Smoking
and Health
in the Americas


Smohg

md Health
in the Ameticas

A 1992 Report
of the Surgeon General,
in collaboration with the
Pan American Health Organization

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
Public Health Service
Centers for Disease Control
National Center for Chronic Disease Prevention and Health Promotion
Office on Smoking and Health

PAN AMERICAN HEALTH ORGANIZATION
Pan American Sanitary Bureau, Regional Office of the
WORLD HEALTH ORGANIZATION


Suggested Citation

U.S. Department of Health and Human Services. Smoking and Health in the Americas.
Atlanta, Georgia: U.S. Department of Health and Human Services, Public Health
Service, Centers for Disease Control, National Center for Chronic Disease Prevention
and Health Promotion, Office on Smoking and Health, 1992; DHHS Publication No.
(CDC) 92-8419.


THE SECRETARY OF HEALTH AND HUMAN SERVICES
           WASHINGTON. O.C. 20201
       FLY i + 1~32

The Honorable Thomas S. Foley'
Speaker of the House of Representatives
Washington, D.C.   20515

Dear Mr. Speaker:

It is my privilege to transmit to the Congress the 1992 Surgeon
General's report on the health consequences of smoking as
mandated by Section 8(a) of the Public Health Cigarette Smoking
Act of 1969 (Pub. L. 91-222).  The report was prepared by the
Centers for Disease Control's Office on Smoking and Health in
conjunction with the Pan American Health Organization.

The topic of this report, Smokina in the Americas, reflects a
concern for the broader problems posed by tobacco consumption.
The report explores the historical, social, economic, and
regulatory aspects of smoking in the Western Hemisphere. It
defines the current extent of tobacco control activities in the
countries of the Americas and stresses the need for regional
coordination and cooperation in our efforts to create a smoke-
free society.

The countries of North America --the United States and Canada--are
in the midst of a major epidemic of smoking-related disease,
including cancer, heart disease,
disease,                chronic obstructive lung
     and adverse outcomes of pregnancy.  The countries of
Latin America and the Caribbean now show evidence of a rising
prevalence of smoking, particularly among young people, and in
the absence of efforts to decrease tobacco use, are likely to be
swept by a similar epidemic.

I believe that we in the United States must provide leadership
through continued efforts to control tobacco consumption and
prevent the uptake of smoking by young people.  In addition, I
believe that we must participate fully in regional efforts to
develop effective smoking-control programs.

Sincerelv.

Enclosure


THE SECRETARY OF HEALTH AND HUMAN SERVICES
           WASHINGTON. O.C. 20201

The Honorable Dan Quayle
President of the Senate
Washington, D.C.   20510

Dear Mr.  President:

It is my privilege to transmit to the Congress the 1992 Surgeon
General's report on the health consequences of smoking as
mandated by Section 8(a) of the Public Health Cigarette Smoking
Act of 1969 (Pub. L. 91-222).  The report was prepared by the
Centers for Disease Control's Office on Smoking and Health in
conjunction with the Pan American Health Organization.

The topic of this report, Smokino in the Americas, reflects a
concern for the broader problems posed by tobacco consumption.
The report explores the historical, social, economic, and
regulatory aspects of smoking in the Western Hemisphere. It
defines the current extent of tobacco control activities in the
countries of the Americas and stresses the need for regional
coordination and cooperation in our efforts to create a smoke-
free society.

The countries of North America --the United States and Canada--are
in the midst of a major epidemic of smoking-related disease,
including cancer, heart disease,
disease,                 chronic obstructive lung
     and adverse outcomes of pregnancy.  The countries of
Latin America and the Caribbean now show evidence of a rising
prevalence of smoking, particularly among young people, and in
the absence of efforts to decrease tobacco use, are likely to be
swept by a similar epidemic.

I believe that we in the United States must provide leadership
through continued efforts to control tobacco consumption and
prevent the uptake of smoking by young people.  In addition, I
believe that we must participate fully in regional efforts to
develop effective smoking-control programs.

Sincerely,

Louis W.  Sullivan, M.D.

Enclosure


Foreword

  By the mid-1980s, an estimated 526,000 people in the Americas were dying
each year of diseases that are directly attributable to smoking. The number contin-
ues to increase. Most of these deaths occur in Canada and the United States, where
smoking has been a widespread, entrenched habit for over 60 years. However,
approximately 100,000 deaths occur annually in the countries of Latin America and
the Caribbean. We are in the unfortunate position of watching an epidemic-like the
one we are currently living with in the United States-begin to gather momentum
among our neighbors.

  The determinants of smoking are complex. Many forces are brought to bear on
the young person who is deciding whether or not to smoke. The current overall prev-
alence of smoking in a population-a general measure of its social acceptability-
plays a large role. The frequency with which peers or role models smoke may be
even more important. The current laws and regulations that govern smoking may
influence the decision, as do the price of cigarettes and the ease with which they
can be purchased. The extent to which tobacco products are advertised and the
forms and mechanisms for tobacco promotion are also likely to have a major influ-
ence on a young person's decision. All of these combine in an intricate way to create
a social norm; the individual decision is hardly an isolated and independent event.

  Considerable gains have been made against smoking in Canada and the
United States in recent years. As documented in previous Surgeon General's
reports, the prevalence of smoking in the United States has been falling at a rate of
approximately 0.5 percentage points per year. But millions continue to smoke, and
the current rate of decline will not reduce smoking prevalence to the goal of 15
percent set for the year 2000. It is clear that the efforts under way in the United
States and Canada are important in maintaining the momentum of smoking abate-
ment, but it is equally clear that they are insufficient. More sectors of society must
be brought into the nonsmoking coalition, and the tools at our disposal must be
further strengthened.

  Other countries of the Americas face different circumstances. For some, still
in the process of economic development, the prevalence of smoking is still low, and
the problem may have a lower priority than more acute public health concerns. For
others, further along in their development, diseases associated with smoking are
already major causes of death, and the prevalence of smoking is high among young
people in urban areas. Overall, the impact of smoking-related illness is not yet as
evident in the other countries of the Americas as in Canada and the United States.
However, the high prevalence among young people in many of these countries is
ominous. Each country must deal with its problem in its own political, economic,
and cultural context. Nonetheless, the countries of the Americas face a common
threat, even though they may be in differing stages of its evolution. A common
approach, characterized by agreement on goals, objectives, and means, can benefit
the entire region.


  The Pan American Health Organization (PAHO) has taken significant steps to
establish a forum for the exchange of ideas and for the development of a joint plan
of action. As a regional branch of the World Health Organization, PAHO in turn
takes part in an international forum for coordinated action against tobacco. The
individual decision to smoke-both now and in the future-will ultimately be
influenced by these efforts of the global community.

  This Surgeon General's report is the twenty-second in a series that was
inaugurated in 1964 and mandated by law in 1969. The current report looks at the
place of smoking in the societies of the Americas and at the current efforts to prevent
and control tobacco use. It is perhaps best viewed as a planning document, a
portrayal of the current situation in the Americas that will provide the basis for a
concerted approach to future prevention strategies.

James 0. Mason, M.D., Dr.P.H.        William L. Roper, M.D., M.P.H.
Assistant Secretary for Health             Director
Public Health Service                Centers for Disease Control


Preface

    from the Surgeon General,
U.S. Department of Health and Human Services

  This 1992 report of the Surgeon General, Smoking and Health in the Americas, is
the second on smoking and health during my tenure as Surgeon General. Over the
years, the reports have systematically examined the effect of smoking on human
health: the biologic effects of substances in tobacco, the risks of disease, the
susceptibility of target organs, the addictive nature of nicotine, and the evolving
epidemiology of the problem. The reports summarize a massive amount of infor-
mation that has accumulated on the untoward effects of tobacco use, now easily
designated the single most important risk to human health in the United States. The
1990 report, The Health Benefits of Smoking Cessation, documented the positive impact
of quitting and thus furthered the logical argument leading to a smoke-free society.

  This report is a departure from its predecessors in that it treats the evidence
against smoking as an underlying assumption. The issue for the future is how we
will go about achieving a smoke-free society, and a consideration of smoking in the
Americas is an early step in that direction. The report explores the historical,
epidemiologic, economic, and social issues that surround tobacco use in the Amer-
icas. It focuses on cultural antecedents and trends, on social and economic struc-
ture, and on the local, national, and regional efforts that are currently under way to
control tobacco use.

  One of the striking inferences to be drawn from the report is that the countries
of the Americas occupy a continuum of consequences related to smoking. This
continuum appears to be related to overall economic development. Countries that
are furthest along the path of industrialization have gone through a period of high
smoking prevalence and are now experiencing the incongruous combination of
declining prevalence and increasing morbidity and mortality from smoking. Other
countries, substantially along the path, are entering a period of high prevalence and
may also be experiencing some of the disease and disability associated with smok-
ing. Still others, less developed industrially, have low prevalences of smoking and
relatively lower estimates for smoking-attributable mortality, but must contend
with numerous other public health issues.

  Not all countries fit easily into such a simple classification. Within countries,
there is considerable diversity in the pace of industrialization, urbanization, and
general development as well as in the manifestation of th'e effects of tobacco use.
But the classification is useful in defining the pathway that all countries are likely
to take. In the absence of coordinated action, the epidemic of tobacco use is likely
to proceed according to a well-defined script: gradual adoption of the smoking
habit, long-term entrenchment of tobacco use, and a major loss of human life.

  The forces that create this script are complex and often difficult to untangle.
One of the major findings of the report is the crucial role of surveillance in
understanding the intricate interrelationship of the factors that influence smoking.

122


The educational level of the population, for example, illustrates the complexity.
Data from selected sources indicate that smoking is more prevalent among highly
educated women than among less-educated women. One would think that in-
creased education would be linked to a greater awareness of and concern about the
health consequences of smoking, but this assumption appears incorrect. It may be
that a higher educational level, especially in developing countries, imparts greater
susceptibility to messages that promote positive associations with smoking. Only
through systematic monitoring of smoking prevalence as well as of the knowl-
edge, attitudes, and behaviors of the population can we appreciate the underlying
reasons for the current epidemiologic configuration. Such appreciation, in turn, is
the basis for a rational prevention and control program.

  Another area in which surveillance is critical is in the monitoring of the tobacco
sector of the economy. Such monitoring should include production, consumption,
price structure, and taxation policy as well as advertising and promotion of tobacco
products. The structure of the industry in any country will have important ramifi-
cations for the growth and "success" of the commodity. One of the fundamental
paradoxes of market-oriented societies is that some entrepreneurs-even acting
completely within the prescribed rules of business practice-will come into conflict
with public health goals. The market structure of the tobacco industry constitutes
a major threat to public health simply because the product is tobacco. In the tobacco
industry, attempts to control a large market share, marketing to target groups,
widespread use of innovative promotional techniques, and corporate growth,
development, and consolidation-in short, the traditional elements of successful
entrepreneurial activity-are ultimately inimical to the public health. Each country
faces its own resolution of this paradox, but recognizing and monitoring it is
fundamental to the prevention and control of tobacco use.

  Most countries of the Americas have begun to face these complex issues.
Several have taken major steps, others tentative ones, but all should recognize the
crucial role of international coordination and cooperation. It is clear that although
most countries can have significant impact on their own smoking-related problems,
the international community can become smoke-free only by acting in concert.
The process is an arduous one that begins with multifaceted efforts to change
social norms regarding smoking and that moves ultimately to a disappearance of
demand for tobacco products. I hope that the current report will serve as an
impetus for continuing activity in the control of smoking and for mobilization of
international resources toward the goal of a smoke-free society.

Antonia C. Novello, M.D., M.P.H.
Surgeon General

iv


     Preface
   from the Director,
Pan American Healfh Organization

Diseases related to smoking are an important cause of premature deaths in the
world, both in developed and developing countries. Eliminating smoking can do
more to improve health and prolong life than any other measure in the field of
preventive medicine.

Developing countries, including those of Latin America and the Caribbean,
are not behind their neighbors in the north with regard to the tremendous growing
problem of noncommunicable diseases related to tobacco consumption.

  Over the last three decades, the countries of Latin America and the Caribbean
have experienced important changes in their demographic, socioeconomic, and
epidemiologic profiles. Increasing numbers of the older, more urban, and espe-
cially the poorer populations of the region, are dying of diseases related to lifestyle
determinants. Consumption of tobacco is one of these harmful threats to the health
and well-being of our populations.

Despite that, in most of the developing countries of our region, not enough
attention has been given to generate actions and the kind of information needed for
policy and program formulation with regard to tobacco control. It is also unfortun-
ate that while the transnational conglomerates in control of almost all tobacco
production and marketing have directed their efforts toward penetrating develop-
ing economies, many governments, given the urgent needs created by other health
problems, and in some cases due to financial or economic reasons, consider tobacco
control a low priority.

  The United States Government and the Pan American Health Organization
(PAHO) have been working in a joint effort to generate the information included
in the Surgeon General's report, and the PAHO country report, which hopefully
will bring more awareness and promote action against smoking in the region of the
Americas.

Our collaboration with the Office of the Surgeon General has been highly
satisfactory, and it will encourage the development of a regional network for
implementing research and exchange of successful experiences in the control of
tobacco addiction.

Carlyle Guerra de Macedo, M.D., M.P.H.
Director


Acknowledgments

  This report was prepared by the Department of
Health and Human Services and under the general
direction of the Centers for Disease Control, National
Center for Chronic Disease Prevention and Health
Promotion, Office on Smoking and Health.

William L. Roper, M.D., M.P.H., Director, Centers for
Disease Control, Atlanta, Georgia.

Jeffrey P. Koplan, M.D., M.P.H., Director, National
Center for Chronic Disease Prevention and Health
Promotion, Centers for Disease Control, Atlanta, Georgia.
Virginia S. Bales, M.P.H., Deputy Director, National
Center for Chronic Disease Prevention and Health
Promotion, Centers for Disease Control, Atlanta,
Georgia.

Michael I'. Eriksen., Sc.D., Director, Office on Smoking
and Health, National Center for Chronic Disease
Prevention and Health Promotion, Centers for Disease
Control, Atlanta, Georgia.

7'he editors of the report were
Richard B. Rothenberg, M.D., M.P.H., Senior Scien-
tific Editor, National Center for Chronic Disease
Prevention and Health Promotion, Centers for Disease
Control, Atlanta, Georgia.

Gwendolyn A. Ingraham, Managing Editor, National
Center for Chronic Disease Prevention and Health
Promotion, Centers for Disease Control, Atlanta,
Georgia.

Barbara Sajor Gray, M.Ln., Senior Writer-Editor,
National Center for Chronic Disease Prevention and
Health Promotion, Centers for Disease Control,
Atlanta, Georgia.

Judith Navarro, Ph.D., Consulting Editor, Chief,
Editorial Services, Pan American Health Orga-
nization, Washington, D.C.

Senior contributing editors were

Aloyzio Achutti, M.D., Professor, Discipline of
Promotion and Protection of Health, School of
Medicine, Federal University of Rio Grande do Sul,
Port0 Alegre, Brazil.
Neil E. Collishaw, M.A., Chief, Tobacco Products
Section, Environmental Health Directorate, Health
and Welfare Canada, Ottawa, Canada.
Ronald M. Davis, M.D., Chief Medical Officer,
Michigan Department of Public Health, Lansing,
Michigan.

Eric Nicholls, M.D., Regional Advisor in Chronic
Diseases, Pan American Health Organization,
Washington, D.C.

Thomas E. Novotny, M.D., M.P.H., Liaison Officer,
School of Public Health, University of California,
Berkeley, California.
Sylvia C. Robles, M.D., Department of Public Health,
School of Medicine, University of Costa Rica, San Jose,
Costa Rica.

Margarita Ronderos Torres, M.D., MSc., Head of
Epidemiology and Prevention Division, National
Cancer Institute, Bogota, Colombia.

Contributing authors were

Jorge Balan, Ph.D., Director, Center for the Study of
State and Society, Buenos Aires, Argentina.
Luis G. Escobedo, M.D., M.P.H., Medical Epidemi-
ologist, Surveillance and Research Branch, Division of
Adolescent and School Health, National Center for
Chronic Disease Prevention and Health Promotion,
Centers for Disease Control, Atlanta, Georgia.
Eugene M. Lewit, Ph.D., Director of Research and
Grants, Economics, David and Lucile Packard
Foundation, Los Altos, California.
Thomas E. Novotny, M.D., M.P.H., Liaison Officer,
School of Public Health, University of California,
Berkeley, California.
Ruth Roemer, J.D., Adjunct Professor, School of
Public Health, University of California, Los Angeles,
California.

Philip L. Shepherd, Ph.D., Associate Professor,
Department of Marketing and Environment, Florida
International University, Miami, Florida.
Robert Sobel, Ph.D., Professor of Business History,
Hofstra University, Hempstead, New York.
Kenneth E. Stanley, Ph.D., Department of Biosta-
tistics, Harvard School of Public Health, Boston,
Massachusetts.

Johannes Wilbert, Ph.D., Emeritus Professor of
Anthropology, University of California, Los Angeles,
Pacific Palisades, California.

Reviewers were

Francisco Lopez Antuiiano, M.D., Director, Health
Program Development, Pan American Health
Organization, Washington, D.C.

vii


Elias Anzola, M.D., Medical Officer, Health
Promotion Program,  Pan American Health
Organization, Washington, D.C.
Howard Barnum, I'h.D., Senior Economist, The World
Bank, Washington, D.C.

Glen Bennett, M.P.H., Coordinator, Smoking
Education Program, Health Education Branch,
National Heart, Lung, and Blood Institute, National
Institutes of Health, Bethesda, Maryland.
Monica Bolis, Advisor on Legislation, Health Policies
Development Program, Pan American Health
Organization, Washington, D.C.
A. David Brandling-Bennett, M.D., Program
Coordinator, Health Situation and Trend Assessment
Program, Pan American Health Organization,
Washington, D.C.

Allan M. Brandt, Ph.D., Associate Professor,
Department of Social Medicine, School of Medicine,
University of North Carolina, Chapel Hill, North
Carolina.

David M. Burns, M.D., Professor of Medicine,
University of California, San Diego Medical Center,
San Diego, California.

Peter W. Burr, Agricultural Economist, Tobacco,
Cotton, and Seeds Division, Foreign Agricultural
Service, U.S. Department of Agriculture, Washington,
D.C.

Juan Chackiel, Chief of Demography, Latin American
Center for Demography, CELADE, Santiago, Chile.
Claire Chollat-Traquet, Ph.D., Scientist, Tobacco or
Health Program, World Health Organization, Geneva,
Switzerland.

Gregory N. Connolly, D.M.D., M.P.H., Director,
Office for Nonsmoking and Health, Massachusetts
Department of Public Health, Boston, Massachusetts.
Joe H. Davis, M.D., M.P.H., Assistant Director for
International Health, Centers for Disease Control,
Atlanta, Georgia.

Ronald M. Davis, M.D., Chief Medical Officer,
Michigan Department of Public Health, Lansing,
Michigan.
Allan C. Erickson, Senior Vice President for Cancer
Control, American Cancer Society, Atlanta, Georgia.
Sev S. Fluss, MS., Chief, Health Legislation, World
Health Organization, Geneva, Switzerland.
William H. Foege, M.D., M.P.H., Executive Director,
Carter Center of Emory University, Atlanta, Georgia.

Clark W. Heath, Jr., M.D., Vice President of
Epidemiology and Statistics, American Cancer
Society, Atlanta, Georgia.

Thomas A. Hodgson, Ph.D., Chief Economist, Office
of Analysis and Epidemiology, National Center for
Health Statistics, Centers for Disease Control,
Hyattsville, Maryland.

Bo Holmstedt, M.D., Director, Department of
Toxicology, Karolinska Institute, Stockholm, Sweden.
Dean T. Jamison, Ph.D., Department of Public Health
and Policy, London School of Hygiene and Tropical
Medicine, London, England.
C. Everett Koop, M.D., Sc.D., Surgeon General,
U.S. Public Health Service, 1981-1989, Bethesda,
Maryland.

Alan Lopez, Ph.D., Statistician/Demographer, Global
Health Situation Assessment and Projections, World
Health Organization, Geneva, Switzerland.
J. Michael McGinnis, M.D., Director, Office of Disease
Prevention and Health Promotion, Department of
Health and Human Services, Washington, D.C.
Anthony R. Measham, M.D., Chief, Population,
Health, and Nutrition Division, The World Bank,
Washington, D.C.

Anthony B. Miller, M.B., FRC, Professor, Department
of Preventive Medicine and Biostatistics, Faculty of
Medicine, University of Toronto, Ontario, Canada.
W. Henry Mosley, M.D., M.P.H., Professor and
Chairman, Department of Population Dynamics,
Johns Hopkins University, School of Hygiene and
Public Health, Baltimore, Maryland.
Eric Nicholls, M.D., Regional Advisor in Chronic
Diseases, Pan American Health Organization,
Washington, D.C.

Donald Maxwell Parkin, Ph.D., Chief, Unit of
Descriptive Epidemiology, International Agency
for Research on Cancer, World Health Organization,
Lyon, France.

Mark A. Pertschuk, J.D., Executive Director,
Americans for Nonsmokers' Rights, Berkeley,
California.

Michael Pertschuk, J.D., Codirector, The Advocacy
Institute, Washington, D.C.
John M. Pinney, Chief Executive Officer, Cooperate
Health Policies Group, Washington, D.C.
Ranate Plaut, M.D., Epidemiologist, Health Situation
and Trend Assessment Program, Pan American
Health Organization, Washington, D.C.

.
Vllf


Gerard0 Reichel-Dolmatoff, Ph.D., Adjunct Professor,
University of California, Los Angeles, California.
Helena Restrepo, M.D., Coordinator, Health
Promotion Program,  Pan American Health
Organization, Washington, D.C.
Laurent Rivier, DSc., Director, Drug Analysis Unit,
Institute of Forensic Medicine, University of Lausanne,
Switzerland.

Thomas C. Schelling, Ph.D., Distinguished Professor
of Economics and Public Affairs, Department of
Economics, University of Maryland, College Park,
Maryland.

Richard Evans Schultes, Ph.D., Professor Emeritus
and former Director, Botanical Museum, Harvard
University, Cambridge, Massachusetts.
Donald R. Shopland, Coordinator for Smoking and
Tobacco Control Program, Division of Cancer
Prevention and Control, National Cancer Institute,
National Institutes of Health, Bethesda, Maryland.
Jesse L. Steinfeld, M.D., Surgeon General, U.S. Public
Health Service, 1969-1973, San Diego, California.
Daniel A. Sumner, Ph.D., Deputy Assistant Secretary
for Economics, Office of the Assistant Secretary for
Economics, U.S. Department of Agriculture,
Washington, D.C.

Cesar A. Vieira, M.D., Coordinator, Health Policies
Development Program, Pan American Health
Organization, Washington, D.C.
Kenneth E. Warner, Ph.D., Professor of Public Health
Policy, School of Public Health, University of
Michigan, Ann Arbor, Michigan.
Ernst L. Wynder, M.D., President, American Health
Foundation, New York, New York.

Other contributors were

Patricia Ardila, Bilingual Editor, The Circle, Inc.,
McLean, Virginia.

Cathy D. Arney, Graphic Artist, The Circle, Inc.,
McLean, Virginia.
John Artis, Courier, The Circle, Inc., McLean, Virginia.
Carol A. Bean, Ph.D., Consultant, Artemis Tech-
nologies, Inc., Springfield, Virginia.
Nowell D. Berreth, Writer-Editor, Public Information
Branch, Office on Smoking and Health, National
Center for Chronic Disease Prevention and Health
Promotion, Centers for Disease Control, Atlanta,
Georgia.

Byron Breedlove, M.A., Assistant Branch Chief,
Editorial Services Branch, National Center for Chronic
Disease Prevention and Health Promotion, Centers for
Disease Control, Atlanta, Georgia.
Kelly L. Byrne, Desktop Publishing/Word Processing
Specialist, The Circle, Inc., McLean, Virginia.
Maria Luisa Clark, M.D., Editor, Editorial Services,
Pan American Health Organization, Washington,
D.C.

Gail A. Cruse, Technical Information Specialist,
Technical Information Services Branch, National
Center for Chronic Disease Prevention and Health
Promotion, Centers for Disease Control, Atlanta,
Georgia.

Alice A. DeVierno, M.L.S., Manager, Technical
Information Center, Office on Smoking and Health,
National Center for Chronic Disease Prevention and
Health Promotion, Centers for Disease Control,
Atlanta, Georgia.

Sue T. Dixon, Secretary, Office of the Director,
National Center for Chronic Disease Prevention and
Health Promotion, Centers for Disease Control,
Atlanta, Georgia.

Seth L. Emont, Ph.D., Epidemiologist, Office on
Smoking and Health, National Center for Chronic
Disease Prevention and Health Promotion, Centers for
Disease Control, Atlanta, Georgia.
Christine S. Fralish, Chief, Technical Information
Services Branch, National Center for Chronic
Disease Prevention and Health Promotion, Centers
for Disease Control, Atlanta, Georgia.
Gary A. Giovino, Ph.D. , Chief, Epidemiology Branch,
Office on Smoking and Health, National Center for
Chronic Disease Prevention and Health Promotion,
Centers for Disease Control, Atlanta, Georgia.
Betty H. Haithcock, Editorial Assistant, Editorial
Services Branch, National Center for Chronic Disease
Prevention and Health Promotion, Centers for Disease
Control, Atlanta, Georgia.

Gwendolyn A. Harvey, Program Analyst, Office of the
Director, National Center for Chronic Disease
Prevention and Health Promotion, Centers for Disease
Control, Atlanta, Georgia.

Susan A. Hawk, Ed.M., MS., Program Analyst, Office
of the Director, National Center for Health Statistics,
Centers for Disease Control, Hyattsville, Maryland.
Phyllis E. Hechtman, Editorial Assistant, The Circle,
Inc., McLean, Virginia.
John Helsel, Senior Systems Analyst, The Circle, Inc.,
McLean, Virginia.

ix


Timothy K. Hensley, Technical Publications Writer-
Editor, Public Information Branch, Office on Smoking
and Health, National Center for Chronic Disease
Prevention and Health Promotion, Centers for Disease
Control, Atlanta, Georgia.

Frederick L. Hull, Ph.D., Writer-Editor, Editorial
Services Branch, National Center for Chronic Disease
Prevention and Health Promotion, Centers for Disease
Control, Atlanta, Georgia.

Delle B. Kelley, Technical Information Specialist,
Technical Information Services Branch, National
Center for Chronic Disease Prevention and Health
Promotion, Centers for Disease Control, Atlanta,
Georgia.

Mescal J. Knighton, Writer-Editor, Editorial Services
Branch, National Center for Chronic Disease Pre-
vention and Health Promotion, Centers for Disease
Control, Atlanta, Georgia.

Gayle Lloyd, M.A., Editor, Technical Information
Center, Office on Smoking and Health, National
Center for Chronic Disease Prevention and Health
Promotion, Centers for Disease Control, Atlanta,
Georgia.

Peggy Lytton, Editor, The Circle, Inc., McLean,
Virginia.

Patricia McCarty, Secretary, Public Information
Branch, Office on Smoking and Health, National
Center for Chronic Disease Prevention and Health
Promotion, Centers for Disease Control, Atlanta,
Georgia.

Rachel R. Merritt, Secretary, Technical Information
Center, Office on Smoking and Health, National
Center for Chronic Disease Prevention and Health
Promotion, Centers for Disease Control, Atlanta,
Georgia.
Jennifer A. Michaels, M.L.S., Technical Information
Specialist, Technical Information Center, Office on
Smoking and Health, National Center for Chronic
Disease Prevention and Health Promotion, Centers for
Disease Control, Atlanta, Georgia.

Reba A. Norman, M.L.M., Technical Information
Specialist, Technical Information Services Branch,
National Center for Chronic Disease Prevention and
Health Promotion, Centers for Disease Control,
Atlanta, Georgia.

Cathie M. O'Donnell, Project Director, The Circle, Inc.,
McLean, Virginia.

Richard Ray, Director of Computer Services, The
Circle, Inc., McLean, Virginia.
Flor M. Rojas-Jaber, Editorial Assistant, Editorial
Services, Pan American Health Organization,
Washington, D.C.

Carlos Rossel, Publications Specialist, Editorial Services,
Pan American Health Organization, Washington,
D.C.

Beverly Schwartz, M.S., Special Advisor, Public
Information Branch, Office on Smoking and Health,
National Center for Chronic Disease Prevention and
Health Promotion, Centers for Disease Control,
Atlanta, Georgia.

Rita Shelton, Senior Editor, Editorial Services, Pan
American Health Organization, Washington, D.C.
Janete da Silva, Health Manpower Development Pro-
gram, Pan American Health Organization, Washington,
D.C.

Daniel R. Tisch, Director of Publications, The Circle,
Inc., McLean, Virginia.
Kymber N. Williams, M.A., Public Information
Specialist, Public Information Branch, Office on
Smoking and Health, National Center for Chronic
Disease Prevention and Health Promotion, Centers for
Disease Control, Atlanta, Georgia.
Rebecca B. Wolf, M.A., Program Analyst, Office of
Program Planning and Evaluation, Centers for
Disease Control, Atlanta, Georgia.

X


Smoking and Health in the Americas

Countries of the Americas   3

Notes on the Text   5

Chapter 1. Introduction, Summary, and Chapter Conclusions   7

Chapter 2. The Historical Context 25

Tobacco Use in Indigenous Societies 2 9
The Emergence of the Cigarette, 1492-1900   23
The Emergence of the Tobacco Companies, 1900 to the Present   32

Chapter 3. Prevalence and Mortality   57
Prevalence of Smoking in Latin America and the `Caribbean   62
Smoking-Attributable Mortality in Latin America and the Caribbean   82

Chapter 4. Economics of Tobacco Consumption in the Americas  202

Economic Costs of the Health Effects of Smoking   205
Economics of the Tobacco Industry   224

Chapter 5. Legislation to Control the Use of Tobacco in the Americas   243

Legislation to Control Production, Manufacture, Promotion, and Sales   248
Legislation to Change Smoking Behavior   253
The Impact of Antitobacco Legislation   262

Chapter 6. Status of Tobacco Prevention and Control Programs in the Americas  2 79

National Programs for Tobacco Control   283
Regional Activities for Tobacco Control in Latin America and the Caribbean   185
Elements of Prevention and Control Programs   186

List of Tables and Figures   207

Index   209



Countries of the Americas

Latin America
Andean Area
   Bolivia
   Colombia
   Ecuador
   Peru
   Venezuela
Southern Cone
  Argentina
   Chile
  Paraguay
  Uruguay
Brazil
Central America
   Belize
   Costa Rica
   El Salvador
   Guatemala
   Honduras
  Nicaragua
   Panama
Mexico
Latin Caribbean
   Cuba
  Dominican Republic
   Haiti
   Puerto Rico

Caribbean
Anguilla
Antigua and Barbuda
Bahamas
Barbados
Bermuda
British Virgin Islands
Cayman Islands
Dominica
French Guiana
Grenada
Guadeloupe
Guyana
Jamaica
Martinique
Montserrat
Netherlands Antilles and Aruba
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and
   the Grenadines
Suriname
Trinidad and Tobago
Turks and Caicos Islands
Virgin Islands

North America
Canada
United States of America

  Data in this report are almost exclusively presented by the above regions. In some
instances, however, information is presented separately for the French overseas depart-
ments in the Americas (French Guiana, Guadeloupe, and Martinique) and the French
territory Saint Pierre and Miquelon, which is in North America. Such instances are noted
in the text.

The designations employed and the presentation of the material in this publication do
not imply the expression of any opinion whatsoever on the part of the Secretariat of the Pan
American Health Organization or the U.S. Department of Health and Human Services
concerning the legal status of any country, territory, city, or area of its authorities, or
concerning the delimitation of its frontiers or boundaries.


Notes on the Text

Trade Names

Use of trade names is for identification only and does not constitute endorsement by
the Public Health Service or the U.S. Department of Health and Human Services.

Company Names

Current names are used to identify companies throughout the report. In some
instances, exact names could not be verified from current sources, and the best available
information was used. On tables reproduced from other sources, the nomenclature used in
the original source was retained.

Sources used to verify company names included Tobacco International's 57th Annual
Directory and Buyer's Guide, 1992 (Vol. 192, No. 21, New York: Lockwood Trade Journal Co.,
Inc., 1990) and the following online databases: D&&Dun's Market Identifiers, ICC British
Company Directory, and ICC British Company Financial Datasheets.
The complete name is used for the first mention of a company, after which an
abbreviated form is generally used.

Organizations, Campaigns, and Slogans

Names of organizations, coalitions, committees, government agencies, and other
groups, as well as names of public information campaigns and health campaigns and their
slogans were verified in online sources (Encyclopedia of Associations, MEDLINE, and
several news services) and in the files of the Pan American Health Organization (PAHO).
Not all such information was verifiable, and translations made into English sometimes
varied. Every reasonable effort was made to obtain the official name and/or standard
translation; we regret any inaccuracies that may have occurred.

Legislation and Health Warnings

The legal and the popular names of legislation and the wording of health warnings
required on advertisements and packaging of tobacco products were verified in several
sources. These included the United States Code Service (online database), PAHO's LEYES
database (see Chapter 5, Appendix 2), the International Digest of Health Legislation, copies of
legislation, and the files of the Centers for Disease Control's Office on Smoking and Health.
We regret any errors that may have resulted from incomplete files or inaccurate translations.

Botanic Substances

Names of substances discussed in Chapter 2 are treated as non-English words unless
they appear in Webster's Third New International Dictionary of the English Language, un-
abridged, Springfield, Massachusetts: G. & C. Merriam Company, 1981. The spelling of
non-English words was verified in foreign language dictionaries or used as cited in original
sources.


Chapter 1
Introduction, Summary,
and Chapter Conclusions

Introduction 9

Development of the Report   9
Major Conclusions 10

Summary 10

Chapter Conclusions 12

Chapter 2. The Historical Context   22
Chapter 3. Prevalence and Mortality   12
Chapter 4. Economics of Tobacco Consumption in the Americas   22
Chapter 5. Legislation to Control the Use of Tobacco in the Americas   23
Chapter 6. Status of Tobacco Prevention and Control Programs in the Americas   13

References 14


Introduction

  Recognition that the problems posed by per-
sonal risks are amenable to social solutions is an im-
portant contribution of modern public health. Each
person makes choices, but such choices are shaped by
social, economic, and environmental circumstances.
On an even broader scale, national choices are made
in a complex regional or global setting. This report
attempts to place the personal risk of smoking in the
Americas in the larger context and to underline both
the heterogeneity and the interrelationship of nations.

  Previous Surgeon General's reports have fo-
cused primarily, although not exclusively, on the epi-
demiologic, clinical, biologic, and pharmacologic
aspects of smoking. With the twenty-fifth anniversary
report (U.S. Department of Health and Human Ser-
vices 1989), in which considerable attention was de-
voted to the social, economic, and legislative aspects
of tobacco consumption, the need to place tobacco in
a larger context was made apparent. Accordingly, this
report now examines the broad issues that surround
the production and consumption of tobacco in the
Americas.

Development of the Report

  The 1992 Surgeon General's report was prepared
by the Office on Smoking and Health (OSH), National
Center for Chronic Disease Prevention and Health
Promotion, Centers for Disease Control, Public Health
Service, U.S. Department of Health and Human Ser-
vices, as part of the department's responsibility, under
Public Law 91-222, to report current information on
smoking and health to the U.S. Congress.

  OSH, a World Health Organization Collaborat-
ing Center for Smoking and Health, works closely
with the Pan American Health Organization (PAHO).
In the Regional Plan of Action for the Prevention and
Control of Tobacco Use, PAHO responded to the
thirty-third meeting (1988) of its Directing Council,
which recommended that PAHO (1) collaborate with
the countries of the Americas in the development of
national programs for the prevention and control of
smoking and (2) cooperate with member states and
government and nongovernment centers and groups
in identifying and mobilizing resources to contribute
to this plan of action (PAHO 1989).

  In February 1988, the Surgeon General, then C.
Everett Koop, M.D., Sc.D., and the PAHO Director,
Carlyle Guerra de Macedo, M.D., M.P.H., agreed to
the development of a Surgeon General's report that

focuses on smoking in the Americas. OSH and the
Health of Adults Program of PAHO began work on
this project.

  OSH and PAHO presented the concept of a col-
laborative effort to attendees of the Fourth PAHO
Subregional Workshop on the Control of Tobacco
(Central America) in November 1988. Meetings of the
Latin American Coordinating Committee on Smoking
Control were also attended by OSH and PAHO staff
in Santa Cruz, Bolivia (January 1989), and in Port of
Spain, Trinidad and Tobago (March 1989).

  Four experts on tobacco and health (from Brazil,
Canada, Colombia, and Costa Rica) served on the
Senior Editorial Board, and a collaborator was identi-
fied in each of the participating member states. In
September 1989, work began on the current report and
on a country-by-country summary of the current sta-
tus of tobacco prevention and control in the Americas,
which PAHO is issuing as a companion document to
this report (PAHO 1992).

  The current report has been prepared from re-
views written by experts in the historical, socio-
demographic, epidemiologic, economic, legal, and
public health aspects of smoking in the Americas. In
addition to standard bibliographic sources, the report
uses data supplied by the U.S. Department of Agricul-
ture, the Centers for Disease Control, The World Bank,
the World Health Organization, the Economic Com-
mission for Latin America and the Caribbean, the
Caribbean Community Secretariat, the Latin Ameri-
can Center on Demography, the International Union
Against Cancer, the International Organization of
Consumers Unions, the American Cancer Society, and
the Latin American Coordinating Committee on
Smoking Control.

  In addition, this report uses information derived
from a data collection instrument developed by
PAHO (with technical assistance from OSH) for the
companion report on the current status of tobacco
prevention and control in PAHO's member states.
The data collection instrument requested current in-
formation on tobacco cultivation, cigarette consump-
tion, legislation, taxation, government and non-
government programs to control tobacco, tobacco-use
surveys, and tobacco-related disease impact. Detailed
information from this data collection instrument was
reviewed at meetings in Caracas, Venezuela (Febru-
ary 1990), and Port of Spain, Trinidad and Tobago
(March 19901, before incorporation into PAHO's country-
by-country status report.

Infroducfion 9


Major Conclusions

  Five major conclusions have emerged from re-
view of the complex factors affecting smoking in the
Americas. The first two relate to the current size of the
problem; the latter three, to current conditions that
have an important influence on the prevention and
control of tobacco use.

1.  The prevalence of smoking in Latin America and
the Caribbean is variable but reaches 50 percent or
more among young people in some urban areas.
Significant numbers of women have taken up
smoking in recent years.

2.  By 1985, an estimated minimum of 526,000 smoking-
attributable deaths were occurring yearly in the
  Americas; 100,000 of these deaths occurred in
  Latin America and the Caribbean.

Summary

3.  In Latin America and the Caribbean, the current
structure of the tobacco industry, which is domi-
nated by transnational corporations, presents a
formidable obstacle to smoking-control efforts.

4.  The economic arguments for support of tobacco
production are offset by the long-term economic
effects of smoking-related disease.

5. Commitment to surveillance of tobacco-related
factors-such as prevalence of smoking; morbid-
ity and mortality; knowledge, attitudes, and prac-
tices; tobacco consumption and production; and
taxation and legislation-is crucial to the develop-
ment of a systematic program for prevention and
  control of tobacco use.

  The use of tobacco in the Americas long predates
the European voyages of discovery. Among indige-
nous populations, tobacco was used primarily for the
pharmacologic effects of high doses of nicotine, and it
played an important role in shamanistic and other
spiritual practices. Its growth as a cash crop began
only after the European market was opened to tobacco
in the early and mid-seventeenth century. During
early colonial times, the focus for tobacco cultivation
shifted from Latin America and the Caribbean to
North America, where a light, mellow brand of to-
bacco was grown. Despite antitobacco movements,
the popularity of tobacco increased dramatically after
the U.S. Civil War, and by the early part of the twen-
tieth century, the cigarette had emerged as the tobacco
product of choice in the United States.

  The first half of the twentieth century witnessed
a spectacular increase in the popularity of cigarettes
and in the growth of several major cigarette manufac-
turing companies in the United States. Interest in
international expansion was minimal until after
World War II. In the early 195Os, preliminary reports
of the health effects of tobacco first appeared; these
were followed in 1964 by the first report of the Surgeon
General on the health effects of smoking (Public
Health Service 1964). These events, which were ac-
companied by a downturn in U.S. tobacco consumption,
ushered in a period of rapid international expansion
by the tobacco companies. Their expansion into Latin

America and the Caribbean was typified by a process
of denationalization-that is, the abandonment of
local government tobacco monopolies and the cre-
ation of subsidiaries by U.S. and British transnational
tobacco corporations. The transnational companies
were particularly successful in altering local demand
by influencing consumer preferences. Local taste for
dark tobacco in a variety of forms was largely replaced
by demand for the long, filtered, light-tobacco ciga-
rettes produced by the transnational companies.

  During the 198Os, several divergent forces influ-
enced the consumption of tobacco in Latin America
and the Caribbean. Changing demographics (primar-
ily declining birth and death rates and an overall
growth in the population), increasing urbanization,
improving education, and the growing entry of
women into the labor force-all expanded the poten-
tial market for tobacco. Although systematic surveil-
lance evidence is lacking, an increased prevalence of
smoking among young people, particularly women in
urban areas, appears to have occurred during this
period. A countervailing force, however, was the
major economic downturn experienced by most coun-
tries of Latin America and the Caribbean during the
1980s. The result was that despite the increasing prev-
alence of smoking in some sectors of the population,
overall consumption of tobacco declined. Unlike the
decline in North America, however, the decline in
Latin America and the Caribbean seems to have been

10   Introduction


based on income elasticity rather than on health
concerns.

  The health burden imposed by smoking in Latin
America and the Caribbean is currently smaller than
that in North America. A conservative estimate is
that, by the mid-1980s, at least 526,000 deaths from
smoking-related diseases were occurring annually in
the Americas and that approximately 100,000 of these
deaths occurred in Latin America and the Caribbean.
Since the smoking epidemic is more recent, less wide-
spread, and less entrenched in Latin America and the
Caribbean than in North America, it may be thought
of as less "mature'`-that is, sufficient time has not yet
elapsed for the cumulative effects of tobacco use to
become manifest. Because health data from Latin
American and Caribbean countries vary in consis-
tency and comprehensiveness, establishing overall
trends for morbidity and mortality is difficult. None-
theless, the available evidence suggests an important
contrast between North America on the one hand, and
Latin America and the Caribbean on the other. In the
United States and Canada, smoking-associated mor-
tality is high and increasing because of high consump-
tion levels in the past, but prevalence of smoking is
declining. In Latin America and the Caribbean, prev-
alence of smoking is high in some sectors, but smoking-
attributable mortality is still low compared with that
for North America. This contrast augurs poorly for
public health in Latin America and the Caribbean,
unless action is taken.

  The health costs of smoking are considerable.
The U.S. population of civilian, noninstitutionalized
persons aged 25 years or older who ever smoked
cigarettes will incur lifetime excess medical care costs
of $501 billion. The estimated average lifetime medi-
cal costs for a smoker exceed those for a nonsmoker by
over $6,000. This excess is a weighted average of the
costs incurred by all smokers, whether or not they
develop smoking-related illness. For smokers who do
develop such illnesses, the personal financial impact
is much higher.

  Available data do not permit a firm estimate for
Latin America and the Caribbean. The estimate will
probably vary with the health care structure of the
country, but the burden is likely to increase with in-
creasing development and industrialization. None-
theless, early evidence suggests that smoking-
prevention programs can be cost-effective under
current economic circumstances.

  The economics of the tobacco industry in the
Americas are complex. Although tobacco had long
been thought to be an inelastic commodity, it has been
demonstrated to be both price and income elastic.

Such elasticity renders tobacco use susceptible to con-
trol through taxation and other disincentives. Reve-
nues from tobacco have been an important, though
variable, source of funds for governments, but the case
for promoting tobacco production on economic
grounds is weak. Currently, only a few countries of
Latin America and the Caribbean have economies that
are largely dependent on tobacco production. The
current economic picture, coupled with consumer re-
sponsiveness to income and price and the potential
health hazards, has created a significant opportunity
for tobacco control in Latin America and the Caribbean.

  This opportunity is reflected, to some extent, in
the fact that most countries of the Americas have
legislation that controls tobacco use. Restrictions on
advertising, the requirement of health warnings on
tobacco products, limits on access to tobacco, and
restrictions on public smoking have all been invoked.
The legislative approach is not systematic, however,
and in many countries, the programs have gaps. Fur-
thermore, the extent to which such legislation is en-
forced is not fully known. Nonetheless, the pace of
enactment suggests a growing awareness of the poten-
tial efficacy of the legislative approach.

  Overall, the public health approach to tobacco
control in Latin America and the Caribbean is variable.
Many countries have adopted some elements of com-
prehensive control, including (in addition to legisla-
tion and taxation) the development of national
coalitions, the promotion of education and media-
based activities, and the development and refinement
of surveillance systems.  Few countries, however,
have adopted the unified approach that characterizes,
for example, the program in Canada.

  The potential exists in the Americas for a strong,
coordinated effort in smoking control at the local,
national, and regional levels. The high prevalence of
smoking that is emerging in many areas is a clear
indicator of an approaching epidemic of smoking-
related disease. The potential for decreasing consumption
in Latin America and the Caribbean has been well
demonstrated, albeit by the unfortunate mechanism of
an economic downturn. The potential for a decline in
smoking prevalence motivated by health concerns has
been well demonstrated in North America. Further-
more, the importance of tobacco manufacturing and
production to local economies is undergoing consid-
erable scrutiny. Regional and international plans for
tobacco control have been developed and are being
implemented. For persons in the Americas in the
coming years, the individual decision to smoke may
well be made in an environment that is increasingly
cognizant of the costs and hazards of smoking.

Introduction 11


Chapter Conclusions

  Following are the specific conclusions from each
chapter in this report:

Chapter 2. The Historical Context

Tobacco has long played a role, chiefly as a feature
of shamanistic practices, in the cultural and spiri-
tual life of the indigenous populations of the
Americas. This usage by a small group of initiates
contrasts sharply with the widespread tobacco
addiction of contemporary American societies.
During the latter half of the nineteenth century,
amalgamation of major U.S. cigarette firms coin-
cided with the emergence of the cigarette as the
most popular tobacco product in the United
States.

In Latin America and the Caribbean, through a
process of denationalization and the formation of
subsidiaries, a few transnational corporations
now dominate the tobacco industry. The current
structure of the industry presents a formidable
obstacle to smoking-control efforts.

After rapid growth in per capita tobacco con-
sumption in Latin America and the Caribbean
during the 1960s and 197Os, a severe economic
downturn during the 1980s led to a decline in
tobacco consumption. In the absence of counter-
measures, an economic recovery is likely to insti-
gate a resurgence of tobacco consumption.

Chapter 3. Prevalence and Mortality

1.

2.

3.

73

Certain sociodemographic phenomena-such as
change in population structure, increasing urban-
ization, increased availability of education, and
entry of women into the labor force-have in-
creased the susceptibility of the population of
Latin America and the Caribbean to smoking.
The lack of systematic surveillance information
about the prevalence of smoking in most areas of
Latin America and the Caribbean hinders com-
prehensive control efforts. Available information
reflects a variety of survey methods, analytic
schemes, and reporting formats.

Available data indicate that the median preva-
lence of smoking in Latin America and the Carib-
bean is 37 percent for men and 20 percent for
women. Variation among countries is considerable,

I&   Introduction

however, and smoking prevalence is 50 percent or
more in some populations but less than 10 percent
in others. In general, prevalence is highest in the
urban areas of the more-developed countries and
is higher among men than among women.
4. The initiation of smoking (as measured by the
prevalence of smoking among persons 20 to 24
years of age) exceeds 30 percent in selected urban
areas. Although systematic time series are not
available, the data suggest that more recent co-
horts (especially of women) in the urban areas of
more-developed countries are adopting tobacco
use at a higher rate than did their predecessors.
5.  The smoking epidemic in Latin America and the
Caribbean is not yet of long duration or high
intensity, and the mortality burden imposed by
smoking is smaller than that for North America.
By 1985, an estimated minimum of 526,000 smoking-
attributable deaths were occurring each year in all
the countries of the Americas; 100,000 of these
  deaths occurred in Latin American and Caribbean
  countries.

6. The estimate of 526,000 deaths annually is conser-
vative and is best viewed as the first point on a
continuum of such estimates. However, it pro-
vides an order of magnitude for the number of
smoking-attributable deaths in the Americas.

7. The time lag between the onset of smoking and the
onset of smoking-attributable disease is forebod-
ing. In North America, a high prevalence of smok-
ing, now declining, has been followed by an
increasing burden of smoking-attributable mor-
bidity and mortality. In Latin America and the
Caribbean, rising prevalence portends a major
burden of smoking-attributable disease.

Chapter 4. Economics of Tobacco
Consumption in the Americas

1.  Because the health costs of tobacco consumption
result from cumulative exposure, they are most
pronounced in the economically developed coun-
tries of North America, which have had major
long-term exposure.  Since many countries of
Latin America and the Caribbean are experiencing
an epidemiologic transition, the economic impact
of smoking is increasing.


2.

3.

4.

5.

6.

7.

The economic costs of smoking are a function of
the economic, social, and demographic context of
a given country. In the United States, estimated
total lifetime excess medical care costs for smokers
exceed those for nonsmokers by $501 billion-an
average of over $6,000 per current or former
smoker. Similar formal estimates for many Latin
American and Caribbean countries are not available.

Evidence of the cost-effectiveness of smoking con-
trol and prevention programs has increased. In
Brazil, for example, the cost of public information
and personal smoking-cessation services is esti-
mated at 0.2 to 2.0 percent of per capita gross
national product (GNP) for each year of life
gained; treatment for lung cancer costs 200 per-
cent of per capita GNP per year of life gained.

In Latin America and the Caribbean, as GNP in-
creases, cigarette consumption increases, particu-
larly at lower income levels. This effect is
attenuated at higher income levels.

Advertising tends to increase cigarette consump-
tion, although the relationship is difficult to quan-
tify precisely.  Advertising restrictions are
generally associated with declines in consump-
tion and, hence, are an important component of
tobacco-control programs.

The case for promoting increased tobacco produc-
tion on economic grounds should be recon-
sidered.  Although tobacco is typically a very
profitable crop, much of the advantage of produc-
ing tobacco stems from the various subsidies,
tariffs, and supply restrictions that support the
high price of tobacco and provide economic rents
for tobacco producers. Although the tobacco in-
dustry is a significant source of employment,
production of alternative goods would generate
similar levels of employment.

Increases in the price of cigarettes, which are a
price-elastic commodity, cause decreases in smok-
ing, particularly among adolescents. Excise taxes
may thus be viewed as a public health measure to
diminish morbidity and mortality, although the
precise impact of taxes on smoking will be influ-
enced by local economic factors.

Although the direct effects of legislation are often
difficult to specify because of interaction with a
variety of other factors, there are numerous exam-
ples of an immediate change in tobacco consump-
tion subsequent to the enactment of new laws and
regulations.

Most countries of the Americas have legislation
that restricts cigarette advertising and promotion,
requires health warnings on cigarette packages,
restricts smoking in public places, and attempts to
control smoking by young people. These laws
and regulations, however, vary in their specific
features. In many areas, the current level of en-
forcement is unknown.

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

1.

2.

3.

4.

5.

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.

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.
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 govemment-
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.

Chapter 5. Legislation to Control the Use
of Tobacco in the Americas

1.  Legislation that affects the supply of and demand
for tobacco is an effective mechanism for promoting
public health goals for the control of tobacco use.

Introduction 13


References

PAN AMERICAN HEALTH ORGANIZATION. Regional
plan of action for the prevention and control of the use of
tobacco. In: Final Reports of the 102nd and 103rd Meetings of
the PAHO Executizle Cornmiftee, XXXIV Meeting of fhe Direct-
ing Council of PAHO, XL1 Meeting, WHO Regional Committee
for the Americas. Official Document No. 232. Washington,
DC: Pan American Health Organization, 1989.

PAN AMERICAN HEALTH ORGANIZATION. Tobacco or
Health: Status in the Americas. Washington, DC: Pan Amer-
ican Health Organization. Scientific Publication No. 536,
1992.

PUBLIC HEALTH SERVICE. Smoking and Heahh. Report of
the Advisory Committee to the Surgeon General of fhe Public
Health Se&e, U.S. Department of Health, Education, and
Welfare, Public Health Service. PHS Publication NO. 1103,
1964.

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES.
Reducing the Health Consequences of Smoking: 25 Years of
Progress. A Report of the Surgeon General. U.S. Department of
Health and Human Services, Public Health.Service, Centers
for Disease Control, Center for Chronic Disease Prevention
and Health Promotion, Office on Smoking and Health.
DHHS Publication No. (CIX) 89-8411,1989.

14   Itztroduction


Chapter 2
The Historical Context

Preface 17

Tobacco Use in Indigenous Societies   29

Introduction 19
Old World Discovery of Leaf Tobacco   19
Methods of Tobacco Ingestion   20
Tobacco Chewing 20
Tobacco Drinking 20
Tobacco Licking 22
Tobacco Enema 22
Tobacco Snuffing 21
Tobacco Smoking 22
Inhaling Airborne Smoke   22
Percutaneous Tobacco Use   22
Transcendental Purpose of Native Tobacco Use   22

The Emergence of the Cigarette, 1492-1900   23
Tobacco as a Cash Crop   23
Tobacco Manufacturing and Trade   24
North America 24
Latin America and the Caribbean   25
The Expansion of Tobacco Manufacturing   26
The Manufacturing of Cigarettes   28
The Popularity of Cigarettes   29

The Emergence of the Tobacco Companies, 1900 to the Present   31
Early Growth and Consolidation   31
The 1903 Cartel   32
The Antitrust Case of 1911   32
Stagnation Domestically and Growth Abroad   33
Diversification 34

International Competition 35
The Current Structure of the Industry   35
Barriers to Entry   40
Profitability 41

The Current Status in Latin America and the Caribbean   42
The Future of Tobacco Control   48

Conclusions 49

References 50


Preface

  Since prehistoric times, tobacco has been part of the life nnd culture of the people of the
Americas and has been a prominent feature of the religious am? healing practices of the
region's indigenous societies. During the eras of discozlery, exploration, and national
independence, tobacco zoas a major commodity in the growth of trade and the development
of an economic base. In more recent times, tobacco use has become intimately entwined with
social mores, economic patterns, and, perhaps most importantly, the health of populations
in the Americas-as it has in the zuorld at large. The recognitio?z of health efiects is a recent
phenomenon in the history of tobacco use. Two main reasons for this recognition have been
proposed. First, only in this century has life expectancy increased to the point at which
smoking-related diseases begin to hazle a significant imyact. Second, only in this century
hasan efficient method of tobacco ingestion-the manufactured cigarette-becomeavailable.

  This chapter considers the historical development of tobacco use in the Americas-from
the prehistoric cultizlation of tobacco to the emergence of the manufactured cigarette and the
grozclth of transnational tobacco corporations. Such an overviezo provides a background for
understanding the current role of tobacco in the Americas.

Historicat Context 17


Tobacco Use in Indigenous Societies

Introduction

  In modern times, tobacco is ingested primarily
by burning the tobacco leaf and inhaling the smoke.
Tobacco is also chewed or placed, in the form of snuff,
in contact with the mucous membranes of the mouth.
The predominance of these methods is a fairly recent
phenomenon, and the most common delivery
system-the manufactured cigarette-has been avail-
able for only a little over a century. In the Americas,
however, tobacco has been used for millennia,
through various routes of administration and for a
broad range of social and cultural purposes. The fol-
lowing discussion reviews but does not attempt to
trace the history of tobacco use in the region's indige-
nous societies. Some of the practices discussed are
rare or extinct; others are in current use, but all con-
tribute to defining the role of tobacco in the cultural and
religious life of these societies.

  Nicotiana is an ancient genus, of which two major
species in South America--N. rustica and N. tahacum-
produce high yields of the principal alkaloid, nicotine.
Many species were present in the Southern Cone of
South America in ancient times, but they were largely
ignored until about 8,000 years ago, when the chang-
ing food supply forced a major shift from hunting and
gathering to land cultivation. At that time, popula-
tions migrated from the open savannas of southern
South America, which were largely unsuited for agri-
culture, to the tropical rain forest of the Amazon and
areas further north, including the Caribbean. Tobacco
became one of the standard crops cultivated by these
early farmers.

Old World Discovery of Leaf Tobacco

  European explorers were introduced to tobacco
in the West Indies in 1492, when natives offered to-
bacco leaves to Christopher Columbus and his men as
a token of friendship. After a subsequent exploratory
excursion through coastal Cuba, two of Columbus's
crew reported having witnessed the custom of cigar
smoking (Brooks 1937-1952). The explorers who fol-
lowed also recorded tobacco use among the Indians,
and these accounts, along with the observations of
missionaries, soldiers, travelers, and scholars, are in-
tegral to our understanding of the role of tobacco in
indigenous cultures.

  Many explorers learned that tobacco use was
addictive and multipurpose, but most of them did not

understand why Indians considered tobacco sacred.
The plant, it was soon recognized, was used in two
main ways. In small doses, it acted as a stimulant, as
a hunger and thirst suppressant, and as an analgesic.
In such quantities, tobacco was used for social pur-
poses, such as sealing friendships; augmenting pala-
vers, war councils, and dances; and strengthening
warriors. Small amounts of tobacco were also used
during ceremonies to ensure fertility; to forecast pro-
pitious weather; to predict successful fishing, lumber-
ing, and planting; and to ensure congenial courtship.
In large doses, tobacco altered states of consciousness
and was reported to facilitate spiritual objectives, such
as spirit consultations, trance states, and psychic curing.
In these excessive quantities, the substance acquired
its sacred status.

  The earliest printed reference to tobacco and the
first mention of tobacco smoking is found in the first
volume of Gonzalo Fernandez de Oviedo y Valdes's
([1535] 1851-1855) monumental account of the discov-
ery of the Americas and the first decades of conquest.
He commented on the practice of divinatory tobacco
smoking by shamans and the methods of tobacco
cultivation among the Caquetio Indians of northern
Venezuela. He also reported in 1549 that the Nicoya
Indians of Nicaragua used ceremonial cigars and that
Spanish soldiers had been offered reed cigarettes by
Maya Indians off the coast of Yucatan (Robicsek 1978).

  During his travels in 1541 to 1555, Girolamo
Benzoni reported that the shamans of Hispaniola and
certain Central American provinces poisoned them-
selves with tobacco smoke during a curing seance. In
the process, some men fell to the ground as if dead and
remained "stupefied for the greater part of the day or
night" (Benzoni 115651 1967, p. 97). After becoming
coherent, these shamans would tell of their visions and
encounters with the gods.

  Other explorers witnessed cigar smoking on the
coast of Brazil. In 1555, the Franciscan friar Andre
Thevet (115571 1928) made contact with the
Tupinamba Indians in Brazil. He reported their use of
cigars to suppress hunger and thirst and during coun-
cil deliberations.

  Thevet's report and similar information by Hans
Staden (115571 1928) were confirmed by Jean de Lery
(1592) who reported smoking and another mode of
tobacco use-ritual tobacco blowing-among the
Tupinamba. Using long canes, chiefs blew tobacco
smoke on theeheads and faces of participants

Historical Context   19


circumambulating during war dances--purlx)rtcdIy to
impart the spirit and fortitude required to olrercomc
enemies. Canes may also have been used by the
Tupinamba as tubular pipes. A few years earlier,
Jacques Cartier (1545) had found L-shaped pipes in
use among the Iroquois of Hochelaga (Montreal).

  Another method of tobacco consumption was
reported among the Taino Indians of the Greater An-
tilles. This tribe reportedly used a forked tube to
inhale tobacco smoke (Fernandez de Oviedo y Valdes
[1535] 1851-1855). The Catalonian friar Ramon Pane
((15111 1974) referred to a similar tube used by the
Indians; however, it was used to inhale psychotropic
snuff (cohoba) (D'Anghiera 1912). The tube may have
been used by the Taino for both purposes.

  Amerigo Vespucci reported the custom of leaf
chewing among Indians (de Navarrete 1880). Vespucci
might have observed tobacco chewing with lime, but
he did not identify the type of plant material. The
custom of chewing whole coca (Erythroxylon) leaves
with powdered lime was widespread along the Carib-
bean coast of South America at the arrival of the Euro-
peans, and it persists today (Plowman 1979). At the
time of European discovery, chewing tobacco powder
with ashes or pulverized shell was also common
among the Carib Indians of the Lesser Antilles and the
northeastern mainland of South America.

Methods of Tobacco Ingestion

   The discussion of traditional tobacco use that
follows is based on sources that span several hundred
years. Some methods are still practiced and some are
not. To avoid the confusion of shifting between past
and present, the present tense is used (the ethno-
graphic present) to allow a cross-sectional view of
tobacco use by indigenous societies. Although this
approach conveys a sense of immutability, some
methods of tobacco use have undergone considerable
change. Some mention is made of tobacco use among
North American indigenous societies, but the discus-
sion focuses on South American practices. The infor-
mation presented is based on Wilbert (1987),1 except
where other references are cited.

  Gastrointestinal, respiratory, and percutaneous
routes of ingestion have been documented among
South American Indians. Intravenous administration
has not been reported. The reported methods of ingestion
comprise chewing tobacco quids, drinking tobacco
juice and syrup, licking tobacco paste, administering
tobacco suppositories and enemas, using snuff, smok-
ing, inhaling airborne tobacco smoke, and applying
tobacco products to the skin and the eyes.

Tobacco Chewing

  The chewing or, more precisely, sucking Of to-
bacco quids is widely practiced in South America and
the West Indies. The widespread distribution of to-
bacco chewing is considered indicative of the antiq-
uity of this method (Zerries 1964). The practice has
been observed in the Lesser Antilles and eastern Ven-
ezuela and from northwestern Colombia and the
upper Amazon to the Montana-to-Gran Chaco region
(an area encompassing parts of Bolivia, Paraguay, and
Argentina) as well as in eastern Brazil. In North Amer-
ica, tobacco chewing was practiced by Indians of the
Pacific Northwest.  With periodic fluctuations, to-
bacco chewing has found wide acceptance in non-
Indian societies as well (U.S. Department of Health
and Human Services [USDHHSI 1986; National Can-
cer Institute 1989; Connolly et al. 1986).

  Indians in South America prepare wads or rolls
for chewing from green tobacco and sometimes dust
the wet leaves with ashes or salt and mix them with
certain kinds of soils or honey. They also use tobacco
pellets prepared by kneading finely chopped green
tobacco leaves mixed with nitrous earth into a dough
or by mixing finely crushed tobacco leaves with ashes
and wetting the powder with water to produce a
smooth paste. Guianese Indians bake a cake of fresh
tobacco leaves that is sprinkled with salt or a surrogate
obtained from o~llin IMourem flrrzliatilis). Strips of the
cake are stored in gourds, and crrmfin (resin; Protium
Izrpfaplzyllum), pepper (Capsicu,n sp.), medicinal herbs,
or lime from sea shells may be used as additives.

  Tobacco quids, rolls, or pellets are carried by the
user in the cheek or between the gum and the lower
lip for protracted periods (Hammilton 1957). Tobacco
chewing frequently occurs in conjunction with other
methods of administration, such as smoking and
snuffing, and tobacco is sometimes chewed with coca.
Indians generally swallow the trickling juices rather
than expectorate them (Bray and Dollery 1983).

Tobacco Drinking

  Along with chewing, ingesting tobacco in liquid
form may be the oldest method of tobacco use (Sauer
1969). The ethnographic distribution of tobacco

For a broader discussion of the general topic and for more
extensive documentation, consult Wilbert, J., Tobacco and
Shamanism in South America, In: Schultes, R.E., Raffauf,
R.F. (eds.) Psychoactiz~e Plants of the World. New Haven,
Connecticut: Yale University Press, 1987. See also the
papers in the Joztrna2 of Ethnopharmacology (Elsevier Scien-
tific Publishers) (Wilbert 1990) and in the proceedings
published by Birkhtiuser Verlag (Wilbert 1991).

