4
Health

INTRODUCTION

The physical changes that signal the transition from childhood to adulthood are accompanied by changes in opportunities and risks that can profoundly affect health and well-being during adolescence and beyond. Habits acquired during these years can enhance or compromise future health, and choices made about health-related behavior have implications for the entire life course. The importance of health status for the transition to adulthood is clear; it is intimately linked with the probability of making successful transitions in other areas. Healthy individuals make better students, more productive workers, more attractive marriage partners, more active community members, and better parents and caregivers than those who experience poor health. At the societal level, a healthy population is a prerequisite for social and economic development.

After infancy, childhood is a period of relatively slow growth. Suddenly, in adolescence, growth accelerates, perhaps to twice the earlier rate for a year or two, then slows, and finally comes to a stop. Along with the growth spurt of adolescence comes the development of secondary sexual characteristics (Ellison, 2001). In the developing world these changes are occurring earlier in life; consistent evidence from various parts of the developing world shows that the average age at puberty has declined over the last several decades.

The physical growth and sexual maturation during adolescence are accompanied by social, psychological, and intellectual maturation during which individuals develop more abstract reasoning skills, consolidate their



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Growing Up Global: The Changing Transitions to Adulthood in Developing Countries 4 Health INTRODUCTION The physical changes that signal the transition from childhood to adulthood are accompanied by changes in opportunities and risks that can profoundly affect health and well-being during adolescence and beyond. Habits acquired during these years can enhance or compromise future health, and choices made about health-related behavior have implications for the entire life course. The importance of health status for the transition to adulthood is clear; it is intimately linked with the probability of making successful transitions in other areas. Healthy individuals make better students, more productive workers, more attractive marriage partners, more active community members, and better parents and caregivers than those who experience poor health. At the societal level, a healthy population is a prerequisite for social and economic development. After infancy, childhood is a period of relatively slow growth. Suddenly, in adolescence, growth accelerates, perhaps to twice the earlier rate for a year or two, then slows, and finally comes to a stop. Along with the growth spurt of adolescence comes the development of secondary sexual characteristics (Ellison, 2001). In the developing world these changes are occurring earlier in life; consistent evidence from various parts of the developing world shows that the average age at puberty has declined over the last several decades. The physical growth and sexual maturation during adolescence are accompanied by social, psychological, and intellectual maturation during which individuals develop more abstract reasoning skills, consolidate their

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Growing Up Global: The Changing Transitions to Adulthood in Developing Countries identity, become more independent and emotionally mature. The “cascade of hormonal, physical, psychological, and behavioral changes” (Cameron, 2003) that marks this stage of life inevitably has implications for health. Research over the last few decades has shown that these implications depend, to a great extent, on the social environment (Boyden, Ling, and Myers, 1998; Bronfenbrenner and Morris, 1998). In other words, the transition to healthy adulthood is dependent on the contexts in which it occurs—parents, other family members, peers, teachers, and other significant adults all play an important role, as do the communities in which young people live (Steinberg and Morris, 2001). The significance of context has become clearer in recent research that points to the many ways in which normative views of healthy childhood and adolescence vary across societies and over time (Boyden, Ling, and Myers, 1998; Caldwell et al., 1998). Across all societies, however, physical and social gender differentiation are key features of this phase of the life cycle. Boys and girls are treated differently from birth onward, but puberty marks the beginning of a widening divide (Mensch, Bruce, and Greene, 1998). After puberty, young men and women’s opportunities and experiences increasingly diverge in ways that are reflective of societal gender norms and expectations, and these differences can have direct implications for young men’s and women’s health as well as for health-related behaviors. While less true than in the past, young women often live more physically circumscribed lives than young men after puberty. Thus they may be relatively more “protected” than young men from some risks, such as dangerous work conditions, violence and military conflict, and road-related accidents, but they face other risks, such as early pregnancy and childbearing and gender-based violence, that are sex-specific. Furthermore, because of their greater “protection,” young women may have fewer opportunities to develop the negotiating skills and the knowledge they need to protect and preserve their health and remain healthy as adults. This chapter examines the transition to a safe and healthy adulthood in developing countries in the context of a range of rapid global transitions in health patterns and health services. For most individuals, adolescence has always been and remains a relatively healthy period of life. At any phase of the epidemiological transition in which societies experience a decline in the importance of infectious diseases and a rise in the importance of chronic conditions, death rates are at their lowest point from ages 10 to 14 and are often relatively low from ages 15 through 24 as well, particularly in countries in which obstetric care is adequate. The panel’s view of a successful transition to adulthood, however, encompasses a view of health that is broader than survival and in which success includes the best possible mental and physical health and the knowledge and means to sustain health during adulthood.

