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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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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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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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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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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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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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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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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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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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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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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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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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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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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
OCR for page 255
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
OCR for page 256
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
OCR for page 257
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
OCR for page 258
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
OCR for page 259
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
OCR for page 260
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 261
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
OCR for page 262
Growing Up Global: The Changing Transitions to Adulthood in Developing Countries
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Representative terms from entire chapter:
developing country