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The Tobacco Epidemic:
An Historical Overview
Jonathan Samet, MD, MS
Institute for Global Tobacco Control
Jonathan M. Samet, MD, MS
„
„
„
„
Professor and chairman of
the Department of
Epidemiology of the Johns
Hopkins Bloomberg School
of Public Health
Clinician in the specialty of
internal medicine and in the
subspecialty of pulmonary
diseases
Research—health effects of
active and passive smoking
Served as consultant editor
and senior editor for Reports
of the Surgeon General on
Smoking and Health
Image source: Institute for Global Tobacco Control
3
Section A
“Discovery” and Early Use of Tobacco and the
Foundations of the Modern Epidemic
“Discovered” in the Americas in 1492 by Columbus
“The Spanish upon their journey met with great
multitudes of people, men and women with
firebrands in their hands and herbs to smoke after
their custom.”
- Christopher Columbus’ journal, November 6, 1492
Image source: www.nps.gov/colo/Jthanout/ TobaccoHistory.html, retrieved 11/2/05
5
Early Forms of Use in the Americas
„
„
„
„
„
Smoking
Ingested orally as syrup
Snuff
Chewing tobacco
Enemas
6
Tobacco
Image source: jones.house.gov/html/ photo.cfm?id=140&cat=3, retrieved 11/2/05
Wild Tobacco
(Nicotiana rustica)
Cultivated Tobacco
(Nicotiana tabacum)
Any of numerous species of Nicotiana or
the cured leaves of several of the species
that are used after processing in various
ways for smoking, snuffing, chewing,
and extracting nicotine.
Source: Encyclopedia Britannica. (1999).
Tobacco is a plant originally indigenous to the Americas. However, tobacco found in modern tobacco products is not the same as the wild
tobacco found growing in the Americas in the 15th century. Today’s cultivated tobacco has been highly engineered for consumption and
nicotine extraction.
7
Global Spread of Tobacco
„
1530—Europeans begin cultivation in Santo Domingo
„
1556–59—Introduced in France, Spain, Portugal, and
Japan
„
1560—Introduced to East Africa
„
1600—Smoking well established in Japan;
introduced in India
Continued
8
Global Spread of Tobacco
„
1612—John Rolfe plants first commercial crop in
Virginia
„
1619—Africans brought to Virginia as indentured
tobacco workers
„
1710—Russia’s Peter the Great encourages his
courtiers to smoke tobacco to look more European
9
Early Concern
King James on Smoking—
“Smoking is a custom loathsome to the eye, hateful to the
nose, harmful to the brain, dangerous to the lungs, and in
the black, stinking fume thereof nearest resembling the
horrible Stygian smoke of the pit that is bottomless.”
King James on Passive Smoking—
“The wife must either take up smoking or resolve to live in a
perpetual stinking torment.”
King James I, A Counterblaste to Tobacco,1604
Source: www.nps.gov/colo/Jthanout/ TobaccoHistory.html, 11/2/05
Continued
10
Early Concern
„
1600
− Chinese Philosopher Fang Yizhi points
out that smoking “scorches one’s lung”
Source: Brook, Timothy. Is Smoking Chinese? Retrieved December 16, 2002, from
http://www.cityu.edu.hk/ccs/Newsletter/newsletter3/HomePage/IsSmokingChinese/IsSmokingChinese.html
11
Early Health Warnings
„
1761—John Hill in England warns of cancer of nose
for snuff users (first clinical study?)
„
1889—Langley and Dickinson publish study on the
effects of nicotine on nerve cells
„
1912—Monograph on lung cancer published by
Dr. Isaac Adler
12
Early Efforts at Control
„
1604—King James I increases import tax by 4,000%
„
1620—Prohibited in Japan
„
1633—Death penalty for smoking in Turkey
„
1638—Use or distribution punishable by
decapitation in China
„
1639—Banned in New Amsterdam (New York)
„
1890—26 U.S. States and territories outlaw sale to
minors
13
Motivation for Early Efforts at Control
„
Tobacco seen as an “evil plant” associated with
savages from the New World
„
Tobacco use viewed as a sin
„
Addictive qualities begin to be recognized
− Smokers are described as “besotted” or
“bewitched”
„
Initial health concerns include cancer, impotency,
“drunkenness”
14
Evolution of the Modern Cigarette
„
„
„
„
„
1789–99
− During the French Revolution, cigarette use
popularized as least like aristocratic snuff
1832
− Invention of rolled cigarette in Turkey
1852
− Introduction of matches
1880
− Bonsack machine patented
1912
− Book matches perfected
by Diamond Co.