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Growing Up Global: The Changing Transitions to Adulthood in Developing Countries The health environment in which young people are making the transition to adulthood has been dramatically altered by global epidemiological shifts as well as many other important changes, such as the rising percentage of young people attending school, changes in poverty rates, rapid urban growth, the growing presence of multinational corporations, the spread of global youth culture, technological change and medical advances, greater access to basic health care and family planning services, and growing acceptance of international norms relating to reproductive rights. Many of these changes have brought improvements in the health environment for young people; others have brought new challenges, and some have created greater risks for young people. The distribution of these changes and their implications for young people’s health varies by context. For example, in many settings, schools provide an institutional setting through which various health interventions for young people can be delivered including health education, nutritional supplements, and some basic health care; thus an increase in the percentage of young people attending school has the potential to bring improved health benefits to a greater population of young people. On the other hand, in parts of sub-Saharan Africa where the HIV/AIDS pandemic is widespread, the risks to young people’s health, most particularly young women, have increased substantially. By contrast, in other regions, such as the Middle East and parts of Asia and Latin America, the risks of HIV/AIDS remain relatively low. The aggressive marketing of tobacco products to young people and the increased global availability of illicit drugs present growing risks to young people, particularly in urban settings. Changing levels of violence due to war and civil disturbances are more context-specific but affect young men differentially. At the same time, some health hazards, such as those related to pregnancy and unsafe abortion, continue to disproportionately affect young women in developing countries. While much of the literature on young people’s health focuses on the problems and risks they face, there is a great deal of evidence that most young people get through the transition to adulthood without developing significant behavioral, social, or emotional difficulties (Barker, 2002; Steinberg and Morris, 2001). Furthermore, while young people may experiment with certain behaviors, such as substance abuse, this does not mean that they will continue to do so as adults. Indeed, during this period many develop positive habits that promote good health and well-being later in life (Call et al., 2002). Puberty is a key health marker for young people, not just a period of “normative disturbance” as it is sometimes described (Steinberg and Morris, 2001). Puberty changes the way in which a young person is treated by others, increases the salience of sexuality, and introduces various reproductive health risks. It also marks the point at which individuals start to be-

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Growing Up Global: The Changing Transitions to Adulthood in Developing Countries come significant actors in determining their own health. Choices about behaviors that affect health and about the use of health services and technologies are increasingly made by individual young people during this phase of life rather than by parents or other adults.1 The design and implementation of health programs and services for young people can thus have a considerable effect on their health. This chapter begins with a health profile of young people, which emphasizes the major health issues of this stage of life as well as evidence of recent change. The predominant causes of mortality and morbidity among developing country young people—maternal conditions, HIV/AIDS, and injuries—are given special attention. Because sexual and reproductive health constitute a key component of a healthy transition to adulthood and because they are so strongly linked with other transitions, a substantial section of the chapter is devoted to an examination of trends in various aspects of sexual and reproductive behavior. Data on each topic were carefully evaluated and were not presented unless the panel felt confident that they were the best available and provided a relatively broad comparative perspective.2 The literature on the factors that influence such behavior is also critically reviewed. Levels and trends in risky behaviors with consequences for health, in particular smoking and illicit drug use, are also addressed. Evidence on the effectiveness of programs and policies that seek to improve health and support healthy development among young people is assessed. Finally, a series of policy and research recommendations are offered. HEALTH PROFILE OF YOUNG PEOPLE Enormous changes are under way in the health context in which young people in developing countries make the transition to adulthood. While there have been some substantial negative trends—perhaps most strikingly the HIV/AIDS pandemic—positive changes in overall health have clearly outweighed the negative changes. Between 1970-1975 and 1995-2000, life expectancy at birth in the developing world increased 8.6 years, compared with an average of 5.8 years for the same period in high-income countries (United Nations Development Programme, 2001). Although there are considerable differences among regions in the developing world in the magnitude of these improvements, all regions have seen some positive change. Increases in life expectancy at birth have been strongly affected by substantial declines in infant and child mortality rates. However, life expectancy at 1   It is worth noting, however, that young women in many settings have less control over decisions affecting their health than young men. 2   A full discussion of the data is provided in Appendix A.

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Growing Up Global: The Changing Transitions to Adulthood in Developing Countries age 10 (i.e., among those who survive to age 10) in developing countries also rose by about one year during the 1990s and is projected to continue increasing (United Nations, 2003a). Improvements in the health environment are important not only for survival chances, but also for overall well-being and productivity. For example, substantial decreases in malnutrition and related nutritional deficiencies have contributed to increasing survival rates in infancy and childhood as well as to improved cognitive and physical development of those entering adolescence (Smith and Haddad, 2000).3 Advances in immunization coverage have reduced the incidence of a range of serious childhood illnesses. Many of the diseases that have contributed substantially to morbidity in developing countries, such as malaria, diarrheal diseases, and respiratory infections, have also been reduced. Furthermore, positive changes in the overall health environment affect productivity both directly and through decisions made in adolescence about investments in human capital. For example, the expected returns to investments in higher education are greater when the number of years of healthy working life increases. Overall, aside from some countries with very high prevalence of HIV/AIDS, young people in developing countries are entering adolescence healthier than ever and with a better chance of surviving to old age. Moreover, the improving health context will enable young people to live better and more productive lives. Mortality and Morbidity Having survived the relatively higher risk of death during childhood and not yet subject to the chronic and degenerative diseases of older adults, individuals are less likely to die between ages 10 and 25 than any other age range (Figure 4-1). In developing countries, the risk of dying between ages 10 and 25 is about 2.5 percent compared with roughly 9 percent between birth and age 10 (United Nations, 2003a). Although mortality rates among young people are low in developing countries, they are still above rates in developed countries by a factor of more than two between ages 10 and 25. While data for the estimation of trends in mortality in developing countries are scarce and often of dubious quality and comparability (Hill, 2003), United Nations estimates indicate that death rates in the 2000-2005 period were slightly lower than in 1990-1995 for ages 10-25 (Figure 4-1). However, at ages 25 to 35 mortality has increased, a change that is particu- 3   However, increasing consumption of foods containing fat, cholesterol, and sugar and declines in physical activity are starting to contribute to increasing levels of overweight and obesity in some countries (see the section on other risk behaviors later in the chapter).

