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1.2 billion smokers globally 83% of global smokers (956 million) live in developing
countries
339 mil27%
537 mil44%.
140 mil11%
212 mil17%
LI LMI UMI HI
Number of smokers by Income Groups in 2000
Prevalence rate (in 90s)
Male Female
Bangladesh 40 10
Turkey 59 26
Vietnam 73 4
Pakistan 36 9
China 63 4
Indonesia 63 2
Russia 63 14
Philippines 75 18
Egypt 43 5
Prevalence rates in selected developing countries 1990s
Smoking- the epidemic of the 20th C
• 100 million people died of tobacco-related causes during the 20th century
• The WHO predicts that, without intervention, tobacco will kill more than 8 million people every year by 2030, and 1 billion this 21st century; 80% of those deaths will occur in developing countries
• The WHO proposes six policies to reduce global tobacco deaths: the FCTC Monitor tobacco use and prevention policies Protect people from tobacco smoke Offer help to quit tobacco use Warn about the dangers of tobacco Enforce bans on tobacco advertising, promotion, and sponsorship Raise taxes on tobacco
Unless current smokers quit, smoking deaths will rise dramatically over the next 50 years
0
340
70
520
220
500
190
0
100
200
300
400
500
1950 2000 2025 2050Year
Toba
cco
deat
hs
(mill
ion)
Baseline
If proportion of young adults taking up smoking halves by 2020
If adult consumption halves by 2020
Source: Peto and Lopez, 2001
Famous Issues in Epidemiology
• A second year medical student Ernst Wynder 1948, attended the autopsy of a two-pack-a-day smoker who had died from lung cancer
• collected case histories of lung cancer victims• Captured the interest of thoracic surgeon
Evarts Graham. He was a sceptical smoker.• 1950 Wynder and Graham published a large
case-control study that had used standardised interviews linking smoking and lung cancer
• In the following decade, hundreds of reports were published linking lung cancer and smoking
• Doctors were convinced of the health risks of smoking. Many doctors quit, including Graham, who quit in 1952, but died of lung cancer in 1957
TOBACCO and LUNG CANCERThe 1950 Large Case Control Studies*
Author Cases Controls OR % of Non-Smokers
Doll & Hill 0.3 4.2 14
Wynder & Graham 1.3 14.6 13
*More than 600 Men per group. Smokers were all life-long smokers, and ex-smokers were carefully excluded
Conclusion: Life-long Smokers are 13-14 times as likely to get lung cancer as life-long never smokers
Cancers associated with smokingCancers associated with smoking
Major causeMajor cause• Lip• Mouth• Pharynx• Oesophagus• Larynx• Lung• Pancreas• Kidney, pelvis• Bladder
AssociatedAssociated• Nose• Stomach• Kidney, body• Liver• Colorectal• Cervix uteri• Childhood cancer
TobNutr AD164
From: Doll, 1988From: Doll, 1988
Cardiovascular disease, mainly heart disease and strokeCancerChronic respiratory diseasesDiabetes
Chronic Non-communicable Diseases-NCD
Adult per capita consumption of tobacco products in the 20th Century in Australia
Year
0.0000
0.5000
1.0000
1.5000
2.0000
2.5000
3.0000
3.5000
4.0000
1903
1906
1909
1912
1915
1918
1921
1924
1927
1930
1933
1936
1939
1942
1945
1948
1951
1954
1957
1960
1963
1966
1969
1972
1975
1978
1981
1984
1987
1990
1993
1996
An
nu
al
am
ou
nt
of
tob
ac
co
du
tie
d p
er
ad
ult
ov
er
15
ye
ars
( k
g)
Depression
World War II
Uptake by women
