10
Cigarette Smoking and Priorities for Tobacco Control in the New Independent States

Alexander V. Prokhorov

From a medical point of view, the widespread use of tobacco in the New Independent States (NIS) should be regarded as a most critical concern on a worldwide scale. As Lopez indicates in this volume, smoking is a major cause of cancer among men in most of the NIS. Although the prevalence of smoking in the NIS varies from country to country, smoking patterns are similar: tobacco use is consistently high among males and relatively low among females by comparison. This chapter examines cigarette smoking in the NIS and priorities for tobacco control in the region.

Cigarette Smoking in the New Independent States

This section reviews the extent of the tobacco epidemic in the NIS, the spread of Western tobacco products in the region, the health consequences of the epidemic, and the need for measures to curb the spread of the epidemic.

The Extent of the Tobacco Epidemic

Smoking prevalence among adult males in the NIS has been estimated to range from 27 percent in Turkmenistan to 67 percent in the Russian Federation, and among adult females from 1 percent in Turkmenistan and Uzbekistan to 20 percent in Estonia (Piha et al., 1993; Tkachenko and Ryazantsev, 1993). Among the adult male population of the Russian Federation, estimated smoking prevalence increased from 53 percent in 1985 to 67 percent in 1992 (Tkachenko and Ryazantsev, 1993). In the period 1990-1993, the highest estimated per adult



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--> 10 Cigarette Smoking and Priorities for Tobacco Control in the New Independent States Alexander V. Prokhorov From a medical point of view, the widespread use of tobacco in the New Independent States (NIS) should be regarded as a most critical concern on a worldwide scale. As Lopez indicates in this volume, smoking is a major cause of cancer among men in most of the NIS. Although the prevalence of smoking in the NIS varies from country to country, smoking patterns are similar: tobacco use is consistently high among males and relatively low among females by comparison. This chapter examines cigarette smoking in the NIS and priorities for tobacco control in the region. Cigarette Smoking in the New Independent States This section reviews the extent of the tobacco epidemic in the NIS, the spread of Western tobacco products in the region, the health consequences of the epidemic, and the need for measures to curb the spread of the epidemic. The Extent of the Tobacco Epidemic Smoking prevalence among adult males in the NIS has been estimated to range from 27 percent in Turkmenistan to 67 percent in the Russian Federation, and among adult females from 1 percent in Turkmenistan and Uzbekistan to 20 percent in Estonia (Piha et al., 1993; Tkachenko and Ryazantsev, 1993). Among the adult male population of the Russian Federation, estimated smoking prevalence increased from 53 percent in 1985 to 67 percent in 1992 (Tkachenko and Ryazantsev, 1993). In the period 1990-1993, the highest estimated per adult

