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--> 9 Mortality from Tobacco in the New Independent States Alan D. Lopez1 Introduction It is widely known that tobacco use, and particularly cigarette smoking, is hazardous to health. But it is not generally known among the public just how hazardous smoking is. The extraordinary public health impact of tobacco use is a result of both the large individual risks smokers incur and the large numbers of people who choose to smoke. Procedures and methods for quantifying the health consequences of smoking are thus of vital importance to those whose responsibility it is to develop and implement an appropriate public health response to this epidemic. Unfortunately, reliable direct evidence on the health hazards of tobacco use is not widely available because of the cost and complexity of organizing epidemiological research. Case-control studies provide valuable, current evidence of the risks of smoking for a specific disease (e.g., lung cancer), but they do not indicate the excess mortality of smokers from a number of diseases, nor are they useful for monitoring the evolution of the epidemic over time. Rather, large prospective studies of the mortality of smokers and nonsmokers are required, with typically 100,000-200,000 adults being followed up for two, three, or even four decades. For most countries, and in all the New Independent States (NIS), such large, nationally representative studies of smoking and mortality are not available to provide risk estimates for the major causes of death associated with smoking. In the United States, however, the American Cancer Society (ACS) has conducted a large prospective study of more than a million adults aged 30 and over who
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--> completed a questionnaire in 1982 and were then followed up (see U.S. Department of Health and Human Services, 1989). The study found that among current smokers (the vast majority of whom were lifelong smokers consuming, on average, about 20 cigarettes per day), overall death rates were 2 to 3 times higher than for lifelong nonsmokers of the same age and sex (Peto et al., 1992). Indeed, for some diseases strongly associated with smoking, such as lung cancer, death rates were up to 25 times higher for smokers compared with nonsmokers. The disease-specific relative risks derived from this study, together with smoking prevalence data for the United States, have been used by the U.S. Surgeon General to estimate smoking-attributable deaths in the United States by applying the classic attributable risk formula (Levin, 1953). where P is the proportion of population exposed (smoking prevalence), and RR is the relative (disease-specific) risk of death for smokers and nonsmokers. Given the size and recency of the ACS study, the question arises of whether its results can somehow be applied, perhaps with suitable scaling, to other populations to estimate smoking-attributable mortality. The problem in doing so is that the ACS study is not even representative of the U.S. population, let alone those of other countries.2 The ACS cohort was biased toward those of higher socioeconomic status and/or adults who were more health conscious than others. The cohort also was undoubtedly contaminated by the "healthy volunteer" effect, whereby those who were already suffering from a serious illness in 1982 were unlikely to participate in the study. There are, in addition, major conceptual problems in applying the ACS results directly to other populations (as has frequently been done), since the hazards of smoking depend very much on past, as well as current, consumption patterns, and on the intensity and distribution of a number of cofactors (e.g., hypertension, hypercholesterolemia). Thus, even if current smoking prevalence (P) were known for a given country, there could be and undoubtedly are sufficiently important differences between smokers in that country and in the ACS cohort to invalidate direct application of the attributable-risk formula. The methodology suggested here for circumventing these difficulties is to estimate smoking-attributable deaths in populations indirectly by assuming that the current lung cancer rate in a given country reflects adequately the entire smoking history of that country in terms of prevalence, duration, intensity, and relative risk for lung cancer. This methodology is described in detail below. It should be noted here, however, that implicit in this methodology is the basic assumption that lung cancer is essentially unicausal (i.e., smoking) and that other cofactors have a negligible impact. This is clearly not the case for many developing countries, where indoor air pollution is a major cause of lung cancer (espe-
