Our novel synthesis of existing data on current smoking prevalence in Russia has shown that for men, the period since 2008 has seen a simultaneous decline in all age groups. This decline is remarkable since it was preceded by a period of many decades where smoking prevalence in men remained almost static at every age. This decline in prevalence has occurred regardless of educational level.
Among women, the increase in smoking prevalence at younger ages appears to have now reversed in the most recent years. However, at older ages, an upward trend remains. These two countervailing trends appear to result in an overall stabilization of the trend for women as a whole. Unfortunately, educational differences in current smoking among women show very divergent trends, with those with the highest levels of education showing small declines, whereas those women with minimal educational attainment have shown a persistent steady increase, resulting in the emergence of a pronounced inverse educational gradient over the last two decades.
Over the past 30 years, smoking in Russia has shown distinctive features that are radically different from those observed in most Western European countries and North America. While smoking prevalence among men has been declining for decades in nearly all high-income countries, in Russia it has been relatively stable. In 2015, WHO projected that male smoking would decline to 54% in 2025 using 3 surveys conducted in the 2000s [26]. Our findings suggest that the decline is underway and that male smoking was below 50% already in 2015–2016. Nevertheless, today the prevalence of current smoking in Russia under the age of 60 years is still far higher than seen in the UK and the USA.
The other distinctive feature is that in the past women in Russia had far lower rates of smoking compared to their counterparts in most Western countries [26]. However, it is known that, since the 1990s, the prevalence of smoking among younger women has been increasing [9]. Our analyses show that compared to current smoking prevalence in the UK and the U.S. up to the age of 45–50, smoking among Russian women is appreciably higher, with the historic low rates remaining confined to older generations.
It is not possible in this analysis to formally evaluate how far the changes in smoking behavior we have found are attributable to the major policy innovations in smoking control introduced in Russia over the past 10 years. A change in smoking prevalence in a population represents the combined effects of three factors, initiation, quitting, and selective mortality. In the absence of long-term cohort data, it is impossible to determine with confidence the precise role that each of the three factors plays. Nevertheless, a substantial decrease both in male and female smoking around age 20 between 2007 and 2016, suggests a lower rate of initiation in younger cohorts (Fig. 1, upper panels). Considerable decreases in smoking of men at ages 30 to 50 and women at ages 30 to 40 may be associated with quitting. These changes in initiation and quitting may have been catalyzed by the policy changes. On the other hand, the rise of smoking among older women may reflect the counter-balancing forces of aggressive marketing by the transnational tobacco industries who saw in the 1990s an unexploited market among Russian women among whom smoking had previously been socially stigmatized [27].
Selective mortality may provide at least a partial explanation of the very pronounced decline in the prevalence of current smoking across ages among males that we have seen. The long-term hazard of death among smokers is about twice that of non-smokers. A simple model we have built (not shown here) suggests that the lower survival of smokers could produce a reduction in the observed cross-sectional prevalence in Russia between ages 25 and 75 of about one quarter. This selective attrition of smokers after age 60 years is particularly pronounced, with half of the rapid decrease in male smoking with age being explained by the high mortality of smokers. This effect would have been particularly pronounced among those who were aged 50 and older in the mid-1990s and who passed through the period of extremely high mortality (“crisis mortality”) in the 1990s and the early 2000s. In contrast among women, because prevalence has been so low, the pattern of smoking from younger to older ages depends mostly on the historical increase in female smoking across generations i.e. cohort increases in smoking.
What is clear is that the policies adopted, focused on price and marketing, are soundly evidence-based and the declines among men have occurred at the same time as their implementation. For younger women, the market downturn in prevalence has also coincided with these smoking control policies being put into effect. To ensure that the tobacco epidemic starts to recede among women overall, in the short and medium-term it will be important to concentrate on measures that encourage people to quit, such as steadily increasing taxes.
In this paper, we have shown that there is consistency across different studies in patterns of smoking behavior among men. This applies to absolute levels, age-patterns, recent declines, and educational gradients. This finding is striking because the studies that were included have a range of designs, sampling frames and were conducted at various points across nearly three decades. This replication of the same pattern provides confidence that in broad terms what we have observed is robust. The stability of patterns seen for men regardless of the survey is notable given the geographic dispersion of the studies. This suggests that there is a geographic homogeneity in the principal patterns of male smoking across the whole of Russia, although the pronounced educational gradients show that smoking among men in the past 20–30 years is not uniform across socio-economic strata.
The situation among women is rather different. We have found a considerably greater heterogeneity in findings across surveys than seen among men. These variations are unlikely to be due to differences in design or sampling frame as the more consistent estimates seen for men are based on the same set of studies. Instead, it is likely to reflect greater geographic variation in smoking behavior among women, consistent with previous analyses that have shown the steepest smoking increases in the large metropolitan centers of Moscow and St Petersburg [9].
In the 1980s and the 1990s, the prevalence of male smoking showed strong educational differences, with the highest levels in the least educated. In comparison among women, educational differences in smoking were initially small but have widened over time. The declines in smoking among men in Russia appear to have occurred in all educational groups. This is the same as has been observed in a diverse range of Western European countries [28] and Canada [29], although unlike in Russia, some other countries have seen the largest declines among the most educated men. In women, the Russian trend of increasing educational differences, driven primarily by increases in prevalence among low educated women is similar to that seen in Western Europe [28] and in Estonia [30], a former Soviet country. Even in the 2010s, age-adjusted smoking did not decrease significantly among Russian women with high education, and it continued to increase in women with low and secondary education.
It has long been assumed that the heavy burden of smoking among men in Russia contributes substantially to the high levels of mortality. For example, using indirect methods, it was estimated that in the year 2000 smoking accounted for 26% of deaths among men. In contrast, the equivalent figure for women was just 3% [31]. What is critical, from a public health perspective, is that individual-level risk of mortality from cardiovascular disease among smokers greatly reduces within a short time after quitting. After 5 years the excessive risk reduces by about 70% and the risk returns to that of non-smokers within 10 years of quitting [25, 32]. This means that declines in smoking prevalence can be expected to have relatively rapid positive effects on the rate of cardiovascular events and deaths in a population. To this extent, the recent decline in smoking among men is already likely to have contributed to the decline in CVD mortality among men in Russia since the late-2000s. Our estimates show that the absolute number of avoided male deaths in 2008–2016 is quite large 48,000, although this constitutes only about 6% of the observed decrease in CVD deaths. Most importantly, maintaining this decline in current smoking will contribute much more to future decreases in CVD, cancers and other diseases. However, the declines in CVD mortality among women that have been seen, particularly at older ages, are almost certainly unrelated to smoking, as trends are in the opposite direction. Moreover, the relatively low prevalence of smoking at older ages in women, where CVD mortality rates are highest, means that smoking among women cannot explain any of the differences in CVD mortality with other countries such as the UK and the USA.