20 Historical Context


drinking is similar to that of tobacco chewing, al-
though it is not reported in the Gran Chaco. Most of
the tribes in greater Guiana and many societies of the
upper Amazon and the Montana of Ecuador and Peru
drink tobacco juice. Tobacco drinking has also been
reported in northwestern coastal Venezuela, north-
western Colombia, and a few scattered places in Bolivia
and Brazil. Tobacco drinking has found little accep-
tance as a method of tobacco use outside South America.

  The Indians in these regions prepare tobacco
juice in various ways. In greater Guiana, tobacco juice
is usually an infusion of whole or pounded green
leaves in water. The steeped or boiled leaves are
strained and pressed by hand. Some tribes add salt or
oulin ashes to the mixture (see "Tobacco Chewing").
Other botanical materials used as ingredients by Gui-
anese tribes include the tree barks nylrcg and cinchona.
Upper Amazon and Montana tribes similarly steep,
press out, and stir tobacco leaves in water, although
these tribes frequently mince or masticate the leaves
and occasionally add pepper (Cn@~nz sp.). Boiling
tobacco leaves in water for the preparation of juice
more frequently occurs among the tribes of the upper
Amazon and the Montana than among Guianese
tribes. Unlike umbil paste, a syrup extract or jelly from
which the water is completely evaporated, the juice is
left viscous enough to allow for drinking.

  Tobacco juice is ingested by mouth or through
the nose, using cupped hands or gourds. The concen-
trate may also be squirted directly from mouth to
mouth. Tobacco drinking is often accompanied by the
consumption of tobacco in other forms, alcoholic bev-
erages, and certain hallucinogenic substances.

Tobacco Licking

  Licking of ambil is limited to the tribes of the
northernmost extension of the Andes in Colombia and
Venezuela, parts of the northwest Amazon, and a few
areas of the Montafia.

  Ambil is prepared differently from region to re-
gion. Indians in the Sierra Nevada de Santa Marta of
Colombia boil tobacco leaves for hours or days and
thicken the black gelatin extract with maniac starch
(MunihotesctlZenta)orarrowroot (Muruntaarundinacea).
Venezuelan tribes east of Lake Maracaibo mix w-m, a
sesquicarbonate of soda, into ambil (Kamen-Kaye
1971), whereas the Montana tribes make ambil with
salt or alkaline ashes. Pepper (Cupsicum sp.), avocado
seeds (Perseu americana), crude sugar, tapioca (maniac
juice), and maniac starch are also occasionally used as
ingredients for ambil.

  A small quantity of ambil is rubbed across the
teeth, the gums, or the tongue. Ambil is sometimes

ingested with other tobacco products, and some tribes
of the Montana consume ambil with coca, ayahuasco
(Bunisteriu cuupi), and possibly other hallucinogens.

Tobacco Enema

  Use of tobacco enemas and suppositories, as a
remedy for constipation and helminthic infestations,
is reported among South American Indians. The Ship-
ibo of Peru apply a mixture of tobacco juice and ginger
as a vermifuge (Gebhart, unpublished). Ritual use of
tobacco enemas among the Aguaruna Indians of the
Peruvian Montana has recently been reported (Davidson,
unpublished). To promote intoxication, South Amer-
ican Indians apply enemas of ayahuasco, purica' (Virolu
sp.), willka fA~zndenunthera colubrinu), and tobacco
(Nicotiurzn sp.) (Roth 1924; Von Nordenskiold 1930).
Use of medicinal or ritual tobacco enemas has not been
reported among Caribbean, Central American, or
North American Indian populations.

Tobacco Snuffing

  The use of tobacco snuff, although secondary to
the use of psychotropic snuff in South America, is
documented in several regions. Ethnographic sources
indicate that tobacco snuffing is customary in the mid-
dle and upper Orinoco River, the northwest Amazon,
and the Montana-the Purus, the Guapore, and the
Andean regions. The practice has also found wide
acceptance in the non-Indian world, although interest
has fluctuated.

  To prepare tobacco snuff, Indians dry tobacco
leaves and then crush, pulverize, and often sift them.
Snuff may be inhaled directly from the hand or a leaf
or, more commonly, through a snuffing tube made of
cane or hollow bone. Snuffing powders are some-
times administered by a partner.

Tobacco Smoking

  Smoking is the most prevalent form of tobacco
consumption in native South America and is particu-
larly common in greater Guiana, the upper Amazon,
the Montaiia, Las Yungas, Mato Grosso, and the Gran
Chaco. Smoking has also been reported in many in-
tervening and peripheral areas, such as central and
northern Colombia, the middle and lower Amazon,
the coast of Brazil, Patagonia, and southern Chile.

  North American Indians, except for the Pueblo
and certain tribes in California, were exclusively pipe
smokers (Linton 1924; Robicsek 1978). In South America,
pipe smoking has prehistoric origins and is still widely
distributed throughout the continent. It is prevalent
in two focal areas-the Maraiion-Huallaga-Ucayali
region and the Gran Chaco. The practice is scattered

Historical Context 22


along the north coast and the Guiana hinterlands,
along the Amazon, and in coastal Brazil. Pipe smok-
ing also occurs farther inland and north of the Gran
Chaco focal area-in central and southern Bolivia and
on the lower Araguaia.  South of the Chaco, pipe
smoking is found in middle and southern Chile and in
Patagonia.

   South American Indians smoke tobacco in the
form of cigars, cigarillos, and cigarettes, and they use
tubular or L-shaped pipes made of reed, bamboo,
wood, fruit shells, bone, clay, or stone. They inhale
deeply and hyperventilate; rarely do they retain a puff
of smoke in the mouth before expelling or swallowing
it. The process is described as taking the smoke into
the lungs with "great sucking gasps" and "working
the shoulders like bellows" (Huxley 1957, p. 195). The
Warao Indians of the Orinoco and several other tribal
societies, such as the Vaupes Indians, hyperventilate
by smoking giant cigars that measure nearly one-
meter long and two-centimeters wide (Wallace llSS91
1972).

  Certain customs may be associated with smok-
ing. For example, cigars are usually rolled by Indian
men, but in some Indian communities, women are
expected to roll the cigars. Women may then light the
cigars and take a few puffs themselves before handing
the cigars to the men. Smoking is often accompanied
by the ingestion of hallucinogens and stimulant bev-
erages, such as guarana (Pudliniu cupunu var. sorbilis)
and cassiri.

  Tobacco is prepared for smoking by sun- or air-
drying the leaves and crushing them; some societies
alter the product with additives. To give cigar or pipe
tobacco a pungent odor similar to frankincense, Indi-
ans of Guiana and Amazonia add the resin of Protim
heptuphy~lum, a tree of the myrrh or Burseraceae fam-
ily. Cararia powder or granules are mixed with to-
bacco to give it a balsamic savor (Schultes 1980). In
Patagonia, culufufe shavings (Berberis sp.) are mixed
into the tobacco to add an acrid taste and to create a
very blue smoke when the tobacco burns. To make
cigars, cigarillos, and cigarettes, South American Indi-
ans use several types of wrappers. Although whole
tobacco leaves or pieces may be used, various kinds of
tree foliage, palm stipples, banana leaves, and maize
husks are more common. The wrappers usually add
flavor and odor to the tobacco, and in some instances,
observers have noted that the cover leaves may en-
hance the narcotic effect (Weyer 1959).

Inhaling Airborne Smoke
   The intentional inhalation of environmental to-
bacco smoke is a peculiarly South American method

of respiratory absorption of nicotine. This practice
occurs on the east coast of Brazil, where religious
practitioners blow tobacco smoke from canes and funnel-
shaped cigars onto the heads and into the faces of
dancing warriors. Men of this region also inhale the
smoke of tobacco leaves burning inside effigy rattles.
Cuna elders of Panama have cigar smoke blown into
their faces, and Jivaro men of Peru blow tobacco smoke
through long tubes into the open mouth of a partner.

Percutaneous Tobacco Use

  The administration of tobacco products to intact
or abraded skin is widespread in native South Amer-
ica and includes the following practices: general and
directed smoke blowing; spit blowing of tobacco juice,
nicotine-laden saliva, or tobacco powder; and admin-
istration of saliva massages, juice ablutions, and snuff
and leaf plasters or compresses. Some of these prac-
tices may serve therapeutic purposes. Tobacco smoke
and juice may also be applied to the eyes for absorp-
tion of nicotine by the conjunctiva.

Transcendental Purpose of Native
Tobacco Use

  Tobacco is traditionally used as a vehicle for
transcendental experience by South American indige-
nous societies. As such, it is central to the religious
rites of these populations and is a primary tool of the
shamans, or spiritual leaders of these societies. To-
bacco features in the initiation rituals of the shamans
and is used throughout their careers as a mechanism
for exercising power and maintaining credibility.

   A fundamental role of the shamans is to serve as
spiritual protectors who defend their societies against
a host of intangible adversaries. Thus, a society's per-
ception of the shaman as being supernatural as well as
human is integral to the shaman's position. This dual
nature is conferred during initiation rituals in which
the novice undergoes a tobacco-induced deathlike
state associated with temporary respiratory depres-
sion (Dole 1964). Revival from this condition is
equated with a rebiih that imparts otherworldly powers.

  During initiation, the novice ingests increasing
amounts of tobacco and achieves acute intoxication.
The candidate manifests a state of illness through
nicotine-mediated nausea, heavy breathing, vomiting,
and prostration. Through tremors, convulsions, or
seizures, the novice progresses to acute narcosis and
apparent death.  The physiologic stages through
which the novice passes depend on the rate of bio-
transformation of nicotine in the body (Larson 1952;
Larson, Haag, Silvette 1961). The induction master's
ability to interpret physical signs is critical.

22   Historical Context


  In Guiana, for example, shamans make initiates
drink liters of tobacco juice, which bring them to the
brink of death. Several cupfuls of tobacco pulp are
ingested in rapid succession, and a large bowl of liquid
tobacco is force-fed through a funnel into the mouth
of a swooning candidate. Initiates who fail to vomit
part of the brew may convulse, become ill over an
extended period, or die.

  Shamans must continually demonstrate their
spiritual power to themselves and to the community
to maintain effectiveness as religious practitioners and
healers (Reichel-Dolmatoff 19751. The pharmacologic
effects of nicotine help them accomplish that goal.
South American shamans reportedly ingest giant ci-
gars while simultaneously chewing tobacco during
ceremonies. Participants in certain rituals and shama-
nit curing seances on the Guapore River (Brazil) have
been observed taking dozens of insufflations of to-
bacco powder and ingesting up to 60 doses of rap6
(snuff). Aguaruna vision seekers of Ecuador use to-
bacco enemas to produce a deathlike state. Shamans
blow tobacco smoke and spittle against atmospheric
enemies, such as thunder and lightning, that threaten
human existence.

  In many societies, shamans exercise power in the
form of aggressive "were-jaguars," another condition
accomplished through tobacco ingestion. Nicotine is
used to provoke several physical changes, including a
deep raspy voice, a furred tongue, and a fusty body
odor. Nicotine also activates cholinergic pregangli-
onic fibers of the sympathetic nervous system to stim-
ulate the adrenal medulla to release epinephrine and
norepinephrine, which mobilize the shaman's body
for emergency reaction (USDHHS 1988; Schievelbein
and Werle 1967). This generalized arousal is interpre-
ted by the properly initiated shaman as characteristic
of jaguar-men, and this experience confirms his
shamanic status and role.

  The use of tobacco for transcendental purposes
in indigenous societies contrasts with its subsequent
use in other American societies.  In modern Latin
American and Caribbean societies, tobacco is increas-
ingly consumed for the social enjoyment of the stimu-
lant rather than for the toxic and organoleptic effects
of nicotine sought by the Indians. Acute intoxication,
and its attendant immediate threat to health, has giv-
en way to long-term addiction and chronic health
consequences.

The Emergence of the Cigarette, 1492-1900

Tobacco as a Cash Crop

  Europeans did not follow native tobacco prac-
tices but developed a tobacco culture of their own
based on trade. One of the earliest references to tobacco
trade appears in Diego Columbus' will (dated 15341,
which mentions a Lisbon tobacco merchant. The French
ambassador to Portugal presented tobacco purchased in
Lisbon to Queen Catherine de Medici of France in 1561,
and a Spanish physician may have introduced tobacco to
the court of King Philip II of Spain around 1560 (Fairholt
1185911968). Tobacco was first brought to England by Sir
John Hawkins about 1565, and England soon had a large
and fast-growing market (Anonymous 1602).

  Within 30 years of Columbus's voyages, a to-
bacco trade had been established by the Spaniards
between the Caribbean and India, and trade later de-
veloped with Japan, China, and the Malay peninsula
(Robert 1967). Spanish tobacco, grown mostly in the
Caribbean, dominated the market in the early six-
teenth century. Sales of tobacco products became so
lucrative that, in 1557, the Havana (Cuba) city council

forbade black women from engaging in the tobacco
trade, thus retaining trade for Europeans (Ortiz 1947).
Tobacco growing thrived in parts of Latin America as
well, especially in areas of Venezuela (Caracas,
Cumanb, and Margarita).

  Although the Spaniards attempted to monopo-
lize the tobacco trade, many growers smuggled the
leaf to Dutch and English ships. To curtail the contra-
band trade, King Philip II banned tobacco planting in
most of the Spanish Colonies in Latin America from
1606-1616, a policy that stimulated England's search
for its own source of tobacco (Robert 1967).

  Sir Walter Raleigh first smoked tobacco in the
Virginia colony in 1585, and John Rolfe introduced
N. tabuctlm to the colony about 1611. Tobacco, a much-
needed cash crop for the struggling Jamestown settle-
ment, was exchanged for imported manufactured
goods, and the colony soon became economically via-
ble. Tobacco was taken to the Maryland settlements,
where the soil produced a yellow tobacco known as
Bright (Tilley 1948). According to Rolfe, Bright was
"as strong, sweet, and pleasant as any under the sun,"

Historical Context 23


and with additional "trial1 and expense," it could com-
pete with leaf grown in the West Indies (Morton 1945,
p. 119). Maryland emerged as an important tobacco
producer, and attempts to cultivate the crop in North
Carolina also proved successful.

  The first shipment of tobacco from Virginia
reached London in 1613. Within three years, tobacco
became the most significant crop and chief export of
the British Colonies in North America (Tilley 1948).
Tobacco was sold for its weight in silver, which en-
couraged production, exportation, and taxation
(Wagner 1971). Thus, tobacco production became
centered in the North American colonies, and the
purchase of tobacco became an expensive indulgence.

  Tobacco cultivation in Virginia allowed England
to begin freeing itself from the Spanish tobacco trade.
By 1614, high-quality Virginia tobacco was considered
comparable to that grown in Trinidad (Bruce 118951
1935). During 1615 to 1616, the Virginia Colony ex-
ported 2,500 pounds of tobacco, all but 200 pounds of
which were sent to England, but the English imported
58,300 pounds from Spain (Brooks 1937-1952). This
importation greatly concerned the English govern-
ment because it created both a trade imbalance and an
outflow of currency (Jacobstein 1907). In 1621, as the
supply of Virginia tobacco increased, Parliament ter-
minated importation of Spanish tobacco, which by
then cost England E60,OOO (Jacobstein 1907).

  But not all Europeans were in favor of tobacco
use. Some Europeans used tobacco for medicinal pur-
poses, perhaps in imitation of South American Indi-
ans, but other Europeans believed that the use of
tobacco was a heathen practice to be strongly discour-
aged. Many people claimed that smoking and chew-
ing tobacco were harmful to health. The most fa-
mous attack on tobacco appeared in 1604, when
King James I anonymously issued A Courltrr-B&c fo
Tobacco, in which he disclaimed any medicinal value
of tobacco and described smoking as a loathsome
practice (James I 116041 1954).

  The King imposed a 400 percent tariff (McCusker
1988), but the tax had little impact on tobacco use,
perhaps because demand was greatest among the
upper classes. By the early seventeenth century,
smoking and chewing tobacco were prevalent
throughout most of Europe. In London in 1614, to-
bacco could be purchased at 7,000 establishments
(Lehman Brothers 19551, and because of its presumed
medicinal value, tobacco was commonly prescribed
by physicians and made available at apothecaries.

  In the New World, a sixpence fine was set for
smoking in public in New Haven, Connecticut, in
1646, but in the following year, the Connecticut general

court ruled that citizens could smoke or chew if they
had a license from the court, unless they already had
a doctor's prescription (Heimann 1960).

  Concerns about tobacco faded, and attempts
were made to grow tobacco in Europe. But climate
and soil contributed to an unsatisfactory leaf. In the
seventeenth century, attempts to produce tobacco
were also made in Russia, Persia, India, Japan, and
parts of Africa (Morton 1945); however, during this
period, Europeans could obtain a sufficient supply of
tobacco through importation from the New World
only.

Tobacco Manufacturing and Trade

North America

  In the Navigation Acts (1651 to 16731, the English
parliament stipulated that all tobacco products from
the colonies had to be shipped to England before being
shipped elsewhere. The Acts were difficult to enforce,
however, and resulted in a policy of benign neglect.
But the passage of the Acts caused prices to rise
sharply. Since tobacco production in the Virginia Col-
ony was low, increased prices encouraged a prolifer-
ation of small farms in North America and, eventually,
large tobacco plantations. The shortage of workers for
these plantations spurred the slave trade, which in-
creased the labor supply.

  Annual tobacco shipments from the colonies in-
creased significantly-from approximately 65,000
pounds in the early 162Os, to 1 million pounds by the
late 163Os, to 20 million pounds in the late 1670s
(Kulikoff 1986). By 1699, of the 30,757,OOO pounds of
tobacco exported to England from its North American
colonies, all but 113,000 pounds were produced in
Virginia and Maryland; 496,000 pounds were im-
ported by England from other areas, including Eu-
rope, Turkey, Africa, and the Caribbean. During the
next 75 years, imports from other areas declined, de-
spite several sharp increases (Table 1). Reexportation
of tobacco increased steadily during the first half of the
eighteenth century and then peaked at 74,000 pounds
in 1775 (U.S. Department of Commerce [USDOC]
1975).

  Tobacco became the most important cash crop of
the British Colonies. Labor for tobacco production
was worth six times that used for wheat production
(Jacobstein 1907), and in 1770, the total value of to-
bacco legally exported from the colonies (E906,638)
was significantly greater than that of flour or rice
(!Z504,553 and E340,693, respectively). Fifty percent of
all British colonists obtained their living from tobacco
production (Jacobstein 19071. In Maryland, wages

24 Historical Corztexf


Table 1.  Tobacco trade* in England, 1700-1775

Year

1700
1705
1710
1715
1720
1725
1730
1735
1740
1745
1750
1755
1760
1765
1770
1775

Imported from
North
American    Other
colonies    countries  Reexported+
         -~ ~~~~~
37,607       233
15,629       32           -
23,472       26     16,000
17,801        8     15,000
34,516       10
21,034        12      16,000
34,949       131      33,000
40,068        1
35,896       106     42,000
41,063       10     43,000
51,278        61
48,867       217     45,000
52,288       59     64,000
48,317        3     68,000
39,184        4      73,000
55,458       510      74,000

Source:  U.S. Department of Commerce (197J).
*In thousands of pounds.

`Reexportation exceeded importation in the later years
because of tobacco grown in the British Isles.

were often paid in tobacco, which also functioned as
a currency WSDOC 1975). In England, all companies
involved in the tobacco industry also profited enor-
mously, including those that provided banking and
related services to planters.

  In the 158Os, the Spaniards developed and ex-
panded the plantation system in the Caribbean but
emphasized sugar production (Brooks 1952). Foreign-
ers began to enter the sugar industry, which required
extensive capital, but tobacco production was domi-
nated by local businesses. By 1606,95 farms in Cuba
specialized in tobacco (Andrews 1978). Little is
known, however, about the industry in Cuba during
this period, perhaps because Cuban farms grew the
expensive and delicate tobaccos used in cigars and
were quite small compared with the Virginia planta-
tions (Ortiz 1947). The competitive advantage for the
Cuban growers may have been that the leaf used for
Cuban cigars produced a richer flavor with less nico-
tine than did the Bright leaf grown in the Chesapeake
Bay area.

  During shipping, tobacco lost much of its mois-
ture, and it had to be moistened before handling. To
prepare tobacco leaves for smoking, the stems and ribs
were removed and additives, such as sugar, glycerine,
gum, and starch, caused the leaves to ferment. The
leaves were either granulated for smoking or snuffing
or pressed into plug for chewing. The different addi-
tives provided tobacco with distinct flavors. These
flavors and the various shapes of plugs (including
thick coil, pigtail, black twist, and Irish) offered the
customer a wide selection in tobacco. Generally, the
moister the plugs, the less expensive.  up to 120
pounds of plug could be manufactured from 100
pounds of tobacco, and carotte, an extremely moist
variety, could yield 150 pounds of plug (Alford 1973).
  But even before the American Revolution, the      In 1717, a tobacco monopoly was granted to
colonies had problems maintaining a steady level of   Martin Arostegui by royal edict. Tobacco manufac-
tobacco production. Tobacco depleted the soil, which   turing was forbidden in Cuba, and raw leaf had to be
resulted in lower yields per acre over time. Tobacco   sent to Spain (Stubbes 1985). As a result, tobacco
growers faced a dilemma: maintaining their level of   farmers revolted in 1717,1718, and 1723. The monopoly
income required expanded planting, but a larger crop   lasted for a century, however, and despite its adverse

  In the Chesapeake Bay area, the choice was be-
tween cotton and tobacco, and tobacco became more
important. In Cuba, the choice was between sugar
and tobacco, and tobacco became the less important
crop (Ortiz 1947). Nevertheless, by 1711, a processing
center was established in Havana to prepare tobacco
leaf for shipment.  In 1734, the center processed 3
million pounds of tobacco, one-third of which was of
the best quality and was used to make snuff (Bray and
Harding 1974).

would also depress prices. Average price per pound
for Maryland tobacco was already fluctuating sharply:
one pence in 1713, 0.71 pence in 1714, 1.19 pence in
1720, and 0.65 pence in 1731. A general slump was
followed by a steadily rising price per pound: 1.48
pence in 1752 and 2.23 pence in 1769. However, prices
again declined in 1773 to 1.13 pence per pound
(USDOC 1975). Some Virginia planters seriously con-
templated abandoning tobacco in favor of wheat, and
some did stop cultivating tobacco (Breen 1985).

  Because of their increasing indebtedness to Brit-
ish merchants, most tobacco growers in the Bright Belt
supported the American Revolution (Breen 1985).
Thomas Jefferson wrote that these debts "had become
hereditary from father to son, for many generations,
so that the planters were a species of property, an-
nexed to certain merchants in London" (Heimann
1960, p. 76). The American Revolution terminated the
Navigation Acts but did not alter the adverse circum-
stances that many planters still faced.

Latin America and the Caribbean

Historicnl Corztext 25


effect on business, the tobacco trade continued to pros-
per (Ortiz 1947). From 1789 to 1794, Cuba produced
about 6.25 million pounds of tobacco per year. A
decline followed, due to imperial interference, the
increasing cost of land, and the preference given to
sugar and coffee production. By 1804, Cuba was obli-
gated to import 1 million pounds of tobacco from the
United States to meet the requirements of the Havana
retail trade. Not until the Spanish government re-
lented did the industry revive enough for Cuba to
dominate the market for tobacco leaf and fine cigars in
the 1830s (Turnbull [18401 1973; Humboldt [18561
1969).

  Tobacco cultivation also flourished in Brazil, de-
spite condemnation by the Roman Catholic Church
and early Portuguese demands to use the land to grow
food. However, these obstacles were overcome be-
cause the sale of tobacco could provide ready funds
for purchasing slaves to work in the sugar cane fields.
Tobacco sales became a state monopoly in Brazil in
1624, but sales were so profitable that the government
yielded to private interests and abolished the monop-
oly in 1642. In 1659, the government reestablished the
monopoly, which by 1716 earned 1.4 million crusades
a year. Tobacco exports from Bahia averaged 375,000
pounds per year, and annual sales of Brazilian tobacco
in London in the early eighteenth century were esti-
mated at 1.9 million crusades (Randall 1977).

The Expansion of Tobacco Manufacturing
  During the American Revolution, tobacco ex-
ported from the British Colonies declined sharply-to
approximately 15 million pounds per year. Subse-
quent wars also contributed to the loss of foreign
markets. Sales declined significantly during the Na-
poleonic Wars and the War of 1812 due to English
blockade of American ports. In addition, revenues to
cover the cost of these wars were raised by increasing
excise taxes. In 1794, a tax was levied on manufac-
tured tobacco to help cover the cost of the national
government, but the tax was discontinued two years
later. It was reintroduced to help defray the costs of
the War of 1812 and remained in effect until 1816.
England increased the tax on tobacco imports in 1815
from 28 cents to 75 cents per pound, which resulted in
decreased consumption-from 22 million to 15 mil-
lion pounds (Jacobstein 1907).

  During the American Revolution, Europeans ac-
celerated importation of tobacco from Latin America
and the Caribbean and attempted to increase tobacco
production elsewhere. Cuba, Colombia, Austria,
Germany, and Italy were among the more active
participants, but Sumatra also became a significant

source of tobacco for Europe. By 1841, European pro-
duction was estimated at 137 million pounds, com-
pared with 219 million pounds in the United States.
Europeans continued to purchase American tobacco,
and in 1860, half of the total U.S. production of approx-
imately 400 million pounds was shipped to Europe
(Jacobstein 1907).

  But taxation and the loss of some foreign markets
contributed to a lower price for tobacco, which made
cotton production more attractive to U.S. farmers. The
United States was the world's leading cotton pro-
ducer, with no competition from Europe. Yet, several
factors contributed to the perpetuation and evolution
of tobacco cultivation, curing, and trade. By law, be-
fore the American Revolution, only England could
manufacture plug, snuff, cigars, and pipe tobacco.
After gaining independence, Americans were free to
manufacture these more profitable tobacco products,
especially pipe and chewing tobaccos, which in addi-
tion to capturing the domestic market, became in-
creasingly popular in Europe.

  In North Carolina, tobacco became even more
attractive because of an accident that changed the
product. In 1839, a slave fell asleep while curing
Bright tobacco. He awoke in time to see the embers
dying and threw more charcoal on the fire to revive it,
not realizing that the sudden heat would alter the
process. What emerged was a brilliant yellow tobacco
with a sweet, pleasant taste. This new curing method
produced a slightly acidic tobacco unlike the more
alkaline old Bright. The new tobacco was quickly
adapted for use as a wrapper for many kinds of plug,
which increased the popularity of this form of tobacco.
The Bureau of the Census called this alteration "one of
the most abnormal developments in agriculture that
the world has ever known" (Sobell978, p. 16).

  Cigar leaf was grown throughout the Caribbean,
the first significant center for export of cigars to Amer-
ica and Europe. Cigars were first introduced in the
United States in the late eighteenth century, and in
1804, more than 4 million Cuban cigars were imported
(Brooks 1952). Cigars were first smoked in the south-
ern colonies, and the practice soon moved north.

  During the American Revolution, cigar manu-
facturing facilities were established in Philadelphia,
Trenton, and New York, which became the centers for
American cigar manufacturing. In 1800, cigar facto-
ries were also built in New Orleans; these factories
produced cigars that resembled Cuban products. In
1810, a Suffield, Connecticut, cigar manufacturer
employed a Cuban cigar roller to teach his craft to
the American workers, and soon small cigar facto-
ries became widespread throughout the Northeast

26 Historical Context


(Heimann 1960). In 1831,50 Cuban cigar rollers relo-
cated to Key West, Florida, where they successfully
transplanted the business (Ortiz 1947). During this
period, trade was primarily local; most towns had at
least one cigar factory (Heimann 1960).

  Many kinds and shapes of cigars were smoked
during the early nineteenth century. The most expen-
sive were the Havanas, made either in Cuba or in
American factories that imported Cuban leaf. La Co-
rona was made exclusively with Havana leaf. The
most popular shape of La Corona was the Perfecto, a
large cigar that tapered from the middle. The
Panatella was a long, straight cigar, open at the end
that was to be lit. The Parejo was similar, but open at
both ends. Cigars other than La Corona included the
Oscuro, which was made from a much darker leaf;
Maduro, made from a brown-black leaf; Maduro Col-
orado, made from a dark brown leaf; Colorado Claro,
made from a light brown leaf; and several others
(Cabrera Infante 1985).

  In the early nineteenth century, Connecticut-
grown tobacco was used to make cheap cigars
(Akehurst 1968). Cigars manufactured with domestic
leaf often used flavored Bright and Virginia tobacco
with wrappers from Connecticut-grown tobacco.
These cigars were called Conestogas, after a type of
covered wagon, or "stogies" for short. Long Nines
were 9 inches (3.5 cm) long and pencil-thin. Short
Sixes were 6 inches (2.4 cm) long and less expensive.
Prices varied from two cigars for a penny to as much
as a 10 cents per cigar (Heimann 1960). Pipe and
chewing tobaccos were inexpensive compared with
the finer, more costly tobacco used for snuff and ci-
gars, and pipe smoking was the most popular form of
tobacco smoking during the first half of the nineteenth
century. Persons of low-income groups used pipes
and plug, while persons of high-income groups used
snuff and cigars (Robert 1967).

  After the Louisiana Purchase was made in 1803,
settlers brought the tobacco culture to the West. By
1830, the western United States produced approxi-
mately one-third of the nation's tobacco used for plug
and pipes (Wagner 1971). The southern states also
produced tobacco for plug and pipe smoking and
continued to produce most of the tobacco for snuff.
Virginia, North Carolina, and Ohio led production (57
million, 12 million, and 10.5 million pounds, respec-
tively). However, the cultivation of tobacco for cigars
remained concentrated in the Northeast. By 1849,
Connecticut, Pennsylvania, and Massachusetts were
producing large amounts of cigar leaf (1,267,624;
912,651; and 138,246 pounds, respectively) (Jacobstein
1907). Just before the Civil War, $1.4 million worth of

cigars was produced in Philadelphia and $1 .l million
in New York City. Before the war, the total value of
manufactured cigars was $9 million; the value of to-
baccos for chewing and pipe smoking was $21 million
(Heimann 19601.

  The popularity of tobacco, combined with in-
creasing urbanization, encouraged some merchants to
enlarge their manufacturing activities and aggres-
sively market their products. The first center of activ-
ity for pipe and plug tobacco was Richmond, Virginia.
In 1830, James Thomas, Jr., one of the earliest
manufacturer-merchants of Richmond, opened his
factory and distributed plug tobacco to many parts of
the country. Thomas relocated in California during
the gold rush of the 1840s and soon established an
almost total monopoly on pIug sales in the territory by
shipping the manufactured product from his eastern
factories. By 1860, approximately 50 factories in Rich-
mond manufactured tobacco; these firms employed
3,400 workers and produced goods valued at almost
$5 million per year (Robert 1967).

  Lorillard was perhaps the largest tobacco manu-
facturing facility during the first half of the nineteenth
century. Pierre Lorillard had opened a snuff factory
in Manhattan in 1760 and owned one of the two mills
that survived British opposition to colonial produc-
tion After the American Revolution, he constructed
a new mill on the Bronx River, which expanded into
warehouses, a facility for packing snuff and smoking
tobacco, workers' quarters, and his own home. The
company outgrew this complex, and Lorillard opened
a new facility across the Hudson River in Jersey City
(Heimann 1960).

  Tobacco products were not highly differentiated
until the mid-1800s. Lorillard was one of the first to
appreciate the significance of marketing. After the
Civil War, his company began to affix tin tags to its
plugs, which distinguished a Lorillard product from
others; one Lorillard brand was called Tin Tag. Other
manufacturers followed suit, and soon the tin tags
were collected as novelties, just like cigarette cards in
later years (Heimann 1960). The use of brand names
for plug products became common in the 1840s and
were used to differentiate products by additives, fla-
vorings, and varieties of tobacco (Robert 1967).

   Because financial centers were located in the
North, tobacco financing was easier to obtain by man-
ufacturing firms concentrated in that part of the coun-
try. By the 185Os, much of Virginia's crop was sent to
New York firms on consignment; these firms then sold
the crop to wholesale jobbers. These firms were so
well established that southern manufacturers and
retailers were obliged to use the northern firms. This


dependence served as another irritant between the
North and South before the Civil War. Indeed, the
system of U.S. tobacco manufacturing in the 1850s
strongly resembled that of the 1770s when colonial
tobacco farmers chafed at Britain's stranglehold. The
financial panic of 1857 did much to inflame relations
further since many New York manufacturers de-
faulted on their financial obligations, which caused
seven of the eight Richmond tobacco manufacturers
to suspend operations (Wagner 19711.

  The Civil War had far-reaching effects on the
tobacco industry.  In the South, the cotton farmers
fully supported the Confederacy, but the tobacco
farmers were divided in their loyalties. Virginia,
North Carolina, and Tennessee seceded from the
Union, but Maryland, Kentucky, and Missouri re-
mained. During the war, tobacco production in Ken-
tucky surpassed that in Virginia. Some southern
tobacco was smuggled through the lines, but Confed-
erate planters clearly suffered during this period.

  Farmers in the Bright Belt continued to plant and
harvest tobacco despite the war. Because of the Union
blockade of Confederate ports and fear of invasion,
tobacco supplies were moved from Richmond to Dan-
ville, Virginia, which became a major center of the
tobacco industry. Durham, North Carolina, also grew
in importance and, in time, outranked Richmond as
the leading manufacturer of plug.

  In 1862, to stimulate production of much-needed
foodstuffs, the Confederate government prohibited
cotton and tobacco cultivation, a moot policy, since
neither cotton nor tobacco products could elude the
Union blockade. In the same year, funds were needed
to finance the Civil War, and tobacco products were
among the commodities taxed (Jacobstein 1907). But
tobacco production continued, perhaps because the
price of tobacco increased as the fighting progressed
(Robert 1967; Coulter 1926).

  Invading Union armies looted tobacco ware-
houses and, during lulls in the fighting, traded their
food and coffee for tobacco from the Confederate
troops. Some Union soldiers looted a Durham ware-
house owned by John Ruffin Green who, in 1858, had
created a fine smoking and chewing tobacco known as
Bull Durham. The soldiers tried the cured, granulated
tobacco, and after the war, they purchased the tobacco
and introduced it to others (Tilley 1948). Just as six-
teenth-century sailors introduced tobacco to the rest
of the world, the Union soldiers brought a demand
back to the North for some of the sweeter, milder,
southern tobaccos they had discovered.

  Within the tobacco industry, attention was fo-
cused on the success of Bull Durham, which had

transformed Durham from a small southern town to a
thriving tobacco center. In 1875, not only was Bull
Durham used for pipe smoking and chewing, but
some smokers had started to roll cigarettes with it,
thus taking business away from the small companies
that manufactured pipe and loose chewing tobaccos.
The success of Bull Durham also contributed to the
growth of the North Carolina tobacco industry. In
1870, Virginia grew 15 times more tobacco than North
Carolina, but 10 years later, Virginia produced five
times less (Tilley 1948).

The Manufacturing of Cigarettes

  Although demand for manufactured cigarettes
had increased gradually from the 1850s to the 187Os,
cigarettes were still an insignificant part of the tobacco
industry. The Duke family were small tobacco farm-
ers and dealers in the Durham area. The family's
patriarch, Washington Duke, was a Confederate vet-
eran who returned to a gutted farm after the Civil War.
He found a small cache of Bright, which he sold under
the name Pro Bono Publico. Duke and his sons
planted Pro Bono Public0 and peddled their crop from
town to town. The Dukes did a prosperous business,
and in 1873 moved to Durham to be closer to the
railroads that transported their product to market
(Tilley 1948).

  By the end of the 187Os, growth in the Duke
business had leveled off. James Duke traveled
throughout the country selling Pro Bono Publico, but
like all the other manufacturers, Duke found it diffi-
cult to compete with Bull Durham (Robert 1967; Sobel
1978). In 1881, James, then the acknowledged head of
the firm, started to manufacture cigarettes called Duke
of Durham.

   Duke was successful from the start. A combina-
tion of shrewd merchandising and aggressive price-
cutting led to the increased popularity of Duke of
Durham and other Duke brands. With the assistance
of Edward Featherston Small, one of the first cigarette
promoters, Duke merchandised his product effec-
tively. At the time, manufacturers used cigarette cards
to stiffen the soft packs; Duke cigarette cards were the
most imaginative and sought after (Wagner 1971).
Within a few years, cigarettes manufactured by Duke
sold in many cities in the South and Midwest. In 1883,
when the federal government reduced the tobacco tax
from $1.75 to 50 cents per pound, most manufacturers
passed part of the savings to customers through lower
prices. Duke not only lowered his prices, he adver-
tised his policy: "The Dukes are ambitious for a very
large cigarette business, and to obtain such are
dir,iliing their profits with the dealers and consumers"

28 Historicn[ Co7ztrxt


(Tilley 1948, p. 557). Cigarettes manufactured by
Duke sold for five cents for a package of 10. They were
now the least expensive on the market, and sales in-
creased dramatically (Wagner 1971).
  Even before Duke turned his attention to the
manufacturing process, several inventors had been
working to produce a cigarette-manufacturing ma-
chine that would replace the workers who rolled cig-
arettes by hand. But most manufacturers believed
that the future of cigarettes was doubtful; they ques-
tioned whether a machine capable of producing tens
of thousands of cigarettes was truly needed.
  In 1881, James Bonsack, announced the inven-
tion of his cigarette-making machine, which was re-
jected by several firms. Duke, however, was
interested and, with his engineer, helped Bonsack per-
fect the machine. By 1884, the Bonsack model could
produce more than 200 cigarettes per minuteA6.8
million cigarettes per year. Twenty of these machines
could have satisfied the entire national demand for
cigarettes for 1885.

  Bonsack signed a long-term contract with Duke,
giving Duke rights to the machine. Although Bonsack
was free to license his machine to others, his contract
provided Duke with rebates, thus reducing Bonsack's
net royalties. Later, Bonsack agreed that Duke's pay-
ments would be at least 25 percent less than those paid
by other firms (Sobel 1978). The Duke firm then had
the lowest production costs in the tobacco industry,
which gave it victory in price wars and a very high
profit margin. Before the Bonsack machine was incor-
porated into the process, most cigarettes sold for 10
cents for a pack of 10 cigarettes; after incorporation,
for five cents.

  In 1880, Duke's total monthly payroll was $500;
five years later, it was $15,000. From 1885 to 1886,
production increased significantly-from 9 million to
30 million cigarettes. In August 1887, the Duke firm
produced 60 million cigarettes (Tilley 1948). The firm
realized high profits, which allowed Duke to acceler-
ate his advertising and promotion campaigns.

  Most other tobacco manufacturers continued to
believe that great profits were based in the production
of smoking tobacco, chewing tobacco, and cigars. At
the time, Duke gave no indication of entering those
market areas. Duke was the only large firm in the
tobacco industry that concentrated on manufacturing
cigarettes (Sobell974).

  Duke believed that cigarettes would be most
popular in urban areas.  The firm relocated to New
York where it soon became the largest cigarette
manufacturer in the city. Allen & Ginter, located in
Richmond, was the only serious competitor of Duke's

in the late 1880s. Tobacco manufacturers competed
fiercely for the purchase of tobacco, and dealer and
smoker loyalty and price wars were frequent (Robert
1967). But cigarettes became increasingly popular,
and consumer changeover was dramatic. In 1884, four
cigars were sold for every cigarette. Three years later,
the ratio was less than two to one-largely owing to
the impact of the Bonsack machine.

The Popularity of Cigarettes

  In 1890, Duke became The American Tobacco
Company (ATC), the foremost tobacco manufacturer.
Between 1895 and 1905, it was the second largest U.S.
industrial firm in capitalization (behind U.S. Steel) and
was more than three times the size of General Electric
Company, Inc., the third largest enterprise (Nelson
1959). Expansion continued with the organization of
American Snuff in 1900 (Sobell978). Reorganized as
a holding company in 1901, ATC dominated the ciga-
rette, snuff, smoking tobacco, and plug markets and
soon purchased a controlling interest in United Cigar
Stores. The firm did not enter into cigar production,
primarily because cigars were rolled manually, which
made competitive pricing difficult. However, cigars
still accounted for 60 percent of the value of manufac-
tured tobacco, and in order to enter this lucrative
market, Duke established the American Cigar Com-
pany in 1901 with an investment of $10 million. The
firm controlled several significant factories, including
Havana Tobacco, American Stogie, and Havana Com-
mercial, but did not dominate the cigar industry. ATC
had only a small market share of the cigar business (14
percent) but a large market share of cigarettes (86
percent), smoking tobacco (76 percent), and snuff (96
percent) (Lehman Brothers 1955). The dominance of
ATC in cigarette production was significant because
cigarettes were rapidly dominating the tobacco mar-
ket (Jacobstein 1907).

  The cigarette's success can be measured by the
excise taxes collected on tobacco varieties after the
Civil War. In 1878, revenues from excise taxes on
cigars and cheroots and on manufactured tobacco
were considerably higher than those on cigarettes
($11.4 million, $25.3 million, and $300,000, respec-
tively). When taxes were reduced by 50 percent in
1879, consumption of tobacco increased. Although
taxes were reduced further in 1889, consumption did
not increase enough to compensate for the lower tax
rate. By 1890, tax revenues were $1.1 million for cigars
and cheroots, $18.3 million for manufactured tobac-
cos, and $1 .l million for cigarettes. When funds were
needed for the Spanish-American War, taxes were
temporarily increased (Arnold 1897; Jacobstein 1907).

Hisfnricfl1 CCJllfYSf 29


U.S. g~~vcrnment rc\vnuc from tobacco sales from
1865 to IXYO is shown in Table 2.
  ln the 1880s and early 189Os, excise taxes on
tobacco products accounted for approximately one-
fourth of tota 1 federal government tax revenues, excIu-
si\rc of tariffs. From 1863 to 1906, tobacco accounted
for about 20 percent of government internal revenue
(Jacobstein 1907), and an increasing proportion was
derived from cigarette tax.

  An antismoking movement that had begun in
the 1860s was revived 10 years later. The increased
popularity of cigarettes may have been at least par-
tially responsible for the effort, which concentrated on
eliminating that particular form of tobacco use. Ad-
vertisements of "cures" for smoking appeared in
newspapers, and in 1880, the General Conference of
the Methodist Episcopal Church resolved that its min-
isters would abstain from tobacco (Robert 1967).

  In 1899, Lucy Page Gaston, who had been active
in the Temperance Movement, established the Chi-
cago Anti-Cigarette League and formed branches in
other cities. The League and similar organizations
opened clinics for curing smokers. Dr. D.H. Kress, the
League's general secretary, patented a mouthwash
containing a weak solution of silver nitrate, which he
believed would cure all craving for cigarettes. Other
remedies were developed, which were supposed to
end the desire for all forms of tobacco (Sobell978).

  By the early twentieth century, several antismok-
ing laws were enacted. New York State prohibited
public smoking by persons less than 16 years of age.
In 1897, under the Dingley Tariff, the federal government
forbade the inclusion in tobacco packs of coupons,
cards, and other inducements to smoking. The follow-
ing year, the government doubled the cigarette tax
(from 50 cents to one dollar per thousand). In 1901,

Table 2.  Tax revenue from tobacco sales, United
     States, 1865-1890

           Percentage of Average
                        rate of tax
Year      Total*    government
            revenue+  per pound

1865       11.4         5.4       ,228
1870       31.4        16.9       .269
1875       37.3        33.8       .211
1880       38.9        31.2       .160
1885       26.4        23.5       .OBO
1890       34.0        23.8       .OBO
Source: Arnold (1897).
*In millions of dollars.
`Although Arnold does not specify, the percentage appears
to be of internal revenue, not total revenue.

30 Historical Context

Table 3.  Manufactured tobacco products,* United
     States, X470-1905

Year

  Pounds of
manufactured
tobacco and snuff

1870        102
1871        107
1872        112
1873        118
1874        124
1875        124
1876        124
1877        123
1878        125
1879        136
1880        146
1881         172
1882        159
1883        194
1884        172
1885        207
1886        210
1887        226
1888        209
1889        246
1890        253
1891        271
1892        274
1893        251
1894        269
1895        274
1896        261
1897        297
1898        275
1899        295
1900        301
1901        314
1902        348
1903        351
1904        354
1905        368

Number
  of
cigars
~___-
1,183
1,353
1,578
1,755
1,835
1,828
1,776
1,816
1,923
2,217
2,510
2,806
3,118
3,232
3,373
3,294
3,462
3,662
3,668
3,787
4,229
4,422
4,675
4,341
4,164
4,099
4,048
4,136
4,459
4,910
5,566
6,139
6,232
6,806
6,640
6,748

Number
  of
cigarettes

  16
  20
  24
  28
  35
  59
113
157
210
371
433
595
599
844
920
1,080
1,607
1,865
2,212
2,413
2,505
3,137
3,282
3,661
3,621
4,238
4,967
4,927
4,843
4,367
3,870
3,503
3,647
3,959
4,170
4,477

                             __________.
Source:  U.S. Department of Commerce (1975).
*In millions.

New Hampshire enacted the strictest legislation, mak-
ing it illegal to manufacture, sell, or smoke cigarettes,
and in 1907, Illinois passed similar legislation. By
1909, 11 states (Iowa, North Dakota, Tennessee, Ar-
kansas, Indiana, Kansas, Minnesota, Nebraska, Okla-
homa, South Dakota, and Wisconsin) had enacted
laws prohibiting or limiting the use of cigarettes, and
many cities had similar statutes (Wagner 1971). A
survey of the period indicates that some form of
anticigarette legislation had been passed in every state


except Wyoming and Louisiana. In general, effort to
control the use of cigarettes was stronger in the Mid-
west than in the West and weakest in the East (Wagner
1971; Sobel 1978). Most of the state laws were re-
scinded by the middle to late 1920s.

  ATC and several other tobacco companies re-
sponded in the 14 states that banned cigarette smok-
ing. One strategy was to sell "the makings" (i.e.,
smoking tobacco and cigarette paper) because ciga-
rettes, not the materials themselves, were prohibited.
In states where the sale of cigarettes was illegal but
smoking was permitted, tobacco companies sug-
gested that merchants provide free cigarettes and
charge for matches.  Cigarettes were also illegally
transported to the states that banned cigarette sales
(Sobel1978).

  It is difficult to assess whether antismoking ef-
forts were effective. At the turn of the century, the
price of plug tobacco declined drastically, and many
cigarette smokers may have switched to plug. Con-
versely, the economic boom that began in 1897 may
have motivated former cigar smokers, who had con-
verted to cigarettes during a previous economic
downturn, to return to cigars. The net effect was that
cigarette sales peaked in 1896 at 4,947 million units
and then declined to 3,503 million in 1901 before again
turning upward (Table 3).

  Although ATC was secure enough financially to
survive the decline in cigarette consumption, most
competitors were not, and many cigarette manufac-
turers went out of business, further increasing Duke's
market share. ATC accounted for slightly more than
80 percent of cigarette sales in 1894 and more than 90
percent in 1900 (Sobel 1978). Thus, the temporary
decline in cigarette consumption served to narrow
competition, a portend of further developments in the
twentieth century.

   Urbanization in the second half of the nineteenth
century contributed to the dominance of cigarettes in
the tobacco market. The cigarette first gained popu-
larity in cities, where the pace of life was faster than in
small towns and rural areas. The desire for "a quick
smoke" could be satisfied more easily with cigarettes
than with cigars or pipes. Moreover, because ciga-
rettes cost less than other tobacco products, smokers
may have given little thought to lighting up a cigarette.
Chewing tobacco, which posed few aesthetic prob-
lems outdoors, caused concern in offices and factories.
Informal social contact was more prevalent in cities
than in rural areas. Offering someone a cigarette had
a certain social cachet; it was an inexpensive way of
socializing. Urban women were unlikely to smoke
cigars, use snuff or pipes, or chew tobacco. But in the
early twentieth century, educated women in the
higher socioeconomic groups had already begun
smoking cigarettes.

The Emergence of the Tobacco Companies, 1900 to the Present

Early Growth and Consolidation

  Once cigarette smoking became established as
the chief form of tobacco ingestion in the United States,
the history of tobacco was dominated by the growth
of large transnational corporations (TNCs) in the
United States and the United Kingdom. ATC was one
of the earliest and largest TNC in the United States
(Wilkins 1970). During the 188Os, in an attempt to
expand demand for his products, Duke sent represen-
tatives on world tours to procure business, and by the
189Os, almost one-third of U.S. cigarette output was
exported to the Far East. ATC had almost complete
control of U.S. cigarette exports (Tennant 19501, and
when tariff barriers prevented exports, Duke established
local manufacturing plants (as in Canada, Japan, Ger-
many, and Australia) (U.S. Bureau of Corporations

[USBOC] 1909). Britain's cigarette industry also ex-
panded rapidly during this period, although growth
was mainly confined to British colonial preserves and
spheres of influence and was not as rapid as in the U.S.
industry (Alford 1973; Corina 1975). By the mid-
189Os, agents for W.D. & H.O. Wills (by then the
largest U.K. firm) and ATC were directly competing
in India, Australia, Japan, and China (Alford 1973).

  By 1901, Duke had consolidated ATC's control
over all segments of the U.S. tobacco industry (except
cigars), and he decided to enter the U.K. market
(USBOC 1909). His decision was influenced by the
wave of antismoking hostility in the United States,
which resulted in prohibitions in 14 states and a de-
pression in sales between 1896 and 1906 (Tate 19891.
In addition, some shift in market preference toward


Turkish tobacco cigarettes led to new competition
from small independents. To better compete with
ATC, several English firms, under the leadership of
Wills, merged into the Imperial Tobacco Company
(ITC), and the two firms soon began to compete world-
wide. ITC was about to enter the U.S. market when
the two competitors came to terms (Corina 1975;
Alford 1973).

The 1903 Cartel

  The settlement created a classic cartel. Ogden's
Imperial Tobacco Ltd., a small tobacco firm, was sold
to ITC in exchange for 14 percent of its securities; ATC
and ITC agreed not to encroach on each other's mar-
kets; and a new London-based company, British-
American Tobacco Company Ltd. (BAT), was orga-
nized to control business outside the United Kingdom,
the United States, Cuba, and Puerto Rico. Two-thirds
of the initial E5.2 million capital was allocated to ATC
and one-third to ITC in exchange for overseas opera-
tions and export trade. Agreements were also made
to ensure consultation and inhibit cheating (USBOC
1909; Alford 1973; Corina 1975).

  In 1903, BAT was a transnational corporation of
impressive size, comparable to current TNCs in its
number of overseas operations. By the end of World
War I, it was the world's largest cigarette manufac-
turer. Although some Chinese boycotted the firm's
products, BAT's expansion was particularly extensive
in China, BAT's largest market for many years
(Cochran 1975; Wang 1960). BAT entered the U.S.
market by acquiring a small Kentucky firm (Brown &
Williamson Tobacco Corporation) in the late 1920s
(Shepherd 1983). BAT also expanded rapidly in Latin
America and in other markets outside the United
States and the United Kingdom.

The Antitrust Case of 1911

  Meanwhile, the structure of the tobacco industry
in the United States was undergoing profound
change. The practices used by ATC in gaining and
maintaining its market elicited opposition from to-
bacco growers, leaf traders, small manufacturers,
wholesalers, retailers, and organized labor (Tilley
1948; USBOC 1909,1911). These groups wanted better
leaf prices for growers, more accessible market entry,
increased price competition, and larger margins for
retailers and jobbers (Tennant 1950; Cox 1933). The
Supreme Court dissolved ATC in 1911 (U.S. 11. Amer-
ican Tobacco Co. 221 U.S. 106 119111; Tennant 1950; Cox
1933; Corina 1975) and ordered that the conglomerate
be split into several successor companies: Liggett &
Myers Tobacco Company, Lorillard, a new ATC, and

R.J. Reynolds Tobacco Company. Distribution of ATC
stockholdings was required, and several permanent
and temporary injunctions against recombination
were issued. Although this action probably did not
accomplish the desired results, the case did have long-
term effects on the international tobacco industry and
upset the structure of the domestic industry enough to
stimulate nonprice domestic competition (Cox 1933).
  In 1913, R.J. Reynolds, which had not previously
produced cigarettes, quickly launched a new type of
cigarette, the American blend, with flavored Burley
tobaccos. This cigarette, Camel, revolutionized the
U.S. cigarette business and was quickly imitated by
the new ATC's Lucky Strike and Liggett & Myers's
Chesterfield. The advent of the American blend stim-
ulated cigarette consumption and set off a long period
(1913 to 1950) of extremely rapid, domestic growth
known as the standard brand era (Sobel 1978). From
1911 to 1949, annual total U.S. cigarette output in-
creased significantly (from 10 billion to 393 billion),
while per capita consumption increased nearly twen-
tyfold (Tennant 1950; Nicholls 1951). Sands (1961)
concluded that the cigarette industry had the highest
growth rate in physical output of all U.S. manufactur-
ing industries for 1904 to 1947 and was second only to
motor vehicles for 1904 to 1937. The average quin-
quennial growth rate for output was 88 percent for
cigarettes versus only 15 percent for all U.S. manufac-
turing from 1904 to 1947 (Sands 1961). Growth in
domestic consumption and output was so spectacular
throughout that period that none of the firms showed
any interest in developing foreign operations or ex-
ports (Shepherd 1983).

  During this same period, the dilution of ATC's
two-thirds holding in BAT meant that the concen-
trated one-third shareholding of ITC was eventually
controlled by BAT. Thus, in the early 192Os, BAT
became a British-controlled corporation. Because U.S.
antitrust law had no jurisdiction over either BAT or
ITC, except in their U.S. leaf-buying operations, the
BAT/ITC market allocation agreements of 1903 were
continued in Britain until the early 1970s. In the ab-
sence of British antitrust action, ITC continued to dom-
inate the U.K. domestic market, while BAT controlled
markets outside the United States. Even after the Eu-
ropean Economic Community regulations forced the
formal repudiation of the BAT/ITC market division in
Europe in the 197Os, BAT/ITC relations remained
close because the British Monopolies Commission did
not take remedial action (Corina 1975).

  As a result, brands developed by ATC became
the property of BAT outside the United States and for
export from the United States (Cox 1933). This severely

32 Historical Context


limited the new ATC from expanding overseas be-
cause many of its top-selling domestic brands (e.g.,
Pall Mall and Lucky Strike) had been ATC brands
before the agreement. As the new ATC came to be one
of the major U.S. firms, this constraint powerfully
reinforced the domestic orientation of the industry.
Finally, although the ruling declared the formal cartel
illegal, the arrangements persisted exactly as before:
U.S. firms marketed domestically; ITC dominated the
British domestic market; and BAT remained the pre-
dominant international force outside theunited States
and United Kingdom well into the 1960s. Thus, U.S.
cigarette firms enjoyed relative protection in expand-
ing sales in the large, rapidly growing U.S. market.

  World War II provided the opportunity for sig-
nificantly increased exports for U.S. firms. European
production facilities had been destroyed, and Ameri-
can cigarettes became a coveted commodity due to the
popularization of everything American. However,
U.S. manufacturers did little to take advantage of this
situation (Shepherd 1983). International markets
were viewed as unstable and unlikely to provide fu-
ture growth. The long period of expansive domestic
growth made overseas markets pale in comparison. A
near doubling of sales during the war and the reemer-
gence of the overwhelming dominance of R.J. Reynolds,

Liggett & Myers, and ATC made the struggle for do-
mestic market shares more important than ever.

Stagnation Domestically and Growth Abroad

  But changes in cigarette consumption had begun
in the United States by the late 1940s (Kellner 1973).
The growth rate of the domestic market began to
shrink as it became saturated at a high level of con-
sumption (see Figure 1 j. The market further declined
when the health effects of smoking first surfaced as a
major public concern in the early 1950s. In association
with media publicity about the relationship between
cigarette smoking and incidence of lung cancer, sales
decreased 5 percent in 1954 (Kellner 1973).

  The small firms were most affected by the de-
cline in sales. The two smallest, Philip Morris Compa-
nies Inc. and Lorillard, began to explore the possibility
of expansion into international markets and of in-
creased exportation (Shepherd 1983). These firms
were particularly concerned that domestic sales might
fall below the minimum level required to finance the
development and promotion of the new filtered ciga-
rette. The first ventures abroad, including those in
Latin America (Shepherd 1983), in the 1950s were
tentative and coincided with increased tariffs in sev-
eral small, though attractive, export markets, such as
Australia, Panama, the Philippines, and Venezuela.

Figure 1. Per capita cigarette consumption, United States, WOO-199l*

Source: U.S. Department of Agriculture (unpublished historical data, 1%5,1991); Grise and Griffin (1988).
*1991, provisional data.

Historical Cmtrxt 33


Philip Morris did establish a partly owned subsidiary
in Australia, but most of the U.S. ventures consisted of
licensing agreements with local firms. In general,
domestic orientation remained strong, and U.S. pro-
ducers did not take advantage of the potential inter-
national popularity of American blend cigarettes. The
reluctance, particularly among the large companies, to
pursue international markets may have been related
to the success of filtered cigarettes, which revived high
domestic growth rates in the late 1950s. Nonetheless,
the smaller firms continued to acquire interests in
foreign operations and were quite successful on a
limited scale. In this way, Philip Morris positioned
itself for a substantial advantage over the rest of the
U.S. cigarette industry.

  The business impact of filtered cigarettes was
temporary (Kellner 1973). In 1962, the U.S. govern-
ment initiated an inquiry into the health hazards of
smoking (Eritschler 1975). In the resulting report of
the Surgeon General, which received considerable at-
tention, smoking was linked to several serious dis-
eases (Public Health Service 1964). The publication of
the report had immediate impact on U.S. cigarette
sales (USDHHS 1989). The expression of public con-
cern in the early 195Os, followed 10 years later by this
formal statement of adverse health consequences,
made it apparent that the health issue would probably
continue to affect sales adversely in the future. During
1900 to 1950, U.S. aggregate cigarette sales failed to
exceed those of the previous year only four times, but
from 1950 to 1977, sales decreased seven times (Shepherd
1983). After 1964, every U.S. cigarette firm sought to
acquire both foreign cigarette manufacturing opera-
tions and domestic nontobacco businesses (Taylor
1984). As sales continued to stagnate, pressure grew
to diversify out of the U.S. cigarette market (Miles and
Cameron 1982; Shepherd 1983,1985).

  Thus, the upsurge in direct foreign investment
and licensing abroad by U.S. cigarette firms was prob-
ably attributable to the stagnation of the U.S. market
that resulted from the smoking and health issue
(Warner 1977). Health concerns provided the decisive
push in the search for alternative markets for the
smallest firms in the 195Os, and after 1964, for the
larger firms as well. Some traditional economic moti-
vations-such as defensive investment, maintenance
of export markets, and protection of a technologically
based oligopoly-probably played a less important
role (Shepherd 1983).

  Few patterns were discernible in the flow of
investment and licensing abroad, and firms did not
necessarily explore markets with high growth rates.
Much activity targeted Europe, for example, where
per capita consumption was already fairly high.

Likewise, cigarette companies did not necessarily seek
large markets nor penetrate high-income markets and
then low-income markets; firms entered both markets
simultaneously. Rates of growth, market size, levels
of cigarette consumption, income, and other market
characteristics appeared less important than the im-
mediate concern of stagnation in the United States
(Shepherd 1983).

  Given the pressure to diversify quickly, most of
the overseas subsidiaries established by U.S. firms
were acquired rather than newly established. Of the
traceable foreign subsidiary operations established
during 1950 to 1976, 76 percent were acquisitions of
foreign manufacturing firms by U.S. companies
(Shepherd 1985). Thus, U.S. firms began foreign oper-
ations by using established national brands and work-
ing through existing distribution networks.
Completely new subsidiaries emerged only where the
local tobacco industry was so underdeveloped that no
local firms were available for acquisition or where
TNC competitors already owned the entire industry.
As an illustration, 77 percent of the 22 subsidiaries
established in Latin America were acquired rather
than newly founded (Shepherd 1985).

Diversification

  In their post-1964 efforts to diversify holdings,
cigarette firms used the same strategy of acquiring
existing companies that they had used earlier. In the
first of three stages of diversification, cigarette firms
focused on acquiring nontobacco businesses. By the
late 197Os, TNCs derived a significant and growing
share of their sales and income from nontobacco pur-
suits (35 to 50 percent of sales and 10 to 30 percent of
earnings were the norm for the larger firms)(Miles and
Cameron 1982). The proportions were somewhat
higher for the smaller enterprises (Shepherd 1983).
For a time, diversification seemed successful, and it
appeared that some firms might become prototypes of
a new form of conglomerate TNC. For example, dur-
ing the 198Os, BAT spent US$7 billion on nontobacco
acquisitions, the same amount as the company's mar-
ket capitalization at the end of 1988 (Euromonitor
Consultancy, Volume I, 1989).

  However, the premise upon which this early
diversification was based proved false. The continuing
association of cigarette smoking with certain chronic
diseases and the resulting decline in consumption
could not be easily countered with nontobacco acquisi-
tions. Diversification was not well received by inves-
tors-the newly acquired nontobacco companies
earned less than the cigarette companies did (White
1988). Thus, mergers with nontobacco firms lowered

34 Historical Cmt~xf


financial results dramatically. Furthermore, investors
tended to judge stocks on the basis of future prospects
rather than current earnings, and tobacco activity was
deemed risky. Nontobacco acquisitions did not raise
the market price of cigarette stocks; instead, the value
of stocks in nontobacco firms were reduced when
these firms were acquired by cigarette companies
(Burrough and Helyar 1990; Euromonitor Consul-
tancy, Volume I, 1989).

  A second phase of takeovers began in the 1980s.
Cigarette firms began to vary their diversification;
some companies continued with new acquisitions,
while others sold their nontobacco holdings (Anony-
mous 1983; Blum and Wroblewski 19851. However, all
firms suffered from low price-earnings ratios, and
their stocks were worth far less than their assets or real
current earnings potential. Nearly all of these firms
were viewed as takeover targets (Nordby 1989) be-
cause of the high cash flow from their core cigarette
business. ITC was taken over by Hanson Trust Ltd. in
1986 (Euromonitor Consultancy, Volume I, 19891,
Nabisco Inc. by R.J. Reynolds in 1988, and the two
latter companies by Kohlberg Kravis Roberts & Com-
pany in 1989 (Burrough and Helyar 1990). BAT nar-
rowly escaped a takeover of this sort in 1989
(Euromonitor Consultancy, Volume I, 1989; Tobacco
Reporter 1989b).

  By the late 198Os, diversification was entering its
third stage, in which company strategies diverged
markedly. Some firms, such as R.J. Reynolds, BAT,
and Hanson Trust, focused more on cigarettes, while
others, such as Philip Morris, ATC, and Loews Corpo-
ration (its tobacco holding is Lorillard), continued to
grow through nontobacco acquisitions (Sherman
1989; Winters et al. 1988; Matlick 1990a,b). For all of
these firms, however, diversification provided greater
power and leverage to protect the cigarette business
from further erosion (White 1988). Diversification
aided in opposing smoking restrictions, product liabil-
ity suits, and advertising and press coverage of health
hazards (McGill 1988), and it broadened political co-
alitions against anticigarette legislation (White 1988).

International Competition

  Entry of U.S. cigarette firms abroad after 1964
generated new competition within the industry,
especially with BAT. Philip Morris and, to a much
lesser extent, R.J. Reynolds were BAT's primary com-
petitors. Liggett & Myers was almost wholly unsuc-
cessful abroad, and Lorillard, which pursued a
strategy of overseas licensing, eventually sold the
rights to its brands abroad to BAT in 1978. ATC's brands
in overseas markets were already largely owned by

BAT. ATC concentrated almost all of its overseas
manufacturing in the U.K. domestic market after ac-
quiring Gallaher Tobacco Ltd. in the late 1960s (Corina
1975). Nevertheless, as U.S. firms continued to ex-
pand in the 1960s and 197Os, it became apparent that the
Anglo-American understanding on separate develop-
ment was over. ATC, through Gallaher, competed
withITCin theUnitedKingdom,whilePhilipMorrisand
R.J. Reynolds competed with BAT almost everywhere.
In the early 197Os, Philip Morris became the world's
second-largest tobacco company, and Marlboro be-
came the world's largest-selling brand. Although it
lagged slightly behind BAT in world cigarette volume
in the 198Os, Philip Morris's sales value and growth
were much higher, and it became the world's largest
cigarette firm (Euromonitor Consultancy, Volume I,
1989).