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Growing Up Global: The Changing Transitions to Adulthood in Developing Countries FIGURE 4-1 Probability of dying by age, according to type of country, 1990-1995 and 2000-2005. SOURCE: United Nations (2001). larly evident when the 48 least developed countries are examined separately; this is due primarily to the effect of the HIV/AIDS pandemic. The United Nations projects that the improvements over the 1990s among 10-25-year-olds will continue over the coming decade with mortality rates in developing countries moving downward at about the same pace although staying above the rates for developed regions. The AIDS pandemic, however, increases the usual level of uncertainty of these projections. For developing countries as a whole, the risk of death between ages 10 and 25 is similar for both sexes, with a slightly lower risk for females (Table 4-1). This contrasts with the more developed countries where, while overall mortality risk is much lower, females have a strong survival advantage. In these regions, the female probability of dying between ages 10 and 25 is less than half that for males. This difference in the male-female ratio is due to relatively high levels of maternal and HIV-related mortality among young women in developing countries. Reliable data on causes of death are rare for developing countries and, internationally comparable data are virtually unavailable for the specific age group of primary interest here (10-24). Nevertheless, the World Health Organization’s (WHO) Global Burden of Disease project provides estimates based on existing data and various modeling techniques that illus-

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Growing Up Global: The Changing Transitions to Adulthood in Developing Countries TABLE 4-1 Probability of Dying Between Age 10 and Age 25 by Country Group, Years, and Sex Region 1990-1995 2000-2005 Males Females Males Females WORLD 0.028 0.024 0.025 0.021 Developed regions 0.014 0.005 0.012 0.005 Developing regions 0.031 0.028 0.027 0.024 Least developed countries 0.074 0.070 0.064 0.059 Sub-Saharan Africa 0.079 0.070 0.075 0.068 SOURCE: Estimated from United Nations (2003a). trate broadly the major causes of mortality in early adulthood (ages 15-29).4 The World Health Organization divides countries by region and level of mortality into groupings that are not exactly comparable to those used above, but countries classified as “low mortality” are roughly equivalent to the developed world, while the “medium” and “high” categories divide the developing countries by level of overall mortality (Figure 4-2). Table 4-2 demonstrates the extent to which HIV/AIDS has come to dominate the mortality profile of young people in sub-Saharan Africa. By extension, because of the heavy weight of deaths in Africa at these ages, it also dominates the distribution of deaths in this age group for high-mortality countries as a group5 as well as for the world as a whole (bottom panel of Figure 4-2). As many as 58 percent of deaths among 15-29-year-olds in sub-Saharan Africa can be attributed to HIV for young women and 43 percent for young men. By contrast, slightly over 10 percent of deaths among young people are due to HIV in Southeast and Southwest Asia. In North Africa, the Middle East, Latin America, and East Asia, HIV is among the least important or the least important cause of death. Among females ages 15-29 in high-mortality countries, almost 40 per- 4   WHO estimates of mortality by cause cover 191 countries, using vital registration data whenever possible. For 63 developing countries with no such data, estimates are derived from projected trends in child mortality using Brass techniques. For an additional 54 countries, vital registration data are incomplete or based on sample systems, so estimates must be adjusted. These limitations apply to data for all African countries, most countries in Asia and the Middle East, and several countries in Latin America (Murray et al., 2001). Given these procedures, as well as such additional problems as age misreporting, the data must be treated with considerable caution. They may be particularly questionable for Africa, where WHO relies perforce on old data and models devised for other regions (INDEPTH Network, 2002; United Nations, 1999a). 5   A group of countries that include India, but not China.

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Growing Up Global: The Changing Transitions to Adulthood in Developing Countries FIGURE 4-2 Percentage distribution of deaths at ages 15-29 by cause for the world as a whole, according to sex and mortality. NOTES: Low = all developed countries (exclusively); medium = mixture of developed and developing countries; high = all developing countries. SOURCE: World Health Organization (2001c). cent of deaths are the result of HIV/AIDS (Figure 4-2). Close to 20 percent are due to maternal conditions, a category that includes pregnancy and delivery complications and the complications of abortion. In medium- and low-mortality countries, where the mortality rate is much lower, deaths due to these causes comprise a much smaller percentage of overall female mortality, while noncommunicable diseases (mostly cardiovascular disease and cancer) and unintentional injuries (mostly road traffic accidents) are much more important. For young adult males in high-mortality countries, almost half of the deaths are the result of communicable diseases, the most important of which is HIV/AIDS. About one-third of deaths are attributable to either unintentional or intentional injuries. The deaths due to unintentional injuries are most commonly road traffic accidents. The intentional injury category includes violence, war, and suicide. The two injury categories predominate among male deaths in the medium- and low-mortality countries. Estimates are also available of a measure that summarizes the loss of healthy life due to both death and ill health. This measure is called disability-adjusted life years (DALYs), and estimates are available for the