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--> cially among nonsmoking females; see Mumford et al., 1987). Hence the methodology suggested in this chapter has been applied only to developed countries, where these assumptions are more likely to apply and where, in addition, reliable cause-of-death data are readily available. Thus the validity of the estimates for the NIS based on this methodology depends entirely on the extent to which the nonsmoker lung cancer rates in these countries approximate those in the United States and elsewhere among the developed countries and the degree to which the cause-of-death data are reliable. On the former issue, data from other populations where smoking has been uncommon (e.g., Spanish females, Norwegian females), as well as from prospective studies carried out in other countries (Britain, Japan, and Sweden), suggest that the ACS nonsmoker lung cancer rates are broadly applicable elsewhere. However, there is very little reliable information about nonsmoker lung cancer rates in the NIS. In developed countries, epidemiological studies have repeatedly identified smoking as the overwhelming cause of lung cancer, based on the observation that the disease occurs very rarely in nonsmokers.3 Calculations of smoking-attributable mortality, such as that by the U.S. Surgeon General, also suggest that smoking claims many more, indeed two to three times more lives from diseases other than lung cancer, such as coronary heart disease and stroke. The methodology proposed here uses the absolute lung cancer rate observed in a population to estimate the proportionate mortality from other diseases attributable to smoking. A high lung cancer rate, such as that for Russian males, thus implies that smoking is also a major cause of death from other diseases, whereas in a population where the lung cancer death rate is still low, such as Azerbaijani females, by implication relatively few deaths from other causes can yet be due to the habit. The next section describes the study methodology, while the following section presents results on mortality from tobacco in the NIS. The final section offers concluding remarks. Methodology In the absence of a major causal factor for lung cancer other than cigarette smoking, the absolute difference between lung cancer death rates for smokers and nonsmokers in the ACS cohort represents the theoretical maximum excess mortality (from lung cancer) due to smoking (assuming, as discussed above, that all lung cancer deaths among smokers are attributable to smoking). In any given population, which will be a mix of smokers and nonsmokers, the observed lung cancer death rate will fall somewhere below this theoretical maximum. The proximity of the observed rate to this theoretical limit is then a reflection of the "maturity" of the smoking epidemic in that population. In other words, the lung cancer death rate in a specific population can be matched to some mix of the ACS smokers and nonsmokers that would yield this rate. The relative risks for dis-
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--> eases other than lung cancer in this mixed population are then assumed to be proportionately reduced according to the measure of the maturity of the epidemic based on lung cancer rates. These adjusted or scaled relative risks thus incorporate the cumulative and simultaneous effects of exposure (P) and calculated relative risks (RR) on mortality, and in principle can be applied to calculate mortality attributable to smoking in the specific population under study. (See Peto et al., 1992, for more details about the methodology discussed here.) To describe the methodology, it is first necessary to distinguish between smoking deaths from lung cancer (since virtually all the excess risk of lung cancer among smokers in the ACS cohort is actually attributable to smoking) and other causes (for which the excess mortality of smokers may be due to other differences, or confounding, between U.S. smokers and nonsmokers). Consider first