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Copyright 2006, The Johns Hopkins University and Jonathan Samet. All rights reserved. Use of these materials permitted only in accordance with license rights granted. Materials provided “AS IS”; no representations or warranties provided. User assumes all responsibility for use, and all liability related thereto, and must independently review all materials for accuracy and efficacy. May contain materials owned by others. User is responsible for obtaining permissions for use from third parties as needed.
The Tobacco Epidemic: An Historical Overview
Jonathan Samet, MD, MSInstitute for Global Tobacco Control
3
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 smokingServed as consultant editor and senior editor for Reports of the Surgeon General on Smoking and Health
Image source: Institute for Global Tobacco Control
5
“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
7
Tobacco
Image source: jones.house.gov/html/ photo.cfm?id=140&cat=3, retrieved 11/2/05
Wild Tobacco(Nicotiana rustica)
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.
Cultivated Tobacco(Nicotiana tabacum)
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.
8
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
9
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
10
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
11
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
12
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 byDr. Isaac Adler
13
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
14
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”
15
Evolution of the Modern Cigarette
1789–99− During the French Revolution, cigarette use
popularized as least like aristocratic snuff1832− 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
16
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
17
Tobacco andadditives
Tipping paper & plugwrap
paper
Filter
Monogramink
Cigarette paper & adhesive
Ventilationholes
The Manufactured Cigarette
Image adapted from: Mackay, J. & M. Eriksen. The Tobacco Atlas. World Health Organization.
18
Smoke Components
PAHsBenzo(a)pyreneAza-arenesN-NitrosaminesAromatic amines−2-Napthylamine−4-Aminobiphenyl
N-Heterocyclic aminesAldehydes
Organic compounds−1, 3-Butadiene−Benzene−Vinyl chloride−Acrylamide
Inorganic compounds−Arsenic−Chromium−Polonium-210
Source: Hoffmann and Hoffmann. (1997).
19
The Process of Manufacturing a Modern Cigarette
Primary Area—Processing− Increase moisture− Casing application− Redrying process− Cutting process− Humidifying− Final blending
Image source: http://www.fas.usda.gov/tobacco/circular/1997/9706/vietnam.htm, 11/2/05
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
20
The Process of Manufacturing a Modern Cigarette
Secondary Area: Fabrication
− Cigarette-making machineWraps tobacco into paperApplies adhesiveCuts to a specified length
− Filter rod machine
− Cigarette packer
Image source: http://www.fas.usda.gov/tobacco/circular/1997/9706/vietnam.htm, 2/3/06
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
21
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
ContinuedImage source: www.loc.gov/exhibits/ british/britobje.html, 11/2/05
22
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
23
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
24
The Changing Cigarette1913—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).
25
The Changing Cigarette: Advertising
Image source: http://cancercontrol.cancer.gov/tcrb/monographs/5/m5_foreword.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: Advertising
Image source: http://cancercontrol.cancer.gov/tcrb/monographs/13/m13_7.pdf retrieved 2/28/06
28
The Changing Cigarette
Tar and Nicotine Content of U.S. Cigarettes, Sales-Weighted Average Basis, 1957–1987
1955
10
01960 1965 1970 1975 1980 1985
20
30
40
1.0
0.0
2.0
3.0
4.01957–Reconstituted Tobacco
1959–Porous Paper
1967—Expanded Tobacco1971–Ventilation
Nicotine
Tar
Sale
s-W
eig
hte
d ta
r (m
g)
Year
Sales-Weig
hted
Nico
tine (m
g)
Source: US Surgeon General Report, 1989 – Update with Monograph 13
29
Sales-Weighted Tar and Nicotine Yields: 1968–1997
Source: US Surgeon General Report, 1989 – Update with Monograph 13Chart is based on data in Table 2-1, pg 14 of Monograph 13.
According to pg 2 of same, figures before 1968 were estimated.
30
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
31
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
32
Cigarette Filters
‘Light’ brands Full flavor brands
• Have more filter perforations • Have less filter perforations
% filter ventilation = 12.65 % filter ventilation = 27.27
33
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 machine-measured yields of tar and nicotine. National Institutes of Health, Monograph 13. October 2001.
