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