1

Epidemiology of Tobacco-Related Health Disparities

SOC W 598, HSERV 590 A

Integrative Seminar on Health Disparities:

The Case of Tobacco

April 1, 2009

Gary A. Giovino, PhD, MSProfessor and Chair

Department of Health Behavior

School of Public Health and Health Professions

University at Buffalo, SUNY

Overview of Today’s Talk

Disparities

Consequences of tobacco use and

exposure to tobacco smoke pollution

Patterns of use

Epidemiologic Model of Tobacco Control

and Nicotine Addiction

Agent

Vector Host

Tobacco Products

Tobacco Product

Manufacturers;

Other Users

Smoker/Chewer

Incidental Host

EnvironmentFamilial, Social,

Cultural, Political,

Economic, Historical,

Media

Involuntary Smoker

Source: Orleans & Slade, 1993;

Giovino 2002

2

Consequences of Use

Global Burden of Tobacco

• Tobacco killed 100 million people

worldwide in the 20th Century

– Leading preventable cause of death - kills up to

half of people who use it

• Unless urgent action is taken

– By 2030 tobacco will kill >8 million people each

year - 80% in developing countries

– Tobacco could kill 1 billion people during the

21st Century - unless we act now

3

0 5 10 15 20 25 30 35

Cardiov ascular

Cancer

Stroke

B rochitis/emphy sema

Unintential injuries

Diabetes

Influenza/pneumonia

Alzehimer's disease

Nephritis/nephrotic

Septicemia

Percentage (of all deaths)

Source: Mokdad et al. JAMA 2004; 291:1238-1245

Leading Causes of Death, United States, 2000*

0 5 10 15 20

Tobacco

Poor diet/lack of ex ercise

Alcohol

Microbial agents

Pollutants/tox ics

Motor Vehicles

Firearms

Sex ual B ehav iors

Illicit drug use

Percentage (of all deaths)

Actual Causes of Death, United States, 2000*

Chronic Disease and Related Factors

Smoking and Tobacco Smoke Pollution

Damage Every Part of the Body

Smoking

Tobacco Smoke Pollution

8Source: WHO, Report on the Global Tobacco

Epidemic, 2008. The MPWOER Package; page 11.

132,332 (30%)

147,009 (33%)

Source: CDC. MMWR;

November 14, 2008

4

Smoking and Tobacco Smoke Pollution

Damage Every Part of the Body

Smoking

Tobacco Smoke Pollution

10Source: WHO, Report on the Global Tobacco

Epidemic, 2008. The MPWOER Package; page 11.

The Health Consequences of Involuntary

Exposure to Tobacco Smoke

Major Conclusions:

1) Secondhand smoke causes premature death and

disease in children and in adults who do not

smoke.

2) Children exposed to secondhand smoke are at an

increased risk for sudden infant death syndrome

(SIDS), acute respiratory infections, ear problems,

and more severe asthma. Smoking by parents

causes respiratory symptoms and slows lung

growth in their children.

Source: USDHHS; A Report of the Surgeon General (2006)

The Health Consequences of Involuntary

Exposure to Tobacco Smoke

3) Exposure of adults to secondhand smoke has

immediate adverse effects on the cardiovascular

system and causes coronary heart disease and

lung cancer.

4) The scientific evidence indicates that there is no

risk-free level of exposure to secondhand smoke.

5) Many millions of Americans, both children and

adults, are still exposed to secondhand smoke in

their homes and workplaces despite substantial

progress in tobacco control.

Source: USDHHS; A Report of the Surgeon General (2006)

5

The Health Consequences of Involuntary

Exposure to Tobacco Smoke

6) Eliminating smoking in indoor spaces fully

protects nonsmokers from exposure to

secondhand smoke. Separating smokers from

nonsmokers, cleaning the air, and ventilating

buildings cannot eliminate exposures of

nonsmokers to secondhand smoke.

