Papers

Decreasing prevalence of cigarette smoking in the middle income country of Mauritius: questionnaire survey

Helen S Cox, epidemiologist ^a, Joanne W Williams, epidemiologist ^a, Maximilian P de Courten, director of research ^a, Pierrot Chitson, director ^b, Jaakko Tuomilehto, professor ^c, Paul Z Zimmet, professor ^a. 

^a International Diabetes Institute, Caulfield 3162, Australia, ^b Non-Communicable Disease Unit, Ministry of Health and Quality of Life, Mauritius, ^c National Public Health Institute, Helsinki, Finland

Correspondence to: H S Cox helen.cox{at}dhs.vic.gov.au

	Abstract

Top Abstract Introduction Participants and methods Results Discussion References

Objectives: To describe changes in the prevalence of cigarette smoking in the middle income country of Mauritius from 1987 to 1998, and to relate these changes to legislative and health promotion efforts over the same period.
Design: Questionnaire survey.
Setting: Mauritius, an island in the Indian Ocean with a population of about 1.2 million (about 70% south Asian, 2% Chinese, and 28% Creole).
Participants: Data were obtained from 5072 participants in 1987, 6573 in 1992, and 6281 in 1998.
Main outcome measures: Prevalence of current smoking in 1987, 1992, and 1998, sales of cigarettes in Mauritius, and information on activities for control of tobacco.
Results: Self reported cigarette smoking has been decreasing in Mauritius since 1987, with the largest decrease between 1987 and 1992. From 1987 to 1998 smoking prevalence decreased by 23% in men and 61% in women. Smoking decreased across all age and ethnic groups and across different levels of income and education. Sales of cigarettes also decreased in line with smoking prevalence.
Conclusions: The introduction of cigarette taxes, a limited health promotion programme, and the absence of massive promotional campaigns by the sole tobacco company on Mauritius have led to a striking and continued decrease in smoking prevalence and cigarette consumption on the island.

	Introduction

Top Abstract Introduction Participants and methods Results Discussion References

Over the past few decades rates of cigarette smoking have decreased in developed countries following considerable legislative controls on tobacco sales and on advertising and with health promotion efforts. ^{1 2} In contrast, smoking rates have increased in many low and middle income countries as tobacco companies switch their efforts towards emerging markets. Of the 1.1 billion people who smoke cigarettes, 80% live in low or middle income countries, and global estimates show that 82 000 to 99 000 young people start smoking each day.³ Therefore greater attention needs to be directed towards cigarette smoking and the actions of tobacco companies in low and middle income countries.

Smoking rates and changes in rates during the 1980s have been reported from 35 European countries.⁴ Generally, smoking among men decreased by on average 3% to 4% over a five year period, except in Beijing, where there was an 11% increase. Smoking among women increased in about half the populations, predominantly where smoking prevalence was relatively low. Many of these countries have instituted intensive programmes to control tobacco. Limited prospective data exist showing changes in cigarette smoking in rapidly developing or middle income countries.

Mauritius is a middle income country, which in 1998 had a per capita gross national product of US$3700 (£2233).⁵ Rapid economic development has occurred over the past two decades, with a peak in the mid-1980s. A high prevalence of type 2 diabetes and cardiovascular disease prompted three surveys on non-communicable disease in 1987, 1992, and 1998. We present data on cigarette smoking collected during these surveys and information on tobacco control activities, and we relate these to changes in smoking prevalence.

	Participants and methods

Top Abstract Introduction Participants and methods Results Discussion References

Mauritius is an island in the Indian Ocean, with a population of about 1.2 million, comprising about 70% south Asian, 2% Chinese, and 28% Creole. Three population based surveys were undertaken in 1987 (age range 25-74 years), 1992 (25 years and older), and 1998 (20 years and older); the numbers of participants were respectively 5072 (86% response rate), 6573 (89%), and 6281 (87%). Details of the survey methodology have been published previously.⁶ All eligible residents residing in population clusters were invited to participate. In 1987, 10 randomly selected population clusters and a purposely selected area of Chinatown in the capital, Port Louis, were surveyed. Population clusters were selected on the basis of enumeration areas used in the 1983 census in Mauritius. Three additional clusters were included in 1992. In 1998, Chinatown was not sampled, and the lower age limit was 20. People in the additional clusters, new residents in the original clusters, non-responders from previous surveys, and young people now eligible to participate made up "independent samples" of 2837 in 1992 and 1758 in 1998. Owing to the different sampling strategies in all three surveys, not all previous participants were invited to participate subsequently; 57% of all the participants took part in more than one survey.

Compared with a 1990 population census, the survey samples were weighted in the middle age group, and more women than men participated in each survey (table 1). Information on household income and ethnicity was unavailable from the 1990 census. The independent samples were, however, similar to the complete samples in 1992 and 1998 for household income, and the proportion of Hindu respondents was similar to the census and across surveys.

