WHELAN, E.M. A Smoking Gun: HOZP the Tobacco lndust y    WORLD HEALTH ORGANIZATION. Tobacco or health.
Gets Azoay With Murder. Philadelphia, PennsyIvania: George   Forty-third World Health Assembly. HarzdbookofRrso(lrfiolls
F. Stickley Co., 1984.                      and Decisions of the World Hra1th Assembly and the Erecutizle
                     Board. Geneva:. World Health Assembly, $lay 17,199Oa.
WORLD HEALTH ORGANIZATION. Smokirlg Corztrol
Strategies in Developing Countries: Report of a WHO Expert     WORLD HEALTH ORGANIZATION. Tobacco or health:
Committee. WHO Technical Report Series, No. 695. Geneva:   Tobacco smoking in the Americas. Weekly Epidemiological
World Health Organization, 1983.            Rrcord/Relezu! Lpidkmiologque Hebdomadaire 65(21):157-164,
                            May 25,199Ob.


Chapter 6
Status of Tobacco Prevention
and Control Programs in the Americas

Preface   181

Introduction   183

National Programs for Tobacco Control   183

United States   783
Canada   184

Regional Activities for Tobacco Control in Latin America and the Caribbean   185

Elements of Prevention and Control Programs   186
Surveillance and Analysis   186
Education, Public Information, and Cessation Programs   287
Taxation   190
Legislation   191
Coalitions   194

Summary   196

Conclusions   296

Appendix 1. Antitobacco Activities in Latin America and the Caribbean   197

Appendix 2. Antitobacco Organizations in Latin America and Ihe Caribbean   202

References   204


Preface

  The Americas comprise diverse countries that hazje not dezyeloped synchronously. The
impact of many of the factors of dezlelopment discussed in the previous chapters-the
fransition to an industrialized economy, the changing populafion sfructure, the consolida-
tion of the tobacco industry, thegrozoing prez~alence of cigarette smoking, and the emerging
burden of smoking-attributable mortality-has differed among countries. Almost all coun-
tries have some form of antismoking activity, but the rrature and e.stent of that actisrity are
shaped by historical, epidemiologic, economic, and legal factors specific to each country.

  The current antismoking actiz,ities of governments and other agencies are described in
this chapter. These activities illustrate the diversity of the public health response to tobacco
use. The emphasis here is on the types of activities, rather than specific content and detail.
Surveillance, monitoring of prevalence, faxation, and legislation are revisited to provide a
comprehensive overview of the current antismoking movement.

Prevention and Control   181


Introduction

  Elements essential to-the prevention and control
of tobacco use, described in reports on developing and
developed countries,' include surveillance, education,
taxation, legislation, and coalition building. These
elements must be developed in the sociodemographic
and economic context of each country in the Americas,
and they must account for the unique nature of the
epidemic of tobacco use in each country. Some ele-
ments, such as taxation, are beyond the responsibility
of ministries of health, and all the elements require the

National Programs for Tobacco Control

collaboration of other ministries, professional organi-
zations, the media, church groups, and community
coalitions.  Concerted efforts of both government
agencies and private or nonprofit organizations are
necessary for successful tobacco control (Jamison and
Mosley 1991). The current, documented tobacco-
control activities of governments and other agencies
are reviewed here to provide an overview and
summary of content described in detail in previous
chapters.

United States

  In the United States, the public health practice of
tobacco control has evolved during the past 25 to 30
years as federal, state, and local governments have
joined voluntary health agencies in prevention activi-
ties. The 1964 advisory committee report to the Sur-
geon General on the health consequences of smoking
provided the scientific information needed to launch
an effective, sustained, national public health cam-
paign against tobacco use (Public Health Service
1964). As the national effort matured, the actions of
state and local health departments became more im-
portant, since municipalities have more opportunities
for aggressive control, Funding and technical assis-
tance for state and local efforts has come from volun-
tary agencies and, more recently, from the Public
Health Service-primarily the National Institutes of
Health (the National Cancer Institute [NC11 and the
National Heart, Lung, and Blood Institute), and the
Centers for Disease Control (CDC). The CDC Office
on Smoking and Health (OSH) was designated the
lead organization for tobacco issues, and the lead
spokesperson is the Surgeon General-largely be-
cause of the federally mandated annual report of the
Surgeon General on the health consequences of smoking.

  The Department of Health and Human Services
(USDHHS) has periodical1 y set national goals for the
reduction of tobacco use among residents of the
United States, but no coordinated program represents
all departments of the federal government. In 1990,

the Secretary of Health and Human Services released
the year 2000 health objectives for the nation, and
tobacco use was addressed by these objectives
(USDHHS 1990a). The objectives call for (1) a reduc-
tion (to 15 percent) in the prevalence of adult smoking,
(2) a reduction (to no more than 15 percent) in the rate
of initiation of smoking by persons less than age 20 (as
measured by the prevalence of smoking among 20 to
24 year olds), (3) an increase (to 50 percent) in the
proportion of smokers who quit smoking for at least
one day each year, (4) an increase (to at least 60 per-
cent) in smoking cessation beginning in early preg-
nancy, (5) a reduction (to 20 percent) in the proportion
of children aged 6 or younger who are exposed to
tobacco smoke at home, and (6) a reduction (to no
more than 4 percent) in smokeless tobacco use among
males aged 12 through 24. Additional objectives call
for the following:
o For all schools to be tobacco-free and to include
prevention of tobacco use within the basic curriculum.
o For an increase to 75 percent in the proportion of
worksites that prohibit or severely restrict smoking.
o  For enactment and enforcement of bans on the sale
of tobacco to minors.
o For the development of state tobacco-control plans.

1 Gray and Daube 1980; Pan American Health Organization
1989a; World Health Organization 1979, 1983a,b; Chap-
man and Wong 1990; Pierce 1991; Novotny et al., in press;
Choi et al., 1991; Davis, Monaco, Roman0 1991; Centers
for Disease Control 1991.


o For a ban or severe restriction on advertising and
promotion of tobacco to which youths are likely to
be exposed.

o For an increase to 75 percent in the proportion of
health care providers who provide smoking cessa-
tion advice and assistance to their patients.
  NC1 has encouraged the integration of effective

cancer control technology (including tobacco control)
into existing health care delivery systems. Interven-
tions include school-based programs, testing and dis-
semination of minimal interventions (such as self-help
programs), training of health care providers, mass
media efforts, programs for groups at high risk for
tobacco use, and programs to control the use of smoke-
less tobacco (Cullen 1988; USDHHS 1990b).

  Additional support for state activities has been
achieved through statecigaretteexcise taxes dedicated
to tobacco-control programs (Bal et al. 1990) and
through ASSIST (American Stop Smoking Interven-
tion Study), a seven-year project sponsored jointly by
NC1 and the American Cancer Society. ASSIST, which
began in 1991, will provide about $120 million to 20
states or large metropolitan areas for tobacco control
(McKenna and Carbone 1989). The goal of ASSIST is
to reduce by 43 percent the prevalence of smoking in
the participating areas by 1998. ASSIST is expected to
help achieve the year 2000 health promotion objectives
for tobacco use.

  The 1989 report of the Surgeon General, Reduciug
the Health Consequemes of Smoking: 25 Years of Progress
(USDHHS 19891, details the accomplishments of U.S.
tobacco-control efforts. For the United States, the re-
port documented a yearly decline, since 1979, of 0.5
percentage points in the prevalence of smoking
among persons 20 years old or older and a mean yearly
percent decrease of 2.4 percent in the adult (218 years
old) per capita consumption of cigarettes. As a result
of these trends, three-quarters of a million fewer
smoking-related deaths occurred between 1964 and
1985 than would have occurred had prevalence not
diminished (USDHHS 1989).

Canada

  The Canadian tobacco prevention and control
movement began over two decades ago when educa-
tional activities were stimulated by the British Royal
College's 1962 report on smoking and health (Royal
College of Physicians 1962). In 1985, the National
Strategy to Reduce Tobacco Use was launched; its
mission statement resolved to "produce a generation
of nonsmokers by the year 2000" (McElroy 1990, p. 2).
Twenty-two national health agencies created a joint
steering committee whose 1987 directional paper

presented a framework for the national program.
Three principal goals were enumerated: protection of
the health and rights of nonsmokers, prevention of
smoking among young persons, and availability of
cessation programs. To accomplish these goals, seven
strategies were identified: legislation, access to in-
formation, availability of services and programs,
message promotion, support for citizen action, inter-
sectoral policy coordination, and research and knowl-
edge development (McElroy 1990).

  Current participants in the national strategy are
Health and Welfare Canada, provincial and territorial
ministries of health, the Canadian Cancer Society, Ca-
nadian Nurses Association, Canadian Council on
Smoking and Health, Canadian Medical Association,
Physicians for a Smoke-Free Canada, Heart and Stroke
Foundation of Canada, Canadian Lung Association,
and the Canadian Public Health Association. Health
and Welfare Canada, through its Tobacco Programs
Unit, is the coordinating agency. The Non-smokers'
Rights Association is not a participating member of
the national strategy but plays a major role in tobacco
control in Canada.

