chile, Cuba, and Uruguay) to those of more recent onset (Mexico and Brazil). 19 Table 1 contains key indicators for these 6 countries (plus the United States for comparative purposes). 24 Males in 4 countries—Argentina, Cuba, Chile, and Uruguay—have higher rates of smoking than do US males, whereas the rates are lower in Brazil and Mexico. As we will show, Cuba’s unique position at the top of the ranking of smoking prevalence translates into the highest estimated excess adult mortality. Female rates lag behind male rates everywhere, but they have reached levels of around 20% in Argentina and Chile. Age-specific smoking prevalence rates for the 6 countries in this study (data available as a supplement to the online version of this article at http://www.ajph.org ) display a high degree of heterogeneity and reflect characteristics typical of different stages of the epidemic. These age patterns reveal telling anomalies: an exceptionally high prevalence among the population younger than 25 years in Chile, signs of a recrudescence of the smoking epidemic, and unexpectedly low levels of adolescent smoking in Brazil, an indication of successful antismoking campaigns. 19,26 TABLE 1— Characteristics of the Smoking Epidemic Among Adults Aged 20–80 Years: Argentina, Brazil, Chile, Cuba, Mexico, Uruguay, and United States; 2005–2009 Argentina, 2005 Brazil, 2008 Chile, 2006 Cuba, 2009 Mexico, 2009 Uruguay, 2009 United States, 2007 Males No. 16 647 15 995 7 981 5 350 2 360 2 228 Smoking prevalence/100 persons (SD)a 35.7 (0.8) 24.0 (0.4) 37.8 (0.6) 44.8c 23.8 (0.7) 32.5 (1.3) 28.4 (45.1) No. of cigarettes/d, mean (SD)a 13.1 (0.3) 15.3 (0.2) 5.8 (0.1) 10.3 (0.5) 11.0 (0.5) 16.5 (11.8) No. of cigarettes/y, mean (SD)a 4 783.0 (109.3) 5 583.7 (88.1) 2 080.8 (48.3) 3 752.9 (174.3) 4 027.6 (166.6) 6 040.7 (4322.1) Deaths/100 persons attributable to tobacco (all causes)b 19 15 11 21 7 24 23 Deaths/100 000 persons attributable to tobacco (trachea, bronchus, and lung cancers)b 75 35 32 90 18 115 103 Females No. 21 907 19 176 7 968 6 220 2 617 2 400 Smoking prevalence/100 persons (SD)a 25.7 (0.7) 14.5 (0.3) 28.0 (0.6) 29.6c 7.7 (0.5) 22.5 (1.0) 21.5 (41.1) No. of cigarettes/d, mean (SD)a 9.6 (0.2) 12.6 (0.2) 4.9 (0.1) 8.5 (0.5) 10.9 (0.4) 14.5 (10.1) No. of cigarettes/y, mean (SD)a 3 507.1 (79.8) 4 614 (83.4) 1 757.6 (47) 3 102.2 (200.0) 3 962.7 (136.8) 5 284.1 (3 702.1) Deaths/100 persons attributable to tobacco (all causes)b 6 6 8 18 6 5 23 Deaths/100 000 persons attributable to tobacco (trachea, bronchus, and lung cancers)b 12 6 10 78 4 10 68 Yearly consumption ratio, female–malea 0.73 0.83 0.80 0.84 0.98 0.87 Open in a separate window Note. Values in the table were computed from information contained in the original sources. Source. National Risk Factors Study (Argentina), 20 Global Adult Tobacco Survey (Brazil, Mexico, and Uruguay), 21 Social Protection Study (Chile), 22 and National Health and Nutrition Examination Survey (NHANES; Smoking Module). 23 aPopulation weighted and age standardized (Standard NHANES 2007–2008) 23 for Argentina, Brazil, Chile, Mexico, and Uruguay. bWorld Health Organization (2012) 24 estimated proportion of deaths attributable to tobacco and death rates correspond with 2004 and are totals for individuals aged 30 years and older. cAge standardized for individuals aged 15 years and older. 25 The typology mentioned here is useful for comparing aggregate, country-specific conditions and is not informed by—nor does it intend to inform—individual psychological traits responsible for smoking-related behavior in the countries to which it is applied.