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--> yearly consumption of cigarettes was in Armenia (3,000) and Turkmenistan (2,400), followed by Moldova, Georgia, and Ukraine. The lowest consumption was in Uzbekistan (less than 1,000). In most of the NIS countries, including the largest (the Russian Federation and Ukraine), the estimated per adult consumption of cigarettes was between 1,500 and 2,000. These per capita cigarette consumption figures are very rough estimates calculated from data on production, imports, and exports (Lopez, personal communication, 1995). Nevertheless, they are sufficiently reliable to suggest the extent of the tobacco epidemic across the NIS. Adolescent smoking is a matter of special concern. According to the Ministry of Health and Medical Industry of Russia (1994), there are about 2.5 million adolescent smokers aged 15-17 in Russia. It is an alarming fact that the smoking rates among youngsters are growing. Increases are especially apparent among girls, rising from approximately 12 percent in 1986 to 20 percent in 1993 (Alexandrov et al., no date). A recent large-scale study of over 36,000 senior high school students (aged 15-17) residing in urban areas of the Russian Federation has revealed that smoking rates vary substantially, from 25 to 26 percent in the areas of Kirov and Tver, to 43 to 48 percent in Moscow and Irkutsk (Komarov and Skvortsova, no date). Among males, the average smoking prevalence is 36 percent; daily tobacco users represent the vast majority of smokers. Among senior high school female students, the average smoking prevalence is 17 percent. It may be expected that the popularity of smoking among children and adolescents will increase immensely with the breakthrough of the Western tobacco industry into the markets of the NIS. Spread of Western Tobacco Products Before the 1990s, Western tobacco products rarely appeared in the former Soviet market. They were practically unknown across the entire vast Soviet territory, except for big cities such as Moscow and Kiev and major seaports such as Odessa and Tallinn. At that time, the vast majority of tobacco products in the NIS consisted of domestically manufactured filter-tipped and plain cigarettes, as well as papirossi (unfiltered tobacco products with a 1 to 1.5 inch-long tobacco-filled portion and a paper holder). Only about 30 percent of the latter tobacco products were filter-tipped (Heseltine et al., 1987). However, in the period 1991 to 1993, as shown in Figure 10-1, the importation of both raw tobacco and cigarettes to Russia almost quadrupled and reached unprecedented levels. Along with this increasing importation of tobacco products, the transnational tobacco companies have been actively engaging in joint ventures with former Soviet tobacco factories or buying the bankrupt and disabled cigarette-manufacturing facilities. The first such company to make a business agreement in Russia was the American Liggett Group, which formed a partnership in 1991 with the Moscow

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--> Figure 10-1 Importation of tobacco leaf and cigarettes, Russia, 1986-1993. Source: Report of the Ministry of Health and Medical Industry of Russia. Dukat Tobacco factory after the well-known 1989-1990 crisis in the Russian domestic tobacco industry resulted in severe tobacco shortages. As a result, a brand-new cigarette factory with a planned capacity of 35 billion cigarettes per year, the largest in Russia, was opened in 1993 (European Bureau for Action on Smoking Prevention, 1993). In 1992, Philip Morris, which already has a joint venture with a cigarette factory in Samara (in the European part of Russia), announced plans to build a new factory in Viborg, north of St. Petersburg and adjacent to the border with Finland. It is understood that the new plant will produce 10 billion cigarettes per year (Ridgway, 1992). Developments in other NIS countries are not far behind. In Ukraine, for example, the four largest cigarette production factories were bought by Reemtsma, BAT, and RJ Reynolds, and these four cover 60 percent of the Ukrainian tobacco market (Naett, 1994). Thus, the ''westernization" of the cigarette markets in the NIS, characterized by an increasing market share of Western-type cigarettes, tobacco promotion, and advertising, is in progress.

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--> Health Consequences The tobacco and health situation today in most of the NIS countries can be characterized as dangerous. As shown by Lopez (in this volume), excess mortality due to smoking among the populations of the NIS (especially middle-aged males) is quite substantial. Some states, such as Kazakstan, Russia, the Baltic States, and Armenia, are experiencing a more extreme problem than others. For example, in Kazakstan, nearly half of deaths from all causes among males and over one-tenth of such deaths among females are attributable to tobacco use. There has also been a substantial increase in major tobacco-attributable diseases in the NIS. For example, the proportion of cancer deaths among overall male mortality in Russia increased from 16.2 percent in 1970 to 18.2 percent in 1988; the proportion of cardiovascular deaths increased from 46 to 52.5 percent within the same period (World Health Organization, 1992). Therefore, there is some urgency to the initiation of anti-smoking measures in the NIS. The health consequences of smoking in the NIS may be even more devastating than elsewhere because of the higher carcinogenicity of the domestically manufactured tobacco products that have been available in the markets of these countries over the last several decades, as compared with the tobacco products manufactured in the United States and Western Europe. As noted above, Western tobacco products appeared in the markets of the NIS just recently, and they are still not affordable to a majority of smokers in those states. The domestic cigarettes that are the most commonly used tobacco products feature exceptionally high tar yields. Table 10-1 shows the tar, nicotine, and carbon monoxide content of selected brands of cigarettes manufactured in the NIS. It is also important to consider that although the American and Western European cigarettes sold in the NIS carry the same brand names as those sold in the West, as a rule they do not meet Western standards in terms of the content of noxious substances. Table 10-2 shows the results of a study conducted by researchers from the Research Institute of Carcinogenesis that illustrate this substantial difference. Overall, the tobacco products available in the markets of the NIS have never met the noxious substance yield standards introduced in most Western countries. It is important to note that even though the content of noxious substances in the domestic brands is significantly higher, switching from domestic to Western brands is unlikely to yield much health benefit. It has been demonstrated that as a rule, such a switch results in a compensatory increase in the number of cigarettes smoked and deeper inhalation (U.S. Department of Health and Human Services, 1981). Considering the potentially higher dose-response effect of tobacco products manufactured and imported in the NIS, one might conclude that tobacco-related mortality in these states (particularly from cancer), calculated on the basis of relative risk measured in the United States, is greatly underestimated.