  Legislation has been a particularly strong com-
ponent of the national strategy. The Tobacco Products
Control Act, which came into force January 1, 1989,
phased out all forms of tobacco advertising in print
and broadcast media, on billboards and mass transit
posters, and on point-of-sale signs. The act prohibits
the free distribution of tobacco products, prohibits the
display of tobacco trademarks on nontobacco items,
restric'ts tobacco company sponsorship to events
sponsored before 1987, and requires tobacco product
packages to prominently display health messages and
to list toxic constituents of tobacco smoke (Kyle 1990).
The Non-Smokers' Health Act (effective December 29,
1989) bans smoking or restricts it to just a few areas in
conveyances, public places, and workplaces under
federal jurisdiction. About 900,000 workers, or 8 per-
cent of the Canadian work force, are affected (Kyle
1990). Retail taxes average US$3.70 for a pack of 20
cigarettes (Claiborne 1991).

  Using the slogan "Break Free for a New Genera-
tion of Non-Smokers," the national campaign has
brought together key groups and individuals and has
encouraged cooperation, coordination, and compre-
hensiveness. Between 1980 and 1989, the prevalence
of smoking among teenagers in Canada decreased by
almost 50 percent (Stephens 19911, while it remained
constant among high school seniors in the United
States (Johnston, O'Malley, Bachman 1987). Tobacco
prevention and control in Canada, along with that of
the French overseas departments and territories (see
Chapter 51, is the most comprehensive in the Americas.

184  Prevention and Control


Regional Activities for Tobacco Control in Latin America and the Caribbean

  In 1984, the Pan American Health Organization
(PAHO) held a meeting in Punta de1 Este, Uruguay,
on programs for control of noncommunicable diseases
(PAHO 1988a). This effort was followed by an advi-
sory group recommendation to hold subregional
workshops to identify strategies and obtain political
commitment for tobacco control in member countries.
Workshops on control of smoking were subsequently
held for the Southern Cone and Brazil in 1985 (PAHO
1986), the Andean Area in 1986 (PAHO 1987a), the
English-speaking Caribbean in 1987 (PAHO 1988b),
and Central America in 1988 (PAHO 1989b). At these
workshops, representatives of each subregion re-
ported on activities related to tobacco control, includ-
ing surveillance, regulatory policies, educational
programs, and media activities. PAHO emphasized
the need for plans of action to include efforts from
government health and education agencies and from
cultural, sports, communications, trade, legislative,
and agricultural programs. PAHO also encouraged
member countries to set up a central office for tobacco
control in each ministry of health (PAHO 1988a). The
World Health Organization (WHO) requested that each
country identify a focal point for tobacco or health activ-
ities (WHO 1986).

  In 1989, a Regional Plan of Action for the Preven-
tion and Control of Tobacco Use was released by
PAHO at the thirty-fourth meeting of its Directing Council
(PAHO 1989a). The plan was accompanied by a resolu-
tion urging member governments to institute the plan
and encouraging the PAHO Director to mobilize
extrabudgetary resources for implementing the plan.
Elements of the plan are as follows:

  Promotion of policies, plans, and programs. Provide
information on control strategies to various agencies;
collaborate in the formulation of national policies; and
develop workshops and meetings, demonstration
projects, guidelines for national programs, legislative
strategies and enforcement, and minimum indicators
essential for program evaluation.

  Mobilization of resources. Identify government
and nongovernment organizations and individuals
that can contribute to the plan; involve WHO collabo-
rating centers in mobilizing resources; collaborate
with professional associations and political leaders;
and collaborate with educational, health, and trans-
portation services in providing smoke-free facilities.

Management and dissemination of information.
Identify agencies that provide tobacco-related educational
material, involve mass media in dissemination of such

information, and evaluate its dissemination through a
regional information network.

  Training. Identify training needs and train pro-
gram managers and health professionals.
  Research. Conduct applied research on overall
program efficacy, on smoking among adolescents and
other high-risk groups, and on effectiveness of cessa-
tion programs.

  Technical advisory semices. Provide direct advice
from PAHO staff or consultants to requesting countries.

  Because this regional action plan is so recent, its
implementation and impact have not yet been evalu-
ated in depth. Nonetheless, the plan is commendable
for having identified the factors important to tobacco
control and for having encouraged participating coun-
tries to develop coordinated programs.

  The Caribbean Community (CARICOM), an or-
ganization of heads of governments from the Carib-
bean area, recommended in 1987 that all members
participate in a Regional Program for Drug Abuse
Abatement and Control. Tobacco is included in the
program, and education is the main focus of interven-
tion activities. Other components include treatment,
data collection, and the establishment of national
councils on drug abuse. Many Caribbean countries
have established these councils (Appendix 2), which
bring national attention to tobacco as a gateway drug
and to the need for education to prevent tobacco use
by young persons. No evaluation studies or reports
on these councils are available.

  Since 1980, the International Union Against Can-
cer has joined public and private health leaders in 18
countries of the Americas in organizing national
workshops on smoking and health. International vol-
untary agencies have provided assistance to these
workshops, in which 6,000 physicians, educators,
health officials, and community activists have partici-
pated. Several countries have established national
plans for tobacco control, which include research on
prevalence of smoking and smoking-related diseases,
educational campaigns on the health consequences of
smoking, and comprehensive smoking-related health
policies.

  In January 1985, leaders of tobacco-control activ-
ities formed the Latin American Coordinating Com-
mittee on Smoking Control (LACCSC) (American Cancer
Society [AC`31 1988), which has the following goals:
o To help coordinate smoking-control efforts
throughout Latin America.

Pree7etltion and Control   185


o To provide a clearinghouse for information sup-
portive of national smoking-control initiatives.
o To provide a forum for planning multinational
strategies.

o To provide guidance and training in smoking-
control advocacy skills.

o To adopt resolutions calling for action by govern-

ments throughout the region.

  By using funding from the International Union
Against Cancer and the American Cancer Society
(ACS), LACCSC, in partnership with PAHO, has dis-
tributed a newsletter several times a year, has devel-
oped a model smoking-education curriculum, and has
developed guidelines for smoking-control coalitions
and media advocacy. Workshops on working with the

media, fostering advocacy, and calculating smoking-
attributable mortality have been held in conjunction
with LACCSC annual meetings. LACCSC has sup-
ported national coordinating committees, national
plans of action, and World No-Tobacco Day (May 31 of
each year).

  In 1991, the Association of Latin American
Women for the Control of Smoking was formed at the
seventh annual LACCSC meeting to help prevent
smoking among women and to combat tobacco adver-
tising directed toward women. Initial goals include
data collection and reporting on smoking among
women and coordination with other multinational
organizations concerned with smoking among
women (ACS 1988).

Elements of Prevention and Control Programs

  The information presented here derives from
joint work of PAHO and the CDC Office on Smoking
and Health. In 1988, a questionnaire was developed,
and an in-country investigator identified for each
Latin American and Caribbean country completed the
questionnaire (PAHO 1992). Information and docu-
mentation about the overall prevention and control of
tobacco use were requested, along with specific data
on the main control elements. The findings are pre-
sented in detail in a companion report (PAHO 1992).
The overview of the findings presented here empha-
size the diverse nature of tobacco-control activities in
Latin America and the Caribbean.

Surveillance and Analysis

  A comprehensive system for surveillance of
tobacco-related events would include surveillance of
the following: (1) adult, adolescent, and special popu-
lations (such as women and physicians) to determine
current and former use of tobacco, rate of smoking
initiation, and rate of smoking cessation; (2) public
knowledge, attitudes, and beliefs about tobacco use;
(3) interventions, such as the prevalence of restrictions
on smoking at worksites and the extent of antismoking
education in schools; (4) legislative and regulatory
activity, both proposed and enacted (Novotny et al.,
in press); and (5) trends in tobacco products. Many
Latin American and Caribbean countries have some
elements of a surveillance system, but none appears to
have all elements (PAHO 1992).

  Most Latin American and Caribbean countries
have conducted some form of an adult survey on
tobacco use (Chapter 3, Table 16), but the methods,
sample size, target groups, sampling methodology,
and questions of these surveys have varied consider-
ably. The survey questions used have been recom-
mended by the International Union Against Cancer
(Gray and Daube 1980), used for the U.S. National
Health Interview Survey (USDHHS 1989), or derived
from other sources.

  Small, non-population-based samples of adults
were generally drawn for one-time surveys. In some
countries, including Colombia, Jamaica, and Mexico,
questions on tobacco use were included in surveys of
drug use (PAHO 1990). In the U.S. Virgin Islands,
CDC's Behavioral Risk Factor Surveillance System
(BRFSS) has been used each year since 1988 to survey
adults aged 18 years or older about smoking, lack of
exercise, contraceptive use, lack of seatbelt use, and
other risk factors (PAHO 1992). The BRFSS permits
trend analyses of behaviors over time and helps iden-
tify population risk patterns. No Latin American or
Caribbean country other than the U.S. Virgin Islands
has periodically monitored tobacco use in the general
population.

  The diverse methodologies limit analysis and
conclusions for specific countries and the region as a
whole. For example, if occasional smokers were in-
cluded in the category for current daily smokers, the
reported prevalence of current smoking may have
been increased. Furthermore, samples were often

186  Prevention and Control


drawn from urban areas, and since the prevalence of
smoking is higher among urban than nonurban dwell-
ers (Chapter 3, "Prevalence of Smoking in Latin Amer-
ica and the Caribbean"), national inferences cannot be
drawn.