Image source: http://resourcescommittee.house.gov/subcommittees/emr/usgsweb/examples/, 11/2/05
15
Birth of the “Modern” Cigarette
„
1913
− Birth of the “modern” cigarette
− R.J. Reynolds introduces the Camel brand
Image source: www.cdc.gov/tobacco/ sgr/sgr4kids/adbust.htm retrieved 2/28/06
16
The Manufactured Cigarette
Tipping paper
& plugwrap
paper
Filter
Monogram
ink
Cigarette paper
& adhesive
Ventilation
holes
Image adapted from: Mackay, J. & M. Eriksen. The Tobacco Atlas. World Health Organization.
Tobacco and
additives
17
Smoke Components
„PAHs
„Benzo(a)pyrene
„Aza-arenes
„N-Nitrosamines
„Aromatic
amines
−2-Napthylamine
−4-Aminobiphenyl
„N-Heterocyclic amines
„Aldehydes
Source: Hoffmann and Hoffmann. (1997).
„Organic
compounds
−1, 3-Butadiene
−Benzene
−Vinyl chloride
−Acrylamide
„Inorganic compounds
−Arsenic
−Chromium
−Polonium-210
18
The Process of Manufacturing a Modern Cigarette
„
Primary Area—Processing
− Increase moisture
− Casing application
− Redrying process
− Cutting process
− Humidifying
− Final blending
Source: Brown and Williamson Tabacco Corporation.
Manufacturing in the Factory.
Cigarette Manufacturing Operation.
Image source:
http://www.fas.usda.gov/tobacco/circular/1997/9706/vietnam.htm, 11/2/05
Retrieved June 2000, from
http://www.bw.com/4_mfgplant/2_inthefactory/cigmanufact.html
19
The Process of Manufacturing a Modern Cigarette
„
Secondary Area: Fabrication
−
Cigarette-making machine
X Wraps tobacco into paper
X Applies adhesive
X Cuts to a specified length
−
Filter rod machine
−
Cigarette packer
Source: Brown and Williamson Tabacco Corporation. Manufacturing in
the Factory.
Cigarette Manufacturing Operation. Retrieved June 2000, from
http://www.bw.com/4_mfgplant/2_inthefactory/cigmanufact.html
Image source:
http://www.fas.usda.gov/tobacco/circular/
1997/9706/vietnam.htm, 2/3/06
20
Foundations of Modern Industry
„
1854—Philip Morris begins
making cigarettes in London
„
1860—348 tobacco factories
in North Carolina and Virginia,
almost all producing chewing
tobacco
„
1874—Washington Duke
builds first factory
Image source: www.loc.gov/exhibits/ british/britobje.html, 11/2/05
Continued
21
Foundations of Modern Industry
„
1878—Liggett & Myers Co. incorporates
„
1884—J.B. Duke signs contract with Bonsack
„
1899—R.J. Reynolds incorporates
„
1901—Imperial Tobacco Group formed in U.K.
„
1906—Brown and Williamson Tobacco Co. formed
„
1910—Duke’s American Tobacco Co. controls 92% of world
tobacco business
„
1911—U.S. Supreme Court dissolves Duke’s trust; American
Tobacco, R.J. Reynolds, Liggett & Myers, Lorillard, and British
American Tobacco emerge
22
Quote
„
“What the [tobacco] industry wants people to believe is
that a cigarette is nothing but a natural product grown
in the ground, ripped out, stuffed in a piece of paper and
served up. It's not. It's a meticulously engineered product.
The purpose behind a cigarette . . . is to deliver nicotine—
an addictive drug.”