  Despite these developments, some de facto
spheres of influence have remained. In all but the
largest national markets, only a few TNCs are usually
present. These historical spheres of influence and pat-
terns of mutual forbearance are most obvious in Asia
and Africa where European firms have dominated,
except for U.S. licensing in the Philippines. Until the
198Os, U.S. firms tended to restrict their operations to
more familiar terrain in Latin America and Western
Europe. The larger markets of Western Europe, Can-
ada, and Latin America have been areas of fairly com-
petitive activity (Shepherd 1985). But on the whole,
oligopolistic competition, market allocation, and re-
straint have characterized TNC operations.

  In general, the normal pattern has not been ag-
gressive, although several markets have been con-
tested. For example, in Brazil and Argentina, after
several years of advertising and new brand launchings,
the parties tended to come to terms, expenses for
demand creation were reduced, and new market
shares and a more settled equilibrium evolved
(Shepherd 1985).

The Current Structure of the Industry

  By the late 198Os, a new transnational equilib-
rium appeared to have been established. The industry
regrouped along a three-tiered stratification of firms.
The first tier included four truly transnational firms:
BAT, Philip Morris, R.J. Reynolds, and Rothmans
International Tobacco Ltd. Second-tier firms, like
American Brands, Inc., and Reemtsma GmbH & Com-
pany, were still international but not global in scope.
These firms continued to retain important foreign
markets but were largely confined to a specific region,
such as Europe. Finally, smaller cigarette firms like
Loews, ITC, and Liggett & Myers retired to their

Historical Context 35


respective national markets and became increasingly
marginalized. After the late 197Os, the creation of new
subsidiaries and licensing agreements slowed, a de-
velopment which contributed to the period of consol-
idation in the 1980s and the subsequent equilibrium
(Shepherd 1985).

  Six of the dominant firms-BAT, Philip Morris,
R.J. Reynolds, American Brands, ITC, and Rothmans
International-recorded total sales in U.S. dollars, in-
cluding taxes and nontobacco merchandise, of 97
billion in 1989 (Table 4). These TNCs are among
the largest U.S. manufacturing firms and among the
largest firms in the world; they exert considerable
economic influence worldwide. The nontobacco op-
erations of these firms are included in Table 4; how-
ever, the cigarette industry forms the basis of the
economic activity of these TNCs (Miles and Cameron
1982; White 1988).

  Complex equity and licensing patterns link the
major firms in the transnational cigarette industry,
and Anglo-American companies dominate the indus-
try (Table 5). Of the seven major firms with extensive
international operations, such as direct investments,
licensing arrangements, and large-scale exports, only
Reemtsma has neither U.S. nor British ownership.
Rothmans International is a unique combination of
South African, British, and Western European tobacco
interests. For the past 20 years, Rothmans Interna-
tional has acquired economically troubled national
tobacco firm-mostly in Western Europe. The latest

Rothmans International acquisition is The Carroll To-
bacco Company Ltd., an Irish cigarette manufacturer
(Harman 1990). In 1981, Philip Morris acquired 29
percent of Rothmans International stock but recently
sold it (Nordby 1990). R.J. Reynolds recently sold its
Brazilian operations to Philip Morris (Tobacco Interna-
tional 19901, and Philip Morris merged its Canadian
and U.K. businesses with Rothmans International
(Harman 1988).

  Four major TNCs (BAT, Philip Morris, R. J. Reyn-
olds, and Rothmans International) account for 31 per-
cent of total world production of cigarettes (5,245
billion in 1988) (Table 6). If socialist-planned econo-
mies of 1988 are excluded, these four firms account for
57 percent of manufactured cigarettes. If countries
with socialist-planned economies or state monopolies
in 1988 are excluded, these four companies account for
almost 75 percent of cigarette sales in private enter-
prise markets worldwide. This percentage may actu-
ally be greater because, due to licensing, brand
concentration of TNCs would be higher. In fact, each
estimate may be subject to a substantial margin of
error because of difficulty sorting out relationships
among participants.

  Since the several socialist-planned economies
and state monopolies of 1988 account for approxi-
mately 60 percent of world cigarette sales (Table 6), the
primary avenues of expansion for the major TNCs are
now through entry into state monopolies, socialist-
planned economies, the former Soviet Union, and

Table 4. Economic activity" and rankings of maior transnational cigarette producers, 1989

Company             Sales5

Philip Morris             39,069

British American Tobacco      23,529

R.J. Reynolds/Nabisco        15,224

Imperial Tobacco/Hanson Trust   9,900

American Brands            7,265

Rothmans International        2,210

   Total              97,197
                    -
Source: Forfllne (1989,1990a,b).
*Includes tobacco and nontobacco activities.
`In U.S. dollars (millions).
TBased on 1988 sales data.

,
Activity+
Profits

2,946

2,123
(1,149)"

1,987

  631

  228
7,915"

Assets

38,528

18,656

36,419

13,210

11,394

3,182

121,389

   Fortune 500 ranking$
U.S.     Global  International

7        14         -

-        36        42

24        66         -

           -        62

64       178

-                352

%ncludes excise taxes on tobacco and nontobacco products.
"Loss due to restructuring of operations following 1989 takeover by Kohlberg Kravis Roberts.  Losses are not included in total.

36 Historical Context


Table 5. Transnational cigarette industry: subsidiaries and affiliates (financial interest) or licensing
    agreements*
-___--~

Subsidiaries and affiliates

Argentina

B.A.T. Industries (Nobleza-Piccardo S.A.I.C.yF.1
Philip Morris (Massalin Particulares S.A.)
Reemtsma GmbH (Massalin Particulares S.A.)

Barbados

B.A.T. Industries (B.A.T. Co. [Barbados] Ltd.)

Brazil

B.A.T. Industries (Cia. Souza Cruz Industria e
Commercio)

Philip Morris (Philip Morris Marketing, S.A.)
R.J. Reynolds (R.J. Reynolds Tabacos do Bras&
Ltd.)

Canada

B.A.T. Industries (Imperial Tobacco Ltd.)
Philip Morris (Rothmans, Benson & Hedges Inc.)
R.J. Reynolds (RJR-Macdonald Inc.)
Rothmans International (Rothmans, Benson &
Hedges, Inc.)

U.S. Tobacco (National Tobacco Company)

Chile

B.A.T. Industries (Chiletabacos SA)

Costa Rica

B.A.T. Industries (Republic Tobacco Company)
Philip Morris (Tabacalera Costarricense, S.A.)
Dominican Republic
Philip Morris (E. Leon Jimenes, C. por A.)
Ecuador

Philip Morris (Tabacalera Andina S.A.)
R.J. Reynolds (Fabrica de Cigarillos El Progreso
S.A.)

El Salvador

B.A.T. Industries (Cigarreria Morazan S.A. de CV)
Philip Morris (Tabacalera de El Salvador, S.A. de
C.V.)

Guatemala

B.A.T. Industries (Tabacalera National S.A.)
Philip Morris (TabacaIera Centroamericana S.A.)
Guyana

B.A.T. Industries (Demerara Tobacco Co. Ltd.)

Honduras

B.A.T. Industries (Tabacalera Hondurena S.A.)
U.S. Tobacco (Centro Americana Cigar, S.A.)
Jamaica

Rothmans International (Carreras Group Ltd.)
Mexico

Philip Morris (Cigarros La Tabacalera Mexicana,
S.A. de C.V.)

Nicaragua

B.A.T. Industries (Tabacalera Nicaraguense S.A.)

Panama

B.A.T. Industries (Tabacalera Istmena S.A.)
Philip Morris (Tabacalera National S.A.)
Puerto Rico

R.J. Reynolds (R.J. Reynolds Tobacco Company)
Suriname

B.A.T. Industries (B.A.T. Co. Ltd. Suriname)

Trinidad

B.A.T. Industries (The West Indian Tobacco
Company Ltd.)
United States

American Brands (The American Tobacco
Company)

B.A.T. Industries (Brown and Williamson Tobacco
Corp.)

Imperial Tobacco (Imperial Tobacco Leaf Services
Inc.)

Philip Morris (Philip Morris U.S.A.)
Reemtsma GmbH (West Park Tobacco Inc.)
R.J. Reynolds (R.J. Reynolds Tobacco Co.)
Svenska Tobaks (The Pinkerton Tobacco
Company)

U.S. Tobacco (United States Tobacco Company;
United Scandia International)

Uruguay

Philip Morris (Abal Hermanos, S.A.)
Venezuela

B.A.T. Industries (C.A. Cigarrera Bigott SUCS)
Philip Morris (C.A. Tabacalera National, S.A.)

Licensing agreements
Argentina

Reemtsma GmbH (Massalin Particulares S.A.)
R. J. Reynolds (Nobleza-Piccardo S.A.I.C.yF.1
Bolivia

B.A.T. Industries (Tabacalera SRL)
Philip Morris (Cia. Industrial de Tabacos S.A.)
Brazil

Reemtsma GmbH (Philip Morris)
Chile

Philip Morris (Fabrica de Cigarillos LTDA)
Costa Rica

Reemtsma GmbH (Tabacalera Costarricense S.A.)

Curaqao

Philip Morris (Superior Tobacco Co. of Curaqao
N.V.)

Historical Context 37


Table 5. Continued

Ecuador

B.A.T. Industries (Tabacalera Ecuatoraria)

Haiti

B.A.T. Industries (Luckett Tobaccos)

Mexico

R.J. Reynolds (Cigarrera La Moderna S.A. de C.V.)
U.S. Tobacco (Philip Morris)
Netherlands Antilles
Philip Morris (Superior Tobacco Co. N.V.)
Panama

Reemtsma GmbH (Tabacalera National S.A.)

Paraguay

B.A.T. Industries (La Vencedora S.A.)

Peru

Philip Morris (Tabacalera National S.A.)
R.J. Reynolds (Tabacalera National S.A.)
Suriname

B.A.T. Industries (Tobacco Company of Suriname
N.V.)

Source: Tobucco~~~orfer(1990).
"Name of transnational corporation given first, followed by
name of local company in parentheses.

Eastern European countries. During the 198Os, the
major TNCs focused on gaining access to the expand-
ing markets of Japan, South Korea, Taiwan, and Thai-
land, where state monopolies had long prevailed
(Zimmerman 1990; Chadha 1989; Heise 1988; Con-
nolly 1989; Wallace 1989; Doolittle 1990b; Mackay
1989; Chen and Winder 1990). The major TNCs are
also opening the Western European monopolies with
large-scale exporting (Stefani 1990a; Shelton 1988; To-
bacco Reporter 1989a). During the 198Os, France lost
nearly 50 percent of its market to cigarettes imported
by TNCs (Manus 1988; Stefani 1990b). Despite consid-
erable difficulty, U.S. and European TNCs are at-
tempting to open the formerly closed markets of
Eastern Europe, the former Soviet Union, and China
(Zimmel 1990; Doolittle 1990a,b; Chadha and Sokohl
1990; American Cancer Society 1991).

  Transnational cigarette companies dominate
the markets in specific countries (Table 7). Non-
transnational firms hold small market shares in most
countries; in only a few countries do nationally
owned, private cigarette firms account for more than
30 percent of the national market. In some countries,
market concentration continues the trend toward in-
creased TNC market control.

  TNCs do not compete against each other in the
world commodity market, except through exporta-
tion; only 10 percent of the total world cigarette pro-
duction is traded internationally (USDA 1990d,e).
Rather, TNCs compete in national markets in which
the level of concentration of firms is much higher than
in the world market. Direct competition is limited
because in only a few of the largest markets do more
than two or three TNCs compete (Shepherd 1985).

Table 6.  Estimated cigarette output, by producing
     group, 1988

29.5
7.2
6.9
0.6
0.5
0.3
45.0

Group                 Number* Percent

Socialist-planned economies
China               1,545
USSR                   378
Eastern Europe             360
Cuba                    30
Vietnam                  25
North Korea               15
   Subtotal            2,353

State mor.opolies
&%% Korea               268
                        86
Spain                    78
Italy                    67
Turkey                   60
France                   53
Egypt                   43
Maghreb countries           35
Thailand                 35
Iran                     15
Austria                   14
   Subtotal               754

Major transnational corporations
British American Tobacco      575
Philip Morris              555
R.J. Reynolds              285
Rothmans International       220
   Subtotal            1,635
Others producers+
American Brands            90
Reemtsma                 48
Loews (Lorillard)            46
Imperial Tobacco            43
   Subtotal               503

5.1
1.6
1.5
1.3
1.1
1.0
0.8
0.7
0.7
0.3
0.3
14.4

11.0
10.6
5.4
4.2
31.2

1.7
0.9
0.9
0.8
9.6

Source:  US. Department of Agriculture (1990d)

*In billions.

`Includes independent domestic cigarette firms and small
state monopolies.

38 Historical Context


Table 7. Cigarette market share of major transnational firms and affiliates,* selected countries, 1988

Americas

Argentina

British American Tobacco (Nobleza Piccardo, 57.21
Philip Morris (Massalin Particulares, 42.8)

Brazil

British American Tobacco (Souza Cruz, 79.6)
Philip Morris (Santa Cruz, 8.0)
R.J. Reynolds (R.J. Reynolds Tobacos de Brasil, 9.5)
Other (2.9)

Canada

British American Tobacco (Imperial, 54.3)
Rothmans (Rothmans, 30.81
R.J. Reynolds (Macdonald, 14.7)
Other (0.2)

El Salvador

British American Tobacco (Cigarreria Morazan,
78.4)

Philip Morris (Tocasa/Tasasa, 21.6)

Guatemala

British American Tobacco (Tabacalera National,
48.9)

Philip Morris (Tabacalera Centro-Americana, 51 .l)

Jamaica

Rothmans (Cigarette Company of Jamaica Ltd.,
100.0)

Mexico

British American Tobacco (La Moderna, 58.8)
Philip Morris (Tabacalera Mexicana, 39.8)
Other (1.4)

Nicaragua

British American Tobacco (British American
Tobacco, 99.9)
Other (0.1)

Panama

British American Tobacco (Tabacalera Istmena,
S.A., 60.4)

Philip Morris (Tabacalera National, S.A., 39.6)

United States

British American Tobacco (Brown & Williamson,

10.9)

Philip Morris (Philip Morris, 39.31
R.J. Reynolds (R.J. Reynolds, 31.8)
American Brands (American Brands, 7.0)
Other+ (11 .O)

Venezuela

British American Tobacco (Bigott Sues, 79.6)
Philip Morris (Tabacalera National, 20.3)

Other countries

Australia

British American Tobacco (Wills, 30.9)
Philip Morris (Philip Morris, 33.2)
Rothmans (Rothmans, 35.1)
Other (0.8)

Belgium

British American Tobacco (British American
Tobacco, 12.1)

Philip Morris (Weltab, 18.1)
Rothmans (Tabacofina, 39.1)
R.J. Reynolds (R.J. Reynolds, 7.3)
Reemtsma (Cinta, 16.7)
Other (6.7)

Denmark

British American Tobacco (Skandinavisk
Tobakskompagni, 98.2)
Other (1.81

Finland

British American Tobacco (Suomen Tupakka, 19.8)
R.J. Reynolds (Rettig, 15.4)
Othert (64.8)

West Germany
British American Tobacco (British American
  Tobacco, 22.3)
Philip Morris (Philip Morris, 27.61
Rothmans (Brinkman, 10.7)
R.J. Reynolds (H. Neuerbur, 9.2)
Reemtsma (Reemtsma, 25.0)
Other (5.2)

Ghana

British American Tobacco (British American
Tobacco, 89.01
Rothmans (Rothmans, 6.0)
Other (5.0)

India

British American Tobacco (India Tobacco
Company/Vizar Sultan Tobacco Company,
68.0)

Philip Morris (Godfrey Philips [India] Ltd., 15.0)
Other (17.0)

Kenya

British American Tobacco (British American
Tobacco, 99.8)
Other (0.2)

Malaysia

Philip Morris (Philip Morris, 3.3)
Rothmans (Rothmans, 46.3)
R.J. Reynolds (R.J. Reynolds, 16.31
Other (34.1)

Historical Context 39


Table 7. Continued

Netherlands

British American Tobacco (British American
Tobacco, 23.0)

Philip Morris (Philip Morris, 18.0)
Rothmans (Rothmans, 40.0)
Other (19.0)

Pakistan

British American Tobacco (Pakistan Tobacco
Company Ltd., 53.0)
Other (47.0)

Sri Lanka

British American Tobacco (British American
Tobacco, 99.9)
Other (0.1)

United Kingdom
Philip Morris (Philip Morris, 5.1)
Rothmans (Carreras Rothmans, 9.2)
R.J. Reynolds (R.J. Reynolds, 3.4)
American Brands (Gallaher, 39.4)
Others (42.9)

Zaire

British American Tobacco (British American
Tobacco, 42.0)

Rothmans (Rothmans, 58.0)

Source: Maxwell (1989a,b, 1990a,b,c,d).
`Name of transnational corporation given first, followed by
name of local company and market share (percentage) in
parentheses.

+Lorillard/Loews, 8.2 percent; Liggett & Myers, 2.8 percent.
SExtensive licensing of locally owned tobacco companies by
transnational firms. '
%cludes Imperial Tobacco/Hanson Trust, 34.6 percent.

  The cigarette industry is also dominated by only
a few top-selling brands (Table 8). The top two brands
account for large shares of most of the world's large
cigarette markets outside of countries with socialist-
planned economies (in 1988 and 1989). The top 10
brands comprise most sales in these markets (from a
low of 71 percent in Italy to 100 percent in Brazil and
France). In 1987, the top 25 brands accounted for 25.5
percent of world sales by volume, or 46 percent of sales
in countries that did not have socialist-planned econ-
omies at the time. Philip Morris's Marlboro was the
best-selling brand (293 billion cigarettes). This vol-
ume was approximately equal to total cigarette sales
in Japan, or the equivalent of total combined sales for
the United Kingdom, Italy, and France. Outside of
countries with socialist-planned economies (includes
the former Soviet Union), more than one cigarette in

10 sold is a Marlboro (Euromonitor Consultancy, Vol-
ume II, 1989).

Barriers to Entry

  Barriers to market entry affect the current
structure of the international cigarette industry.
Three major barriers are commonly cited (Bain 1956):
(1) absolute cost advantages for existing firms,
(2) economy of scale (or other advantages of large-
scale production), and (3) consumer preference for the
products of existing firms. The last fact& is probably
the most important.

  Several factors ensure sustained consumer pref-
erence for the existing products: the location of plants
or sales outlets, the provision of exceptionally good
service by the firms, the technology to produce phys-
ical differences in the product, and the creation of a
favorable image of the product (Scherer 1980). All
four factors contribute to the creation of demand by
the cigarette industry. The first two factors result from
the manufacturer's investment in distribution net-
works, sales forces, and market research, but they are
unlikely to be as decisive in most markets as are the
second two factors.

  The third factor, technology for producing dif-
ferences in products or packaging, has permitted
TNCs to gain a foothold in the foreign market. How-
ever, the advantages gained by firms on the frontier of
product technology are usually short-term, mainly
because the differences are easy to copy. Examples in
which a competitor has copied a new product form

Table 8. Percentage of sales by top cigarette brands
     in selected countries, 1988-1989

Country       Top two  Top five Top ten

Australia          41.3      63.3     77.6

Brazil            66.3      94.2     100.0

Canada           41.1      67.3     81.2

France           67.7      85.6     100.0

Italy

48.8      62.2     71.4

Mexico           42.1       71.7     87.7

United Kingdom     31.5      57.0     74.0

United States

35.6      53.3     71.8

West Germany      40.3      58.7     73.2

Source: Maxwell (1989a,b, 1990b,d).

40 Historical Context


and eventually became the market leader for that type
of cigarette are common in the history of the cigarette
industry (Kellner 1973). Consequently, although
these innovations are a barrier to entry for potential
competitors, they do not usually ensure the major
TNCs a durable monopoly.

  The fourth factor, the creation of favorable brand
images through mass advertising and other types of
promotion, reinforce differences in product form and
packaging. Most industry analysts agree that estab-
lished consumer preferences for existing products
constitute the major obstacle to new entrants and that
demand creation (i.e., marketing) has been the most
important source of the high degree of concentration
in the industry (Tennant 1950; Nicholls 1951; Kellner
1973; Cox 1933; United Nations Conference on Trade
and Development [UNCTADI 1978). The term
marketing, however, is a misnomer; it implies some
process of adaptation to a given, autonomous market
when, in fact, the activities described above often con-
trol and change or, in effect, transcend the market.

  The consumer loyalty that existing brands have
gained from previous and current promotional activ-
ities is a powerful barrier. According to fragmentary
market research from the 197Os, approximately 50
percent of U.S. cigarette smokers have never changed
brands, and an additional 25 to 30 percent have
smoked the same brand for three or more years (Key
1976). Profound product-form modifications, such as
the introduction of filters in the 1950s or the change to
low-tar brands in the 1970s and 198Os, tend to alter
brand loyalties, but these modifications are infrequent
(USDHHS 1989). Furthermore, since a new brand has
to overcome not only current advertising of existing
brands but also the effect of previous advertising, a
high level of expenditure is required to introduce a
new brand, even by existing firms. A potential com-
petitor must spend more than the established firms do
on advertising. Thus, cigarette advertising is an in-
vestment (although it is not treated as such by account-
ing conventions or tax laws) (Comanor and Wilson
19751, and the return on investment may continue for
many years (Weiss 1969).

Profitability

  The high barriers to entry and high levels of
concentration in the industry have led to oligopolistic
price-setting, a development which implies profits in
excess of a competitive profit-rate equilibrium. Before
cigarettes were proven to be harmful, this characteristic
was the main complaint about the industry in the
United States (Tennant 1950) and the main concern of
the literature on the cigarette industry. Two major
U.S. antitrust cases against the industry ensued in 1911

and 1946 (Tennant 1950; Nicholls 1951; Cox 1933;
USBOC 1909,1915; Kellner 1973). These same consid-
erations led to an inquiry into concentration, pricing,
and excess profit in Britain (U.K. Monopolies Commis-
sion 1961).

  Despite official concern, and even after cigarette
smoking was linked to certain chronic diseases in the
post-World War II period, the industry's high levels of
profitability continued. The U.S. tobacco industry led
all U.S. industries in profitability, return to investors,
and minimization of import penetration (Miles and
Cameron 1982). Throughout the 1960s and 197Os,
profitability of the post-World War11 TNCs continued
to be well above the average for all manufacturing
firms (Kellner 1973; Shepherd 1983,1985).

  Available measures of profitability for the U.S.
tobacco industry are conservative because they in-
clude the small tobacco firms that do not make ciga-
rettes, for which profitability is presumed to be lower,
as well as the nontobacco operations of tobacco firms
(Table 9). Nonetheless, the more profitable firms have
done very well. Philip Morris averaged a 33 percent
return on domestic sales in 1984 through 1988 and 9.5
percent internationally, for a weighted average of 16
percent (Euromonitor Consultancy, Volume 1, 1989).
Despite its recognition as a cigarette company, Philip
Morris was a popular stock in the 1980s because of its
performance (Sherman 1989). To the extent that the
figures can be compared, profitability in the 1980s
appears similar to that enjoyed by U.S. firms during
the height of the American cigarette industry-from
1911 to 1950. This level of profitability has been char-
acterized as "far above competitive levels and [it] be-
speaks a high degree of market control vigorously
exercised" (Tennant 1950, p. 342).

  In the United States, increased profitability in the
1980s has been related to both decreased overall sales
and a diminished regulatory environment for busi-
ness. Because of the long history of antitrust concerns,
tobacco companies avoided for decades any obvious
price-setting patterns, even as they continued to regu-
larly raise prices. In the deregulated business climate
of the 1980s (Burrough and Helyar 19901, however, the
cigarette firms started raising prices regularly, begin-
ning with four increases in 1982 and continuing to the
present with semiannual (June and December) increases
(USDA 1987, 1990a). The price of tobacco products
has outpaced the consumer price index since 1983 by
an ever wider margin (USDA 1990a,c), although some
of this increase is attributable to taxation. This pattern
has resulted because, in an unregulated oligopoly,
dwindling sales are balanced by higher prices and
thus higher profit margins from sales to the remaining,
presumably less price-elastic, "hard-core" smokers.

Historical Context 41


  The distribution of returns from cigarette sales
highlights the increased profitability of the industry in
the 1980s (Table 10). By 1985, the federal excise tax and
leaf growers' shares had declined substantially. Total
excise taxes decreased from almost 50 percent of the
consumer dollar spent on cigarettes to less than a
third, and the U.S. farm value fell to only 5 percent.
Although cigarette producers' 22 percent share in 1980
was not significantly different from their 21 percent
share in 1950, it increased to 34 percent in 1985 (Table
10). More efficient manufacturing (better equipment
and increased use of tobacco stems and reconstituted
tobacco sheets), greater use of cheaper imported to-
bacco (about one-third of U.S. cigarettes in the mid-
198Os), and product form changes (filter tips and slim
cigarettes) all contributed to the increase in profitability
(USDA 1987,1990a,d), as did the decisive use of mar-
ket power in the 1980s.

  The high and increasing profitability of the in-
dustry in the United States is of concern because the
richer the industry becomes, the more powerful it

becomes and the more difficult it is to control (White
1988). The public health community faces the politi-
cal, legislative, and economic strength of the tobacco
industry, built up over time by the phenomenal cash
flow and profitability of the cigarette business.

The Current Status in Latin America and
the Caribbean

  As described, a striking feature of the world
cigarette industry in the last several decades has been
the displacement in many countries of the nationally
owned tobacco company by a TNC subsidiary. This
phenomenon is perhaps most evident in Latin Amer-
ica and the Caribbean, where it has major implications
for the future social and health-related outcomes of
smoking (Connolly 1989). An overview of the history
and current aspects of the cigarette industry in the
region follows.

  Tobacco often figured in the economic and polit-
ical struggles of the colonial era in Latin America and
the Caribbean. The Comunero Rebellion in Socorro,

Table 9.  Income and profitability of tobacco manufacturing corporations,* United States, 1970-1985

                                                 Profit

                                          Percentage of
               Net income              Per dollar of sales      stockholders' equity
          (in millions of dollars)            (in cents)           (annual basis)
               Before     After       Before     After       Before      After
Year     Net sales   income tax income tax    federal tax federal tax     federal tax   federal tax

1970      9,839     1,098       569         11.2       5.8         30.3       15.7
1971      10,551     1,217       643         11.5       6.1         29.8       15.7
1972      11,308     1,246       676         11.1        6.0         28.4       15.4
1973      12,205     1,254       704         10.3       5.8         26.4       14.8
1974      14,267     1,354       770          9.5       5.4      26.4+     15.0+
1974$      8,933     1,053       801         11.8       9.0      26.4+     20.0+
1975      9,987     1,396       919         14.0       9.2         26.6       16.6
1976      11,964     1,638     1,011         14.3       7.8         28.8       15.9
1977      13,969     1,938     1,239         14.2       9.1         32.0       17.5
1978      15,493     2,591     1,461         16.7       9.4         32.4       18.3
1979    15,331_
     17,471_     2,740     1,752         17.9       11.-l         30.9       19.2
1980             3,027     2,044         17.3       11.7         31.0       19.8
1981    20,228:    3,560     2,221         17.6       11.0         30.8       19.2
1982     20,126g     3,558     2,354         18.6       11.8         31.4       19.8
1983    21,185:     3,440     2,589         16.2       12.2         29.8       18.5
1984    24,13B9    4,291     3,015         18.3       12.4         34.5       20.8
1985    25,096s     3,596     3,447         22.6       13.8         34.8       21.2

Source: U.S. Department of Agriculture (1980b, 1987).
"Includes nontobacco enterprises.
`Estimated on the basis of an equity increase of 8 percent.
IIndustry classification changed, and foreign subsidiary results were omitted beginning with 1974. For 1974, the new
classification resulted in net sales reduced by 37 percent and profits before taxes reduced by 22 percent. Profits after taxes
increased 4 percent.
SExcludes excise taxes.

42 Historical Context


Table 10. Expenditures, farm value, marketing bill, and taxes for cigarettes, United States, selected years
                   Marketing bill'               Excise taxes'

     Consumer    Farm                                     State and
Year expenditures*   value"+   Manufac- Wholesaling/
               turingj   retailing5    Total      Federal    local    Total

1950     3,586     482 (13)"    757 (21)     681 (19)   1,438 (40)    1,243 (35)   423 (12)  1,666 (47)
1960     6,244     651 (10)   1,537 (25)   1,240 (20)   2,777 (45)    1,864 (30)   953 (15) 2,816 (45)
1970    10,438     718 (7)    2,574 (24)   2,680 (27)   5,254 (51)    2,036 (19)  2,430 (23)  4,466 (43)
1980    19,400    1,445 (7)    4,332 (22)   7,105 (37)  11,437 (59)    2,564 (13)  3,954 (21) 6,518 (34)
1984    28,750    1,478 (5)    8,973 (31)   9,137 (32)  18,110 (63)'   4,749 (17)  4,413 (15)  9,162 (32)
1985    30,250    1,565 (5)   10,349 (34)   9,383 (31)  19,732 (65)'   4,443 (15)  4,510 (15)  8,953 (30)
Source:  U.S. Department of Agriculture (1987).
In millions of dollars.
`Estimated by multiplying quantity of domestic tobaccos used in cigarettes consumed domestically by growers' prices from
previous year.
TDifference between farm value and manufacturers' gross receipts from cigarettes, less federal tax.
RDifference between manufacturers' gross receipts and consumer expenditures, less tax.
"Percentage of consumer expenditures given in parentheses.
%ource data recalculated to correct arithmetic error.

Colombia, in 1781, for example, began as a protest
against policies affecting the cultivation and market-
ing of tobacco under the Crown monopoly (Leonard
1951). Eventually, the deep-seated hatred of the colo-
nial monopoly led to the dismantling of most tobacco
monopolies (Stein and Stein 1970; Harrison 1952). By
the mid-nineteenth century, most tobacco industries
in the region had become at least formally private.

  As Latin American and Caribbean countries be-
came increasingly linked to the international system
of trade, they experimented with various commodities
in which they might enjoy some advantage. Leaf to-
bacco was one of these products, and several countries
experienced sporadic surges in tobacco exportation.
Tobacco production was crucial to government reve-
nue in almost all Latin American and Caribbean coun-
tries before and after independence from colonial
powers (Stein and Stein 1970).

  The tobacco industry in the region was based on
locally grown, dark tobacco, which was used for cigars,
snuff, and chewing tobacco in the precigarette era.
Dark, air-cured tobaccos of this type were favored in
regions with a history of Latin cultural influence. In
the late nineteenth century, when cigarettes were first
introduced, dark-leaf production for cigars was al-
ready well established. Thus, Latin American and
Caribbean cigarette manufacturers would naturally
produce cigarettes from these dark cigar leaf-cuttings
(Brooks 1952).

  Tobacco manufacturing played a key role in the
early economic development of Latin America be-
cause tobacco products were logical commodities for

local industrialization. Tobacco products were a lux-
ury to import, domestic raw materials were readily
available, scale requirements were not large, technol-
ogy was not unduly difficult to acquire or adapt to
local conditions, and leaf production was labor inten-
sive. Because tobacco manufacturing provided tax
revenue for the state and reduced nonessential im-
ports, the industry frequently received considerable
tariff protection. However, once the cigarette became
the chief form of tobacco use, the evolution of the
domestic tobacco industry was soon altered by the
sudden appearance of TNCs.

  In the largest markets of Latin America and the
Caribbean, such as Argentina, Brazil, and Mexico,
BAT entered the industry fairly early-just before and
after World War I-usually by acquiring a local firm
(Shepherd 1983). As it aggressively strived to carve
out large market shares, BAT often met with opposi-
tion from owners of national firms, economic nation-
alists, and other groups that feared foreign control of
the local economy. In some countries, such as Colom-
bia, BAT was unable to gain a permanent foothold in
the market despite four attempts from 1919 to 1959
(Shepherd 1983). However, BAT's strategy for dealing
with economic nationalism was usually accommodating,
and in some countries, local firms often prospered
along with BAT subsidiaries. The takeover of these
firms by other, mostly U.S., firms in the 1960s led to
the "denationalization" of the region's tobacco industry.
  The entry of U.S. TNCs into the Latin American
market in the 1960s had a strong temporal relationship
with contraband trafficking in cigarettes, as measured

Historical Context 43


by the disparity between recorded world exports and
imports (Table 11). USDA acknowledged that the
difference was "largely a result of contraband trade,
since cigarettes that are shipped and recorded as offi-
cial exports by the country of origin are not always
reflected in the trade data of the recipient countries"
(USDA 1976). The discrepancy is illustrated by the
Netherlands Antilles, which imported 4,126 million
cigarettes from the United States in 1976. If none of
these cigarettes were exported, per capita consump-
tion of cigarettes would have been seven times that of
the United States at the time (USDA 1977).

Table 11. Recorded exportation and importation
    of cigarettes worldwide, selected years,