  Several countries have also surveyed groups at
high risk for tobacco-related disease. Because of the
well-documented effects of maternal tobacco use on
infant health (Malloy et al. 19881, women of reproduc-
tive age (15 to 44 years old) have often been surveyed
(Chapter 3, Tables 11-18). Women of reproductive
age in the Americas were asked about tobacco use in
eight surveys conducted with assistance from CDC
and in 10 surveys performed by PAHO's Latin Amer-
ican Center for Perinatology and Human Develop-
ment (PAHO 1987bj.

   Several Latin American and Caribbean countries
have surveyed youths about cigarette smoking (Chap-
ter 3, Table 171, but the definitions used for categories
of smokers were again quite variable. Furthermore,
the surveys may have missed an important segment
of the young population because most of them were
performed in schools. In many of these surveys, ques-
tions about tobacco use were part of drug-use surveys;
because tobacco is addicting, it is considered a sub-
stance that can lead to the use of other drugs (Fleming
et al. 1989). In the United States, school-based surveil-
lance of behavioral risk factors is accomplished
through a uniform survey instrument, the Youth Risk
Behavior Survey (Hare1 et al. 1990). Standard ques-
tions on ever use of cigarettes, use of cigarettes in the
last 30 days, and current daily use of cigarettes are
included in this survey. Persons aged 12 to 18 are
surveyed because, in the Americas, initiation of smok-
ing generally occurs in this age group.

  Physicians are generally educated about the
health consequences of smoking, and their health-
related behavior may set an example for other persons
(Adriaanse and Van Reek 1988). Prevalence of smok-
ing among physicians may be an indicator of diffusion
of the nonsmoking norm and of a society's willingness
to combat the health consequences of smoking (Pierce
1991). In several Latin American countries, the prev-
alence of smoking among physicians and physicians-
in-training has generally been similar to or only
slightly lower than that in the general population
(Chapter 3, Table 16).

  Surveys in Latin America and the Caribbean
have often not included questions on knowledge,
attitudes, and beliefs regarding tobacco (Chapter 3,
Table 18). This information is important for monitor-
ing the effect of public information campaigns (Pierce
1991) and in tracking public support for legislative and
policy interventions. Data from youth surveillance

may be extremely helpful when establishing school-
based educational programs.

   But data on tobacco use must be collected in a
standardized way to allow for planning and evalua-
tion of national programs and comparison of trends
within and between countries. Furthermore, the key
variables of a surveillance system should not be mod-
ified significantly over time. In 1990, WHO convened
an internal working group to update standard mea-
sures of tobacco use. Standard definitions for world-
wide surveillance have not yet been agreed upon, but
WHO continues to pursue consensus for worldwide
surveillance (WHO 1983a, 1988).

  A recent example of surveillance of tobacco
products serves to demonstrate the value of a coordi-
nated, regional approach. Under the sponsorship of
PAHO, the Health Protection Branch of Health and
Welfare Canada measured the tar, nicotine, and car-
bon monoxide yield from popular cigarette brands in
20 countries (Table 1). The results suggest that smok-
ers in most Latin American and Caribbean countries
are exposed to levels of toxic constituents similar to
those to which North American smokers are exposed
(e.g., 14 to 18 mg of tar per cigarette). Continued
monitoring of product characteristics is an important
component of surveillance of tobacco-related disease.

   More than half the world's deaths due to cancers
and cardiovascular disease and 85 percent of deaths
due to chronic obstructive pulmonary disease occur in
developing countries. To assess the cost and effective-
ness of intervention strategies against several chronic
diseases, The World Bank commissioned a series of
studies that incorporated economic, epidemiologic,
and clinical data for developing countries (Jamison
and Mosley 19911, most of which lacked empirical data
about many of the major chronic diseases of adults.
The lack of data systems that enable analyses of mor-
tality trends and of trends in determinants of chronic
diseases now hampers meaningful policy and pro-
gram development.

Education, Public Information,
and Cessation Programs

  School-based educational activities against to-
bacco are uncommon in Latin America and the Carib-
bean, but through the efforts of LACCSC, ministries of
health and education, and nongovernment organiza-
tions, several countries have begun to include anti-
tobacco education in school curricula (see Appendix
1). Few of these programs have been evaluated; how-
ever, a 1988 antitobacco education program in Chile,
initiated with the assistance of WHO, has been evalu-
ated by the Ministry of Health in Chile. This evaluation


Table 1.  Selected data for popular brands of cigarettes in 20 countries

Brand name*

Derby KS FI
Jockey Club KS FT

L&M KS F-l-

Astoria

Belmont KS FT

Mustang KS FT
Players Light RS ET
Export A RS ET
Derby Super-longs L'S ET
Advance Superlongs F'S FT
Pichoja RS P

Delta KS FT

Derby KS ET

Marlboro RS ET

Cremas KS P

Lark KS FT

Lider Suave KS ET         Ecuador        13.01     0.90     16.32

Delta I'S FT             El Salvador      18.02      1.12     18.67

Diplomat deLuxe 100s F'S FT   El Salvador      18.60      1.14     20.10

Rubios KS FT            Guatemala      14.99     0.85     15.90

Belmont KS FT           Guatemala      14.28     0.64     16.62

Royal KS FI             Honduras      13.39     1.05     14.48

Belmont KS ET           Honduras      13.65     1.07     15.73

Craven A RS FT         Jamaica        17.68      1.51     14.12

Raleigh RS FI            Mexico        15.87     0.85     17.44

Delicados Oscuros RS FT     Mexico        14.33     0.73     17.66

Viceroy KS ET            Panama        15.15     1.05     15.04

Marlboro KS FT           Panama        14.78     0.96     15.02

188   Pram tion and Control

Country
Argentina
Argentina

Bolivia

Bolivia

Brazil

Brazil

Canada

Canada

Chile

Chile

Colombia

Costa Rica

Costa Rica

Dominican
Republic

Dominican
Republic

Ecuador

Tar    Nicotine
(mg/cig)  (mg/cig)

13.44     0.90

14.16     0.96

14.82     1.07

21.79     1.60

19.93     1.48

14.44     0.85

14.86     1.34

15.03     1.27

14.64     1.36

8.69     0.70

23.79     1.58

16.20      1.24

16.08     1.35

Carbon
monoxide
(mg/cig)

15.46     Acetate

16.85     Acetate

17.38     Acetate

17.56      None

19.51     Acetate

18.20     Acetate

15.21     Acetate

15.91      Acetate

18.80      Acetate

10.75      Acetate

16.31      None

19.04     Acetate

15.98     Acetate

15.45

1.17

15.88

21.77     0.98     18.77

14.90     1.06     17.31

Filter
type

Acetate

None

Acetate/
charcoal

Acetate/
charcoal

Acetate

Acetate

Acetate

Acetate

Acetate

Acetate

Acetate

Acetate

Acetate

Acetate

Acetate

Market
share (%)

14.0

  5.3

48.4

16.6

19.1

  4.1

12.9

  5.7

24.7

11.9

21.7

53.7

21.6

51.1

3.5

36.1

31.3

57.3

15.6

28.6

16.9

39.0

23.0

76.7

22.9

8.4

32.7

19.3


Table 1. Continued

Brand name*

Country

              Carbon
Tar    Nicotine monoxide
(mg/cig) (mg/cig) (mg/cig)

Filter
type

Market
share (%)

Union Club I'S ET

Clayton 100s PS FT
Broadway Extra RS FI

Paraguay
Paraguay

Trinidad and
Tobago

Trinidad and
Tobago
Uruguay
Uruguay

United States

United States

Venezuela

18.15

1.00

17.77

20.10

Acetate -

21.39

1.87

Acetate -

14.53      1.20     13.26     Acetate        -

du Maurier RS FI

Nevada KS FI

Casino KS FT

Marlboro KS FI

Winston KS FT

Belmont Extra Suave RS FT

15.29      1.38     14.34

15.55      1.41     14.10

16.06     1.34     20.43

17.00      1.20     17.00

17.00      1.10     16.00

15.43     0:92     16.01

Astor Super Suave RS FI     Venezuela

15.09

0.85

16.37

Acetate -

Acetate      76.8

Acetate      23.2

Acetate      12.3

Acetate      4.0

Acetate/      45.7
charcoal

Acetate/ -
charcoal

_______
Source:  Collishaw, unpublished data (1991 ).
*Codes refer to product types, where KS = king size, FT = filter tip, RS = regular size, I'S = premium size, and P = plain

suggested that school-based education was effective
in preventing the uptake of smoking by younger
adolescents but was ineffective in persuading adoles-
cents who were already smokers to stop smoking
(Sepulveda 1990). By the end of the intervention, 3.2
percent of students in the intervention group were
daily smokers, versus 10 percent of students in the
nonintervention group.

  Programs in a few Latin American and Carib-
bean countries rely on physicians to provide informa-
tion to patients visiting government facilities. In
Cuba, the National Program to Reduce Cancer Deaths
uses the islandwide system of primary-care providers.
An 18 percent decrease in smoking prevalence was
reported in communities with intervention sites and a
4 percent decrease at nonintervention sites (Suarez-
Lugo 1988).

  Public information campaigns focus attention on
tobacco as a serious health issue and help craft preven-
tion and cessation messages for target audiences. For-
mal public information programs train public health
professionals in communications, and these persons
can then build working relationships with local media
(Erickson, McKenna, Roman0 1990). In 1990, most coun-
tries in the Americas reported some public information

activity on tobacco use. In many Latin American and
Caribbean countries, public information activities
have revolved around a "smokeout" day similar to the
ACS's Great American Smokeout held on the third
Thursday in November each year in the United States
(CDC 1990a). Many countries have promoted the
WHO-sponsored World No-Tobacco Day, held on
May 31 each year (CDC 1991). WHO has distributed
press packets and video messages in several lan-
guages, including Spanish, for this event. Further-
more, public information announcements broadcast
in the United States may be viewed in Caribbean coun-
tries on cable networks.