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Growing Up Global: The Changing Transitions to Adulthood in Developing Countries TABLE 4-2 Percentage Distribution of Deaths at Ages 15-29 by Cause, According to Sex and Region Region Sex Cause of Death Communicable Diseases Maternal Mortality WORLD Females 14.6 15.4   Males 14.1 0.0 Sub-Saharan Africa Females 12.0 16.6   Males 19.8 0.0 Southeast/Southwest Asia Females 20.3 16.7   Males 15.6 0.0 North Africa and Middle East Females 16.2 25.4   Males 20.2 0.0 Latin America Females 14.0 16.4   Males 8.7 0.0 East Asia Females 11.3 6.1   Males 7.5 0.0 SOURCE: World Health Organization (2001a). age group 15-29, for two categories of developing countries, and for each of the major categories of diseases and conditions. These data support the findings presented above based on mortality alone and in addition reveal an additional important cause of ill health among young people: neuropsychiatric or mental health illnesses and conditions, which account for about 20 percent of all DALYs lost in high-mortality developing countries and almost 40 percent of all DALYs in low-mortality developing countries (World Health Organization, 2002, 2003). In high-mortality developing countries, HIV/AIDS represents 17 percent of DALYs lost and in low-mortality developing countries 2 percent of DALYs lost. While HIV/AIDS is of considerable concern in the higher mortality developing countries, other causes of death and disability surpass it for all young people in developing countries as a whole. Depression, anxiety disorders, and other mood disorders are among the most common mental health problems among young people with diagnoses typically peaking during the 20s (Schulenberg and Zarrett, forthcoming; World Health Organization, 2003). A number of researchers would suggest that in fact young women are more likely to suffer from depression than

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Growing Up Global: The Changing Transitions to Adulthood in Developing Countries HIV Noncommunicable Diseases Unintentional Injuries Intentional Injuries 30.3 19.4 11.6 8.8 17.3 21.7 28.2 18.6 57.8 6.9 2.6 4.1 43.1 12.7 10.7 13.8 11.8 25.4 18.3 7.5 13.2 25.9 32.6 12.7 7.2 29.5 12.0 9.7 5.0 28.7 30.8 15.3 7.1 35.2 14.7 12.6 6.0 16.8 27.0 41.5 1.8 33.7 22.4 24.6 3.0 31.0 41.6 16.8 young men (Gureje, 1991; Lewinsohn et al., 1993; Sorenson, Rutter, and Aneshensel, 1991). Mental health problems are important not only because of the suffering they cause, but also because they are known to be linked to other health outcomes and behaviors. For example, a study in New Zealand has documented links among 21-year-olds between neuropsychiatric disorders and risky sexual behavior, as well as sexually transmitted disease (Ramrakha et al., 2000). How such findings apply to young people in developing countries is not yet known due to lack of research. The impact of war on the mental health of young people in affected countries and the effect of HIV/AIDS stigma have both received increased attention in recent years (e.g., Booth, 2002; Joint United Nations Programme on HIV/AIDS [UNAIDS], 2002; UNICEF, 2005). Nevertheless, when young people in developing countries are asked about their lives, they appear generally content. Two questions on this subject were part of the World Values Survey (2003), which covered 21 developing countries between 1990 and 1996 (including such major countries as Brazil, China, India, and Nigeria). Males and females ages 18-24 rated their level of unhappiness at 1.9 on a scale from 1 to 4, for which a

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Growing Up Global: The Changing Transitions to Adulthood in Developing Countries score of 4 represents “quite unhappy” and a score of 2 represents “quite happy.” This was not as positive a rating as that of their counterparts in 21 countries covering Australia, Canada, Japan, the United States, and Western Europe, but clearly more positive than ratings in 24 Eastern European countries. In a recent study of nine Caribbean countries, 83 percent of in-school young people attending school reported being generally happy and 88 percent were satisfied with their appearance (Halcón et al., 2003). Young people also tend to assess the status of their own health positively. In the World Values Survey, young people ages 18-24 rated their own health as “good” (a mean score of 2.0 on a scale that goes up to 5 for very poor health). This rating is more positive than that of any older age group (Figure 4-3). It is not as high as ratings by young people in major industrial countries, but somewhat better than ratings by young people in Eastern Europe. A series of opinion polls conducted in 2000-2001 corroborate this generally positive outlook. On average across 17 countries in East Asia and the Pacific, 83 percent of 14-17-year-olds thought that their lives would be FIGURE 4-3 Self-rated health by age, sex, and country group, 1990-1996. NOTES: 1 = very good health, 5 = very poor health. LDC = developing countries and MDC = developed countries, which in this figure exclude Eastern Europe. SOURCE: World Values Survey (2003).