the estimation of smoking-attributable deaths from lung cancer. In this case, we assume that all of the excess mortality from lung cancer observed among smokers is due to the habit, and estimate the national smoking-attributable lung cancer mortality by subtracting the smoothed U.S. nonsmoker rates from the national rate and multiplying by the population at risk in the given country (see Peto et al., 1992:1278, for the age-sex-specific smoothed rates). This is done for each age group 35-79 years. Below age 35, lung cancer is extremely rare (as indeed are most smoking-induced illnesses). Above about age 80, lung cancer death rates may become unstable or unreliable, and hence the attributable fraction for ages 80+ is assumed to be the same as for ages 75-79. Since the procedure is based on the assumption that the smoothed U.S. nonsmoker lung cancer rates adequately describe the levels for nonsmokers in other countries, if the observed national rate at any age is less than the U.S. nonsmoker rate, smoking-attributable deaths in that and all higher age groups are conservatively set to zero. That is, if the effects of smoking on lung cancer are not yet evident at younger ages, the epidemic is assumed not to be present at older ages. To estimate smoking-attributable mortality from diseases other than lung cancer, a more complex procedure is required, since it cannot be assumed that the absolute rates among nonsmokers will be comparable in different populations as was done for lung cancer. There may well be important differences in other major risk factors for vascular disease (e.g., hypertension, blood lipid levels) or upper aerodigestive cancers (alcohol) among nonsmokers in different countries. For the same reason, it cannot be assumed that all of the excess mortality from these diseases among smokers in the ACS cohort, compared with nonsmokers, is due to tobacco. Smokers can be expected to be generally less health conscious than nonsmokers, and hence are more likely to adopt other deleterious health habits (e.g., poor diet, excessive alcohol consumption) that either independently or synergistically interact with smoking to increase the risk of death. Thus in the ACS cohort, part of the excess mortality of smokers from diseases other than lung cancer may well be attributable to factors other than smoking. In an attempt to control for this confounding and thus to ensure that the risks of tobacco are not
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--> exaggerated, the estimated excess mortality of smokers in the "mixture" population is halved before the attributable mortality due to smoking is calculated. For example, if the rate of chronic obstructive pulmonary disease among the "mixture" of ACS smokers and nonsmokers corresponding to a given country (on the basis of lung cancer rates) is seven times the rate among nonsmokers (i.e., a sixfold excess), then instead of attributing six-sevenths of the chronic obstructive pulmonary disease deaths to smoking, we attribute three-fourths of them, implying a threefold excess. The method of estimation in this case is as follows. First, on the basis of the observed lung cancer death rate (lc), a smoking impact ratio (SIR) is calculated to estimate the position of the country along the theoretical spectrum of excess mortality, defined from "pure" cohorts of smokers and nonsmokers in the ACS. This can be expressed as where S and NS refer to smokers and nonsmokers, respectively, in the ACS study. This scaling factor (which in effect is an indirect estimate of the cumulative exposure to smoking in the population) is then applied to the disease-specific relative risks from the ACS study, RRi, to estimate the excess risk from smoking in the implied "mixture" population as for each smoking-related disease, i. Finally, the number of smoking-attributable deaths for each cause i (SAMi) is estimated from the usual formula (after adjustment for confounding) as where Di is the observed number of deaths from cause i. These estimates were prepared for the same age groups and under the same assumptions as for lung cancer, except that relative risks were assumed to be independent of age for nonrespiratory cancer and chronic obstructive pulmonary disease, as suggested by the ACS data (see Peto et al., 1992:1278). On the basis of the comparative size of disease-specific relative risks suggested by epidemiological studies in different countries, six broad categories of causes of death in addition to lung cancer were constructed for the estimation of smoking-attributable mortality. Thus the extremely high relative risks for cancers of the upper aerodigestive organs (mouth, esophagus, pharynx, and larynx) implied that they should be separated from all other cancers. Conversely, the