  Education and public information activities in
the Americas have increasingly focused on use of
drugs, including tobacco. Efforts have included both
school-based education and public information cam-
paigns. Many organizations in the Americas that ad-
dress tobacco use are responsible primarily for
drug-abuse prevention.

  Cessation programs, an important component of
tobacco-control programs (Novotny et al., in press),
have been regularly provided bv the Seventh-Day
Adventist Church in many countries of the Americas.
The church has strong tenets against several health


risk-factors, including smoking, using alcohol, and
eating meat. The standard five-day classes, which are
open to the public, include a spiritual approach to
health issues (Proctor 1985). A few countries report
that other private smoking-cessation programs are
sporadically offered. No information is reported on
widely available, self-help cessation programs, such
as those used effectively in the United States (Glynn,
Boyd, Gruman 1990). But most smokers quit without
the aid of formal programs and may rely on minimal
interventions (e.g., those that provide the skills and
information necessary for persons who want to quit
smoking) (Fiore et al. 1990). Because smoking behav-
ior patterns in many Latin American and Caribbean
countries differ from those in the United States, mini-
mal interventions may have to be adapted to specific
cultures.  More information is needed on public
knowledge, behavior patterns, and methodologies
effective for developing such interventions.

Taxation

  The World Health Assembly has recognized the
potential of taxation as a tool for the control of tobacco
use (WHO 1986). Among the countries of the Ameri-
cas for which data are available, variability is wide in
the type of taxes levied, their contribution to the price
of tobacco and cigarettes, and the proportion of gov-
ernment revenue they generate (see Chapter 4, "Eco-
nomics of the Tobacco Industry"). In Peru, for
example, cigarette taxes are only 16 percent of the price
of cigarettes, but in Colombia, taxes are 120 percent of
the price (Table 2). Tariffs vary from 14 percent to 130
percent of the price of manufactured cigarettes. Tax
as a percentage of total central government revenue
also varies substantially; however, assessment is
complicated because different revenue generating and
collecting systems are used by Latin American and
Caribbean countries.

Table 2.  Tobacco tax and tariff in selected countries of the Americas, 1988 or earlier

Country

North America
Canada
United States

Latin America
Argentina
Brazil
Chile
Colombia
Cuba"
Ecuador
El Salvador
Guatemala
Haiti
Mexico
Peru
Venezuela

Caribbean
Suriname
Trinidad and Tobago

Tax (as %
of price)*

Tariff (as %       Tax (as %
of price of        of total
manufactured
cigarettes)+      government
           revenue)'

75             20             2.4
353            14             1.9

75s             36
76            105
              15
120             50

57             20
16        llO_

90
80
80
130

45             35

50
20

22.5
7.4
5.6
13.2
1.8

4.7
41.3
1.1
2.8
2.7

Source: U.S. Department of Agriculture (1984,1989); Agro-economic Services Ltd. and Tabacosmos Ltd. (1987); U.S. Depart-
ment of Health and Human Services (1989).
`1983.
+1988.
SIncludes state tares.
51987.
k2overnment tobacco monopoly.
IIncludes 24% surcharge; import of cigarettes is banned.

190   Prevention and Control


  Tobacco taxes may be dedicated for specific
health purposes.  Several states in the United States
have used cigarette tax revenues to finance tobacco-
related health programs, and the most substantial pro-
gram of this kind is in California. In November 1988,
the state's cigarette tax was increased from 10 cents to
35 cents per pack. Three-quarters of the revenues from
this tax increase are used for health education, re-
search, medical treatment, and environmental conser-
vation programs (Tobacco Tax and Health Protection
Act of 1988; Bal et al. 1990).

  But the level of taxation is not necessarily an
indicator of concern for health. For example, in Can-
ada, where taxes add an additional 75 percent to the
price of cigarettes, health concerns and a concerted
antismoking movement have strongly influenced pol-
icy. But in several Latin American countries where the
level of taxation is as high or higher (Table 2), health
concerns may not have been a strong influence.
Throughout Latin America, the influence of health
concerns on level of taxation has varied (PAHO 1992).

  Data regarding tobacco taxation for 1989 or later
(Table 3) differ somewhat from the information re-
ported earlier (Table 2). These differences may reflect
short-term changes in taxation @olicy, but they may
also reflect differences in the methods used to calcu-
late the proportion of tobacco price and the proportion
of government revenue contributed by tobacco tax.

Legislation

  The legislative efforts to control tobacco use in
the Americas are extensive (see Chapter 5), but how
well the written laws are enforced in day-to-day life is
unclear. In the United States, for example, laws in
most states ban cigarette sales to minors, but these
laws are rarely enforced (CDC 1990b). Systematic
information on enforcement in the Americas is not
available.

  Table 4 summarizes tobacco-control legislation
in the Americas-the base on which continued efforts
are expanding. Some key points about the legislation
are given below. (The French overseas departments
and territories are counted as Caribbean countries, as
in Chapter 5.)
o Fifteen Latin American and four Caribbean coun-
tries have either a total ban on or some type of legis-
lation restricting advertising and cigarette promotion.
o Three countries prohibit all advertising of tobacco.
o Bolivia limits advertising to the tombstone format,
which allows print and a picture of the package.
o Two countries-Argentina and Bolivia-prohibit
advertising associated with sports.
o Sixteen countries restrict advertising that influ-
ences young people.

Table 3.

-

Excise taxes on manufactured cigarettes
as percentage of total retail price and of
total national tax revenue, 1989 or most
recent year available

Retail
price
61+
55s
  50

Tax
revenue

75
75
lo/3531
60
73

75
43

60

13
41
39

1.4
i::

22.0
10.0
8.6
5.0
5.0-7.0

5.0
21.0
3.0
2.0
1.7

2.3

3.0

  64
  48
  41
Tax free

Country
Andean &ea
Bolivia
Pert4
Venezuela"
Southern Cone
Argentina
Chile
Paraguay
Uruguay
Brazil
Central America
Costa Rica
El Salvador
Guatemala
Panama
Mexico
Latin Caribbean
Dominican Republic
Haiti
Puerto Rico
Caribbean
Aruba
Bahamas
Barbados
British Colonies**
French overseas depart;+
   ments and territories
   French Guiana
Guyana
Jamaica
Netherlands Antilles
Organization of East
  Caribbean States
   St. Lucia
   Dominica
   St. Vincent and the
    Grenadines
Suriname
Trinidad and Tobago
U.S. Virgin Islands
$r;: Pan American Health Organization (1992).
+17% surtax on imports.
$1988.
97% of taxes allocated to cancer hospital.
"Average 1978-l 988.
_Light tobacco/dark tobacco.
*`Includes Anguilla, Bermuda, British Virgin Islands, Cayman
Islands, Montserrat, and Turks and Caicos Islands.
`+Except French Guiana. For this table and associated text,
the French overseas departments and territories are
counted with the Caribbean countries.
*tOf consumption taxes.

  75
52$$
  50
  42
Tax free

18
35

41
55
15
4

35.0$$
4.0

0.5
1.0

1.0

1.1

Prezjention and Control   192


Table 4. Principal legislative measures* for control of tobacco in the Americas, by type of measure and
     country

Country+
North America

Canada
United States3

Latin America

                   Health warning      Statement of tar
Restriction on
advertising   Advertising    Rotating              and nicotine
             ban      or strong     Standard     yield

               X           X                      X

    X                      X

Argentina
Bolivia

Brazil

Chile

Colombia

Costa Rica

Cuba

Ecuador

El Salvador

Guatemala

Honduras

Mexico

Panama
Paraguay
Peru
Uruguay
Venezuela

Caribbean

Bahamas

Barbados

Bermuda

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

French overseas
departments
and territories5

X           X                      X

Trinidad and Tobago        X                                 X           X

so urce:  Copies of national legislation provided by individual countries to the Pan American Health Organization.
*Provisions of the legislation are summarized in Chapter 5, Appendix 1, notes to Tables 2, 4, 5, and 6.
tThe countries listed are those in the Americas that have any type of legislative control of tobacco use.
tDoes not necessarily imply federal legislation, but acknowledges activities of several states.
_For this table and associated text, the French overseas departments and territories are counted with the Caribbean countries.