Source: USDHHS; A Report of the Surgeon General (2006)

Moist

snuff

Fine cut

Long cut

Chewing Tobacco

Loose leaf

Moist plug

Dry snuff

Other products

Twist Roll

Disease Caused by Tobacco Use

Tobacco smoke pollution (secondhand smoke, environmental tobacco smoke) is a cause of:

Lung cancer and coronary heart disease in nonsmokers

- 49,400 annual deaths (11% of SAM)

Respiratory infections and symptoms in the children of

parents who smoke

Smokeless tobacco causes:

Oral cancer

Oral leukoplakia

Dental caries (possibly)

Cigars cause:

Cancers of the mouth, larynx, and lung

Coronary heart disease

COPD

6

Oral Cancer in a 20 Year-Old

Man Who Used ST

7

8

9

40.0

60.0

80.0

100.0

120.0

16 20 24 28 32Current Smoking Prevalence

Isch

emic

Hea

rt D

isea

se

Mo

rta

lity

(1

00

,00

0)

State-Specific Estimates of Current Smoking Prevalence (1) and Ischemic

Heart Disease Mortality (2) among Persons 35 to 64 Years in the United

States, 1998-2000

1. Source: NCI-sponsored Tobacco Use Supplement to the Current Population Survey, 1998-99;

2. Source: NCHS mortality data from CDC Wonder System, 1999-2000.

Note: Mortality data were age-adjusted to the 2000 U.S. population.

r2 =0.548

ß =3.929

P <0.001

N = 51

MS

KY

UT

CA

OK

AR

40.0

50.0

60.0

70.0

80.0

90.0

100.0

110.0

120.0

130.0

140.0

150.0

160.0

22 26 30 34 38 42 46Current + Former Smoking Prevalence

Lu

ng

Ca

nce

r M

ort

ali

ty (

10

0,0

00

)

Prevalence of Current and Former Smoking Quit Less than 15 Years (1)

and Lung Cancer Mortality (2) among Persons 35 Years or Older in the

United States, 1998-2000

1. Data from Current Population Survey, 1998-99;

2. Data from CDC Wonder System, 1999-2000.

Note: Smoking and mortality estimates were age-adjusted to the 2000

projected U.S. population

r2 =0.520

ß =4.161

P <0.001

N = 51

WV

KY

ME

UT

CA

HI

State-Specific Estimates of Cigarette Smoking Prevalence (1)

and Smoking-Attributable Mortality Rate(2) among U.S.

Adults

140.0

165.0

190.0

215.0

240.0

265.0

290.0

315.0

340.0

365.0

390.0

8 12 16 20 24 28Current Smoking Prevalence

Sm

ok

ing

Att

rib

uta

ble

Mo

rta

lity

Ra

te

1. Among persons age 30 years and older; Source: NCI Tobacco Use Supplement to the Current

Population Survey, 2003 estimates

2. Source: MMWR 2005;54:625-628.

r2 = 0.49

ß = 10.36

P < 0.001

N = 51

KYNV WV

CA

HI

UT

MN

10

Age-adjusted Lung Cancer Mortality Rates among

Women > 35 years old: 1979-2002

0

25

50

75

100

1979

1981

1983

1985

1987

1989

1991

1993

1995

1997

1999

2001

Dea

th R

ate

KENTUCKY ARKANSAS

USA

UTAH

CALIFORNIA

Age-adjusted to the 2000 US population

Racial/Ethnic Differences in Lung

Cancer – The Multiethnic Cohort Study

• Among persons smoking < 30 CPD lung cancer was: – Highest among African Americans and

Native Hawaiians

– Intermediate among Whites

– Lowest among Japanese Americans and Latinos

– Consistent by sex and by histological type

• Among persons smoking > 30 CPD:– No significant differences

Source: Haiman et al. Ethnic and Racial Differences in Smoking-Related Risk of Lung Cancer. NEJM

2006.354(4):333-342.