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--> similar age pattern and level of risk for stroke, coronary heart disease, and other major vascular diseases provided a basis for amalgamating these diseases. This is all the more important for comparative mortality estimates since the likelihood of misclassification of diagnosis is probably greatest for these diseases. Estimates were prepared separately for chronic obstructive pulmonary disease and all other respiratory diseases. Finally, a residual category of diseases (labeled ''other medical causes") was constructed, since death rates for these diseases were consistently higher for smokers than for nonsmokers in the ACS study. This is perhaps not surprising since the residual category includes such diseases as peptic ulcer, for which smoking has been identified as a principal causal factor (U.S. Department of Health and Human Services, 1989), and may well contain a significant number of misclassified deaths from a respiratory, neoplastic, or vascular cause due to smoking (Peto et al., 1992). Results Table 9-1 provides an overview of the percentage of all deaths attributable to smoking in 1990 for each of the NIS countries separately (see Peto et al., 1994, for more detailed estimates). The proportionate mortality from smoking is shown for all ages and for the age group 35-69 years. This latter age group, roughly representative of "middle age," is intended to reflect the amount of premature mortality from smoking in these populations. As noted, death due to smoking before age 35 is extremely rare, while beyond about age 70 or so, the reliability of diagnoses of cause of death becomes increasingly uncertain because of the multiple pathologies often present in older people. Moreover, many of those who died from smoking in old age may well have died soon in any case from other causes. The estimates suggest that the NIS can be grouped into three broad categories based on the proportionate mortality from smoking among males. The first group includes Armenia, Belarus, Estonia, Kazakstan, Latvia, Lithuania, the Russian Federation, and Ukraine, with about 25 to 30 percent of all male deaths currently due to smoking. In middle age, roughly 40 percent of deaths among men in these countries are estimated to be due to smoking. These are remarkably high proportions that, if true, emphasize the urgent need for comprehensive tobacco control policies in these countries. It must be remembered, as discussed in the introduction, that these estimates are being driven entirely by the reported lung cancer rates, and their validity is thus very much dependent on the accuracy of reporting of lung cancer mortality. For the Baltic states, as well as the Russian Federation, Belarus, and Ukraine. the estimated attributable fractions of mortality from smoking are comparable to those of neighboring countries including Poland (29 percent of all male deaths, 42 percent in middle age) and the Slovak Republic (26 and 38 percent, respectively).
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--> TABLE 9-1 Estimated Percentage of Deaths (All Causes) Due to Smoking in the New Independent States, 1990 All Ages Ages 35-69 Country Males Females Males Females Armenia 23 3 38 6 Azerbaijan 14 0 24 0 Belarus 26 1 39 2 Estonia 26 3 38 6 Georgia 15 24 2 Kazakstan 28 7 43 12 Kyrgyz 17 4 28 4 Latvia 25 3 38 6 Lithuania 25 3 38 3 Moldova 20 3 31 3 Russian Federation 30 4 42 7 Tajikistan 6 0 14 0 Turkmenistan 9 22 0 Ukraine 28 4 40 6 Uzbekistan 8 2 20 5 Former Socialist Economies (all)a 26 4 39 7 a Including the New Independent States. SOURCE: Peto t al. (1994). The comparatively high attributable fractions for Kazakstan and Armenia are more difficult to interpret. Lung cancer rates among middle-aged men in Kazakstan are substantially higher than in the United States, for example, and are comparable to those observed elsewhere in Eastern Europe. Death rates from the disease in Armenia are also high, similar to those in Belgium and The