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--> TABLE 10-1 Content of Noxious Substances in Selected Cigarettes Manufactured in the New Independent States Brands Tar Nicotine Carbon Monoxide Unfiltered Cigarettes Vatra 28.2-30.2 1.0-1.2 2.7-3.0 Verkhovina 27.6-33.6 1.2-1.3 2.7-3.9 Astra 29.1-34.6 1.0-1.4 2.7-3.8 Reis 24.2-29.3 1.0-1.1 3.4-3.7 Polyot 28.3-37.8 1.0-1.3 2.7-3.7 Prima 22.5-31.9 1.1-1.6 2.9-3.8 Dymok 26.5 1.0 3.9 Filter-Tipped Cigarettes Kosmos 17.8-24.5 0.9-1.7 2.5-3.6 Stolichnye 19.0-26.8 0.6-1.2 2.7-3.5 Pegas 18.7-21.9 0.7-1.0 3.4-3.5 Tallinn 22.2 1.0 3.1 St. Petersburg 26.8 0.7 2.9 Leningrad 22.4 1.0 2.9 Kirgizstan 33.1 1.3 3.0 Fluerash 15.8-18.7 1.0 3.2 NOTE: Brands shown manufactured in Russia, Ukraine, Estonia, Moldova, and Kyrgyz. SOURCE: Unpublished data of the Research Institute of Carcinogensis, Moscow, Russia. TABLE 10-2 Comparative Data on Tar, Nicotine, and Carbon Monoxide (CO) Yields (mg/cigarette) in Brands of Cigarettes Sold in Both Russia and the United States, May 1993   Russia United States Brand Tar Nicotine CO Tar Nicotine CO Kent 20.2 1.0 4.4 13.0 1.0 3.6 Winston 19.0 1.2 3.4 15.0 1.0 4.1 Camel 19.2 1.0 4.6 16.0 1.0 4.1 Marlboro 21.5 1.1 3.4 16.0 1.1 3.9 L & M 16.7 1.0 5.0 14.0 1.0 3.6   SOURCE: Safayev (1993).

