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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

Section A

“Discovery” and Early Use of Tobacco and the Foundations of the Modern Epidemic

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

6

Early Forms of Use in the Americas

SmokingIngested orally as syrupSnuffChewing tobaccoEnemas

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”

Section B

Scientific Discovery and Efforts at Control

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

46

Reports of the Surgeon General

Image source: Institute for Global Tobacco Control

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.)

Section C

The Spread of the Tobacco Epidemic in the U.S.

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

Section D

The Global Epidemic

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