195111960* and 1967-1990t

Year

Exports
~~~

                     ~~~  ~-~-

                           Percent
             Imports   difference
                                 -~-~

1951       126,735    106,508     16.0
1952       115,324    95,732     17.0
1953       114,869    90,708     21.0
1954       108,317    91,939      15.1
1955       108,420    92,179     15.0
1956       109,717    85,379     22.2
1957       110,129    92,334     16.2
1958       110,484    93,208     15.6
1959       108,609    86,425     20.4
1960       110,428    84,162     23.8
1967~1971$   136,356    92,058     32.5
1972       178,415    126,016     29.4
1973       191,938    133,306     30.5
1974      203,888    153,615     24.7
1975       222,659    170,778     23.2
1976       235,370    192,076     18.4
1977       257,039    200,406     22.0
1978       279,089    213,558     23.5
1979       301,866    254,855     15.6
1980       322,820    254,250     21.2
1981       340,200   256,810     24.5
1982       331,961    259,737     21.8
1983       319,667   274,318     14.2
1984       331,444    292,323     11.8
1985       355,857   313,253     12.0
1986       363,074    324,805     10.5
1987       405,779    364,530     10.2
1988       460,238    389,888     15.3
1989       508,336   401,490     21.0
1990       543,148    417,951     23.0

Source: U.S. Department of Agriculture (USDA) (1958,
1960,1962,1976,1977,1980a, 1982,1986,1990d).
*In thousands of pounds of cigarettes.
+In millions of cigarettes.
kJSDA stopped publishing data on world trade in
cigarettes after 1962 and did not resume until 1976 when
it provided the average for 1967-1971.

  In Latin America and the Caribbean, two exam-
ples with different outcomes illustrate the possible
effects of contraband. Based on estimates provided by
the Colombian government, the proportion of total
cigarette consumption attributable to contraband rose
from less than 4 percent before 1970 to nearly 18
percent in 1976 (Shepherd 1983). During these years
a complex series of events took place, including two
licensing agreements for the local manufacture of sev-
eral popular TNC brands. The local firms, which con-
stituted one of the last nationally owned, private
cigarette industries, tried to preserve the market for
dark-tobacco cigarettes, and continued to resist entry
of the TNCs.

  Based on estimates by the Argentine govern-
ment , apparent contraband rose precipitously-from
2 percent to 12 percent of total consumption in the
early 1960s (Shepherd 1979). In 1962, low-duty legal
importation was briefly permitted, and contraband, as
expected, declined. Several national firms established
themselves as exclusive importers of TNC brands.
When legal importation was again enjoined, these
importers developed licensing arrangements for local
manufacture of the same brands. However, contra-
band increased, to 15 percent, in 1966; all the nation-
ally owned firms were then acquired by TNCs. In the
early 197Os, after local versions of TNC brands had
been established, contraband declined to 2 percent of
total consumption.

  Nearly 80 percent of the documented, U.S.-
owned, TNC subsidiaries in Latin America and the
Caribbean were acquired through takeover (Shepherd
1983). Although some European TNCs also entered
the Latin American and Caribbean industry in the
196Os, most BAT subsidiaries were established much
earlier and, therefore, BAT remains the major Euro-
pean TNC in the region. Denationalization has been
pursued more aggressively in Argentina, Brazil, Mex-
ico, Venezuela, and other markets with considerable
potential for growth. In many of the smaller markets,
such as those in Peru, Bolivia, and Paraguay, TNCs
have settled for licensing arrangements or minority
equity positions.

  TNCs have been established in every national
market in Latin America (except in Belize and Cuba)
and in several Caribbean countries (Table 12).
Because TNC market shares are very large, these firms
control almost the entire cigarette industry in the re-
gion. Nationally owned tobacco industries survive in
only a few countries, such as Bolivia, Paraguay, Peru,
and Colombia. These firms are often involved with
the TNCs through licensing agreements, and TNC
influence continues to increase.

  After TNCs entered Latin American and Carib-
bean cigarette markets, the industry underwent radical

44 Historical Context


transformation, especially in Brazil, Argentina, and
Mexico. Intense nonprice oligopolistic competition
for larger market shares began almost immediately. A
five-year period of intense, somewhat evenly divided,
competition for market shares was followed by a
period of considerable market fluctuation, during
which firms with initially large market shares weakened,
while firms with small market shares prospered. This
period of instability was followed by renewed concen-
tration and consolidation (Shepherd 1983,1985).

  Several factors have contributed to high levels of
market concentration in the Latin American and Ca-
ribbean cigarette industry. Not all of these factors are
directly attributable to TNCs; however, the entry of

TNCs accentuated and further concentrated market
structure. The history of TNCs in Argentina may
serve as an example. Before TNC entry in 1966, seven
major tobacco firms operated in Argentina. Sixty-five
percent of the total market was evenly divided among
locally owned firms, and 35 percent was controlled by
a subsidiary of BAT. After a short period of intense
oligopolistic rivalry following TNC takeovers, succes-
sive mergers reduced the industry to only two firms-
a duopoly controlled by BAT and Philip Morris. Thus,
the transition in the Argentinean tobacco industry was
from loose oligopoly to workable competition and
then to renewed concentration and consolidation
(Fidel, Lucsngeli, Shepherd 1977).

Table 12.  Subsidiaries, licensing arrangements, and market shares* of transnational cigarette firms,

selected countries of Latin Akerica and the Caribbean, c.1989

Country

Argentina
Barbados
Bolivia
Brazil
Colombia
Costa Rica
Chile
Dominican Republic
Ecuador
El Salvador
Guatemala
Guyana
Haiti
Honduras
Jamaica
Mexico
Netherlands Antilles
Nicaragua
Panama
Paraguay
Peru
Puerto Rico
Suriname
Trinidad and Tobago
Uruguay
Venezuela

British
American
Tobacco

S57
S-98
L-l 6
S-80

S-72
598

S-74
S50
5100
L-NR
!+99

558

s-100
S-64
L-NR
L-NR
S-3_
SlOO
S-100
S-77
S73

Philip
Morris

S-43

L-84
s-8
L-l
527
L-2
S-70
S-80
S-26
S-50

L-NR

540
L-NR

S-36
L-NR
L-NR
s-15

s-23
%27

R.J.
Reynolds

S-9

520

L-NR
S-82

Rothmans     Total
International  output+

          33,700
             133
          1,200
         162,700
       18,3009
          2,050
          9,930
          4,473
          4,600
          1,970
          1,997
             266
             870
          2,582
  S-100      1,273
         49,510
             NR
          2,400
          1,150
          2,730
          4,200
          3,200
             528
          1,250
          3,900
         18,035

Market
share3

100
98
95
97
43"
99
100
70
100
100
100
100
NR
99
100
98
NR
100
100
NR
20
100
100
100
100
100

Source: U.S. Department of Agriculture (1990b;d); Maxwell (1990b,c,d).
S = Subsidiary with significant equity holdings. L = Licensing agreement with a local company (either locally owned or
another transnational corporation) in which no equity is owned. Percentage of market share (by volume) follows dash.
+NR = Not reported.
In millions of cigarettes.

fpercentage; excludes export sales (either legal or illegal).
*Total consumption is estimated at approximately 27 billion cigarettes a year (Nares 1989).
"Transnational corporation cigarette imports account for 43 percent of consumption, as estimated in 1989 (Tobacco
lnfernafiod 1989).

`These subsidiaries appear to be sales companies that do not manufacture tobacco products.

Historical Context 45


  In Latin America and the Caribbean, as in the rest
of the world, consumption patterns have converged
toward TNC product forms. This convergence is
partly the result of TNC demand creation and partly
the result of the diffusion of industrialized nations'
lifestyles-first to the elite in less-developed countries
and then to broader portions of the population. Four
major shifts have occurred in the consumption of to-
bacco products in the last 30 years: first, from all other
tobacco products to cigarettes; second, from dark to
light tobaccos; third, from unfiltered to filtered ciga-
rettes; and, fourth, from short (70 mm) to long (85 mm,
100 mm, and 120 mm) cigarettes. The trend has been
toward TNC product forms-that is, long, filtered,
light-tobacco cigarettes-and away from the short,
nonfiltered, dark-tobacco products of national pro-
ducers. In particular, a decisive shift was made to
American blend cigarettes, once specific to the United
States only. One measure of this shift is the growth in
market share of Marlboro cigarettes in several
countries throughout the world (Table 13) (Davis
1986). The example of the Dominican Republic
demonstrates an extreme case: an increase in market
share from 9.3 percent in 1975 to 51.1 percent in 1989.
In contrast, because of consequences of the 1911 anti-
trust case (see comments earlier in this section), the
Philip Morris product cannot be sold in Canada.

  In Latin America and the Caribbean, the popu-
larity of Marlboro cigarettes illustrates the shift in
taste from dark-tobacco to light-tobacco cigarettes

(Table 14). This shift testifies to the success of TNCs
in guiding production and consumption patterns
away from local idiosyncrasies (which give local firms
an advantage) and toward international patterns.

  Another consequence of the expansion of TNCs
into Latin American and Caribbean markets and the
creation of demand was the rapid growth in total
output and per capita consumption of cigarettes in the
1960s and 1970s (Shepherd 1983). This increased
growth was often in marked contrast to stagnant
growth rates reported by nationally owned firms. In
Argentina, for example, during 1950 to 1966, sales of
domestic cigarettes increased 38 percent, or an average
of 2.4 percent per year. After TNC entry in 1966 and
1967, sales increased 58 percent during 1966 to 1975,
an average of 6.4 percent per year. From 1950 to 1966,
per capita sales increased 5 percent, or 0.3 percent per
year; during 1966 to 1975, they increased 37 percent,
or 4.1 percent per year (Shepherd 1983).

  The rapid growth resulted from increased de-
mand creation, primarily through advertising and dis-
tribution, larger sales forces, and other promotional
techniques. Figured on the basis of constant 1960
prices in Argentina, the average annual cigarette ad-
vertising expenditure (per 1,000 packs) was 71.6 pesos
from 1961 to 1966 but 266.8 pesos from 1967 to 1971-
almost a fourfold increase. For the Philip Morris sub-
sidiary, reported advertising expenditures were
actually larger than reported earnings in 1967, and
high levels of advertising resulted in reported losses

Table 13.  Market share (`%I of Marlboro cigarettes, selected countries, 1975-1989

                                      Year

Country       1975  1976  1977  1978  1979  1980  1981  1982  1983  1984  1985  1986  1987  1988  1989

Latin America
Dominican
  Republic      -   9.3   11.3  15.0  18.7  22.1  26.0  31.4  35.0  36.4  38.7  43.4  45.1  49.3  51.1
Mexico         -   1.2   1.8   2.7   3.9   5.1   6.5   8.2   8.8  10.1  13.1  14.7  14.3  15.5  20.1
Argentina     0.5   1.2   0.7   1.0   3.2   6.7   6.6   4.0   3.6   4.9   7.0   9.6  10.7   8.9  10.2

Asia
Hong Kong      -   1.2   2.0   4.3   7.9  12.7  16.9  19.9  20.1  25.9  25.3  27.7  29.4  38.0  36.8
Singapore      1.5   1.6   1.4   4.7   7.5  13.4  15.1  16.7  18.8  19.3  16.9  15.8  20.8  20.3  20.7

Europe
Greece       0.3   0.5   1.0   2.4  11.8  10.3  13.9  15.6  16.2  15.2  14.9  16.9  16.8  13.4  14.0
Federal Republic
  of Germany    -    -   6.8   8.5  11.0  13.0  14.1  13.8  11.4  14.7  18.5  21.6  23.5  25.4  27.8
Spain           -   0.3   0.6   0.5   0.4   0.6   0.6   1.2   1.6   2.2   2.8   3.5   5.0   7.1   8.7
France          -   1.1   1.8   2.7   4.2   6.7   8.7  10.6   -  13.8  14.7  15.4  16.2  16.8  18.2
Italy           -   7.6   8.8  11.7  11.9  15.6  14.1  11.5  11.1  12.3  14.5  15.2  15.2  15.7  15.5
Source: Maxwell (1990b,c,d). -                .~~___~

46   Historical Context


Table 14.  Percentage of cigarette sales by type of tobacco blend, selected Latin American countries,
       1950-1989                                         -

         Argentina          Colombia            Peru            Mexico

Year      Light     Dark    Light     Dark    Light     Dark    Light     Dark

1950         36       64          -                              -          -         -
1955         50       50          -                5       95                    -
1960         46       54          -         -        13       87          -
1965         52       48          -         -        19       81                    -
1966         55       45          -                33       67          -         -
1967         60       40          -                50       50          -         -
1968         67       33        10       90        52       48          -         -
1969         71       29        11       89        55       45                    -
1970         72       28        12       88        57       43          -         -
1971         72       28        16       84        56       44                    -
1972         72       28        23       77        64       36                    -
1973         72       28        24       76        67       33          -         -
1974         72       28        25       75        77       23                    -
1975         75       25          -         -                    -          -         -
1976         78       22          -         -          -               63       37
1977         77       23          -         -                    -        65       35
1978          74       26          -         -                    -        69       31
1979         75       25          -         -          -         -        73       27
1980         75       25          -         -          -         -        76       24
1981          74       26        50       50                    -        78       22
1982         75       25        57       43          -         -        79       21
1983         75       25        61       39          -         -        77       23
1984         75       25        69       31                    -        76       24
1985         77       23        69       31          -                79       21
1986         79       21        71       29          -                76       24
1987         80       20        76       24          -         -        70       30
1988         83       17       76       24          -         -        70       30
1989            -         -        77       23          -         -        75       25
                   --_____.                  ___~. __~.
Source:  Republica de1 Argentina, Departamento de Tabaco, Secretaria de Estado de Agriculfura y Ganadetia (1978); Maxwell
(1989a,b, 1990b,c,d).

for three of the five TNCs during 1967 to 1970. After
this initial period of intense competition-marked by
introduction of new brands and the repositioning or
elimination of old brands-advertising and other pro-
motional expenditures declined (Shepherd 1983).

  Despite this rapid growth over a decade or more,
the economic results for the TNCs in Latin America
and the Caribbean were disappointing in the 1980s
because of severe macroeconomic problems and the
impoverishment of broad sectors of the population.
Toward the end of the decade, the region's per capita
gross domestic product declined by nearly 10 percent
from the 1980 figure, while per capita income de-
creased by nearly 15 percent (Economic Commission
for Latin America and the Caribbean 1989; Inter-
American Development Bank 1991). Since cigarette
consumption has long been recognized as income-elastic,

especially at lower levels of income, the decline in per
capita income in Latin America and the Caribbean had
a depressing effect on cigarette consumption in the
region (Figure 2).

  Per capita cigarette consumption declined some-
what uniformly throughout the Americas during the
198Os, but the reasons differ by region. In the United
States and Canada, decreased consumption may well
have been related to enactment of tobacco-control
policies and mounting public awareness of the harm-
ful effects of smoking (LJSDHHS 1989). In Latin Amer-
ica and the Caribbean, the widespread economic
depression almost certainly reduced consumption, al-
though growing antismoking efforts may have had a
limited impact in some countries. The TNC policy of
producing higher-priced, higher-margin products
and raising prices to counter decreasing sales may also

Historical Context 47


Figure 2. Per capita cigarette consumption in the Americas, 1970-1990

  4w 1

United States*

Brazil
Argentina
Latin America*

Peru

01             I             I             /             1             I
1970       1974       1978        1982       1986       1990

Source: Centro Latinoarnericano de Demograffa (1990); US. Department of Agriculture (1990b); Maxwell (1990b).
Persons aged 18 years or older.
+Persons aged 16 years or older.

tPersons aged 15 years or older; excludes Belize and Puerto Rico.

have had some impact on decreasing consumption by
volume (Shepherd 1985). Financially troubled gov-
ernments throughout Latin America and the Carib-
bean raised cigarette taxes, which also led to decreased
consumption.

  After having increased in most markets of the
region in the 197Os, adult per capita cigarette con-
sumption was level or declined in 19 of 20 Latin Amer-
ican and Caribbean countries and declined overall in
the region by 17 percent in the 1980s. (This reported
decline, however, does not consider the potential ef-
fect of contraband; see Chapter 4.) In one exception,
Colombia, adult consumption increased 14 percent
during the 1980s. These data suggest why TNCs have
now focused attention on other regional markets, es-
pecially those in Asia (Zimmerman 1990).

The Future of Tobacco Control

  In developed, industrialized countries, the de-
cline in cigarette consumption has been steep and
fairly uniform (Figure 2) (USDHHS 1989). In the
United States, adult per capita consumption has

decreased to approximately that of the mid-1940s (Fig-
ure 1). A similar recent downward trend in consump-
tion has also been documented for Canada (Figure 2).
This decline has powerfully reinforced TNC pursuit of
new cigarette markets, especially in the Third World
(Muller 1978; UNCIAD 1978; Clairmonte 1979; Shepherd
1983; Taylor 1984; Dollars 0 Sense 1985; Nath 1986;
Heise 1988; Food and Agriculture Organization of the
United Nations [FAO] 1989; Wallace 1989; Connolly
1989; The World Bank 1989; Taylor 1989; Crofton 1990;
Dollars 0 Sense 1990; Doolittle 1990a,b; Chapman and
Wong 1990).

  The basic system of leaf production, cigarette
manufacturing, and leaf exporting in less-developed
countries has long been established. For decades, BAT
has been promoting these activities throughout the
Third World, while also operating as a leaf dealer
(Shepherd 1985). In Latin America and the Caribbean
especially, and in less-developed countries generally,
several factors are likely to make tobacco production
and exportation and cigarette manufacturing more
important in the near future.

48 Historical Context


  First, various demographic trends, such as
changing population structure and income elasticity,
are likely to have a positive influence on cigarette
consumption. Second, the emphasis placed on indi-
rect taxes, such as excise taxes on cigarettes, is typical
of economic austerity programs recommended by
some international financial institutions. This empha-
sis might force governments of the region to rely even
more on the tobacco industry for revenue, thus rein-
forcing an already high degree of reliance on cigarette
taxation. Furthermore, these debt-related economic
austerity programs promote exportation to earn the
necessary foreign exchange to repay debts, finance
importation, and correct chronic balance-of-payments

Conclusions

deficits. This process may also lead to greater reliance
on leaf-export sectors and even cigarette exportation.

  In Latin America, the individual smoker-or the
young person who considers taking up smoking-
stands at the center of complex and changing eco-
nomic forces. The TNCs have successfully established
market dominance and created demand for their
products. In recent years, the overall economic pic-
ture has been one of diminished consumption. How-
ever, if economic conditions improve in Latin America
in the 199Os, growth in cigarette consumption may
resume and even increase substantially by the year
2000, as some studies suggest (FAO 1990).

1. Tobacco has long played a role, chiefly as a feature    3.  In Latin America and the Caribbean, through a
of shamanistic practices, in the cultural and spiri-    process of denationalization and the formation of
tual life of the indigenous populations of the     subsidiaries, a few transnational corporations
Americas. This usage by a small group of initiates    now dominate the tobacco industry. The current
contrasts sharply with the widespread tobacco    structure of the industry presents a formidable
addiction of contemporary American societies.      obstacle to smoking-control efforts.

2.  During the latter half of the nineteenth century,   4. After rapid growth in per capita tobacco con-
amalgamation of major U.S. cigarette firms coin-    sumption in Latin America and the Caribbean
tided with the emergence of the cigarette as the    during the 1960s and 197Os, a severe economic
most popular tobacco product in the United    downturn during the 1980s led to a decline in
  States.                       tobacco consumption. In the absence of counter-
                        measures, an economic recovery is likely to insti-
                       gate a resurgence of tobacco consumption.

Historical Context 49


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Historical Context 55


Chapter 3
Prevalence and Mortality

Preface 59

Prevalence of Smoking in Latin America and the Caribbean   61

Introduction 61
Demographic Characteristics 62
Population Configuration 61
Urbanization 62

Educational Opportunities 63
Income Distribution and the Labor Force   64
Prevalence Estimates 65

Prevalence Reported by the Pan American Health Organization   66
Prevalence Reported by the Gallup Organization   67
Prevalence Reported by Reproductive Health Surveys   68
Additional Prevalence Estimates Reported Since 1980   70

Smoking-Attributable Mortality in Latin America and the Caribbean   81

Introduction 81
Mortality Data 81
Coverage 81
Data Quality 82
Coding 83

Life Expectancy and Mortality   83
Trends in Life Expectancy and Overall Mortality   83
Estimates of Mortality   84
Total, Cause-Specific, and Age-Specific Mortality   8.5
Mortality from Smoking-Related Diseases   86
Estimates of Cause-Specific Mortality   86
Estimates of Relative Risk Due to Smoking   87
Smoking-Attributable Mortality 89
Estimates of Smoking-Attributable Mortality Worldwide   89
Lung Cancer Mortality as an Index of Prior Smoking in a Population   89
Estimates of Smoking-Attributable Mortality in the Americas   91
  Unadjusted Estimates 91
  Adjusted Estimates 92

A Comment on the Methodology   93

Conclusions 97

References 98


Preface

  In any population, the prevalence of smoking and the demonstrable health effects of
tobacco consumption are out of phase. For some diseases, such as lung cancer, the lag may
be 20 years or more; for heart disease or adverse outcomes of pregnancy, the lag may be
considerably shorter. But the overall burden of disease reflects the cumulatizle long-term
impact of tobacco use, or "maturity" of the smoking epidemic. This relationship betzrleen
prevalence of smoking and smoking-related disease has been examined in detail for North
America and zoill not be reiterated here. Rather, thefocus is on the countries ofthe Americas
in which tobacco use is an emerging problem.

  This discussion juxtaposes estimates of the current prevalence of smoking in Latin
America and the Caribbean zuith estimates of smoking-attributable mortality. Both esti-
mates attempt to define the dimensions of the current and future health threat posed by
tobacco use in the region.

Prez~alence and Mortality   59


Prevalence of Smoking in Latin America and the Caribbean

Introduction

  The expansion of transnational corporations into
international markets (described in Chapter 2) began
in the early 195Os, accelerated in the 196Os, and was
characterized by denationalization of local tobacco
industries and development of consumer preference
for the products of these corporations. In Latin Amer-
ica and the Caribbean, these events occurred along
with complex social and demographic changes-often
characterized as a demographic transition (Omran
1971; Jamison and Mosley 19911--that made the area
an attractive market for tobacco. These changes were
not uniform throughout the region nor even, in some
instances, uniform within a single country.

  Nonetheless, four main sociodemographic fac-
tors have contributed to the potential of the popula-
tion in Latin America and the Caribbean to initiate
cigarette smoking. These factors are growth of groups
likely to smoke, dissemination of an urban lifestyle,
greater access to education, and the entry of women
into the labor force. These factors are summarized
below and related to available data on the prevalence
of smoking.

Demographic Characteristics

Population Configuration

  The population size and growth rate in Latin
America and the Caribbean have been affected pri-
marily by changes in the birthrate and death rate; with
some regional exceptions, migration and emigration
have been less important. Changes in fertility, natal-
ity, and mortality have been dramatic (Table 1).

  In 1930, overall mortality was high in Latin
America, and life expectancy was only 35 years, al-
though in several countries, such as Argentina, Uru-
guay, and Cuba, life expectancy was greater because
an export-driven economy (Merrick 1986) had encour-
aged environmental and sanitary improvements.
Most Latin American countries, however, did not in-
troduce widespread methods for control of endemic
diseases until after World War II. Between 1950 and
1970, improved methods for the control of major in-
fectious diseases of children and adults may have
accounted for 30 percent of the increase in life expec-
tancy (Palloni 1981). By the 196Os, life expectancy at
birth for citizens of most Latin American and Caribbean

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

Indicator        1950-55+ 1955-60 1960-65 1965-70 1970-75 1975430 198&85 198590
Annual growth rate (%)$     2.73     2.75     2.79     2.60    2.48     2.29     2.17     2.06
Crude birthrates          42.5     41.7     4 ..l     38.0    35.4     32.4     30.6     28.7
Crude mortality rate"       15.4     13.6     12.1     10.9     9.7     8.6     7.9     7.4
Total fertility rate'         5.87    5.90     5.96     5.53    4.99     4.36     3.93     3.55
Life expectancy at birth**     51.9     54.8     57.3     59.2    61.3     63.3     65.2     66.7
Infant mortality rate++       126     112     100     91      81      70      61      54
Source: United Nations (1991).
*Excludes Belize and Puerto Rico.
%om July of the first year to July of the last year in each period.
*otal increase in population during one year divided by mean population for the same period.
_Number of births during one year divided by mean population for the same period; per 1,000 persons.
`Number of deaths during one year divided by mean population for the same period; per 1,000 persons.
IAverage number of children that would be born during the fertile period of each woman in a hypothetical cohort (in accordance
**with the fertility rate by age for the cohort) who was not at risk for mortality before the end of the fertile period.
Average number of years that would be lived by a newborn in a hypothetical cohort subject to the mortality schedule in effect
at the time.
tiNumber of deaths per year among children under one year of age divided by number of births during the same period; per
1,000 persons.

Prevalence and Mortality   61


Table 2.  Estimated population,* Latin America, the Caribbean, and the United States, 1950-1990

Region                  1950         1960         1970         1980         1990

Latin America and the
Caribbean
  Total              165.9        218.1        285.7        362.7        449.9
  215 years of age     98.5 (59.4)+   125.4 (57.5)    164.3 (57.5)    220.2 (60.7)    287.5 (63.9)

United States
Total               152.3        180.7        205.1        227.8        251.3
215 of
   years  age        111.3 (73.1)    124.5 (68.9)    147.0 (71.7)    176.5 (77.5)    197.0 (78.4)

Source: United Nations (1991).
`In millions.
?ercentage of total population 215 years is given in parentheses.

countries was about 60 years. But since advances were
not uniform, less industrially developed countries,
such as Bolivia, Haiti, and the Central American coun-
tries (except for Costa Rica), reported a life expectancy
at birth of less than 50 years. Nonetheless, for the
region as a whole, overall crude mortality and infant
mortality have declined by over 50 percent since 1950
(Table 1).

  Through the first half of the twentieth century,
the birthrate increased in Latin America, except for the
urban populations of some countries (such as Argen-
tina and Uruguay) that experienced early economic
improvements. After 1965, the birthrate in larger
countries, such as Brazil, Mexico, and Colombia,
began to decrease, and the region as a whole experi-
enced declining fertility. Total fertility has diminished
by 40 percent since 1960 (Table 1).

  As a result of these changes, the population
growth rate for Latin America and the Caribbean in-
creased between 1900 and 1940, peaked just after
World War II, and leveled off at 2.8 percent per year
from 1945 to 1965. Since then, the rate of growth has
slowed; it is estimated at 2.1 percent from 1985 to 1990
(Table 1). In 1950, the total population of the region
was only slightly greater than that of the United States,
but by 1990, it was 1.8 times greater (Table 2). Al-
though the proportion of the population in Latin
America and the Caribbean under 15 years of age has
remained high (from 41 percent in 1950 to 36 percent
in 1990) compared with that of the United States (from
27 percent to 22 percent), the number of persons aged
15 or over (the main tobacco users) in Latin America
and the Caribbean increased dramatically over that in
the United States. In 1950, the population aged 15 or
over in Latin America and the Caribbean was 13 per-
cent smaller than that in the United States; in 1990, it
was 32 percent larger.

  These population shifts have created a large po-
tential market of tobacco consumers in Latin America.
Further, the trend in the birthrate ensures that a sub-
stantial number of young people will continue to enter
the market for some time to come.

Urbanization

  Although immigration and emigration have had
local effects, they have not had a large effect on the
demographic composition of the Latin American re-
gion as a whole. However, internal migration has.
Large-scale internal migration began in Latin America
in the 1930s; by the 195Os, approximately one-third of
the population of the region resided in urban areas,
and by 1980, two-thirds of the total population was
urban (Table 3).' In countries where economic growth
began early (Argentina, Brazil, Chile, Colombia, Cuba,
Mexico, Uruguay, and Venezuela), approximately 70
percent of the population is concentrated in urban
areas, but Haiti, Bolivia, and several Central American
countries, such as Honduras, Guatemala, and El Sal-
vador, remain primarily rural.

  The urban lifestyle-which includes social dif-
ferentiation, division of labor, greater availability of
community services, and greater access to popular
goods-has generally characterized Latin American
life in the last several decades. Nationwide television
networks and an upgraded network of roads link
regions and consolidate markets for goods, services,
and labor nationwide (Wilkie 1984). Features of urban
life are now more available in rural areas as well.

' The definition of an urban area differs from countrv to
country. When a uniform definition is used-population
centers with more than 20,000 inhabitants-the propor-
tion is considerably smaller, although the trend remains
the same.

62  Prevalence and Mortality


Table 3. Percentage of population living in urban centers, by country in Latin America,* 1950-1980
            Census definition of urban area+        20,000 or more inhabitants

Country              -
Argentina
Bolivia
Brazil
Chile
Colombia
Costa Rica
Cuba
Dominican Republic
Ecuador
El Salvador
Guatemala
Haiti
Honduras
Mexico
Nicaragua
Panama
Paraguay
Peru
Uruguay
Venezuela

Total

1950     1960

62      74
35      24
36      46
60      68
39      53
33      35
51      55
24      30
28      36
36      39
25      34
12      15
18      23
43      51
35       41
36      42
35      36
41      47
57       72
35      63

37      44

1970     1980

78      83
38      45
56      67
75      81
57      64
39      43
60      68
39      50
40      47
39      43
34      37
20      24
28      35
59      66
47      51
47      50
37      42
58      64
82      85
72      79

58      65

1960     1970

59      66
23      27
27      36
51      61
34      44
19      26
39      43
19      30
27      33
18      21
15      16
10      13
11      18
29      35
20      31
33      39
22      27
27      39
60      63
47      59

32      40

1980

70
34
46
68
54
30
48
41
40
25
19
17
24
43
37
41
32
47
66
67

47

Source: Wilkie and Ochoa (1989); Centro Latinoamericano de Demografia (1990).
*Excludes Belize and Puerto Rico.
`Differs by country.

  The trend toward urbanization in Latin America
has concentrated and consolidated the market for to-
bacco products, as it has for most other consumer
items. The techniques of demand creation (described
in Chapter 2) largely depend on an easily reachable
mass audience-an audience which in Latin America
has demonstrated persistent relative and absolute growth.

Educational Opportunities
  As a by-product of urbanization, access to edu-
cation in Latin America has increased substantially in
recent decades. Only 58 percent of the total population
aged 6 to 11 years was enrolled in primary schools in
1960 (Table 4). By 1987, this enrollment had increased
to 86 percent. Since 1970, enrollment in secondary

Table 4. Percentage of population in Latin America and the Caribbean enrolled in school, by age group
     and sex, 1960-1987

Year

   6-11 years         12-17 years
Total Males Females  Total Males Females

1960   57.7   58.1    57.4    36.3   38.7    33.9     5.7 7.1     4.3    36.9   38.2   35.5
1970    71.0   70.7    71.3    49.8   52.1    47.5    11.6   13.6     9.7    48.3   49.5    47.1
1975    76.3   76.4    76.1    58.0   59.8    56.1    18.9   21.0    16.8    54.3   55.6   52.9
1980    82.4   82.8    81.9    62.6   63.6    61.6    23.6   25.1    22.0    58.8   59.8    57.7
1985   85.2   85.8    84.7    66.2   67.3    65.1    23.8   24.8    22.8    60.4   61.2   59.4
1986   85.9    86.6    85.3    66.7   67.8    65.6    24.2   24.9    23.5    60.8   61.7   60.0
1987   86.3    86.9    85.7    68.2   69.2    67.2    25.1   25.8    24.4    61.8   62.6    60.9

18-23 vears

Total Males Females

   6-23 years
Total Males Females

Source: United Nations Educational, Scientific, and Cultural Organization (1989)


schools has also increased significantly, and the num-
ber of university students has dramatically increased
as well-from 500,000 in 1960 to 6 million in 1990
(Brunner 1990). Women continue to have somewhat
less access to education than do men, but since 1960,
gains in enrollment have been equivalent for both
sexes (Table 4).

  The gains in education have brought a more
literate and more discriminating group of consumers
to the marketplace. The net effect may be complex-
although sophisticated consumers may be more ex-
posed to tobacco marketing techniques and are more
likely to have disposable income for tobacco products,
they may also have better knowledge of the adverse
health effects of tobacco use. Data on smoking preva-
lence and educational status are ambiguous (see
"Prevalence Estimates" later in this chapter).

Income Distribution and the Labor Force

  In Latin America between 1950 and 1980, the
agricultural sector of the labor force declined, but both
the trade sector and the manufacturing sector in-
creased (4.5 percent and 3.3 percent per year, respec-
tively) (Economic Commission for Latin America and
the Caribbean [ECLACI 1989). In urban areas, more
than one-third of the total labor force is employed in
these two sectors. A study of occupational stratifica-
tion in six countries found a large increase in non-
manual employment (De Oliveira and Roberts 1989).
But despite an apparent increase in the size of the
middle class in Latin America, theunevenness of income
distribution still exceeds that of the United States

(Table 5). In 1975, high-income groups in Latin Amer-
ica accounted for a larger percentage of total income
than did the corresponding groups in the United
States. Conversely, the lowest income group ac-
counted for a much smaller percentage of total income
in Latin America than in the United States (7.7 vs. 17.2
percent, respectively). Perhaps more important, how-
ever, the average income of the lowest income group
in Latin America was one-tenth that of the lowest
income group in the United States. These income
disparities have persisted into the mid-1980s. For se-
lected Latin American and Caribbean countries for
which data are available (Table 61, the concentration
of income in the upper 20 percent of households is
substantially greater than for North America.

   A critical socioeconomic factor has been the in-
creasing entry of women into the labor force. Among
developing nations worldwide during the 196Os, the
highest percentage of female nonagricultural wage
earners was found in Latin America (Anker and Hein
1987). Between 1970 and 1980, the size of the female
labor force increased at twice the rate of that of the
male labor force (5.1 vs. 2.5 percent, respectively)
(ECLAC 1989).

  The main sociodemographic effect of changes in
the labor force has been the creation of a group of
middle-income wage earners with increased dispos-
able income, a group in which women figure promi-
nently. Such a consumer group is of interest to the
tobacco industry because it may serve as a focus for
creation of demand for tobacco (Ernster 1983).

Table 5.  Income distribution in Latin America* and the United States, 1960 and 1975
                                               ~- __.~~ -~ ~~~~ ~~~ _~

                  Percentage of total income     Annual income per family+
Income bracket                  1960        1975              1960        1975

Latin America
10% richest                   46.6         47.3           11,142      15,829
20% below the richest 10%          26.1         26.9            3,110       4,497
30% below the richest 10%          35.4        36.0            2,542       3,636
60% poorest                   18.0         16.7               833       1,095
40% poorest                   8.7         7.7              520         6-18

United States
10% richest                   28.6        28.3           15,538      21,488
20% below the richest 10%          26.7         26.9           13,490      17,807
30% below the richest 10%         36.7        36.9           11,577      15,891
60% poorest                  34.8        34.8            6,099       8,276
40% poorest                  17.0        17.2            4,976       6,635

Source: Portes (1984).
*Excludes Belize, Cuba, and Puerto Rico.
`In 1970 U.S. dollars.

64  Prevalence and Mortality


Table 6.  Income distribution in selected countries of the Americas

Country

Year

   Percentage of household income (by percentile group)
Lowest    Second    Third    Fourth   Highest   Highest
quintile   quintile    ouintile   auintile   auintile     10%

Brazil             1983
Canada         1987
Colombia           1988
Costa Rica       1986*
Jamaica        1988+
Peru        1985-1986+
United States      1985*
Venezuela          1987

Source:  The World Bank (1991).
Based on per capita income.
`Based on per capita expenditure.

2.4       5.7
5.7      11.8
4.0       8.7
3.3       8.3
5.4       9.9
4.4       8.5
4.7      11.0
4.7       9.2

1

10.7      22.8      62.6
17.7      24.6      40.2
13.5      20.8      53.0
13.2      20.7      54.5
14.4      21.2      49.2
13.7      21.5      51.9
17.4      25.0      41.9
14.0      21.5      50.6

46.2
24.1
37.1
38.8
33.4
35.8
25.0
34.2

   The four main factors discussed here have all
affected prevalence of smoking in Latin America,
which is summarized below. The economic signifi-
cance of these sociodemographic changes is discussed
further in Chapter 4 (see "Economics of the Tobacco
Industry").

Prevalence Estimates

  Systematic surveillance of smoking prevalence
has generally not been conducted for most regions of
Latin America. Consistent time series and uniform
methods of data collection are just now being devel-
oped (see Chapter 6). Available information on prev-
alence is primarily derived from the following
sources: an eight-city survey conducted by the Pan
American Health Organization (PAHO) in 1971 (Joly

1977); a set of surveys conducted by the Gallup Orga-
nization for the American Cancer Society in 1988 (Gal-
lup Organization 1988); and a set of reproductive
health surveys conducted by local public sector or
private sector agencies, principally sponsored by the
U.S. Agency for International Development, with
technical as&stance provided by the Centers for Dis-
ease Control (CDC). Prevalence data from additional
surveys (Tables 16-19) have been compiled by PAHO
and are available in a companion document to this
report (PAHO 1992). Very few of the almost 150 sur-
veys compiled have been formally published, and
they differ widely by sampling strategy, target popu-
lation, method of weighting and adjustment, and re-
porting format. Definitions of various categories of
smokers also differ across studies (e.g., heavy vs. light,

Table 7.  Prevalence of cigarette smoking (%) among persons aged 1.574 in eight cities* in Latin America,
   adjusted for age and sex,+ 1971                                                        --

                         Total                Men              Women

                    Current    Former     Current    Former     Current    Former
City                  smoker    smoker     smoker    smoker     smoker    smoker

La Plata, Argentina            40        8         58       13         26        5
Sso Paulo, Brazil             37        4         54        10         26        3
BogotA, Colombia             36        7         52        7         24        3
Caracas, Venezuela           36        8         49                  21        2
Santiago, Chile              35        5         47   1;         20        4
Mexico City, Mexico           30        5         45        8         17        3
Guatemala City, Guatemala      22        6         36        11         10        9
Lima, Peru                 21        4         34        7          7        1
Source: Joly (1977).
+In order of prevalence ot current smokers.
Adjusted by the direct method, based on the age distribution of respondents.


regular vs. occasional, and current vs. former). Most
surveys provide crude prevalence for the group exam-
ined (number of smokers divided by number of per-
sons surveyed), and some surveys report results by
age, sex, ethnic group, residence, and occupation.
Comparison of prevalence by country or by group
within countries is problematic, and the only sum-
mary statistics are ranges, distributions, and medians.

Prevalence Reported by the Pan American Health
Organization

by using the combined total population of the eight
cities as the standard. The age-adjusted prevalence of
smoking ranged from 21 to 40 percent. For men, it
ranged from 34 to 58 percent (median = 48 percent),
and for women, from 7 to 26 percent (median = 21
percent). The prevalence for U.S. males and females
at the time was 44 percent and 30 percent, respectively;
however, the figures are not directly comparable to
those of the PAHO survey because of methodologic
differences (U.S. Department of Health and Human
Services [USDHHSI 1989).

  The 1971 PAHO survey reported prevalence of     Most smokers (98 percent) reported that they
cigarette smoking for persons in eight major cities of   smoked cigarettes rather than cigars or pipes (Joly
Latin America (Table 7). Estimates were age-adjusted   19771, and most of them (71 percent of men and 79

Table 8.  Standardized ratio* of cigarette smoking among persons aged 15-74 in eight cities of Latin America,
    by sex and level of education, 1971

No

Men
Second- Post-

Primarv arv

Women
  Second- Post-

secondary
school

  No
schooling Primary ary
   school  school

secondary
school

City       schooling school school

Bogota, Colombia
Current smoker
Former smoker

Caracas, Venezuela
Current smoker
Former smoker

Guatemala City, Guatemala
Current smoker
Former smoker

La Rata, Argentina
Current smoker
Former smoker

Lima, Peru
Current smoker
Former smoker

Mexico City, Mexico
Current smoker
Former smoker

Santiago, Chile
Current smoker
Former smoker

SBo Paulo, Brazil
Current smoker
Former smoker

All eight cities
Current smoker
Former smoker

0.9      1.0    1.0     1.0         0.7     0.8    1.2     2.0
0.8      1.2    0.8     1.0          1.4      1.2    0.9     2.0

1.1      1.1     0.9     0.9         1.4      1.1    0.9     1.1
-     0.8    1.1     1.8         1.4     0.7     1.1     1.0

1.6     0.9    0.9     1.1         0.6     0.7     1.7     2.3
1.1      0.9     1.1     1.0          1.1      0.8    0.8     1.8

0.8      1.1     1.0     1.0
1.6      1.1     0.9     1.2

0.7

0.7     1.2     1.4
0.6     1.2     1.9

1.6

0.8    1.0     1.4
1.3    0.8     0.7

0.5

0.6     1.4     2.1
1.1     1.2     1.1

1.4      1.1     1.0     1.1         0.7     0.8    1.0     1.6
-      1.1    0.9     1.5         1.4      1.1    0.8     0.7

0.9     0.8     1.1     1.1         0.7     0.8
0.2      1.1     1.1     1.2         0.6     0.8

1.5
2.5

0.8
1.5

1.0
1.0

1.1
1.0

1.1     0.9         1.2      1.1
0.6     1.3         1.3     0.9

1.1
1.1

0.9
0.5

1.2
1.1

2.0
0.9

1.1
0.7

1.0     1.1         0.8     0.8
0.9     1.2         0.9     0.8

1.6
1.6

Source: Joly (1977).
Each entry represents the age-adjusted rate for the subgroup divided by that for the total sample. Educational categories
are assumed to have the same age distributions within each sex group.

66  Prevalence and Mortality


Table 9. Prevalence of smoking (%) in 12 Latin American countries, 1988

                 Total                  Men                 Women

           Current       Former      Current    Former      Current      Former
Country       smoker      smoker      smoker      smoker      smoker      smoker

Chile           39          14          41          17         31          11
Uruguay        32          16         44          25         23           9
Colombia        28          16         37          21         18           11
Costa Rica        28          16         35          23         20          10
Peru           22          12         28          19         17           6
Brazil          38          12         40          18         36           6
Ecuador         27           7         39          10         16           5
Mexico          27          10         37          13         17           6
Argentina        35          17         43          25         27           9
Honduras        24          15         36          19         11          12
El Salvador       25           8         38          10         12           5
Venezuela        27          15         32          21          23           11

Source: Gallup Organization (1988).

percent of women) preferred light-tobacco cigarettes
(Joly 1977). The percentage of smokers who smoked
light-tobacco cigarettes was greater among persons
with at least a high school education-from 54 to 77
percent for men and from 58 to 89 percent for women.
Preference for dark tobacco was much greater among
older (55 to 74 years) than among younger (15 to 24
years) persons (40 vs. 14 percent).

  Although all cities reported a lower prevalence
of smoking for women than for men, the difference
was less for areas in which overall consumption was
higher. For example, in La Plata, Argentina, and Ca-
racas, Venezuela, the prevalence of smoking for
women was approximately half that for men. How-
ever, in Lima, Peru, the prevalence of smoking for
women was one-fifth that for men. Furthermore, in
almost all sample populations, the age-adjusted prev-
alence of cigarette smoking increased with educa-
tional level for women but not for men (Table 8). In
most areas, the prevalence of smoking for women
with postsecondary school education was about two
times higher than that for women with no schooling-
evidence that education may have served demand
creation rather than hazard recognition. However,
the incidence of quitting was also greater among
better-educated women than among better-educated
men; thus, several factors may have been operating
simultaneously.

  In 1971, the proportion of heavy smokers (de-
fined as persons who smoke 20 or more cigarettes per
day) was greater for men (29 percent) than for women
(15 percent). In addition, more men than women

began smoking before age 16 (33 percent and 23 per-
cent of those who smoke, respectively). Imitation of
friends and companions was the reason adolescents
most often gave for starting to smoke.

Prevalence Reported by the Gallup Organization

  The only other multicountry survey was con-
ducted by the Gallup Organization in 12 countries in
1988 (Tables 9,16-18). Unfortunately, the methods of
the 1988 Gallup survey and the 1971 PAHO survey
differed substantially. The sampling frame and meth-
odology were not reported in detail for the Gallup
survey, although some weighting scheme was used,
and prevalence was not age-adjusted. Only seven
countries were in both surveys. The 1971 PAHO sur-
vey focused exclusively on urban areas; the 1988 Gal-
lup survey concentrated on urban areas but included
rural areas as well. The accuracy and precision of the
Gallup survey are difficult to judge, and direct com-
parisons with the PAHO survey may be misleading.
For example, data from the Gallup survey suggest that
the overall prevalence of smoking decreased in the
seven countries included in both surveys (Tables 7 and
9), but results from other surveys (Tables 16-18) are
not consistent with these findings.

  Comparisons within each survey may be legiti-
mate, although they must still be interpreted with
caution. In the 1988 Gallup survey, the overall preva-
lence of smoking was higher in countries that under-
went early modernization, such as Chile (39 percent),
Brazil (38 percent), Argentina (35 percent), and Uru-
guay (32 percent). Overall prevalence was lower in

Prezwleme nnd Morfalify   67


Table 10.  Male-to-female ratio of smoking
    prevalence in seven Latin American
     countries, 1971 and 1988

Country           1971         1988

Argentina          2.4          1.6
Brazil             2.7          1.1
Chile             1.8          1.3
Colombia          2.5          2.1
Mexico            2.7          2.2
Peru             5.3          1.6
Venezuela          1.8          1.4

Source: Joly (1977); Gallup Organization (1988).

less economically developed countries, such as Peru
(22 percent), Honduras (24 percent), and El Salvador
(25 percent). In both surveys, a higher proportion of
men than women were heavy smokers, although the
definition of heavy smoking appears to differ between
the two surveys. The difference in prevalence by sex
has decreased substantially (Table 10). In several
countries (particularly Brazil and Chile), almost as
many women as men are smokers.

Prevalence Reported by Reproductive Health
Surveys

  Since the late 197Os, CDC, in collaboration with
national investigators, has surveyed reproductive
health practices of women in Latin America. Most of
these household surveys have asked questions about
smoking. Additional household surveys of young
adults (men and women aged 15 to 24 years) have also
asked about smoking practices. These surveys pro-
duced weighted prevalence estimates representative
of the area studied. The overall results have not been
age-adjusted, but age-specific results are directly com-
parable. These surveys are discussed together be-
cause of the general uniformity of the methods used;
other surveys of women of reproductive age are dis-
cussed later in this section.

  Among women of childbearing age, the prevalence
of smoking in the late 1980s varied from 6 to 33 percent
in the areas studied (Table 11). Again, because of
differences in data collection, direct comparisons cannot
be made with earlier work, but the data at least suggest
that the prevalence of smoking among women in S~O
Paulo, Brazil, may have increased-the prevalence for
women aged 15 to 44 was somewhat higher in 1986 (31
percent) than that for women aged 15 to 74 in 1971 (26
percent), although lack of methodologic detail pre-
vents formal testing. In contrast, the prevalence of

68  Prevalence and Morfalify

smoking for women in Guatemala may have declined
during that period.

  Surveys of young adults, conducted in selected
Latin American countries in the late 1980s (Table 12),
suggest that the smoking initiation rate (also referred
to as the rate of smoking uptake) is high in at least
some areas. Uptake of smoking is higher in the more-
developed countries, although probably in urban
areas only. In several countries surveyed (Guatemala,
Jamaica, and Costa Rica), prevalence of smoking
among young women is low. The increased tendency
to smoke among women in urbanized areas is also
evident in Brazil (Table 121, where women in the more
urbanized southern areas have almost twice the prev-
alence of smoking as do women in the northeast.

  Results from the 1988 survey of young adults in
Chile (Valenzuela, Herold, Morris 1989) illustrate
some important patterns (Table 13). In this survey,
over 1,600 men and women aged 15 to 24 were sam-
pled, although the sample size varied for specific ques-
tions. In Santiago, 53 percent of the young men and

Area            Year
Brazil+           1986
Rio de Janeiro     1986
Siio Paul0        1986
South          1986
Northeast        1986
Guatemala3        1983
Guatemala5        1987
Costa Rica"        1986
Jamaica'          1989
Puerto Rico*        1982

U.S.-Mexico Border*'
Whites (non-
  Hispanic)       1979
Mexican-Americans 1979

Table 11.  Prevalence of smoking among women
     of reproductive age W-44 years*),
     selected areas of the Americas, 1979-1989

Sample Prevalence
size     (%`c)

5,892     30.6
749     33.0
769     30.8
846     32.2
1,792     29.6

3,670      6.6

5,160      4.0

3,277     12.4

6,112      6.2

2,861     15.6

798     31.6
1,235      18.5

`Age group 1549 years for women in Costa Rica and Jamaica.
`All values for Brazil are from Centers for Disease Control
(CDC) (1986).
tAnderson (1985).
kDC (1987a).
"Asociaci6n Demogr6fica Costarricense and CDC (1987).
_McFarlane and Warren (1989).
**Smith, Warren, Garcia-Nwiez (1983).


Table 12.  Prevalence of smoking among persons aged 15-24, selected countries of the Americas,
       1986-1990

Country and city        Year

       Men                    Women
Sample size  Prevalence (%)    Sample size  Prevalence (%)

Brazil*              1986
Salvador+           1987
SBO Pauloj          1988
Curitiba_           1989
Rio de Janeiro5        1989
Recife_             1989
Chile (Santiago)"        1988
Costa Rica'            1990
Guatemala**           1987
Jamaica tt             1989

*Centers for Disease Control (CDC) (1986).
`Sakamoto, Freire, Morris (1991).
*Universidade Federal da Bahia and CDC (1989).
%DC (1990a).

!Valenzuela, Herold, Morris (1989).
:,CDC (1990b).
,,CDC (1987a).

' `National Family Planning Board and CDC (1988)

-             -          2,479
871         13.9            956
750         33.7            804
950         24.4            913
848        22.5            831
1,154        23.9            989

800         53.3            865

1,405        23.7          1,582

-                   2,204

-                   2,605
.~.

41 percent of the young women were current smokers,
and prevalence of smoking increased with age. For
younger people (in these data, persons 15 to 17 years
old), the prevalence of smoking approximates the rate
of smoking initiation. In Santiago, the initiation rate
was 46 percent for men and 34 percent for women. By
ages 22 to 24, more than half of both sexes were current
smokers, and 22 percent of both sexes stated that they
were former smokers. The vast majority of both men

27.3
14.1
26.2
22.0
22.0
12.0

41.0

5.4

2.5

2.6

and women were light smokers: 78 percent of men
and 89 percent of women smoked less than 10
cigarettes per day. The proportion of heavy smokers
increased with age.

  With regard to educational attainment and
smoking, the 1988 results from Santiago are consistent
with those of the PAHO survey of 1971. A greater
percentage of educated women were smokers (46 per-
cent of women with superior education and 42 percent

Table 13.  Prevalence of smoking and cluantitv smoked among; persons aged 15-24, Santiago, Chile, 1988

Group

Women

Total       15-17       18-19       20-21       22-24

Current smoker
Former smoker

Less than one-half pack per day
One-half pack or more per day

41.0
22.7

88.5
11.3

33.9       44.0       36.0       52.1
24.1        20.7       23.8       21.6

93.0       89.4       83.1       86.5
6.0       10.6       17.0       13.5

Men

Current smoker                53.3       46.0       60.1        55.2       56.2
Former smoker                 22.3       25.4        19.0       20.8       21.9

Less than one-half pack per day
One-half pack or more per day
Source:  Valenzuela, Herold, Morris (1989).

78.2       85.6       75.5       76.5        73.7
21.8        14.4       24.5       23.5       26.3

PrezTaleuce and Mortality   69


Table 14. Prevalence of smoking and quantity smoked among persons aged 15-24, by educational level

and sex, Santiago, ChGe, 198h

Group

Women

Current smoker
Former smoker

Less than one-half pack per day
One-half pack or more per day

41.5
24.6

90.1
9.9

Men

Current smoker                 56.7
Former smoker                 23.6

Less than one-half pack per day       79.8
One-half pack or more uer dav        20.2

Source:  Valenzuela, Herold, Morris (1989).
*l-8 years.
+9-l 2 years.
b12 years.

Basic*
or less

of women with basic education or less), but the reverse
was true for men (47 percent vs. 57 percent for the
corresponding educational levels) (Table 14). Women
with greater educational attainment also tended to
smoke more (one-third smoked more than 10 ciga-
rettes per day). The prevalence of smoking as a func-
tion of the educational level of the father of the
respondent followed the pattern for the educational
level of the respondent.

  History of pregnancy appeared to have little ef-
fect on the prevalence of smoking among women in
Santiago (Table 15). On the contrary, prevalence of
smoking was slightly higher for women who had been
pregnant (43 percent) or who had given birth (47
percent) than for women who had never been preg-
nant or had never given birth (around 40 percent for
both groups). Since the data are not age-adjusted, this
difference may result from the generally lower age
distribution of women who have never been pregnant.
The data suggest that pregnancy has little influence on
the smoking habits of the population studied.

  The data from Chile are not necessarily general-
izable to Latin America as a whole, but they support
the supposition that smoking is common among
young people in some of the more-developed coun-
tries and that the quantity smoked is not great. Al-
though the results do not permit the calculation of a
single estimate of the prevalence of smoking among
young people in Latin America, they do suggest that

   Educational level
Middle+       Middle
(incomplete)    (complete)

Superior*

38.4         42.3          46.4
22.4          22.6          20.6

91.8          92.4          66.7
7.5          7.6         33.3

55.0         52.3         46.5
22.4         22.7         19.3

81.4          77.9          66.0
18.6          22.1          34.0

prevalence varies by level of socioeconomic develop-
ment and that prevalence may be over 50 percent in
some areas.

Additional Prevalence Estimates Reported Since 1980

  PAHO has assembled prevalence data, as well as
some information on knowledge and attitudes, from
country-specific surveys (Tables 16-19). Most of these
surveys report a crude prevalence for the population
studied, and as noted, the methodologies of these
surveys differ substantially.

  Theoverall prevalence of current smoking varies
widely in Latin America and the Caribbean-from 6

Table 15.  Prevalence of smoking (%I among women
    aged 15-44, by reproductive history and
    smoking status, Santiago, Chile, 1988   -

              Pre nant
        P          At least
Smoking    Never  at east No live one live
status    pregnant once   births   birth

Current
smoker

40.3    43.3     39.6    46.6

Former
smoker

22.4    23.3    23.0    21.4

Never
smoker

37.3     33.3    37.4    32.0

Source:  Valenzuela, Herold, Morris (1989).

70  Prevalence and Mortality


percent in rural La Paz, Bolivia, to 49 percent in Port0
Alegre, Brazil. Prevalence of smoking is higher for
men than for women. The distribution of results
(Table 20) from the surveys of adults (Table 16)--dis-
played as a stem-and-leaf plot (Tukey 19771-reveals
that the prevalence for men is centered in the 30 to 49
percent range (median = 37 percent); 74 percent of
observations were greater than 30 percent. For
women, most results were in the 10 to 29 percent range
(median = 20 percent); 24 percent of observations were
greater than 30 percent. Most reports of low preva-
lence for women were from less-developed, predom-
inantly rural areas. A similar rural-urban gradient
was also found for men.

  In general, crude prevalence was highest in the
Andean region, the Southern Cone, and Brazil (Table
16). Prevalence tended to be intermediate in Central
America, Mexico, and the Latin Caribbean and lowest
in the other Caribbean countries (Table 16). Lifetime
prevalence (51 percent) was reported for men in Ja-
maica. For Trinidad and Tobago, a 42 percent preva-
lence is given for men in a single urban area. The
available information suggests that for male, urban
dwellers in the more-developed countries of Latin
America and the Caribbean, the prevalence of smok-
ing exceeds 50 percent; for rural women in less-
developed countries, the prevalence is less than 10
percent. The data do not permit calculation of a single
estimate of the prevalence of smoking in the region,
since no unified, planned prevalence survey of the
region has been attempted.

  Cigarette smoking was also common among
physicians. The range for the 11 studies that reported
prevalence among medical students, physicians in
training (residents or house staff), and physicians was
17 to 49 percent (Table 16).

  Prevalence of smoking for adolescents appears
to follow a pattern similar to that for adults (Table 17).
Prevalence is higher for young men than for young
women and higher in urban areas of the more-
developed countries. The regional pattern is also similar,
except that smoking among young people appears to
be more common in the non-Latin Caribbean than in
Central America, Mexico, and the Latin Caribbean.
The prevalence of smoking for adolescents is high in
some areas-perhaps even higher than the prevalence
for adults. A prevalence of greater than 30 percent is
reported by almost half of the surveys for young men
and almost one-third of the surveys for young women.

  Surveys of women of childbearing age have been
conducted in some Latin American and Caribbean
countries (Table 18). The results generally confirm
those cited earlier (also included, in part, in Table 18).

The prevalence of smoking varies considerably; 25
percent of surveys reported a prevalence over 30 per-
cent, and more than half reported a prevalence greater
than 20 percent. Since women of reproductive age
span the adolescent and adult years, younger women
may disproportionately contribute to the high overall
prevalence of smoking in some areas.

  The few studies available about public knowl-
edge and attitudes with regard to smoking suggest a
high level of awareness of the general health hazards
of tobacco use (Table 19). One study in Cuba indicated
a high level of public approval for an indoor ban on
smoking. In contrast, a survey among physicians in
Paraguay showed that only 30 percent agreed with the
statement that smoking is undesirable. Information
on public awareness of the specific health risks of
smoking and on the degree to which smokers perceive
a personal risk is not available for Latin America and
the Caribbean; data for the United States, however,
have been considered in detail (USDHHS 1989). Col-
lection of such information for Latin America and the
Caribbean will be important to enhancing tobacco
control in those regions (see Chapter 6).

  Another aspect of the prevalence of smoking in
the Americas is smoking patterns among Hispanic
persons who reside in the United States. A large prob-
ability survey of Hispanic Americans (Hispanic
Health and Nutrition Examination Survey [Hispanic
HANES]), conducted in 1982 to 1984, revealed that, for
both men and women, the pattern of smoking differs
among persons of Mexican origin in the southwest
United States, persons of Puerto Rican origin in the
New York City area, and persons of Cuban origin in
the Miami area. For all three groups, the weighted
prevalence of cigarette smoking was higher for men
than for women (Table 21). But persons of Puerto
Rican or Cuban origin were more likely than persons
of Mexican origin to be heavy smokers (Haynes et al.
1990). Compared with the prevalence of smoking for
the general U.S. population WSDHHS 19891, the prev-
alence of smoking was higher for men of all three
Hispanic groups and for women of one group (Puerto
Rican origin).

  The Hispanic HANES survey of 1982 to 1984 also
showed that with decreasing income and educational
attainment, the prevalence of smoking increases
among Hispanic men (Haynes et al. 1990). In addition,
for women of Puerto Rican origin residing in the New
York City area, the prevalence of cigarette smoking is
approximately twice that of women in Puerto Rico
(Becerra and Smith 1988).

  Approximately five years after the Hispanic
HANES survey, the National Health Interview Survey


(NHIS) revealed that the prevalence of smoking for all
these groups had declined substantially, parallel with
the decline in prevalence in the general U.S. population
(Table 21) (Schoenboml989). Detailed analysis of prev-
alence of cigarette smoking among successive birth
cohorts, however, shows little reduction for women of
Mexican origin and an increase for women of Puerto
Rican or Cuban origin (Escobedo, Remington, Anda
1989).

  Direct comparison with data for populations in
the areas of origin is not possible (Table 16) because of

differences in sampling methods, but thedata suggest
that some trends for Hispanic persons residing in the
United States may be the same as those for the general
U.S. population (Escobedo, Remington, Anda 1989;
Escobedo et al. 1990; Harris 1983). Although preva-
lence of smoking has declined among Hispanic men
and women, uptake of smoking is increasing among
young Hispanic women. In general, persons of His-
panic origin in the United States reflect a mixture of
the cultural forces in Latin America and North America.

Table 16. Prevalence of tobacco use among adults reported by surveys in Latin America
     and the Caribbean, 1980s and 1990s

Re ion
%                     Survey
an Country   Year    Sample area  Number Age

                         I

Andean Area
Bolivia     1983   La Paz          945
          1986   Sucre         1,028

          1986   Rural La Paz     1,060

         1986   Urban La Paz    1,058

          1987  Physicians in La Paz   72

215
215

215

215

Colombia

1980   Nationwide     6,277

1985  Medellin (excludes 2,432
    persons of low
      socioeconomic
     status)
1987   Urban areas     2,400

1988   Nationwide     1,512

Ecuador

1988 Quito, Guayaquil, 3,657
     and three rural
    capitals
1988   Urban areas     1,323

215

216

216

Sponsor

Bolivian Cancer Foundation
Department of Mental
Health
Department of Mental
Health
Department of Mental
Health
Osorovic and
Rios-Dalenz

National Institute of
Health
University of Antioquia

Public Health School
Drug Survey

18-60+ American Cancer
    Society/Gallup
    Organization

20-65  Ministry of Public Health,
     Our Youth Foundation

Peru

1990 Quito         1,805

1980   Households in    2,167
     Lima/Callao
1985   Male firearm      359
     licensees in Lima

13-60+ American Cancer
   Society/Gallup
    Organization
210   Ministry of Public Health
12-45 Police Force, Antidrug
      Unit
18-70 Police Force, Antidrug
      Unit

Source:  Pan American Health Organization (1992).
*Given for current daily smokers/occasional smokers, or for the former only.
+Smoked during the previous year.

Prevalence* (% 1

Men Women Total
         ____-

41/37 32/33 36/35
35 18   28/41

6     3    6/48

46/38 29/33 38/36

       35/17

52 26 39

      30+

43 25 34+

37 18 28

27127 11/20 22/24

39 16 27

        23/27

49/14 23/11 36/13

36/23

72  Prevalence and Mortality


Table 16. Continued

Region

Survey

a&I Country   Year   Sample area   Number

Peru
(contd.)

1987   Lima         1,800

1988   Urban areas       400

1989

Towns >2,500
population

6,761

Venezuela

1984   Nationwide
1986   Caracas
1988   Urban areas

          1989

Southern Cone
Argentina   1981
          1988

Caracas

1988

Buenos Aires      306
Buenos Aires      128
pediatric hospital
staff
Urban areas       826

Chile

1984
1985
1987

Paraguay   1988

1989

1989

Uruguay

1984
1985

1988

1989

852

400

Santiago       1,050
Twelve cities     2,700
Three communities 1,800
near Santiago

Medical students    375
and doctors at
Catholic Univer-
sity Medical School
Less than one-half   394
of all medical
students
Physicians        837
nationwide

Montevideo       396
Ministry of Public   525
Health employees
Urban areas       799

Fourth-year medical
students in
Montevideo

Age       Sponsor
~~____
15-50 Peruvian Public
    Opinion
18-35+ American Cancer
    Society/Gallup
    Organization
12-50 Information Center,
      Education for the
    Prevention of Drug
      Abuse

Prevalence* (7r)

Men Women Total

68    40

28    17

22

42    13  26$

   Ministry of Health
   Ministry of Health
18-64 American Cancer
   Society/Gallup
    Organization
   Ministry of Health

32    23

38
42
27

36

15-74 Alvarez              39    27
20-55 Pediatric Hospital       48    49

18-50+ American Cancer
    Society/Gallup
    Organization

>15   Public Health School
>I5   Gallup Chile
>15  Catholic University
    Department of
     Public Health

43    27

33

35

34/10

35/16

28/11 30/11
    31
32/11 33/13

Estigarribia           25    24 25

16-36 Martinez             18    14 17

20-80 Chaparro

218   Prevention Volunteers
218   Epidemiology Division,
    Ministry of Health
18-50+ American Cancer
    Society/Gallup
    Organization
22-26 Ruocco

35

49/9
45

44

24 32

31/14 40/12
45 45

23 32

24

`Given for current daily smokers/occasional smokers, or for the former only.
ISmoked during the previous month.


Table 16. Continued

Region

Survev

ana Country   Year

Brazil

1981

1982
1987
1987
1988
1988
1989

Sample area   Number

Physicians in Port0
Alegre
Medical association
P&to Alegre
Siio Paul0
Two state capitals  1,297
Twelve state capitals
Physicians in Rio de
Janeiro

Central America5
Costa Rica   1986

          1987

          1988

Households
nationwide
Nationwide

Nationwide

35,000

2,700

1,213

El Salvador 1988  Nationwide, urban 1,300

Guatemala   1982
        1987

1989
1989

Guatemala City   2,403
University of San    170
Carlos students
and teachers
Urban areas     7,372
Finance Office     350
employees

Honduras

1987

1988

Ministry of Health   293
employees
Urban areas     1,200

Nicaragua

Panama

1988

1983
1986

1989

Employed persons   520

Nationwide     1,631
Health Depart-   11,385
ment employees
Health Department 100
pensioners

Mexico

1983
1986
1988
1988

1988

Physicians        495
Households     14,528
Urban areas     12,581
National Respira-
tory Institute
employees
Urban areas     2,600

                -
`Given for current daily smokers.
SExcludes Belize.

49      Sponsor

    Saltz et al.

20-64 Achutti
15-59 Ramos
18-50+ Gallup Organization
18-55  Ministry of Health
   Campos

215   Office of Statistics

14-60 Alcohol and Drug
    Dependency Institute
18840+ American Cancer Society/
   Gallup Organization

35    14     30

33    11     22

35    20     28

18-40+ American Cancer Society/
   Gallup Organization

38    12    25

210   Drug Institute
    San Carlos Medical
     School

53    30     47
34    36     34

215

Health Department       38    18     27
Health Department       48    38     44

Ministry of Health

18840+ American Cancer Society/
   Gallup Organization

~18   Mount Sinai Medical
      Center

218

National Cancer Association
National Cancer Association

255   National Cancer Association

212   National Health Survey
12-65  Secretary of Health

15-45+ American Cancer Society/
    Gallup Organization

Prevalence* (X)

Men  Women Total

26    40

32    27
52    34
45    31
40    36
45    33
28    23

49
38
38
39

36    11

22

24

51     6     41

56    20
10     4

48    13

38
7

33

27     8
38    14
41     18

33
17
26
28

37    17     27

74  Prevalence and Mortality


Table 16. Continued

Reeion

Survev

Prevalence* (o/o)

ana Country   Year   Sample area   Number

Mexico      1989  Physicians in Mexico 818
(contd.)         City (telephone)
Latin Caribbean"
Cuba      1984   Nationwide     4,968

1988   Nationwide     5,933

Dominican  1989  Health Department  704
Republic      employees
        1989   Nationwide       502
        1991   Households in    1,392
           Santo Domingo

Puerto Rico  1989   Behaviorial Risk    772
          Factor Survey, San
          Juan (telephone)

Selected Caribbean countries

Anguilla    1989   Islandwide       101
Bahamas    1988   Areawide        933
Bahamas    1989   Areawide      1,000

Jamaica

1987  Household Council 6,007
1987   Household      1,000

Aruba and   1989
Netherlands
Antilles

Random sample of   623
population (1%)

Trinidad and 1981  St. James (Port of  2,491
Tobago       Spain)

U.S. Virgin   1989
Islands

1989

Household
Behavioral Risk
Factor Survey
(telephone)
2%' population
sample after
hurricane

141

727

49       Sponsor

    Menese et al.

217

214

Cuban Institute for
Research and
Orientation of
Internal Demand
Cuban Institute for
Research and
Orientation of
Internal Demand

Ministry of Health

20-79 Ministry of Health
15-55+ Vincent et al.

218   School of Public Health    23    11

15-74 Health Department
215   Health Department
16-59 Health Department
    Drug Survey

10/9
20
19

212
210

National Council on
Drug Abuse
Jamaican Medical
Association

51**
25

2/10 7/9
5    11
4    10

15**
6

Ministry of Health       32    13 21

35-69 State government and
      Medical Research
     Council (United
    Kingdom)

42     8   27

218   Health Department      15

Men Women Total

48    26 36

25    22 20

66   14 40%
36    33 35

9    12

   11

23

42

*Given for current daily smokers/occasional smokers, or for the former only.
"Excludes Haiti.
IDefinition of smoking status unavailable.
**Smoked during lifetime.

Preaaltwe and Mortality   7.5


Table 17.  Prevalence of tobacco use among adolescents reported by surveys in Latin America
     and the Caribbean, 1980s and 1990s

Prevalence* (%I
  -.____-

Re ion
%                     Survey
an Countrv   Year    Sample area  Number Age       Sponsor

Men  Women Total

51
72

   42
   63
43 44
61

5

30+
4  5+
16+

6+

10/22+

15

15 15+
   16

44

41

   64
90

34
71

14
3

69    65 67
37    28 34

51

33
50

75"

32
45

13/15

11 11
16 /
20$
16+

27t

Andean Area
Bolivia     1980
          1983
          1983
          1986

La Paz        18,956
Tarija           120
La Paz          707
La Paz        1,359

Medellin
Urban areas       400
Cab, private school  283

14-22  Committee on Drugs
18    Bolivian Cancer Foundation
13-18  Bolivian Cancer Foundation

Colombia

1985
1987
1985

lo-15
12-15
16-18

Public Health School

Cab, public school   512

National school   7,513

Nationwide     2,599
Nationwide       329

11-25

University of Valle
drug survey
University of Valle
drug survey
Education Ministry

10-19
13-19

Ministry of Public Health
American Cancer
Society/Gallup
Organization

Lima/Callao      419   12-19
Public school     1,311   <18
Private school      206   <18
University      1,379   15-22

1989   Nationwide            12-19

Police Force, Antidrug Unit
Cancer Institute
Cancer Institute
University of Sacred
Heart
Drug Abuse Center

Caracas         225   12-15  Ministry of Health

1985

1989

Ecuador

1988
1988

Peru

1980
1982

1985

Venezuela   1984
Southern Cones
Argentina   1981
          1986

Buenos Aires

1,007

15-21
12-15

Chile

1981  Santiago         330   18-20
1986   Rural areas       415   18-20

Tobacco Industry

Department of Health
Universitv of
Conception
Department of Health

1986

Uruguay

1975

1980
1984
1987

Santiago         761

Montevideo    10,496
Ten high schools
P&to Alegre
P&-to Alegre
Ten state capitals

1989  Ten state capitals 42,475

18-20

12-16
17-18

10-19
10-19
lo-18
218
lo-18

Brazil

Rosito et al.
Rosito et al.
Barbosa et al.

Corlini et al.
(Psychotropic Drug
Center)

218

1989  Street boys in three
      cities
1989   Sao Paul0

Corlini et al.

6-18   Moraes et al.                 6/27

Source:  Pan American Health Organization (1992).
Given for current daily smokers/occasional smokers, or for the former only.
+Smoked during the previous year.
tEver smoked.
SExcludes Paraguay.

ISmoked during the previous month.

76  Prevalence and Mortality


Table 17. Continued

Reg;ion

Survey

akl Country   Year
Central America'

1986

Sample area   Number

Belize

National Drug
Use Survey

12,595

Costa Rica

Honduras

1984

1986

Nicaragua   1988

Panama

1984
1989

Mexico      1989

1988

1980

San Jose
Preuniversity
students

487   15-20 Calderon et al.           17    10 13

694  15-30 National University       29     4 17

High school students 468
in Managua

Nationwide     11,383
Private college      464

Secondary students 9,967

First year      88,735
university
students
Mexico City sec-   3,408
ondary students

Latin Caribbean++
Cuba      1988   Nationwide     1,067

Selected Caribbean countries
Bahamas    1987   Areawide      4,838
               Out-of-school     74
            youths
            In-school youths 4,767
Cayman    1985   Areawide      2,077
  Islands

French
Guiana

1986   Areawide

Jamaica     1987  Secondary students

Suriname

1988   Seven cities and
      rural areas

Aruba and   1988   Aruba
Netherlands
Antilles

Trinidad and 1985  All secondary
Tobago         students

U.S. Virgin 1988   Household
Islands         Behavioral Risk
          Factor Survey

`Given for current daily smokers.
`Smoked during the previous year.
*Ever smoked.
"Smoked during the previous month.

2,192

Age      Sponsor

lo-20 Pride Belize

15-18  University of Nicaragua

1 l-l 8  National Cancer Association
15-19  Department of Health

National University

Mexican Insitute of
Psychiatry

473

13-17 Consumer Institute        8     3 6

United Nations Fund
for Drug Abuse

20$

103  32$

10-l 7  Drug Advisory
      Committee

11-13

1 l-21  National Council on
    Drug Abuse

13-21                     24    12

Prevalence* (%)

Men  Women Total

12$

40    52 46

10    4 7**
3     3 6

6
42$
9+

15$
23$

2%

40   19 29$
7     3   5"

36    12

23

12 17+

1 l-19  Trinidad and Tobago
    Government Drug
    Survey

12-17 U.S. Virgin Islands

Government

_Excludes El Salvador and Guatemala.
**Smoked during the previous week.
`+Excludes Dominican Republic, Haiti, and Puerto Rico.
"SOccasional smoker.


Table 18.  Prevalence of smoking among women of childbearing age, selected Latin American
     and Caribbean countries, 1979-1987                               -

                                    Survev

1
Number    Sponsor   Prevalence (%)

Country

Argentina

Brazil

Chile

Colombia

Costa Rica

Ecuador

Guatemala

Mexico

Panama

Paraguay

Puerto Rico

Suriname

Uruguay

Venezuela

Year      Sample area

1987       Nationwide

1981        Southern Brazil          CDCS
1982        Piaui State                CDC
1982        Amazonas State             CDC
1987        Nationwide               CLAP

1983      Santiago

1987        Nationwide

1986        Nationwide

1987        Nationwide

1983        Nationwide
1987        Nationwide

1979        U.S. border

1987        Nationwide        986

1987        Nationwide      1,935

1982      Entire territory

1985        Urban areas

1987        Nationwide

1987        Nationwide        980       CLAP

4,605       CLAP*

1,480       CLAP

2,009

4,187

CLAP
EP

CDC

CLAP

CLAP

5,169

CLAP

Source:  Pan American Health Organization (1992).
`Centro Latinoamericano de Perinatologia y Desarrollo Human0 de la Organizacibn Panamericana de Salud.
%ix months before pregnancy.
*enters for Disease Control.
BBefore pregnancy/during pregnancy.

Table 19.  Public knowledge and attitudes on smoking and health in Latin America
     and the Caribbean, 1982-1990

38+

25
27
22
36
58/26_

21

12

8

7
3

19

4

7

16

26
44+

34

Country

Bolivia

Year   Sample

1983   344 daily smokers
1983   120 adolescents

1987   72 physicians

Question                Response (%I
Is smoking dangerous? (yes)             83
Is smoking harmful to health? (somewhat     96
or very)
Is smoking harmful to health? (somewhat     94
or very)

Brazil

1988   P&-to Alegre

1988   PBrto Alegre

Is the life expectancy of smokers
decreased by smoking? (yes)
Is environmental tobacco smoke harmful
to children? (yes)

48

100

78  Prevalence and Mortality


Table 19. Continued

Country

Costa Rica

Year

1984

Sample

Urban students

Cuba         1988   Nationwide

Guatemala      1989   Treasury employees

Honduras

1986

1987

Preuniversity students
aged 15-30
Ministry of Health
employees in
Tegucigalpa

Mexico

Panama        1989   Students

Paraguay

Peru

1990   Physicians

1982    Adolescents
1989    Adult smokers

Puerto Rico     1989   San Juan

Uruguay       1984    Montevideo

Venezuela

1984    Nationwide
1984    Caracas

1988    Nationwide
1988    Nationwide

1984    Nationwide

1986   Caracas
1986   Caracas

1986   Caracas

1989   Caracas

Question                  Response (X)

Are health risks associated with smoking?
(adequate knowledge of such risks)

Do you approve of a ban on indoor
smoking? (yes)

Are health risks associated with smoking?
(low level of knowledge)

Does smoking cause lung cancer and
other diseases? (yes)
Do you favor a worksite smoking
regulation? (yes)

Are you bothered by smoking at your
worksite? (yes)

Is smoking harmful to health? (yes)
Is smoking less harmful than use of other
drugs? (yes)

Are you bothered when other people
smoke? (yes)

Is smoking undesirable? (yes)

Is smoking harmful? (yes)
What is the most important reason to stop
smoking? (health)

Do you believe that smoking is harmful
to the health of smokers? (yes)

Does smoking affect health negatively?
(yes)

Is smoking harmful to health? (yes)
Should smoking be restricted in public
places? (yes)

Should all forms of tobacco advertising be
banned? (yes)

Is smoking harmful to others? (yes)
Are some cigarettes less harmful than
others? (yes)

Should smoking be restricted in public
places? (yes)

Should radio and television advertising of
tobacco be banned-including indirect
advertising? (yes)

81

98

64/56*

50

70

77

90
55

60

30

95
66

89

81

94
83

72

75/81'
53

89

60

so urce:  Pan American Health Organization (1992).
`Smokers/nonsmokers.


Table 20. Modified stem-and-leaf display of prevalence of smoking (%) among adults,
     selected countries of Latin America and the Caribbean, 1980s and 1990~~
                                                     -

Men

o-9
10-19
20-29
30-39
40-49
50-59
60-69

Women

o-9   2 3 4 4 5 6 6 8 8 9
10-19  11 11 11 11 12 13 13 13 14 14 14 14 15 16 17 17 18 18 18 18
20-29  20 20 22 23 23 23 23 24 24 25 26 26 27 27 27 28 29
30-39  30 31 31 32 32 33 33 34 36 36 38
40-49  40 40 45 49

6
10 10 15 18 19

20 23 25 25 25 26 27 27 28 28
32 32 32 33 34 34 35 35 35 35 35 36 36 36 37 37 38 38 38 39 39
40 41 41 42 42 43 43 44 45 45 45 46 48 48 48 48 49 49
51 52 52 53 56
66 68

Median = 37

Median = 20

*Prevalence data from Table 16 are grouped by decile (stem) and listed in ascending order (leaf). The data are from different
sources and derive from various methodologies. This display provides a visual overview of the range of measured values.

Table 21.  Prevalence of smoking (%) among
     Hispanic persons in the United States,
     aged 20-74, by ethnic group and sex,
     selected years

Ethnic group and sex    1982-1984*   1987+

Mexican origin
(southwest United States)
Men                 43.6      31.8
Women               24.5      17.4

Cuban origin (Miami area)
Men                 41.8      23.3
Women              23.1      20.4

Puerto Rican origin
(New York City area)
Men                41.3      38.6
Women               32.6      24.1
*Hispanic Health and Nutrition Examination Survey, 1982-
1984 (Escobedo, Remington, Anda 119891).
`Schoenborn (1989).

80  Prevalence and Mortality


Smoking-Attributable Mortality in Latin America and the Caribbean

Introduction

  Births and deaths are the most widely collected
and reported health events, and mortality is a stan-
dard measure of the health status of a population.
Mortality has traditionally been used as an indicator
of socioeconomic status and standard of living, espe-
cially in countries for which measures of economic
productivity are inappropriate.

  Mortality is a useful measure when setting
health priorities, communicating health-related infor-
mation, and marshalling political support for a health
initiative. It is a measure easily understood by the
public, and it can affect the public's perception of risk.
For example, the following statement about the
United States has a po\sJerful simplicity: "cigarette
smoking, alone, causes more premature deaths than
do all the following together: acquired immunodefi-
ciency syndrome, cocaine, heroin, alcohol, fire, auto-
mobile accidents, homicide, and suicide" (Warner
1987, p. 2081). Yet the data that allow such a statement
are difficult to assemble, and the methodologies used
to determine the number of deaths attributable to
smoking are complex (USDHHS 19891.

  Although useful, mortality data do not indicate
the full effect of a disease or set of diseases on a
community. They do not describe the pain, morbidity,
disability, economic costs, and decreased quality of
life of persons who live with an illness, nor do they
describe the secondary effects on family members who
lose a close relative.

  However, other measures of the effect of a dis-
ease have limitations as well. For example, life expec-
tancy, which can express the health status of a
population, may be misleading. For developing coun-
tries, life expectancy is strongly inff uenced by infant
and childhood mortality and much less so by disease
prevention or therapeutic advances that affect adult
health. People who have died from a smoking-related
disease would have lived approximately 15 years
longer if they had not been smokers (Warner 1987).
This powerful effect is diluted if the improvement in
smokers' life expectancy is averaged over the whole
population.

  In the following discussion, an attempt is made
to specify the number of deaths in Latin America and
the Caribbean attributable to smoking, while keeping
in mind the limitations of common disease measures.
The result is an approximation, an early step in an
iterative process for determining the health impact of

tobacco use in the Americas. The methodology, which
applies the concept of attributable mortality, is com-
plicated by the need to estimate and adjust data to
compensate for missing or insufficient data. A step-
by-step description of the methodology is provided in
Table 22. The effects of the empirical decisions made
are discussed at the end of the chapter (see "A Com-
ment on the Methodology").

Mortality Data

   The data in this section are from the PAHO
Technical Information System, a data base that in-
cludes mortality information. PAHO collects mortal-
ity data (by age, sex, and cause of death) from source
jurisdictions by using questionnaires, national publi-
cations, and other methods. Most of the data are from
civil registries, which rely on death certificates com-
pleted by health personnel in the field. These mortal-
ity data have several problems: the coverage of the
population is incomplete, the quality of some data is
questionable, and the cause-of-death groupings of the
World Health Organization (WHO)/PAHO data col-
lection questionnaire limit comparability with other
data.

Coverage

  PAHO has estimated that the underregistration
of mortality is more than 20 percent in Brazil, Colom-
bia, Dominican Republic, Ecuador, EI Salvador, Hon-
duras, Panama, and Peru (PAHO 1990b). The diverse
reporting standards from various countries necessi-
tated several country-specific decisions. In Brazil, for
example, the most populous country in Latin America
and the Caribbean, the estimated underregistration is
approximately 25 percent. The level of underreport-
ing differs between areas, although it tends to be
worse in the poorer, northern part of the country. The
number of reported deaths was used for the whole
country, although it is an underestimate. In Paraguay,
mortality information is published for only a portion
of the country, and the information may not be repre-
sentative of the remainder of the country. However,
the areas not covered by the mortality registry are
geographically defined and include about 40 percent
of the population. Thus, reasonably reliable disease
rates can be determined for a portion of Paraguay but
not for the country as a whole. For this country, data
from the well-defined reporting areas only were used;
for other countries, similar decision rules were used.

Prez~alrircc mrd Mortality   81


Estimate overall mortality
For each country, evaluate vital registration and use the
portion of the data that provides an accurate
population-based mortality estimate.
For the 10 jurisdictions without mortality data, use
United Nations population schedules and apply
mortality rates from countries with similar socio-
demographic configurations.
Do not correct for underreporting.
Exclude and do not correct for ill-defined causes.

(Resultant population and mortality estimates are
reported in Table 25.)

Estimate cause-specific mortality
Identify the major smoking-associated disease groups
(coronary heart disease; cerebrovascular disease;
lung cancer; oral, laryngeal, and esophageal cancer;
bladder cancer; and chronic obstructive pulmonary
disease [COPDI).

Use cause-specific mortality data for countries for
which such data are available.

For the 10 jurisdictions without such data, use data
from four countries representative of the de-
mographic and socioeconomic spectrum of the
Americas (Guatemala, Colombia, Argentina, and
the United States).

(Resultant cause-specific mortality estimates are in
Table 26.)

Estimate relative risk and attributable risk

Use U.S. estimates for relative risk since country-
specific relative risk is generally not available.
Determine the smoking-attributable fraction (SAF) for the
United States by using the attributable-risk calculation.

Data Quality

  One measure of the quality of mortality information
is the proportion of deaths assigned to the rubric "symp-
toms, signs, and illdefined conditions" (Manual oflnter-
national Statistical Classification of Diseases, Injuries, and
Causes of Death, Ninth Revision [ZCD-91). Currently,
the percentage of mortality ascribed to ill-defined

Table 22. Method used for calculating smoking-attributable mortality in the Americas

Adjust estimates by using an index related to lung
cancer

Use an index of the maturity of the epidemic that
relates the lung cancer rate for each country to that
of the United States.

For each country, determine an adjusted SAF for each
disease by multiplying the index by the U.S. SAF for
each disease (Table 32).

For each country, multiply the adjusted SAF for each
disease by the number of deaths from the disease to
obtain smoking-attributable mortality (SAM)
(approximately 375,000).

Adjust the estimate further

Calculate SAM for the United States alone by using
this method and compare the result with the official
value reported for 1985 (U.S. Department of Health
and Human Services 1989).

For each cause, calculate the difference between the
result from this method and from the official
method.

Apply these upward adjustments to the cause-specific
SAMs: increase COPD by 230R, increase cancers by
10.4% (using the difference in lung cancer esti-
mates), and increase other diseases and causes by
16.4% (see footnotes to Table 33).

Calculate the adjusted estimate of SAM in the
Americas (526,000).

causes is greater than 10 percent for 16 of the 39
jurisdictions submitting mortality information
(PAHO 1990a). In this analysis, ill-defined causes were
excluded from calculations of proportions or rates.

  Because a decedent may not have received
health care or the certifying physician may not have
been the physician who treated the decedent, diagnostic

82  Prevalence and MortaZity


imprecision may occur. More serious distortion may
result because the certifying physician did not have
the diagnostic tools necessary for accurately determin-
ing the cause of death.* Furthermore, managers of
health services may not be willing or able to ensure
accurate recording or conduct the diagnostic tests that
would yield an accurate diagnosis, especially for the
elderly. As a result, assessments of mortality levels
and trends are often made by considering disease-
specific rates for middle-aged rather than elderly pop-
ulations (Doll and Peto 1981).

Coding

  Since 1979, PAHO's participating member states
have classified cause of death by using the ICD-9
coding scheme. To store these data, PAHO developed
a grouping of causes of death based on, but not iden-
tical to, the Basic Tabulation List of the ICD-9. The
PAHO grouping is also similar, but not identical, to
the groupings used by WHO and CDC. The difference
in grouping, which has a variable effect on disease
classification, does not affect deaths categorized as
due to the following conditions:

Com~ition                     ICD-9 code
Coronary heart disease              410414
Cerebrovascular disease             430-438
Lung cancer                       162
Cancers of the lip, oral cavity, or pharynx   140-149
Cancer of the esophagus                 150
Cancer of the larynx                   161
Cancer of the bladder                  188

  However, PAHO grouped cancers of the pan-
creas (ICD-9 157) and kidney (ICD-9 189) with other
cancers. Chronic obstructive pulmonary disease
(COPD), when coded as ICD-9 490-492 and 496, can-
not be isolated in the PAHO grouping. The relevant
PAHO categories are "bronchitis (chronic and unspec-
ified), emphysema, and asthma" fICD-9 490-493).
Thus, unlike the grouping for COPD used in the cal-
culation of smoking-attributable mortality (SAM) in
the United States (CDC 19911, the PAHO grouping
includes ICD-9 493 (asthma) and excludes ICD-9 496.

Life Expectancy and Mortality

Trends in Life Expectancy and Overall Mortality

  For all countries and subregions of the Americas,
the overall trend is an increase in life expectancy at
birth (Table 23). Over the last 35 years in Latin Amer-
ica and the Caribbean, the average life expectancy at

Table 23.  Life expectancy* at birth for persons
     born during selected periods, by region

and count6

Region
and country

Year of birth

1950-55  1970-75  1985-90

51.8     61.2     66.6
40.4     46.7     53.1
37.6     48.5     54.7
43.9     55.5     61.4
42.1     54.0     62.0
45.3     58.8     62.2
42.3     54.7     63.3
42.3     54.0     64.0
51.0     59.8     64.9
48.4     58.9     65.4

2000

Latin America
Bolivia
Haiti
Peru
Guatemala
El Salvador
Nicaragua
Honduras
Brazil
Ecuador
Dominican
Republic
Paraguay
Colombia
Mexico
Venezuela
Argentina
Chile
Uruguay
Costa Rica
Cuba

69.7
60.5
59.4
67.9
68.1
68.8
69.3
68.2
68.0
68.2

            46.0     59.9     65.9   69.7
            62.6     65.6     66.9   67.9
            50.6     61.6     68.2   70.7
             50.8     62.6     68.9   72.1
            55.2     66.2     69.7   71.3
             62.7     67.3     70.6   72.3
            53.8     63.6     71.5   72.7
            66.3     68.8     72.0   73.0
            57.3     68.1     74.7   75.8
            59.5     71.0     75.2   76.3

Caribbean       56.4     67.1     72.4   74.7

North America   69.1     72.2     76.1   78.1
United States   69.0     71.3     75.4   77.6
Canada       69.1     73.1     76.7   78.5

Source: Centro Latinoamericano de Demografia (1990); Pan
American Health Organization (1990a).
*Estimates through 1985 are based on actual data. After
1985, estimates are projections based on trends and on
comparisons with data from similar countries.

birth has increased by about 15 years-from 51.8 to
66.6 years. In North America, the increase was seven
years-from 69.1 to 76.1 years, reflecting a slower
increase as life expectancy at birth reaches age 75 to 80.

  Among Latin American and Caribbean coun-
tries, the current differences in life expectancy at birth
are great-ranging from 53.1 and 54.7 years in Bolivia
and Haiti, respectively, to 75.2 years in Cuba. Over the
last 35 years, the range has diminished somewhat.

2 Historically, the lack of appropriate diagnostic tools had
a major impact on the number of deaths assigned to lung
cancer. When diagnostic radiology was introduced in
England in the 192Os, the rate of certified lung cancer
deaths increased threefold (Pet0 7986).

Prmahce mzd Mortality   83


During 1950 to 1955, the range was 28.7 years; today
it is 22.1 years, and by the year 2000, it is expected to
decrease to 16.9 years. Few Latin American and Ca-
ribbean countries are at the low end of the range. Cur-
rently, only about 3 percent of the population of Latin
America and the Caribbean lives in countries with a
life expectancy at birth lower than 55 years, while 86
percent lives incountries with a life expectancy at birth
of 65 years or more. All countries except Bolivia and
Haiti are expected to achieve a life expectancy at birth
of 65 years or more by the year 2000 (PAHO 1990a).

   Differences in the rate of increase are also evident
among countries. For example, although life expec-
tancy at birth in Chile and Uruguay is now similar, it
increased three times more in Chile than in Uruguay
over the last 35 years. In general, the increase in life
expectancy at birth was slower in the 1970s and 1980s
than in the 1950s.

  The current life expectancy at birth in Latin
America and the Caribbean is equivalent to that in the
United States around 1945 to 1950-before many
major advances in chronic disease prevention and
treatment occurred (PAHO 1990a). Based on the cur-
rent rate of improvement, the life expectancy at birth
in Latin America and the Caribbean should reach that
currently found in the United States by about the first
quarter of the next century (Centro Latinoamericano
de Demografia 1990).

  The range of population and mortality parame-
ters is illustrated by data for four countries (Guate-
mala, Colombia, Argentina, and the United States)
that represent the broad spectrum of variation within
the Americas (Table 24). This variation highlights the

diverse potential effects of smoking on a population.
For example, for all deaths in women (excluding
deaths from ill-defined causes), the fraction of deaths
in women aged 35 or older ranges from 34 percent in
Guatemala to 95 percent in the United States. Since
most SAM occurs among persons 35 years old or older,
it is this group whose health is most affected by a
tobacco habit.

Estimates of Mortality

  The PAHO Technical Information System con-
tains national mortality data suitable for this analysis
for all but 10 jurisdictions in the Americas: Antigua
and Barbuda, Bermuda, Bolivia, Guadaloupe, Gre-
nada, Haiti, Montserrat, Netherlands Antilles, Nicara-
gua, and Saint Pierre and Miquelon.

   To determine the number of deaths in the Amer-
icas attributable to smoking, the number of deaths for
these 10 jurisdictions had to be estimated. The United
Nations (1989) population estimates for these jurisdic-
tions were used for this calculation. Crude population
mortality rates and other major mortality parameters
were applied by using data for countries in the PAHO
Technical Information System believed to be similar
with respect to life expectancy, geographic region,
per capita gross national product, tobacco consump-
tion rates, and other factors. These estimates were
used along with others obtained by standard means
(Table 25).

   These nonstandard estimates are sensitive to the
choice of country used to model the mortality struc-
ture. In general, these are underestimates of actual
mortality because of underreporting and because

Table 24.  Mortality from defined causes,* selected countries, c. 1985
                                  Persons aged 235 years

Country

Sex

Population+

Total
Mortality+

Mortality+

Percentage of
total mortality

Guatemala         M         3,914
               F         3,826

Colombia         M         14,103
               F         14,007

Argentina         M         15,049
              F         15,283

United States       M        116,160
              F        122,571

Source:  Pan American Health Organization (1990b).
*Excludes ill-defined causes; see text.
+Number, in thousands.

32            11           34
27             9           34

74           45            61
55           39           70

129           110           85
103           89           86

1,080           987           91
975           930           95

84  Prevalence and Mortality


Table 25.  Mortality from defined causes,* regions of the Americas, c. 1985

Region

Latin America

Sex

M
F

Andean Area

Southern ConeS

Brazil                M

Central Americas

Mexico

M     39,744         224
F     39,631          171

Latin Caribbean

M     12,934         101
F      12,801          87

32           41
26           42

134           60
112           66

63           62
52           60

Caribbean

M      3,510          21           17           78
F      3,571          18           15           82

North America"

M     128,768       1,179
F     135,410       1,055

1,078           92
1,006           95

1,831           77
1,614           82
3,444           80

All regions of the Americas    M     329,301       2,368
                    F     335,868       1,965
   Total                  665,169       4,333

Population+

Total
Mortality+

197,023       1,168
196,887         892

40,177          207
39,705          166

24,377         190
24,785         153

Mortality+

  736
  592

  109
   95

  159
  131

Percentage of
total mortality

    63
    66

    53
    57

    84
    86

67,601         367          239           65
67,963         254          177           70

12,190          78
12,002          62

Source:  Pan American Health Organization (1990b)
*Excludes ill-defined causes; see text.
+Number, in thousands.
SIncludes Falkland Islands.
SExcludes Belize.
IlIncludes Bermuda and St. Pierre and Miquelon.

mortality from ill-defined causes has been excluded   to a high of 92 to 95 percent in North America. Most
(as discussed earlier). The resultant estimates of   of the population of Latin America lives in countries
smoking-related mortality are conservative.       where this fraction is between 60 and 70 percent.

Total, Cause-Specific, and Age-Specific Mortality

  The composite of reported and estimated mor-
tality indicates that approximately 4,300,OOO deaths
occur in the Americas each year; about half of these
deaths (2,060,OOO) occur in Latin America (Table 25).
In the Americas overall, about 80 percent of deaths
occur among persons aged 35 or older; in Latin Amer-
ica, the fraction is about 64 percent. The fraction of
deaths occurring among persons aged 35 or older
varies from a low of about 41 percent in Central America

  The greatest absolute increase in life expectancy
at birth is generally associated with improvements in
mortality rates for children. In Latin America, a gra-
dient of economic development is associated with
increased life expectancy. In general, the death rate
for children is lower in more highly developed coun-
tries, but the death rate for older persons is similar in
various economic settings. For example, in Argentina,
the mortality rate per 1,000 persons under five years
of age is 7.9, and for persons aged 65 or older, it is 65.8.
In Guatemala, the rate for persons under five years of

Persons aged 235 years

Prevalence and Mortality   85


age is 21.4, but for persons aged 65 or older, it is 67.5
(PAHO 1990a).

  The gradient of economic development is also
reflected in the cause-of-death mortality structure.
Among men aged 45 to 64, mortality from heart dis-
ease, expressed as a percentage of total mortality, is 11
percent in Guatemala, 27 percent in Colombia, and 37
percent in the United States. But some similarities are
emerging. For both the 45 to 64 and the 65 or older age
groups, the three leading causes of death for each sex
are the same in both Colombia and the United States.
For the oldest age group, the leading cause of death-
diseases of the heart-is also the same in Guatemala
(PAHO 1990a).

  This pattern-increasing similarity of causes of
death-is likely to intensify. As life expectancy im-
proves, the epidemiologic profile of a country
changes. Countries with a lower life expectancy tend
to have a younger population, and the greatest mor-
tality is in the younger age groups. In these countries,
deaths are primarily due to infections (such as acute
respiratory infections and diarrhea), malnutrition,
and conditions originating in the perinatal period. As
these diseases are controlled and life expectancy in-
creases, deaths from chronic diseases-in particular,

cardiovascular diseases and cancer-become the
dominant health problem (PAHO 1990a).

Mortality from Smoking-Related Diseases

Estimates of Cause-Specific Mortality

  The major diseases associated with tobacco
smoking include coronary heart disease, cerebrovas-
cular disease, COPD, and cancers of the lung, lip, oral
cavity, pharynx, larynx, esophagus, pancreas, blad-
der, and kidney. In the United States, each of these
causes (considering cancers of the lip, oral cavity, and
pharynx as a single group) contributes at least 2,000
deaths to the total number of deaths attributable to
smoking (USDHHS 1989).

  The four countries for which population data
were assessed (Table 24) and the six smoking-related
conditions (Table 26) were the focus of this analysis of
the effect of smoking on countries of the Americas.
Cancers of the lip, oral cavity, pharynx, larynx, and
esophagus were grouped because of the similar smoking-
attributable risk for these conditions (USDHHS 1989).
Cancers of the kidney and pancreas were excluded
because they cannot be specifically identified in the
PAHO Technical Information System. The four countries

Table 26.  Deaths from six major causes as a percentage of all deaths from defined causes,* for persons
     aged 35 or older, selected countries, c. 1985

   Corm-;ry Cormr~ry Cerebro- Cerebro-      Oral,+          Chronic
                      vascular  vascular     laryngeal,        obstructive
Country    disease   disease   disease   disease  Lung and esopha- Bladder pulmona-ry   All
and sext  (aged 35-64) (aged 265) (aged 3.564) (aged 265) cancer geal cancer   cancer  diseases categories

Guatemala
Men       2.2      3.6      1.2      2.5     0.1     0.3      0.1      1.2     11.2
Women     1.6      3.2      1.8      3.8     0.4     0.1      0.0      1.1     12.0

Colombia
Men       6.3      10.1      3.4      6.8     2.1      1.6      0.3      1.9     32.5
Women     4.7     10.2      4.7      9.5     1.3     1.0      0.2      1.8     33.4

Argentina
Men       4.8      8.1      3.6      7.0     5.6     2.5      0.9      1.2     33.7
Women     1.6      8.6      2.7      9.9     1.1     0.8      0.2      0.9     25.8

United States
Men       7.6     21.3      1.0      5.0     8.5      1.5      0.7      1.3     46.9
Women     2.8      24.1       1.0      8.9     4.2     0.6      0.3      0.9     42.8

Source:  Pan American Health Organization (1990b).
*Codes from Manual uflntm~ational Stntistical Classification of Diseases, [Injuries, ad Causes of Death, Ninth Revision: coronary
heart disease, 410-414; cerebrovascular disease,430438; lung cancer, 162; cancers of lip, oral cavity, and pharynx, 140-149;
cancer of the esophagus, 150; cancer of the larynx, 161; cancer of the bladder, 188.
`Cancer of the lip, oral cavity, and pharvnx.

SThe denominator for each row is the total number of deaths from defined causes, by country and sex.
%ee text for a description of this rubric.

86  Prevalence and Mortality


chosen represented four different points on the spec-
trum of mortality rates. Guatemala was chosen, even
though its lung cancer rate is low, because it reports
nationwide mortality statistics and has one of the low-
est levels of life expectancy in Latin America.

  For persons aged 35 or older, the distribution of
deaths from the six major causes was expressed as a
percentage of all deaths from defined causes (Table
26). Because SAM from coronary heart disease and
cerebrovascular disease differs significantly between
persons aged 35 to 64 and persons aged 65 or over
(USDHHS 1989), estimates for both these age groups
are presented.

  For all six smoking-related illnesses and age sub-
categories taken together (Table 26, last column), the
proportion of deaths caused in persons aged 35 or
older differed among the countries. In Guatemala,
these diseases accounted for slightly over IO percent
of adult deaths. In Argentina and Colombia, they
accounted for 25 to 33 percent of deaths, while in the
United States, they contributed approximately 45 per-
cent of deaths.

  To estimate the number of deaths from smoking-
related conditions for subregions of the Americas
(Table 27), both the reported mortality data (Table 25)
and synthetic mortality estimates for the 10 jurisdic-
tions without data were used. For these jurisdictions,
the mortality distribution patterns from the four se-
lected countries (Table 24) were applied, as described.

  Substantially more deaths in North America
than in Latin America and the Caribbean were attrib-
uted to coronary heart disease, lung cancer, and blad-
der cancer. The number of deaths was similar in
North America and in Latin America and the Carib-
bean for cerebrovascular disease, COPD, and oral can-
cer. Using these estimates, 81 percent of lung cancer
deaths in the Americas occur in North America. When
accounting for underreporting, the proportion is prob-
ably closer to 75 percent. (Using a different approach,
other researchers have estimated that North America
accounts for 77 percent of lung cancer deaths [Parkin,
Laara, Muir 19881). Because lung cancer is a strong
indicator of all smoking-attributable diseases, a rough
approximation suggests that the number of deaths in
Latin America and the Caribbean attributable to
smoking will be about one-third to one-fourth of the
number in North America.

Estimates of Relative Risk Due to Smoking

  Relative risk is defined as Y = &1)/d(O), where d(l)
and d(O) are the incidence of a particular disease for
exposed and unexposed cohorts, respectively. For
current smokers, the relative risk for a disease estimates

the increase in disease incidence associated with a
history of smoking. This risk varies widely among
population groups due to differences in smoking-
related factors, such as person-years of smoking con-
tributed by heavy smokers, age at initiation, and ciga-
rette product smoked. For example, among current
smokers in a population, the relative risk for lung
cancer would be expected to be relatively low if a
sizable proportion of the population recently began to
smoke heavily. If, however, heavy smoking has been
common since World War II, the risk would be rela-
tively high. The main reason for this effect is that the
exposure category defined by "current smokers" is
based on current rather than past smoking habit, but
lung cancer rates primarily depend on smoking pat-
terns of 20 or more years ago.

  For many of the smoking-related causes of death,
few country-specific estimates of relative risk are
available for Latin American and Caribbean popula-
tions, and most have focused on cancer. For current
cigarette smokers in the United States, aged 35 or
older, the estimated relative risk for lung cancer is 22.4
for men and 11.9 for women (USDHHS 1989). In
Cuba, the relative risk is 14.1 for men and 7.3 for
women. Dark tobacco is the variety of tobacco most
commonly smoked in Cuba and many other areas of
Latin America. In Cuba, dark tobacco is associated
with a higher relative risk for lung cancer than light
tobacco is: for men, 14.3 and 11.3, respectively, and for
women, 8.6 and 4.6, respectively (Joly, Lubin, Car-
aballoso 1983). In Colombia, the relative risk for lung
cancer among current smokers was 10.3 in one case-
control study of 102 persons with lung cancer, 74
percent of whom were men (Restrepo et al. 1989).

  The study in Colombia also reported relative risk
for cancer of the bladder, larynx, and oral cavity/ hy-
popharynx of 3.7, 37.9, and 11.2, respectively. In La
Plata, Argentina, where the rate of bladder cancer is
high, a relative risk of 7.2 for bladder cancer was found
for men who were current smokers (Iscovich et ~31.
1987). In a study of 232 cases of cancer in Brazil (87
percent of patients were men), the relative risk for
cancer of the tongue, gum, floor of the mouth ~1~1
other parts of the oral cavity was 9.3 for current snlok-
ers of manufactured cigarettes (Franc0 et al. 1989). 11~
a 1966 case-control study of male cigarette smokers
and nonsmokers in Puerto Rico, the relati\,e risk \VII~
1.5 for esophageal cancer, 1.1 for cancer of the scroll
cavity, and 2.7 for cancer of the pharynx (Martine'
1969). In Montevideo, Uruguay, the relati\,e risk for
laryngeal cancer was 35.4 for male smoker5 Of d&irk
tobacco and 14.7 for male smokers of light tobacco (IX
Stefani et al, 1987). For comparison, for U.S. mc'il \\`llo


Table 27.  Deaths (in thousands) from six major causes, * for persons aged 35 or older, selected regions

                                                           -
     of the Americas, c. 1985
                  _.~. ~~__~
       Coronary Coronary Cerebro- Cerebro-
           heart    heart    vascular   vascular
Re ion
Fi         disease   disease   disease   disease   Lung
an sex     (aged 35-W (aged 265) (aged 3S64) (aged 265)   cancer

Oral,+
laryngeal,
and esopha-
geal cancer

Bladder
cancer

Chronic
obstructive
p;;ye;;;q

"

Latin America
Men         38.1
Women       16.7

Andean Area
  Men        5.5
  Women      3.1
Southern Cones
  Men        7.3
   Women      2.2

Brazil
  Men        16.6
   Women       7.2
Central America"
   Men         1.0
   Women      0.5

Mexico
  Men         4.2
   Women       1.9

Latin Caribbean
  Men        3.5
  Women       1.8

Caribbean
Men          0.8
Women        0.4
North America'
Men         82.2
Women       27.8

All regions of
the Americas
Men         121.0
Women       44.9
   Total      165.9

59.7     28.5     49.8     22.4      14.1      3.0     15.6
53.2      22.6      55.5      6.8      4.0      1.0     11.3

8.7      3.2      6.1      2.1      1.3      0.3      2.0
7.6      3.3      7.2      1.0      0.6      0.1      1.8

13.8      5.5      11.9      8.2      3.9      1.2      2.9
12.6      3.7      14.4      1.4       1.1      0.3      1.7

19.3      15.7      21.0      6.1       6.2      0.9      4.8
17.5      11.5      21.7      1.9       1.4      0.3      2.7

2.0      0.5      1.3      0.3      0.2      0.05     0.6
1.6      0.6       1.5      0.2      0.01      0.02     0.5

7.1      2.3      5.6      2.8       1.1       0.3      4.5
6.3       2.2      6.8      1.3       0.4      0.1      3.8

8.9      1.4      3.9      2.5       1.4      0.3      0.9
7.5      1.3      3.9      0.9      0.4      0.1      0.7

1.2      0.7      1.9      0.4      0.3      0.1      0.3
1.1      0.6      2.2      0.1       0.1       0.03     0.2

230.3      11.2      54.7     92.0      16.4      7.5      14.2
242.2       9.6      89.8     41.7      6.1       3.4      9.2

291.2      40.4     106.3     114.4      30.8      10.6     30.1
296.5      32.8     147.5     48.5      10.1       4.4     20.6
587.7      73.2     253.8     162.9     40.9      15.0     50.7

Source:  Pan American Health Organization (1990b).
*Codes from Manual of Intertrational Statistical CIassificatim of Diseases, I?rjuries, fl?~d Cawes (?f Dmth, Ninth Revision: coronary
heart disease, 410414; cerebrovascular disease, 43&438; lung cancer, 162; cancers of lip, oral cavity, and pharynx, 14G149;
cancer of the esophagus, 150; cancer of the larynx, 161; cancer of the bladder, 188.
`Cancer of the lip, oral cavity, and pharynx.
% ee text for a description of this rubric.
_Includes Falkland Islands.
"Excludes Belize.
`Includes Bermuda and St. Pierre and Miquelon.

88  Prevalence and Mortality


are current smokers, the relative risk for cancer of the
bladder is 2.9, cancer of the esophagus 7.6, cancer of
the larynx 10.5, and cancer of the lip, oral cavity, and
pharynx 27.5 (USDHHS 1989).

  Two case-control studies were conducted to in-
vestigate the factors associated with esophageal can-
cer in Uruguay, which has one of the highest rates of
esophageal cancer in the world. In one study of 226
cases, the relative risk was 6.5 for ever smokers (82
percent were men) (Vassallo et al. 1985). In the other
study of 199 cases, the relative risk was 5.7 for current
male smokers (De Stefani et al. 1990). In bordering
southern Brazil, which also has a high rate of esopha-
geal cancer, the relative risk was 8.4 for male smokers
(Victora et al. 1987).

  For countries for which relative risk estimates
were lacking, relative risks were derived from U.S.
data and used in the following computations of SAM
(USDHHS 1989, 1990). Small differences in relative
risk estimates are unlikely to have a large overall effect
on SAM because of the structure of the formula for
calculating attributable risk (see below).

Smoking-Attributable Mortality

Estimates of Smoking-Attributable Mortality
Worldwide

  Interest in attempting to quantify the extent of
the health hazard caused by tobacco led to develop-
ment of smoking-attributable fractions (SAFs). These
values estimate the proportion of cases of a specific
disease in a population that can beattributed to smoking.

SAF = P(u-ll---
  1 +p (r-l)

in which p is the proportion of the population that has
ever smoked and Y is the risk for ever smokers relative
to never smokers. The SAF calculated for each disease
of interest is multiplied by the number of deaths for
that disease, and the result is the SAM for that disease.
The sum of SAM values for all diseases associated
with tobacco use gives the total number of deaths
attributable to smoking.

  The SAF can be refined to account for differences
in smoking status (never, current, or former smoker)
and for age and sex subgroups. Smoking prevalence
and relative risk can be estimated for each of these
subgroups. SAFs have been calculated for 10 selected
causes of death in the United States (Table 28).

  Recent studies have estimated the number of
deaths attributable to smoking in the United States
(Table 29). The estimates by Rice and colleagues,

Table 28. Smoking-attributable fraction for 10
     selected causes of death, United States,
       1985

Men   Women
~~~ ~~~ L?) ~
(7c'c)