Source: MMWR, July 11, 2008

11

The Health Consequences of Smoking:

Nicotine Addiction

Major Conclusions:

1) Cigarettes and other forms of tobacco are

addictive.

2) Nicotine is the drug in tobacco that causes

addiction.

3) The pharmacologic and behavioral processes

that determine tobacco addiction are similar to

those that determine addiction to drugs such

as heroin and cocaine.

Source: USDHHS; A Report of the Surgeon General (1988)

Patterns of Use

12

Conceptual Model of Factors

Influencing Trends in Adolescent

Smoking – United States, 1975-2001

0

5

10

15

20

25

30

35

40

45

1975 1977 1979 1981 1983 1985 19871989 1991 1993 1995 1997 1999 2001

YEAR

PE

RC

EN

T

Data Source: Institute for Social Research, University of Michigan, Monitoring the Future Surveys

Total Cigarette Sales and Cigarette Prices, US, 1970-2005

18000

20000

22000

24000

26000

28000

30000

1970 1973 1976 1979 1982 1985 1988 1991 1994 1997 2000 2003

Fiscal Year

To

tal S

ale

s (

millio

n p

ac

ks

)

$1.20

$1.70

$2.20

$2.70

$3.20

$3.70

$4.20

Real

Cig

arett

e P

ric

e

Cigarette Sales (million packs) Real Cigarette Price

Source: Tax Burden on Tobacco, 2006, and author’s calculations

Trends in Per Capita Consumption of Various Tobacco Products – United

States, 1880-2004

Source: Tobacco Situation and Outlook Report, U.S. Department of Agriculture, U.S. Census

Note: Among persons > 18 years old.

Beginning in 1982, fine-cut chewing tobacco was reclassified as snuff. Estimates for 2002 and 2003 are preliminary.

0

2

4

6

8

10

12

14

16

1880

1885

1890

1895

1900

1905

1910

1915

1920

1925

1930

1935

1940

1945

1950

1955

1960

1965

1970

1975

1980

1985

1990

1995

2000

YEAR

PO

UN

DS

Cigarettes Cigars Pipe/Roll your own Chewing Snuff

13

Per Capita Consumption (in pounds) of Tobacco

Products Other than Cigarettes -- United States,

1992-2005

0

0.1

0.2

0.3

0.4

1992 1994 1996 1998 2000 2002 2004

po

un

ds

of

tob

acc

o Snuff

Chew

Large Cigars

Small Cigars

RYO/Pipe

Source: US Department of Agriculture; Cristine Delnevo, UMDNJ

Adult Per Capita Cigarette Consumption and Major

Smoking and Health Events – United States, 1900-2005

0

1000

2000

3000

4000

5000

1900 1910 1920 1930 1940 1950 1960 1970 1980 1990 2000

YEAR

Nu

mb

er o

f C

igarett

es

Source: United States Department of Agriculture; Centers

for Disease Control and Prevention

End of WW II

1st Smoking-Cancer

Concern

Fairness Doctrine

Messages on TV

and Radio

Non-Smokers

Rights Movement

Begins

Federal Cigarette

Tax Doubles

Surgeon

General’s

Report on ETS

1st Surgeon

General’s Report

Broadcast

Ad Ban1st Great American

Smoke-out

OTC Nicotine

Medications

Master

Settlement

Agreement

Great Depression

14

Adult Per Capita Cigarette Consumption and Major

Smoking and Health Events – United States, 1900-2005

0

1000

2000

3000

4000

5000

1900 1910 1920 1930 1940 1950 1960 1970 1980 1990 2000

YEAR

Nu

mb

er o

f C

igarett

es

Source: United States Department of Agriculture; Centers for Disease Control and Prevention