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Growing Up Global: The Changing Transitions to Adulthood in Developing Countries APPENDIX TABLE 4-1 Smoking Among Students Ages 13-15, Global Youth Tobacco Survey, 1999-2003 (Percentage) Region and Country Ever Smoked Cigarettes Currently Smoke Cigarettes Male Female Male Female Eastern and Southern Africa Botswana 2001 24.1 10.0 8.7 2.6 Kenya 2001 21.0 8.5 10.1 4.2 Lesotho 2002 40.0 15.1 23.0 6.0 Seychelles 2002 56.4 42.9 31.3 21.7 Swaziland 2001 27.5 10.6 14.6 4.6 Malawi: Blantyre 2001 22.3 7.8 4.1 1.6 Malawi: Lilongwe 2001 28.6 10.1 9.1 2.8 Mozambique: Gaza Inhambe 2002 12.7 7.2 4.3 3.3 Mozambique: Maputo City 2002 23.9 10.7 5.9 2.6 Uganda: Arua 2002 38.2 21.7 24.3 15.7 Uganda: Kampala 2002 22.8 11.5 6.7 3.3 Uganda: Mpigi 2002 23.7 14.2 11.5 3.3 Zambia: Chongwe / Luangwa 2002 30.5 28.1 14.9 12.4 Zambia: Kafue 2002 23.4 15.3 12.2 8.2 Zambia: Lusaka 2002 36.0 22.3 10.8 8.3 Zimbabwe: Harare 1999 30.1 21.5 11.4 10.1 Zimbabwe: Manicaland 1999 29.0 16.3 12.6 9.7 Central and Western Africa Ghana 2000 14.7 13.0 5.3 3.8 Mauritania 2001 38.9 22.9 24.1 10.6 Niger 2002 43.2 11.9 24.8 6.5 Togo 2002 31.8 10.0 14.9 4.0 Burkina Faso: B. Dioulasso 2001 58.4 23.5 31.2 8.3 Burkina Faso: Ouagadougou 2001 61.9 27.4 30.9 9.1 Mali: Bamako 2001 59.0 14.7 43.7 7.6 Nigeria: Cross River State 2001 20.4 13.7 9.7 5.7 Senegal: Dakar 2002 36.0 6.8 20.8 5.6 Senegal: Diourbal 2002 35.8 3.7 23.0 1.8 South-eastern/Southern-central Asia Cambodia 2002 11.3 1.2 7.9 1.0 Iran 2003 19.1 9.4 4.2 0.4 Myanmar 2001 n.a. n.a. 29.1 3.1 Nepal 2001 12.0 3.8 6.3 0.6 Philippines 2000 57.0 32.0 32.6 12.9 Singapore 2000 29.5 21.9 13.4 8.8 Sri Lanka 1999 17.5 6.8 6.8 1.7 India: Andara Pradesh 2002 14.9 9.6 3.5 1.4 India: Arunachal Pradesh 2001 29.8 8.4 21.9 3.0 India: Assam 2001 23.5 9.3 14.6 4.4

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Growing Up Global: The Changing Transitions to Adulthood in Developing Countries Currently Use Any Tobacco Products Never Smokers Likely to Initiate Smoking Next Year Smokers Wanting to Stop Smokers Who Have Tried to Stop Male Female 17.0 11.6 8.1 63.5 68.3 15.8 10.0 19.7 73.5 70.2 31.6 19.7 35.1 80.1 73.5 36.0 24.5 16.4 76.1 76.4 20.7 10.0 17.4 76.3 75.3 17.9 15.3 15.3 91.4 61.0 21.1 14.7 17.1 82.0 92.1 10.0 10.5 28.6 n.a. n.a. 12.8 9.7 28.6 n.a. n.a. 35.0 27.7 11.0 80.7 71.8 15.2 12.2 5.8 77.9 76.9 23.0 12.1 9.1 68.7 70.7 27.1 27.9 36.0 75.7 67.8 22.7 21.6 34.0 77.5 67.9 25.7 23.7 34.9 70.2 61.7 21.5 17.2 29.8 66.2 49.1 23.0 20.0 36.6 70.6 60.3 19.5 18.8 16.5 87.4 78.4 33.7 22.7 17.6 78.8 73.7 27.3 14.2 12.5 71.8 75.9 19.5 9.7 6.7 91.7 82.8 31.5 11.3 14.6 87.3 86.9 32.1 12.1 16.8 87.8 82.1 44.9 12.6 8.6 83.2 78.2 23.9 17.0 20.4 81.7 66.4 25.1 7.7 n.a. 86.6 84.8 25.6 3.5 n.a. 86.1 79.2 11.4 3.2 12.0 n.a. 87.0 14.0 4.5 13.6 n.a. n.a. 37.3 4.7 n.a. 86.5 83.2 15.3 6.4 10.6 81.9 69.7 37.3 18.4 26.5 84.8 84.0 n.a. n.a. 9.0 63.3 79.6 14.5 6.1 4.9 80.0 40.5 11.3 6.3 8.0 82.2 57.8 54.2 43.9 23.1 60.3 34.7 45.2 25.0 22.5 67.3 21.0