Netherlands (see Annex 9-1). If these rates are accurate, and if nonsmoker rates in these two countries are in fact comparable to those of the ACS population, then smoking may indeed be a major cause of death among Armenian and Kazakstani men. In the absence of data on trends in smoking prevalence and consumption, as discussed in the introduction, these estimates cannot be substantiated and should be viewed as very preliminary.4 A second group of countries may be considered as being at an intermediate stage of their tobacco epidemics, with proportionate mortality attributed to smoking varying between about 15 and 20 percent. These countries include Azerbaijan, Georgia, Kyrgyz, and Moldova. Again, the plausibility of these estimates is difficult to assess without detailed knowledge of the smoking history of these populations. However, the estimates are not inconsistent with what has been estimated for Romania ( 18 percent of all male deaths due to smoking), with the
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--> degree of concordance being closer for Moldova than for the other states (as might be expected). The third group of countries (Tajikistan, Turkmenistan, and Uzbekistan) would appear to be at the very beginning of their tobacco epidemics, with 6 to 9 percent of all male deaths (and 14 to 20 percent of those in middle age) attributable to smoking. Smoking among women is, and has been, extremely uncommon in the NIS, as it has been in most developing countries (see Prokhorov in this volume). Therefore, one would expect very low lung cancer rates among NIS women. comparable to those among nonsmoking American women in the ACS, and very low smoking-attributable mortality from other diseases as well. Table 9-1 shows that this is indeed the case. The percentage of smoking-attributable deaths among women in the NIS varies from 0 (i.e., lung cancer rates at or below those of U.S. nonsmokers) to 4 percent (0 to 7 percent in middle age). The single exception is Kazakstan, where the methodology suggests that 7 percent of female mortality is currently due to smoking. This estimate is extremely difficult to interpret in the absence of data on smoking trends among Kazakstani women. Their lung cancer rate in middle age (8.9 per 100,000) is comparable to that observed in Poland (9.2) and Norway (10.3), for example, where about 5 percent of female deaths at all ages are due to smoking. However, other factors suggest that this proportion is too high. Typically, females begin to smoke in large numbers with social modernization and a change in social norms that discourage smoking among women (see Pierce in this volume). This social transition generally occurs in parallel with a demographic transition that, according to some indicators at least, is still occurring in Kazakstan, where the total fertility rate remains comparatively high (3.0 births per woman), as does the infant mortality rate (28 deaths per 1,000 live births). If the smoking epidemic requires a receptive social environment to spread among women in Kazakstan as is the case elsewhere (and there is no reason to believe that it does not), then smoking cannot yet be widespread among Kazakstani women, and hence their mortality from the habit must still be low or negligible. This would suggest that the data issues discussed in the introduction have come into play: either factors other than smoking are raising the lung cancer rate among Kazakstani women, or lung cancer is overdiagnosed among these women, or both. In addition to all-cause estimates of smoking-attributable mortality, detailed estimates of the proportions of various main causes of death due to smoking have been prepared (see Peto et al., 1994). For women, these proportions are still very low, but for men, results of the methodology applied here suggest that tobacco is already a leading cause of cancer and other chronic diseases. Table 9-2 summarizes the estimated attributable fractions (in percent) for all sites of cancer. The variation in attributable fractions follows the general pattern estimated for all causes of death.