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--> Curbing the Spread of the Epidemic Without some obstacles to the penetration of the transnational tobacco companies into the markets of the NIS, there is likely to be a major increase in tobacco use in the region over the next few years, leading to an increase in smoking-related diseases and deaths. Tobacco advertising is one of the most important factors contributing to such a major increase in tobacco use (see Pierce, in this volume). The impact of tobacco advertising on the populations of the NIS, especially the younger generations, will be even stronger than would be expected in Western countries. This is because most of the NIS countries have been isolated and virtually unexposed to Western-type advertising for decades; the exception is the Baltic states, which have had greater access to Western European cultures. Using medical terminology, these states have not been "immunized" against tobacco advertising; therefore, they are particularly sensitive to it. Another important issue is that throughout the Soviet era, Western-manufactured cigarettes not only were more socially acceptable than Soviet-made tobacco products, but also were highly attractive because, in a sense, they symbolized a desirable Western lifestyle. Now these products are widely available, and they are rapidly gaining popularity. The tobacco industry aggressively promotes the perceived "wealthy lifestyle with Western cigarettes" among youth by advertising and sponsoring popular events in ways that are familiar to all in the West. Most recently, ads in 1994 offered a lottery with a grand prize of a new sports utility vehicle (shown with three young adults clearly enjoying themselves), decorated with the cigarette company logo. Measures to curb the further spread of tobacco advertising are urgently needed. These measures should take into account the extensive experience gained over the years in the West and the success of Western anti-smoking programs (see Pierce, in this volume). At the same time, they should also be specific to the region. It is important to remember that in terms of social norms and public awareness of smoking hazards, the NIS countries differ a great deal from Western countries. Priorities for Tobacco Control During the recent Ninth World Conference on Tobacco and Health (Paris, October 10-14, 1994), a group of experts from Central and Eastern European countries outlined the priorities for tobacco control in the region. The NIS countries were represented by experts from Russia, Estonia, and Lithuania. The priorities identified are shown in Table 10-3. These priorities are based on detailed knowledge of the tobacco situation in each of the countries represented and comprise the basic needs for each regional anti-smoking campaign.

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--> Readiness to Implement the Priorities Implementation of the priorities listed in Table 10-3 in the near future is crucial for successful tobacco control in the NIS. However, government officials and the public need to reach a certain level of commitment to achieving these goals in order to bring about change in the smoking situation in their countries. Unfortunately, the republics of the former Soviet Union have a long and quite disappointing history of procrastinating when it comes to tobacco control programs. Over decades of Soviet history, numerous anti-smoking propaganda campaigns were declared by the Central Committee of the Communist Party and by the government, but were never properly executed at the local level. Many of them were short-lived or poorly carried out. Perhaps in the future, a less declara- TABLE 10-3 Central and Eastern European Priorities for Tobacco Controla Priorities suggested by experts representing the NIS:   Reducing smoking prevalence among health professionals and involving them in tobacco control activities (Lithuania, Russia) Developing health education for young people (Estonia, Russia) Developing cost-effective interventions for different populations (Russia) Introducing controls regulating the toxicity of tobacco products (Russia) Promoting the establishment and development of voluntary organizations for tobacco control (Russia) Priorities suggested by experts representing other Central and Eastern European countries:   Passing tobacco legislation Imposing taxation and other economic measures on tobacco Creating tobacco control alliances and a national forum within each country for tobacco control Controlling smoking advertising and promotion Improving and standardizing data collection and indexes to monitor smoking prevalence and tobacco use Introducing surveys to monitor the economic consequences of tobacco use Developing an infrastructure and training for professionals to provide smoking cessation support to smokers Planning mass media anti-smoking campaigns for each region Raising awareness of involuntary smoking and promoting nonsmoking as the norm Strengthening the impact of health education programs through the media Increasing awareness of the role of mass media in reducing smoking Banning smokeless tobacco Holding a regional meeting of health ministers and members of parliament addressing chronic diseases caused by tobacco Introducing controls on vending machines a Suggested during the World Conference on Tobacco and Health, Paris, October 10-14, 1994. SOURCE: Ministry of Health and Medical Industry of Russia (1994).