End of WW II

1st Smoking-Cancer

Concern

Fairness Doctrine

Messages on TV

and Radio

Non-Smokers

Rights Movement

Begins

Federal Cigarette

Tax Doubles

Surgeon

General’s

Report on ETS

1st Surgeon

General’s Report

Broadcast

Ad Ban1st Great American

Smoke-out

OTC Nicotine

Medications

Master

Settlement

Agreement

Great Depression

15

16

Adult Per Capita Cigarette Consumption and Major

Smoking and Health Events – United States, 1900-2005

0

1000

2000

3000

4000

5000

1900 1910 1920 1930 1940 1950 1960 1970 1980 1990 2000

YEAR

Nu

mb

er o

f C

igarett

es

Source: United States Department of Agriculture; Centers for Disease Control and Prevention

End of WW II

1st Smoking-Cancer

Concern

Fairness Doctrine

Messages on TV

and Radio

Non-Smokers

Rights Movement

Begins

Federal Cigarette

Tax Doubles

Surgeon

General’s

Report on ETS

1st Surgeon

General’s Report

Broadcast

Ad Ban1st Great American

Smoke-out

OTC Nicotine

Medications

Master

Settlement

Agreement

Great Depression

17

Adult Per Capita Cigarette Consumption and Major

Smoking and Health Events – United States, 1900-2005

0

1000

2000

3000

4000

5000

1900 1910 1920 1930 1940 1950 1960 1970 1980 1990 2000

YEAR

Nu

mb

er o

f C

igarett

es

Source: United States Department of Agriculture; Centers for Disease Control and Prevention

End of WW II

1st Smoking-Cancer

Concern

Fairness Doctrine

Messages on TV

and Radio

Non-Smokers

Rights Movement

Begins

Federal Cigarette

Tax Doubles

Surgeon

General’s

Report on ETS

1st Surgeon

General’s Report

Broadcast

Ad Ban1st Great American

Smoke-out

OTC Nicotine

Medications

Master

Settlement

Agreement

Great Depression

Brown & Williamson on Nicotine….

“Moreover, nicotine is addictive… We are, then, in the business of selling nicotine, an addictive drug….”

Addison Yeaman; General Counsel to

the Brown & Williamson Tobacco

Company; July 17, 1963.

Source: U.S. Food and Drug Administration, 1996.

18

Philip Morris on Nicotine….

“Think of the cigarette pack as a storage container for a day’s supply of nicotine….

Think of the cigarette as a dispenser for a unit dose of nicotine…

Think of a puff of smoke as a vehicle of nicotine…

Smoke is beyond question the most optimized vehicle of nicotine and the cigarette the most optimized dispenser of smoke.”

Dr. William Dunn; Philip Morris Tobacco Company, 1972.

Source: U.S. Food and Drug Administration, 1996.

R. J. Reynolds chimes in….

“In a sense, the tobacco industry may be thought of as being a specialized, highly ritualized, and stylized segment of the pharmaceutical industry. Tobacco products uniquely contain and deliver nicotine, a potent drug with a variety of physiological effects.”

Claude Teague, R.J. Reynolds Tobacco Company, 1972.

Source: U.S. Food and Drug Administration, 1996.

19

Adult Per Capita Cigarette Consumption and Major

Smoking and Health Events – United States, 1900-2005

0

1000

2000

3000

4000

5000

1900 1910 1920 1930 1940 1950 1960 1970 1980 1990 2000

YEAR

Nu

mb

er o

f C

igarett

es

Source: United States Department of Agriculture; Centers for Disease Control and Prevention

End of WW II

1st Smoking-Cancer

Concern

Fairness Doctrine

Messages on TV

and Radio

Non-Smokers

Rights Movement

Begins

Federal Cigarette

Tax Doubles

Surgeon

General’s

Report on ETS

1st Surgeon

General’s Report

Broadcast

Ad Ban1st Great American

Smoke-out

OTC Nicotine

Medications

Master

Settlement

Agreement

Great Depression

20

21

Adult Per Capita Cigarette Consumption and Major

Smoking and Health Events – United States, 1900-2005

0

1000

2000

3000

4000

5000

1900 1910 1920 1930 1940 1950 1960 1970 1980 1990 2000

YEAR

Nu

mb

er o

f C

igarett

es

Source: United States Department of Agriculture; Centers for Disease Control and Prevention