− Jeffrey Wigand
23
The Changing Cigarette
„
1913—Introduction of the American blend
„
1940s—Change in cigarette length
„
1954—Introduction of filter tips; reconstituted tobacco added to
blend; addition of flavorants
„
1950s—Porous wrapper in wider use
„
1960s—Expanded blends reduce total volume; introduction of
ammonia technology
„
1970s—Ventilation and dilution techniques perfected
„
1980s—Further change in length
„
1990s—Alternative smoking prototypes
Source: Bollinger and Fagerstrom. (1997).
24
The Changing Cigarette: Advertising
Image source: http://cancercontrol.cancer.gov/tcrb/monographs/5/m5_foreword.pdf retrieved 2/28/06
25
The Changing Cigarette: Advertising
Image source: http://cancercontrol.cancer.gov/tcrb/monographs/13/m13_7.pdf retrieved 2/28/06
26
The Changing Cigarette: Advertising
Image source: http://cancercontrol.cancer.gov/tcrb/monographs/13/m13_7.pdf retrieved 2/28/06
27
The Changing Cigarette
Tar and Nicotine Content of U.S. Cigarettes, Sales-Weighted Average Basis, 1957–
1987
4.0
1957–Reconstituted Tobacco
1959–Porous Paper
30
3.0
1967—Expanded Tobacco
1971–Ventilation
20
2.0
Tar
10
1.0
Nicotine
0
1955
Sales-Weighted Nicotine (mg)
Sales-Weighted tar (mg)
40
0.0
1960
1965
1970
1975
1980
1985
Year
Source: US Surgeon General Report, 1989 – Update with Monograph 13
28
Sales-Weighted Tar and Nicotine Yields: 1968–1997
Source: US Surgeon General Report, 1989 – Update with Monograph 13
Chart is based on data in Table 2-1, pg 14 of Monograph 13.
According to pg 2 of same, figures before 1968 were estimated.
29
How Yields are Measured
„
Federal Trade Commission (FTC) method
− Originated in early efforts of tobacco industry
researchers to compare cigarettes, when most brands
had similar characteristics
− Variation in cigarettes over past 30 years necessitated a
standard protocol
„
Standardized smoking machine simulates precise manner
of smoking (e.g., puff size, puffing rate, puff duration)
„
Labelling conventions based on FTC method
− ‘Ultra-Light’ brands yield 1-5 or 6 mg tar
− ‘Light’ brands yield 6 or 7-15 mg of tar
− ‘Regular/Full-Flavor’ brands yield > 15 mg tar
30
Weakness of the FTC (ISO) Method
„
Does not quantify actual delivery of toxins to
smoker due to large variation in individual smokers’
puff profiles
„
Number of ways to increase delivery
− Blocking filter air vents with lips/fingers
− Increasing puff number and/or volume
Continued
31
Cigarette Filters
‘Light’ brands
Full flavor brands
• Have more filter perforations
• Have less filter perforations
% filter ventilation = 27.27
% filter ventilation = 12.65
32
Two Reports
1.
Clearing the Smoke - Assessing
the science base for tobacco
harm reduction. Institute of
Medicine. 2001.
2.
Risks associated with smoking
cigarettes with low machinemeasured yields of tar and
nicotine. National Institutes of
Health, Monograph 13. October
2001.
33
Additional Information
„
For more information on the industry’s rational for
ammonia technology and other changes to cigarettes,
see the lecture entitled “Nicotine Addiction”
34
Section B
Scientific Discovery and
Efforts at Control
Early Health Warnings
Tobacco and longevity survivorship of white males after 30
years of age according to smoking habits
100
90
Thousands of survivors
80
70
60
Nonsmokers
Moderate smokers
Heavy smokers
50
40
30
20
10
0
30
40
50
60
70
Age in years
80
90
Š1938: Dr. Raymond Pearl reports
smokers do not live as long as non-smokers
Data source: http://medicolegal.tripod.com/pearl1938.htm retrieved 2/26/06
36
Early Health Warnings
„
1939—Franz Hermann
Muller of Germany finds
strong dose-response
between smoking and
lung cancer
Image source: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1117732 retrieved 2/26/06
37
Early Health Warnings
Image source: BMJ. 2004 December 18; 329(7480): 1424–1425.
Retrieved from http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pubmed&pubmedid=15604167, 2/7/06.