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--> tive approach should be used, and an effective means of changing public perception of the severity of the tobacco and health problem should be identified. In essence, borrowing from the transtheoretical model of change (Prochaska and DiClemente, 1982),1 the vast majority of the governments and populations of the NIS are still in the precontemplation stage of change with regard to smoking. In other words, the societies do not yet intend to invest heavily in antismoking measures, at least in the foreseeable future. It would be as wasteful to try to implement action-oriented national anti-smoking campaigns in these contexts as to prescribe nicotine replacement agents for smokers who are not intending to quit. Similar to many smoking individuals in the precontemplation stage, the societies of the NIS seem to be preoccupied with other problems that require urgent solutions, including the critical state of their economies and increasing crime rates. Yet this does not mean one should simply wait until the countries of the NIS reach a desirable level of readiness to control smoking. The transtheoretical model of change suggests appropriate activities that individuals at each stage can use to accelerate their progress toward healthier behavior. One of the activities suggested for early stages is consciousness raising, that is, increasing information about self and the problem. Thus, again extrapolating the model to the societal level, efforts should be concentrated on this very issue-the raising of public awareness about the devastating consequences of smoking for the nation's health and economy. Top Priority: Raising Awareness The tobacco situation in the NIS today is similar to that in the United States preceding the release of the first Report of the Surgeon General in 1964. Cigarette smoking rates are high, smoking is socially acceptable throughout the countries of the region, and there is no serious governmental effort to reduce the smoking epidemic. To a large degree, this situation is caused by a lack of awareness and, as a result, an underestimation of the devastating health consequences of tobacco use. There have been attempts to raise public awareness about tobacco hazards in Russia, Belarus, and other republics of the former Soviet Union (Shevchuk et al., 1991; Shevchuk, 1987). However, these sporadic, local anti-tobacco campaigns did not provide locally salient information on smoking and health issues. In the absence of any national reports on tobacco and health, evidence from Western countries was used. Not surprisingly, that approach typically had little or no impact. To increase public awareness of tobacco and health issues and launch a broad anti-tobacco campaign in the NIS, one has to answer two basic questions: What type of information will be meaningful and appealing to both governments and the general public?

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--> Who should be mobilized to get this message across? These two questions are addressed below. Type of Information Needed A historically proven way of dramatically raising public awareness of smoking hazards is to prepare and publish a comprehensive national report on tobacco and health. As indicated by Pierce (in this volume), the first U.S. Surgeon General's report on smoking and health increased belief among two-thirds of the U.S. population that smoking causes lung cancer. It seems timely and appropriate to consider releasing a similar type of document based on research conducted predominantly in the NIS. The main goal of such a report would be to explain to the public how the use of tobacco increases premature death and related disease caused by tobacco and to promote the benefits of smoking prevention and cessation. In the interim, an analysis such as that by Peto et al. (1994) could be used. Such reports should be written and formatted in a way similar to those of the U.S. Surgeon General. In Russia, the initial report might be written by Russian experts in the area of smoking and health, with the concurrence of the Ministry of Health and Medical Industry of Russia. The national background of the data would make the information provided relevant to Russia. The National Center for Preventive Medicine, Moscow, a foremost research institution in the area of behavioral risk factor control, has agreed to take the lead in completing the first Report on Tobacco and Health in Russia should financial support be forthcoming. It will also be important to invite internationally recognized experts in tobacco control to review the report before publication. Such external scientific expertise and financial support will ensure the essential quality of the document. Who Should Deliver the Message The message about the health effects of smoking could be delivered by social/professional groups, the mass media, and the school health education system. Social/Professional Groups Among the tobacco control priorities for Central and Eastern Europe shown in Table 10-3 is "reducing smoking prevalence among health professionals and involving them in tobacco control activities." Although the involvement of health care providers in tobacco control seems quite natural (see also Pierce, in this volume), it would be unwise to take their influence for granted, at least at present. As far as cigarette smoking is concerned, the health care providers in the NIS are different from their counterparts in Western countries: a substantial proportion, especially males, smoke. One study in Lithuania, for example, revealed that 30 percent of male physicians smoked regularly