Cigarette smoking was assessed through questionnaires administered by an interviewer. Participants were asked whether they were never smokers, ex-smokers, or current smokers and how many cigarettes they smoked per day: fewer than 10, 10-20, or more than 20. We defined smokers as those reporting current smoking at the time of survey.

We restricted statistical analyses to ² tests for differences and for trend, and we analysed data with SPSS 9.0 for Windows. Values for prevalence were standardised for age and sex to the 1990 census population by using the direct method.

	Results

Top Abstract Introduction Participants and methods Results Discussion References

Smoking prevalence
The prevalence of smoking among Mauritians has decreased dramatically since 1987, with the largest decrease between 1987 and 1992 (table 2). Prevalence rates in the independent sample from each survey were similar. Smoking rates decreased greatly in men (23%) and women (61%) between 1987 and 1998. Rates have decreased in all three ethnic groups. The proportion of male smokers who smoked fewer than 10 cigarettes per day increased, whereas those smoking more decreased. Most female smokers smoked fewer than 10 cigarettes per day, with little change across the three surveys (table 3).

Quitting and starting smoking
Although questions aimed at separating never and ex-smokers were asked, we think the distinction between these options was not clear in the interview. We believe, however, that current smokers were correctly identified. To identify those quitting and those starting to smoke, data from those participating in at least two surveys were assessed. Quitters were defined as those smoking in one survey and not smoking in a subsequent survey, and vice versa for those starting to smoke. Rates of quitting were relatively high, whereas rates for those starting to smoke were low (table 4). From 1987 to 1992 and 1992 to 1998, women were significantly more likely to quit smoking than men and less likely to start (P<0.05). No difference was found in the quitting rate in men between the two periods, but the proportion of women quitting reduced from 52% to 33% (P<0.05). The rate of starting smoking increased among women but not among men.

Sales of cigarettes
Based on sales of cigarettes per person per day since 1987 in Mauritius, there has been a gradual but consistent decline in cigarette consumption (figure). Between 1992 and 1998 the tobacco company gradually withdrew regular sized brands of cigarettes and replaced them with king sized brands, leaving Mauritius as a 100% market for buying king size cigarettes.

View larger version (16K): [in this window] [in a new window]   Sales of cigarettes per person per day (line) and tax excise on cigarettes (percentage of ex-factory price) from 1981 to 1998 in Mauritius. Data obtained from Tobacco Board of Mauritius

Taxes and health promotion
The excise duty on cigarettes increased from 75% of the ex-factory price in 1988 to 180% in 1998, a few months before the 1998 survey (figure). Between 1992 and 1996 the excise was stable at 120%. In 1987 a health promotion strategy was launched by the Mauritian government, which contained elements directed at quitting smoking, including a general media campaign with radio and television advertisements and talks to targeted high risk groups. After 1992 this programme lost momentum but was resurrected in 1998. Various non-government organisations have also provided antismoking programmes in Mauritius throughout the 1990s.

	Discussion

Top Abstract Introduction Participants and methods Results Discussion References

In Mauritius, smoking rates decreased by 23% in men and 61% in women between 1987 and 1998 despite the already low rate of smoking in women. Prevalence rates decreased across all ethnic and age groups and income and education levels. A noticeable gradient was observed between smoking prevalence and income in men, with the greatest change across surveys in the low income group. Cigarettes sales in Mauritius have also been decreasing in conjunction with smoking prevalence.

Study limitations
The surveys reported here relied on self reported smoking behaviour. This may result in underreporting of smoking, particularly where there is great social pressure not to smoke. In the Hindu, Muslim, and Chinese populations of Mauritius there is a strong cultural resistance to smoking, particularly among women. It is still customary for middle aged people to refrain from smoking in front of their parents and other elders. The taboo of women smoking is much stronger among Asian families than among the Mauritians of European, African, or mixed descent. However, westernised European, African, and Chinese Mauritian women still refrain from smoking in the street. Smoking prevalence may be underestimated in Mauritius, particularly among women. However, by using the same question to elucidate smoking status across the surveys, any error in reporting should be consistent. Involvement in a health survey may constitute an intervention; however, the independent samples in each of the surveys also showed a substantial decrease in smoking prevalence.

	Acknowledgments

We thank the people of Mauritius, Australia, and Finland who have been involved in the planning and conduct of non-communicable disease research activities in Mauritius since 1987.

Contributors: HSC conceived the rationale for this paper, analysed the data, and wrote the paper. JWW assisted in data analysis and in critical review of the manuscript. MPdeC planned and coordinated the 1998 survey and helped with the analysis and review of the manuscript. PC was involved in the design of the surveys and in initiating tobacco control initiatives in Mauritius. JT designed the survey instrument and reviewed the paper. PZZ, as head of the research group, planned and monitored the conduct of all three surveys and is the guarantor for the paper.

	Footnotes

Funding: The surveys were supported by a grant from the US National Institutes of Health (No DK-25446) and the Government of Mauritius.

Competing interests: None declared.

	References

Top Abstract Introduction Participants and methods Results Discussion References

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(Accepted 27 June 2000)