38
1950: Three Key Case-Control Studies
Š
Morton Levin publishes study linking smoking and
lung cancer in the Journal of the American Medical
Association (JAMA)
Š
Ernst L. Wynder and Evarts A.Graham publish study
in JAMA in which 96.5% of lung cancer patients
interviewed were smokers
Š
Richard Doll and Bradford Hill publish study in the
British Medical Journal finding that heavy smokers
are 50 times more likely to get lung cancer
(continued)
39
Evidence Builds
„
1953—Wynder’s landmark study showed that tobacco
painted on the backs of mice produced tumors
„
1954—Doll and Hill’s study of British doctors
published in British Medical Journal
40
Industry Places Nationwide Ad
A Frank Statement to Cigarette Smokers
“We accept an interest in people’s health as a
basic responsibility, paramount to every other
consideration in our business.”
“We believe the products we make are not
injurious to health.”
“We always have and always will cooperate
closely with those whose task it is to safeguard
the public health.”
41
The Industry Reacts
„
„
Announced formation of Tobacco Industry
Research Committee (TIRC) in 1954; later
renamed Council for Tobacco Research
Launched a campaign of fraud and deceit
designed to mislead American people
Image source: http://cancercontrol.cancer.gov/tcrb/monographs/5/m5_foreword.pdf retrieved 2/26/06
42
Confidential Philip Morris Memo—1969
The Present Position: Main Evidence Against Smoking
„
“. . . I am going to start by asking you to face certain facts,
certain vital statistics . . . The vital statistics I would like you
to bear in mind are 7, 57, 139, and 227.
. . . They are the death rates per 100,000 per year from
cancer of the lung of men who were non-smokers (they are
the 7), men who smoked 1–14 cigarettes daily (they are the
57), men who smoked 15–24 cigarettes daily (they are the
139) and men who smoked 25 or more cigarettes daily
(they are the 227). . . . Those vital statistics are basically the
reason why we are here tonight . . . These vital statistics are
really vital. They threaten the life of the tobacco industry in
every country of the world.”
43
1st Report of the Surgeon General on Smoking and Health
„
Advisory Committee concluded
that cigarette smoking is—
− A cause of lung and
laryngeal cancer in men
− A probable cause of lung
cancer in women
− The most important cause
of chronic bronchitis
− “A health hazard of
sufficient importance to
warrant appropriate
remedial action”
Surgeon General Luther Terry
holding the 1964 Report
Source: Centers for Disease Control. History of 1964 Surgeon General’s Report.
Retrieved 11/26/02, from http://www.cdc.gov/tobacco/30yrsgen.htm
44
From Hypothesis To Publication to Policy
Hypothesis: Smoking Causes Lung Cancer
Studies: Levin, Wynder, Doll
Evidence Evaluation: SGR 1964
Policy: Health Warning on all
cigarette packs 1967
45
Reports of the Surgeon General
Image source: Institute for Global Tobacco Control
46
Smoking-Caused Diseases
Cancers
Leukemia—1990
Nasal and Oral
Pharynx—1982
Larynx—1980
Esophagus—1982
Lung—1964
Stomach—2001
Pancreas—1990
Kidney—1982
Ureter—1990
Liver—2001
Cervix—2001
Bladder—1990
Chronic Diseases
Stroke—1983
Coronary Heart
Disease—1979
Aortic Aneurysm—
1983
Atherosclerotic
Peripheral Vascular
Disease—1983
Chronic Obstructive
Pulmonary Disease
(COPD)—1964
Image source: http://www.cdc.gov/tobacco/sgr/sgr_2004/consumerpiece/page2a.htm, retrieved 2/6/06
47
Age-adjusted Cancer
Death rates in Males,
US, 1930-2001
Age-adjusted Cancer
Death rates in Females,
US, 1930-2001
Source: American Cancer Society, Cancer Facts & Figures 2005.
http://www.cancer.org/docroot/MED/content/MED_1_1_Most-Requested_Graphs_and_Figures_2005.asp retrieved 2/26/06
48
Effects of Cigarette Smoking on Survival
Effects of Cigarette Smoking on Survival to Ages 70 and 85
in 40-Year Prospective Study of Male British Doctors
Data source: Doll, Peto, et al. (1994). BMJ. 1994 Oct 8;309(6959):901-11.