Early research on health effects of smoking Report of the US Surgeon
GeneralBroadcast of tobacco advertising phased out
Commencement of Quit Campaigns Tobacco Taxation
Workplace smoking bans introduced
New health warnings
Introduction of manufactured cigarettes
0
10
20
30
40
50
60
70
80
0
5
10
15
20
25
30
35
40
45
50
1940 1950 1960 1970 1980 1990 2000
Lungcancer
mortality
Smokingprevalence
0
10
20
30
40
50
60
70
80
0
5
10
15
20
25
30
35
40
45
50
1940 1950 1960 1970 1980 1990 2000
Lung cancermortality
Smokingprevalence
Male Female
Trends in lung cancer mortality and smoking prevalence in Australia 1940-2004
AD145
Impact of lung cancer on male cancer mortality trends in Australia: 1910–94
18
0
17
0
16
0
15
0
14
0
13
0
12
0
11
0
10
0
90
80
Ag
e s
tan
dard
ised
mort
ality
per
100,0
00 m
ale
s
Year of Death
1910
All cancer
All cancer without lung
Anti-Cancer Council of Victoria Epidemiology Centre, 1996
1920 1930 1940 1950 1960 1970 1980 1990
TobNutr
Taxation is the most effective measure
around the globe – As taxes/prices increase, consumption falls
• A 10% increase in price reduces cigarette consumption by:
– 4% in developed countries,
– 8% in developing countries
– People with low incomes (including youth) are more price-sensitive
• A 10% price increase reduces smoking as much as 10% among youth and poor groups
• Deters youth from taking up smoking
How Price/Tax Measure WorkPrice Elasticity Evidence
As price/ tax increases, consumption decreases
Trend in Consumption and Price per pack of Cigarettes in China,
1990-1999
65
66
67
68
69
70
71
72
1990 1991 1992 1993 1994 1995 1996 1997 1998
Source: USDA and Teh-Wei Hu,2000
Pa
ck p
er c
apit
a
0
0.5
1
1.5
2
2.5
Re
al p
rice
per
p
ack
(198
7=10
0)
Yu
an
Packs/capita
Real price/pack
Prevalence of Tobacco Use in China: Taxation Works
CURRENT ADULT SMOKING:PERCENTAGES
Year Total Adults Men Women
1996
Yang et al
32 63 5
2002
Yang et al
31 57 3
2004
1st BRFS
26 49 2
Tobacco advertising: Most effective way of gaining market share and
attracting new smokers
Evidence show that: Smokers often associate smoking imported-cigarettes with: – Glamour– Economic independence – High social status– Smoking healthier cigarettes
• with low tar and nicotine level and “light” brands
– Better taste and easy inhale “quality”– Competitive prices with domestic brands
Countries that support advertising ban with comprehensive TC measures are more successful on reducing consumption
Banning Tobacco Advertising Works
Advertising ban in Norway
,
1 9 5 0 '5 5 '6 0 '6 5 '7 0 '7 5 '8 0 '8 5 9 0 9 5 '0 0 '0 51 0 0 0
1 1 0 0
1 2 0 0
1 3 0 0
1 4 0 0
1 5 0 0
1 6 0 0
1 7 0 0
1 8 0 0
1 9 0 0
2 0 0 0
2 1 0 0
G ra m s o f to b a c c o c o n s u m e d p e r c a p ita
Complete ban on advertising
Smoking Rates: CaliforniaAnti Tobacco Mass Media Works
1.5
2
2.5
3
1980
1982
1984
1986
1988
1990
1992
1994
Pac
ks
smok
ed (
bill
ion
s)
Proposition 99
Media campaign suspended and reinstated
Historical trend
Stan Glanz Tobacco Wars-Media impact
Government ResponsibilitiesWHO Framework Convention on Tobacco
Control (FCTC) 2005, Signed by Most Countries and Ratified by Many: includes
Monitor tobacco use and prevention policies
Protect people from tobacco smokeOffer help to quit tobacco useWarn about the dangers of tobaccoEnforce bans on tobacco advertising,
promotion, and sponsorship Raise taxes on tobacco