45      41

21      12

51      55

24       6
90      79

92      61
81      87
78      75
29      34
47     37
48      12

84      79
-.

Cause of death

Coronary heart disease
(aged 35-64)
Coronary heart disease
(aged 565)
Cerebrovascular disease
(aged 35-64)
Cerebrovascular disease
(aged 265)
Cancer of the lung
Cancer of the lip, oral cavity,
and pharynx
Cancer of the larynx
Cancer of the esophagus
Cancer of the pancreas
Cancer of the bladder
Cancer of the kidney
Chronic obstructive pulmonary
disease

Source:  U.S. Department of Health and
(1989).

Human Services

CDC, and USDHHS all considered smoking status,

age, and sex. The estimates vary for several reasons:
the diseases included, the specific methodology used,
the target year, and the source of the smoking preva-
lence data and the relative risk estimates. The most
recent (1988) estimate for the United States (434,000
smoking-attributable deaths) is discussed in Chapter
4, "Economic Costs of the Health Effects of Smoking."
The 1985 estimate is used here to maintain consistency
with data available for Latin America and the Caribbean.
  SAM has been estimated for many European
countries (Table 30), and the current worldwide esti-
mate is 3 million smoking-attributable deaths per year.
  The methodology described earlier for calculat-
ing SAM can be used for countries for which reliable
information is available on smoking prevalence and
on the risk for major tobacco-associated diseases
among ever smokers relative to never smokers. Un-
fortunately, few countries in Latin America have such
data; an alternative methodology for calculating SAM
is described below.

Lung Cancer Mortality as an Index of Prior
Smoking in a Population
  Numerous attempts have been made to describe
the relationship between smoking habits and mortality

Prezahce nud Mortality   89


Table 29. Smoking-attributable mortality       smoking habits of the population, as expressed by the
      in the United States            risk of dying from lung cancer.

Reference

Rice et al., 1986

U.S. Office of Technology
Assessment, 1985

Centers for Disease Control,
1987b

Year   Estimate

1980   270,000

1982   314,000

1985   320,000

for R(US,N-Sj < R(C) < RKIS)

U.S. Department of Health
and Human Services, 1989

1985*  390,000

in which R(C) is the lung cancer mortality rate for a
country in the Americas, R(US) is the lung cancer rate
for the United States (Table 31), and RtUS,N-S) is the
lung cancer rate for never smokers in the United States
(12.7 for men and 11.1 for women). When R(C) is
greater than RfUS), the index is arbitrarily set to 1.
  The index has the following properties:
o It equals 0 for the few countries in Latin America
and the Caribbean with a lung cancer rate below
that of never smokers in the United States.
o It equals 1 for countries that have a lung cancer rate
higher than that of the United States (although there
were none).

*The 1985 estimate (rather than the 1988 estimate of 434,000
reported in Chapter 4, Table 1) is used here to maintain
consistency with the demographic and vital data available
for Latin America and the Caribbean.

from lung cancer in a population. Many of these
attempts have not been entirely successful, primarily
due to the lack of key information. Current lung cancer
mortality rates reflect smoking habits of 20 to 40 years
ago. Reliable data on lung cancer incidence and mor-
tality are available for many industrialized countries,
but only limited information is available on previous
smoking habits. Furthermore, the relationship between
smoking and lung cancer is affected by many factors.
Duration of smoking is the factor most strongly corre-
lated with risk for lung cancer. For example, when
duration of regular tobacco use is doubled from 15 to
30 years, lung cancer incidence increases about 20-fold
Pete 1986). Other factors that affect lung cancer risk
include number of cigarettes smoked per day, age at
initiation, tar yield of tobacco products, use of filters,
blend of tobaccos, and depth of inhalation. Many of
these factors vary over time, not only for a national
population but for individuals within a population.
Only in recent years have surveys in a few industrial-
ized countries collected data on these factors in some
detail. Thus, data are unavailable for building an
optimal model of smoking habits and lung cancer risk.

  Nevertheless, tobacco consumption is highly
correlated with lung cancer; the SAF has been calcu-
lated at over 90 percent for countries that have popu-
lations with a long history of high prevalence of heavy
smokers (Table 31). This strong association suggests
that lung cancer mortality can be used as a surrogate
to measure the impact of smoking on a population.

  The following index (0 uses lung cancer mortal-
ity rates for the population aged 55-64. This index, a
measure of smoking maturity in a population, con-
tains population risk factor information related to the

o It falls between 0 and 1 for countries with a lung
cancer rate between the U.S. rate for never smokers
and the overall U.S. rate, and the value increases as
the country's rate approaches that of the United
States.
  This index can be used to develop estimates of

SAM for countries in Latin America and the Carib-
bean. For a given country, the lung cancer rate and
index are calculated, and this lung cancer index is used
to adjust all diseases. The index is multiplied bv the
disease-specific SAF for the United States to obtain an
adjusted disease-specific SAF for a specific country.
The number of deaths from a specific cause is then
multiplied by the adjusted SAF to obtain the SAM.

  Thus, the index adjusts the SAF downward-to
a level appropriate for the extent of lung cancer in the
population. The index is nonlinear; large changes in
the upper range of lung cancer rates have only a small
effect on the SAF. But changes in the lower range, closer
to the rate for never smokers, have a proportionately
larger effect on the SAF. In Table 31, the SAF is given
with and without the index adjustment. The index
uniformly offers a more conservative estimate of SAF.

  Because of the potential for diagnosis of lung
cancer to be more inadequate in some elderly popula-
tions than in younger populations, and because of the
need to choose a relatively stable measure of smoking
habits, the lung cancer rate for persons aged 55 to 64
was used in creating the index. If older age groups are
used, significant diagnostic misclassification occurs,
and the relationship to smoking is more tenuous. The low
rates for younger age groups render the rate estimates

90  Preztalence and Mortality


Table 30.  Estimated number of deaths due to tobacco use in 27 countries of the World Health Organization
     (WHO) European Region*

Country

Austria
Belgium
Bulgaria
Czechoslovakia
Denmark
Finland
France
German Democratic Republic
Germany, Federal Republic of
Greece
Hungary
Iceland
Ireland
Israel
Italy
Luxembourg
Malta
Netherlands
Norway
Poland
Portugal
Romania
Spain
Sweden
Switzerland
United Kingdom
Yugoslavia

Total for region

Total worldwide

Year

1985
1984
1984
1984
1985
1984
1984
1984
1985
1984
1985
1984
1983
1984
1981
1985
1985
1985
1984
1985
1985
1984
1980
1985
1985
1984
1982

1991

Male         Female

5,527         3,354
8,905         2,664
6,129         3,215
14,693         7,363
5,531         3,311
4,094         1,900
25,751        10,102
12,393         6,178
49,572        26,433
5,305         1,718
10,742         5,541
  115            78
2,754         1,449
1,416           859
39,489        15,324
  298            121
  115            54
12,140.         3,892
3,046         1,553
23,858         7,337
3,656         1,778
12,178         7,907
14,492         5,738
7,104         4,339
4,299         1,610
60,764        33,916
9,103         3,732

343,469        161,466

  Total

  8,881
11,569
  9,344
22,056
  8,842
  5,994
35,853
18,571
76,005
  7,023
16,283
   193
  4,203
  2,275
54,813
   419
   169
16,032
  4,599
31,195
  5,434
20,085
20,230
11,443
  5,909
94,680
12,835

504,935

3,000,000

Source:  WHO (1988, 1991 [for worldwide estimate]).
Represents about 6OYG of the regional population. Tobacco is held responsible for about 90% of all deaths from lung cancer,
75% of bronchitis/emphysema deaths, and 257c of all deaths from ischemic heart disease. The estimate for each country is
based on the most current data provided to WHO by the countries themselves.

unstable. Further, the use of a single, well-defined
group at risk has the virtue of simplicity-data di-
rectly available to a country are used, and adjustment
that might be necessary for cross-country compari-
sons is avoided.

Estimates of Smoking-Attributable Mortality in
the Americas

Unadjusted Estimates

  Before adjustment, approximately 375,000
deaths in the Americas were attributable to smc.king
around 1985 (Table 32). These were distributed by
disease as follows:

Disease                     Total SAM
Coronary heart disease             144,200
Cerebrovascular disease             46,800
Lung cancer                  128,600
Oral, laryngeal, and esophageal cancer     23,200
Bladder cancer                  5,700
COPD                      27,300
  In Latin America and the Caribbean, an interme-

diate estimate of 64,000 smoking-attributable deaths
was obtained, and most of these deaths were from
coronary heart disease (about 18,500), cerebrovascular
disease (about 17,000), and lung cancer (about 13,000).
The largest contribution to SAM in Latin America was
made by Brazil, followed closely by the Southern Cone
subregion.

Prezlalence and Mortality   91


Table 31.  Smoking-attributable fraction (SAF) and adjusted SAF for lung cancer mortality,
     selected industrialized countries, 1978-1981

                                         Index of
                 Crude lung
Country            Sex     cancer rate*     SAF    smoking
                               maturity  A%Fd

Canada             M       142.8       .90        .92        .85
                 F        34.0        .71        .77        .60

England and Wales      M        228.5        .94       1 .oo        .92
                 F        63.3       .80       1.00        .78

Japan              M        64.8        .83         .58        .53
                 F        21.0        .58        .50        .39

Sweden             M         85.0       .83        .69        .63
                  F         28.0       .57        .66        .51
United State&         M        166.7       .92       1 .oo        .92
                  F        50.0        .78       1.00        .78

Source:  Adapted from International Agency for Research on Cancer (1986).
:For persons aged 35 or older. The calculation actually uses the rate for persons aged 5544 years.

Difference
between SAF
and adjusted
  SAF

.05
.ll

.02
.02

.30
.19

.20
.06

.oo
.oo

:Calculated by multiplying the SAF for the United States by the country-specific index of smoking maturity; see text.
+Total population.

  SAM was calculated as the percentage of deaths    exclusion of deaths attributed to ill-defined causes.
for persons aged 35 or older (last column of Table 32).   SAM was adjusted for the first four of these factors as
For the Latin American subregions, the proportion    follows. For the United States, the estimate of SAM
was highest for men in the Southern Cone and lowest   was calculated and compared with that made for 1985
for men in Central America. In the Southern Cone, the   KJSDHHS 1989). The latter estimate, which provided
difference in the rate for men and women reflects a   a benchmark, was 37.2 percent larger than the estimate
large historical difference in the rate of tobacco con-   computed in this analysis. The percent difference be-
sumption (see "Prevalence of Smoking" earlier in this   tween these two estimates was used to alter upward
chapter). The lung cancer mortality rate for women in    the estimates for the other countries in the Americas.
Peru was less than that for U.S. women who were   The adjustments were made by cause (Table 33, see
never smokers. The index was zero, and by this   footnotes), since the degree of underestimate varied
method, no deaths were attributable to smoking.       with the condition.

Adjusted Estimates

  The estimates of SAM (Table 32) are under-
estimates for several reasons: (1) COPD was un-
dercounted due to differences in cause-of-death
groupings; (2) cancers of the kidney and pancreas
were omitted; (3) the SAF for cancers of the oral cavity,
esophagus, and larynx is an underestimate (the three
cancers were grouped, and the smallest SAF for the
three was used); (4) other categories of disease or death
were omitted, including other types of cardiovascular
and respiratory disease, cervical cancer, infant deaths
due to maternal smoking during pregnancy and post-
natal exposure to environmental tobacco smoke, lung
cancer deaths due to passive smoking, and deaths
from smoking-related fires; and (5) an undercount of
deaths due to both underregistration of cases and the

  After adjustment, an estimated 526,000 annual
deaths in the Americas are attributable to tobacco use;
about 100,000 of these are in Latin America and the
Caribbean. About two-thirds of these deaths occur in
Brazil and the Southern Cone. The estimated 36,000
deaths for Bermuda, Canada, and St. Pierre and
Miquelon correspond closely with estimates derived
by using several different methods and previously
reported for Canada alone (Collishaw, Tostowaryk,
Wigle 1988; PAHO 1992). As discussed below, the
100,000 annual deaths in Latin America and the Car-
ibbean, estimated from data for the mid-1980s, is
conservative. If the current U.S. SAF is applied and if
Latin American and Caribbean countries follow a tra-
jectory similar to that of North America, over 1 million
smoking-attributable deaths per year will occur in
Latin America and the Caribbean by the year 2030.

92  Prevalence and Mortality


A Comment on the Methodology
  The attribution of mortality requires an empiri-
cal approach. In the method used here, which varies
somewhat in detail, but not in fundamental approach,
from other methods (WHO 19891, at least five basic
empirical decisions were made. First, the analysis
excluded mortality data for which cause of death was
inadequately specified, and no attempt was made to
adjust for the underreporting of deaths. Second, syn-
thetic estimates of mortality structure were used for
countries with little or no data. Third, a proration was
used to adjust for causes of death that could not be
analyzed by using PAHO data. Fourth, an empirical
index was developed to adjust for the many factors
that influence the risk that smoking imposes on a
population. Fifth, the SAM calculation made for the
United States (USDHHS 1989) was used as a bench-
mark for adjusting the estimates derived in this anal-
ysis. Each of these decisions influenced the final
estimate; in addition, some specific features of the
index and factors related to attributable risk in general
also had an influence.

The net effect of the empirical decisions is diffi-
cult to assess, but the first decision-no correction for
underreporting and no proration for ill-defined
causes-probably dominates and results in a sizable
underestimate. The order of magnitude of the under-
estimate can be approximated by comparing the esti-
mate of total mortality in Latin America derived for
this analysis (2,060,OOO [Table 251) with an estimate,
derived by using regression methods, that attempted
to account for underreporting (3,197,OOO [Hakulinen
et al. 19861). Based on this difference in overall mor-
tality of about 55 percent, the number of smoking-
attributable deaths might be as high as 155,000. The
more conservative estimate of 100,000 smoking-
attributable deaths was deemed more appropriate be-
cause it directly relates to the data with which
ministries of health in Latin American and Caribbean
countries actually work. In addition, the conservative
method allows a simple, uniform decision rule to be
used by all countries of the region in making their own
computations. Finally, this approach allows for in-
creasingly credible estimates of SAM to be made as
better mortality data become available and the esti-
mates are gradually refined.

  The index of smoking maturation is based on a
comparison of lung cancer rates. Although accurate
information is more readily available for lung cancer
than for other conditions, it may not be the optimal
condition for use in calculating the index. Although
tar levels affect the risk for lung cancer, they appar-
ently do not affect the risk for cardiovascular disease

and COPD (USDHHS 1981). Further, the lag between
increased consumption of tobacco and a rise in lung
cancer mortality may not be representative of the lag
for other diseases. In addition, use of the 55 to 64 age
group for calculating the index underestimates the
population's exposure to smoking in most Latin
American and Caribbean countries because peak
tobacco-consumption rates have not yet been reached.
  Because the index is empirical, there is no clear
methodologic justification for the square root transfor-
mation. Many transformations are available; the
square root was used because of properties appropri-
ate to the analysis. Specifically, taking the square root
of numbers less than one produces a nonlinear effect:
it increases all numbers that are less than one, but it
has a greater effect on numbers close to zero than on
numbers close to one. Thus, upward revision is pro-
portionately greater for countries with low rates than
for countries with high rates. This choice modulates,
to some extent, the conservative nature of the index.
On the other hand, no deaths were attributed to smok-
ing in countries with lung cancer rates less than those
for U.S. never smokers. Since smoking is not uni-
formly distributed in such countries, rates may be
higher for some subgroups, and at least some deaths
should have been attributed to smoking.
  Finally, this methodology is weakened by a lack
of information on multiple risk factors. The SAF may
be higher or lower when risks other than smoking play
a significant role in disease causation. Because smok-
ing is the dominant risk factor for lung cancer, this
effect is probably negligible. In cardiovascular disease,
however, smoking interacts with hypertension, hyper-
cholesterolemia, physical inactivity, obesity, diabetes,
and possibly other risk factors as well, and this effect
may be considerable.

  Thus, the empirical choices and the specifics of
the analysis may have differing effects, but the final
estimate of 526,000 annual deaths attributable to
smoking in the Americas is almost certainly conserva-
tive. This estimate-perhaps best viewed as the first
point on a continuum of such estimates-provides an
order of magnitude for the number of smoking-related
deaths in the Americas.

  If, as suggested in the first half of this chapter,
the prevalence of cigarette smoking is increasing in
some areas, accurate assessment of SAM is of consid-
erable importance. As noted, the lack of some critical
data diminishes the precision of the estimates and
fosters a greater reliance on empirical decisions. As
data systems develop, individual countries will be
better able to apply these methods for calculating
SAM for their own populations.


Table 32.  Smoking-attributable mortality* for men and women in the Americas, c. 1985

Region and
country

Men
Latin America
Andean Area
  Colombia
  Peru
  Venezuela
Southern Cone'
Argentina
  Chile
Brazil
Central America**
Mexico
Latin Caribbean
Cuba

Caribbean

North America++
Canada
United States

All regions of the
Americas

Women
Latin America
Andean Area
  Colombia
  Peru
  Venezuela
Southern Cone'
Argentina
  Chile
Brazil
Central America**
Mexico
Latin Caribbean
Cuba

Caribbean
North America++
Canada
United States

All regions of the
Americas

Lung cancer
mortality rateS

Index of
smoking
maturity
--__

   -

   -
.302
.140
.444
   -
.829
.566
.456
   -
,376
   -
.716

(aged ~65)
SAfl "

(aged 265)    (aged ~65)

SAM"
-___

SAF   SAM    SAF   SAM

  -

  -
34.1
19.5
55.6
  -
155.5
80.6
57.8
  -
44.3
  -
119.8

-   8,426       -   6,432       -    7,090
-    785       -    557      -     462
.136    386    ,063    287    .154     237
.063     24    .029     25    .072      24
,200    354    .093    228    .226     167
-   2,583       -   2,245       -    2,151
.373   1,983    .174   1,156    .423    1,659
.255    290    .119    344    .288     261
.205   3,411    .096   1,844    .233   3,652
-     71       -     89       -      36
,169    708    ,079    559    .192     435
-    867       -   1,138       -     355
,322    711    ,150    974    .365     298

-

-        -    128       -     108       -     129

  -           -
209.0       .975
219.0      1.000

-  36,907       -  48,251       -    5,696
.439   3,376    .205   4,044    .497     449
.450  33,526    .210 44,204    .510    5,243

-                    -  45,460       -   54,791       -   12,914

-

-
16.1
7.8
23.7
-
16.6
19.5
15.0
-
16.4
-
42.2

-

-
,267
-
,409
-
,279
,338
,240
.2;
-
.632

-

-
,710
-
,167
-
.114
,139
.098
-
.112
-
,259

1,848
346
198

-   1,837
-     234
,032     126
-       -
,049     108
-    403
,033     259
.041     119
,029    505
      28
,033     207
-    459
,076     405

-

-
149
236
162
63
706
20
209
331
299

-
,147
-
,225
-
.153
,186
,132
-
,151
-
,347

857
101
59

-
42
223
149
58
313
10
113
98
85

-

-
75.1
90.1

-

  -

.901
1 .ooo

  -

-

-
.369
,410

  30

11,315
768
10,547

-     27       -

-  28,854       -
.108   1,919    .496
.120  26,934    .550

29

5,343
386
4,957

-   13,194       -  30,718       -    6,229

Coronary
heart disease    Coronary
           heart disease

Cerebro-
vascular
disease

Source:  Pan American Health Organization (1990b).
"Mortality from defined causes for persons aged
`Cancer of the lip, oral cavity, and pharynx.   35 or older, in thousands.
tThe lung cancer rate for U.S. never smokers used for the index calculation was 15.5 per 100,000 men aged 5.564 and 10.4
per 100,000 women aged 55-64.

94  Prevalence and Mortality


-

-
,073
.034
,107

,199
,136
,109
-
,090

,172

5,959      -   11,549     -   5,946     -    845      -   5,819   52,066    ,071
418      -     579     -     305     -     36      -    441   3,584    ,033
222    .272     258   .236     164   ,142     17    .254    212   1,784    ,040
26    .126     33   ,109      12   ,066     2    ,118     38     184    .009
143    ,400     263   .346     116   ,209     15    ,373    148   1,434    .063
2,182      -   5,952     -   2,446     -    468      -   1,727   19,754    .124
1,527    .746   4,580   ,647   1,782   .390    368    ,697    916   14,370    ,131
315    .509     492   ,441     260   .266     35    475    553   2,549    .083
2,302    .410   2,522   .356   2,197   .214    191    ,383   1,827   17,945    .075
56      -     75     -     33     -     5      -     67     431    .013
503    .339     938   .293     322   .177     47    .316   1,409   4,920    .037
498      -   1,483     -     645     -     98      -    348   3,432    .086
399    ,644   1,334   ,558     462   ,336     86    .601    252   4,517    ,146

-      198      -     214     -     131     -     18      -    105   1,030    ,062

-    13,098      -   82,569     -   12,781     -   3,503      -  11,892  214,696    .199
.234    1,162    .878   7,249   .761    1,254   .458    367    ,819   1,245   19,147    .211
.240   11,932    ,900   75,310   ,780   11,523   .470   3,135    ,840  10,645  195,519    .198

-    19,255      -   94,331     -   18,859     -   4,366      -  17,817  267,792    ,146

-

857
101
59

-

1,567
210
102

-

673
97
64

-

-
,016
-
,025
-
.017
.020
,014
-
.016
-
.038

-
.211
-
.323
-
.220
.267
.190
-
.217
-
.499

-
,163
-
,249
-
,170
,206
.147
-
,167
-
.385

-
.099
-
.151
-
,103
,125
.089
-
,102
-
.234

103
11
7

-

2,257   12,247    .021
289   1,716    .018
151     977    .025

-
42
223
149
58
313
10
113
98
85

108
317
220
87
360
2%
389
352

33
181
116
55
207
10
74
104
89

-
5
30
22
6
30
1
10
20
17

-
,211
-
.323
-
.220
,267
,190
-
.217
-
.499

-       -
138     739
386   2,308
170   1,473
203     727
517   4,156
35     140
827   2,052
203   1,877
167   1,671

-
.039
.018
.016
,029
,023
,005
,018
.036
,069

-

29

5,343
386
4,957

-

-
.054
.060

-
.712
.790

  26

32,706
2,242
30,463

-

-
.550
,610

11

3,657
312
3,345

-    6,229      -   34,299     -   4,342

-

-
.333
,370

-

  3

1,253
105
1,148

-

-
.712
.790

33     218    ,015

7,170   95,562    ,095
532   6,631    .088
6,638   88,928    ,096

1,359      -   9,460  108,027    .067

Cerebro-
  vascular
  disease
(aged 265)
SAF    SAM

Lung
cancer

SAF   SAM   SAF   SAM   SAF   SAM   SAF   SAM

Oral,+
laryngeal, and
esophageal
   cancer

`Smoking-attributable fraction.
`iSmoking-attributablemortality.
`Includes Falkland Islands.
*`Excludes Belize.
`+lncludes Bermuda and St. Pierre and Miquelon.

Bladder
cancer

Chronic
obstructive
pulmonary
disease

Total
SAM

Total SAM
t~:~~:~l
mortality


Table 33. Adjusted estimates of smoking-attributable mortality (SAM) in the Americas, c. 1985
-

                            Chronic
                         obstructive                           Total
Region and            Total   p;;;e;;:+q           Other diseases5
country              SAM*              Cancer4     and causes    adjusted
                                                               SAM

Latin America         64,300      18,600       1,400       13,800       98,100
Andean Area         5,300       1,700          10       1,200
Southern Cone/l                                              8,200
                22,100       4,900         700       4,500       32,100
Brazil             22,100       5,400          300       4,600
Central America1                                          32,400
                     600         200          10         100          900
Mexico            7,000       5,100          100       2,000       14,200
Latin Caribbean        7,300       1,300         200       1,400       10,200

Caribbean            1,200         300          30         300        1,900

North America        310,300      43,800       12,000      60,000      426,100
United States        284,400      39,800       11,000       55,000       390,200
Other**            25,800       4,100        1,000       5,100       36,000
All regions of the
Americas          375,800      62,700       13,400       74,100       526,000

Source: Pan American Health Organization (1990b). Adjustments were based on 1985 estimates for the United States; U.S.
Department of Health and Human Services (1989). Percentages used for upward adjustment for chronic obstructive pulmo-
nary disease and other diseases and causes were specific to those diagnostic rubrics. Upward adjustment for cancers was
based on lung cancer.
*Total for men and women from Table 32.
+230% adjustment to compensate for undercounting.
*10.4% increase added to adjust for omission of cancers of the kidney and pancreas and for underestimates of smoking-
attributable fraction for cancers of oral cavity, esophagus, and larynx.
516.4% increase added to adjust for exclusion of cervical cancer, other types of cardiovascular and respiratory diseases,
deaths among newborns due to smoking by the mother, lung cancer deaths due to passive smoking, and deaths from
smoking-related fires.
IlIncludes Falkland Islands.
IExcludes Belize.
**Includes Bermuda, Canada, and St. Pierre and Miquelon.

96  Prevalence and Mortality


Conclusions

1. Certain sociodemographic phenomena-such as
change in population structure, increasing urban-
ization, increased availability of education, and
entry of women into the labor force-have in-
creased the susceptibility of the population of
Latin America and the Caribbean to smoking.

2.  The lack of systematic surveillance information
about the prevalence of smoking in most areas of
  Latin America and the Caribbean hinders com-
prehensive control efforts. Available information
reflects a variety of survey methods, analytic
schemes, and reporting formats.

3. Available data indicate that the median preva-
lence of smoking in Latin America and the Carib-
bean is 37 percent for men and 20 percent for
women. Variation among countries is consider-
able, however, and smoking prevalence is 50 per-
cent or more in some populations but less than 10
percent in others. In general, prevalence is highest
in the urban areas of the more developed coun-
tries and is higher among men than among
   women.

4. The initiation of smoking (as measured by the
prevalence of smoking among persons 20 to 24
years of age) exceeds 30 percent in selected urban
areas. Although systematic time series are not

available, the data suggest that more recent co-
horts (especially of women) in the urban areas of
more developed countries are adopting tobacco
use at a higher rate than did their predecessors.
The smoking epidemic in Latin America and the
Caribbean is not yet of long duration or high
intensity, and the mortality burden imposed by
smoking is smaller than that for North America.
By 1985, an estimated minimum of 526,000 smoking-
attributable deaths were occurring each year in all
the countries of the Americas; 100,000 of these
deaths occurred in Latin American and the Carib-
bean countries.

The estimate of 526,000 deaths annually is conser-
vative and is best viewed as the first point on a
continuum of such estimates. However, it pro-
vides an order of magnitude for the number of
smoking-attributable deaths in the Americas.
The time lag between the onset of smoking and the
onset of smoking-attributable disease is forebod-
ing. In North America, a high prevalence of smok-
ing, now declining, has been followed by an
increasing burden of smoking-attributable mor-
bidity and mortality. In Latin America and the
Caribbean, rising prevalence portends a major
burden of smoking-attributable disease.

Prezvlrrm~ md Mortality   97


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200  Prevalence and Mortality


Chapter 4
Economics of Tobacco Consumption
in the Americas

Preface   103

Economic Costs of the Health Effects of Smoking   105
Latency of the Health Consequences   105
Estimating the Economic Costs   105
General Considerations and Limitations   105
Prevalence- and Incidence-Based Studies   110
Application to Developing Countries   112
Financing of Health Care and Pension/Disability Funds   112
Costs of Smoking-Control Policies and Programs   114

Economics of the Tobacco Industry   214

The Tobacco Sector   114
Overview   114
Demand for Tobacco   115
Advertising   128
Supply of Tobacco   119
Manufacturing   122
Distribution   121
Trade   122
Subsidies to Tobacco Production   122
Contribution of Tobacco to Economic Growth and Development   125
Externalities   125
Price, Production, and Substitution   125
Future of Tobacco Production   127
Tobacco Taxation   127
Subnational Taxes   128
Effects of Excise Taxes on Smoking   129
Modeling Addiction   131
Analysis of Recent Tax Increases   132
Health Consequences of Tax Changes   133
Equity, Incidence, and Distribution of the Tax Burden   134
Use of Tobacco Taxes   135

Conclusions   136

References   137


Preface

Although the economic aspects of smoking in North America have been extensively
examined, detailed data are not availablefor Latin America and the Caribbean. For the latter
region, a definitive analysis of the health costs of smoking and the economic configuration
of the tobacco industry await more systematic reporting and collection of data.

In the first part of this chapter, a generic approach to assessing the costs associated
with the major adverse health effects of smoking is outlined. The background for this
approach, which uses concepts introduced in Chapter 3, is described. Data and examples
from the United States and Canada are provided, and the work done in these countries is
summarized.

In the second part, an overview of the tobacco sector of the economy is offered. Again,
more data are available from North America than from Latin America and the Caribbean,
but the economic issues (supply and demand, advertising, subsidies, taxation, and others)
are relevant to all countries of the Americas. This overview provides a framework for
weighing the relative costs and benefits of tobacco production and consumption.

Economics   703


Economic Costs of the Health Effects of Smoking

Latency of the Health Consequences

  Since 1964, when a report on the health conse-
quences of smoking was released by the Surgeon
General's Advisory Committee on Smoking and
Health (Public Health Service 19641, extensive re-
search has assessed the disability, morbidity, and pre-
mature mortality attributable to tobacco use. The
many effects of smoking on health were documented
in the Surgeon General's twenty-fifth anniversary re-
port on smoking and health (U.S. Department of
Health and Human Services IUSDHHSI 1989). A
detailed examination of smoking-attributable mortal-
ity (SAM) in the United States summarizes these asso-
ciations (Table 1). (See Chapter 3 for an assessment of
SAM in Latin American and Caribbean countries.)

  As an epidemiologic transition occurs in Latin
America and the Caribbean, noncommunicable dis-
eases are expected to become increasingly prominent
as causes of death. For example, although Brazil bears
a burden from certain infectious diseases (such as
Chagas' disease) and the growing incidence of human
immunodeficiency virus infection, many other infec-
tious and parasitic diseases have been brought under
control. Many cases of lung cancer are now antici-
pated in Brazil (The World Bank 1989a). Cardiovas-
cular disease is the leading cause of death in Brazil
(The World Bank 1989a), and the number of deaths
due to cardiovascular disease is likely to increase sig-
nificantly. Among Latin American women, for whom
prevalence of smoking appears to have increased (see
Chapter 3), an increased incidence of lung cancer may
soon become apparent (Crofton 1990).

  Numerous studies have reported a 20- to 30-year
latent period between the initiation of smoking on a
regular basis and the development of lung cancer
(USDHHS 1982), a phenomenon well documented in
North America. In the United States, many men
started to smoke as adolescents or young adults
around World War I, and many women started as
adolescents or young adults during or after World
War II. The incidence of lung cancer in the United
States began to increase for men around 1940 and for
women around 1960 (USDHHS 1989). A similar lag
occurred in Canada; from 1976 to 1986, the rate of lung
cancer doubled (Millar 1988). An epidemiologic and
economic result of latency is the continued rise in lung
cancer deaths despite a decline in the prevalence of

smoking. In the United States, the lung cancer mortal-
ity rate for men did not begin to level off until 1985
(USDHHS 1989). For women, deaths from lung can-
cer have not yet peaked, and lung cancer has become
the most common cause of cancer mortality, surpass-
ing breast cancer (USDHHS 1989).

  The correlation between the level of cigarette
consumption in a population cohort when it enters
adulthood and the lung cancer rate for that cohort
when it enters middle age provides further evidence
of the 20- to 30-year latency (Figure 1). In Brazil, lung
cancer mortality among adult males has increased as
a lagged response to the increase in tobacco consump-
tion (Figure 2) that began during World War II. Thus,
the consequences of tobacco consumption-including
economic consequences-are long in developing, and
the full impact of disease, disability, and death is
measured over decades.

Estimating the Economic Costs
  Many estimates have been made of the costs of
smoking in the United States and Canada. A similar
body of work is not available for Latin America and
the Caribbean-in part because the data required for
such analyses are often not available. In addition, a
single estimate would probably not serve adequately
because of the heterogeneity among countries of the
region. An approach to estimating the health costs of
smoking is described below, along with some esti-
mates that have been made.

General Considerations and Limitations

  Estimates of the economic effects of the health
consequences of smoking generally consist of three
components (U.S. Office of Technology Assessment
[USOTAI 1985):
o An attempt to identify an increased incidence of
smoking-related illness in current or former smok-
ers and attribution of that increase to smoking.
o An application of these attribution ratios to esti-
mates of the direct (health care) costs of caring for
persons with smoking-related illness-to obtain an
estimate of the direct costs of smoking.

o An estimate of the indirect costs of smoking-
related illness, which is made by measuring the
increased rate of morbidity and mortality in current
and former smokers and then valuing (1) time lost
due to morbidity by their current wage rate and
(2) excess mortality by discounted future earnings.

Economics   105


Table 1.  Relative risks* (RR) for death attributed to smoking and smoking-attributable mortality (SAM)
    for current and former smokers, by disease category and sex, United States. 1988

  Men
RR ~-_____-

Disease category (ICD-9-CM)+

Current Former
smokers smokers   SAM

Adult diseases (235 years of age)
Neoplasms
Lip, oral cavity, pharynx (140-149)  27.5
  Esophagus (150)              7.6
  Pancreas (157)                2.1
Larynx (161)               10.5
Trachea, lung, bronchus (162)     22.4
  Cervix uteri (180)            NA
Urinary bladder (188)          2.9
Kidney, other urinary (189)       3.0

Cardiovascular diseases
  Hypertension (401404)         1.9
  Ischemic heart disease (410-414)
   Persons aged 35-64 years       2.8
   Persons aged 265 years        1.6
  Other heart diseases (390-398,
   415-417,42&429)           1.9
  Cerebrovascular disease (43&438)
   Persons aged 35-64 years       3.7
   Persons aged 165 years        1.9
  Atherosclerosis (440)           4.1
Aortic aneurysm (441)          4.1
  Other arterial disease (442448)     4.1

Respiratory diseases
  Pneumonia, influenza (480-487)    2.0
  Bronchitis, emphysema (491-492)   9.7
Chronic airways obstruction (496)   9.7
Other respiratory diseases
   (Olcl-012,493)              2.0
Pediatric diseases (~1 year of age)
Short gestation, low birthweight (765)
Respiratory distress syndrome (769)
Other respiratory conditions of
  newborn (770)
Sudden infant death syndrome (798)
Burn death&
Passive smoking deaths5

   Total

Source:  Centers for Disease Control (1991).
*Relative to never smokers.

8.8    4,942     5.6       2.9     1,460   6,402
5.8    5,478     10.3      3.2     1,609   7,087
1.1    2,775      2.3       1.8    3,345   6,120
5.2    2,401     17.8      11.9      589   2,990
9.4   78,932     11.9      4.7    33,053  111,985
NA       0      2.1       1.9     1,246   1,246
1.9    2,951      2.6      1.9      963   3,914
2.0    2,729      1.4       1.2      363   3,092

1.3    3,441      1.7       1.2    2,254   5,695

1.8   29,263      3.0       1.4    9,105  38,368
1.3   41,821      1.6      1.3    27,990   69.811

1.3   27,503      1.7       1.2    14,638  42,141

1.4    5,121      4.8       1.4    4,504   9,625
1.3    11,554      1.5       1.0    5,134  16,688
2.3    4,644      3.0       1.3    3,612   8,256
2.3    5,798      3.0       1.3     1,435   7,233
2.3    1,874      3.0       1.3     1,111   2,985

1.6   11,580
8.8    9,670
8.8   29,838

1.6      828

2.2
10.5
10.5

2.2

1.4    8,098  19,678
7.0    5,269  14,939
7.0    16,884  46,722

1.4      690   1,518

1.8         344          1.8         261     605
1.8         351          1.8         233    584

1.8
1.5

  384
  422

  850

1,330

286,824

1.8
1.5

  277    661
  280    702

  453   1,303

2,495   3,825

147,351  434,175

      Women
      _____~-~~
     RR
Current   Former
smokers   smokers   SAM

Total
SAM

Tlnternational Classijication of Diseases, Nirlfh Revision, Clirzicnl Modificofiolr
`Data from the Federal Emergency Management Agency, 1990.
$Deaths among nonsmokers from'lung cancer attributable to passive smoking; hational Research Council (1986).

106 Economics


   Several estimates have been made for the United   with regard to the medical conditions attributed to
States (Rice et al. 1986; Hodgson 19881, Canada (Col-   smoking. Some studies include lung cancer only,
lishaw and Myers 1984; Forbes and Thompson 1983a),    while others include heart disease and chronic ob-
the United Kingdom (Atkinson 1974), Sweden (Hjalte   structive pulmonary disease (COPD). Other studies
19841, and Switzerland (Leu and Schaub 1984). Vari-   compare differences in the overall use of health care
ous factors should be included in a complete picture   by smokers and nonsmokers. However, these esti-
of the economic impact of smoking-related illness   mates do not include nonmedical components of di-
(Table 2), but few published studies have addressed   rect costs, such as the costs of transportation to health
all of these factors, and most studies have concen-   care providers or of modifying an environment to
trated on factors for which data are available.      accommodate a person with a severe chronic illness.

  Most estimates of the costs of smoking-related
illness calculate the direct costs of treating persons
with smoking-related diseases, including the costs of
hospital and nursing-home care, physicians` fees, and
medications (Table 3). The specific items included in
the estimates vary among studies, which also differ

  Estimates of the indirect costs of smoking-related
illness attempt to measure the productivity lost or
output forgone as a result of smoking-related illness
or death (Table 4). This so-called human capital ap-
proach has been criticized for placing a high value on
losses sustained by young adults, men, and more-

Figure 1.  Correlation between cigarette consumption per person who entered adult life in 1950 and lung
    cancer rate for that generation as it entered middle age in mid-1970

100 -

+ United States

so-

Source:  Doll and Pete (1981).

Number of manufactured cigarettes consumed
  f  Rate based on over 100 deaths.
    O  Rate based on 25-100 deaths.
  0 U.S. nonsmokers 1959-1972.

Economics   107


Figure 2.  Per capita rate of cigarette consumption in Brazil and lung cancer deaths for men in Rio
     Grande do Sul, Brazil

     t--
    /     7
   /         \
  /           \
/             \
/

              14           /'
                 /    \            /
                /       \
              /          \
             /             b-- d'
           /
          /
        /
       /
    / /*
   /
/        S-to 30-year lag
d   1

,            I            I            I            I

1940      1950       1960

Source:  The World Bank (1989a).

educated persons (Markandya and Pearce 1989). In
addition, earnings lost because of illness and mortality
may have little relationship to the value people place
on their life or health (Markandya and Pearce 1989).
A more appropriate measure of that value may be the
amount they are willing to pay to reduce the probabil-
ity of death or disease. Although several attempts
have been made to estimate willingness-to-pay for
non-smoking-related illness (Viscusi 19901, this ap-
proach has not been applied to cost-of-smoking stud-
ies. In addition, no value has been assigned to
intangible items, such as pain and suffering, prema-
ture death, and loss experienced by relatives; accord-
ingly, these intangibles have not been included in any
published estimates of the costs of smoking. Some
estimates include costs associated with the harmful
effects on the fetus and on newborns of maternal
smoking during pregnancy and of postnatal exposure
to environmental tobacco smoke (Forbes and Thomp-
son 1983b); however, most published estimates do not
incorporate measures of external costs (those borne by
persons other than smokers).

  The transfer payments (pension benefits and sick
benefits) associated with smoking-related illness have

/
I,

30

20

10

0

1970       1980

been a source of confusion and controversy. Transfer
payments reflect who pays for and who benefits from
smoking-related illness; these transfers are not, strictly
speaking, economic costs because they do not reflect
resources consumed or lost due to smoking. How-
ever, discussions of smoking-control policies have fre-
quently asked whether smokers in economically
advanced societies (with well-developed public or pri-
vate health care financing, disability, and pension sys-
tems) cover the costs of their own illness (Manning et
al. 1989; Schelling 1986; Garner 1977).

  Accurate estimation of the cost of smoking is
influenced by the quality of data available, current
demographic circumstances, and competing mortality
risks. Cost estimates require reliable data on smoking
behavior, the incidence of smoking-related illnesses,
and the prevalence of such illnesses at death. In many
developing countries, vita1 statistics are unreliable or
incomplete (see Chapter 3, "Smoking-Attributable
Mortality in Latin America and the Caribbean"), al-
though several Latin American and Caribbean coun-
tries have well-established national statistical
registries (World Health Organization [WHO] 1989)
from which reliable estimates can be constructed.

108   Economics


Table 2.  Components of the costs of the health effects of smoking
                -

Component          Definition

Direct costs
Medical care      Costs of treatment for smoking-related illness.
Other         Nonmedical costs of smoking-related illness.

Indirect costs
Morbidity costs
Mortality costs     Loss of earnings and/or housekeeping services due to smoking-related illness.
          Loss of earnings and/or housekeeping services due to premature death from
            smoking-related illness.

Intangible costs
Pain and suffering
Premature death
Relatives' loss

Cost to individual of pain and suffering from smoking-related illness.
Cost to individual of premature death due to smoking.
Cost to smoker's relatives and friends because of concern for smoker's health,
observation of sickness and suffering, and grief and suffering due to smoker's
premature death.

Transfer payments
Taxes
Pension benefits

Sick benefits

Reduced taxes paid by smokers due to illness-related reductions in earnings.
Value of transfer payments such as pensions paid or forgone due to premature
death.
Health care costs paid by public or private insurance plans. Sick pay and disability
benefits paid to smokers during illness.

External costs

Effects of smoking on nonsmokers, including deleterious health effects and the
annoyance of exposure to environmental tobacco smoke. Includes the deleterious
effects of maternal smoking on the fetus, on infants, and on children.

  A country's demographic configuration influ-
ences the degree to which smoking-related illness be-
comes manifest. Since many smoking-related
illnesses do not have an important impact on persons
under age 50, such illnesses do not significantly con-
tribute to mortality in countries where life expectancy
after infancy is low; however, low life expectancy
affects only a small proportion of the population in
Latin America and the Caribbean (Chapter 3, "Life
Expectancy and Mortality").

  The manifestation of smoking-related illness is
also a function of competing morbidity and mortality.
Latin American and Caribbean countries are at differ-
ent stages of epidemiologic transition, and the chronic
conditions associated with smoking may be obscured
by the continued presence of infectious diseases and
other disorders. Countries also vary in the extent to
which background conditions (nutritional, genetic, or
environmental) interact with smoking.

  Another limitation of cost-of-smoking studies is
the method used to calculate attributable risk (AR).'
Although quite useful, this calculation must be ap-
plied judiciously; it attributes all differences between
ever smokers and never smokers to smoking, and it

may overestimate the level of smoking-related illness.
Smokers and never smokers differ in several charac-
teristics, including diet and level of alcohol consump-
tion, exercise, and education KJSDHHS 1990), all of
which may be associated with differences in health
outcomes. Leu and Schaub (1983) developed the hy-
pothetical construct of the "nonsmoking smoker-
type," a person who is like a smoker in all ways except
smoking, to serve as the standard of comparison in
estimating costs of smoking. This construct was also
used by Manning and associates (1989) to calculate the
lifetime external costs of smoking in the United States.
However, the concept may not be useful in many
developing countries because of the variability of
competing factors in different settings.

  In attempting to estimate tobacco-related dis-
eases in developing countries, some researchers have
used a single measure of AR for each of the major
smoking-related illnesses, such as lung cancer, heart

A detailed discussion of the theory, limitations, and other
methodologic issues concerning the calculation of AR and
smoking-attributable disease and mortality is presented
in the Surgeon General's 1989 report KJSDHHS 1989).

Economics   109


Table 3.  Medical care costs for smokers, by study type and author

                                       Year of
Study type and author          Country         estimate

Annual costs (prevalence-based estimates)
Collishaw and Myers (1984)+        Canada           1979

Lute and Schweitzer (1978)         United States        1976

Rice et al. (1986)               United States        1984
Stoddart et al. (19861t5           Canada (Ontario)     1978
Thompson and Forbes (1983)+       Canada           1980

U.S. Office of Technology
  Assessment (1985)             United States        1985

Lifetime costs (incidence-based estimates)
Manning et al. (1989)"             United States        1983

Oster, Cold&, Kelly (1984)         United States        1980

Total cost
(billions)*

  1.64

52.02

24.85

  0.34

  3.04

12-35

  cost
per smoker*

  164

  868
444$

   127

  302

214-870

6,113
2,474-6,576:
1,147-4,138

Hodgson (1990)                United States        1985        501 .o     6,239++
Hjalte (1984)+                  Sweden           1980         0.18         73
*Converted to 1985 U.S. dollars by using U.S. Bureau of the Census (1988) Table 738 consumer price index.
+Markandya and Pearce (1989) report these estimates converted to 1980 U.S. dollars.
STotal cost divided by 56 million smokers in the United States in 1985; U.S. Department of Health and Human Services
(1989).
%ublic expenditure only.

110.33 cost per pack x 16,300 packs = $5,379 (1983 U.S. dollars).
_Men aged 4044 light (l-14 cigarettes per day) to heavy (235 cigarettes per day) smokers.
"Women aged 4&44 light (l-14 cigarettes pe; day) to heavy (235 cigarettes per day) smokers.
`+Lifetime cost for all smokers >25 years old.

disease, and COPD (90,26, and 75 percent, respectively)
(Pan American Health Organization [PAHOI 1989).
Such use of AR can be misleading because the propor-
tion of current and former smokers varies across
countries and over time, and the relative risk is a
function of smoking patterns (e.g., the number of
cigarettes smoked daily and the duration of smoking),
which also vary (USDHHS 1989). For example, Joly
and colleagues (1983) reported that of all lung cancers
for Cuba in 1984, 63 percent among women and 91
percent among men were caused by smoking; for U.S.
women and men in the mid-1980s, the attribution
proportions were 75 and 80 percent, respectively
(Centers for Disease Control [CDC] 1987). Moreover,
the relative risk for smoking is also determined by
nontobacco causes of illness, and these differ among
countries. Applying an exogenously determined set
of AR proportions to any country's population may

lead to unreliable estimates of the level and costs of
smoking-related illness. However, for countries that
lack endogenous data, this procedure is often the only
alternative (see Chapter 3, "Smoking-Attributable
Mortality in Latin America and the Caribbean").

Prevalence- and Incidence-Based Studies

  The prevalence-based approach to measuring
the economic costs of tobacco-related disease has fre-
quently been used, largely because of its relatively
simple methodology, the availability of the data
needed for the calculations, and the consistency of
carefully made estimates (Rice et al. 1986) (Table 3).

  Several of these prevalence-based studies (Lute
and Schweitzer 1978; USOTA 1985; Rice et al. 1986;
Collishaw and Myers 1984) indicate that the costs of
smoking in any one year are likely to be great and that
the economic costs of smoking should be taken

110 Economics


Table 4.  Value of productivity lost due to mortality and morbidity, by study type and author
                                                    _____ ___~~           .__

                               Mortality        Morbidity
                             Year of  Total cost    Cost er   Total cost  Cost  er
Study type and author      Country     estimate (billions)   l!
                                                              smo er    (billions)   K
                                                                           smo er

Annual costs (prevalence-based estimates)

Collishaw and Myers (1984)   Canada

U.S. Office of Technology
  Assessment (1985)       United States

Rice et al. (1986)          United States

Lifetime costs (incidence-based estimates)

1979     4.04       405       0.75      74

1985     27-61   484-1,080*+

1984     9.63     172t      21.74    388t

Leu and Schaub_ (1984)     Switzerland

Oster, Colditz, Kelly (1984)   United States

1976    0.28-0.35   149-183     0.14-0.25   76-132

1980       24,221-68,316+"
        5,894-21,765+'

*Total cost divided by 56 million smokers in the United States in 1985; U.S. Department of Health and Human Services
(1989).
`Range includes both mortality and morbiditv losses.
*Converted to 1985 U.S. dollars by using U.S.`Bureau of the Census (1988) Table 738 consumer price index.
_Markandya and Pearce (1989) report these estimates converted to 1980 U.S. dollars.
"Men aged 40-44 light (l-14 cigarettes per day) to heavy (235 cigarettes per day) smokers.
_Women aged 40-44 light (l-14 cigarettes per day) to heavy (235 cigarettes per day) smokers.

seriously. These studies estimate expenditures for
medical care for tobacco-related diseases, workdays
lost, and future productivity lost due to smoking-
related deaths during the year. However, these stud-
ies do not address other issues that most concern
policymakers, including the economic impact of de-
creased prevalence of cigarette smoking, the length of
time before economic effects are realized, the eco-
nomic benefits of not smoking, and a comparison of
the lifetime illness costs of smokers with those of
nonsmokers (Hodgson 1990). Health care expendi-
tures tend to increase just before death, but smoking
shortens life expectancy and changes the pattern of
health care expenditures. The question arises whether
the health care costs incurred by smokers, when ad-
justed for the altered temporal pattern, exceed costs
incurred by never smokers.

   Most cost-of-illness studies are based on esti-
mates of the prevalence of illness in a particular year.
Because many smoking-related illnesses are chronic
and the latent period between initiation of smoking
and onset of illness is long, prevalence-based cost
estimates reflect the consequences of historical trends
in smoking, which may differ among countries at
different times. Accordingly, prevalence-based cost
estimates cannot be used to predict the impact of

smoking-control policies or to predict the impact of
increases in smoking, except after long periods.

  For policymakers, incidence-based, or lifetime,
estimates of the costs of smoking-related illness may
be more useful than prevalence-based estimates (Leu
and Schaub 1983; Manning et al. 1989; Oster, Colditz,
Kelly 1984). In the incidence-based model, the eco-
nomic costs of smoking are estimated as the average
additional costs per smoker, due to smoking-related
illnesses, incurred over the smoker's lifetime. Esti-
mates can be made of direct (medical care expendi-
tures) and indirect (e.g., lost wages, salaries, and
housekeeping services) costs of smoking and of the
benefits of quitting. For lung cancer, coronary heart
disease, and emphysema, the discounted value of an-
ticipated lifetime costs has been estimated for smoking-
related diseases in persons who smoked in 1980 and
continued to smoke (Oster, Colditz, Kelly 1984). The
costs of the benefits of quitting can be estimated as the
difference between the cost-of-smoking estimate and
the expected costs of former smokers, which reflect the
gradual rate of decline in risk for smoking-related
diseases.