34
Additional Information
For more information on the industry’s rational for ammonia technology and other changes to cigarettes, see the lecture entitled “Nicotine Addiction”
36
Early Health Warnings
1938: Dr. Raymond Pearl reports smokers do not live as long as non-smokers
Tobacco and longevity survivorship of white males after 30 years of age according to smoking habits
0
10
20
30
40
50
60
70
80
90
100
30 40 50 60 70 80 90Age in years
Thou
sand
s of
sur
vivo
rs
NonsmokersModerate smokersHeavy smokers
Data source: http://medicolegal.tripod.com/pearl1938.htm retrieved 2/26/06
37
Early Health Warnings
1939—Franz HermannMuller of Germany findsstrong dose-responsebetween smoking andlung cancer
Image source: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1117732 retrieved 2/26/06
38
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.
39
1950: Three Key Case-Control Studies
Morton Levin publishes study linking smoking and lung cancer in the Journal of the American Medical Association (JAMA)
Ernst L. Wynder and Evarts A.Graham publish study in JAMA in which 96.5% of lung cancer patients interviewed were smokers
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)
40
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
41
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.”
42
The Industry Reacts
Announced formation of Tobacco Industry Research Committee (TIRC) in 1954; later renamed Council for Tobacco ResearchLaunched 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
43
Confidential Philip Morris Memo—1969The 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.”
44
1st Report of the Surgeon General on Smoking and Health
Surgeon General Luther Terryholding the 1964 Report
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”
Source: Centers for Disease Control. History of 1964 Surgeon General’s Report. Retrieved 11/26/02, from http://www.cdc.gov/tobacco/30yrsgen.htm
45
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
47
Smoking-Caused Diseases
Larynx—1980
Cancers
Esophagus—1982
Nasal and Oral Pharynx—1982
Lung—1964
Bladder—1990
Leukemia—1990
Kidney—1982
Stomach—2001
Cervix—2001
Liver—2001
Pancreas—1990
Ureter—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
48
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
49
Effects of Cigarette Smoking on Survival
Effects of Cigarette Smoking on Survival to Ages 70 and 85in 40-Year Prospective Study of Male British Doctors
Data source: Doll, Peto, et al. (1994). BMJ. 1994 Oct 8;309(6959):901-11.
50
Mortality Risks and Smoking-Attributable Deaths
Changes in Cigarette-RelatedMortality Risks and Percentagesof Deaths Attributable to ActiveCigarette Smoking
51
U.S. Age-Adjusted Lung Cancer Death Rate & Cigarette Consumption
0
500
1000
1500
2000
2500
3000
3500
4000
4500
5000
1900
1905
1910
1915
1920
1925
1930
1935
1940
1945
1950
1955
1960
1965
1970
1975
1980
1985
1990
1995
2000
Year
Per C
apita
Cig
aret
te C
onsu
mpt
ion
0
10
20
30
40
50
60
70
80
90
100
Age-
Adju
sted
Lun
g Ca
ncer
Dea
th
Rat
es*
*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.
Per capita cigarette consumption
Male lung cancer death rate
Female lung cancer death rate
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
52
Industry Regarding Addiction in 1994Seven 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
53
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
54
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
55
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
56
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.
57
Standard Mortality for Lung Cancer
0
10
20
30
40
Sta
ndar
d m
orta
lity
rate
for l
ung
canc
er p
er 1
00,0
00
21,895 69,645 17,366
Population at enrollment
(Non-smoker wives of non-smoker
husbands)
(Non-smoker wives of husbands with smoking habits)
(Women with smoking habits)
Non-smoker Familial passive
smoking (-)
Cigarette smokers
Non-smoker Familial passive
smoking (+)
Total 108,906
8-70
32-79
15-50
Data source: T. Hirayama. 1990. Contributions to Epidemiology and Biostatistics Vol. 6.
58
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.