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--> (Misjavicene et al., 1988). Across the entire group of physicians studied, the surgeons smoked six times more frequently than the outpatient general practitioners (48 vs. 8 percent), which can be explained by the gender differences between the two groups (Misjavicene et al., 1988). Smoking was also found to be highly prevalent among Russian medical students: Agranovsky and colleagues (1990) report that among sixth-year medical students, 54 percent of males and 19 percent of females smoked cigarettes. More important, only 33 percent of the sixth-year medical students believed that smoking is unacceptable for a health care provider (Agranovsky et al., 1990). In addition, medical professionals in the NIS are not held in high esteem by the general population. In Russia, for example, the popular image of a poorly compensated doctor in an outpatient clinic whose tasks rarely reach beyond writing sick-notes is quite unlikely to bring success to an anti-smoking campaign. Thus in contrast with Western countries, one cannot just assume that physicians or other health care providers in the republics of the former Soviet Union will make the best candidates for leading an anti-smoking campaign. It is therefore appropriate to conduct sociological studies aimed at identifying the social/ professional groups in the NIS that are most capable of influencing the public in this regard (e.g., democratic politicians, church leaders, persons with high profiles) and thus serving as potential leaders of national anti-smoking campaigns. Mass Media It seems appropriate to conduct simultaneously a mass media campaign that would demonstrate the popularity of the nonsmoking lifestyle in the West. Such a campaign would counteract the massive tobacco advertising that targets primarily youth. Further, such a campaign would not require any substantial monetary investment since it could be based on existing Western anti-smoking infomercials. School Health Education Early smoking prevention through the school health education system is an extremely important priority for the NIS, especially in light of the increase in tobacco advertising. Some of the NIS countries have gained experience in implementing school-based smoking control programs. In Russia, for example, the first research-based school curriculum on smoking prevention was recently published (Alexandrov et al., 1993). This curriculum is based on experience from a 7-year randomized trial among Moscow students in grades 4 through 10 (Prokhorov and Alexandrov, 1994) and combines internationally accepted, theoretically sound approaches to smoking prevention. Although the preventive measures used in this trial failed to reduce experimentation with cigarettes, the age-specific increments of cigarette smoking (at least once in the past month) in the intervention group were lowered among boys by the third year (p < 0.001) and among girls by the fourth year (p < 0.05) of the study as compared with smokers in the control group. The observed significant difference in smoking rates was sustained until the end of the project (Prokhorov and

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--> Alexandrov, 1994). However, an updated and refined version of the curriculum is required to meet today's rapidly changing tobacco situation. Also, a sufficient number of copies must be provided to satisfy the needs of hundreds of thousands of schools in Russia, perhaps through international assistance efforts. Summary and Conclusions In the NIS, effort should be concentrated on increasing public awareness of the devastating consequences of tobacco smoking. The measures outlined above are essential before the broader set of Central and Eastern European priorities outlined in Table 10-3 can be implemented. Release of a national report on tobacco and health for each of the states would seem to be a proven first step to this end. Sociological studies should also be conducted to identify public leaders who would be able to serve as the mediators of future national tobacco control campaigns. At the same time, a counteradvertising mass media campaign and school smoking prevention curricula should be implemented to prevent further dramatic increases in smoking among young adults. Finally, given the scarce domestic resources of the NIS, success in these endeavors will require international financial assistance and tobacco control expertise. References Agranovsky, M.Z., N.P. Kandybor, A.O. Karelin, and V.S. Luchkevich 1990 Epidemiology of nicotinism among medical students. Gigiena i Sanitaria 6: 66-67. (in Russian). Alexandrov, A.A., V. Yu. Alexandrova, and A.V. Prokhorov 1993 Prevention of Cigarette Smoking Among Children and Adolescents. (Guidelines for Parents and School Teachers). Moscow: Glants, Inc. (in Russian). Alexandrov, A.A., V.Yu. Alexandrova, A.D. Vaganov, A.Yu. Rytenko. A.V. Prokhorov, and E.V. Zaikin no date The Prevalence of Smoking in Moscow Children and Adolescents. Unpublished manuscript. European Bureau for Action on Smoking Prevention 1993 Test the East: The Tobacco Industry and Eastern Europe. The B.A.S.P. Report, February. Brussells: Publiset & Associes, pp. 1-16. Heseltine, E., E. Riboli, L. Shuker, and J. Wilborn 1987 Tobacco or health. Smoke-free Europe: 4. Copenhagen: World Health Organization Regional Office for Europe. Komarov, Yu. M., and E. S. Skvortsova 1994 Risk Factors in the NIS-Incidence of Bad Habits Among the Adolescents in Urban Areas of the Russian Federation. Paper presented at the Workshop on Adult Health Priorities and Policies in the New Independent States, November 17-18. National Research Council, Washington, D.C. Ministry of Health and Medical Industry of Russia 1994 Federal Target Antismoking Program for the Period 1994-1996. Unpublished manuscript.