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Growing Up Global: The Changing Transitions to Adulthood in Developing Countries Region and Country Ever Smoked Cigarettes Currently Smoke Cigarettes Male Female Male Female India: Bihar 2000 23.3 8.1 16.5 4.6 India: Calcutta 2000 15.4 9.5 8.8 2.6 India: Central Bihar 2001 9.6 3.1 4.6 1.1 India: Delhi 2001 5.7 2.2 1.5 0.7 India: Goa 2000 5.0 2.5 1.0 0.6 India: Hyderabad 2001 6.2 5.8 2.4 0.2 India: Maharashtra 2000 10.2 9.6 3.0 4.2 India: Manipur 2001 31.8 9.8 24.9 5.6 India: Meghalay 2001 22.8 14.2 16.5 6.5 India: Mizoram 2001 38.9 21.5 32.8 13.4 India: Mumbai 2000 5.9 1.7 2.4 0.2 India: Nagaland 2001 37.0 20.3 25.7 12.9 India: Navoday 2001 8.2 2.0 1.0 0.2 India: Orissa 2002 8.4 3.5 2.8 0.6 India: Rajasthan 2002 18.1 7.7 3.9 1.8 India: Sikkim 2001 31.9 15.5 24.1 10.5 India: Tamil Nadu 2000 6.3 4.1 2.3 1.0 India: Tripura 2001 16.0 8.0 13.4 6.6 India: Uttar Pradesh 2002 14.8 10.2 8.3 6.4 India: West Bengal 2000 14.1 6.3 6.1 1.4 Indonesia: Jakarta 2000 69.3 18.8 37.1 4.4 Eastern Asia China: Chongqing 1999 42.4 18.5 11.5 1.8 China: Guangdong 1999 27.1 17.4 7.3 2.3 China: Shandong 1999 26.5 7.6 4.9 0.2 China: Tianjin 1999 36.5 11.0 12.0 1.5 Macau 2001 33.0 23.4 8.5 6.0 Russia/Former Soviet Asia Russian Fed.: Moscow 1999 71.4 61.7 38.3 28.7 Russian Fed.: Sarov 2002 70.1 51.7 40.8 25.0 Ukraine: Kiev City 1999 84.0 69.1 46.8 33.8 Western Asia/Northern Africa Bahrain 2001 41.5 14.1 23.1 4.6 Gaza Strip 2001 56.2 24.4 18.5 3.8 Georgia 2002 55.5 32.7 32.6 12.1 Jordan 1999 44.1 25.8 22.6 11.4 Kuwait 2002 37.6 17.6 21.1 6.7 Lebanon 2001 39.9 27.1 16.1 7.4 Libya 2003 22.0 6.7 9.4 1.7 Morocco 2001 19.4 5.9 6.3 1.5 Oman 2003 31.4 6.8 16.2 1.8

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Growing Up Global: The Changing Transitions to Adulthood in Developing Countries Currently Use Any Tobacco Products Never Smokers Likely to Initiate Smoking Next Year Smokers Wanting to Stop Smokers Who Have Tried to Stop Male Female 61.4 51.2 22.7 66.7 56.7 18.6 14.6 29.3 48.0 51.8 12.2 9.4 9.1 67.2 60.4 5.5 3.1 8.3 n.a. n.a. 5.5 3.2 9.4 n.a. n.a. 9.4 3.3 8.5 n.a. n.a. 13.2 11.1 13.7 n.a. n.a. 74.4 47.2 38.4 21.6 12.0 54.7 32.0 22.2 59.3 45.1 58.4 48.7 45.9 85.3 79.3 5.9 1.6 6.3 80.9 72.8 69.1 56.4 26.7 81.3 55.3 13.0 7.5 9.5 92.1 92.2 16.8 10.3 23.4 n.a. n.a. 21.7 10.3 13.3 70.9 64.7 68.1 38.3 46.1 27.2 8.3 8.0 5.3 5.6 72.9 76.5 50.4 36.9 20.1 32.9 10.7 23.2 16.1 12.0 n.a 97.8 16.5 8.1 26.9 76.1 65.8 36.7 5.0 13.6 82.7 91.2 19.8 9.8 5.4 73.2 64.5 13.9 7.6 4.7 64.5 62.8 11.1 6.4 4.3 86.2 81.6 16.0 5.5 4.9 82.1 70.3 9.4 6.2 11.4 58.3 64.1 40.6 29.8 31.1 69.8 74.8 42.5 25.5 34.5 69.5 73.1 46.1 34.6 26.3 58.0 62.3 33.5 11.9 n.a. 65.3 62.8 24.3 6.6 8.1 60.5 64.8 33.8 13.0 22.7 41.2 49.0 27.5 15.2 13.9 40.2 79.3 33.3 18.4 20.0 63.9 27.6 45.5 39.6 16.9 52.7 49.6 18.7 9.4 19.8 80.0 85.3 17.4 9.3 12.5 76.3 62.8 27.3 8.9 14.3 77.7 67.3