59
Health Effects of SHS Exposure in Children
Sudden infant death syndrome (SIDS)Acute respiratory illnesses (ARI)Chronic respiratory symptomsReduced lung function growthAsthma and exacerbation of asthmasymptomsAcute and chronic middle ear disease
60
Health Effects of SHS Exposure in Adults
Established− Lung cancer− Respiratory symptoms − Cardiovascular disease− Exacerbation of asthma
Potential− Reduced lung function− Other cancers
61
Secondhand Smoke
1986—Surgeon General’s Report on Passive Smoking1993—EPA classifies SHS as a “Class A” carcinogen1994—Canadian scientists report finds evidence of cigarette smoke in fetal hair1998—California becomes first state to ban smoking in bars
62
The Industry Counterattack
Discount science
Maintain controversy
Hire consultants
Produce counter-science
63
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.
64
The Attack on Meta-Analysis
Tweedie, R.L. & K.L. Mengersen. 1995. Meta-analytic approaches to dose-response 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 Epidemiology44 (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.”
65
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.
66
Counter-Science
Junkscience.com
“All the junk that’s fit to debunk”
Articles:
- Secondhand smokescreen
- Passive smoke – the EPA’s betrayal of science
67
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.)
69
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
70
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
ContinuedImage source: http://memory.loc.gov/ammem/awhhtml/awgc1/periodicals.html retrieved 2/9/06
71
The Spread of the Tobacco Epidemic in the U.S.
1939—Sixty-six percent of U.S. males younger than forty are smokers1939–45—During World War II, cigarettes included in rations; Roosevelt makes tobacco a protected crop1940—U.S. per capita cigarette consumption has doubled since 1930 to 2,558 per year1948—Lung cancer increasing five times faster than other cancers (now second most common)1954—Marlboro cowboy campaign created for Philip Morris
Continued
72
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
73
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 Research Service, 2001. USDA Publication No. ERS-AO-278.
74
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).
75
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
76
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
77
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
79
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
80
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
81
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)
ContinuedSource: Peto and Lopez. (2001).
82
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
83
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.
84
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
85
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
World Bank Region Males Females Overall Millions Percentage of Smokers
East Asia and Pacific 59 4 32 401 35 Eastern Europe and Central Asia 59 26 41 148 13
Latin America and Caribbean 40 21 30 95 8
Middle East and North Africa 44 5 25 40 3
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
86
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).
87
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
88
Global Youth Tobacco Survey (GYTS)
33
19
27
40
18
59 58
34 35 33
41
23
0
10
20
30
40
50
60
Buenos Aire
s
Russian Federa
tion
(Mosc
ow)
South A
frica
Ukrain
e (Kie
v)Unite
d State
s
Bahamas
Bolivia
(Cochabam
ba)
Chile (C
oquimbo)
CubaIn
dia (B
ihar)
Palau
Poland (U
rban)
Percentage of Students Currently Using Any Form of Tobacco
Data source: http://www.cdc.gov/tobacco/global/GYTS.htm retrieved 2/26/06
89
The Global Tobacco Burden—The Poor
64%58%
42%
21%
0%
20%
40%
60%
Illiterate <6Years
6-12Years
>12Years
Length of Schooling
Smo
kin
g P
reva
len
ceSmoking Prevalence among Men in Chennai, India, by Education Levels
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.
90
Spreads Worldwide Through . . .
Trade liberalization
Direct foreign investment by industry
Advertising and marketing by industry
91
Top Tobacco Companies’ Global Market Share, 1999
British American Tobacco
16%
Japan Tobacco13%
China National Tobacco Corp
25%
Other Companies Combined
27%
Philip Morris17%
Reemstma2%
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
92
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
93
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
94
Quote
“Tobacco exports should be expanded aggressively, because Americans are smoking less.”
− Vice President Dan Quayle, 1990
95
Philip Morris International Tobacco Operations
0
5
10
15
20
25
30
35
Bill
ion
s of
Dol
lars
1989 1990 1991 1992 1993 1994 1995 1996 1997
RevenuesProfits
Data source: http://www.altria.com/investors/02_01_AnnualReport.asp accessed 2/10/06
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