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--> TABLE 9-2 Percentage of Cancer Deaths (All Ages) Due to Smoking, New Independent States, 1990 Country Males Females Armenia 45 4 Azerbaijan 29 0 Belarus 46 1 Estonia 48 4 Georgia 36 1 Kazakstan 52 10 Kyrgyz 36 4 Latvia 47 4 Lithuania 46 3 Moldova 42 3 Russian Federation 52 5 Tajikistan 17 0 Turkmenistan 30 0 Ukraine 50 5 Uzbekistan 26 4 Former Socialist Economies (all)a 48 5 a Including the New Independent States. SOURCE: Peto et al. (1994). Concluding Remarks Results of the methodology applied here indicate that smoking as a cause of cancer is still relatively uncommon among women of the NIS (less than 5 percent of cancer deaths). However, it is a major cause of cancer among men in most of these states, accounting in many states for about one in two cancer deaths—52 percent in the Russian Federation, 50 percent in Ukraine, 46 to 48 percent in Belarus and the Baltic states (see Table 8-2)—and one in four deaths overall. These estimates strongly suggest that campaigns to control cancer in these states (as indeed is the case in most other industrialized countries) must give priority to tobacco control. At the same time, it must be remembered that the estimates presented in this chapter are indirect and are limited by the constraints of the comparability of nonsmoker lung cancer rates and the reliability of cause-of-death data. Thus they can only indicate what the likely mortality from smoking in the NIS may be if nonsmoker lung cancer rates in these states are low and comparable to those of the United States and if mortality data for these states are reliable (particularly lung cancer data). Large prospective studies in one or more of these states are urgently required to document and monitor smoking-attributable mortality in the
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--> NIS. The simple attempts made here to ensure that the hazards of smoking are not overestimated need to be confirmed or amended by direct evidence. Given the strong dependence of the method on the assumption that nonsmoker lung cancer rates are low and comparable to those observed in the United States and the United Kingdom, the results presented here should be seen as merely suggestive of the probable impact of tobacco, pending confirmation based on direct evidence from these countries. A case-control study of lung cancer in Krakow, Poland, covering the period 1980-1985, found a significant effect of both air pollution and occupational exposures on lung cancer risk for men (Jedrychowski et al., 1990). According to this study, tobacco caused about 75 percent of lung cancer cases in the region, compared with 20 percent from occupational exposures and 5 percent from air pollution. If these proportions were to be more widely applicable in Eastern Europe, including the NIS, then the proportionate mortality due to tobacco would be lower than what is estimated in this chapter. In their study of the causes of cancer in the United States in the late 1970s, Doll and Peto (1991) extensively review the evidence on occupation and air pollution and estimate that about 15 percent of male lung cancers and 5 percent of female lung cancers could be ascribed to occupational hazards, commenting that "we suspect that they [the estimates] are a little high" (p. 1245). On the other hand, high background death rates from cardiovascular diseases (and from chronic lung diseases) may well mean that the risks of smoking for these diseases are higher than observed elsewhere. This in turn would mean that the smoking-attributable mortality estimates presented here for some countries, particularly in Eastern Europe, are seriously underestimated. In the meantime, much more needs to be done to document and disseminate information on smoking patterns in the NIS. Reliable disaggregated data on smoking patterns are an essential information support for tobacco control strategies and programs. In particular, reliable data on tobacco use among women need to be collected and monitored carefully in the hope that they will be used to prevent the appalling epidemic of tobacco-related deaths that will surely occur within the next few decades if women in the NIS begin to smoke in large numbers. References Doll, R., and R. Peto 1991 The Causes of Cancer: Quantitative Estimates of Avoidable Risks of Cancer in the United States Today. Oxford: Oxford University Press. Goskomstat U.S.S.R. 1989 Natsional'nii sostav naseleniia, Chast II. Moscow: Informatsionnoizdatel'skii sentr. International Agency for Research on Cancer 1986 Tobacco Smoking. IARC Monographs on the Evaluation of the Carcinogenic Risk of Chemicals to Humans. Vol. 38. Lyon: International Agency for Research on Cancer.