49
Mortality Risks and Smoking-Attributable Deaths
Changes in Cigarette-Related
Mortality Risks and Percentages
of Deaths Attributable to Active
Cigarette Smoking
50
5000
100
4500
90
4000
80
3500
70
3000
60
Per capita cigarette consumption
2500
50
Male lung cancer death rate
2000
40
1500
30
1000
20
500
10
Age-Adjusted Lung Cancer Death
Rates*
Per Capita Cigarette Consumption
U.S. Age-Adjusted Lung Cancer Death Rate & Cigarette Consumption
Female lung cancer death rate
2000
1995
1990
1985
1980
1975
1970
1965
1960
1955
1950
1945
1940
1935
1930
1925
1920
1915
1910
1905
0
1900
0
Year
*Age-adjusted to 2000 US standard population. Source: Death rates: US Mortality Public Use Tapes, 1960-2000, US
Mortality Volumes, 1930-1959, National Center for Health Statistics, Centers for Disease Control and Prevention, 2002.
Cigarette consumption: US Department of Agriculture, 1900-2000.
Image retrieved on 2/8/06 from the American Cancer Society:
http://www.cancer.org/docroot/PRO/content/PRO_1_1_Cancer_Statistics_2005_Presentation.asp
51
Industry Regarding Addiction in 1994
„
Seven CEOs of cigarette companies testify before Congress that
it is their opinion that nicotine is not addictive
Image source: http://www.nlm.nih.gov/hmd/frankenstein/frank_promise.html retrieved 2/8/06
52
Industry Regarding Addiction in 2002
„
Cigarette smoking and addiction
− “We agree with the overwhelming medical and
scientific consensus that cigarette smoking is
addictive. It can be very difficult to quit smoking,
but this should not deter smokers who want to
quit from trying to do so.”
Source: http://philipmorris.com/default.asp retrieved 2/26/06
53
Industry Regarding Health and Active Smoking in 2002
„
Cigarette smoking and disease in smokers
− “There is an overwhelming medical and scientific
consensus that cigarette smoking causes lung
cancer, heart disease, emphysema, and other
serious diseases in smokers. Smokers are far more
likely to develop serious diseases, like lung cancer,
than non-smokers. There is no "safe" cigarette.
These are and have been the messages of public
health authorities worldwide. Smokers and
potential smokers should rely on these messages
in making all smoking-related decisions.”
Source: http://philipmorris.com/default.asp retrieved 2/26/06
54
Secondhand Smoke
Image source: Neuroscience of psychoactive substance abuse and dependence, WHO. Accessed
from http://www.who.int/substance_abuse/publications/en/Neuroscience.pdf, 2/10/06
55
Hirayama’s Study
T. Hirayama. 1990. Lifestyle and
mortality: A large-scale census-based
cohort study in Japan. Contributions to
Epidemiology and Biostatistics Vol. 6.
56
Standard Mortality for Lung Cancer
Standard mortality rate for lung
cancer per 100,000
40
Cigarette smokers
32-79
30
20
10
Non-smoker
Familial passive
smoking (+)
Non-smoker
Familial passive
smoking (-)
15-50
8-70
Total
108,906
0
21,895
69,645
(Non-smoker wives
of non-smoker
husbands)
(Non-smoker wives
of husbands with
smoking habits)
17,366
(Women with
smoking habits)
Population at enrollment
Data source: T. Hirayama. 1990. Contributions to Epidemiology and Biostatistics Vol. 6.
57
1986—Three Key Reports on Secondhand Smoking
1. IARC Monographs on the Evaluation of the
carcinogenic risk of chemicals to humans:
Tobacco smoking. World Health Organization.
2. Environmental Tobacco Smoke: Measuring
exposures and assessing health effects. Medical
Research Council
3. The health consequences of involuntary smoking.
A report of the Surgeon General.