  Estimates of each smoker's lifetime cost of smok-
ing differ by the person's age, sex, and quantity
smoked (Oster, Colditz, Kelly 1984). For example, the


lifetime costs of smoking for a 45-year-old man who is
a heavy smoker are significantly greater than those of
a 65-year-old woman who is a light smoker ($46,334
vs. $2,462; in 1980 U.S. dollars). Oster and colleagues
suggest that estimates of the costs of the benefits of
quitting are less than the costs of smoking and that
benefits vary according to the characteristics of indi-
vidual smokers. The expected costs of both smoking
and the benefits of quitting were sizable for all groups
of smokers foster, Colditz, Kelly 1984).

  Recently, Hodgson (1990) analyzed data on use
and costs of medical care and on mortality for specific
age groups in cross sections of the U.S. population to
generate profiles of lifetime health care costs begin-
ning at age 17. Because expenditures are higher for
persons who die than for those who survive, the anal-
ysis distinguished between the two groups within a
given age range. The profiles, estimated for men and
women by age and amount smoked, include the costs
of inpatient hospital care, physician services, and
nursing-home care. However, the cost of drugs and
dental care, as well as morbidity and mortality costs,
are excluded. Hodgson concluded that, despite the
higher death rate for smokers, the cumulative impact
of the excess medical care used by smokers while alive
outweighs their shorter life span and that smokers
incur higher medical care costs during their lifetime.
For all smokers, excess medical care costs increase
with the amount smoked. Hodgson (1990) estimated
that the U.S. population of civilian, noninstitutional-
ized persons aged 25 years or older who ever smoked
cigarettes will incur lifetime excess medical care costs
of $501 billion (1990 U.S. dollars discounted at 3 per-
cent) or $6,239 per current or previous smoker
(Table 3). This excess is a weighted average of the
costs incurred by all smokers, whether or not they
develop smoking-related illness. For smokers who do
develop such illnesses, the personal financial impact
is much higher.

  Lifetime or incidence-based cost-of-illness esti-
mates are preferred over prevalence-based estimates
for measuring the costs of changes in, and trends
affecting, the incidence of disease. However, lifetime
cost estimates require knowledge of the natural his-
tory of disease, the pattern of medical care use, and the
occurrence of co-morbidity. Lifetime costs are often
estimated from current profiles for cross sections of
populations at different ages and at different stages of
disease. To measure the potential impact of changes
in public policies and demographics on future health
care costs, projections of cost estimates must be made.
Changes in parameters, such as technologic change
and its rate of diffusion, must be considered, or esti-
mates may be biased and misleading (Hodgson 1988).

  The incidence-based approach is better suited
than the prevalence-based approach for estimating the
costs of smoking because the former relates current
changes in smoking behavior to future changes in the
costs of smoking-related illness. The incidence-based
approach, however, suffers from the limitations of
transferability between countries (mentioned above);
it does not directly address intangible costs and
externalities; and it values mortality and morbidity by
measuring forgone earnings rather than willingness-
to-pay. Moreover, even for economically advanced
countries, including the United States, the incidence-
based approach is limited by the lack of adequate and
comprehensive data; for less-developed countries,
this limitation may be exacerbated.

Application to Developing Countries

   The cost-of-illness studies conducted in the
United States and other developed countries reflect
health care rendered in technologically sophisticated,
expensive health care systems. In many other parts of
the world, health care delivery systems are less tech-
nologically advanced, and access to sophisticated
therapy is frequently limited to residents of large met-
ropolitan areas. Thus, the costs and benefits of health
care services in one area may differ significantly from
those found in other areas. Using the experience of
North American and European countries to predict
trends in health care for much of the rest of the world
is speculative because both the future development of
medical technology and the rate of its transference
across national boundaries are largely unknown.

  Few estimates are available on the costs of smoking-
related illness in Latin American and Caribbean coun-
tries. In one report, an average of 19,000 deaths were
attributable to smoking-related diseases in Venezuela
during 1980 to 1984 (PAHO 1992). The costs of medi-
cal care and employee absenteeism associated with
smoking-related illness in Venezuela increased signif-
icantly from 1978 to 1985 (from US$69 million to
US$llO million). Because of the wide variation among
countries in demographic structure, morbidity and
mortality, health care systems, and prevalence of
smoking, these results cannot be generalized to all of
Latin America and the Caribbean.

Financing of Health Care and Pension/
Disability Funds

   Considerable attention has been focused on not
only the size of the economic burden of smoking-related
illness but also on how societies will bear that burden.
Miscalculations of economic burden have been de-
rived by dividing prevalence-based estimates of the
costs of smoking-related illness by the quantity of

112   Economics


cigarettes sold. The resultant quotient has been re-
ported as the per cigarette cost of smoking borne by
society. For example, in the United States, $2.17 is
frequently quoted as the cost of smoking per pack of
20 cigarettes (USOTA 1985). This overall cost fails to
distinguish between the costs of smoking borne by
smokers (internal costs) and those borne by others
(external costs). The discussion of taxation (later in
this chapter) explains how the magnitude of the bur-
den imposed on nonsmokers by smokers is as much a
function of the institutional arrangements for financ-
ing health care, sick pay, disability, and retirement
pensions as it is of the costs of smoking-related illness.
Therefore, the incidence of the health costs of smoking
varies among countries depending on the structure
and scope of each country's social insurance system.

  Different national systems finance health care,
disability, and retirement within the Americas. In
some countries, participation in benefit programs is
financed by payroll taxes or job-related insurance pre-
miums. These types of programs are limited to per-
sons who participate in the formal economy.
Although national health insurance systems are man-
dated in some countries, a Iow level of funding may
limit the scope of public systems and lead to the cre-
ation of private markets for health services. Informa-
tion on the formal health care system may be
inadequate for measuring the external costs of smok-
ing-related illness; data may be needed on the actual
source and disposition of funds.

  The U.S. health care system is financed by vari-
ous government and private payment sources. In the
United States in 1985, direct payments accounted for
24 percent and private insurance-principally pro-
vided by businesses for their employees-ac-
counted for 33 percent of the total personal health care
expenditures. The federal government paid for 30
percent, mostly through Medicare (a federal program
for disabled persons and persons aged 65 or older) and
Medicaid (a program that provides health care for the
poor). State and local governments paid for 11 percent
of health care expenditures, largely through contribu-
tions to the Medicaid program. Government health
programs are financed by various mechanisms, in-
cluding a payroll tax. The cost of employer-financed
health insurance is included in total payroll costs and
is reflected in prices; profits, and wage rates. Public
old-age pensions and disability payments are financed
through the federal Social Security Administration for
most persons in the work force, but private plans
account for a substantial proportion of benefits
(Lazenby and Letsch 1990).

  In Canada, health care is financed through a
national system separately administered by each
province, with some direction and funding from the

federal government.  The Canadian government
finances a comprehensive set of medical benefits and
restricts funding by private sources, but Canadian
citizens can select their own health care providers.
Physicians' fees and hospital budgets are negotiated
by the government, and savings are achieved in part
through the administrative simplicity of the insurance
plans. In 1987, Canada spent US$1,483 per person for
personal health services, and the United States spent
US$2,031 (Igelhart 1989). In 1987, personal health ser-
vices accounted for 8.6 percent of the total gross do-
mestic product (GDP) in Canada and 11.2 percent in
the United States (Igelhart 1989). These comparisons
suggest that, on a per capita basis, Canada spends less
on smoking-related illness than the United States
does.

  Brazil has a mixed public and private system for
financing health care but is moving toward a new
constitutionally mandated, unified, and decentralized
health system (The World Bank 1989a). Brazil spends
approximately 5 to 6 percent of its total GDP on health
care, an amount divided almost equally between the
private and public sectors. About half of all public
financing for health care is channeled through the
National Institute for Medical Assistance and Social
Security and is tied to employment (The World Bank
1989a). Health services, primarily basic services for
the urban and rural poor, are funded by the Ministry
of Health through the general budget. State and local
governments, which also finance health care, ac-
counted for 27 percent of public expenditures on
health in 1986. Private health care is financed by indi-
vidual persons, who directly pay fees for services, and
private insurance, largely financed by employers,
which features various capitation and reimbursement-
for-expenditures insurance plans. In a recent survey
of the Brazilian health care system, The World Bank
concluded that "resources have been poorly allocated;
little is spent on prevention and much on curative care
(70 percent on hospitals alone); little is spent on the
poor, and much on the middle class" (The World Bank
1989a, p. 44).

  In Venezuela, as in Brazil, access to health care is
constitutionally guaranteed, but care is delivered both
privately and through various government programs
(Morgado 1989). The Ministry of Health is responsible
for providing health care, and approximately two-
thirds of the country's physicians are employed by the
Ministry in some capacity. In addition, largely unreg-
ulated private insurance reimburses both physicians
and private hospitals on a fee-for-service basis. The
physician-to-population ratio is high; however, as in
other Latin American countries, physicians are con-
centrated in the large urban centers.

Ecolromics   113


  The costs of smoking-related diseases may be
substantial in Brazil, Venezuela, and other countries
of the Americas with similar health care systems. The
concentration of health care resources for curative care
(mainly hospital and fee-for-service physicians' care)
in urban, middle- and upper-class areas suggests that
these groups consume a disproportionate share of the
resources and that smoking-related diseases in these
groups are treated aggressively. Smoking-related dis-
eases may also be a more important source of illness
in urban, high-income groups than in low-income
groups because persons of high income are likely to
have a longer, more intense exposure to tobacco
use and a longer life span during which smoking-
associated diseases may become manifest.

Costs of Smoking-Control Policies
and Programs

  Knowledge of the dangers of tobacco use and
concern for public health have led to the development
of smoking-control policies in several countries. (See
Chapter 6 for a discussion of control efforts.) Many of
these policies-such as restrictions on advertising,
warning labels on tobacco packages and in advertise-
ments, restrictions on smoking in public places, and
increases in tobacco taxes-use few direct resources,
but hidden or intangible costs may be associated with
such policies.  However, other smoking-control
policies-such as public and school education pro-
grams, lobbying efforts of smoking-control advocates,
and enforcement of restrictions on cigarette sales, ad-
vertising, and smoking in public places-use re-
sources that can be considered part of the costs of
smoking.

  The 1989 report of the Surgeon General presents
a detailed analysis of smoking-control activities in the
United States (USDHHS 1989). Such activities have

Economics of the Tobacco Industry

recently increased significantly in Canada, where the
federa& provincial, and municipal governments have
moved to increase tobacco taxes, restrict tobacco ad-
vertising, strengthen product warnings, restrict smok-
ing ir public places, and help tobacco growers
diversify and produce other crops (Collishaw, Kaiser-
man, Rogers 19901. Except for the program to dis-
courage tobacco cultivation, these policies and
programs use few direct resources. These programs
reflect, in part, the health advocacy of more than 30
voluntary agencies working individually and collec-
tively (as the Canadian Council on Smoking and
Health). Such advocacy activities, although rarely
costed-out, consume resources that should be in-
cluded in estimates of the costs of smoking-control
activities.

  Through the initiative of local medical leaders
and health and education authorities, Brazil's first
antismoking campaign began in Port0 Alegre in 1976
(The World Bank 1989a), spread to other regions, and
gained support. In 1985, the Ministry of Health began
to develop a national program to control smoking. A
recent evaluation by The World Bank (1989al cited the
Brazilian program as a success, although the effects of
the program on smoking patterns have not been for-
mally assessed.  Health planners from The World
Bank found that "public information and personal
smoking-cessation services," which cost only 0.2 to 2
percent of per capita gross national product (GNP) for
each year of life gained, were the most cost-effective
of the preventive and therapeutic interventions re-
viewed. In contrast, treatment for lung cancer cost 200
percent of per capita GNP per year of life gained. This
comparison suggests that public information pro-
grams designed to control smoking in Brazil are ex-
tremely cost-effective.

The Tobacco Sector

Overview

  From an economic perspective, the existence of
a market for tobacco indicates that tobacco produces
some economic benefits, including (1) consumer satis-
faction from smoking and other forms of tobacco use
and (2) income to producers in excess of the cost of

resources for tobacco production. Tobacco produc-
tion also generates costs-principally the value of re-
sources used to manufacture tobacco products.
Confusion about the costs and benefits of tobacco pro-
duction has been spawned by tobacco industry ana-
lysts who label the value of the land, labor, and capital
used in tobacco production as a benefit of such pro-
duction (Tobacco Growers' Information Committee, nd.;

114 Economics


Agro-economic Services Ltd. and Tabacosmos Ltd.
1987). In fact, because the resources used in tobacco
production are not being used for other products, the
cost of these resources is the true resource cost of
tobacco production.  The value of the alternative
goods that could be produced with the resources allo-
cated to tobacco production is a measure of the oppor-
tunity costs of producing tobacco. A tobacco industry
may also generate tax revenues, which are neither
benefits nor costs to a society. Rather, taxes are trans-
fers of resource claims from one segment of society to
the government for redeployment. Subsidies, such as
agricultural support programs, are also transfer
payments.

  The cultivation of tobacco is prima facie evi-
dence of tobacco's net contribution to growers' in-
comes. Although tobacco production may be very
profitable for the individual producer, it is not neces-
sarily beneficial economically. Subsidies and exter-
nalities associated with the production of tobacco may
lead to a divergence between what is best for produc-
ers and what is best for society as a whole.

Demand for Tobacco

  Worldwide consumer demand for tobacco prod-
ucts drives the market for tobacco. In the economist's
view, this demand originates from consumer efforts to
satisfy exogenously determined wants, which are sub-
ject to constraints on consumer resources. Such con-
straints include limits on time and disposable income.
By using information about products and prices, each
consumer purchases a mix of goods to maximize con-
sumer satisfaction.

   One of tobacco's benefits is the avoidance of
nicotine withdrawal symptoms by addicted smokers.
This benefit and other pleasurable sensations, called
"utility" by economists, may have many components,
including status, enjoyment, relaxation, a sense of se-
curity, affihation with other smokers, and perhaps in
certain cultures, a sense of being modern or progres-
sive. However difficult these attributes are to mea-
sure, economists posit that when consumers choose to
spend some of their own limited resources on tobacco,
they reveal their preference for purchasing tobacco
than for engaging in other forms of consumption or
savings.

   Price is a measure of the amount of alternative
goods forgone to purchase tobacco products. (The
effects of variation in cigarette price on tobacco con-
sumption are discussed later in this section.) Tobacco
products, as well as most consumer goods, tend to
obey the law of downward sloping demand-as price
falls (rises), quantity demanded increases (decreases).

Factors that increase the retail price of cigarettes, in-
cluding taxes, tariffs, and import quotas decrease con-
sumption. The cost of raw tobacco is generally not an
important factor in the retail price of tobacco products.
In addition, although the supply of cigarettes does not
affect demand directly, supply influences consump-
tion through the market price: as supply increases,
price tends to decrease, which stimulates consump-
tion until the additional sales clear the market. Factors
other than price that influence the demand for ciga-
rettes and other tobacco products are cited in Figure 3.
   Income determines a consumer's command over
resources and limits consumption options. In general,
the consumption of most goods increases as income
increases, but at a decreasing rate as consumers reach
satiety for a particular good. The income elasticity of
demand is defined as the percent change in the quan-
tity demanded divided by the percent change in in-
come that caused the demand change. The relation of
consumption to income can be observed for individu-
als, groups, and countries, for which income and con-
sumption fluctuate over time, and for variations in
income and consumption among groups at a particu-
lar time.

  For countries in the Americas, the correlation is
positive between per capita cigarette consumption
and per capita GNP (Figure 4 and Table 5). This
relation is stronger in less-developed countries in

Figure 3.  Factors, other than price, that affect the
     demand for tobacco products

       Reducing Factors

     Restrictions on sales to minors

   Restrictions on places for smoking

Public education on harmful effects of tobacco use

Health warnings on packaging and in advertising

I    Perception of harm from tobacco use
         1
            Demand
         t

Augmenting Factors

Disposable income of smokers and potential smokers
Smokers preference for attributes of tobacco products
     Advertising and promotion

         Addiction to nicotine

Economics   115


Figure 4. Per capita cigarette consumption and annual per capita gross national producF (GNP) in 24
    countries of the Americwt 1985

r

.

.

O       ?
   o ?
  ?
          ?

0   2poO 4poO 6poO ~Poo  10,000 12,000 14poO 16JXKl 18,000 20,tUbO
                Per capita GNP

*Using a model that compares the annual per capita consumption of cigarettes to the log of the GNP, the n$ationship is
expressed by the following linear regression equation: Consumption = -3241+ 616 ln(GNP per capita) (I? = 68). This
equation was used to calculate the elasticities discussed in the text.
`See Table 5.

which rising incomes frequently lead to increased
cigarette consumption due to an increase in the per-
centage of the population that smokes and in the
amount each smoker smokes and to a shift from
homemade and roll-your-own cigarettes to more-
expensive, factory-made, higher-quality tobacco
products.

  Several studies indicate that income elasticity
measured for multiple countries is higher than that
measured for a single country (Table 6). The estimates
reported by Chapman and Richardson (1990) and
Townsend (1990), and the estimate based on the data
in Figure 4, cluster around 0.50 (0.45 to 0.55). How-
ever, elasticity tends to fall as income rises, and near-
zero estimates have been reported for developed
countries (Table 6). In the model that compared

consumption to the logarithm of GNP (Figure 41, esti-
mated income elasticity of demand is approximately
2.0 at the lower end of GNP but falls to almost zero
(0.04) at the upper end.

  Restrictions on cigarette sales or on where smok-
ing is permitted make smoking more difficult. These
restrictions raise the total effective price of cigarettes
for consumers and reduce cigarette consumption. In-
creased perception of the harm of cigarette smoking
also depresses demand by increasing the total price of
cigarettes (including health-associated costs) or by
affecting taste.

  Physical characteristics of cigarettes, such as fil-
ters, and aspects of taste, which include strength,
flavor, and smoothness, augment demand. In many
countries, the modern tobacco industry developed

116 Economics


Table 5.  Per capita* cigarette consumption and income in the Americas

              Per capita
              cigarette    GNP+ per capita    Change in    Average annual
                                           growth in
             consumption       KJS$)     consumption (%)     GNP (%I
Country              (1985)         (1987)        (1970-1985)    (1965-1987$

North America
United States          3,370         18,530           -15              1.5
Canada             2,392         15,160           -30             2.7

Latin America
Argentina            1,780         2,390             3             0.1
Bolivia                 330            580            10             -0.5
Brazil              1,700         2,020           30             4.1
Chile              1,000         1,310             -7             0.2
Colombia            1,920         1,240            15              2.7
Costa Rica            1,340         1,610           -20             1.5
Cuba              3,920                          -2
Dominican Republic         930           730           -11              2.3
Ecuador                880         1,040            26             3.2
El Salvador              750            860           -21             -0.4
Guatemala              550            950           -26              1.2
Haiti                  240            360           -55             0.5
Honduras             1,010            810             7             0.7
Mexico              1,109         1,830                         2.5
Nicaragua            1,380           830            10             -2.5
Panama                894         2,240                          2.4
Paraguay            1,000            990             4             3.4
Peru                  350         1,470           -10             0.2
Uruguay             1,760         2,190            14              1.4
Venezuela            1,890         3,230            -4             -0.9

Caribbean
Barbados            1,380                         20
Guadeloupe           1,080                           -1
Guyana             1,000            390           -26             -4.4
Jamaica              1,190            940           -34             -1.5
Suriname            1,660                         60
Trinidad and Tobago      1,600         4,210           -16             1.3
Source:  The World Bank (1989b); U.S. Department of Health and Human Services (1989); Chapman and Wong (1990).
Aged 18 years or older.
`GNP = Gross national product.
$1982-1988 data.

because of a shift in consumption from traditional
forms of tobacco to modern, machine-made, quality-
controlled, flavored cigarettes made from blends of
tobacco, including fabaco rubio, a flue-cured tobacco.
Some authorities have suggested that the develop-
ment of filter-tipped cigarettes and long, slim ciga-
rettes has increased smoking among women (see
Chapter 2, "The Emergence of the Tobacco Compa-
nies"). The addictive nature of tobacco, another
demand-augmenting factor, is discussed in a prior
report (USDHHS 1988).

  The degree of competitiveness or structure of the
market for tobacco products can also affect the de-
mand for cigarettes by operating on retail price, prod-
uct differences, and product promotion. In many
countries, the market for tobacco products may be
reserved for a government-operated or sanctioned
monopoly, but cigarette markets in the Americas are
characterized by oligopoly-dominance of the market
by several large firms (see Chapter 2, "The Emergence
of the Tobacco Companies"). Prices tend to be lower
and aggregate advertising and promotion expenditures

Economics   117


Table 6.  Estimates of income elasticity of
     demand for cigarettes

Study
Chapman and
Wong (1990)

Chapman and
Wong (1990)

Walsh (1980)

Witt and Pass
(1981)

Lewit and Coate
(1982)

Townsend (1990)

Data in Figure 4

Data

Worldwide, 1980

Countries with
gross national
product ~$5,000
per capita, 1980

.55*

Ireland, 1953-1976

United Kingdom,
1955-1975

.33

.13

United States, 1976    .08

Europe, 1987-1988

24 countries of the
Americas, 1985

Elasticity
.45*

.46

.49

`Estimates calculated for this report from data provided in
Chapman and Wong (1990).

tend to be higher in oligopoly markets than in monop-
oly markets, because of competition. In addition, oli-
gopoly markets are characterized by greater variety as
firms attempt to capture market niches for specific
products.

  Cigarette advertising and the sponsorship of en-
tertainment, sporting, and cultural events are intended to
increase the demand for particular cigarette brands.
Measuring the effect, if any, of such advertising on
aggregate demand is problematic. Accordingly, pub-
lic policy toward cigarette advertising and promo-
tional activities is controversial in many countries.
Assessment of the impact of tobacco advertising and
advertising restrictions was presented in the Surgeon
General's 1989 report (USDHHS 1989) and is updated
below.

Advertising

  In the United States, cigarettes are one of the
most heavily advertised products, and the mix of ad-
vertising and promotion has changed over time. Cig-
arette commercials have been prohibited from
television and radio since 1971. In 1975,75 percent of
expenditures were directed toward traditional print
advertising media (newspapers, magazines, bill-
boards, and point-of-sale posters) and 25 percent to-
ward promotional activities, such as coupons, free

samples, public entertainment, and allowances to re-
tailers (CDC 1990). By 1988, when total expenditures
reached $3.27 billion, promotional activities ac-
counted for more than two-thirds of all advertising
and promotional expenditures. Despite the sizable
decline in the use of traditional print media from 1975
to 1988, cigarettes were in 1988 the product most heav-
ily advertised on outdoor media, the second most
heavily advertised in magazines, and the sixth most
heavily advertised in newspapers (CDC 1990).

  In many other countries of the Americas, tobacco
advertising expenditures are substantial (Table 7),
despite restrictions on advertising activities (see
Chapter 5). The Canadian Tobacco Products Control
Act banned all tobacco advertising in the Canadian
print media beginning January 1,1989, and required
that outdoor advertising on billboards and spon-
sorship of sporting and cultural events be phased out
(Collishaw, Kaiserman, Rogers 1990). This advertis-
ing ban is currently being contested by Canadian
tobacco companies in a protracted court case (Col-
lishaw, Kaiserman, Rogers 1990).

  Advertising aims to increase profit by increasing
demand for a particular product (Scherer 1980). In
oligopoly markets, advertising is used to differentiate

Table 7.  Estimated advertising expenditures* of
    tobacco industry in selected countries of
      the Americas

Country

Cost

United States            $3,270.0
Canada              88.0+
Argentina                   18.5
Brazil                     68.0
Costa Rica                    1.8
Dominican Republic              2.4
Ecuador                    1.0
El Salvador                   0.9
Guatemala                    1.8
Mexico                     19.8
Panama                     1.8
Uruguay                     0.7

Source:  Philip Morris International Inc. (1988); ERC Sta-
tistics International Limited (1988); Centers for Disease
$2ontrol(1990); Chapman and Wong (1990).
Estimates are for 1986,1987, or most current year available;
in millions.
`A phased-in ban on tobacco advertising began in January
1989 and is scheduled for completion by January 1993.
A court ruling declared the law unconstitutional, but it
remains in effect pending appeal (RJR-Macdonald Inc. v.
Attorney General of Canada 1990; Imperial Tobacco Limited
v. Attorney General of Canada 1990).

228 Economics


among similar products and to build sales or to sustain
the price of a particular product (Scherer 1980). Ad-
vertising attempts to associate smoking with attri-
butes generally considered positive, such as high-style
living, healthful activities, and economic, social, and
political success; it fails to voluntarily provide infor-
mation on the substantial hazards of cigarette con-
sumption. In emphasizing the positive attributes of a
product, advertising may increase demand for both a
particular brand and a class of products. Much of the
debate over tobacco advertising has focused on
whether such advertising increases cigarette sales and,
consequently, has a negative impact on public health,
or whether advertising is strictly a competitive device
tobacco companies use to determine relative market
share in a stable or declining market, in which case
such advertising would have little effect on public
health (USDHHS 1989). The results of many analyses
of the effects of advertising on cigarette consumpt-ion
were reviewed in the Surgeon General's 1989 report,
which cited the conclusion that it is "more likely than
not that advertising and promotional activities do
stimulate cigarette consumption" (Warner et al. 19861,
although precisely quantifying the influence of these
activities on the level of consumption may not be
possible.

  Evidence from the Canadian advertising ban
and the continuing debate over increasing restrictions
on advertising in the United States (Koop 1989) and
other countries suggest that focus has shifted from the
impact of advertising per se to the effects of advertis-
ing restrictions on consumption. An extensive study
of this issue was performed by the New Zealand Toxic
Substances Board (1989) in support of its recommen-
dation for a total ban on tobacco promotion in that
country. The relation between tobacco advertising
bans and tobacco consumption was examined from
1976 to 1986 in 33 countries. The study demonstrated
that "government tobacco advertising bans and con-
trols are accompanied by enhanced rates of fall in
tobacco consumption" (page xxiii) and that "the
greater a government's degree of control over tobacco
advertising and promotion, the greater the annual
average faI1 in tobacco use in adults and young
people" (page xxiv). As a follow-up to the New
Zealand report, Laugesen and Meads (1990) examined
the effects of tobacco advertising restrictions, price,
and income on tobacco consumption between 1960
and 1986 in 22 economically developed countries.
They found that a total ban on tobacco advertising
would have lowered average consumption by 5.4 per-
cent in 1986 in countries without a total ban at that
time.

  However, these studies have limitations-pri-
marily a failure to account for the potential bias that
antitobacco sentiment may be stronger in countries
that ban advertising than in countries that do not.
Accordingly, restrictions on tobacco advertising are,
to some extent, markers of antitobacco sentiment, and
a portion of the decline in consumption in countries
with bans may be attributable to this sentiment rather
than to advertising restrictions. In addition, both
studies primarily included developed countries with
a high but declining level of tobacco consumption.
Extrapolation of these findings to less-developed
countries with different patterns of tobacco consump-
tion may be inappropriate.

Supply of Tobacco

  Tobacco, which is grown in more than 120 coun-
tries, is the most widely grown nonfood crop. It is
grown in most developing countries, and the share of
tobacco production in developing countries has in-
creased steadily from 50 percent of world production
in 1961 to 1963 to 58 percent in 1972 to 1974 to 69
percent in 1987 (Stanley, in press) (also discussed in
Chapter 2, "The Emergence of the Tobacco Compa-
nies"). In the past decade, most of the increase in
worldwide tobacco production has been in China,
which accounts for about 34 percent of total world
production (Table 8). Major producers in the Ameri-
cas include the United States (almost 10 percent of

Table 8.  Share of world tobacco production, 1990

Country

Major producers
China
United States
India
Brazil
USSR

Other producers in the Americas
Canada
Argentina
Mexico
Cuba
Colombia
Dominican Republic
Paraguay
Venezuela
Chile

Production*

33.5
9.8
7.3
6.3
5.4

1.1
1.0
0.9
0.6
0.6
0.4
0.3
0.2
0.1

Source:  Food and Agriculture Organization of the
United Nations (1990).
*As percentage of world output; computed from weight of
crop.

Economics   119


total world production) and Brazil (about 6 percent).
Worldwide, about 22 percent of tobacco leaf by weight
is grown in the Americas. Tobacco production is in-
creasing more rapidly in developing than in devel-
oped countries and is expected to increase in
developing countries to more than 72 percent of world
production by the year 2000 (Food and Agriculture
Organization of the United Nations [FAO] 1990). In
the Americas, tobacco production is expected to de-
cline from 23 percent of world production in 1984 to
1986 to 21 percent by the year 2000 (FAO 1990).

  Considerable differences exist between the
quality and, hence, the price of tobacco leaf produced
in different countries. For example, tobacco grown in
the Americas is worth almost four times as much as
tobacco produced in China, although by weight,
the American crop is only 65 percent of the Chinese

crop (Agro-economic Services Ltd. and Tabacosmos
Ltd. 1987).

  Tobacco production is mainly concentrated on
small farms in limited geographic areas. The value of
the typical tobacco crop frequently makes tobacco an
important source of income not only for growers but
for local agricultural workers, even though tobacco is
often grown in rotation with other crops. Compared
with most other crops, tobacco uses little arable land
(about 0.3 percent worldwide), but tobacco cultivation
is labor intensive (Table 9) (Muller 1978). The tobacco
industry's ability to create employment is valued in
areas where labor is plentiful and production alterna-
tives are few. Millions of persons are involved in or
dependent on some stage of the tobacco-production
process for a portion of their livelihood (Agro-
economic Services Ltd. and Tabacosmos Ltd. 19871,

Table 9. Labor* and land use in tobacco growing, processing, and manufacturing in the Americas, 1983
                           -

Country

North America
United States
Canada

Latin America
Argentina
Bolivia
Brazil
Costa Rica
Chile
Colombia
Cuba
Dominican Republic
Ecuador
El Salvador
Guatemala
Haiti
Honduras
Mexico
Nicaragua
Panama
Paraguay
Peru
Uruguay
Venezuela

Caribbean
Tamaica

  Growing
No.     FTE+

66.80

105.40

43.90

600.00

288.90

3.76       1.93
302.00     100.50
20.00      17.00

24.20       6.55
1.23      1.23

351.00

117.00

10.00

95.00

59.68$      77.00      228.08      75.80
20.40       8.10       31.18       9.58

3.50

22.90

9.73

43.87

1.95
9.35
40.10

1.48
0.44

4.81

1.44

3.57

215.76

352.00

42.00
108.00
23.20

55.02
12.20

197.50

22.00

100.00

Processing and
manufacturing     Distribution
FTE - No.       FTE

7.70

120.20

2.60
30.30
13.40

0.93
1.52

25.90

1.90

6.70

Arable land
used (%I

0.21$

0.20
1 .oo
0.50
0.20
0.10
0.40
2.10
1.10
0.10
0.50
0.40
0.10
0.50
0.10
0.20
0.20
1.70
0.10
0.10
0.20

0.40

Source: Agro-economic Services Ltd. and Tabacosmos Ltd. (1987); Chapman and Wong (1990).
*In thousands of workers.
+FTE = Full-time equivalent.
SFor 1989; U.S. Department of Agriculture unpublished estimates.

120 Economics


and persons in certain regions may substantially de-
pend on tobacco.

  Tobacco farming is also highly seasonal. If the
work could be spread evenly throughout the year, the
average-sized tobacco farm could be managed by one
full-time farmer, with some time remaining (Stanley,
in press). However, because many workers are
needed for harvesting and planting, tobacco farming
provides many countries with part-time, seasonal em-
ployment for many laborers (Table 9). The average
number and full-time equivalent (FTE) number of
workers employed in tobacco growing and other
aspects of the tobacco industry vary widely in the
Americas.

  After tobacco is harvested, the crop is processed
in various ways before being made into cigarettes and
other consumer products. This processing includes
sorting and grading, curing and drying, and destemm-
ing the raw tobacco leaves. In most countries, these
activities occur in agricultural areas and are included
in statistics for the agricultural sector. In other coun-
tries, some of these activities are associated with the
initial stages of the manufacturing process and are
included in statistics for that sector.

  Many features of the tobacco market make to-
bacco particularly attractive to growers in many coun-
tries.  First, and most important, when tobacco is
grown extensively, it yields a higher net income per
unit of land than most other cash crops and substan-
tially more than most food crops. In addition, price
does not fluctuate substantially for tobacco as it does
for other cash crops.  Moreover, in most countries,
tobacco growers protect themselves from the unex-
pected price fluctuations that plague other crops by
negotiating sales prices for crops before planting;
growers are paid in cash immediately upon sale (Econ-
omist Intelligence Unit 1983). The combination of
prenegotiated price and quick sale makes tobacco
growing easy to finance. The extremely favorable
conditions of sale offered to tobacco farmers are not
usually offered to growers of other crops. Various
combinations of government and transnational tobac-
co company activities, including controls on planting,
production quotas (guaranteed prices, incentives, and
subsidies), import duties, state tobacco monopolies,
state trading in tobacco, foreign aid programs, and
limitations on marketing, benefit tobacco growers in
many countries. As a result, much of the risk of tobac-
co growing is shifted from the farmer to the purchaser.

  Although tobacco provides most farmers with
higher gross returns per hectare than many other
crops do, considerable costs are associated with to-
bacco growing. In addition to being labor intensive,

tobacco cultivation requires large amounts of fertiliz-
ers and pesticides, and in many areas, fuel (wood, gas,
or oil) is needed for tobacco curing. The U.S. Depart-
ment of Agriculture (USDA) estimated that, excluding
land and quota cost, the cost of growing flue-cured
tobacco in the United States in 1990 amounted to 70
percent of the value of the crop produced (Clauson
and Grise 1990). In examining the opportunity costs
of tobacco growing in Brazil in terms of alternative
crops, Barrows (unpublished) found that the value that
labor employed in tobacco growing would have in alter-
native activities is the most important factor in deter-
mining the profitability of tobacco.  Barrows
estimated that in 1986 in Rio Grande do Sul, total
returns to land, labor, and management for tobacco
were 130 percent of those for maniac and 118 percent
for potatoes. However, cultivation of tobacco re-
quired 7.5 times as many man-hours of labor as man-
ioc did and 5.3 times as many man-hours as potatoes
did. Accordingly, all of the apparent additional re-
turns to the tobacco grower were in fact returns to the
additional labor invested, and the actual profitability
and net social benefit of the tobacco crop depended on
the wage rate and the potential alternative uses of the
labor employed in tobacco growing.

Manufacturing

  Most of the tobacco grown worldwide is flue-
cured and processed on the farms. Tobacco is then
manufactured into cigarettes, cigars, smokeless tobac-
co products, and loosely cut smoking tobacco. About
85 percent of worldwide tobacco production is used
for cigarettes. Flue-cured tobacco accounts for almost
60 percent of the tobacco in American-style cigarettes
and all of the tobacco in British-style cigarettes.

  The manufacturing of cigarettes provides sub-
stantial employment in many countries, but the labor
intensity of cigarette manufacturing varies consider-
ably by country. In the United States, production is
highly automated; seven factories produce enough
cigarettes for the domestic market and for the large
and growing export market. In Latin America, ciga-
rette manufacturing is less automated and more labor
intensive (Table 9). Cigar manufacturing is more
labor intensive than cigarette manufacturing, which is
reflected in the employment figures for countries that
are important producers of cigars (e.g., Cuba and the
Dominican Republic).

Distribution

  Tobacco is distributed in many forms. Ciga-
rettes are sold in cartons of 10 packs and in packs of 10,
15,20, and 25 cigarettes. In many areas, street vendors

Economics   121


sell cigarettes individually from broken packs. In
some countries, cigarettes are sold by tobacconists;
however, cigarettes and other tobacco products are
typically sold by retail merchants who also sell a
variety of other consumer goods. Accordingly, in
most countries, total employment in tobacco distribu-
tion is many times FTE employment because tobacco
sales represent a small part of the employees' jobs
(Table 9).

   Distribution in the tobacco sector is a small com-
ponent of larger distribution activities in most econo-
mies. Although attributing some proportion of
employment to tobacco distribution activities is statis-
tically appropriate, such attribution may be inappro-
priate for analytic reasons. In the absence of tobacco
products, consumers would purchase alternative
goods, and the production of these goods would result
in employment-not only in the distribution sector
but in the manufacturing and farming sectors as well.
Although the level and type of employment generated
by alternative consumption patterns may change with
changes in the tobacco sector, total employment
would not change significantly. Some persons, how-
ever, may be affected by shifts in consumption pat-
terns; some persons may become unemployed, and
some may change jobs or job activities.

  The tobacco industry also creates output in other
parts of the economy-both directly, by creating de-
mand for products such as fertilizers, fuel, and paper
used in the manufacture of tobacco products, and
indirectly, when persons employed in the industry
spend their earnings for their own consumption.
Every economic activity, however, has both direct and
indirect links to other economic activities. The exact
nature of the links differs among industries and coun-
tries, but the net aggregate effect of shifts in demand
into or out of specific industries is small, except per-
haps for some transitional costs. Exceptions may
occur, however, for factors that receive higher-than-
normal returns (called "rents" by economists) from a
specific activity. Such factors are particularly disad-
vantaged by a reduction in rent-producing activity;
however, even their losses are balanced by gains to
other factors of production or to consumers.

Trade

  Most tobacco is consumed within the country of
production; only 25 percent of world production is
traded internationally, primarily as a raw commodity.
Only the United States, the United Kingdom, and the
Netherlands are important exporters of cigarettes, and
the United States is the leading cigarette exporter-at
25 percent of the worldwide total. In addition, the

United States exports much high-quality tobacco,
which in several countries, is blended with tobacco
from other sources to make the increasingly popular
American-style cigarettes. The United States imports
oriental tobaccoand other less-expensive filler tobacco
to blend with U.S.-produced tobacco to make ciga-
rettes for domestic consumption and export. Brazil,
another major tobacco exporter sells much of its crop
in Europe. On the whole, countries in the Americas
have a substantial balance-of-trade surplus in tobacco
(Table 10).

Subsidies to Tobacco Production

  Subsidization may be used in an attempt to de-
velop or protect a domestic tobacco industry or to
control the importation of cigarettes or tobacco to
conserve foreign exchange. The growing and curing
of tobacco is frequently controlled and directed by the
main tobacco purchasers-either large, private com-
panies or government agencies. In many areas, these
organizations set the price of tobacco before planting
and provide seeds or seedlings to tobacco farmers,
who are thus guaranteed a minimum income for their
crop at harvest time. These production controls are
primarily designed to encourage the production of a
limited amount of high-quality, marketable tobacco
(Lewit 1988).

  The situation in southern Brazil exemplifies an
industry-sponsored support program for tobacco
growers that has fostered the development of a tobacco-
growing sector. The cigarette manufacturers provide
the growers with all purchasable inputs-including
seed, pesticides, and fertilizers-at wholesale prices,
and maintain agricultural extension programs to de-
velop tobacco plants and technology appropriate for
the area. Farmers are visited regularly by technical
advisers provided by the tobacco companies. The
purchasers also control the chemicals used in growing
tobacco so that the crop will conform to U.S. and
European standards and be exportable (about 37 per-
cent of the Brazilian crop is exported) (Economist
Intelligence Unit 1983). The value of the extension
services rendered to farmers is estimated at 30 to 35
percent of the prices paid to farmers for the tobacco
(Economist Intelligence Unit 1983).

  A similar relationship exists in Venezuela among
the government, two tobacco processors, and several
hundred tobacco farmers. The farmers receive finan-
cial and technical aid from the companies, along with
guaranteed prices for crops. As a result, the compa-
nies have some control over the quality and quantity
of the tobacco crop, but the companies can also set
retail cigarette prices. The Venezuelan government

122 Economics

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

Country

   Imports              Exports
Total    Percentage of      Total    Percentage of     Trade
value    all imports       value    all exports     balance

0.1
1.3

0.6
1.7
0.1
0.6
<O.l
1.0
3.5
<O.l
<O.l
1.4

North America
Canada+            51,066        0.1         97,579
United States+         734,082       0.3       2,658,053
    Subtotal         785,148              2,755,632

Latin America
Argentina            1,210       <O.l         46,310
Brazil                  140       <O.l        468,570
Chile                 800       <O.l         4,200
Colombia            9,681        0.2         22,243
Costa Rica               312       <O.l            521
Cuba                  375       <O.l         64,866
Dominican Republic       1,687       0.1         30,872
Ecuador             1,900        0.1            993
El Salvador            1,041        0.1            510
Guatemala            1,000       <O.l         16,099
Haiti               4,100        0.9               -
Honduras            3,170        0.3         15,562
Mexico              6,290       <O.l         30,420
Nicaragua               137       <O.l          4,222
Panama             1,458       0.1         1,873
Paraguay            8,964        1.7         14,653
Peru               3,173       0.1            292
Uruguay             4,842       0.6         1,136
Venezuela            1,140       <O.l         14,380
    Subtotal          51,420                737,722

Caribbean
Guyana                695       0.1
Jamaica             4,868        0.4         14,750
Trinidad and Tobago      6,723        0.4            318
    Subtotal          12,286                15,068

    Total           848,854              3,508,422
Source: Agro-economic Services Ltd. and Tabacosmos Ltd. (1987); Chapman and Wong (1990).
Unmanufactured tobacco only; in U.S. dollars.
`1983 data.

2.1
1.3
1.1
0.7
4.4
<O.l
0.1
0.1

-
1.9
<O.l

provides tobacco farmers with subsidized inputs and
low-inteiest loans but receives a steady stream of tax
revenues from a 50 percent tax on retail cigarette sales
(Tobucco International 1989).

  Canadian tobacco manufacturers offer subsidies
to Canadian tobacco growers, which allow growers to
competitively price Canadian leaf for export (Col-
lishaw, Kaiserman, Rogers 1990). But in a unique turn
of events, the Canadian government developed a sub-
sidy program to downsize the Canadian tobacco in-
dustry (Collishaw, Kaiserman, Rogers 1990).

+46,513
+1,923,971
+1,970,484

+45,100
+468,170
+3,400
+12,562
  +209
+64,491
+29,185
  -907
  -531
+16,753
-4,100
+12,392
+24,130
+4,085
  +415
+5,689
-2,881
-3,706
+13,240
+686,302

-695
+9,882
-6,405
+2,782

+2,659,568

  In Argentina, a levy on cigarette sales is used to
finance a fund to support tobacco prices, but the fund
is fairly static. Support prices have tended to fall as
output increased, which has resulted in inadequate
incentives to sufficiently increase crop quality for an
export market (FAO 1990).

  In other countries, such as the United States,
tobacco production is encouraged by the establish-
ment or support of high prices and the institution of
production controls to avoid excess supplies. Since
1933, USDA has operated a tobacco price-support

Economics   123


program to increase the returns to tobacco cultivation
(Warner 1988; Congressional Research Service 1989).
Although the program was revised substantially in
1986, it still controls supply to reduce U.S. production
and supports higher-than-free-market prices of U.S.
tobacco for both domestic and foreign consumption.
The current program also restricts the location of to-
bacco farms in the United States (Grise 19881, which
probably makes U.S. tobacco production more costly
than it might otherwise be.

  Subsidization may introduce distortions into the
tobacco market. By making tobacco growing more
profitable to the farmer than it would be if prices were
determined solely by market forces, subsidization en-
courages a shift of resources from other crops to to-
bacco. In competitive markets, such a resource shift
would lead to an expansion in supply and an equili-
brating fall in price. When supply is controlled and
unable to expand, price does not fall, and farmers earn
excess profits for their production. Many developing
countries also attempt to discourage importation of
foreign tobacco (either in raw form or as cigarettes) by
setting bans, quotas, or high tariffs. Consequently,
prices received by tobacco growers in these countries
are likely to be above free-market prices; domestic
production becomes stimulated; and tobacco farmers'
incomes increase.

  Excess profits, or rents, encourage producers to
organize politically to protect themselves against in-
creases in supply, falling prices, and government cam-
paigns designed to discourage smoking. Such
rent-seeking behavior has been observed in markets
for many products around the world (Tollison 1982)
and should be considered a consequence of most reg-
ulatory and subsidy policies. Furthermore, the net
effect of programs that limit tobacco importation or
production is beneficial to domestic producers but at
the expense of consumers. These programs do not
confer a net benefit on the country as a whole and only
transfer income between groups. However, because
such measures usually increase cigarette prices and
may decrease cigarette quality, consumption may be
reduced. But high tariffs and import restrictions can
encourage the growth of an illegal market in smuggled
cigarettes.

  Although no official trade statistics estimate the
size of the world market in illegally traded tobacco
products, these statistics indicate that from 1984
through 1986, exports were 13 percent greater than
imports (FAO 1990) (see also Chapter 2, "The Emer-
gence of the Tobacco Companies"). Cigarettes smug-
gled from the United States have been a problem in
several Latin American countries over the years, most

recently in Colombia (Nares 1984). Cigarette smug-
gling also appears to be a problem in Uruguay and
Paraguay, and the growing disparity in cigarette taxes
between the United States and Canada has increased
the incidence of border crossings to purchase ciga-
rettes in conveniently located duty-free shops in the
United States (USDA 1990). Illegal reimportation of
Canadian cigarettes is also becoming increasingly
common. Canadian cigarettes smuggled back into
Canada from the United States accounted for an esti-
mated 1 to 4 percent of total Canadian cigarette con-
sumption in 1990 (Collishaw, personal communication
1991).

  The United States is the world's second largest
tobacco producer (after China) and the largest ex-
porter of tobacco. U.S. tobacco exports accounted for
18 percent of all nonmanufactured tobacco traded
internationally in 1984 to 1986, down substantially
from the 35 percent market share held in 1955 to 1959
(FAO 1990). Spillover effects of the U.S. tobacco price-
support program affect the development of tobacco-
growing sectors in many developing countries.
Higher-than-free-market prices, received by U.S. to-
bacco growers as a result of the U.S. tobacco program,
benefit the growers and entitlement holders (those
with permits to grow tobacco) at the expense of do-
mestic and foreign consumers. These high prices also
create opportunities for foreign producers to profit-
ably produce tobacco for both domestic consumption
and export (sometimes to the United States). U.S.
tobacco, although very expensive, is perceived to be of
high quality. Accordingly, a substantial fall in the
price of U.S. tobacco could have a significant impact
on the world market.

   Sumner and Alston (1984) have estimated that
elimination of the U.S. tobacco-support program
would very conservatively result in a 50 percent in-
crease in U.S. tobacco production and a 25 percent
reduction in the price of U.S. tobacco. Very little of this
increased production would be absorbed in the United
States or abroad through increased consumption of
cigarettes. Some of the tobacco (27 percent) would
substitute for that currently imported by the United
States, but most (73 percent) would be exported (Sum-
ner and Alston 1984). The excess U.S. tobacco would
be highly competitive with tobacco produced in other
countries, and as a result, tobacco growing would
become much less profitable in other countries. In
fact, an increase in U.S. tobacco exported or substi-
tuted for imports could be devastating to developing
countries that depend on tobacco export earnings for
foreign exchange. Tobacco exported by developing
countries amounts to over one-third of the current
export market (Lewit 1988).

124   Economics


  The various subsidies provided to many tobacco
producers make the evaluation of tobacco-production
policies complex, and each case should be examined
individually to determine the true "benefits" of to-
bacco production. The vulnerability of tobacco expor-
tation and prices to changes in U.S. farm policy is
difficult to value, but tobacco-development projects
should be evaluated in terms of potential changes to
this policy. Tobacco production is profitable in many
countries primarily because it allows participation in
a subsidized market established by USDA. Thus, the
subsidization of U.S. producers has created an oppor-
tunity for subsidization in other tobacco-producing
countries as well.

Contribution of Tobacco to Economic
Growth and Development

  Tobacco production can contribute to economic
growth and development directly by raising national
income and investment and indirectly through
various spillover effects. Heavily subsidized tobacco
production enables transfer of resources from tobacco
consumers to producers. When producers are con-
centrated in developing countries and consumers are
concentrated in the developed world, this transfer
tends to raise incomes and stimulate growth and in-
vestment in the developing countries. For example,
Brazil, the second largest tobacco exporter in the world
(after the United States), accounted for more than 14
percent of all tobacco exported in 1989. Most of
Brazil's tobacco exports are sent to the United States
and Western Europe (USDA 1985). Brazil obtains an
above-market price for tobacco exports, due to sub-
sidy programs in other countries, and profits from this
exportation.

  Because tobacco is readily marketable, invest-
ments in agricultural projects supporting tobacco
production are usually self-liquidating, and in the
past, such investments may have been thought attrac-
tive by international development agencies, which
financed projects designed to enhance tobacco pro-
duction in Latin America and the Caribbean (Chap-
man and Wong 1990). Such financing is currently
under review by some international lenders because
of concerns about the long-term health effects of en-
couraging tobacco-industry growth in developing
countries.

Externalities

  Several positive externalities, or technologic spill-
over effects, have been associated with both tobacco
growing and manufacturing. Improvements in farm-
ing practices, for example, have increased yield from

not only tobacco but other crops as well because many
of the modern farming procedures introduced for to-
bacco growing can also be applied to other crops
grown in rotation with tobacco (Sofranko, Fliegel,
Sharma 1976; Economist Intelligence Unit 1983). Pro-
ducing a tradable tobacco crop requires a high degree
of quality control, and in many countries, tobacco
purchasers provide the technical support and inputs
necessary for a high-quality crop. Furthermore, man-
ufacturing and marketing of tobacco products may
require highly trained workers to maintain and sup-
port modern factories in developing countries (Philip
Morris International Inc. 1988). The training, except
for that specific to tobacco production, helps to in-
crease the supply of sophisticated managers and tech-
nicians. These positive externalities, however, could
probably be achieved for many other commodities as
well.

  One potentially negative externality is deforesta-
tion associated with curing tobacco. Several early re-
ports indicate that curing with wood requires felling
one tree per 300 cigarettes (Muller 1978). Stated in
other terms, one hectare of woodland is required to
cure either one hectare (Eckhold et al. 1984) or one-half
hectare (International Agricultural Development
1984) of tobacco. The latter source also estimates that
one in 12 trees cut worldwide is used for curing to-
bacco. These estimates correspond to a specific fuel
consumption (SFC) of between 100 and 230 kg of wood
per 1 kg of tobacco.

  The only multicountry analysis of deforestation
associated with the curing of tobacco was commis-
sioned by the International Tobacco Information Cen-
tre (an industry-sponsored group) and was performed
by the International Forest Science Consultancy (Fra-
ser 1986). For the few countries examined, the re-
searchers estimated that the SFC for individual farms
ranged from 2.5 to 40 kg/kg (average of 7.8 kg/kg)
and that the SFC for Brazil was 15 to 20 kg/kg. Over-
all, the report estimated that in tobacco-growing, de-
veloping countries, only 0.7 percent of trees cut for all
purposes are cut for tobacco curing. Because no avail-
able data question these findings, deforestation asso-
ciated with tobacco curing cannot currently be
considered a significant negative externality, although
deforestation in general is a major concern in many
parts of Latin America.

Price, Production, and Substitution

  A decline in the price of tobacco, which would
discourage production, would occur if demand for
tobacco were significantly reduced or if the subsidies
and tariffs that support tobacco production were

Ecotlomics   125


reduced. Worldwide, a significant excess supply of
tobacco would result if production controls were
relaxed (FAO 1990). The substantial price reduction
that would probably result from this excess supply
would make tobacco growing less profitable than it
currently is.

  As described earlier, tobacco produced for ex-
port allows a country to participate in a subsidized
international market and capture some of the eco-
nomic transfers between consumers and producers
that occur in such markets. Such participation may
benefit a country's net income, provided that no seri-
ous externalities are associated with tobacco produc-
tion. When tobacco is produced for domestic
consumption, however, most subsidies enjoyed by
domestic producers are financed by domestic con-
sumers, and domestically financed subsidies are likely
to encourage rent-seeking behavior. Such behavior
may in turn lead to increased efforts to protect the
domestic market from foreign competition. It may
also result in attempts to encourage tobacco consump-
tion and restrain policies designed to discourage con-
sumption for health reasons. However, the higher
prices that result from controls on supply may alone
reduce consumption.

  Tobacco production has also been encouraged to
allow substitution for imported tobacco. Economic
development through import substitution was a pop-
ular economic policy in South America in the 1950s
(Fishlow 1990). For the tobacco sector, this policy may
appear attractive in the short term because import
substitution saves on foreign exchange, creates em-
ployment, and shifts the subsidy paid by consumers
from foreign suppliers to domestic producers. The
development of a domestic tobacco sector almost cer-
tainly results in increased tobacco use because of a
decline in tobacco's real price. In addition, develop-
ment of a domestic sector makes it more difficult for a
country to mount successful antitobacco campaigns
because domestic producers rather than foreign sup-
pliers are affected. Because of these conflicting inter-
ests, the measurement of the net costs or bene-
fits associated with developing a domestic sector is
difficult and must reflect the idiosyncrasies of each
country.

  Increased support for the production of crops
other than tobacco might effectively control tobacco
production (Warner et al. 1986). For example, some
farmers in the tobacco-growing area of southern Brazil
choose not to grow tobacco because of the large labor
input required (Economist Intelligence Unit 1983),
which suggests that tobacco may be only marginally
advantageous for many growers in that area. But a

policy of support for other products must be carefully
considered for each country. In some areas, alterna-
tives to tobacco growing are feasible. For example,
vegetables (such as tomatoes1 have been suggested as
alternatives in North Carolina. However, because of
soil and climatic conditions, the cultivation of other
crops in other areas may not be economically viable.

  Market response to attempts to substitute other
crops for tobacco may complicate this policy. In-
creased production of alternative crops may lead to a
fall in their prices, which not only makes them less-
attractive substitutes for tobacco, but also harms tra-
ditional producers of these crops. Similarly, a decline
in tobacco production by established producers may
merely produce opportunities for competitors to initi-
ate or increase production. Given the potential excess
supply of tobacco in many countries, programs that
encourage production of alternative crops will proba-
bly require strict controls to successfully reduce to-
bacco production. The main attraction of such policies
may be that they provide a politically acceptable way
to "buy off" tobacco growers. By offering growers an
acceptable, profitable alternative to tobacco, policies
designed to reduce the demand for tobacco may be
easier to implement.

  In 1987, Canada instituted a C$30 million to-
bacco diversification plan, and by 1990, about C$80
million had been allocated to the plan. One compo-
nent of the plan, the Alternative Enterprise Initiative
Program, focuses on the development of alternative
crops and production technologies to benefit tobacco-
growing regions (predominantly Ontario). A second
part of the program offers cash incentives to encour-
age tobacco farmers to retire from the industry (USDA
1987a,b). The Canadian government has only recently
begun to evaluate this program; anecdotal evidence
suggests, however, that most retired Canadian to-
bacco growers have found alternative employment
and that the local economy in the tobacco-growing
area of Ontario is flourishing (D&i News-Record 1990).
This trend in Canada is consistent with trends in the
United States where, even without a program de-
signed to underwrite downsizing, tobacco agricul-
tural employment declined by 20 percent between
1977 and 1985 (U.S. Bureau of the Census 1988). From
1979 to 1989, U.S. tobacco acreage declined by 16
percent, but because of an increase in yield per acre,
production fell by only 4 percent. To some extent, the
shifts in U.S. tobacco production during the 1980s
reflected changes in the USDA crop-support program,
which reduced prices to make U.S. tobacco more com-
petitive in international markets and bring supply and
demand into better balance.

126   Economics


Future of Tobacco Production

  Health considerations aside, the case is weak for
promoting long-term, worldwide increased tobacco
production for economic reasons. Although tobacco
is often a very profitable crop, much of its advantage
stems from the various subsidies, tariffs, and supply
restrictions that support its high price and provide
economic rents for its producers. If the U.S. tobacco
price-support program, which is an important deter-
minant of the price of tobacco in international markets,
were abolished or radically altered, foreign tobacco
producers might have to contend with a massive in-
crease in the supply of U.S. tobacco and a fall in
tobacco prices that would make tobacco production
much less profitable.

  Other changes in the world tobacco market may
also make tobacco a much less attractive crop. At
present, despite substantial growth in tobacco con-
sumption in China, which has a self-sustaining mar-
ket, worldwide per capita consumption of tobacco is
projected to be similar in the year 2000 to that in 1974
to 1976 (FAO 1990). Demand for tobacco in the major,
developed countries has been decreasing because of
health concerns. Therefore, even without a major shift
in U.S. tobacco policy, tobacco-exporting countries
may find it increasingly difficult to market their crop
to their traditional markets in economically developed
countries. In closed markets or in developing coun-
tries, this difficulty may put pressure on prices and
cause countries to look for domestic outlets for their
tobacco crops.

  The economic implications of shifts in interna-
tional tobacco markets could be significant. When
producers are concentrated in the less-developed
countries, as they now are (except for the United
States), and their customers are concentrated in the
developed world (primarily Europe and Japan), the
income transfer may benefit the developing countries.
If developing countries begin trading tobacco among
themselves, the transfers would benefit the recipients
at the expense of other developing countries, and no
net gain would result for less-developed countries as
a group. This intercountry transfer would be similar
to that which results when high tariffs and import
restrictions benefit domestic producers at the expense
of domestic consumers.

  The U.S. tobacco industry recently opened mar-
kets for U.S.-manufactured cigarettes in Japan, South
Korea, and Taiwan (Council on Scientific Affairs
1990). Previously, sales of U.S.-manufactured ciga-
rettes and, to a lesser extent, U.S. tobacco were re-
stricted by these countries to protect their domestic
industries. The Canadian tobacco industry is also

looking for foreign markets in which to develop or
expand to compensate for the decline in the Canadian
cigarette market (Ontario Flue-Cured Tobacco
Growers' Marketing Board 1990). In China, if domes-
tic demand slackens, domestic health concerns in-
crease, or the desire to earn foreign exchange
develops, Chinese tobacco producers may enter the
international market and have a significant impact on
supply, exert downward pressure on tobacco prices,
and reduce returns for other countries.

  Regardless of future tobacco policies in the
United States and China, a significant, excess supply
of tobacco is possible. Many policies have been insti-
tuted to constrain the supply of tobacco and support
current prices. Increased demand for excess tobacco
is likely to come from developing countries, but de-
mand will depend on rates of growth in income and
on government tobacco policies.

Tobacco Taxation

  Almost all countries levy taxes directly on to-
bacco products, mostly on manufactured cigarettes
and imported tobacco. In some countries, the right to
manufacture, distribute, and import tobacco products
is reserved for a government monopoly. In such coun-
tries, the excess profits of the monopoly are a form of
indirect taxation on tobacco, in addition to the taxes
nominally levied.

  Taxes may be extracted during most stages of
tobacco processing. Import tariffs and customs duties
are frequently levied on both raw tobacco and
manufactured tobacco products. In many countries,
some brands of manufactured cigarettes are made
from tobacco blends, which include imported tobac-
cos. As a result, an import duty is usually included in
the price of these cigarettes. In addition, imported
cigarettes, usually American or European brands, are
available in many countries. Because of high tariffs,
these imported cigarettes sell at a substantial premium-
when compared with domestically produced ciga-
rettes, including domestically produced versions of
international brands licensed by the large multina-
tional tobacco companies. In addition to import du-
ties, many countries levy excise taxes on domestically
produced tobacco products and levy value-added,
general sales, and general business income taxes.

  Tobacco taxes are popular primarily because of
their low administrative cost relative to generated
revenues. Tobacco taxes are easy to collect because
most tobacco passes through only a few physical loca-
tions (cigarette factories and/or ports of entry) during
manufacturing. In countries where tobacco production
and distribution are government controlled, the

Economics   127


government may set the margins received by retailers,
as well as the prices paid to the various factors of
production. Because these prices are frequently set
administratively, rather than by the market, judging
the net profitability of the government tobacco mo-
nopoly or determining the extent of the subsidies paid
to the various production factors is difficult.

   While in some countries tobacco taxes account
for a substantial amount of all central government tax
revenues (Chapter 6, Table 21, in the United States and
Canada, these taxes account for only about 2 percent.
In 1985, income tax collections accounted for less than
1 percent of GDP in Argentina (Dornbusch and De
Pablo 1990) but almost 10 percent in both the United
States and Canada (The World Bank 1987). In Argen-
tina, a country of more than 30 million residents, only
1.5 million residents were registered taxpayers, and
only 29,000 persons actually paid any tax. Tobacco
taxes accounted for 4 percent of GDP in Argentina in
1985 (Achutti, personal communication 1990).

  Recently, taxes of all kinds have not been an
important source of finance for government opera-
tions in some Latin American countries. In these
countries, government operations are largely financed
by printing money, which resuhs in inflation. Then,
the relative importance of tobacco taxes in public fi-
nance is reduced, and if tax rates are not adjusted to
an increase in the cost of living, the real value of
tobacco taxes and retail prices may fall substantially.

  Tobacco taxes and tariffs may be either unit or
ad valorem taxes. Unit taxes are denominated at a
specific nominal rate per unit of a good (per cigarette,
per pack of 20 cigarettes, per kilogram of tobacco) and
are most susceptible to erosion in real terms as prices
increase. Even in countries such as the United States
and Canada, which have had a moderate rate of infla-
tion, unit tobacco taxes may decline over time if the
nominal tax rate is not increased enough to keep pace
with increases in the overall price level (Lewit 1988;
USDHHS 1989). To compensate for this tendency, the
Canadian cigarette tax was indexed in the early 1980s
to changes in the general price level. The Canadian
national tax is no longer indexed, but it has been
increased more rapidly than inflation in recent years,
In many countries, tobacco tariffs are ad valorem lev-
ies, which are denominated as a percentage of price
(e.g., a general sales tax). Ad valorem taxes tend to
track with inflation since the tax rises as the cost of
cigarettes increases. Although changes in the price of
imported tobacco may be captured by this mecha-
nism, little impact on cigarette prices may result be-
cause imported tobacco and tobacco products are a

small part of the tobacco market in most countries of
the Americas.

Subnational Taxes

  Local and provincial governments may also tax
tobacco products. In the United States, all states, the
District of Columbia, and many municipalities levy
taxes on tobacco products, and many also tax tobacco
products via general sales taxes. In recent years, the
amount of tobacco tax collected by all states combined
has been almost equal to that collected by the federal
government. In Canada, all provincial governments
also levy taxes on tobacco products, and these taxes
accounted for more than 50 percent of all tobacco taxes
collected in Canada in 1989 (Canadian Council on
Smoking and Health 1989). In Colombia, approxi-
mately 10 percent of the revenue of provincial govern-
ments is derived from levies on Colombian cigarette
sales (Nares 1984).

  Differences in cigarette tax rates among coun-
tries and subnational divisions can complicate the
enforcement of tax laws. In particular, big differences
in tax rates provide an incentive for smuggling-the
purchasing of cigarettes in low-tax jurisdictions for
consumption or resale in high-tax jurisdictions. Vari-
ous tax-evasion activities have been identified: buy-
ing cigarettes in neighboring lower-tax areas for
personal consumption; organized smuggling of ciga-
rettes for commercial resale; purchasing cigarettes
through tax-free outlets (international ports of entry,
military stores, and Indian reservations); and illegal
diversion of cigarettes within the traditional distribu-
tion system (forged tax stamps and underreporting)
(Advisory Commission on Intergovernmental Rela-
tions 1977).

  In the United States, as the differentials in state
tax rates increased rapidly during the late 1960s and
early 197Os, the level of cigarette tax evasion also
increased substantially. In response, the Federal Cig-
arette Contraband Act was enacted. Law enforcement
problems, stemming from organized interstate ciga-
rette smuggling, contributed to the deceleration of
state tax increases in high-tax states (Advisory Com-
mission on Intergovernmental Relations 1985). Be-
cause the range of real prices has declined among
states, interstate smuggling has become less profit-
able. This decline in profitability and increased fed-
eral enforcement have probably accounted for the
subsequent decline in cigarette smuggling (Advisory
Commission on Intergovernmental Relations 1985).

  International cigarette smuggling can have an
adverse impact on national tobacco companies and
reduce revenue for governments. In Colombia, where

128   Economics


cigarettes are subject to indirect taxation of up to 120
percent of the wholesale price, contraband U.S. ciga-
rettes have been smuggled into the country from the
United States, Panama, Venezuela, and the Caribbean
(Nares 1989; TobaccoInternaf'ional1989). The president
of Coltabaco (Cia. Colombiana de Tabaco S.A.), the
Colombian tobacco company, estimates that smug-
glers now control 35 percent of the national cigarette
market (Nares 1989). In Canada, citizens cross the
U.S.-Canadian border to purchase Canadian ciga-
rettes in U.S. duty-free shops. The increase in this
activity may be linked to recent substantial increases
in Canadian cigarette taxes (USDA 1990).