292   Prevention and Control


Restriction on smoking

In ublic
P
p aces

In the
workplace

X           X

X           X

X

X

X           X

X

X            X

X           X

Prevention of
smoking among
young people

X

X

Health
education
~~~

X

X

X

X

X

X           X           X           X

X                       X


o Nearly all countries that have legislation on adver-
tising require health warnings in advertisements.
o Two countries specify the frequency and duration
of health warnings required on the broadcast media.
o Fourteen Latin American and five Caribbean coun-
tries require health warnings on cigarette packages.
o Two Latin American countries require strong
health warnings, but none requires multiple warn-
ings used in rotation, as do Canada, the United
States, and the French overseas departments and
territories.

o Only three Latin American countries, three Carib-
bean countries, and Canada require a statement of
tar and nicotine yield on cigarette packages.
o Restrictions on where cigarettes can be sold are
generally not found in Latin American and Carib-
bean countries.
o The State of Rio Grande do Sul, Brazil, prohibits the
sale of cigarettes in any establishment subsidized
by the government and recommends that tobacco
not be sold in hospitals and health services institutions.
o Nineteen countries restrict smoking in public places.
o Seven countries ban smoking on work premises,
and thirteen ban smoking in health establishments.
o In the United States, a major statement on the haz-
ards of smoking in the workplace has been issued
(National Institute for Occupational Safety and
Health 1991).
o Nineteen countries have laws that control smoking
by young people.
o Thirteen Latin American countries restrict cigarette
advertising that influences young people, but only
five of these countries prohibit the sale of tobacco
products to minors.
o Argentina and Ecuador prohibit free distribution of
samples of cigarettes to minors, and Uruguay pro-
hibits the sale of loose cigarettes.
o Nine Latin American and Caribbean countries pro-
hibit smoking and sales of tobacco in schools and
places frequented by young people, although many
schools may prohibit smoking on school property.
. Eleven Latin American and Caribbean countries
mandate health education about the hazards of
tobacco use.

o Five Latin American countries mandate anti-
tobacco education in schools, but many schools
undoubtedly provide such education voluntarily.

Coalitions

  A comprehensive tobacco-control program calls
for a national smoking and health organization dedicated
to the development of policy and the coordination of
government and voluntary efforts. The organization

may be an official government agency, or it may be a
voluntary agency with or without government sup-
port. Nongovernment coalitions or commissions may
function outside of the government structure but may
include representatives from various ministries, usually
health and education. In several countries, medical
societies, often a part of a larger coalition, have sus-
tained activities against tobacco use.

  Several countries in L.atin America have estab-
lished national commissions with a wide range of
functions regarding tobacco control: promotion of
research, development of policy, provision of educa-
tion and information, coordination of intergovern-
ment actions, and evaluation of the effects of
tobacco-control programs. These national bodies
have the capacity to mobilize support from many
departments of government and the private sector.

   Most national commissions are concerned with
measures to control tobacco use rather than the pro-
duction of tobacco. The Permanent National Advisory
Commission on the Control of Smoking is a govern-
ment agency created in Argentina to advise on and
assist with the production, processing, and exportation
of tobacco. The commission, which is composed of
government officials and representatives of the em-
ployers and employees engaged in tobacco production
and processing, does not control the use of tobacco.

  In the absence of a national smoking and health
organization, the tobacco-control effort is usually han-
dled by the ministry of health. In two Latin American
countries, legislation sets forth this responsibility. In
Bolivia, a 1978 decree makes the Ministry of Social
Welfare and Public Health the only agency that can
regulate all aspects of the promotion and sale of to-
bacco that affect health. The decree specifically recog-
nizes that tobacco is harmful to health. In Brazil,
legislation enacted in 1986 provides that the Ministry
of Health shall promote week-long activities in con-
nection with National No-Smoking Day, observed an-
nually on August 29.

  In seven Latin American countries, legislation
creates a national smoking and health organization. A
1986 decree in Chile established the National Commis-
sion for the Control of Smoking, which includes the
Minister of Health as chairperson and the undersecre-
taries of interior, economic affairs, agriculture, labor,
transport and telecommunications, and justice. The
commission (1) continually reviews the situation on
smoking and assesses the place of the tobacco industry
in the economy; (2) coordinates monitoring of the
prevalence of smoking; (3) determines the effects of
smoking on mortality and morbidity; (4) identifies
public and private resources for information, education,

194  Prevention and Control


and health care; (5) analyzes legal texts concerning
antismoking measures; (6) proposes smoking-control
policies; and (7) designs and evaluates medium- and
long-term smoking-control activities.

  In Ecuador, a 1989 resolution of the Ministry of
Public Health created the Interinstitutional Anti-
smoking Committee under the National Bureau for
Epidemiological Control and Surveillance. The com-
mittee, which comprises representatives from the
public and private sectors and is chaired by a repre-
sentative of the Ministry of Public Health, plans, ad-
vises on, and carries out the national program against
smoking.

  The General Health Law of 1983 in Mexico pro-
vides that the Secretariat of Health, the governments
of the federated entities, and the Council on General
Health in each geographic area shall coordinate activ-
ities for the Antismoking Program. The program aims
to prevent and treat the illnesses caused by smoking;
to educate citizens, especially families, children, and
adolescents, about the health effects of tobacco use;
and to promote research on the causes of smoking.
The federal government of Mexico has entered into
agreements with the various states to coordinate
smoking-control activities of the National Council
Against Addictions. These activities include the fol-
lowing: (1) encouraging legal measures to control
smoking, (2) promoting cooperation between federal
and state agencies, (3) integrating government activi-
ties with those of the private sector, (4) establishing a
government center for information and documenta-
tion, (5) strengthening surveillance, (6) promoting re-
search, (7) undertaking epidemiologic studies, and
(8) undertaking other studies for early identification
of persons with smoking-related problems.

  In Panama, a 1989 decree created the National
Commission to Study Tobacco Use, which was
charged with producing a report on the harmful ef-
fects of tobacco use and gathering statistical data on
progress in combating smoking. The report is to in-
clude information on legislation and on progress at the
international level on tobacco and health.

  A 1988 Ministerial Resolution in Peru created the
Permanent National Commission Against Tobacco,
which provides information and formulates recom-
mendations on the health risks of smoking. The com-
mission determines the role of the Ministry of Health
and other health institutions in combating tobacco
use. These agencies provide support and facilities for
the commission, which includes representatives from
different sectors of society.

  In Uruguay, legislation enacted in 1970 provides
for a special commission of the Ministry of Public
Health, acting in collaboration with the Ministry of

Education and Culture, to study the effects of smoking
and to disseminate information on the health risks of
tobacco use. Legislation proposed in 1988 would cre-
ate the Bureau for the Control of Smoking, within the
Ministry of Public Health, with broad power to (1)
conduct epidemiologic studies, (2) coordinate preven-
tive strategies, (3) conduct public education programs
(with cooperation from the National Administration
of Public Education, the University of the Republic,
and other educational organizations), (4) establish
maximum levels of tar and nicotine in tobacco prod-
ucts, and (5) develop actions to reduce smoking.

  In Venezuela, a 1984 decree of the Ministry of
Health and Social Welfare established a permanent
national council under the jurisdiction of the Division
of Chronic Diseases. The council studies the health
problems related to smoking and formulates policies
for preventing smoking and smoking-related dis-
eases. The multidisciplinary council is composed of
two representatives from the Ministry of Health and
Social Welfare (the Chief of the Division of Chronic
Diseases, who serves as president, and the Director of
Oncology) and representatives from the ministries of
agriculture, labor, transportation and communica-
tions, justice, environment and natural resources,
information and tourism, and youth affairs; the Vene-
zuelan Social Security Institute; the National Acad-
emy of Medicine; the Venezuelan Cancer Society; and
the Venezuelan Medical Federation. A technical unit,
composed of physicians, epidemiologists, political sci-
entists, sociologists, academicians, publicists, and social
communicators, supports and coordinates the devel-
opment of antismoking actions. The Ministry of Health
and Social Welfare coordinates educational programs
among the agencies represented on the council.

  No legislation that establishes national organiza-
tions for tobacco policy development is available from
Caribbean countries. Although national efforts may
occur in other countries as well, they lack the critical
support that government sanction provides. Yet the
lack of such support does not necessarily vitiate anti-
smoking efforts.  In the Americas, nongovernment
groups, such as citizens' coalitions, voluntary agen-
cies, and special-interest groups, have effectively pro-
moted good health.

  This compendium of legislation and coalitions
does not indicate the extent to which tobacco-control
activities are implemented. Many of the recently es-
tablished government and nongovernment commis-
sions on tobacco may still be rudimentary, but some
efforts are well established.  For Latin America and
the Caribbean, a listing of national organizations,
sponsors, and activities of these organizations is pro-
vided in Appendix 2.

Prezretltion and Control   195


Summary

  Activities critical to controlling tobacco use in-