58
Health Effects of SHS Exposure in Children
„
„
„
„
„
„
Sudden infant death syndrome (SIDS)
Acute respiratory illnesses (ARI)
Chronic respiratory symptoms
Reduced lung function growth
Asthma and exacerbation of asthma
symptoms
Acute and chronic middle ear disease
59
Health Effects of SHS Exposure in Adults
„
Established
− Lung cancer
− Respiratory symptoms
− Cardiovascular disease
− Exacerbation of asthma
„
Potential
− Reduced lung function
− Other cancers
60
Secondhand Smoke
„
„
„
„
1986—Surgeon General’s Report on Passive Smoking
1993—EPA classifies SHS as a “Class A” carcinogen
1994—Canadian scientists report finds evidence of
cigarette smoke in fetal hair
1998—California becomes first state to ban smoking
in bars
61
The Industry Counterattack
„
Discount science
„
Maintain controversy
„
Hire consultants
„
Produce counter-science
62
Industry vs. Science
„
“The massive effort launched across the
tobacco industry against one scientific
study is remarkable.”
Source: Ong, E. K. and Glantz, S. A. (2000, April 8). Tobacco industry efforts
subverting International Agency for Research on Cancer’s second-hand smoke study.
The Lancet 355 (9211): 1253–1259.
63
The Attack on Meta-Analysis
Tweedie, R.L. & K.L. Mengersen. 1995. Meta-analytic approaches to doseresponse relationships, with application in studies of lung cancer and exposure to
environmental tobacco smoke. Statistics in Medicine 14: 545-569.
Excerpt from Acknowledgements – “The paper was completed at Colorado State
University, with partial support from several tobacco companies; the methods
and analysis here are however entirely those of the authors and should not be
otherwise ascribed.”
Bailar, J.C. 1997. The promise and problems of meta-analysis.
New England Journal of Medicine 337 (8): 559-61.
Fleiss, J.L. & A.J. Gross. 1991. Meta-analysis in epidemiology, with special
reference to studies of the association between exposure to environmental
tobacco smoke and lung cancer: a critique. Journal of Clinical Epidemiology
44 (2): 127-139.
Excerpt from Acknowledgements – “This research was supported by a grant
from The Tobacco Institute, Washington, D.C., USA. We thank Dr Myron
Weinberg, President of the Weinberg Group/WASHTECH, for encouraging us
to develop this critique.”
64
Undermining Epidemiology
Principles for evaluating epidemiologic data in regulatory
risk assessment. Developed by an expert panel at a
conference in London, England, October 1995. Federal
Focus, Inc.
Milloy, S.J. 1995. Science without sense. The risky
business of public health research. Cato Institute,
Washington D.C.
65
Counter-Science
Junkscience.com
“All the junk that’s fit to debunk”
Articles:
- Secondhand smokescreen
- Passive smoke – the EPA’s betrayal of science
66
U.K. House of Commons Health Committee
„
“It seems to us that the companies have sought to
undermine the scientific consensus until such time as
that position appears ridiculous. So the companies
now generally accept that smoking is dangerous (but
put forward distracting arguments to suggest that
epidemiology is not an exact science, so that the
figures for those killed by tobacco may be
exaggerated); are equivocal about nicotine's
addictiveness; and are still attempting to undermine
the argument that passive smoking is dangerous.”
[bold added]
− U.K. House of Commons Health Committee
Source: (May 2001). Trust Us: We’re the Tobacco Industry. Campaign for Tobacco-Free Kids. (U.S.) and Action on
Smoking and Health. (U.K.)
67
Section C
The Spread of the Tobacco Epidemic in the U.S.
The Spread of the Tobacco Epidemic in the U.S.
„
1776—“I say, if you can’t send money, send tobacco.”
− George Washington’s request to help finance the
American Revolutionary War
„
1861–65—During the U.S. Civil War, tobacco given
with rations; many Northerners introduced to tobacco
Continued
69
The Spread of the Tobacco Epidemic in the U.S.
„
1900—Four billion
cigarettes sold in U.S.
„
1914–18—Cigarettes
included with war rations
„
1923—Camel has 45% of
U.S. market
„
1924—Philip Morris
introduces Marlboro as a
women’s cigarette
Image source: http://memory.loc.gov/ammem/awhhtml/awgc1/periodicals.html retrieved 2/9/06
Continued
70
The Spread of the Tobacco Epidemic in the U.S.