Effects of Excise Taxes on Smoking

  One nearly universal economic concept is the
law of downward-sloping demand-that is, the quan-
tity of a commodity demanded declines as the price
for that commodity increases. Numerous econo-
metric studies have confirmed that this law holds for
cigarettes, even though they are addictive, and the
relation has also been demonstrated for various addic-
tive drugs (Henningfield 1986). Because excise taxes
increase the price of cigarettes, such increases should
reduce the demand for cigarettes.

  An analysis of the price elasticity of demand for
cigarettes estimates the effect on consumption of a
change in excise tax rates. Price elasticity of demand
measures the degree of responsiveness of demand to
changes in price; it is the percent change in the quan-
tity of a good demanded, divided by the percent
change in price that caused the demand change. Thus,
an elasticity of -0.5 means that a 10 percent increase
(decrease) in price would reduce (increase) by 5 per-
cent the quantity of cigarettes demanded. To deter-
mine the effect of a tax change, the price elasticity of
demand must be multiplied by the percent change in
price that resulted from a tax change, since cigarette
taxes account for only a part of the total retail price of
cigarettes. The elasticity of demand with respect to a
tax change is generally less than the price elasticity of
demand.

  Numerous attempts have been made to measure
the price elasticity of demand for cigarettes (Table 11).
The estimates are from econometric studies that at-
tempt to explain differences in cigarette consumption
as a function of price, income, and demographic vari-
ables. Different data sets, units of observation, and
statistical techniques were used. Estimates were
derived from (1) time series of per capita cigarette
consumption for countries as a whole or for cross
sections of states or countries and (2) survey data on
the smoking behavior of cross sections of populations

at a point in time and over time. Each of these proce-
dures may result in problems of interpretation. In the
time-series studies, the estimates of both price and
income elasticity are sensitive to the construction of
the different models. In addition, time-series esti-
mates are frequently unstable because the indepen-
dent variables tend to be highly correlated with each
other. On the other hand, estimates based on cross
sections of tax-paid sales may be biased upward be-
cause some cigarettes sold in low-tax areas are con-
sumed by smokers in high-tax areas. As a result, the
estimated price elasticity of sales exceeds the price
elasticity of actual consumption.

  Data for participants in two national U.S. sur-
veys were used to evaluate the effects of price (tax)
differences on individual smoking behavior (Lewit,
Coate, Grossman 1981; Lewit and Coate 1982). For a
sample of 19,288 persons aged 20 to 70 from the 1976
National Health Interview Survey, the overall price
elasticity was estimated at -0.42 for cigarettes (Lewit
and Coate 1982). A more detailed breakdown sug-
gested that increased prices primarily reduced the
number of smokers (measured as prevalence, or the
participation rate) (Lewit and Coate 1982). The esti-
mated effects on the number of cigarettes consumed
per smoker were not statistically significant. Differ-
ences in the estimated price elasticity were also found
among groups; reported elasticity was much higher
for adult males than for adult females and much
higher for persons aged 20 to 25 than for those in other
age groups (Table 12).

  In a methodologically similar study, smoking
was analyzed for a national sample of 6,788 youths,
aged 12 to 17, surveyed between March 1966 and
March 1970 (Lewit, Coate, Grossman 1981). Because
antismoking messages were broadcast during this
period (under the Federal Communications Com-
mission's Fairness Doctrine), these researchers were
also able to investigate the effect of that policy on
teenage smoking. They reported that elasticity of de-
mand for cigarettes was greater in absolute value for
teenagers than for adults (Table 12). In addition,
smoking participation was more responsive to price
than was quantity smoked. The estimated teenage
smoking participation elasticity was -1.20, and the
elasticity for quantity smoked, conditional on smok-
ing, was -0.25.

  These results suggest that increases in tobacco
taxes can deter smoking. Since teenagers appear to be
more responsive than adults to changes in the price of
cigarettes, excise tax increases may be very effective in
preventing the onset of smoking by teenagers. By
preventing the onset of this addictive behavior,

Economics   129


Table 11.  Recent estimates of the price elasticity of demand for cigarettes

Reference

Walsh (1980)*

Lewit, Coate, Grossman (1981)

Lewit and Coate (1982)

Peturinen (1984)*

Advisory Commission on
Intergovernmental Relations (1985)

Bishop and Yoo (1985)

Mullahy (1985)

Radfar (1985)*

Collishaw, Myers, Rogers (1985)

Porter (1986)                          -0.27

Worgotter and Kunze (1986)*
Becker, Grossman, Murphy (1990)

Chaloupka (1990)                      -0.26

Townsend (1990)

Jacobson and Rodway (1990)
Studies mentioned in Townsend (1990).

  -0.40       Europe, 1987-l 988

LT -0.6 to -0.8     Canada, 1973-1988

`The first estimate is pre-1961, and the second post-1961.
sU.S. Health Examination Survey, Cycle III.
_National Health Interview Survey.
`khe first estimate is for a price increase, and the second for a decrease.
$T = Short term; LT = Long term.
National Health and Nutrition Examination Survey.

-0.42

-0.48"
-0.96

-0.45

-0.45

  -0.47

ST'-0.23
LT -0.39

ST -0.42
LT -0.91

  -0.54

LT -0.75

Estimated aggregate
price elasticity        Data, country, dates    ~__
  -0.79, -0.38+    Ireland, 1953-1976

   -1.44      HES III*
          12- to 19-year olds
            United States, 1966-1970

NHIS_
Elasticities by age and sex
20- to 74-year olds
United States ,1976

Finland, 1960-1981
Tested, 1982-1983

Pooled time series of state cross sections
United States, 1981-1983

Time-series aggregate data
United States, 1954-1980

NHISS bv sex
United Siates, 1979

United Kingdom, 1965-1980
(quarterly)

Canada, 1950-1982

Time-series aggregate data
United States, 1947-l 982

Austria, 1955-1983

Pooled time series of state cross sections
United States, 1956-1985
NHANES II*'
Full sample; also by age, sex, race, and
education
United States, 1976-1980

130   Economics


Table 12.

Age group
(years)

12-17

20-25

26-35

36-74

Estimates of the price elasticity of
demand for cigarettes in the United
States,* by age group

     Elasticity
Total Participation Quantity+
                   ..~-

-1.40     -1.20      -0.25

-0.89     -0.74      -0.20

-0.47     -0.44      -0.04

-0.45     -0.15      -0.15

All adults (20-74)  -0.42     -0.26      -0.10

All ages (12-74)   -0.47     -0.31       -0.11

Source:  Lewit and Coate (1982); Lewit, Coate, Grossman
$1981); Lewit (1985).
Calculated from source data.
`Elasticity for quantity smoked for persons who smoke.

prevalence of smoking and its associated detrimental
health effects would decline grkdually but substan-
tially over several decades-rather than in the years
immediately after a tax increase. In addition, since
price elasticity affects prevalence of smoking far more
than quantity smoked, attempts by smokers to com-
pensate for fewer cigarettes (by inhaling more deeply
and frequently, reducing idle burn and butt length, or
even switching to higher tar and nicotine brands)
appear to be relatively infrequent responses to price
increases.

  Formal estimates of the price elasticity of de-
mand for cigarettes in Latin America and the Carib-
bean are not readily available, and few data have been
gathered for other developing countries (Chapman
and Richardson 1990). In many developing countries,
the price elasticity of demand for all tobacco products
may be difficult to measure and may be much lower
than that for cigarettes. In response to a tax increase
on cigarettes, smokers may substitute lower-priced
tobacco products. In many Latin American and Car-
ibbean countries, the price of cigarettes varies widely
by brand, and smokers may respond to a tax (price)
increase by switching to a lower-priced brand. This
recently occurred in the Philippines; when cigarette
taxes were increased more on high-priced than on
low-priced brands, consumers switched to low-priced
brands. Total cigarette tax collections declined even
though the tax rate had been increased on all brands
(Singh 1988a,b,c,d). Marginal consumers may

respond to a tax increase by switching to "roll-your-
own" or homemade cigarettes. In addition, as noted
above, high taxes and tariffs encourage smuggling,
which may provide cigarettes at less-than-fully taxed
prices.

Modeling Addiction

  Although the addictive nature of cigarette con-
sumption has been recognized for some time
(USDHHS 1988), most economic studies of the
demand for cigarettes have not explicitly allowed for
addiction. The consumption of addictive goods in
general was not believed to conform to the rational,
utility-maximizing model that is the paradigm of
standard economic analysis. Recently however,
Becker and Murphy (19881, among others, have devel-
oped models of rational addiction that distinguish
between the consumption of addictive and nonaddic-
tive goods and that allow for economic analysis. The
Becker-Murphy models recognize that current con-
sumption of addictive goods depends on the level of
past and future consumption. The model accounts for
tolerance, reinforcement, and withdrawal-factors
that distinguish between use of addictive and non-
addictive substances (USDHHS 1988). With regard to
the price elasticity of demand for cigarettes, the
Becker-Murphy approach implies that lower past
prices and lower future prices lead to greater current
consumption and that the long-term response will
exceed the short-term response to a permanent price
change.

   To test the rational addiction model, Becker and
colleagues (1990) used a time series of cross-sectional
samples of U.S. per capita state tax-paid cigarette sales,
by state, for 1956 to 1985. The results demonstrated a
linkage across time periods between price and ciga-
rette demand. In particular, the authors found that a
10 percent permanent increase in the price of cigarettes
would reduce current consumption by 5 percent ini-
tially and by 7.5 percent over the long term.

  Using data for participants aged 18 to 74 in the
second National Health and Nutrition Examination
Survey, Chaloupka (1990) tested several implications
of the rational addiction model. The resultant esti-
mates of the price elasticity of demand were less than
those reported by Becker and colleagues (1990) and by
Lewit and Coate (1982); the latter analysis did not
explicitly allow for the addictive component in ciga-
rette demand.

  The application of the rational addiction model
to cigarette consumption is a recent development; fur-
ther investigation and refinement are required before
the contribution of the model to the understanding of

Economics   131


smoking behavior can be fully evaluated. The range
of estimates of the long-term price elasticity of ciga-
rette demand derived from the model are not incon-
sistent with previously published estimates; thus,
analyses of the effect of doubling the U.S. cigarette tax
in 1983 (discussed next) are not likely to be invalidated
by further refinement of the model.

Analysis of Recent Tax Increases

  After the federal excise tax on cigarettes was
doubled in 1983, total U.S. cigarette consumption de-
clined (Lewit 1988). Before 1982, retail cigarette prices
had been increasing more slowly than the general rate
of inflation, and as a result, the real price of cigarettes
was declining. In anticipation of the January 1,1983,
tax increase, U.S. tobacco companies increased the
wholesale price of cigarettes at regular intervals begin-
ning in August 1982 (see also Chapter 2, "The Emer-
gence of the Tobacco Companies"). From 1983 to
1991, the federal excise tax did not increase, but retail

cigarette prices continued to increase more rapidly
than the general rate of inflation-because of an
aggressive pricing policy of the tobacco companies
and increases in taxes in many states. Between 1981
and 1988, the price of cigarettes, adjusted for inflation,
rose by 57 percent. Based on a price elasticity of -0.42,
per capita consumption should have declined by
about 23 percent over this period (Figure 5). Data from
USDA indicate a decline of about 20 percent. US. per
capita cigarette consumption had been declining
slowly-about 1 percent per annum since the mid-
1970s. The very rapid acceleration in the rate of de-
cline-to about 3 percent annually after the excise tax
and associated price increases-is consistent with
Lewit and Coate's (1982) estimates and serves as fur-
ther evidence that excise taxes may be a potent tool for
reducing cigarette consumption.

  The Omnibus Budget Reconciliation Act of 1990
provides for two increases in U.S. federal excise taxes
on cigarettes and other tobacco products (USDA 1990).

Figure 5. Predicted and actual per capita (218 years of age) consumption of cigarettes, United States,
      1979-1988*

4poo-

3w-

3,60@

3poo-

3#200-

3poo-,

1982   1983   1984   1985    1986   1987    1988

  o Actual   + Predicted

Source: Crise and Griffin (1988); U.S. Department of Agriculture (1991).
`Actual values from source; predicted values calculated by Lewit (unpublished data). Predicted values are based
on a price elasticity of -0.42.

132   Economics


Figure 6. Per capita consumption and real price of cigarettes in Canada, 1982-1987

500

      0
      1982       1983        1984

Source:  ERC Statistics International Limited (1988).
*Relative cost per pack of cigarettes (1981= 1.0).

The cigarette tax was increased four cents per pack
beginning January 1,1991, and will increase an addi-
tional four cents on January 1,1993. The tax on snuff
increased from 24 cents per pound to 30 cents per
pound in 1991 and will increase to 36 cents in 1993.
Chewing tobacco tax will increase by eight cents per
pound (to ten cents) in 1991 and by 12 cents in 1993.
Taxes on other tobacco products were also increased.
Although it is still too early to judge the effect of these
taxes on tobacco consumption, the impact may not be
the same as that from the 1983 tax increase because of
the substantial increase in retail tobacco prices since
1982 (also discussed in Chapter 2, "The Emergence of
the Tobacco Companies"). The current tax increases
will result in a smaller percent increase in retail prices
than did the percent increase that accompanied the
1983 tax rise.

  In Canada, in part due to a very aggressive
antismoking campaign, both federal and provincial
cigarette excise taxes have increased substantially
since 1980 (Figure 6). The federal tax rose by 179
percent between 1980 and 1988, and provincial taxes

2.5

2.0

    cd
   2.
  8
1.5 g
K

1.0 z

0.5

0.0

1985        1986       1987

rose by an average of 367 percent during the same
period. Overall, the real price of a pack of cigarettes
almost doubled between 1982 and 1987, and per capita
consumption fell by more than 30 percent during the
same period.

  In Latin America, evidence of the impact of cig-
arette tax increases on consumption is found in Brazil,
where after years of rapid growth, per capita cigarette
consumption fell substantially in the early 1980s in
response to a large cigarette tax increase and a general
economic slowdown (USDA 19851. In developing
countries, income may play an important role in de-
termining smoking behavior. A decline in per capita
cigarette consumption in Peru and Bolivia in the 1980s
has been attributed to falling incomes in both coun-
tries (Chandler 1986).

Health Consequences of Tax Changes

  In some countries, a policy of aggressively in-
creasing cigarette taxes could lead to a large reduction
in smoking-related illness and an improvement in the
general level of health. The information on price and

Economics   133


income elasticity given here can be used to make
rough estimates of the health effects of changes in
tobacco taxation in the United States and Canada.

  Both Warner (1986) and Harris (1987) have pro-
vided crude estimates of some of the health effects that
might result from the 1983 U.S. federal tax increase.
Based on the conservative assumption that one of
every four lifelong smokers dies of smoking-related
illness (Mattson, Pollack, Cullen 1987), Warner calcu-
lated upper-bound estimates of the impact on mortal-
ity of increases or decreases in federal excise tax.
Warner estimated that an eight-cent tax increase,
maintained in real value over time, would avert
450,000 premature deaths among Americans aged 12
or older in 1984 and that this number would rise to
860,000 after a 16-cent increase.

  Harris estimated that as a result of the post-1983
tax-induced price changes and their impact on con-
sumption, 100,000 additional persons will live to age
65. About 54,000 of these persons are among the
600,000 teenagers who will live to age 65 as a result of
having been discouraged from starting to smoke.
Thus, for the 1983 U.S. federal tax increase, the main
effect on mortality will not be realized for decades.
Although no estimates have been published on the
impact of the tax increase on other health measures,
reductions in smoking-related morbidity and disabil-
ity should raise aggregate health levels long before the
projected reduction in mortality is fully realized.

  For other countries in the Americas, elasticity
estimates from the United States and Canada may be
misleading, and country-specific estimates are
needed. More precise estimates depend on additional
information about the number of persons who smoke
less, stop smoking, or do not start to smoke as a result
of tax changes. But the declining economy in Latin
America and the Caribbean and the attendant decline
in tobacco consumption suggest that excise taxes
could have a substantial impact on long-term morbid-
ity and mortality in the region. This supposition is
reinforced by the latency of the health effects of to-
bacco use (addressed earlier) and by the fact that the
tobacco epidemic is still immature in many countries
of Latin America and the Caribbean (Chapter 3,
"Smoking-Attributable Mortality in Latin America
and the Caribbean").

Equity, Incidence, and Distribution of the
Tax Burden

  Tobacco excise taxes are primarily a revenue-
generating device. As such, attention must be paid to
the distribution of the burden of these taxes among the
general population and to their impact on the economy.

Tobacco taxes are mainly collected from manufactur-
ers and distributors at the wholesale level. To the
extent that these businesses can raise the retail price of
cigarettes, they do not pay the tax but shift the inci-
dence of the tax burden to consumers. In addition, the
tax may lower the demand for tobacco, which would
result in lower tobacco prices (Sumner and Wohlgen-
ant 1985) and place some of the incidence of the tax
burden on tobacco growers.

  Because the tobacco tax is primarily paid by
smokers (Sammartino 19871, the distribution of the tax
burden in the general population mirrors the distribu-
tion of smokers. In the United States, as the health
hazards posed by tobacco use have become more well
known, tobacco consumption has decreased more
rapidly in higher than in lower socioeconomic groups
(USDHHS 19891. Consequently, tobacco consump-
tion has become more concentrated in lower socio-
economic groups, and tobacco tax increases, as a share
of income, would fall most heavily on these groups.
Sammartino (1987) analyzed the distributional ef-
fects of a hypothetical $1 billion increase in the U.S.
federal excise taxes on beer, wine, distilled spirits,
tobacco, gasoline, airfares, and telephone service and
concluded that an increase in the tobacco tax would be
the most regressive.

   In some Latin American countries, such as Bra-
zil, Uruguay, and Venezuela, prevalence of smoking
is also higher for lower socioeconomic groups (Chap-
ter 3, "Prevalence of Smoking in Latin America and
the Caribbean"). In these countries, tobacco tax in-
creases might also be regressive. In most other coun-
tries of the Americas, however, cigarette smoking is
positively correlated with income. Moreover, in most
Latin American and Caribbean countries, high-in-
come smokers are more likely than low-income smok-
ers to consume more cigarettes and purchase
expensive brards of cigarettes. When increased reve-
nues from tobacco taxes reflect expenditures on to-
bacco, the taxes may be proportional relative to
income even in countries in which smoking is more
common among the lower socioeconomic groups. To-
bacco taxation may be progressive in countries in
which smoking prevalence is positively correlated
with income. The actual incidence of tobacco taxes
must be determined for each country, and attempts to
make cigarette taxes progressive, as was recently done
in the Philippines, can be thwarted if high tax rates
cause smokers to substitute low-price/low-tax brands
for high-tax brands (Singh 1988a,b,c,d).

  Although the potential regressiveness of tobacco
taxes is a valid concern, the desire for proportional or
even progressive tax systems does not require that all

134 Economics


potentially regressive taxes be avoided. Most tax sys-
tems are a mix of many different taxes, and fairness
can be achieved by increasing progressiveness else-
where in the tax system to balance tobacco tax in-
creases or, perhaps more importantly, by directing
revenues to the maintenance of or increases in benefits
for low-income groups.

Use of Tobacco Taxes

  Health care costs and work-loss rates are greater
for smokers than for nonsmokers. In the United States
and Canada, both public and private insurance plans
provide much of the financing for health care and
disability benefits. Thus, increases in tobacco taxes
have recently been advocated as a form of user tax
(similar to the U.S. federal gasoline tax used to finance
highways) or as a corrective tax to compensate for the
additional health-related costs that smokers impose
on others.

  Several studies have attempted to measure the
medical care, morbidity, and mortality costs attribut-
able to smoking in a particular year. These estimates
(described earlier in this chapter) cannot be used to
establish the appropriate level of tobacco taxation be-
cause, in addition to several methodological limita-
tions, the estimates do not explicitly distinguish
between costs borne by smokers (e.g., the cost of pre-
mature death) and costs shifted to others (i.e., external
costs). Moreover, these estimates do not adequately
account for the social insurance benefits that non-
smokers realize but smokers do not because of their
premature death associated with smoking.

  Smokers tend to contribute to retirement plans
at the same rate as nonsmokers do, but they do not
collect, on average, the same total pension over a
lifetime as nonsmokers do. Smokers' uncollected pen-
sion claims revert to nonsmokers by increasing the
ratio of benefits to contributions that nonsmokers re-
ceive. In any particular country, the magnitude of the
burden of smoking-related costs borne by nonsmokers
is determined by the costs of the excess illness, the
morbidity and mortality caused by tobacco, and the
national system for financing health care, disability,
and retirement in that country. The key variable is the
amount of excess tobacco-related costs borne by non-
smokers relative to the rate of taxation on tobacco. In
reviewing the situation in Ontario in 1978, Stoddart
and colleagues (1986) found that, even with a govern-
ment health care system and high-technology medical
care, health care expenditures attributable to smoking
amounted to a maximum of 30 percent of the tax
revenue on tobacco products. They also concluded that

no uncompensated externality existed in Ontario in
1978. Collishaw and Myers (19841, using a different
methodology, also found that for Canada in 1979, total
tobacco taxes exceeded government-financed health
care costs attributable to smoking.

  In the most recent and comprehensive examina-
tion of the external costs of smoking in the United
States, Manning and co-workers (1989) found that
cross-subsidies, implicit in the current U.S. system for
financing health care, disability, and pension benefits,
transfer from never smokers to smokers and from
smokers to never smokers. Thus, on average, never
smokers subsidize the excess nonaged health care,
disability, and sick-leave benefits of smokers, and
smokers subsidize the Medicare and retirement bene-
fits (pensions and Social Security) of never smokers.
Manning and associates (1989) reported that their es-
timates of the net external economic costs of smoking
are quite sensitive to two parameters: the rate of dis-
count and the determination of which health differ-
,ences between smokers and never smokers are
actually caused by, rather than merely associated
with, smoking. Nonetheless, their best and high esti-
mates of the external economic costs of smoking fell
below the average excise tax (state plus federal) im-
posed at the time of their analysis, which suggested
that, at that rate of taxation, smokers probably com-
pensated for the costs of smoking imposed on never
smokers. Since the publication of their analysis, evi-
dence of additional hazards of passive smoking has
been reported (Glantz and Parmley 1991). Such evi-
dence suggests that the net costs that smokers impose
on never smokers in the United States may have been
underestimated.

   No known studies from other countries in the
Americas evaluate the excess financial burden im-
posed on never smokers by smokers. However, un-
compensated financial externalities may be sub-
stantial in countries at the upper end of the income
scale where life expectancy and patterns of tobacco
consumption are similar to those in the United States
and Canada. In the few countries at the lower end of
the income scale, such uncompensated externalities
may be minimal for two reasons: (1) in the absence of
well-organized institutional support systems, the ex-
cess costs of smoking are unlikely to be shifted from
smokers to never smokers and (2) the total cost of
smoking-related illness may be low if life expectancy
is short (as in Bolivia and Haiti [PAHO 199011, if many
competing causes of disease and death are operative,
if smoking is a recently introduced activity, or if med-
ical care is inexpensive.

Economics   135


  The essence of the argument for tobacco taxes is
that tobacco-related illnesses may impose an uncom-
pensated burden on never smokers regardless of their
income class. If, however, smoking is positively cor-
related with income, smoking-related illness is more
likely to occur among persons higher in the income
distribution.  Hence, increases in smoking-related
illnesses may result in a shift in health care resources
to provide expensive hospital-based care for affluent
smokers. If such a shift occurs at the expense of health
programs for low-income groups, it may have an un-
desirable effect on the health of the disadvantaged and
on the total income distribution, including transfers
(Lewit 1988). As a means of addressing this particular

Conclusions

inequity, high tobacco taxes might be justified,
whether they discouraged smoking or were used to
finance excess health care for smokers.

  Another justification for a high tobacco tax is
that, to smokers or potential smokers who lack complete
information on the dangers of tobacco use, the tax may
signal the total costs of tobacco use, including the costs
of ill health. An increase in tobacco taxes could im-
prove health by discouraging tobacco use among per-
sons who would not have used tobacco if they were
fully informed. The effect would be particularly ben-
eficial if it interfered with the initiation of tobacco
use-before smokers became addicted.

1.  Because the health costs of tobacco consumption
result from cumulative exposure, they are most
pronounced in the economically developed
countries of North America, which have had
major long-term exposure. Since many countries
of Latin America and the Caribbean are experienc-
ing an epidemiologic transition, the economic im-
pact of smoking is increasing.

2.  The economic costs of smoking are a function of
the economic, social, and demographic context of
a given country. In the United States, estimated
  total lifetime excess medical care costs for smokers
exceed those for nonsmokers by $501 billion-an
average of over $6,000 per current or former
smoker. Similar formal estimates for many Latin
  American and Caribbean countries are not available.

3.  Evidence of the cost-effectiveness of smoking con-
trol and prevention programs has increased. In
Brazil, for example, the cost of public information
and personal smoking-cessation services is esti-
mated at 0.2 to 2.0 percent of per capita GNP for
each year of life gained; treatment for lung cancer
costs 200 percent of per capita GNP per year of life
gained.

4.  In Latin America and the Caribbean, as GNP in-
creases, cigarette consumption increases, particularly
  at lower income levels. This effect is attenuated at
higher income levels.

5.  Advertising tends to increase consumption of cig-
arettes, although the relationship is difficult to
quantify precisely. Advertising restrictions are
generally associated with declines in consump-
tion and, hence, are an important component of
tobacco-control programs.

6.  The case for promoting increased tobacco produc-
tion on economic grounds should be reconsid-
  ered.  Although tobacco is typically a very
profitable crop, much of the advantage of produc-
ing tobacco stems from the various subsidies, tar-
iffs, and supply restrictions that support the high
price of tobacco and provide economic rents for
tobacco producers. Although the tobacco indus-
try is a significant source of employment, produc-
tion of alternative goods would generate similar
levels of employment.

7.  Increases in the price of cigarettes, which are a
price-elastic commodity, cause decreases in smok-
ing, particularly among adolescents. Excise taxes
may thus be viewed as a public health measure to
diminish morbidity and mortality, although the
precise impact of taxes on smoking will be influ-
enced by local economic factors.

136   Economics


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Economics   242


Chapter 5
Legislation to Control the Use of Tobacco
in the Americas

Preface   145

Introduction   147
Purposes of Legislation   147
Method of Analysis   147

Legislation to Control Production, Manufacture, Promotion, and Sales   148
Control of Advertising   148
North America   149
Latin America   150
Caribbean   150
Requirements for Health Warnings and Statement of Tar and Nicotine Yield   150
North America   151
Latin America   152
Caribbean   152
Restrictions on Sales to Adults   152

Legislation to Change Smoking Behavior   253

Control of Smoking in Public Places   153
North America   153
Latin America   154
Caribbean   154
Control of Smoking in the Workplace   154
North America   156
Latin America   157
Caribbean   157
Preventing Young People from Smoking   157
North America   157
La tin America   158
Caribbean   158
Mandating Health Education on Tobacco   158
North America   159
Latin America   161
Caribbean   161
Model Legislation   161

The Impact of Antitobacco Legislation   161

Conclusions   162

Appendix 1. Notes to Tables   163

Appendix 2. Legislation Reviewed for the Americas   169

References   175


Preface

  Governments express their will fhrough legislation and regulation. Historically,
many public health issues have been managed by governmental rule making. Some of the
major scientific advances of recent years haue been translated into public health pracfice
through thegradual dezlelopment of sanitary codes, public health laws, or equiz,alent sets of
regulations.

  In recent years, the pace of enacting legislation to prezlent and control tobacco use has
accelerated. The current status of tobacco-control legislation in the Americas is reuiewed
in this chapter, and a comprehensive set of current legal citations is provided for selected
countries of the Americas.

Legislation

145


Introduction

  Ninety-one countries worldwide have enacted
legislation to control tobacco use (Roemer, in press).
Less than one-third of these countries are in the Amer-
icas, and their laws vary in scope and rigor. Com-
prehensive laws, which provide a wide range of
control, are rare; most laws in the Americas are cate-
gorical and deal with one or another aspect of tobacco
promotion and use. Restrictive legislation has gener-
ally been enacted at the national government level,
but the potential of subnational legislation is reflected
in the large number of restrictive laws, ordinances,
and bylaws enacted by state or provincial and local
governments in Canada, in the United States, and,
increasingly, in many Latin American and Caribbean
countries.

  Although tobacco has been in use in the Ameri-
cas for centuries (see Chapter 2), public policy on
tobacco control is fairly recent. The sale of tobacco to
minors has long been prohibited, but more for moral
rather than health reasons. For years, local ordinances
have prohibited smoking in cinemas and theaters as a
fire-prevention measure. But legislation focusing on
control of tobacco use to prevent chronic disease
began in North America only 25 years ago. Following
the issuance in 1964 of the Surgeon General's land-
mark report (Public Health Service 19641, the U.S.
Congress passed the Federal Cigarette Labeling and
Advertising Act in 1965.

  In 25 years of worldwide efforts to control the
smoking epidemic, the key role of legislation has be-
come clear. In 1990, the 43rd World Health Assembly
reaffirmed the effectiveness of tobacco-control strat-
egies and, in particular, legislation and policies to
(1) protect against exposure to environmental tobacco
smoke in workplaces, public places, and public trans-
portation; (2) increase the real price of tobacco; and
(3) control direct and indirect advertising and promo-
tion of tobacco products (World Health Organization
[WHO] 1990a,b).

Purposes of Legislation
  Law is a powerful tool for closing the gap be-
tween social policy and scientific knowledge about
tobacco. The purposes of such legislation are as follows:
o To set forth government policy on production,
promotion, and use of tobacco, and to place the
government squarely on the side of health.

o To encourage smokers to stop smoking, and to
dissuade young people from starting to smoke or
from using smokeless tobacco.
o To provide protection against the dangers of expo-
sure to environmental tobacco smoke in enclosed
public places.

o To monitor and control the content of manufac-

tured tobacco products.
o To contribute to the development of a social climate
in which smoking and other forms of tobacco use
are unacceptable.

o To provide for the allocation of resources to support
effective programs to combat smoking.

o To provide the legal basis for enforcement of a

tobacco-control policy.

These purposes are widely recognized, although they
may be formulated in various ways (Bechara and
Jacob 1985).

  Two principal types of legislation have been
enacted:  (1) legislation to change the production,
manufacture, promotion, and sale of tobacco (supply)
and (2) legislation to change smoking behavior (de-
mand). Within each of these two broad categories,
specific kinds of laws have been enacted to combat
tobacco use. For example, the latter category includes
nonsmokers' rights laws, which aim to protect non-
smokers from the health effects of exposure to envi-
ronmental tobacco smoke.

Method of Analysis

  The kinds of laws in these two categories of
legislation were examined through 1990 for North
America, Latin America, and eight Caribbean coun-
tries (Bahamas, Barbados, Bermuda, Grenada, Guy-
ana, Jamaica, Saint Lucia, and Trinidad and Tobago).
Special comment is made on the French overseas de-
partments and territories in the Americas. The princi-
pal focus is on the laws of countries in Latin America
and the Caribbean. Particularly noteworthy national
legislation and regulation are described in Appendix 2.

Le@sla tion

147


Legislation to Control Production, Manufacture, Promotion, and Sales

  Laws and policies in this category are directed
toward controlling the tobacco industry (including
growers, manufacturers, and distributors), as well as
advertising agencies, the media, and tobacco retailers.
However, these laws can change the social environ-
ment for a whole population and thus influence the
conduct of individual persons. For example, laws
banning the advertising and promotion of tobacco
alter the environment in which young people grow
up and help free them from pressure to smoke.

  Table 1 summarizes the types of legislation (and
the number of countries that have enacted each type)
designed to control the production, sale, and promo-
tion of tobacco. Several of these controls are discussed
further below. Economic strategies, such as tax and
price policies, are discussed in Chapter 4.

Control of Advertising
  The tobacco industry's enormous expenditure
on advertising and promotion-approximately $3.3
billion in the United States in 1988 (Centers for Disease

Table 1.  Number of countries that control the production, sale, and promotion of tobacco, by type of legislation*
    and region

                                     North         Latin
Type of legislation           Worldwide+      America       America     Caribbean*
Total ban on advertising            20            1             1            1
Some restrictions on advertising        38            2            15            4
Restrictions on sponsorship of
sports and cultural events       NAS           1             3
Rotating or stronger warnings          9            2            2           3
Standard warning"                53           0            12            2
Statement of tar and nicotine
yield                        22            1            3           3

Restrictions on sales to adults          6            2            3
Increased taxes and pricesPI           NA           2           NA

Revenue from taxes allocated to
health purposes                NA            1             1
Economic strategies9               NA            1           NA

Control [CDCI 1990a)-reflects the importance that
the industry attaches to advertising. The role of ad-
vertising and promotion in increasing sales and con-
sumption is difficult to quantify precisely (U.S. Depart-
ment of Health and Human Services [USDHHSI 1989;
Tye, Warner, Glantz 1987; Toxic Substances Board
1989; Warner 1986b) (see Chapter 4).

  Advertising sends the message that smoking is
acceptable and pleasurable. Moreover, the depen-
dence of newspapers and magazines on advertising
revenue from the tobacco industry may hinder the
publication of information about the hazards of to-
bacco use (Whelan 1984; USDHHS 1989). As preva-
lence of smoking has declined in Canada, the United
States, and other industrialized countries, transna-
tional tobacco corporations have intensified their pro-
motion of cigarettes in developing countries (Muller
1978; Nath 1986; Lokschin and Barros 1983; Stebbins
1987; Davis 1986). (See Chapter 2, "The Emergence of
the Tobacco Companies.")

  Several types of legislation control advertising
and promotion of tobacco products in the Americas

`Includes national and subnational legislation.
`Roemer (1986).

SIncludes the French overseas departments and territories.
_NA = Not available.                 Blank indicates that no such legislation is known to exist.
"A single statement of warning not rotated with other statements.
`Tax and price policies and economic strategies are discussed in Chapter 4.

148 Legislation


(Table 2). Except for Canada, Cuba, and the French
overseas departments and territories, all countries in
the Americas that have enacted legislation to control
cigarette advertising have imposed moderate, partial
bans.

North America

  Canada was the first country in the Americas to
enact a total ban on advertising and promoting to-
bacco. The Tobacco Products Control Act (Health and
Welfare Canada 1989al took effect on January 1,1989;
it provides, in Section 4, as follows:
No person shall advertise any tobacco product of-
fered for sale in Canada.

  The statute and the regulations, however, pro-
vide the tobacco manufacturing, importing, and ad-
vertising industries with a period of adjustment
during the transition to the new requirements and
with a few limited exceptions to the ban (Kyle 1990).
Per capita tobacco consumption decreased 8 percent
in the year after the act took effect (Kaiserman and
Allen 19901, although this decrease may have resulted
from the combined effect of several factors. The law
was challenged in court by Imperial Tobacco Ltd.
(Montreal) and RJR-MacDonald Inc. In July 1991, the
challenge was upheld; the law was declared unconsti-
tutional but was allowed to remain in effect pending
appeal (RJR-Macdonald Inc. v. Attorney General of
Canada 1990; Imperial Tobacco Limited v. Attorney
General of Canada 1990).

  In the United States, all cigarette advertising has
been prohibited on television and radio since the en-
actment of the Public Health Cigarette Smoking Act of
1969, which became effective in January 1971. This
ban was extended to little cigars in 1973 and to smoke-
less tobacco in 1986. Health warnings are required in
cigarette and smokeless tobacco advertisements (see
next topic).

  State and local legislation to control tobacco ad-
vertising has been used to a limited extent in the
United States because such legislation was preempted
by the federal act of 1969. Nevertheless, some cities
have restricted local advertising; bans on advertise-
ment of tobacco in transit systems and on distribution
of free tobacco products have been adopted in several
cities, including Boston, New York, and Atlanta
(USDHHS 1989). Sports stadiums in a few large cities
in the United States have voluntarily banned tobacco
advertising.

  The continued advertisement of cigarettes in
newspapers, in magazines, and on billboards in the
United States has led to several proposals to extend
restrictions to these media (USDHHS 1989). These
proposals have included the following: a total oan on

advertising and promotion of tobacco products; re-
strictions on the imagery, content, and format of to-
bacco advertisements; bans on certain types of
promotion, such as targeting of children and sponsor-
ship of sports and cultural events; and economic dis-
incentives (for example, eliminating the tax deduction
allowed, as a business expense, for advertising tobacco).

Table 2.  Countries that control tobacco advertising
    and promotion, by type of restriction*

X    W"

     W

                             Form
            Total   Mass  Spon-   and
Country        ban  media+ sorshipl content5

North America
Canada        X     X
United States           X

Latin America
Argentina            X     X     xw
Bolivia              X     X     xw

Brazil               X     X     xw

Chile               X            W

Colombia            X          xw
Costa Rica           X          X

Cuba         X

Ecuador             X            W
El Salvador           X

Mexico              X            W

Panama             X            W
Paraguay            X

Peru               X            W
Uruguay             X            W

Venezuela            X            W
Caribbean
Bahamas                        W

Bermuda                        W
French overseas
  departments
and territories'  X
Trinidad

  and Tobago         X           W
*For a summary of legislation in selected countries, see the
notes in Appendix 1 to this chapter.
`Restrictions on use of television, radio, press, and billboards.
*Restrictions on sponsorship of sports and cultural ex'ents.
`Restrictions on content, format, or location of ad\~crti~ing.
`h = Health warning required.
`For this table, the French overseas depnrtnlentc JIK~
territories are counted lvith the Cnribht3n icwtltrit'~.


Latin America                     or formal government broadcasts. Televised cigarette

  Fourteen Latin American countries have legisla-
tion restricting tobacco advertising and promotion.
The most stringent statutes restrict advertising to
statements about the quality, origin, and purity of
tobacco; ban the representation of persons; or prohibit
the association of smoking with pleasurable activities.
Argentina, Bolivia, Brazil, Colombia, Mexico, and
Paraguay have stringent laws. Bolivia requires the
tombstone format, which allows no more than the
name, brand, symbol, and representation of the to-
bacco product in a box. Argentina and Bolivia both
prohibit advertising associated with sports.

  A common type of Latin American law prohibits
tobacco advertising that targets young people or that
is displayed at times and places available to children
and young people. Argentina, Brazil, Colombia, Ecua-
dor, El Salvador, Mexico, and Peru have statutes of
this type.

  Virtually all Latin American countries that con-
trol tobacco advertising require a health warning on
cigarette advertisements. Some statutes, such as those
in Brazil, Colombia, Chile, and Uruguay, specify the
frequency and duration of the health warning in the
broadcast media. Brazil specifies the size, color, and
prominence of the health warnings on advertisements
on television, in the print media, on billboards, and on
neon signs. Brazil also regulates the content of tobacco
advertising by explicitly prohibiting claims of health,
relaxation, stimulation, or sexual success. Scenes of
children or adolescents are prohibited, and Argentina
prohibits the use of minors in tobacco advertising.

  In contrast, a few countries, such as Venezuela,
have generic statutes that prohibit broadcast media
from accepting advertising that directly or indirectly
encourages consumption of cigarettes and tobacco
products. Some countries-for example, Bolivia,
Costa Rica, and Panama-have statutes that authorize
the health authority to approve tobacco advertising
and thereby restrict messages that are detrimental to
health.

Caribbean

  Only Trinidad and Tobago has adopted regula-
tions that restrict the advertisement of cigarettes and
tobacco products. Regulations of the Bureau of Stan-
dards prohibit the advertisement of cigarettes and
tobacco products in cinemas or in films certified for
viewing by general audiences or by audiences that
include persons under 18 years of age. No advertising
bf tobacco products is allowed on television during
children's programs, religious programs, educational
programs, current affairs broadcasts, or parliamentary

advertisements may not exceed six minutes per hour,
averaged over the day's programs, nor seven minutes
in any single program period.

  A health warning is also required in advertise-
ments for cigarettes and other tobacco products in
Trinidad and Tobago, the Bahamas, and Bermuda,
although in Bermuda, the health warning need not be
used on television and radio.

  Jamaica has no legislation restricting tobacco ad-
vertising, but the Carreras Group Ltd., which has a
monopoly on the Jamaican cigarette market, has vol-
untarily withdrawn advertising from television,
radio, billboards, print media, and cinemas. The Car-
reras Group, however, sponsors sports and cultural
events, notably annual awards for Sportsman and
Sportswoman of the Year. The British Virgin Islands
has no local television station but receives U.S. televi-
sion programs; thus, the U.S. ban on advertising to-
bacco products on television applies to the U.S. and
British Virgin Islands.

   None of the Caribbean countries restrict the to-
bacco industry from sponsoring sports or cultural
events. In fact, in Trinidad and Tobago, the West
Indian Tobacco Company Ltd. recently received an
award as Company of the Year, largely because of its
extensive sponsorship of sports and cultural events.
In Bermuda, 1987 legislation allows the use of a brand
name when sponsoring an event or congratulating a
person or group on an achievement. Furthermore, a
health warning is not required during these activities
because they are exempt from the definition of a to-
bacco advertisement.

Requirements for Health Warnings and
Statement of Tar and Nicotine Yield

  Mandatory warnings on packages and in adver-
tisements of tobacco products are a form of health
education; these warnings alert the public to the dan-
gers of tobacco use. Most countries require warnings
that state that smoking is harmful to health. Because
such a warning is weak and may not get a smoker`s
attention, several countries have adopted several
stronger warnings, which are used in rotation (Table 3).

  Statements of tar and nicotine yield on packages
of cigarettes constitute another form of health
information. Canada, three Latin American countries,
and two Caribbean countries have enacted legislation
that mandates a statement on toxic substances in to-
bacco products.

  Only a few countries have enacted legislation
that sets a maximum level on harmful substances in
tobacco products or tobacco smoke. Canada requires

150  Legislation


detailed reporting from manufacturers and importers
of tobacco products about toxic constituents. In Uru-
guay, the Commission for the Control of Smoking,
under legislation enacted in 1988, is authorized to set
maximum allowable levels of tar and nicotine for to-
bacco products.

North America

   The Tobacco Products Control Act of Canada
prohibits the sale of a tobacco product unless it dis-
plays one of the required health messages, lists the
toxic constituents of the product and, when applica-
ble, of the smoke produced from its combustion, and
indicates the quantities of these constituents. As of
1990, manufacturers have been required to list on
packages of cigarettes and fine-cut tobacco the yield of
tar, nicotine, and carbon monoxide.
  The regulations for the Act prescribe that one of
the following messages appear on cigarette packages:
Smoking reduces life expectancy.
Smoking is the major cause of lung cancer.
Smoking is a major cause of heart disease.
Smoking during pregnancy can harm the baby.
  Every package of cigars or pipe tobacco must
display a list of toxic constituents and one of the
following messages:

This product can cause cancer.

This product is not a safe alternative to cigarettes.
Every package of smokeless tobacco must dis-

play the following message:

This product can cause mouth cancer.

  All these warnings must appear in English and
French. A new warning will state that smoking is
addictive. Other new warnings-for a total of eight
possible warnings-will include messages about en-
vironmental tobacco smoke, lung disease, and stroke.

  Canada is introducing an innovative way to dis-
tribute health warnings by requiring leaflets that must
be removed from inside packages of cigarettes before
the user can remove the cigarettes. The leaflets will
contain messages more comprehensive than those of
the health warning. The warnings on the exterior of
cigarette packages will be enlarged so that they oc-
cupy 25 percent of the two major faces of the packages.
Information on toxic constituents will also be required
to be clearly displayed on the packages (Sweanor and
Mahood 1990).

  To obtain more precise information than that
which is currently available about exposure to tobacco
smoke, the Tobacco Products Control Regulations
(Health and Welfare Canada 1989a) set forth detailed
reporting requirements for cigarette manufacturers

Table 3.  Countries that require health warnings
    or statement of tar and nicotine yield
                   -

Countrv

     Rotating
Standard or strong Statement
warning'  warnings  of yield

     ,
North America

Canada

United States

Latin America
Argentina
Bolivia

Brazil

Chile

Colombia

Costa Rica

Ecuador

El Salvador

Mexico

Panama
Paraguay
Peru
Uruguay
Venezuela

Caribbean

Bahamas

Barbados

Bermuda
French overseas
departments
and territories+

Trinidad and

       X       X

       X

X

X

X

       X

X

       X

X              X

X

X               X

X

X

X

X

X

       X

X

       X       X

       X       X

X               X

Tobago

*A single statement of warning not rotated with other
statements.
`For this table, the French overseas departments and
territories are counted with the Caribbean countries.

and importers. These requirements concern the con-
stituents of the tobacco product, the quantity of each
constituent (expressed as a proportion of the total
weight of the product), and the quantity of each toxic
constituent (milligrams per cigarette) in the smoke
produced by the tobacco product. Moreover, the reg-
ulations prescribe the specific methods to be used in
determining the quantities of such constituents.

Legislation   151


  In the United States, one of the following health
warnings has been required on cigarette packages and
advertisements since October 12,1985:
SURGEON GENERALS WARNING: Smoking
Causes Lung Cancer, Heart Disease, Emphysema,
and May Complicate Pregnancy.
SURGEON GENERAL`S WARNING: Quitting
Smoking Now Greatly Reduces Serious Risks to
Your Health.

SURGEON GENERAL'S WARNING: Smoking by
Pregnant Women May Result in Fetal Injury, Pre-
mature Birth, and Low Birth Weight.
SURGEON GENERAL'S WARNING: Cigarette
Smoke Contains Carbon Monoxide.

  Since February 17, 1987, one of the following
warnings has been required on smokeless tobacco
packages and advertisements:
WARNING: This product may cause mouth
  cancer.

WARNING: This product may cause gum disease
and tooth loss.

WARNING: This product is not a safe alternative
to cigarettes.
No legislation or regulation in the United States

requires that the tar and nicotine yield of cigarettes be
listed on cigarette packages or in advertisements, al-
though the Departme:.t of Health and Human Ser-
vices and the Federal Trade Commission have
recommended such requirements. The tobacco indus-
try complies with a plan for voluntary disclosure of tar
and nicotine yield in advertisements, and disclosure is
often made voluntarily on packages for cigarettes
yielding 8 mg of tar or less, but rarely for higher-tar
brands (Davis, Healy, Hawk 1990).

  In the United States, federal legislation requires
that manufacturers provide the Secretary of Health
and Human Services with information (which must be
kept confidential) on the nicotine yield of smokeless
tobacco products but does not require the nicotine
yield to be listed on packages or in advertisements.

Latin America

   All but two of the 14 Latin American countries
requiring health warnings use the standard warning
that smoking is dangerous to health (Table 3). Chile,
which formerly used this warning, required in 1986
that the following stronger warning be clearly dis-
played on the package:

Tobacco may cause cancer-Ministry of Health.

  As of 1989, Costa Rica also has required stronger
warnings:

Smoking during pregnancy damages the child and
provokes premature births.
Smoking produces lung cancer, heart disease, and
emphysema.
Statement of tar and nicotine yield is required by

three Latin American countries-Ecuador, Mexico,
and Uruguay. Uruguay's legislation requires ciga-
rette manufacturers and importers to publish the tar
and nicotine yield of each brand once or twice a year
in the major advertising media.

Caribbean

  Four Caribbean countries require health warn-
ings on cigarette packages, and two require statements
of tar yield. The standard warning is required in
Barbados and Trinidad and Tobago, but the Bahamas
requires a stronger warning: "Tobacco smoking may
cause heart disease or lung cancer among other dis-
eases." The Bahamas also prohibits the sale of loose
cigarettes; cigarettes must be sold in a package with a
warning. Bermuda requires a health warning on cig-
arettes and other tobacco products, and the warning
required for imported cigarettes is the same as that
required by their country of origin.

  Only Bermuda requires statements of tar yield.
In Trinidad and Tobago, standards prohibit using the
phrase "low tar" in a brand name. Regulations of the
Bureau of Standards specify that low-tar cigarettes
have less than 10 mg of tar per cigarette; medium-tar
cigarettes have 10 to 17 mg of tar; and high-tar ciga-
rettes have 18 mg of tar or more. These standards
apply to cigarettes manufactured in Trinidad and To-
bago only. Average nicotine yield and tar group are
requested by Bureau of Standards regulations; how-
ever, all these standards are voluntary, and statements
of warning do not appear on packages of locally made
products.

Restrictions on Sales to Adults

  Restrictions on where cigarettes may be sold
make a strong statement to the public about the
product's harmfulness and lack of social acceptability.
Sale of tobacco may be banned in health institutions
and government buildings or banned or limited from
vending machines.

  Few countries have restrictions on where ciga-
rettes may be sold. In 1986, the Chilean Ministry of
Health prohibited the sale of tobacco products in all
establishments of the National Health Service. The
Ministry of the Interior in Chile recommended

152  Legislation


restrictions on the sale of tobacco products in kiosks
and other places of all government services. In Cuba,
the sale of tobacco products is prohibited in health
centers and in educational and recreational facilities
that are primarily for young people (Su6rez-Lugo
1988). The State of Rio Grande do Sul, which produces
70 percent of Brazil's tobacco, prohibits the sale of
cigarettes in any establishment that is administered or
subsidized by the state, including buildings of the

Legislative Assembly. The government of Rio Grande
do Sul also recommends that the sale of tobacco be
avoided in hospitals and health services.

  Legislation restricting sales to adults is not com-
mon, perhaps because legislation to control smoking
in public places is considered a better approach. Also,
many educational and health institutions have volun-
tarily stopped selling tobacco products on their
premises.

Legislation to Change Smoking Behavior

  Legislation can help change smoking behavior
by fostering an environment in which smoking is so-
cially unacceptable. The effectiveness of tobacco-
control activity is closely linked to changes in social
norms that tolerate smoking (WHO 1983). The need
to control such norms is enunciated by the 1988 mis-
sion statement of the Canadian tobacco company, Im-
perial Tobacco Ltd. (ITL) (Imperial Tobacco Ltd. v.
Attorney General of Canada, 1990):
The following philosophies have effectively gov-
erned ITL's marketing, planning and activities.
They remain valid. . 4. Support the continued
social acceptability of smoking through industry
and/or corporate actions (e.g. product quality, pos-
itive lifestyle advertising, selective field activities
and marketing public relations programs).
  Considerable legislative effort has been devoted
to protecting nonsmokers from exposure to tobacco
smoke and potential smokers from encouragement to
smoke. An important concomitant of such legislation
has been a reduction in the social acceptability of smoking.

Control of Smoking in Public Places

  The health risks to nonsmokers from exposure to
environmental tobacco smoke (sidestream smoke,
emitted from a burning tobacco product, combined
with exhaled smoke) have been established. Studies
in many countries have demonstrated the dangers of
exposure to environmental tobacco smoke; an exam-
ple is the 30 percent increase in lung cancer among
nonsmoking wives of smokers compared with those
of nonsmokers (USDHHS 1986; National Research
Council 1986). As this knowledge has been dissemi-
nated, legislators and policymakers at the national and
subnational levels have responded by restricting
smoking in public places.

North America

  The Non-smokers' Health Act, passed by the
Canadian Parliament in June 1988 and amended in
1989, regulates smoking in workplaces under federal
jurisdiction and controls smoking on Canadian air-
lines and other forms of transportation subject to na-
tional legislation. Smoking is banned on flights of six
hours or less, and by 1993, smoking will be banned on
all flights of Canadian carriers (Collishaw, Rogers,
Kaiserman 1990). Since October 1990, all scheduled
flights made by Air Canada throughout the world
have been smoke-free.

  A directive of Transport Canada declares public
areas in airports to be nonsmoking, except for a few
designated smoking areas. Ticket lines and baggage
claim areas are nonsmoking, but passenger waiting
areas of 30 seats or more may contain smoking sec-
tions. Restaurants in airports are expected to maintain
a nonsmoking-to-smoking ratio of 60 to 40 in their
seating (Health and Welfare Canada 1989b).

  As of 1988, three Canadian provincial govern-
ments and multiple municipalities within the 10 prov-
inces had enacted legislation to control smoking in
public places and the workplace (Calgary Health Ser-
vices 1988). Both the types of public places and the
degree of restrictiveness vary. The public places in-
clude restaurants with more than 40 seats, areas for
private social functions (such as banquets), beverage
rooms or lounges with more than 40 seats, indoor
places for public assembly (including banks, theaters,
and schools), reception areas and waiting rooms, hos-
pitals, retail stores with more than 10 employees, ser-
vice lines, elevators and escalators, public areas of
buildings, public washrooms, school and public
buses, bus shelters, and taxis.


required signs deter the smoker from smoking and
encourage the nonsmoker to request a nonsmoking
area. Most municipalities report that compliance with
the bylaw is high. In Toronto, enforcement occurs
either by the issuance of a ticket similar to a traffic
ticket or by a formal charge that requires the offender
to appear in court (Calgary Health Services 1988).

  In the United States, most legislation to control
smoking in public places is enacted at the state and
local levels to protect the health, welfare, and safety of
the people. Forty-three states and the District of
Columbia restrict smoking in public places in some
manner (Tobacco-Free America 19891, and about 400
city and county smoking-control ordinances have
been enacted. In general, state laws tend to be weaker
and less comprehensive than local smoking ordi-
nances (Pertschuk and Shopland 1989).

  Although the federal government has not en-
acted smoking restrictions for nongovernment public
places, it has adopted regulations controlling smoking
in federal facilities and workplaces, and legislation has
been passed restricting smoking on commercial air-
lines WSDHHS 1989). In 1989, the temporary law
banning smoking on domestic flights of two hours or
less expired, and Congress enacted a statute banning
smoking on all scheduled airline flights of six hours'
duration or less within the contiguous 48 states, the
District of Columbia, Puerto Rico, and the Virgin Is-
lands; within the states of Alaska and Hawaii; and
between Alaska or Hawaii and a point in the contigu-
ous 48 states, the District of Columbia, Puerto Rico, or
the Virgin Islands. This ban applies to both domestic
carriers and foreign airlines (Federal Aviation Act of
1958, annotated 1990).

  State legislation restricting smoking in public
places, called clean indoor air acts, varies in the number
of public places covered and in the degree of restric-
tiveness, Thirteen states have extensive statutes that
limit smoking in several public places (in addition to
restaurants) and private worksites KJSDHHS 1990bl.
Thirteen states are moderate in restrictiveness; they
limit smoking in at least four public places, but not in
restaurants. Eleven states have basic restrictiveness;
smoking is limited in at least four public places, but
not in restaurants or private worksites.

  State legislation generally restricts smoking in
public transportation vehicles, health care offices and
facilities, and elevators. In addition, many states re-
strict smoking in indoor cultural and recreational fa-
cilities, such as libraries, museums, theaters, galleries,
arenas, and auditoriums. In 31 states, smoking in
schools and on school grounds is restricted for stu-
dents, school personnel, and other persons with access
to the school WSDHHS 1990a). In 29 states, smoking

in government buildings is restricted, and in 23 states,
smoking is prohibited or restricted at public meetings.
But less than half of the states prohibit smoking in
supermarkets, grocery stores, or other retail stores or
require restaurants to establish nonsmoking areas.

  Local ordinances restricting smoking in public
places were first passed in the early 198Os, and they
soon spread to 397 cities and counties to affect
52,471,053 persons, or 21.7 percent of the total U.S.
population. Of these ordinances, 369 control smoking
in restaurants, and 298 limit smoking in enclosed pub-
lic places and/or retail stores. These local ordinances
were quickly adopted from 1982 to 1989 Pertschuk
and Shopland 19891, and a high level of compliance
has generally been achieved.

Latin America

  Many Latin American countries have enacted
restrictions on smoking in public places, generally at
the national level, but also at the subnational level.
Smoking is generally restricted in public transporta-
tion vehicles, health establishments, schools, cinemas
and theaters, and government buildings, but legisla-
tion limiting smoking in restaurants is rare. Although
not all Latin American countries have enacted such
legislation, the legislation is quite extensive and covers
a variety of public places (Table 4). In many countries,
however, enforcement is weak or nonexistent.

Caribbean

  In the Caribbean, legislation on control of smok-
ing in public places is rare. The Ministry of Transport
of the Bahamas issued regulations prohibiting smok-
ing during domestic interisland flights of the national
airline, Bahamasair. In Barbados, health services
(food hygiene) regulations prohibit smoking while
handling food or when in a room with open food.

Control of Smoking in the Workplace

  Many public places, such as schools and hospi-
tals, are also workplaces; therefore, statutes restricting
smoking in public places benefit both the employees
and the public entering these places. Legislation to
restrict smoking in the workplace is especially impor-
tant because people spend more time at work than
they do at meetings, in an elevator, or in a theater.
Moreover, smoking is particularly dangerous when it
accentuates the toxic effects of hazardous materials.
In 1985, a report of the Surgeon General on cancer and
lung disease in the workplace concluded that, for most
U.S. workers, cigarette smoking is a more serious
cause of death and disability than the other threats
posed by the workplace environment (USDHHS 1985).

154 Legislation


Table 4.  Countries that restrict smoking in public places, by type of place+

              Food
Indoor        storage
public  Cinemas,  places,
places   theaters restaurants Other

Public

Schools+  transpor-
       tation

Country         Govem-   Health
and selected         ment    estab-
jurisdiction     agencies lishments

North America

Canada

United States

Latin America
Argentina
  Province of
   Cordoba
Province of Jujuy
  Province of
   Mendoza

  San Fernando de1
    Valle de
   Catamarca
Valle Viejo
  Buenos Aires

Bolivia

Brazil

  Rio Grande do Sul

  Sao Paul0
  Rio de Janeiro
  Port0 Alegre
  Curitiba
Florianopolis
Chile

Colombia
  Bogota
Costa Rica

Cuba

Guatemala

Honduras

Mexico

  Federal District

Panama
Paraguay
  Asuncion

Peru
Uruguay
  Montevideo

Venezuela

X       X

X       X

X

X       X

X       X

X

X

       X

X       X

       X

       X

       X

X       X

X       X

X       X

X       X

X

X       X

       X

X       X

       X

X       X

X       X

X       X

X

X       X

X       X

X       X       X

X       X       X

X              X

X       X

X       X

X       X

X       X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X


Table 4. Continued

Country
and selected
jurisdiction
Caribbean

                                             Food
Govem-   Health          Public   Indoor
ment    estab-              public  Cinemas,  storage
agencies lishments Schools+  transpor-
                     tation   places        places,
                             theaters restaurants Other
                                                ..______.

Bahamas                                X

French overseas
departments
  and territories t            X       X              X

Trinidad and
  Tobago                               X
`For a summary of legislation in selected countries, see the notes in Appendix 1 to this chapter.
`Includes other places where voung people congregate.
$For this table, the French overseas departments and territories are counted with the Caribbean countries.

X

North America

  In Canada, the Non-smokers' Health Act of 1988
restricts smoking in all workplaces under federal ju-
risdiction. The statute covers 900,000 workers in both
the public and private sectors-about 8 percent of the
Canadian work force. Employers are required to en-
sure that workers refrain from smoking in any work-
place under their control, except in designated
smoking areas for which size, ventilation, and other
characteristics are prescribed.

  Legislation in several provinces in Canada, in-
cluding Quebec, Manitoba, and Ontario, restricts
smoking in the workplace by controlling smoking in
public places or in the workplace. In Ontario, The
Smoking in the Workplace Act of 1988 prohibits smok-
ing in all areas of the workplace, except designated
smoking areas, public areas, and areas used for lodg-
ing and private dwellings.

  Municipal bylaws, enacted by 22 municipalities
in Canada as of 1988, have been the major legal mech-
anism for controlling smoking in the workplace. This
legislation generally requires employers to have writ-
ten smoking policies that attempt to accommodate
both smokers and nonsmokers in the workplace (Cal-
gary Health Services 1988). The most stringent legis-
lation bans smoking when the concerns of smokers
and nonsmokers cannot be accommodated. Bylaws
may also set forth requirements for compliance, post-
ing of signs, and penalties (Calgary Health Services
1988). In the city of Toronto, more than C$500,000 was
budgeted for educating the public and hiring staff for
consultation and enforcement. This extensive promo-
tion campaign included radio commercials in several
languages, a television campaign, mass transit and

newspaper advertisements, direct mail to employers,
and a telephone hotline service (Calgary Health Ser-
vices 1988).

  In the United States, policies of federal agencies
generally restrict but do not ban smoking in the work-
place; most federal employees are covered by such
policies. The General Services Administration has is-
sued regulations on smoking in federal buildings
(USDHHS 1989), and the Department of Health and
Human Services has issued a total ban on smoking in
its buildings (Bureau of National Affairs 1987). Laws
in 31 states restrict smoking at public worksites, and
in additional states, smoking at public worksites is
restricted by action of the executive branch of the state
government.

  Governments have been slower to mandate
smoking restrictions for private worksites than for
their own employees (USDHHS 19891, but 13 states
have enacted such legislation. The New York State
clean indoor air act of 1989 (Public Health Law Article
13-E, Regulation of Smoking in Certain Public Areas),
for example, provides that each employer shall adopt
and implement a written smoking policy that requires,
at a minimum, a smoke-free work area for nonsmok-
ing employees; a work area for smoking, if all employ-
ees assigned to the area agree to the designation; and
contiguous nonsmoking areas in employee cafeterias,
lunchrooms, and lounges sufficient to meet the de-
mand. The policy must prohibit smoking in auditori-
ums, gymnasiums, rest rooms, elevators, classrooms,
hallways, employee medical facilities, and company
vehicles occupied by more than one person. Any
place may be designated by its owner, operator, or
manager as a nonsmoking area in its entirety. Viola-
tion of these restrictions is punishable by civil penalty

156  Legislation


of up to $1,000 (if imposed by the state) and up to $500
(if imposed by a local enforcement official) (New York
Public Health Law 19901.

  Most laws governing smoking in the workplace
are local ordinances. In the United States, 297 cities
and counties require both public and private employ-
ers to maintain a written smoking policy (Pertschuk
and Shopland 1989). Most of these ordinances make
no exception for small workplaces; provide that, in a
conflict between the concerns of nonsmokers and
smokers, nonsmokers' concerns will take precedence;
and prohibit retaliation against employees who exer-
cise their rights under a smoking ordinance.

Latin America

  In Latin America, restrictions on smoking in the
workplace are generally included in legislation pro-
hibiting smoking in public places (Table 4). National
and local legislation that restricts smoking in public
places affects both employees and the public. A few
statutes specifically ban smoking on work premises,
especially by employees of health establishments-as
stated in the legislation of Brazil, Chile, Costa Rica,
Cuba, Mexico, Peru, Uruguay, and Venezuela. Costa
Rica's 1988 legislation imposes a general ban on smok-
ing in the workplace and requires the director of the
workplace, or his or her representative, to ensure strict
compliance with this prohibition. An area of the
workplace may be reserved for smokers, when possi-
ble. The statutes on smoking in public places often do
not specify work settings, but they may be included.

Caribbean

  No known legislation regulates smoking in the
workplace in the Caribbean countries.

Preventing Young People from Smoking

  Restrictions on advertising and on smoking in
public places benefit young people as well as adults.
Other types of legislation are specifically directed at
controlling tobacco use by minors. As of 1986, 22
countries worldwide had enacted measures specific-
ally designed to prevent young people from smoking
(Roemer 1986).

  Easy access to tobacco products by minors may
contribute to the early use of tobacco and to the devel-
opment of tobacco addiction as adults (Choi,
Novotny, Mickel, in press). Laws prohibiting the sale
of tobacco to minors have long been on the statute
books in many countries, but enforcement has been
weak or nonexistent.  Because minors obtain ciga-
rettes from retailers and vending machines, banning
or restricting the sale of tobacco through vending

machines is critical (USDHHS 1989). Prohibiting cig-
arette vending machines or limiting their location
makes tobacco less available.

  Prohibiting the distribution of free cigarettes is
another strategy for protecting young people. More
than a dozen cities in the United States prohibit the
distribution of free cigarettes, and two states-
Minnesota and Utah-prohibit the distribution of free
smokeless tobacco products as well (Davis and Jason
1988). Although several countries (e.g., Hong Kong,
Australia, and Ireland) prohibit the importation, sale,
and use of smokeless tobacco (European Bureau for
Action on Smoking Prevention 19901, and other coun-
tries require health warnings on smokeless tobacco
products, no such restrictions have yet been enacted
in Latin America or the Caribbean.