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Growing Up Global: The Changing Transitions to Adulthood in Developing Countries Region and Country Ever Smoked Cigarettes Currently Smoke Cigarettes Male Female Male Female Sudan 2001 30.0 10.0 14.1 2.1 Syrian Arab Republic 2002 15.4 6.1 8.4 3.8 Tunisia 2001 39.0 11.8 23.1 4.2 United Arab Emirates 2002 29.5 10.9 14.3 2.9 West Bank 2001 70.4 41.4 29.4 5.9 Saudi Arabia: Riyadh 2001 34.5 n.a. 10.8 n.a. Yemen: Aden 2002 16.4 6.3 6.4 0.9 Yemen: Hadhramout 2002 16.1 4.6 7.5 1.6 Yemen: Sanaa 2002 21.3 13.9 7.5 4.5 Egypt 2001 16.2 10.7 4.4 3.4 Caribbean/Central America Antigua/Barbuda 2000 29.2 18.2 5.9 4.2 Bahamas 2000 33.6 27.5 9.0 6.0 Barbados 2002 35.0 30.0 7.0 7.0 Belize 2003 48.1 28.9 20.2 11.1 British Virgin Islands 2001 28.6 19.0 4.9 2.6 Costa Rica 2002 44.7 41.9 16.6 17.4 Cuba 2001 27.7 32.3 13.0 11.9 Dominica 2000 42.7 30.9 13.7 11.4 El Salvador 2003 45.1 27.4 18.8 11.3 Grenada 2000 34.0 20.9 9.7 6.8 Haiti 2001 22.6 24.6 11.0 12.1 Jamaica 2001 39.3 28.9 19.3 11.7 Montserrat 2000 21.1 23.1 4.0 5.3 Panama 2002 35.1 26.5 13.2 10.7 St. Kitts/Nevis 2002 25.4 12.1 8.0 2.5 St. Lucia 2001 45.3 27.7 13.5 6.5 St. Vincent/Grenadines 2001 43.0 27.7 17.6 11.5 Trinidad/Tobago 2000 46.5 32.6 17.6 9.5 Guatemala: Chimaltenango 2002 38.6 26.8 9.5 7.6 Guatemala: Guatemala City 2002 52.7 44.5 18.1 11.3 Honduras: San Pedru Sula La Ceiba 2003 48.5 37.6 17.9 9.2 Honduras: Tegucigalpa 2003 51.3 46.7 17.4 15.0 Mexico: Guadalajara 2003 52.2 51.4 17.9 20.3 Mexico: Monterrey 2000 57.3 43.7 22.3 14.6 South America Guyana 2000 36.7 22.2 11.1 5.5 Suriname 2000 62.8 46.0 23.4 10.0 Venezuela 1999 22.6 18.0 6.1 7.0 Argentina: Buenos Aires 2000 57.3 62.6 27.8 31.8

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Growing Up Global: The Changing Transitions to Adulthood in Developing Countries Currently Use Any Tobacco Products Never Smokers Likely to Initiate Smoking Next Year Smokers Wanting to Stop Smokers Who Have Tried to Stop Male Female 20.3 12.9 24.6 73.9 79.2 23.7 15.2 9.6 71.6 67.2 28.7 7.2 20.6 80.6 69.7 29.7 12.6 11.1 66.8 64.2 31.8 8.3 10.9 59.8 66.8 20.2 n.a. n.a. 72.8 54.8 19.4 11.7 31.3 91.8 77.0 21.8 11.2 29.4 83.4 66.8 22.4 17.7 39.6 79.7 65.9 22.8 15.8 n.a. 61.9 63.5 15.5 11.3 8.6 n.a. n.a. 22.5 14.3 15.8 75.2 77.3 16.0 13.0 15.0 45.0 53.0 23.9 13.9 19.9 75.3 67.8 18.0 10.1 8.5 47.5 40.6 19.5 19.3 18.7 52.2 59.4 16.8 18.3 11.9 58.8 65.6 23.8 16.0 n.a 54.8 52.4 25.1 15.3 11.5 97.1 74.0 17.9 13.8 11.3 72.1 69.8 18.1 18.4 22.3 83.1 81.4 24.1 14.7 14.8 73.3 68.1 14.3 13.9 12.8 n.a. n.a. 19.4 15.5 13.2 57.5 68.6 20.4 15.7 15.2 64.7 n.a. 18.5 10.1 13.0 75.7 n.a. 27.3 19.9 12.8 77.8 83.9 19.5 11.7 12.4 69.4 76.5 12.6 12.3 9.9 77.0 74.0 20.8 12.6 15.2 60.9 66.5 28.7 17.4 24.9 60.0 63.3 26.0 19.4 25.4 60.4 67.5 21.4 22.8 28.1 52.7 62.0 26.7 16.2 25.0 54.4 58.5 21.1 10.8 14.2 n.a. n.a. 28.3 13.5 18.8 75.0 68.3 15.4 12.3 11.6 69.6 69.4 30.9 33.8 25.1 47.4 51.6

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Growing Up Global: The Changing Transitions to Adulthood in Developing Countries Region and Country Ever Smoked Cigarettes Currently Smoke Cigarettes Male Female Male Female Bolivia: Cochabamba 2000 61.2 45.7 29.7 17.7 Bolivia: La Paz 2000 63.5 47.5 32.2 22.4 Bolivia: Santa Cruz 2000 60.7 49.7 29.5 20.8 Brazil: Goiania 2002 48.2 46.5 16.0 23.5 Brazil: Matto Grosso do Sul 2002 48.9 48.1 20.6 18.3 Brazil: Paraiba 2002 45.3 42.2 14.4 12.4 Brazil: Rio Grande do Norte 2002 40.1 38.7 14.5 13.1 Chile: Coquimbo 2000 65.1 69.7 35.4 40.8 Chile: Santiago 2000 67.4 74.7 30.9 43.8 Chile: Valparaiso V. del Mar 2000 61.7 71.6 31.3 40.6 Colombia: Bogota 2001 63.4 58.7 28.4 27.2 Ecuador: Guayaquil 2001 31.1 26.9 9.2 7.5 Ecuador: Quito 2001 62.1 40.4 23.8 11.1 Ecuador: Zamora 2002 64.0 46.8 26.6 17.4 Paraguay: Altoparana Ituapua 2003 36.8 30.1 15.4 12.3 Paraguay: Amambay Caaguazu 2003 30.0 27.1 14.1 13.3 Paraguay: Asuncion 2003 36.0 37.0 18.4 17.0 Paraguay: Central 2003 26.0 25.1 11.7 12.2 Peru: Huancayo 2000 60.0 37.9 22.7 10.8 Peru: Ica City 2002 48.6 37.5 19.6 11.8 Peru: Lima 2000 63.1 48.9 23.6 17.4 Peru: Tarapoto 2000 56.2 32.2 21.7 10.1 Peru: Trujillo 2000 59.9 38.2 27.1 10.5 Uruguay: Colonia 2001 32.4 41.2 15.1 17.1 Uruguay: Maldonado 2001 49.4 51.8 15.7 24.6 Uruguay: Montevideo 2001 52.2 52.3 20.5 26.5 Uruguay: Rivera 2001 42.7 48.7 18.1 21.0 Venezuela: Tachira State 2001 23.8 21.2 7.8 6.5 Venezuela: Yaracuy State 2001 14.5 10.0 4.4 3.5 Venezuela: Zulia State 2001 24.2 17.2 11.3 5.9 Oceania Fiji 1999 47.4 27.2 18.8 9.6 Northern Marianas 2000 78.2 81.3 37.5 40.7 Palau 2000 63.0 60.1 23.3 20.0 Europe Bosnia and Herzegovina 2003 45.5 38.5 16.8 10.0 Bulgaria 2002 64.4 73.4 31.3 42.7 Croatia 2002 62.5 56.3 18.5 14.3 Czech Republic 2002 75.0 71.2 34.4 34.9 Estonia 2002 82.4 73.8 33.9 29.8 FYR Macedonia 2002 25.8 19.5 9.3 6.7