„
„
„
„
„
1939—Sixty-six percent of U.S. males younger than
forty are smokers
1939–45—During World War II, cigarettes included in
rations; Roosevelt makes tobacco a protected crop
1940—U.S. per capita cigarette consumption has
doubled since 1930 to 2,558 per year
1948—Lung cancer increasing five times faster than
other cancers (now second most common)
1954—Marlboro cowboy campaign created for Philip
Morris
Continued
71
The Spread of the Tobacco Epidemic in the U.S.
„
1956—Lung cancer death rate among U.S. white
males is 31/100,000
„
1964—Marlboro Country ad campaign launched; sales
rise ten percent per year
„
1969—R.J. Reynolds sponsors Winston Cup NASCAR
races
„
1981—Annual U.S. consumption peaks at 640 billion
cigarettes
72
Yearly per Capita Cigarette Consumption
Sources: Centers for Disease Control and Prevention. Tobacco use – United States, 1900-1999. Morbidity and Mortality Weekly Report
1999;48(43):986; Department of Agriculture, Economic Research Service, Marketing and Trade Economics Division, Specialty Crops
Branch, unpublished data; Department of Agriculture. Agricultural Outlook. Washington (DC): Department of Agriculture, Economic
73
Research Service, 2001. USDA Publication No. ERS-AO-278.
NIH
„
Overall, lung cancer incidence rates decreased 1.6
percent per year between 1992 and 1998, due mainly
to a decline of 2.7 percent per year in men and a
leveling off of rates in women, both manifestations of
reductions in tobacco smoking since the 1960s.
Source: National Institutes of Health. (2001).
74
U.S. Tobacco Industry Litigation
„
1954—First tobacco liability suit
− Pritchard vs. Liggett & Meyers (dropped by plaintiff
12 years later)
„
1954—Philip Morris hires David R. Hardy as lawyer
(begins relationship with Shook, Hardy & Bacon Law
Firm)
„
1963—Seven liability suits filed
„
1964—17 liability suits filed
Continued
75
U.S. Tobacco Industry Litigation
„
1994—Minnesota first state to sue the tobacco
industry; Philip Morris files $10 billion libel suit against
ABC for Day One report
„
1995—Supreme Court orders the release of
confidential industry documents
Continued
76
U.S. Tobacco Industry Litigation
„
1997—Attorneys General and tobacco companies
come to historic settlement—U.S. $206 billion over the
next 25 years
„
1997—Flight attendants suing for suffering caused by
secondhand smoke settle with industry for $300
million
77
Section D
The Global Epidemic
The Global Tobacco Health Burden
„
Single most important cause of preventable
death in the world
„
Projected to be leading cause of death by
2020s—one in eight deaths
„
Predicted to kill 500,000,000 people alive today
79
DALYs Attributable to Diarrhea, HIV, and Tobacco
Adapted from The Global Burden of Disease http://www.hsph.harvard.edu/organizations/bdu/GBDseries_files/gbdsumintro.pdf accessed 2/9/06
80
The Global Tobacco Health Burden
„
Kills four million a year, expected to kill 8.4 million a
year by 2020
„
One in two long-term smokers killed by their addiction
„
Half of the deaths occur in middle-ages (35–69)
Source: Peto and Lopez. (2001).
Continued
81
The Global Tobacco Health Burden
„
70% of tobacco deaths in the 2020s will be in
developing countries (DC)
1990—70% Tobacco
Agriculture in DC
2000—70% Tobacco
Consumption in DC
2020—70% Tobacco
Deaths in DC
82
Regional Attributable Mortality—2020
„
Africa and Middle East—1.1 million
„
China—2.2 million
„
India—1.5 million
„
Latin America/Caribbean—450,000
Source: WHO Tobacco Free Initiative.