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--> Jedrychowsky, W., H. Becher, J. Wahrendorf, and Z. Basa-Cirpialek 1990 A case-control study of lung cancer with special reference to the effect of air pollution in Poland. Journal of Epidemiology and Community Health, 44:114-120. Levin. M.L. 1953 The occurrence of lung cancer in man. Acta-Unio Internationalis Contra Cancrum 9:531-541. Mumford, J.L., X.Z. He, R.S. Chapman, S.R. Cao, D.B. Harris, X.M. Li, Y.L. Xian, W.Z. Jiang, C.W. Xu, J.G. Chuang, W.E. Wilson and M. Cooke 1987 Lung cancer and indoor air pollution in Xuan Wei, China. Science 235:217-220. Peto, R., A.D. Lopez, J. Boreham, M. Thun, and C. Heath, Jr. 1992 Mortality from tobacco in developed countries: Indirect estimation from national vital statistics. Lancet 339:1268-1278. 1994 Mortality from Smoking in Developed Countries, 1950-2000. Oxford: Oxford University Press. U.S. Department of Health and Human Services 1989 Reducing the Health Consequences of Smoking: 25 Years of Progress. A Report of the Surgeon General. U.S. Department of Health and Human Services, Public Health Service; Centers for Disease Control, Center for Chronic Disease Prevention and Health Promotion; and Office on Smoking and Health. DHHS Publication No. (GDC) 89-8411. Notes 1. The views expressed in this chapter are entirely those of the author and do not necessarily reflect the opinions or policies of the World Health Organization. Richard Peto (Oxford University) collaborated closely on all aspects of this work. 2. For example, the probability of death before age 70 of a man aged 35 years in 1985 was 34 percent for the United States as a whole, but only 13 percent and 32 percent for nonsmokers and smokers, respectively, in the ACS cohort. 3. For a comprehensive review of these studies, see International Agency for Research on Cancer (1986:200-244). 4. The ethnic composition of Kazakstan, as enumerated by the 1989 census, may be one explanation of its high lung cancer rates. Only about 40 percent of the population were Kazakstanis, compared with 45 percent who were either ethnic Russians, Ukranians, or Belarusians, populations among whom lung cancer rates are comparatively high (Goskomstat U.S.S.R., 1989)
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--> ANNEX 9-1 Lung Cancer in Developed Countries, 1990 (age standardized death rates per 100,000) Countries All Ages Ages 35-69 Females USA 36.7 23.5 Denmark 34.3 23.6 Iceland 32.1 21.5 United Kingdom 30.7 18.5 Canada 30.3 19.4 Ireland 27.3 15.6 New Zealand 26.4 16.7 Hungary 22.6 13.9 Australia 18.4 11.1 Norway 15.2 10.3 Netherlands 14.7 10.2 Poland 14.2 9.2 Sweden 14.0 9.1 Kazakstan 13.6 8.9 Israel 13.3 6.2 Austria 12.8 7.4 Luxembourg 12.5 9.0 Czechoslovakia (former) 12.4 7.7 Japan 12.2 5.4 Germany 11.5 7.0 Belgium 11.2 7.2 Switzerland 11.1 6.8 Italy 10.9 6.0 Yugoslavia (former) 10.7 6.9 Russian Federation 10.7 6.5 Greece 10.7 6.0 Ukraine 10.6 6.3 Estonia 10.1 6.4 Finland 10.1 5.5 Latvia 9.7 6.4 Armenia 9.3 6.5 Romania 9.2 6.5 Moldova 9.2 4.9 Lithuania 8.9 4.0 Kyrgyz 8.7 5.0 Bulgaria 8.2 5.0 Uzbekistan 7.8 5.0 France 7.4 4.6 Portugal 6.6 3.6 Belarus 6.6 4.1 Tajikistan 6.3 3.4 Azerbaijan 6.2 3.6 Georgia 6.1 4.1 Spain 5.2 2.7 Turkmenistan 4.9 3.2 Malta 4.6 2.3
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--> Countries All Ages Ages 35-69 Males Hungary 113.6 77.5 Belgium 109.4 57.8 Czechoslovakia (former) 107.8 73.0 Russian Federation 103.7 73.3 Netherlands 103.6 48.4 Poland 101.7 70.8 Kazakhstan 98.9 71.5 Estonia 92.4 64.8 Luxembourg 92.3 47.8 Ukraine 89.7 65.1 Latvia 89.5 64.3 United Kingdom 87.5 42.7 Lithuania 87.3 61.4 USA 86.5 49.3 Canada 85.1 46.0 Italy 83.9 50.4 Belarus 79.5 57.6 Denmark 78.4 42.1 Greece 73.5 42.4 Finland 73.2 36.7 Germany 71.9 41.4 Ireland 71.3 36.6 Yugoslavia (former) 70.6 50.6 France 67.9 42.3 Spain 67.6 40.1 Armenia 67.3 50.3 Austria 66.7 38.1 Switzerland 66.7 37.5 New Zealand 65.9 33.7 Moldova 64.3 48.3 Malta 62.8 34.2 Australia 62.5 32.5 Bulgaria 56.2 42.4 Romania 52.9 43.1 Kyrgyz 50.6 34.9 Japan 47.3 19.7 Iceland 45.4 23.6 Norway 44.4 24.8 Georgia 42.2 28.0 Israel 40.3 25.0 Portugal 40.2 25.2 Azerbaijan 38.0 25.9 Sweden 35.6 19.0 Turkmenistan 31.2 23.4 Uzbekistan 28.9 21.3 Tajikistan 21.1 14.1 Note: Countries in bold indicate the New Independent States.
Representative terms from entire chapter: