Voir page 320 le resume en francais. En la pagina 321 figura un resumen es espanol.
In developing countries, the decline in infant mortality and prevalence of communicable diseases has shifted the disease profile towards chronic diseases (1, 2), which are influenced by behavioural and lifestyle risk factors that are amenable to change (3). For example, a simple intervention such as advice from physicians to their patients that smoking is hazardous has been shown to increase smoking cessation rates (4).
In developed countries, current morbidity associated with smoking is due to the past high prevalence of the habit, which is now declining. It has been estimated that, during the 1990s, tobacco will remain the single largest cause of premature death in developed countries (5). In Canada, studies between 1986 and 1992 reported smoking prevalences of 26-29%, down from a peak of 50% in 1965 (6, 7). This contrasts with the situation in Latin American countries, such as Costa Rica, where smoking-related morbidity is only now becoming apparent because of a high prevalence of tobacco use; the current 28% smoking prevalence in this country, unlike the situation in Canada, is showing signs of increasing (1).
In 1991, smoking-attributable mortality in Canada was estimated to be responsible for 26% of all male and 15% of all female deaths (8). These mortality figures are very closely related to the Canadian population's smoking behaviour two decades ago; despite the current fall in smoking prevalence, it is expected that smoking-related disease will continue to be a significant cause of mortality during the next decade (9). While few studies are available, it is known that in Costa Rica the principal causes of death among adults since 1970 have been chronic noncommunicable diseases such as heart disease and neoplasms (1). Using lung cancer as a marker, smoking-related morbidity in Costa Rica is still low, but has been increasing since the mid-1970s (10).
The major transnational tobacco corporations have been experiencing declines in cigarette sales in developed countries (11). These companies have therefore shifted their efforts to new markets in Latin America and elsewhere in the developing world, where they are aggressively promoting tobacco products (12). In these countries, there is little to obstruct the growth of the tobacco industry, and cigarettes can be marketed and sold freely and relatively cheaply.
A number of anti-smoking and smoking-cessation initiatives have been developed in North America, which have been shown to be effective in reducing smoking-associated morbidity (2). Costa Rica has the opportunity to adopt similar programmes and legislation to modify risk behaviours before the problem reaches the magnitude currently being experienced in North America. With universal access to state-insured health care services and a focus on health promotion, Costa Rica is in an excellent position to adopt public health measures to combat the smoking epidemic. Several anti-smoking initiatives have been initiated (1), such as warnings on cigarette packs, prohibition of sales to minors, and restrictions (even if only minimal) on advertising (13), but cigarettes are still cheap and lack the heavy tax burden imposed in developed countries. At present, the anti-smoking initiatives are sporadic and regulations are not enforced, and there is no unified antismoking plan (1). In addition, there is a noteworthy absence of physician involvement, and training programmes and support structures are needed to promote physician-assisted smoking cessation.
Physicians can play several critical roles, such as role model, provider of information, identifier/ modifier of risk behaviours, lobbyist and researcher (14), which they are beginning to fulfil in North America. Smoking prevalence among them has declined to [is less than] 10% (15, 16), and specific programmes to help them promote smoking cessation have been created (17). …