clude surveillance of tobacco consumption, collection
of excise taxes, and coordination of local, national, and
regional efforts. Surveillance data can be used to mon-
itor trends in tobacco use and to provide a basis for
targeting populations. The collection of tobacco tax
revenue can be used for monitoring tobacco consump-
tion, and such revenue can be dedicated to health-
related programs, as has been done in Peru. The
coordination of tobacco-control activities augments
the scarce resources that any single jurisdiction might

Conclusions

have available to it. Communication networks, such
as the LACCSC and the Advocacy Institute's
GLOBALink electronic bulletin board (ACS 19901, can
assist joint efforts.

  In many countries of the Americas, the frame-
work for effective tobacco control is in place. As
PAHO's Regional Plan of Action for the Prevention
and Control of Tobacco Use is implemented, all
tobacco-control efforts in the Americas are likely to
become increasingly effective.

1. A basic governmental and nongovernmental in-
frastructure for the prevention and control of to-
bacco use is present in most countries of the
Americas, although programs vary considerably
in their degree of development.

2.  The need is now recognized, and work is under
way, for developing a comprehensive, systematic
approach to the surveillance of tobacco-related
factors in the Americas, including the prevalence
of smoking; smoking-associated morbidity and
mortality; knowledge, attitudes, and practices
with regard to tobacco use; tobacco production
and consumption; and taxation and legislation.

3.

4.

5.

School-based educational programs about to-
bacco use are not yet a major feature of control
activities in Latin America and the Caribbean.
The few evaluation studies reported indicate that
such programs can be effective in preventing the
initiation of tobacco use.

Cessation services in most countries of the Amer-
icas are often available through church and com-
munity organizations. Private and government-
sponsored cessation programs are uncommon.
Media and public information activities for to-
bacco control are conducted in most countries of
the Americas, but the extent of these activities and
their effect on behavior are unknown.

196  Prezlen tion and Control


Appendix 1. Antitobacco Activities in
Latin America and the Caribbean

   The antitobacco activities described here include
school-based education, public information cam-
paigns, and cessation activities. PAHO (1992) is the
source of this summary.

School-Based Educational Activities

Argentina

  With help from the Argentine Cancer League,
the ministries of health and justice developed an anti-
smoking educational program for 561 secondary
schools.

Bahamas

  Antitobacco information is minimally included
in the antidrug curriculum.

Belize

  The Curriculum Development Unit of the Min-
istry of Education and Pride Belize (an antidrug orga-
nization) developed a school health education
program that includes information on health and on
developing skills for resisting substance abuse.

Bermuda

  Antitobacco information is incorporated into the
Family Life Education curriculum.

Bolivia

  The Ministry of Education and Culture devel-
oped a natural science curriculum for the third and
fifth years of primary school. The National Commis-
sion Against Tobacco Use (CONLAT) offers classes to
primary and secondary schools.

Brazil

  Materials are sometimes included in curricula, as
determined by individual schools or states. Educa-
tional materials are widely available.

British Virgin Islands

  The health studies curriculum for high school
students uses British antitobacco materials.

Chile

  The ministries of health and education, health
services, and provincial education departments spon-
sor school-based educational prevention programs
that include evaluation. Students aged 13 or older are
now included.

Colombia

  The Ministry of Education offers a program on
preventing smoking and other forms of drug addic-
tion. A booklet, EI Pincer dc No Fumnr (The Pleasure of
Not Smoking), is included in the compulsory behavior
and health section of the school curriculum.

Costa Rica

  Information on the effects of smoking are in-
cluded in primary and secondary curricula and in
science textbooks. Educational material is provided
by the Social Security Fund, and references to smoking
have been eliminated from textbooks. The National
Antismoking Association sponsors workshops for
secondary school students.

Cuba

  Since 1991, antismoking education is offered in
all schools islandwide, beginning with the seventh
grade.

Guatemala

  The National Antismoking Commission is plan-
ning an educational program for schools. The Youth
Congress on Smoking, held in 1990, provided instruc-
tion and training on prevention activities.

Guyana

  The National Coordinating Council for Drug Ed-
ucation includes tobacco in curriculum development.

Honduras

  Lectures on tobacco use are provided to schools
by the Institute for the Prevention of Alcoholism and
Drug Abuse.

Jamaica

  Antitobacco information has been incorporated
into the health education curriculum of primary and
secondary schools.

Mexico

   Antitobacco information is to be included in
public primary school textbooks. The national anti-
smoking program has produced book!ets for use in
schools by youth groups and by parent groups. Uni-
versities include tobacco and health material in
schools of medicine, psychology, and social work.

Panama

  The Ministry of Education is required by law to
include information on the health aspects of smoking

Prezmtion aid Control   197


in school curricula (science courses during the first
year of secondary school).

Paraguay

  Antitobacco education is included in some way
in grades four through six. An antismoking associa-
tion has targeted school-based education as a future
activity.

Peru

  Each year, the National Cancer Institute, the
Ministry of Health, and the Ministry of Education
sponsor programs in Lima for 50,000 students aged
nine to 12.

Puerto Rico

  The Puerto Rican Lung Association sponsors
contests, nonsmoking day, and an educational cam-
paign in secondary schools, vocational schools, and
universities. By giving talks to seventh-grade stu-
dents, the American Cancer Society reaches 85 percent
of public schools and 30 percent of private schools.

Suriname

   The Teachers' Union collaborates with the Min-
istry of Health in training teachers in smoking preven-
tion education.

Trinidad and Tobago

  The Ministry of Education includes antitobacco
education in the syllabus of the general health educa-
tion program for primary, junior high, and senior high
school students.

Uruguay

  General education for grades three through six
targets health behavior, environmental pollution,
clean indoor air, and tobacco use as a risk factor for
disease.

U.S. Virgin Islands

  The Department of Education adopted a revised
health curriculum that includes a unit on smoking and
on prevention of cardiovascular disease.

Venezuela

  The Ministry of Education has an official pro-
gram. Parents, teachers, and students are organized
into extracurricular groups to help develop educa-
tional messages.

Public Information Campaigns

Anguilla

  Television and radio spots, prepared by health
care providers, are occasionally aired.
Argentina

  Television and radio campaigns are sponsored
by the Public Health Foundation. Campaigns directed
toward youths were sponsored by the Argentine Can-
cer League in 1978 and 1983 and by the Ministry of
Health and Social Action in 1979,1980, and 1982.

Barbados

  Government and nongovernment agencies focus
antitobacco activities around World No-Tobacco Day.

Belize

  Medical and dental associations sponsored a
television campaign and bumper stickers in 1989. The
National Drug Abuse Advisory Council and Pride
Belize distribute pamphlets and sponsor billboards
discouraging drug and alcohol use. Smoking-cessation
messages are aired on cable television.

Bolivia

  In 1983, CONLAT sponsored a meeting on ciga-
rettes and cancer. The biennial Tobacco or Health Day
is addressed through mass media and public meet-
ings. Children's poster campaigns have been spon-
sored, and Bolivia observes both a smokeout in
November and World No-Tobacco Day in May.

Brazil

  On National Antismoking Day, a race is spon-
sored by the Ministry of Health in 400 cities. The
National Program Against Smoking sponsors a school
poster contest each year and publishes a newsletter.
The Brazilian Medical Association has an official Anti-
smoking Commission. Five million copies of an anti-
tobacco comic book have been distributed.

British Virgin Islands

  Print media cover smoking as a risk factor for
cardiovascular disease. Public information materials
from the United Kingdom are used. Medical associa-
tions provide seminars and public information and
support World No-Tobacco day. Cable television
from the United States provides antismoking messages.

Cayman Islands

   Public information materials from the United
Kingdom are used.  Medical associations provide
seminars and public information and support World

198   Prevention and Control


No-Tobacco Day.  Business and anti-drug-abuse
groups are active in smoking control. The Cayman
Radio and Government Information Service broadcasts
antitobacco messages on the radio. Cable television
from the United States provides antismoking messages,

Chile

  The NationalCancer Society, in partnership with
the pharmaceutical industry, sponsors a television
campaign. The Association of Laryngectomy Patients
has a mobile presentation for use at schools and work-
sites. The Ministry of Health publishes numerous
articles, and World No-Tobacco Day is celebrated by
diverse activities.

Colombia

  A national no-smoking day, established in 1984,
is coordinated by the Colombian Cancer League.
Since 1989, the campaign has coincided with World
No-Tobacco Day. In 1990, public service announcements
from the Public Health Service of the United States
were translated and adapted for the Colombian television
audience. In 1991, a mass media campaign was begun
with the slogan "Smokers: An Endangered Species."

Costa Rica

  Printed materials are distributed through hospi-
tals and clinics.

Smoke-free Day is supported by print and elec-
tronic media. The Social Security Fund produces tele-
vision advertisements, and religious radio stations
broadcast tobacco-related information. Journalists
have been trained on health topics, including smoking.

Cuba

A mass media campaign, the backbone of a gov-
ernment program, includes television announce-
ments, posters, stickers, and T-shirts.  Public
education, aimed at parents, teachers, physicians, and
government employees, emphasizes the effect of
smoking on family income. The National Program to
Reduce Cancer Deaths has enlisted a large network of
family physicians.

Ecuador

The Lung Association sponsors antitobacco ed-
ucation and media messages. A pharmaceutical