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--> Misjavicene, I., A. Palujanskene, and T. Stanikas 1988 Smoking among physicians and their attitudes towards smoking as a social phenomenon. Pp. 32-33 in Yu.P. Nikitin and L.D. Sidorova, eds., Tobacco Smoking and Health. Materials of the National Conference, Novosibirsk: U.S.S.R. (in Russian). Naett, C. 1994 The tobacco industry and Eastern Europe: International Trade Fair and Symposium, Moscow, 21-24 September 1993. Tobacco Control 3:163-165. Peto, R., A.D. Lopez, J. Boreham, M. Thun, and C. Heath, Jr. 1994 Mortality from Smoking in Developed Countries, 1950-2000. Oxford: Oxford University Press. Piha, T., E. Besselink, and A.D. Lopez 1993 Tobacco or health in the newly independent states of the USSR. World Health Statistics Quarterly 46(3):188-194. Prochaska, J.O., and C.C. DiClemente 1982 Transtheoretical therapy: Toward a more integrative model of change. Psychotherapy: Theory, Research and Practice 19:276-288. Prokhorov, A.V., and A.A. Alexandrov 1994 Prevention of adolescent smoking in Russia: General situation and results from a Moscow randomized trial. European Journal of Public Health 4:169-174. Ridgway, L. 1992 Russian tobacco manufacturers choose path to privatization. World Tobacco 11:17-21. Safayev, R. 1993 What do we smoke? Argumenty i Facty 28:7 (in Russian). Shevchuk, A.G 1987 The antismoking campaign in the USSR. P. 36-39 in New and Innovative Approaches to Promotion of Lifestyles Conducive to Health with Particular Reference to Tobacco. 2nd World Health Organization Workshop, Dresden, June 22-26. Shevchuk, A.G., E.V. Kosenko, and S.M. Shapiro 1991 Some aspects of anti-nicotine propaganda (an experience of Mozyr Health Center). Gigiena i Sanitaria 3:77-79 (in Russian). Tkachenko, G.B., and V.K. Ryazantsev 1993 Report prepared for the World Health Organization Regional Office for Europe. Copenhagen. November. U.S. Department of Health and Human Services 1981 The Health Consequences of Smoking. The Changing Cigarette. A Report of the Surgeon General. U.S. Department of Health and Human Services, Public Health Service. U.S. Government Printing Office. World Health Organization 1992 Highlights on Health in the Russian Federation. World Health Organization, Regional Office for Europe. Unedited draft. Note 1.   The transtheoretical model of change has been conceptualized to assess the readiness of an individual to change a problem behavior and provide more efficient intervention strategies. The model defines five stages of change: precontemplation (not intending to change the behavior in the foreseeable future), contemplation (intending to change the behavior in the foreseeable future), preparation (intending to change the behavior in the immediate future), action (undertaking overt behavioral modification for a period of 6 months or less), and maintenance (keeping the modified pattern for longer than 6 months) (Prochaska and DiClemente, 1982).