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Growing Up Global: The Changing Transitions to Adulthood in Developing Countries Currently Use Any Tobacco Products Never Smokers Likely to Initiate Smoking Next Year Smokers Wanting to Stop Smokers Who Have Tried to Stop Male Female 33.2 21.7 25.8 56.3 59.8 36.8 25.9 28.0 64.7 66.9 34.3 25.3 24.1 69.8 63.7 21.8 17.5 12.5 69.9 64.1 26.2 21.0 15.9 67.4 75.9 18.1 16.6 14.1 83.2 82.0 18.4 16.3 13.6 72.0 70.0 36.3 41.3 27.5 51.7 61.2 32.6 43.0 28.4 44.3 59.7 31.8 39.9 21.9 50.8 61.3 30.2 28.7 22.9 69.5 69.8 14.4 13.7 14.0 67.2 65.6 23.1 15.5 16.7 72.5 65.6 32.5 28.6 21.0 79.0 66.1 24.3 22.5 18.3 61.8 69.3 24.8 24.0 17.8 74.1 73.2 27.2 24.5 22.7 49.8 62.2 21.6 19.5 15.0 59.5 67.5 27.7 13.7 31.4 75.1 68.0 21.6 13.8 24.5 82.9 76.7 26.9 20.1 24.4 67.7 63.4 23.4 13.2 20.1 86.3 80.3 28.0 14.1 25.9 78.3 76.5 17.1 19.8 19.4 46.0 50.4 19.9 26.9 18.9 52.1 58.2 26.2 28.8 23.0 58.7 63.6 22.1 22.8 16.8 65.5 60.6 14.1 11.5 14.1 53.1 58.4 14.6 7.8 11.0 74.2 69.9 19.0 25.4 16.6 67.7 64.3 24.1 13.4 21.4 79.7 82.3 68.4 57.1 35.9 80.7 76.8 54.8 62.3 16.8 76.8 n.a. 18.8 12.2 24.6 58.4 69.9 33.0 42.4 30.5 63.6 71.0 19.3 14.8 17.0 49.9 73.5 35.8 33.4 n.a. 48.8 69.1 34.9 29.8 35.5 60.9 69.0 11.7 7.9 15.9 59.9 77.3

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Growing Up Global: The Changing Transitions to Adulthood in Developing Countries Region and Country Ever Smoked Cigarettes Currently Smoke Cigarettes Male Female Male Female Latvia 2002 86.6 72.7 38.2 29.7 Montenegro 2003 34.8 26.5 3.7 3.4 Republika Srpska 2003 49.6 45.2 14.0 12.2 Serbia 2003 54.4 55.2 15.5 16.8 Slovakia 2002 69.9 58.0 25.5 22.5 Slovenia 2003 66.5 65.7 25.4 29.9 Poland: Rural 1999 68.2 49.8 21.7 11.6 Poland: Urban 1999 71.8 67.0 30.0 27.3 United States 2000 50.5 48.6 17.8 17.7 NOTE: n.a. = not available. SOURCES: World Health Organization and Centers for Disease Control (2002).

OCR for page 168
Growing Up Global: The Changing Transitions to Adulthood in Developing Countries Currently Use Any Tobacco Products Never Smokers Likely to Initiate Smoking Next Year Smokers Wanting to Stop Smokers Who Have Tried to Stop Male Female 41.4 33.0 n.a. 75.0 71.6 4.9 5.0 15.2 n.a. 83.0 14.5 12.2 23.0 53.9 73.2 16.2 17.2 19.1 54.4 77.8 26.6 23.3 22.9 64.0 80.8 27.1 29.3 27.3 41.6 68.5 25.2 14.5 21.6 79.5 79.1 37.2 30.3 23.7 74.6 73.5 26.0 20.1 n.a. 55.8 58.2

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