workers' union sponsors antitobacco information.

El Salvador

The Department of Mental Health (of the Minis-
try of Public Health and Social Welfare) occasionally
provides television messages and conferences on
smoking and health.

French overseas departments and territories

  Posters, pamphlets, and radio and television
programs provided by the French government are
infrequently used.

Guatemala

  The National Antismoking Commission pro-
vides limited public information through the media.
The Association of Physicians and Surgeons provides
strong antitobacco support.

Honduras

Radio programs occasionally address scientific
information on smoking. World No-Tobacco Day is
supported through the National Smoking Control
Commission.

Jamaica

  The National Council on Drug Abuse (of the
Ministry of Health), the Jamaican Medical Associa-
tion, and the Jamaican Cancer Society are active in
public information campaigns.

Mexico

A government program disseminates informa-
tion through print and electronic media. World No-
Tobacco Day is supported through various media.

Panama

A prevention program, based on public informa-
tion, began in 1990 on the local level. Smoking-related
information is periodically broadcast on radio and
television. The staff of health care facilities are trained
about smoking. The National Cancer Association and
a civic committee sponsor a smoke-free day.

Paraguay

  The Tuberculosis and Lung Disease Associ-
ation's booklet on the health consequences of smoking
has been distributed by pharmaceutical companies to
3,000 physicians. Nongovernment organizations' ac-
tivities against drug abuse (including tobacco) receive
limited radio and newspaper coverage.

Peru

  World No-Tobacco Day has been celebrated
since 1985, with parades and activities for children.
Antismoking posters are displayed in sports centers.
A radio campaign against tobacco began in 1989. In-
formation is also disseminated by the Center for Infor-
mation and Education for the Prevention of Drug Abuse.

Prellention and Control   399


Puerto Rico

  The Puerto Rican Lung Association sponsors a
nonsmoking day, as well as print, radio, and television
messages. The local American Cancer Society sponsors
community presentations, materials for physicians,
and the Great American Smokeout.

Cessation Activities

St. Vincent and the Grenadines

The government sponsors print materials.

Suriname

  Public service announcements are made through
television and print media. The National Council on
Drug Abuse, the Association of Heart Disease Pa-
tients, and the Medical Association of Suriname spon-
sor a public information campaign.

Trinidad and Tobago

  The Cancer Society sponsors Smokeout Day dur-
ing annual Cancer Week, gives lectures to community
groups, and offers no-smoking signs to organizations.

Uruguay

  The Office on Smoking Control (of the Ministry
of Public Health) produced a program and five-second
spots on healthy living for commercial television. Ma-
terials were also developed for health care facilities.
Community health activities include development of
a booklet, Tobacco and Its Consequences. The Cancer
Society supports the celebration of Clean Air Day, and
the Ecological Party supports clean indoor air policies.

U.S. Virgin Islands

  The Department of Health supports the Great
American Smokeout, and local public service an-
nouncements use U.S. materials on the risk of smok-
ing, especially during pregnancy. The American
Lung Association sponsors a weekly 15-minute radio
program on lung health and uses the Christmas seal
campaign to inform the public about the health conse-
quences of smoking.

Venezuela

  The Venezuelan Cancer Society and the Tuber-
culosis and Lung Disease Society have sustained pro-
grams, including National Smoke-Free Day, World
No-Tobacco Day, lo-minute public service announce-
ments, and interviews with officials of the Ministry of
Health and Social Welfare.

Argentina

  Workshops are conducted by the Public Health
Foundation and the Argentine Antismoking Union.
Cessation classes are offered by the Argentine Cancer
League and the Seventh-Day Adventist (SDA) Church.

Bahamas

  Insurance companies offer a nonsmoker life in-
surance discount of 35 percent.

Barbados

  The Barbados Cancer Society conducts five-
week smoking-cessation clinics based on the Ameri-
can Cancer Society model.

Bermuda

The SDA Church offers smoking-cessation clinics.

Bolivia

  In conjunction with CONLAT, the SDA Church
offers cessation programs.

Brazil

  Numerous companies offer classes and semi-
nars. Banco do Brasil supports a systematic campaign
against smoking that includes a cessation program.

British Virgin Islands
  The SDA Church offers smoking-cessation clinics.

Cayman Islands

  One private clinic and the SDA Church support
smoking-cessation activities.

Chile

  Cessation services are offered by the SDA
Church, private physicians, and clinics. Primary
health care providers are trained in smoking cessation,
especially for women of childbearing age (as part of
the Women's Health Plan).

Colombia

  Cessation programs are offered by private clinics
in Bogata, Cali, and Medellin.

Costa Rica

  The Institute on Alcoholism and Drug Abuse and
the Social Security Fund sponsor cessation programs.

200  Prevenfion and Control


Ecuador

  A pilot project for college-level students was
coordinated by the ministries of health and education.
The SDA Church offers cessation programs.

Honduras

  The National Smoking Control Commission or-
ganizes workshops for community organizations,
unions, student groups, and the general public, and
the SDA Church offers cessation programs.

Jamaica

  The SDA Church and several private practition-
ers offer smoking-cessation clinics.

Mexico

  Cessation programs are offered in university
hospitals in Mexico City and in hospitals in other
states.

Netherlands Antilles

Health care providers support cessation activities.

Panama

  Cessation programs are offered by the SDA
Church, the Civic Support Committee for No Smoking
Day, and the National Cancer Association. Most in-
surance companies use a nonsmoker life insurance
premium differential of 10 to 25 percent.

Paraguay

  The SDA Church and a Baptist hospital sponsor
cessation programs.

Peru

  The Young Men's Christian Association and the
Inca Union (of the SDA Church) support cessation
activities.

Puerto Rico

  The Puerto Rican Lung Association sponsors
clinics and physician training in smoking cessation.
The American Cancer Society and the SDA Church
sponsor clinics. Two insurance companies use a non-
smoker life insurance discount of one-third.

Trinidad and Tobago
  The SDA Church sponsors clinics and classes.

Uruguay

  The national school of medicine, the SDA
Church, and many nongovernment organizations and
private clinics offer cessation services.

U.S. Virgin Islands
  The American Lung Association sponsors smoking-
cessation clinics.

Venezuela

   The SDA Church and Venezuelan Petroleum
support cessation activities.

Preofwfiorl and Control   201


Appendix 2. Antitobacco Organizations
in Latin America and the Caribbean
  Organizations for the prevention and control of
tobacco use are cited below (PAHO 1992).

Argentina

Colombia
Coalition or program: National Council on Smoking
  and Health (est. 1984)
Sponsor: Ministry of Health, National Cancer Insti-
  tute, Colombian Cancer League, and a press rep-
   resentative

Coalition or program: Antismoking Action and Health
  Council (est. 1990)

Activities: Conducts studies on tobacco control, taxa-
  tion, contraband, and advertising restrictions

Sponsor: Ministry of Health and Social Action, medi-
  cal association, Rotary Club, Mainetti Founda-
  tion, Favaloro Foundation
Acfivifies: Promotes community education, research,
  and legislation

Barbados

Costa Rica
Coalition or program: Costa Rican Social Security Fund;
  Institute on Alcoholism and Drug Abuse
Sponsor: Ministry of Health
Activities: Concerned with education, cessation pro-
  grams, and legislation

Coalition or program: National Drug Abuse Council
Sponsor: Ministry of Health
Activities: Includes tobacco in drug-abuse prevention
  activities and is planning data collection activities

Belize

Coalition or program: National Drug Abuse Advisory
   Council

Sponsor: Ministry of Health
Activities: Includes tobacco in drug-abuse prevention
   activities

Bolivia

Coalition or program: National Commission Against
  Tobacco Use (est. 1983)
Sponsor: Bolivian Cancer Foundation
Activities: Supports legislation, protects nonsmokers,
  reduces advertising, conducts research, and co-
  ordinates with international organizations

Brazil

Cuba

Coalition or program:  National Program to Reduce
  Cancer Deaths (est. 1987)
Sponsor: Ministry of Health and 15 other government
  agencies

Acfivifies: Develops public information, provincial
  working groups, legislation, and mass media
   messages

Dominican Republic

Coalitiorz or program: Dominican Committee on Smok-
  ing and Health (est. 1989)

Sponsor: Nongovernment organization; Secretariat of
   Public Health and Social Welfare
Activities: Supports media activities and workshops

El Salvador
Coalition or program: Department of Mental Health
Spomor: Ministry of Public Health and Social Welfare
Activities: Supports media campaigns and legislation

Coalition or program: Advisory Group on the Control
  of Smoking; National Oncology Program (est. 1985)
Sponsor: Ministry of Health (National Cancer Insti-
  tute, Respiratory Diseases Department), non-
  government organizations, religious groups,
  legislators, state health departments
Activities: Supports legislation, promotes prevention
  programs, and evaluates the national program by
  using public information, media, and surveillance

Chile

Coalition or program: Chronic Disease Program; Na-
  tional Commission for the Control of Smoking
  (est. 1986)

Sponsor: Government, medical association, nongov-
  ernment organizations

Activities: Sponsors educational planning, data collec-
  tion, and international linkage

French overseas departments and territories

Coalifioii or program:  French Committee on Health
   Education

Spomor: French government
Activities: Distributes print materials to overseas de-
  partments and territories

Guatemala

Coalifion or program: Mental Health Department; Na-
  tional Antismoking Commission
Sponsor: Ministry of Public Health and Social Welfare,
  government and nongovernment organizations,
  and physicians' association
Activities: Promotes public education and informa-
  tion, and international and national coordina-
  tion of data collection, research, and government
   consultation

202  Prevention and Control


Guyana

Coalition or program: National Coordinating Council
  for Drug Education

Sponsor: Ministry of Health and nongovernment or-
  ganizations

ActizGties: Develops school curriculum

Honduras

Coalition or program: Institute for the Prevention of
  Alcoholism and Drug Abuse (est. 1988)
Sponsor: Ministry of Public Health and Social Welfare