83
The Global Tobacco Burden—Women
„
Closing gender gap—over 236 million women smoke
globally
„
Only ≈ 3% of women in Southeast Asia smoke
cigarettes
„
High exposure to secondhand smoke
Continued
84
The Global Tobacco Burden—Women
Estimated Smoking Prevalence by Gender and Number of Smokers
in Populations Aged 15 or More, by World Bank Region, 1995
Smoking Prevalence (%)
Total Smokers
Percentage
World Bank Region
Males
Females
Overall Millions
of Smokers
East Asia and Pacific
59
4
32
401
35
Eastern Europe and
59
26
41
148
13
Central Asia
Latin America and
40
21
30
95
8
Caribbean
Middle East and
44
5
25
40
3
North Africa
South Asia (cigarettes)
20
1
11
86
8
South Asia (bidis)
20
3
12
96
8
Sub-Saharan Africa
33
10
21
67
6
Low/Middle Income
49
9
29
933
82
High Income
39
22
30
209
18
World
47
12
29
1,142
100
Note: Numbers have been rounded.
Source: Author’s calculations based on World Health Organization (1997), Tobacco or
health: A Global Status Report, Geneva, Switzerland.
Continued
85
The Global Tobacco Burden—Women
„
“No discussion of the tobacco industry in the
year 2000 would be complete without
addressing what may be the most important
feature on the landscape, the China market. In
every aspect, China confounds the imagination.”
Source: Philip Morris—regarding women in China. (1986).
86
The Global Tobacco Burden—Youth
„
Every day 80,000 to 100,000 youths become
regular smokers
„
One-fifth of young people begin before they are
ten years old
„
High exposure to secondhand smoke
„
Predicted to kill 250 million children and
adolescents alive today
87
Global Youth Tobacco Survey (GYTS)
Percentage of Students Currently Using Any Form of Tobacco
59
60
58
50
40
34
33
27
30
20
41
40
19
35
33
23
18
10
Bu
en
os
Ai
Bo
re
liv
s
B
ia
ah
(C
a
oc ma
ha
s
Ch
ba
ile
m
ba
(C
oq
)
ui
m
bo
)
Cu
ba
In
di
a
(B
ih
ar
)
Po
Pa
Ru la
la
ss nd
u
ia
n (Ur
Fe ba
d
n
(M era )
So osc tion
ut ow
h )
Af
Uk
ric
ra
a
in
e
(K
Un
ie
v)
ite
d
St
at
es
0
Data source: http://www.cdc.gov/tobacco/global/GYTS.htm retrieved 2/26/06
88
The Global Tobacco Burden—The Poor
Smoking Prevalence
Smoking Prevalence among Men in Chennai, India, by Education Levels
64%
60%
58%
42%
40%
21%
20%
0%
Illiterate
<6
Years
6-12
Years
>12
Years
Length of Schooling
Source: Gajalakshmi, C. K., P. Jha, S. Nguyen, and A. Yurekli. Patterns of Tobacco Use and Health Consequences.
Background paper. Accessed from http://www1.worldbank.org/tobacco/book/pdf/02-Tobacco-Chap1.pdf on 2/10/06.
89
Spreads Worldwide Through . . .
„
Trade liberalization
„
Direct foreign investment by industry
„
Advertising and marketing by industry
90
Top Tobacco Companies’ Global Market Share, 1999
Other Companies
Combined
27%
China National
Tobacco Corp
25%
Reemstma
2%
Japan Tobacco
13%
British American
Tobacco
16%
Philip Morris
17%
Data sources: The Tobacco Industry Factsheet No.18 http://www.ash.org.uk/html/factsheets/pdfs/fact18.pdf,
The World Health Report 1999 http://www.who.int/whr/1999/en/whr99_ch5_en.pdf retrieved 2/10/06
91
Total World Cigarette Production in Trillions, 1950–1998
Source: US Department of Agriculture. Accessed from
http://www.ash.org.uk/html/international/pdfs/globaltrends.pdf on 2/10/06
92
Total World Cigarette Production in Trillions, 1950–1998
= US Consumption Rates
Source: US Department of Agriculture. Accessed from
http://www.ash.org.uk/html/international/pdfs/globaltrends.pdf on 2/10/06
93
Quote
„
“Tobacco exports should be expanded
aggressively, because Americans are
smoking less.”
− Vice President Dan Quayle, 1990
94
Philip Morris International Tobacco Operations
35
Billions of Dollars
30
25
20
15
10
Revenues
5
0
Profits
1989
1990
1991
1992
1993
1994
1995
1996
1997
Data source: http://www.altria.com/investors/02_01_AnnualReport.asp accessed 2/10/06
95