End of WW II

1st Smoking-Cancer

Concern

Fairness Doctrine

Messages on TV

and Radio

Non-Smokers

Rights Movement

Begins

Federal Cigarette

Tax Doubles

Surgeon

General’s

Report on ETS

1st Surgeon

General’s Report

Broadcast

Ad Ban1st Great American

Smoke-out

OTC Nicotine

Medications

Master

Settlement

Agreement

Great Depression

US Consumption of Cigars1950 - 2002

0

2

4

6

8

10

1950 1954 1958 1962 1966 1970 1974 1978 1982 1986 1990 1994 1998 2002

Year

Billio

ns

of

cig

ars

Large cigars Small cigars

SGR

Begin advertising

little cigars

Ban advertising

of little cigars

Cigar

Aficionado

Source: USDA Tobacco Yearbook 2002; Tobacco Outlook 2003 TBS-254

22

23

Ariva Cigaletts “Medical” Packaging;

Claim-For when you can’t smoke

New Non-Combusted Products

Face the Future; Join the Movement

Electronic Cigarettes

A battery-powered device that provides inhaled

doses of nicotine by delivering a vaporized

propylene glycol/nicotine solution (Wikipedia) http://en.wikipedia.org/wiki/E-cigarette

24

Current Use Among U.S. Adults of Various

Tobacco Products, by Sex – National Health

Interview Survey, 2000

0

5

10

15

20

25

30

35

Any Use Cigarettes Cigars Pipes Snuff Chewing

Tobacco

Bidis

PE

RC

EN

T

Males

Females

Note: Current users report using either every day or on some days

Source: National Center for Health Statistics

31.3

21.3

25.7

21.0

4.5

0.2 1.00.1

2.5

0.1 0.1

2.5

0.10.2

Men

Women

0

10

20

30

40

50

60

1955 1960 1965 1970 1975 1980 1985 1990 1995 2000 2005

YEAR

% C

UR

RE

NT

SM

OK

ER

S

Trends in cigarette smoking* among adults aged

>18 years, by sex - United States, 1955-2007

Source: 1955 Current Population Survey; 1965-2007 National Health Interview Surveys (NCHS, CDC).

*Before 1992, current smokers were defined as persons who reported having smoked >100 cigarettes

and who currently smoked. Since 1992, current smokers were defined as persons who reported having smoked >100 cigarettes during their lifetime and who reported now smoking every day or some days.

22.3%

17.4%

0

10

20

30

40

50

60

1965

1967

1969

1971

1973

1975

1977

1979

1981

1983

1985

1987

1989

1991

1993

1995

1997

1999

2001

2003

2005

2007

Year

18-24 25-44 45-64 >=65

Per

cen

t

Trends in cigarette smoking* by age -

United States, 1965-2007

*Before 1992, current smokers were defined as persons who reported having smoked >100 cigarettes

and who currently smoked. Since 1992, current smokers were defined as persons who reported having

smoked >100 cigarettes during their lifetime and who reported now smoking every day or some days.

Source: various National Health Interview Surveys from 1965 - 2007, National Center for Health Statistics

25

05

1015

2025

3035

4045

50

1965

1970 72

1974 76 78

1980 82 84 86 88

1990 92 94 96

1998

2000

2002

2004

2006

Year<8 years 9-11 years 12 years 13-15 years >=16 years

Per

cen

t

Trends in cigarette smoking* among adults

aged >25 years, by education- United

States, 1970-2006

*Before 1992, current smokers were defined as persons who reported having smoked >100 cigarettes

and who currently smoked. Since 1992, current smokers were defined as persons who reported having

smoked >100 cigarettes during their lifetime and who reported now smoking every day or some days.

Source: various National Health Interview Surveys from 1970 - 2006, National Center for Health Statistics

Cigarette Smoking Trends among

Adults, by Race/Ethnicity, 1978-2004

Source: National Health Interview Surveys, 1978-2004, selected years, aggregate data

0

10

20

30

40

50

60

70

1978-

1980

2003-

2004

Year

Pe

rce

nt

American Indian

Hispanic

Asian

White

African American

1997-1998

1983-1985

1987-1988

1990-1991

1992-1993

1994-1995

1999-2000

Percentage of Adults Who Smoke Cigarettes

by Race/Ethnicity - United States, 2007

0

5

10

15

20

25

30

35

40

White Afr Amer Hispanic Native Asian/PI

Males

Females

Source: National Center for Health Statistics, 2007 National

Health Interview Survey

26

0

5

10

15

20

25

30

35

40

45

1982

1984

1986

1988

1990

1992

1994

1996

1998

2000

2002

2004

2006

YearAt/above Below

Per

cen

t

Trends in cigarette smoking* among adults,

by poverty status - United States, 1983-2007

*Before 1992, current smokers were defined as persons who reported having smoked >100 cigarettes and who

currently smoked. Since 1992, current smokers were defined as persons who reported having smoked >100 cigarettes

during their lifetime and who reported now smoking every day or some days.

Source: various National Health Interview Surveys from 1983 - 2007, National Center for Health Statistics, CDC.

28.8%

20.3%

0

10

20

30

40

50

60

70

80

1965 69 73 77 1981 1985 89 93 97 2001 2005

Year

18-24 25-44 45-64 >=65

% F

orm

er S

mo

ker

s

Source: various National Health Interview Surveys, 1966 - 2006

*Ever-smoked 100 + Cigarettes

Also known as the “quit ratio”, estimates since 1992 incorporates same-day smoking

Percentage of Ever Smokers* Who Are Former

Smokers , by Age – United States, 1965 -2006

0

10

20

30

40

50

60

70

80

69 73 77 1981 1985 89 93 97 2001 2005

Year

<8 9-11yrs 12 13-15 > = 16

% F

orm

er S

mo

ker

s

Source: various National Health Interview Surveys, 1970 -2006

*Ever-smoked 100 + Cigarettes

Also known as the “quit ratio”, estimates since 1992 incorporates same-day smoking

Percentage of Ever Smokers* Who Are Former

Smokers, by Education, Adults Aged > 25

Years – United States, 1970 -2006

27

Percentage of Ever Smokers* Who Are

Former Smokers, Adults Aged ≥ 18 Years,

by Race/Ethnicity-United States, 1978-2006

0

10

20

30

40

50

60

1978

1980

1982

1984

1986

1988

1990

1992

1994

1996

1998

2000

2002

2004

2006

Year

Percen

t

Hispanic

African American

White

Asian

American Indian

Source: National Health Interview Surveys, 1965-2006;

Centers for Disease Control and Prevention: National Center for Health Statistics and Office on Smoking and Health.

*Ever-smoked >100 cigarettes,

Also known as the quit ratio. Note: estimates since 1992 incorporate same-day smoking

0

10

20

30

40

50

60

1982

1984

1986

1988

1990

1992

1994

1996

1998

2000

2002

2004

2006

Year

Per

cen

t

Percentage of Ever Smokers* Who Are Former

Smokers, Adults Aged > 18 Years, by Poverty

Status - United States, 1983-2006

Source: National Health Interview Surveys, 1983-2006;

Centers for Disease Control and Prevention: National Center for Health Statistics and Office on

Smoking andHealth.

*Ever-smoked >100 cigarettes,

Also known as the quit ratio. Note: estimates since 1992 incorporate some-day smoking

52.2%

30.9%

Below poverty line

At/above poverty line

28

29

0.0

10.0

20.0

30.0

35,000 45,000 55,000 65,000Median Household Income ($)

Cu

rren

t S

mo

kin

g P

rev

ale

nce

(%

)

Median Household Income and Current Smoking

Prevalence, Ages 25+, by State – United States,

2006/2007

Source: Tobacco Use Supplement to the Current Population Survey, U.S. Census Bureau

40.0

45.0

50.0

55.0

60.0

65.0

35,000 45,000 55,000 65,000Median Household Income ($)

Per

cen

t F

orm

er S

mo

ker

s

Median Household Income and the Prevalence of

Ever Smokers Who’ve Quit, Ages 25+, by State –

United States, 2006/2007

Source: Tobacco Use Supplement to the Current Population Survey, U.S. Census Bureau

30

0.0

50.0

100.0

150.0

200.0

250.0

300.0

35,000 45,000 55,000 65,000Median Household Income ($)

Cig

are

tte

Ex

cise

Ta

x (

cen

ts)

Median Household Income and the Cigarette Excise

Tax Rate, by State – United States, 2006/2007

Source: Tobacco Use Supplement to the Current Population Survey, U.S. Census Bureau

0.0

10.0

20.0

30.0

40.0

35,000 45,000 55,000 65,000Median Household Income ($)

Str

eng

th o

f S

mo

ke-

Fre

e L

egis

lati

on

Median Household Income and the Strength of State-level

Smoke-Free Air Legislation, by State – United States,

2006/2007

Source: Tobacco Use Supplement to the Current Population Survey, MayaTech Corporation

Youth Tobacco Use

• Approximately 90% of adult smokers in the

US smoked their first cigarette before age

18 years.

• Each day in the United States approximately

4,000 12-17 year old youths try their first

cigarette and another 1,140 become daily

cigarette smokers

31

Current Use Among Middle and High School

Students by Type of Tobacco Product –

National Youth Tobacco Survey, 2004

0

5

10

15

20

25

30

Any Use Cigarettes Cigars Smokeless Pipes Bidis Kreteks

PE

RC

EN

T

Middle School

High School

Note: Used tobacco on > 1 of the 30 days preceding the survey

Source: American Legacy Foundation, National Youth Tobacco Survey

11.7

28.0

8.1

22.3

5.2

12.8

2.9

6.0

2.6 3.1 2.61.5

2.3 2.3

Trends in Cigarette Smoking Anytime

in the Past 30 days by Grade in School

– United States, 1975-2008

0

5

10

15

20

25

30

35

40

45

1975

1977

1979

1981

1983

1985

1987

1989

1991

1993

1995

1997

1999

2001

2003

2005

2007

YEAR

PE

RC

EN

T

Source: Institute for Social Research, University of Michigan, Monitoring the Future

Surveys

12th Grade

8th Grade

10th Grade 20.4% in 2008

12.3% in 2008

6.8% in 2008

0

5

10

15

20

25

30

35

40

1973

1975

1977

1979

1981

1983

1985

1987

1989

1991

1993

1995

1997

1999

2001

2003

2005

2007

Year

Adults HS Seniors

Per

cen

t

Trends in cigarette smoking among

adults and high school seniors --

United States, 1974-2007

*Adult data are from the National Health Interview Surveys., ages > 18 year olds. Before 1992, current smokers were

defined as persons who reported having smoked >100 cigarettes and who currently smoked. Since 1992, current smokers

were defined as persons who reported having smoked >100 cigarettes during their lifetime and who reported now smoking every day or some days. High School Senior data are on daily smoking. Source: University of Michigan, Institute for Social

Research, Monitoring the Future

32

Trends in Prevalence of Past Month Cigarette

Smoking Among High School Seniors by

Gender – United States, 1975-2008

0

5

10

15

20

25

30

35

40

45

1975 1978 1981 1984 1987 1990 1993 1996 1999 2002 2005 2008

YEAR

PE

RC

EN

T

Source: Institute for Social Research, University of Michigan, Monitoring the Future Surveys

Male

Female

Trends in Prevalence of Past Month

Cigarette Smoking Among High School

Seniors by Race – United States, 1977-2008

0

5

10

15

20

25

30

35

40

45

1977 1980 1983 1986 1989 1992 1995 1998 2001 2004 2007

YEAR

PE

RC

EN

T

Source: Institute for Social Research, University of Michigan, Monitoring the Future Surveys; for racial subgroups,

data for the current year and the previous year are combined

White

Black

Hispanic

Trends in Smokeless Tobacco Use Anytime in the Past

30 Days Among High School Seniors by Sex – United

States, 1992-2008

0

5

10

15

20

25

1991

1993

1995

1997

1999

2001

2003

2005

2007

YEAR

PE

RC

EN

T

Source: Institute for Social Research, University of Michigan, Monitoring the Future Surveys

Males

Females

11.8% in 2008

1.0% in 2008

33

Trends in Smokeless Tobacco Use Anytime in the Past

30 Days Among High School Seniors by Population

Density – United States, 1992-2008

0

2

4

6

8

10

12

14

16

18

20

1991

1993

1995

1997

1999

2001

2003

2005

2007

YEAR

PE

RC

EN

T

Source: Institute for Social Research, University of Michigan, Monitoring the Future Surveys

Non-MSA

Large MSA

Other MSA

11.8% in 2008

6.2% in 2008

2.6% in 2008

National Youth Risk Behavior Survey, 2007

* Used chewing tobacco, snuff, or dip on at least 1 day during the 30 days before the

survey.

** M > F *** W > H > B

Percentage of High School Students Who Currently

Used Smokeless Tobacco,* by Sex** and

Race/Ethnicity,*** 2007

13.410.3

1.24.7

7.9

2.3

0

20

40

60

80

100

Total Female Male White Black Hispanic

Perc

en

t

National Youth Risk Behavior Survey, 2007

* Smoked cigars, cigarillos, or little cigars on at least 1 day during the 30 days before the

survey.

** M > F*** W > H > B

Percentage of High School Students Who

Currently Smoked Cigars,* by Sex** and

Race/Ethnicity,*** 2007

19.414.8

10.012.7

13.6

7.6

0

20

40

60

80

100

Total Female Male White Black Hispanic

Perc

en

t

34

Past Month Cigarette Use among Persons Aged 12

or Older, by Age: 2006

Percent Using in Past Month

1.7

9.1

19.9

35.6

40.2

36.4

32.0

28.029.4 29.6

26.7

22.7

18.6

9.5

0

10

20

30

40

50

12-13 14-15 16-17 18-20 21-25 26-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65+

Age in YearsSource: National Survey on Drug Use and Health, SAMHSA

Trends in Per Capita Consumption of Various Tobacco Products – United

States, 1880-2004

Source: Tobacco Situation and Outlook Report, U.S. Department of Agriculture, U.S. Census

Note: Among persons > 18 years old. Beginning in 1982, fine-cut chewing tobacco was reclassified as snuff.

0

2

4

6

8

10

12

14

16

1880

1885

1890

1895

1900

1905

1910

1915

1920

1925

1930

1935

1940

1945

1950

1955

1960

1965

1970

1975

1980

1985

1990

1995

2000

YEAR

PO

UN

DS

Cigarettes Cigars Pipe/Roll your own Chewing Snuff

Trends in Per Capita Consumption of Various

Tobacco Products – United States, 1880-2004 and

Linear Projection to 2035

0

2

4

6

8

10

12

14

16

1880

1885

1890

1895

1900

1905

1910

1915

1920

1925

1930

1935

1940

1945

1950

1955

1960

1965

1970

1975

1980

1985

1990

1995

2000

2005

2010

2015

2020

2025

2030

2035

YEAR

PO

UN

DS

Cigarettes Cigars Pipe/Roll your own Chewing Snuff

35

Paradigm for Tobacco Control

Price/economic

Smoke-free air

Anti-Tobacco Mass Media

Cessation activities

Prevention activities

Product Regulation

Liability

Access

Industry Marketing

Society

Tobacco

AddictionIndividual