Activities: Coordinates government and nongovernment
organizations, legislation, and school education
Coalifion or program: National Smoking Control Com-
   mission

Sponsor: Nongovernment organizations
Activities: Supports local community action and
  World No-Tobacco Day

Jamaica

Coalition or program: National Council on Drug Abuse
Spunsur: Ministry of Health and nongovernment or-
ganizations (Jamaican Medical Association, Ja-
  maican Cancer Society)

Acfivifies: Promotes school education, public informa-
  tion, media activities, and legislation

Mexico

Coalition or program:  National Committee for the
Study and Control of Smoking (est. 1985)
Sponsor: Nongovernment organization
Activities: Offersadviceonsmokingand health programs

Coalition or program: Antismoking Program (est. 1986)
Sponsor: Secretariat of Health and National Council
  Against Addictions

Acfivities: Supports educational activities, improved
  treatment for persons with smoking-related ill-
  ness, legislation, and research

Panama

Coalition or program: Adult Health Department (est.
  1990)

Sponsor: Ministry of Health interdisciplinary group of
  professionals

Activities: Promotes prevention program for youths
  and sets guidelines for local action; reports on
  and evaluates prevention programs

Paraguay

Coalition or program: Paraguayan Antismoking Asso-
   ciation

Sponsor: Nongovernment organizations
Activities: Encourages legislation and physicians'
   actions

Puerto Rico

Coalition or program: Coalition on Smoking and Health
Sponsor: Puerto Rican Lung Association, American
  Cancer Society, and American Heart Association
Activities: Supports legislation, education, media ac-
  tivities, and cessation programs

Suriname

Coalition or program: National Council on Drug Abuse
Sponsor: Nongovernment organizations, medical
  association, heart-disease patients, and sports
   association

Acfiuities: Promotes public service announcements
  and school education

Uruguay

Coalifiou or program: Office on Smoking Control (est.
  1988)

Sponsor: Ministry of Public Health (intersectoral)
ActizGties: Supports media activities, health care and
  community education, and publications

Venezuela

Coalition or program: National Antismoking Program
  (est. 1984)

Sponsor: Ministry of Health and Social Welfare
Actiuifies: Promotes educational programs, media ac-
  tivities, and technical information

Prezlenfion arld Confrol   203


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206  Prevention and Control


List of Tables and Figures

Chapter 2
The Historical Context

Table 1.

Table 2.

Table 3.

Table 4.

Table 5.

Table 6.

Table 7.

Table 8.

Table 9.

Table 10

Table 11.

Table 12.

Table 13.

Table 14.

Figure 1.

Figure 2.

Tobacco trade in England, 170@1775   25
Tax revenue from tobacco sales, United States,
1865-1890 30

Manufactured tobacco products, United States,
1870-1905 30

Economic activity and rankings of major trans-
national cigarette producers, 1989   36
Transnational cigarette industry: subsidiaries
and affiliates (financial interest1 or licensing
agreements   3 i-38
Estimated cigarette output, by producing group,
1988 38

Cigarette market share of major transnational
firms and affiliates, selected countries, 1988  39-40
Percentage of sales by top cigarette brands in
selected countries, 1988-1989 40
Income and profitability of tobacco manufactur-
ing corporations, United States, 1970-1985   42
Expenditures, farm value, marketing bill, and
taxes for cigarettes, United States, selected
years 43

Recorded exportation and importation of ciga-
rettes worldwide, selected years, 1951-1960 and
1967-1990 44

Subsidiaries, licensing arrangements, and market
shares of transnational cigarette firms, selected
countries of Latin America and the Caribbean,
c. 1989 45

Market share of Marlboro cigarettes, selected coun-
tries, 19751989 46
Percentage of cigarette sales by type of tobacco
blend, selected Latin American countries,
1950-1989 47

Per capita cigarette consumption, United States,
1900-1991 33

Per capita cigarette consumption in the Americas,
1970-1990 48

Chapter 3
Prevalence and Mortality

Table 1. Demographic indicators, Latin America and the
    Caribbean, 1950-1990 62

Table 2.  Estimated population, Latin America, the Carib-
    bean, and the United States, 1950-1990   62

Table 3.  Percentage of population living in urban centers,
    by country in Latin America, 1950-1980   63

Table 4.

Table 5.

Table 6.

Table 7.

Table 8.

Table 9.

Table 10.

Table 11.

Table 12.

Table 13.

Table 14.

Table 15

Table 16

Table 17.

Table 18

Table 19

Table 20

Table 21

Table 22.

Percentage of population in Latin America and
the Caribbean enrolled in school, by age group
and sex, 1960-1987 63
Income distribution in Latin America and the
United States, 1960 and 1975   64
Income distribution in selected countries of the
Americas 65

Prevalence of cigarette smoking among persons
aged 15-74 in eight cities in Latin America, ad-
justed for age and sex, 1971   65
Standardized ratio of cigarette smoking among
persons aged 15-74 in eight cities of Latin Amer-
ica, by sex and level of education, 1971   66
Prevalence of smoking in 12 Latin American
countries, 1988   67
Male-to-female ratio of smoking prevalence
in seven Latin American countries, 1971
and 1988 68

Prevalence of smoking among women of repro-
ductive age (15-44 years), selected areas of the
Americas, 1979-1989 68
Prevalence of smoking among persons aged
15-24, selected countries of the Americas,
1986-1990 69

Prevalence of smoking and quantity smoked
among persons aged 15-24, Santiago, Chile,
1988 69

Prevalence of smoking and quantity smoked
among persons aged 15-24, by educational level
and sex, Santiago, Chile, 1988   70
Prevalence of smoking among women aged
15-44, by reproductive history and smoking
status, Santiago, Chile, 1988   70
Prevalence of tobacco use among adults reported
by surveys in Latin America and the Caribbean,
1980s and 1990s   72-75
Prevalence of tobacco use among adolescents
reported by surveys in Latin America and the
Caribbean, 1980s and 1990s   76-77
Prevalence of smoking among women of child-
bearing age, selected Latin American and Carib-
bean countries, 1979-1987   78
Public knowledge and attitudes on smoking
and health in Latin America and the Caribbean,
1982-1990   78-79
Modified stem-and-leaf display of prevalence of
smoking among adults, selected countries of
Latin America and the Caribbean, 1980s and
1990s 80

Prevalence of smoking among Hispanic persons
in the United States, aged 20-74, by ethnic
group and sex, selected years   80
Method used for calculating smoking-attributable
mortalitv in the Americas   82

207


Table 23.

Table 24.

Table 25.

Table 26.

Table 27.

Table 28.

Table 29.

Table 30.

Table 31.

Table 32.

Table 33.

Life expectancy at birth for persons born during
selected periods, by region and country   83
Mortality from defined causes, selected countries,
c. 1985 84

Mortality from defined causes, regions of the
Americas, c. 1985   85
Deaths from six major causes as a percentage of
all deaths from defined causes, for persons aged
35 or older, selected countries, c. 1985   86
Deaths (in thousands) from six major causes, for
persons aged 35 or older, selected regions of the
Americas, c. 1985   88
Smoking-attributable fraction for 10 selected
causes of death, United States, 1985   89
Smoking-attributable mortality in the United
States 90

Estimated number of deaths due to tobacco use
in 27 countries of the World Health Organization
(WHO) European Region   91
Smoking-attributable fraction (SAF) and adjusted
SAF for lung cancer mortality, selected industri-
alized countries, 1978-1981   92
Smoking-attributable mortality for men and
women in the Americas, c. 1985   94-95
Adjusted estimates of smoking-attributable mor-
tality in the Americas, c. 1985   96

Table 1.

Table 2.

Table 3.

Table 4.

Table 5.

Table 6.

Table 7.

Table 8.

Table 9.

Chapter 4

Economics of Tobacco Consumption
in the Americas

Relative risks for death attributed to smoking and
smoking-attributable mortality for current and
former smokers, by disease category and sex,
United States, 1988   106
Components of the costs of the health effects of
smoking   109
Medical care costs for smokers, by study type
and author   110
Value of productivity lost due to mortality and
morbidity, by study type and author   111
Per capita cigarette consumption and income in
the Americas   117
Estimates of income elasticity of demand for
cigarettes   118
Estimated advertising expenditures of tobacco in-
dustry in selected countries of the Americas   218
Share of world tobacco production, 1990   119
Labor and land use in tobacco growing, processing,
and manufacturing in the Americas, 1983   120

Table 11

Table 12

Figure 1.

Figure 2.

Figure 3.

Figure 4.

Figure 5.

Figure 6.

Recent estimates of the price elasticity of demand
for cigarettes   130
Estimates of the price elasticity of demand for
cigarettes in the United States, by age group   131
Correlation between cigarette consumption per
person who entered adult life in 1950 and lung
cancer rate for that generation as it entered mid-
dle age in mid-1970   107
Per capita rate of cigarette consumption in Brazil
and lung cancer deaths for men in Rio Grande
do Sul, Brazil   108
Factors, other than price, that affect the demand
for tobacco products   115
Per capita cigarette consumption and annual
per capita gross national product in 24 countries
of the Americas, 1985   116
Predicted and actual per capita (2 18 years of
age) consumption of cigarettes, United States,
1979-1988   132
Per capita consumption and real price of ciga-
rettes in Canada, 1982-1987   133

Chapter 5

Legislation to Control the Use of Tobacco
in the Americas

Table 1.

Table 2.

Table 3.

Table 4.

Table 5.

Table 6.

Number of countries that control the production,
sale, and promotion of tobacco, by type of legis-
lation and region   148
Countries that control tobacco advertising and
promotion, by type of restriction   149
Countries that require health warnings or state-
ment of tar and nicotine yield   751
Countries that restrict smoking in public places,
by type of place   155-156
Countries that attempt to prevent young people
from using tobacco, by type of restriction   159

Countries that mandate health education on to-
bacco use, by type of provision   160

Chapter 6

Status of Tobacco Prevention
and Control Programs in the Americas

Table 1.  Selected data for popular brands of cigarettes in
      20 countries   188-189

Table 2.  Tobacco tax and tariff in selected countries of
     the Americas, 1988 or earlier   190

Table 3.  Excise taxes on manufactured cigarettes as per-
    centage of total retail price and of total national
    tax revenue, 1989 or most recent year available  191

Table 4.  Principal legislative measures for control of
    tobacco in the Americas, by type of measure
    and country   192-193

Table 10. International trade in tobacco, 1984 and 1985   123

208