   Another measure restricts manufacturers'sale of
tobacco products to licensed distributors only. The
licensing law may include a provision for penalizing
a licensee who furnishes tobacco to minors, and revo-
cation of the license may be a penalty for a subsequent
offense.

North America

  In Canada, federal legislation makes it an offense
for a person under the age of 16 to possess tobacco, but
this law is seldom enforced. Similar but little-used
laws are long-standing in the provinces of Saskatche-
wan, New Brunswick, and Newfoundland. The prov-
inces of Ontario, Manitoba, and Saskatchewan have
passed laws making it an offense, punishable by a fine,
to sell or give cigarettes to a minor. A recent amendment
to the Minors Protection Act of Ontario increased the
fine from (350 to C$25,000.

  In the United States, the only federal legislation
regulating minors' access to tobacco is the Com-
prehensive Smokeless Tobacco Health Education Act
of 1986, which authorizes the federal government to
assist the states in establishing 18 as the minimum age
for the purchase of smokeless tobacco.

  Tobacco access laws are generally enacted by
state and local governments. As of 1989,44 states and
the District of Columbia restricted the sale of tobacco
to minors, but six states allowed children of any age to
buy tobacco in any form (Tobacco-Free America 1989).
The age for legal purchase of tobacco products is
generally set at 18 years, although in three states, it is
19 years (CDC 1990b). In 17 states, the vendor is
required to post signs stating that sale of tobacco to
minors is illegal.

  In 17 states, statutes regulate the sale of tobacco
products from vending machines (Tobacco-Free
America 1989). In 14 states, owners, operators, or
supervisors of tobacco vending machines are required

Legislatiorr   157


to post signs stating that minors are prohibited from
buying cigarettes from a vending machine. In five
states, vending machines must be placed in super-
vised areas so that minors cannot use them. Wiscon-
sin prohibits the placement of tobacco vending
machines within 500 feet of a school. Utah has banned
tobacco vending machines, except in places to which
minors presumably do not have access, such as bars.
Only Colorado bans the sale of smokeless tobacco
products through vending machines.

  Some local communities-many of which are in
Minnesota, where the first clean indoor air act was
passed in 1975-have prohibited or restricted the use
of cigarette vending machines. Some communities
have banned the machines entirely; others have
banned them from public places or restricted them to
places licensed to sell liquor; and others require them
to be under constant supervision by employees.

  Sellers of tobacco products are required to be
licensed in 46 states (Tobacco-Free America 1989).
Four states have laws requiring revocation of the li-
cense for violation of minors' access laws, and other
states have provisions for such license revocation as
part of local criminal or administrative proceedings
KDC 1990bl.

  Compliance with tobacco access laws has been
poor because vendors are unaware of the laws and
because state and local authorities fail to enforce them
(USDHHS 1989; CDC 1990b). In May 1990, USDHHS
proposed a model law for states and localities that
would facilitate enforcement of a ban on the sale of
tobacco products to minors. The Model Sale of To-
bacco Products to Minors Control Act provides for the
creation of a licensing system, similar to that used to
control the sale of alcoholic beverages, by which a
store may sell tobacco to adults only if it avoids mak-
ing sales to minors; sets a graduated schedule of
penalties-from monetary fines to license suspen-
sion; provides separate penalties for failure to post a
sign stating that sales to minors are illegal; places
primary responsibility for investigation and enforce-
ment in a designated state agency; relies mainly on
state-administered civil penalties to avoid the delay
and cost of the court system; sets the legal age of
purchase at 19; and bans the use of vending machines
to dispense cigarettes.

  Restrictions on smoking in schools are imposed
by statute and by action of school authorities. Legis-
lation in 15 states bans smoking in schools, and in 17
additional states, smoking is restricted to designated
areas (USDHHS 1989). Smoking by teachers has cus-
tomarily been permitted in areas away from students,
but increasingly, school smoking policies are banning
all smoking on school property.

Latin America

  In many Latin American countries, the laws that
regulate tobacco advertising, require health warnings
on cigarette packages, and control smoking in public
places discourage smoking by young people. Fifteen
Latin American countries have also enacted legisla-
tion specifically to control smoking by children and
adolescents. The most common type, which restricts
advertising that influences young people, has been
adopted in 13 Latin American countries. Statutes in
six countries prohibit sales of tobacco to minors. Three
countries-Argentina, Brazil, and Ecuador-prohibit
the distribution of free samples of cigarettes to minors,
and one country (Uruguay) prohibits the sale of single
or loose cigarettes. Legislation in seven countries pro-
hibits smoking or tobacco sales in schools and places
frequented by young people, but such prohibitions
may also be imposed by school authorities (Table 5).

Caribbean

  In the Caribbean, only Trinidad and Tobago has
legislation designed to prevent smoking by young
people. The legislation restricts advertising in cine-
mas, during films certified for showing to persons
under age 18, and on children's television programs.
Under the Children Act of 1925, Trinidad and Tobago
prohibits the sale of cigarettes to persons under age 16.
The prohibition on the sale of loose cigarettes in the
Bahamas may, to some extent, prevent young people
from purchasing tobacco products.

  Smoking in schools is generally regulated by the
schools. In Grenada, the Minister of Education issued
regulations that no child is allowed to smoke in school
(Pan American Health Organization [PAHO] 1988).

Mandating Health Education on Tobacco

  The WHO Expert Committee on Smoking Con-
trol Strategies in Developing Countries emphasized
that no legislation can be expected to succeed without
education and urged countries to make education on
the health hazards of tobacco mandatory before intro-
ducing legislation (WHO 1983). Health education
about tobacco use may be effective without legislation;
in some countries, such education has been provided
to the general public and through school systems
without legislation. For example, the 1983 Principles
of Medical Ethics of Cuba set forth the obligation of
teachers to fight against customs, including the smok-
ing habit, that affect health (Ministry of Public Health
1983). But a law mandating education on smoking
and health expresses government policy and promotes
implementation of such education,

158  Legislation


Table 5.  Countries that attempt to prevent young people from using tobacco, by type of restriction*
                                                                  -                   .-

Country
North America

Canada
United States"

Latin America
Argentina
Bolivia

Brazil

Chile

Colombia

Costa Rica

Cuba

Ecuador

El Salvador

Mexico

Panama
Paraguay
Peru
Uruguay
Venezuela

Caribbean

French overseas
departments and
territories'
Trinidad and Tobago

Sales to
minors

Sales from   Smoking or
vending      sales in
machines     schools+

X           X           X

X           X           X

X

X

X

X

Advertising 4

X5

XS

X

X

X

X

X

X

X

X

X                     X       X5

                      X           X
          .-

`For a summary of legislation in selected countries, see the notes in Appendix 1 to this chapter.
`Includes other places frequented by young persons.
tThat influences young people.
%otal ban on advertising.

"Does not necessarily imply federal legislation, but acknowledges activities of several states.
`For this table, the French overseas departments and territories are counted with the Caribbean countries

  Three types of legislation mandating education
about the health effects of tobacco use have been en-
acted. These are (1) requirements for public education,
(2) requirements for education in the schools, and
(3) allocation of funds for such education (Roemer 1986,
in press). The third type of legislation may require
that educational programs be funded from the general
budget or from specific sources, such as tobacco taxes.

North America

  In Canada, the publication in 1974 of the landmark
Lalonde Report launched a movement for disease

prevention and health promotion (Lalonde 1974). By
1989, Canada had implemented a comprehensive
tobacco-control program, which includes a ban on
tobacco advertising, regulations and increased taxes
on tobacco products, legislation and other measures
to control smoking in public places, and intensified
educational efforts.

  The program has been remarkable for its cohe-
sive coalition of national voluntary and health orga-
nizations-particularly the Non-Smokers' Rights
Association, the Canadian Cancer Society, the Cana-
dian Council on Smoking and Health, Physicians for

Legislation   159


a Smoke-Free Canada, and the Canadian Medical As-
sociation (Lachance, Kyle, Sweanor 1990). These and
other organizations have banded together as the Ca-
nadian Council on Smoking and Health, a nonprofit
voluntary coalition of 10 provincial chapters and more
than 50 local interagency councils across Canada.

  Health and Welfare Canada allocated both per-
sonnel and financial resources to health promotion; in
1985, it launched the National Strategy to Reduce
Tobacco Use by introducing the slogan "Break Free for
a New Generation of Non-Smokers." Although not
legislatively mandated, this strategy enjoys strong
support from the federal and provincial governments
and from national health organizations. A steering
committee consisting of representatives from the fed-
eral government, each of the 10 provinces, the two
northern territories, and eight nongovernment orga-
nizations meets regularly to coordinate activities
(McElroy 1990). The National Clearinghouse on To-
bacco and Health was established to increase public
access to current information on tobacco issues. The
national strategy has created a strong partnership be-
tween the government and the voluntary groups for
an organized, targeted campaign against the use of
tobacco.

  In the United States, one of the federal govern-
ment's most significant contributions to education
and information about the health hazards of tobacco
use has been the publication over the past 25 years of
annual reports of the Surgeon General. These reports
provide current, scientific information on and analysis
of research and policy related to tobacco use. In addi-
tion, the Office on Smoking and Health publishes
annual and cumulative bibliographies of publications
on tobacco. Other agencies of the Public Health Ser-
vice have also made major contributions to education
and information (USDHHS 1989; see also Chapter 6).

  From 1967 to 1970, the federal government man-
dated that messages about the health hazards of to-
bacco use be broadcast through the media to balance
commercial cigarette advertisements. This use of the
Federal Communications Commission's fairness doc-
trine had a substantial effect on tobacco use. Per capita
consumption decreased in 1967 and continued to de-
cline each year through 1970. When cigarette adver-
tising on the broadcast media was banned and the
fairness doctrine antismoking messages were
stopped, cigarette sales increased by 2.5 percent per
year (Warner 1979,1986b; USDHHS 1989).

  Under the Comprehensive Smokeless Tobacco
Health Education Act of 1986, the federal government
is required to develop educational programs, materials.

and public service announcements on the dangers of
using smokeless tobacco. The federal government
also authorizes grants and technical assistance to the
states for developing such programs.

  Many states require education on the hazards of
tobacco use. In 1981, 38 states and the District of
Columbia mandated school health education on to-
bacco, but the number fell to 19 states and the District
of Columbia in 1987. These counts are not directly
comparable because the former figure was derived
from a survey of drug education, and the latter from a
survey that specifically asked about tobacco education.

Table 6.  Countries that mandate health education
   on tobacco use, by type of provision*

Country
or selected
municioalitv

Public   Student Allocation
education education of funds

North America

Canada
United States+

Latin America
Argentina
  San Fernando
  de1 Valle de
  Catamarca

Bolivia

Brazil

  sao Paul0

Chile

Colombia

Costa Rica

Cuba

Ecuador

El Salvador

Mexico
Uruguay
Caribbean
French overseas
departments and
territories+

X       X

X       X       X

X

X       X

X

X       X

X       X       X

X

X

X

X

X       X

X       X

X       X       X

X

`For a summary of legislation in selected countries, see the
notes in Appendix 1 to this chapter.
`Does not necessarilv imply federal legislation, but
acknowledges activities of several states.
$For this table, the French overseas departments and
territories are counted with the Caribbean countries.

160  Legislation


Information is not available, however, on the content
of antitobacco curricula nor on the level of compliance
with state government mandates (USDHHS 1989).

   A 1989 initiative in California allocates revenues
from the tobacco tax to health purposes, including
education on the health hazards of tobacco use. Revenues
for the first year were $525 million (Bal et al. 1990).

Latin America

  Ten countries in Latin America (Table 6) man-
datqpublic education on the health hazards of tobacco
use. In Uruguay, a special order of the Ministry of
Health requires hospitals and special services, partic-
ularly maternal and child health clinics, to provide
intensified education on tobacco use. Only Bolivia
and Mexico have enacted national legislation requir-
ing antitobacco education in the schools, although
such education may be provided voluntarily in other
countries. In 1980, the municipality of Sao Paulo in
Brazil passed legislation requiring antitobacco educa-
tion in all sectors of the community, with special em-
phasis on antitobacco education in the schools. In its
legislation, Chile has provided for the allocation of
resources for informational and educational activities
against tobacco use.

The Impact of Antitobacco Legislation

Caribbean

  No Caribbean country mandates health educa-
tion on tobacco use, but the school systems in some
Caribbean countries voluntarily include such educa-
tion (PAHO 1988).

Model Legislation

  The French overseas departments and territories
in the Americas are subject to French law. The French
National Assembly passed legislation in 1991, to take
effect January 1, 1993, banning all forms of tobacco
advertising. This far-reaching legislation prohibits
the sale of cigarettes to minors, withdraws tobacco
products from the consumer price index, requiresa
health warning stronger than the current message that
abuse is dangerous, and will allow the Minister of
Health to require other health warnings on cigarette
packages. Currently, smoking in schools, food stores,
community recreation centers, elevators, clinics, and
hospitals is prohibited by French law. The new legis-
la tion bans smoking in all public places.

  This new law provides the French overseas de-
partments and territories, together with Canada, with
the most comprehensive tobacco-control legislation in
the Americas. The effectiveness of this model pro-
gram will be of particular interest to other countries of
the Americas in planning legislative programs.

  Evaluating the effects of legislation is difficult
because many factors are involved in tobacco use (see
USDHHS 1989, Chapter 7). However, worldwide ev-
idence indicates that specific legislative interventions
do have positive effects:
o A decline in cigarette consumption is associated
with the required airing of antismoking messages
in the U.S. broadcast media (Warner 1979,1986b).
o A decline in smoking is associated with price in-
creases (Townsend 1990; Lewit 1989; Warner 1986a;
USDHHS 1989).

o Of 15 European countries, those with legislative
programs made more progress in reducing smok-
ing than did those that used a voluntary agreement
(Cox and Smith 1984).
o In Norway, in the five years following enactment of
the Tobacco Law of 1975, which banned advertising,

raised tobacco taxes, and stimulated strong educa-
tional programs, cigarette sales declined by 15 per-
cent, particularly among young people (Tye,
Warner, Glantz 1987).

o In Finland, a decline in total consumption of to-
bacco products has been related to antismoking
measures (Advisory Committee on Health Educa-
tion [Finland] 1985).

  Similar successes specific to legislative efforts
have not yet been documented for Latin America and
the Caribbean. Growing awareness of the potential
power of legislative and regulatory interventions may
increase interest in their enactment and formal evalu-
ation. Determining the extent to which statutes are
enforced and obeyed is an important first step in eval-
uating their impact.

Legislation   161


Conclusions

1.  Legislation that affects the supply of and demand
for tobacco is an effective mechanism for promot-
ing public health goals for the control of tobacco
   use.

2.  Although the direct effects of legislation are often
difficult to specify because of interaction with a
variety of other factors, there are numerous exam-
ples of an immediate change in tobacco consump-
tion subsequent to the enactment of new laws and
regulations.

3.  Most countries of the Americas have legislation
that restricts cigarette advertising and promotion,
requires health warnings on cigarette packages,
restricts smoking in public places, and attempts to
control smoking by young people. These laws
and regulations, however, vary in their specific
features. In many areas, the current level of en-
  forcement is unknown.

162  Legislatio7i


Appendix 1. Notes to Tables

  Details are provided below on selected legisla-
tion summarized by four tables in this chapter. This
legislation concerns advertising and promotion (Table
21, smoking in public places (Table 41, preventing
tobacco use by minors (Table 51, and health education
on tobacco use (Table 6). The information is organized
by table and then by country, in alphabetical order.
Appendix 2 cites specific legislation that corresponds
with the descriptions given here.

Controls on Tobacco Advertising and Promotion
(Table 2)

Argentina

  Except for stating the brand, advertising on tele-
vision and radio is prohibited from 8:00 p.m. to 1O:OO
p.m. Advertising directed to persons under age 21 is
prohibited in theaters and cinemas to which persons
under 18 are admitted. The distribution and promo-
tion of samples at colleges and universities are prohib-
ited. Advertising associated with the practice of
sports is prohibited. Young persons may not be
shown as models in tobacco advertising, and the rep-
resentation of persons smoking excessively is prohib-
ited. Low-nicotine cigarettes may not be represented
as beneficial to health.

Bolivia

  Advertising of tobacco is restricted to the tomb-
stone format, in which only the name, brand, symbol,
and tar and nicotine yield are given. Only activities
directly associated with smoking may be depicted.
The content of advertising is restricted to statements
about the quality, origin, and purity of tobacco prod-
ucts. Persons inhaling or exhaling cigarette smoke,
adolescents, pregnant women, and children may not
be shown. Tobacco advertisements may not be asso-
ciated with sporting, domestic, or occupational activ-
ities. Labels and advertisements for tobacco must be
licensed by the health authority to prevent indiscrim-
inate promotion of tobacco consumption.

Brazil

  Advertising of tobacco products is permitted on
television between 9:00 p.m. and 6:00 a.m. only. Ad-
vertising in theaters before 800 p.m. is prohibited if
persons under 18 are admitted. Tobacco advertise-
ments must meet certain requirements. The advertisement
must not incite excessive or irresponsible consumption;
it must not allude to health or holidays or state that
tobacco has soothing properties; it must not associate
tobacco products with sexuality, virility, or femininity.
Reference to children and adolescents is prohibited,

and tobacco advertising may not be addressed to
young people. The size and frequency of health warn-
ings are prescribed. Announcement of sponsorship of
events by tobacco companies is limited to the presen-
tation of the name and logo of the company, and such
announcement is not permitted as part of the program
of the event.

Canada

   The Tobacco Products Control Act of Canada
prohibits advertising of any tobacco product offered
for sale in Canada. Until January 1, 1991, a tobacco
manufacturer or importer could advertise the product
by signs, subject to a limit on the amount expended on
the preparation and presentation of the sign. The
legislation limits the amount that a tobacco manu-
facturer or importer may contribute to cultural or
sporting activities or events, at which brand names of
tobacco products are used, to the value of contribu-
tions to such events in 1987. Regulations under the act
specify the health warnings that must appear on signs
and vending machines and the number and size of
signs at retail outlets.

Chile

  A health warning is required on advertisements
of tobacco products in print media, on television and
radio, and in cinemas, at which the warning must
remain on the screen for at least five seconds after the
advertisement is shown. No direct or indirect refer-
ence to minors may be made, and young people may
not be depicted in tobacco advertisements.

Colombia

  Tobacco advertising is restricted to presentation
of brand, quality, price, and system of marketing.
Depiction of minors and the act of smoking is prohib-
ited. Advertising of tobacco is allowed on television
after 11:OO p.m. only and is limited to 30 seconds for
each brand. All commercials advertising cigarettes
must devote 20 percent of transmission time to a warn-
ing that tobacco is harmful to health. The Council of
the District of Bogota prohibits tobacco advertising in
children's sports and scientific publications; on murals,
posters, or signs at sports, cultural, educational, or
residential places; and in public transportation vehicles.

Costa Rica

  All advertising or promotion of cigarettes
through newspapers, radio, television, and cinemas
must be approved by the Ministry of Health to avoid
publicity detrimental to the public health. Advertis-
ing of tobacco is prohibited on radio and television
programs intended for children.


Ecuador                       Trinidad and Tobago

  Tobacco advertising directed at or referring to
minors is prohibited. Also prohibited are the broad-
cast of tobacco advertisements before 7:30 p.m., the
insertion of such advertisements in programs for chil-
dren, the use of minors as models, the placement of
advertisements near schools and colleges or in comics,
and the depiction in tobacco advertisements of sports
figures or people who have contributed to the litera-
ture and history of Ecuador.

El Salvador

  Tobacco advertising on radio or television and in
cinemas during programs directed to children is pro-
hibited, but advertising during programs not directed
to children is allowed.

Mexico

  The legislation prohibits tobacco advertising
that asserts that the product enhances social prestige
or that induces consumption by (1) asserting that to-
bacco is a sedative or reduces fatigue or tension or
(2) attributing stimulant qualities leading to success.
Advertising that induces persons to consume the
product for health reasons is also prohibited. Tobacco
advertising must not associate tobacco with sports,
domestic, or professional activities; emphasize femi-
ninity or virility; suggest greater success in sexual
relations; depict children or adolescents; attribute an
effect of well-being; or depict persons smoking in
public. Tobacco advertising is limited to information
on the characteristics, quality, and techniques of prep-
aration of these products.

Panama

  All advertising of tobacco must be approved by
the Ministry of Health. Advertising that shows people
smoking is prohibited.

Paraguay

  Tobacco advertisements may refer to the quality
and origin of the tobacco only and must not encourage
consumption. The use of figures or characters repre-
senting children or adolescents is prohibited as is the
association of tobacco with sports, work, study, or
home. Tobacco advertisements may not be televised
before 7:00 p.m., except during presentations of inter-
national meetings, whether produced locally or abroad.

Peru

  Advertising of cigarettes is prohibited before
8:00 p.m. on radio and television and during shows
suitable for minors in places of entertainment.

   The Bureau of Standards enunciated standards
based on the Code of Advertising Practice, 1979, of the
Advertisers' Association of Trinidad and Tobago,
which was developed in cooperation with the Adver-
tising Standards Authority and other agencies. These
standards require a health warning on tobacco adver-
tisements, permit advertisements for free samples in
the trade press only, prohibit the inclusion of coupons
or trading stamps in cigarette packages, and forbid the
directing of tobacco advertisements and promotion at
audiences that include children.

United States

  Federal legislation prohibits advertising of ciga-
rettes, little cigars, and smokeless tobacco on televi-
sion and radio. Health warnings are required in print
advertisements and on billboards.

Uruguay

  Legible health warnings, required on written to-
bacco advertisements, must remain on a screen long
enough to be read. Oral advertising must refer to the
health warning once for every five references to to-
bacco products. No promotion of tobacco products,
direct or indirect, may be undertaken in schools or
other educational institutions, whether public or pri-
vate. Legislation proposed in 1988 would set forth
standards for advertising tobacco products, including
a prohibition on advertisements directed to or depict-
ing young people. Low-tar and low-nicotine ciga-
rettes could not be depicted as beneficial to health, and
advertising could not associate smoking with sports,
physical strength, social prestige, virility, or feminin-
ity. Advertising would also be restricted to objective
facts on the characteristics of the product, its price, and
its quality.

Venezuela

  All advertising of tobacco products on television
or radio that directly or indirectly encourages con-
sumption of cigarettes and tobacco products is
prohibited.

Restrictions on Smoking in Public Places (Table 4)

Bolivia

  Smoking is prohibited in schools, health prem-
ises, indoor public places, and public transportation
vehicles. Separate smoking areas are to be provided
in indoor public places.

164  Legislation


Brazil

  On May 31,1990, the Ministry of Health adopted
a resolution prohibiting smoking in any public or
private health institution. The Ministry recommends
that the states, the Federal District, and the municipal-
ities adopt measures restricting smoking in public
premises, public transportation vehicles, elevators,
auditoriums, cinemas and theaters, public libraries,
and premises for use by the public. Smoking is pro-
hibited on all flights of two hours or less. On flights
exceeding two hours, space must be reserved for
smokers in the rear of the plane. A legal challenge to
the restrictions on smoking on short flights was re-
jected by the Supreme Court of Justice in Brasilia in
December 1989.

  In 1988, an order of the national government
recommended that federal, state, and municipal gov-
ernments adopt or encourage limitations on smoking
in enclosed public places that lack adequate ventilation.

  In 1980, the Secretary of State for Health and the
Environment prohibited cigarette smoking in places
where service is provided to the public in health units,
hospitals, and other agencies of the Secretariat.

  At the state level, Rio Grande do Sul prohibits
smoking in public educational establishments; halls
used for meetings, entertainment events, and lectures;
museums and libraries; public health establishments;
gymnasiums or other closed premises used for sports
activities either maintained or subsidized by the state;
and intercity passenger-transportation vehicles.

  In Sao Paulo, smoking is prohibited on intercity
buses, in schools, hospitals, health centers, and other
local public health buildings. Both the smoker and the
person in charge of the facility are subject to fines for
violating this legislation. Since July 1990, all restau-
rants of more than 100 square meters must reserve 50
percent of the space for nonsmokers.

  In the state of Rio de Janeiro, smoking is prohib-
ited in meetings of the Federal Council on Medicine.
  At the municipal level, the city of Rio de Janeiro
has enacted legislation prohibiting smoking on buses
and in elevators, cinemas and theaters, stores and
supermarkets, hospitals and health services, muse-
ums, schools, garages, and taxis.
  Port0 Alegre prohibits smoking in businesses,
cinemas, theaters, schools, elevators, buses, and places
where explosives or flammable materials are pro-
cessed or stored.

  The municipalities of Curitiba and Florianopolis
prohibit smoking in enclosed public places and
businesses.

Chile

  In 1981, the Ministry of Education issued a circu-
lar requiring teachers and professors to refrain, when-
ever possible, from smoking in class and while
complying with their obligations to students. The
head of the institution is responsible for enforcement.
  In 1981, the Ministry of Health prohibited smok-
ing by staff on the premises of the National Health
Service and in patients' waiting rooms, administrative
offices, elevators, auditoriums, and meeting rooms.
  Acting on the recommendation of WHO, the
Minister of the Interior recommends that smoking be
prohibited in the waiting rooms, offices, anterooms,
and places of public service in government organizations.
  Legislation in 1985 prohibits smoking in public
transportation vehicles.

Colombia

  The Special District of Bogota prohibits smoking
in covered coliseums, movie houses, theaters, public
libraries, museums, and other buildings to which the
public is admitted or that are devoted to cultural or
sports activities; in buses and taxis; in enclosed areas
of hospitals, sanatoriums and health centers; and in
government offices where the public is served.

Costa Rica

  Smoking by employees and visitors is prohibited
in national government buildings, except for persons
incarcerated in buildings of the national penitentiary
system. But in each public institution, a smoking area
is to be provided.

  Smoking is prohibited in places for public enter-
tainment, including cinemas and theaters, throughout
the country. The owners or managers of these facili-
ties are responsible for enforcement.

  Smoking is also prohibited in all means of public
transportation. Drivers are responsible for enforce-
ment; they may refuse to continue service and seek
help from the authorities.

  Legislation enacted in 1988 imposes a general
ban on smoking in the workplace and requires the
director of the workplace, or his or her representative,
to ensure strict compliance with the prohibition. An
area may be reserved for smokers-to the extent
possible.

Cuba

  Smoking by the staff, patients, and visitors of the
National Health System is prohibited. A 1981 minis-
terial resolution prohibits smoking on all means of
public transportation.


Guatemala

  Guatemalan Government Accord No. 681 (August 3,
1990) prohibits smoking in public transportation vehi-
cles and in public places in government and private
offices.

Honduras

  Comprehensive legislation enacted in 1989 pro-
hibits smoking in public and private schools; cinemas
and theaters; collective ground, air, and sea transpor-
tation; public and private hospitals; government of-
fices and workplaces; sports centers; and sessions of
the national Congress.

Mexico

  A 1990 decree of the Secretary of Health restricts
smoking in the medical facilities of the Secretary of
Health and the National Institute of Health, including
areas for preventive, curative, and rehabilitative care;
auditoriums and places for group meetings, lectures,
and teaching; and other areas.

  In the Federal District of Mexico, a regulation for
the protection of nonsmokers, dated July 5, 1990, re-
stricts smoking in a wide range of indoor public
places, including public transportation vehicles; kin-
dergartens; primary, secondary, and high schools;
waiting rooms of health facilities, hospitals, and clin-
ics; libraries; cinemas, theaters, and auditoriums; gov-
ernment offices; and shops and businesses providing
service to the public, such as automobile service shops,
banks, and financial, industrial, and commercial offices.

Panama

A 1978 decree prohibits smoking in buses.

Paraguay

  A resolution of the Ministry of Public Health and
Social Welfare, issued on January 23, 1990, prohibits
smoking in the clinics and waiting rooms of the health
services as well as in other offices and buildings of the
Ministry.

  In Asuncion, the municipal council has prohibited
smoking in vehicles of the public transportation system.

Peru

  A ministerial resolution prohibits smoking in
buildings and offices of the Ministry of Health and its
decentralized agencies.  The text of the resolution
must be posted at the entrance and other prominent
places of the buildings and offices of the Ministry.
Managers and staff are required to ensure strict com-
pliance with the ban on smoking.

Trinidad and Tobago

  Although no national legislation restricts smok-
ing on aircraft, British West Indian Airways Ltd., in
compliance with regulations of the International Air-
line Transport Association, prohibits smoking on
flights of less than one and one-half hours.

Uruguay

  Since 1976, the School of Medicine of the Univer-
sity of the Republic of Uruguay has prohibited smok-
ing by physicians, students, staff, patients, and visitors
in hospitals of the medical school. A Special Order of
the Ministry of Health, No. 3904, prohibits smoking in
all hospitals of the Ministry of Health. This ban ap-
plies to patients, visitors, physicians, students, and
technical and administrative personnel while on duty
and in contact with patients and their visitors. Smok-
ing is prohibited in plenary sessions and working
committee sessions of the Chamber of Deputies. Leg-
islation proposed on June 16, 1987, would prohibit
smoking in public offices, health centers, public and
private schools, and public transportation.

  Municipal legislation in Montevideo prohibits
smoking in theaters, cinemas, circuses, and all other
places where public performances are presented, al-
though a 1979 decree of Montevideo permits sale of
cigarettes in theaters. Montevideo also prohibits
smoking in city buses and on short trips (less than 110
km) of interdepartmental buses. A 1975 decree pro-
hibits smoking on school buses. On long-distance
lines, including national and international tourism
buses, smoking is permitted in the last three rows of
seats. Smoking is also prohibited by personnel of
companies engaged in the storage, sale, and transpor-
tation of flammable liquids; in storage places for
microcontainers of "supergas"; in storage places for
cylinders and equipment for respiratory therapy; and
in storage places for bulk liquid petroleum gas.

Venezuela

  A 1979 regulation under the Tax Law on Ciga-
rettes and Manufacturing of Tobacco bans smoking in
public transportation vehicles; in buildings where
people gather, such as waiting rooms in theaters and
cinemas; in hospitals and other health facilities; in
sports arenas; and in other places that may be designated.
Smoking areas may be set aside in these facilities.
No-smoking signs must be posted, and managers of
these public places are responsible for compliance.

  In 1984, the Venezuelan Social Security Institute
prohibited smoking in all the administrative service
units of the Institute, and the Ministry of Education
prohibited smoking in school buildings.

166 Legislation


Restrictions Preventing Tobacco Use by Minors
(Table 5)

Argentina

  A statute enacted in 1986 prohibits tobacco ad-
vertising on radio and television from 8:00 a.m. to
IO:00 p.m., except that the name of the brand may be
presented. Tobacco advertising is prohibited in pub-
lications intended for young people and in theaters
and cinemas to which persons under 18 are admitted.
Distribution and promotion of samples of cigarettes at
colleges and universities are prohibited. Young peo-
ple may not be used as models in advertisements of
tobacco. Advertising directed at young people or
associated with sports is prohibited.

Bolivia

  Regulations introduced in 1982 ban smoking in
schools because smoking exposes persons of low re-
sistance to the polluting effects of tobacco and because
minors are susceptible to example. Tobacco advertis-
ing must not depict children or adolescents, nor may
it associate tobacco with sports. In 1984, the Minister
of Education and Culture prohibited students, profes-
sors, and parents of students from smoking in public
and private educational institutions.

Brazil

  Legislation enacted in 1988 specifies that no ref-
erence to children may be made in tobacco advertising
and that such advertising must not be addressed to
them. Tobacco advertising cannot be presented in
theaters before 8:00 p.m. if persons under 18 may
attend. Advertising on television is allowed between
9:00 p.m. and 6:00 a.m. only. An order of the Ministry
of Health in 1990 prohibits the sale of cigarettes to
minors and prohibits the distribution of free samples
of tobacco products at public events. The municipal-
ities of Rio de Janeiro, SBo Paulo, and P&-to Alegre
prohibit smoking in schools.

Chile

  Tobacco advertising on radio or television is pro-
hibited before 9:30 p.m. Young people may not be
depicted in tobacco advertisements. In May 1981, the
Ministry of Education prohibited smoking in schools
and by teachers during classes.

Colombia

  Sales to minors under age 14 and smoking in
schools are prohibited.

Costa Rica

  A 1988 decree prohibits the sale of cigarettes to
minors in all commercial establishments. Administra-
tors or managers of the establishments must ensure
compliance with the decree. Violators are sentenced
under the General Health Law, which provides a pen-
alty of five to 30 days in jail.

Ecuador

  Distribution of samples of cigarettes to minors is
prohibited. Tobacco advertising aimed at children or
referring to them is also prohibited. Tobacco adver-
tisements may not be presented on television before
7:30 p.m. nor be included in programs intended exclu-
sively for children. Tobacco may not be advertised in
or near schools, on school buses, in sports centers, or
in comic books. Sports stars and young artists may not
be depicted using or smoking cigarettes in posters, in
movies, or on record albums. A similar ban applies to
use of historical figures and members of the learned
professions in advertising. Encouraging smoking to
improve concentration or performance is prohibited.

El Salvador

  Tobacco advertising is permitted on radio, on
television, and in movie houses during programs not
intended for children.

Mexico

   The General Health Law of 1983 sets forth the
objectives of the Program Against Smoking, which
includes education of the family, children, and adoles-
cents about the effects of tobacco on health through
individual methods and mass communication. The
statute contains no specific ban on advertising di-
rected at children, but it prohibits the sale of tobacco
products to minors under any circumstances.

Panama

  All advertising of tobacco must be approved by
the Ministry of Health. Tobacco advertising may not
depict persons smoking.

Paraguay

  Tobacco advertising that depicts children or adoles-
cents or that associates tobacco with sports is prohibited.

Peru

  Cigarette advertising may be presented on radio
and television after 8100 p.m. It is an offense to present
tobacco advertising before 7:00 p.m. in performances
suitable for minors.

Legislation   167


Uruguay

Colombia

  The sale of cigarettes, cigars, and tobacco prod-
ucts to minors (persons under 18 years of age) is
prohibited. The sale of single or loose cigarettes is
prohibited. Advertising of cigarettes is allowed on
radio and television after 9:00 p.m. only. Television
stations must avoid guests' smoking on programs
between 6:00 a.m. and 12:00 p.m.

  Legislation of 1986 provides for educational pro-
grams and campaigns to prevent tobacco use.

Costa Rica

  A 1988 decree urges campaigns and activities to
mark World No-Tobacco Day, established by WHO,
that emphasize the injury to health caused by smoking.

Venezuela                              Cuba

  A 1980 decree prohibits television and radio ad-
vertising that leads to the use of cigarettes and tobacco
products, especially by young people. Violation of
this decree is punishable by suspension or revocation
of the broadcasting permit.

  A 1981 decree requires the staff of the National
Health System to use all opportunities to provide
information on the harmfulness of tobacco and to
persuade citizens of this effect.

Ecuador

Legislation Mandating Health Education on
Tobacco Use (Table 6)

  The 1979 Constitution of Ecuador recognizes the
right to welfare of all Ecuadorians, which includes
protection of health, and requires programs aimed at
eliminating alcoholism and other addictions.

Bolivia

  Legislation enacted in 1982 requires the Ministry
of Social Welfare and Public Health to create mass
education programs to counter the harmful effects of
tobacco and to supervise the use of the media for
tobacco advertising. A council for health training and
education, created by joint action of the Ministry of
Social Welfare and Public Health and the Ministry of
Education and Culture, is charged with analyzing the
educational programs, including compulsory anti-
smoking education, for systematic and programmed
teaching of health education.

Brazil

  Legislation enacted in 1986 provides for a na-
tional antismoking day (on August 29 each year) and
a national campaign in the preceding week that alerts
people to the dangers of tobacco use.

Chile

   The National Commission for Control of Smok-
ing, established by a 1986 decree, is charged with
designing and evaluating a program for smoking con-
trol that includes education, information, and regula-
tion. The Commission is required to identify
resources in the public and private sectors for infor-
mational, educational, and smoking-cessation activi-
ties. The function of the Intersectoral Commission for
Primary Prevention of Alcoholism in Schools, estab-
lished in 1980, has been expanded to prevent the use
of drugs and tobacco.  In 1984, the Decree on the
Advisory Joint Commission on Education was modi-
fied to strengthen joint activities of the ministries of
health and education and their constituent bodies and
to increase support at the local level.

El Salvador

  A decree of May 11,1988, requires the Ministry
of Public Health and Social Welfare to develop pro-
grams on the effects of consumption of drugs and
tobacco and to encourage cultural and sports activi-
ties that prevent such consumption.

Mexico

   The General Health Law of 1983 sets forth the
objectives of the Program Against Smoking, which
include education of the family, children, and adoles-
cents through individual methods and mass commu-
nication. Emphasis is on education of the family to
prevent tobacco use by children and adolescents. Co-
ordination agreements between the Ministry of Health
and Welfare and the states provide for implementing
smoking-control programs in institutions of higher
education and for preventing smoking by children
and adolescents.

Uruguay

  Concerned about the increase in smoking among
young people, the Ministry of Public Health, with
participation from the Ministry of Education, organ-
ized No Tobacco Day, which involves educational
councils at the primary, secondary, and teacher train-
ing levels. Legislation proposed in 1988 would autho-
rize a commission for the control of smoking to coordi-
nate educational programs on tobacco with the Nation-
al Administration of Public Education, the University of
the Republic, and other educational organizations.

168 Legislation


Appendix 2. Legislation Reviewed for the
Americas

  Many of the references cited here are available
from multiple sources, including the International Di-
gest of Health Legislation (IDHL), edited by the Health
Legislation Office, World Health Organization, Ge-
neva, and the LEYES database produced in the WHO
Regional Office for the Americas, or Pan American
Health Organization (PAHO), by the Health Legisla-
tion Project (HLE), Health Policies Development Pro-
gram. Several state and local statutes were provided
by PAHO. The list contains related laws not specific-
ally discussed in the text.

  For a useful summary and analysis of Latin
American legislation to control smoking, see Bolis, M.,
Frame of Reference for the Annlysis of Latin Americfln
Legislation Relating to Control of Smoking, Washington,
DC: Pan American Health Organization, Health Pol-
icies Development Program, December 1989 (in Span-
ish and English).

Argentina

  Order No. 33.266 prohibits drivers of school
buses from smoking and prohibits smoking on vehi-
cles transporting dangerous substances.
  Order No. 22.900 prohibits smoking on public
transportation vehicles.

  Order No. 09-12-910 prohibits smoking in the-
aters, including interior vestibules and corridors.
  Resolution No. 422 of May 23,1984, prohibits the
use of minors in tobacco advertising.  (LEYES
database)

  Law No. 23344 of July 31, 1986, restricts the
advertising of tobacco, cigars, cigarettes, and other
products intended for smoking and their packaging.
(IDHL, 1986,37(4):796-797) (LEYES database)
  Parliamentary Decree No. 226 of April 27,1988,
requires that all advertising and promotion of tobacco
carry a warning that smoking is prejudicial to health.
  Argentine Food Code, Article 18, prohibits the
use of tobacco in food establishments and in places
where food products are handled.

Argentina (Buenos Aires)

  Order No. 6762-DOCS-84 of December 5, 1984,
concerns smoking in public transportation, stations of
the underground, school buses, vehicles transporting
dangerous substances, theaters, and food establishments.
  Law No. 10.600 of November 12,1987, prohibits
smoking in public transportation vehicles.

Argentina (C6rdoba)

  Order No. 8425 of October 11, 1988, prohibits
smoking in offices of the municipal government that
serve the public.

  Law No. 7827 of September 20, 1989, prohibits
smoking in enclosed places of the executive, legisla-
tive, and judicial branches of the government.

Argentina (Jujuy)

  Law No. 4292 of June 17,1987, prohibits smoking
in public buildings, school rooms, hospitals, and
means of urban and suburban transportation.

Argentina (Mendoza)

  Law of December 3,1988, prohibits smoking in
indoor public places, elevators, public offices, hospi-
tals and health centers, official banks, and educational
establishments,

Argentina Walle Viejo)

  Order of October 25,1988, prohibits smoking in
government offices, indoor public places, and means
of transportation.

Argentina (San Fernando de1 Valle de Catamarca)

  Order No. 565-C-89 prohibits smoking in en-
closed places of the municipal government and orders
a campaign against smoking with the objective of
extending the prohibition to all public and private
places.

Bermuda

  The Tobacco Products (Public Health) Act 1987
requires warnings on packages and advertisements
for tobacco products. (IDHL, 1989,40(1):100)
  The Tobacco Products (Public Health) Regula-
tions 1988 requires health warnings on cigarette pack-
ages. (IDHL, 1989,40(1):100-101)

Bolivia

  Decree Law No. 15.629 of July 18, 1978, Health
Code, contains a provision on cigarette marketing.
(LEYES database)

  Supreme Decree No. 18.955 of May 26, 1982,
forbids the importation of cigarettes into Bolivia.
(LEYES database)

  Regulations of March 15, 1982, on the use of
tobacco, restrict advertising, require a health warning,
and prohibit smoking in schools, indoor public places,
and transportation vehicles.  (IDHL, 1983, 34(3):
538:539) (LEYES database)

Lecgisiflfion   169


  Ministerial Resolution No. 883 prohibits smok-
ing in any educational establishment, private or pub-
lic, throughout Bolivia. (Provided by HLE/PAHO)

Brazil

  Law No. 7488 of June 11, 1986, establishes a
national antismoking day. (IDHL, 1989, 40(2):406)
(LEYES database)

  Order No. 490 of August 25,1988, restricts smok-
ing in public places, requires a health warning on
tobacco packages, and restricts advertising. (IDHL,
1989,40(2):406)

  The Brazilian Political Constitution of 1988 stip-
ulates that commercial advertisement of tobacco (and
other products mentioned) will be subject to legal
restrictions and requires that a warning appear on
advertisements of these products stating the harmful
effects caused by their use.

  Regulation No. 731 of the Ministry of Health,
dated May 31, 1990, restricts advertising of tobacco
products, requires a health warning on packages and
advertising, regulates smoking in health institutions
and on airline flights, encourages federal districts and
municipalities to restrict smoking in public places, and
forbids the sale of tobacco products to persons under
18 years of age. (Resolution No. 490 of August 25,
1986, is repealed)

  Law No. 2.845 of May 20,1981, prohibits smok-
ing oh school premises, on sports grounds, and in
public health establishments. (Provided by HLE/
PAHO)

  Decree No. 17.451 of July 22, 1981, regulating
Law No. 9.120 of October 8, 1980, prohibits smoking
in public places, hospitals, and elementary and sec-
ondary schools. (Provided by HLE/PAHO)

Canada

  Tobacco Products Control Act, 1988, Chapter 20,
Revised Statutes of Canada. (IDHL, 1988, 39(4):858-
859)

  Non-smokers' Health Act, 1988, Chapter 21, Re-
vised Statutes of Canada, as amended by Chapter 7,
Revised Statutes of Canada, 1988. (IDHL, 1988,
39(4):859-860, IDHL, 1990,41(1):83-84)
  Non-smokers' Health Regulations. (IDHL, 1990,
41(1):84-85)

  Aeronautics Act: Air Regulations, amendment.
(IDHL, 1988,39(1):86)

Canada (Manitoba)

   An Act to Protect the Public Health and Comfort
and the Environment by Prohibiting and Controlling
Smoking in Public Places, Bill 71,1987.

Canada (Ontario)

Brazil (Rio Grande do 511)

The Smoking in the Workplace Act, 1988.

  Order No. l/80-SSMA of April 8,1980, concerns
smoking in the workplace, smoking in health institu-
tions, and restrictions on tobacco sales in health insti-
tutions. (IDHL, 1981,32(1):87)
  Law No. 7813 of September 21, 1983, contains
provisions on smoking. (IDHL, 1983,34(4):768)

Canada (Quebec)
  Law on the protection of nonsmokers in certain
public places, Bill 84,1987. (IDHL, 1987,38(1):6=6)

Chile

Brazil (SHo Paula)

  Law No. 3.938 of September 8, 1950, prohibits
smoking in public transportation vehicles, elevators,
and places of public entertainment. (Provided by
HLE/PAHO)

  Decree No. 106 of April 8, 1981, prescribes a
warning in connection with the marketing and adver-
tising of tobacco.  (IDHL, 1982, 33(4):732) (LEYES
database)

  Law No. 8.421 of July 14,1976, prohibits smoking
in indoor supermarkets and other stores. (Provided
by HLE/PAHO)

  Circular No. 601/81 of the Ministry of Educa-
tion, da ted May 11,1981, restricts smoking by teachers
and in the schools.

  Law No. 9.032 of March 27,1980, concerns edu-
cational programs in schools on the harmful consequences
of tobacco and alcohol consumption. (Provided by
HLE/PAHO)

  Circular No. 3H/95 of June 23,1982, of the Min-
istry of Health prohibits smoking by health profes-
sionals, health officials, and the general public in
hospital rooms, clinics, waiting rooms, administrative
offices serving the public, elevators, auditoriums, and
waiting rooms of the National Health Service.

  Law No. 9.120 of October 8, 1980, prohibits
smoking in public transportation vehicles in urban     Law No. 18290 of February 1985 concerns the
areas, public places, health establishments, and ele-   public transportation of passengers and prohibits

mentary and secondary schools.            smoking in the interior of public vehicles. (LEYES
                                 database)

170  Legislation


  Decree No. 1 of January 2,1986, establishes the
National Commission for the Control of Smoking.
(IDHL, 1987,38(4):78&787) (LEYES database)
  Resolution No. 35 of April 21, 1986, forbids
smoking in public vehicles. (LEYES database)
  Decree No. 164 of June 4,1986, prescribes a new
warning for use in the marketing and advertising of
tobacco. (IDHL, 1987,38(4):787) (LEYES database)
  Circular No. 3F/l23 of August 13, 1986, of the
Ministry of Health, restricts smoking in the health
facilities of the National Health Service. (LEYES
database)

  Circular No. l-27 of July 1989, of the Ministry of
Health, concerns promotion of the antitobacco cam-
paign in the community and in schools of the munic-
ipal education system.

  Circular 27 of July 4,1989, of the Ministry of the
Interior, recommends restrictions on smoking in gov-
ernment services and on the sale of tobacco products
in kiosks and other places of the government services.

Colombia

  Decree No. 1.188 of June 25, 1974, promulgates
the National Statute on Narcotics, Section 20 of which
restricts tobacco advertising in cinemas and the broad-
cast media. (IDHL, 1978,29:23-26)
  Decree No. 3.430 of November 26,1982, concerns
restrictions on advertising of tobacco.
  Resolution No. 4.063 of 1982, regulating Decree
No. 3430 of November 26, concerns restrictions on
advertising. (Provided by HLE/PAHO)
  Resolution No. 7.559 of June 12,1984, creates the
National Board on Tobacco and Health. (Provided by
HLE/PAHO)

   Decree No. 3.788 of 1986 concerns educational
campaigns against tobacco.  (Provided by HLE/
PAHO)

  Law No. 30 of January 31, 1986, refers to cam-
paigns aimed at, among other topics, preventing to-
bacco consumption. (LEYES database)

Colombia (BogotP)

  Accord No. 3 of 1983 concerns smoking in public
places, public vehicles, schools, health establishments,
and government offices. (Provided by HLE/PAHO)

Costa Rica

  Decree No. 1.520-SPPS of February 24,1971, re-
quires warnings on cigarette packages. (IDHL, 1974,
24:61)

  Decree No. 11.016-SPPS of December 17, 1979,
forbids advertising of cigarettes, unauthorized by the
Ministry of Health, through newspapers, radio, televi-
sion, cinemas, and other media. (LEYES database)

  Decree No. 20.196-S of December 13,1990, refers
to advertisement, health warnings on packages, and
places in which smoking is prohibited. (LEYES
database)

  Executive Decree No. 17.398-S-J of January 21,
1987, forbids civil servants to smoke at work. (LEYES
database)

  Executive Decree No. 17.964-S of August 3,1987,
forbids smoking in cinemas and theaters. (LEYES
database)

  Executive Decree No. 18.771 of January 16,1989,
requires the director of public institutions to place
no-smoking signs in visible places. (LEYES database)
  Executive Decree No. 18.780 of January 19,1989,
requires warnings on tobacco's harmful effects.
(LEYES database)

  Decree No. 17.967-S of February 4, 1988, con-
cerns restrictions on sales to minors. (IDHL, 1989,
40(1):101) (LEYES database)
  Decree No. 17.969-S of February 4, 1988, con-
cerns tobacco information programs. (IDHL, 1989,
40(1):101) (LEYES database)
  Decree No. 18.216-S-TSS of June 23, 1988, con-
cerns smoking in the workplace. (IDHL, 1989,
40(1):101) (LEYES database)
  Decree No. 18.248-MOPT S of June 23, 1988,
concerns smoking on public transportation vehicles.
UDHL, 1989,40(1):101-102) (LEYES database)

Cuba

  Ministerial Resolution No. 165 of August 17,
1981, concerns smoking in health institutions and in
the workplace. (IDHL, 1989, 40(2):407) (LEYES
database)

Ecuador

  Supreme Decree No. 965 of August 24, 1973,
promulgates regulations governing manufacturing,
sales, and advertising activities associated with the
use and consumption of cigarettes and alcoholic bev-
erages. (IDHL, 1978,29:6&65) (LEYES database)
  Political Constitution of January 10, 1979, states
that the social security system will be aimed at the
elimination of alcoholism and other drug addictions.
(LEYES database)

  Accord No. 955 of January 13, 1989, creates a
national committee against smoking. (LEYES
database)

El Salvador

  Decree No. 955 of May 11,1988, promulgates the
Health Code concerning information programs, ad-
vertising restrictions, and health warnings on pack-
ages. (IDHL, 1990,41(1):1-15) (LEYES database)

Legislatiorz   272


French overseas departments and territories

Panama

  Law number 91-32 (January 10, 1991), of the
French National Assembly, concerns the fight against
tobacco addiction and alcoholism.

Guatemala

  Government Accord No. 681 of August 3,1990,
prohibits smoking in public transportation vehicles
and public places in government and private offices.
(LEYES database)

Honduras

  Law of the Honduran Institute for the Preven-
tion of Alcoholism and Drug Addiction, Decree No.
136-89, of October 14, 1989, provides for control of
smoking in public places.

Mexico

  General Health Law of December 23,1983, refers
to the control of tobacco importation and exportation.
(LEYES database)

  Regulations of the General Health Law of January 4,
1988, refer to the importation and exportation of vari-
ous products, including tobacco. (LEYES database)
  Coordination Agreement of November 10,1986,
between the Federal Executive and the Executive of
the State of Tabasco, supports the Smoking Control
Program. (IDHL, 1987,38(4):787-788)

  Decree of February 26,1973, prescribes the Health
Code of the United Mexican States, Section 37 of which
authorizes the Secretariat for Health and Welfare to
regulate publicity for or advertising of alcoholic bev-
erages and tobacco. (IDHL, 1974,25:123-141)

  Regulations of December 16, 1974, on advertis-
ing for foodstuffs, beverages, and medicaments,
Chapter IV of which restricts advertising of tobacco.
(IDHL, 1976,27:163-168)

  Decree of the Secretary of Health of April 17,
1990, restricts smoking in medical facilities of the Secretary
of Health and in the National Institute of Health.

Mexico (Federal District)

  Regulation for the protection of nonsmokers,
dated July 5,1990, prohibits smoking in indoor public
places, public transportation vehicles, public and pri-
vate schools, hospitals and clinics, government offices,
cinemas, theaters, and shops and business places
where the public is served.

Nicaragua

  Decree of June 30, 1976, establishes a health
warning on cigarette packages.

  Cabinet Decree No. 56 of March 17,1970, prescribes
measures against cigarettes. (IDHL, 1973,24:581)
  Decree No. 129 of June 19,1978, refers to, among
other things, advertising of cigarettes and tobacco.
(LEYES database)

  Resolution No. 1.561 of November 8, 1989, cre-
ates a national commission to study tobacco use in
Panama. (LEYES database)

Paraguay

  Law No. 836/80 promulgates the Health Code of
December 15, 1980, Sec. 202 of which restricts adver-
tising of tobacco and authorizes the Ministry of Health
to require a health warning on tobacco products.
(IDHL, 1981,32:624-634) (LEYES database)

  Decree-Law No. 4012 regulates Articles 202-205
of the Sanitary Code on Advertising of Tobacco and
Alcohol.
  Resolution S.G. No. 20 of the Ministry of Public
Health and Social Welfare, January 23,1990, prohibits
smoking in the facilities of the Ministry of Public
Health and Social Welfare and sets forth means of
control.

Paraguay (Asuncibn)

  Capital Municipality Transit Rule #298 of August
1981 prohibits smoking in urban passenger vehicles.
  Capital Municipality Ordinance 15,381, dated
February 2, 1984, prohibits smoking in cinemas, the-
aters, and other similar public places.
  Order of the Municipal Council, Article 298, in
relation to World No-Tobacco Day 1991, prohibits
smoking in collective public transportation vehicles.

Peru

  Ministerial Resolution No. 570-86-SA-DM for-
bids smoking in dependencies of the Ministry of
Health. (LEYES database)
  Ministerial Resolution No. 449-88-SA-DM of
May 12, 1988, creates a permanent national commis-
sion against smoking. (LEYES database)
  Supreme Decree No. DS-0079-70-SA of April
1970 requires health warnings on cigarette packages
and advertisements and restrictions on advertising.
(IDHL 1977,28:689)

  Law No. 23.482 of October 20, 1982, concerns
the selective consumption tax on cigarettes made
from blond tobacco. (IDHL, 1987, 38(1):67) (LEYES
database)

172  LegisIation


Trinidad and Tobago

  Trinidad and Tobago standard. Requirement
for advertising, advertising of tobacco products of
June 15,1984. TIS 2120500 Part 3:1984.
  Trinidad and Tobago Compulsory Standard.
Requirements for labeling; Part II - Labeling of retail
packages of cigarettes. ITS 2110500 Part II: March 10,
1989.

  Chap. 46:01, Laws of Trinidad and Tobago,
March 17,1925, the Children Act, relates to the protec-
tion of juvenile offenders, children, and young persons,
and to persons in industrial schools and orphanages.

United States

  The Federal Cigarette Labeling and Advertising
Act, 1965, as amended by the Public Health Cigarette
Smoking Act, 1969, and the Comprehensive Smoking
Education Act, 1984. (IDHL, 1971,22:998; IDHL, 1985,
36(3):649)

  The Comprehensive Smoking Education Act
concerns information programs, warnings on pack-
ages, evaluation of smoking-control programs, and
advertising restrictions. (IDHL, 1985,36(3):649652)

  The Comprehensive Smokeless Tobacco Health
Education Act of 1986 concerns information pro-
grams, smokeless tobacco, restrictions on sales to mi-
nors, health warnings on packages, advertising
restrictions, levels of toxic constituents, and evalua-
tion of smoking-control programs. (IDHL, 1987,
38(1):67-70)

  Regulations under the Comprehensive Smoke-
less Tobacco Health Education Act of 1986. (IDHL,
1987,38(3):547)

  Smoking Regulations. Part 101-20 (Manage-
ment of Buildings and Grounds) of Title 41 Public
Contracts and Property Management) of the U.S. Code
of Federal Regulations. (IDHL, 1987,38(3):547-548)

  The Department of Transportation and Related
Agencies Appropriations Act 1988 concerns smoking
aboard aircraft (IDHL, 1988,39(4):865); U.S. Code An-
notated, Title 49, Appendix, Section 1374(d), Prohibi-
tion against smoking on scheduled flights and
tampering with smoke alarm devices, as most recently
amended by P.L.lOl-164, Section 335, November 21,
1989,103 Stat. 1098.

  Smoking aboard aircraft. Parts 121 and 135 of
Title 14 (Aeronautics and Space), U.S. Code of Federal
Regulations. (IDHL, 1989,40(1):104)

United States (New York)

  An act to amend the public health law, in relation
to smoking restrictions and to repeal article 13-E of
such law relating thereto concerning smoking in

public places, workplaces, health institutions, and on
public transportation vehicles. Approved by the Gov-
ernor: July 5,1989. (IDHL, 1990,41(1):88); New York
Public Health Law, Article 13-E, Sections 1399n-1399x,
1990.

Uruguay

  Resolution No. 1150/970 of July 21,1970, assigns
to the Ministry of Health the task of studying the
effects of smoking and disseminating information
thereon through a special commission. (IDHL, 1973,
24:680)

  Resolution 765602, adopted September 23,1976,
prohibits smoking in the clinics and hospital of the
Faculty of Medicine by physicians, students, and tech-
nical and administrative personnel; requires inclu-
sion of smoking history in patient charts; establishes
smoking-cessation programs in the hospital; intensi-
fies education against tobacco in the maternal and
child clinics; and increases information on smoking
and its risks at all levels of instruction-professional,
middle level, and primary education.

  Decree No. 407/981 of December 17, 1980, pro-
hibits the smoking of tobacco products in any form in
buses used for interdepartmental transport of passengers.

  Law No. 15.361 of December 24, 1982, adopts
provisions on the advertising and marketing of ciga-
rettes, cigars, and other tobacco products. (IDHL,
1983,34(3):539) (LEYES database)

  Decree No. 263.983 of July 22,1983, regulates the
marketing and advertising of tobacco products.

  Decree No. 163 of July 22,1983, regulates adver-
tising and marketing of cigarettes and tobacco prod-
ucts. (LEYES database)

  Law No. 15.656 of October 10,1984, extends the
interval for publishing the maximum yield of nicotine
and tar by cigarette manufacturers and importers.
(IDHL, 1988,39(2):396)

  Resolution of the Chamber of Deputies, dated
May 9,1989, prohibits smoking in the plenary sessions
and working committee meetings of the Chamber of
Deputies.

  Ministry of Public Health Special Order No.
3.904 (undated) prohibits smoking in the hospitals of
the Ministry of Public Health by patients and their
visitors, and by physicians, students, and technical
and administrative personnel while on duty and in
contact with patients. The order also calls for intensi-
fied education on tobacco, especially in the maternal
and child health clinics, and requires inclusion of in-
formation on smoking in clinical histories recorded in
the hospital.

Legislation   173


Uruguay (Montevideo)

  Decree No. 16.750 of March 21, 1975, prohibits
smoking by drivers of buses for school children. (Pro-
vided by HLE/PAHO)

   Decree No. 19.067 of March 1979 concerns re-
quirements for theatrical performances, including
authorization for the sale of nonalcoholic drinks, cig-
arettes, and other items in theaters. (Provided by
HLE/PAHO)

  Decree 407/981 of August 12, 1981, concerns
smoking on interdepartmental passenger transporta-
tion. (Provided by HLE/PAHO)

Venezuela

  Law of September 13,1978, prescribes the tax on
cigarettes and tobacco products. (IDHL, 1979,30:925)
(LEYES database)

  Decree No. 3.007 of January 2, 1979, prescribes
regulations for the implementation of the law pre-

scribing the tax on cigarettes and tobacco products.
(IDHL, 1979,30:925-926) (LEYES database)

  Decree No. 849 of November 21,1980, prohibits
television advertising of tobacco products. (LEYES
database)

  Decree No. 996 of March 19,1981, prohibits radio
advertising of tobacco products. (LEYES database)

  Decree No. 849 of November 21,1980, prohibits
the transmission by television stations of any commer-
cial advertising that directly or indirectly encourages
the consumption of cigarettes and other products de-
rived from tobacco manufacture. (IDHL, 1982,
33(3):499) (LEYES database)

  Resolution of October 23, 1984, establishes a
Standing Honorary National Council, attached to the
Division of Chronic Disease of the Ministry of Health
and Social Welfare, for studying health problems as-
sociated with smoking-with a view to formulating
policies for the prevention of smoking and the organic
diseases resulting therefrom. (IDHL, 1986,37(2):276-277)

174 Legislation


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176  Legislation


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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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204  Prevention and Control


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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


Index

Ad valorem taxes   228
Addiction
    models of   232-232
Adolescents
  price elasticity of demand  229, 232
  smoking prevalence of   72
Advertising of tobacco
    bans  128-129, 249, 250, 260, 262,184
    economics   118-119
  expenditures   218
  legislation   248.250,291-194
Age factors, costs of smoking   722
Age-specific mortality   85-86
Airborne smoke inhalation   19.20,22
Allen & Ginter   29
Alternative crops   126
American Brands, Inc.   35,36
American Cigar Company   29
American Revolution   26
American Snuff 29
American Stogie   29
American Tobacco Company  29,31-33,35
Antismoking movements, early   30-31
Antitobacco activities, Latin America and the Caribbean,
see Chapter 6, Appendix 1
Antitobacco education
   Chile  187,189
   Cuba   289
Antitobacco legislation, impact   261
Antitobacco organizations, Latin America and the
Caribbean, see Chapter 6, Appendix 1
Antitrust case of 1911   32
Argentina
   tobacco subsidies   123
   tobacco-control commission   294
Attitudes towards smoking  71,78-79
Attributable risk calcmations   109-l 20

Birthrate 62
Bladder cancer, mortality from  86-89,91-93
Bolivia, tobacco-control commission   294
Bonsack, James 29
Brand preferences   40-41
Brazil
  antismoking campaign costs   114
  early tobacco production and trade   26
  health care system   123
   sales restrictions   253
  tobacco growing   222
   tobacco subsidies   222
   tobacco-control commission   294

British Colonies, tobacco production and trade   23-25
British-American Tobacco Company, Ltd.  32.33,35-40,
43,44
Brown & Williamson Tobacco Corporation   32
Bull Durham 28

C

Canada
   health care system   213
   minors' tobacco access regulations   157
    Non-smokers' Health Act  153,156
   product labeling requirements   252
   public smoking restrictions   153-754
   tobacco-control program  159-l 60, 284
   tobacco diversification plan   226
    tobacco subsidies   223
    tobacco taxation   233
    Tobacco Products Control Act  128,249,151, 284
   workplace smoking restrictions   256
Cancer mortality, see specific types
Carbon monoxide yield, cigarette brands   288-189
Caribbean
   advertising-control legislation   150
   health education   262
  prevalence of smoking, see Chapter 3
   product labeling requirements   252
  public smoking restrictions   254
   tobacco industry   42-48
  tobacco manufacturing and trade   25-26
   tobacco taxation   237
  workplace smoking restrictions   157
  youth smoking regulations   258
Caribbean Community, tobacco control activities of   285
Cartel of 1903   32
Cause-specific mortality  85.89,91-92
Centers for Disease Control, tobacco-control
programs   183,184
Cerebrovascular disease, mortality from  S&89,91-93
Chewing, tobacco 20
Chicago Anti-Cigarette League   30
Chile
   antitobacco education   287,189
   sales restrictions   152-153
  smoking and health organization   194
  smoking prevalence estimates   68-70
Chronic obstructive pulmonary disease, mortality
from  86-89,91-93
Cigar manufacturing, nineteenth century   27
Cigarette characteristics   116-217
Cigarette, development and emergence, see Chapter 2
Cigarette manufacturing
  early development of   28-29
  legislation   148
Cigarette package labeling   250-252
Cigarette-manufacturing machine 29
Cigarettes, popularity   29-31
Civil War   27-28.29

209


Coalitions, tobacco-control   294
Coding, mortality 83
Colonies, North American, tobacco production and
trade   23-25
Columbus, Christopher 19
Comprehensive Smokeless Tobacco Health Education
Act   160
Comuuero Rebellion   42-43
Constituents, labeling of, in tobacco products   251
Consumer demand for tobacco   21.5118
Consumer preferences 40
Consumption, see Tobacco consumption
Consumption patterns, Latin America and
the Caribbean   46-48
Contraband, see Smuggling, cigarette
Coronary heart disease, mortality from  86-89,91-93
Cost-of-illness studies
   incidence-based   122-212
  prevalence-based  llO-222,112
Costs of smoking
   considerations and calculations  205, 207-120
  productivity measures   207-208
  smoking-related illness   222-222
Crop substitution   126
Cuba
   antitobacco education   289
  early tobacco production and trade  26,27
   sales restrictions   253
Customs duties   127

D

De Medici, Queen Catherine   23
Deforestation   125
Demographic characteristics   61-65
Developing countries, costs of smoking-related
illness   222
Dingley Tariff 30
Direct cost estimates, smoking-related diseases
Distribution, tobacco   221-222
Diversification, tobacco companies   34-35
   Canada   126
Drinking, tobacco   20-21
Duke, James   28-29
Duke of Durham   28
Duke, Washington   28

E                             -

Economic growth, tobacco in   225-126
Economic predictions, tobacco production   127
Economics, tobacco and health, see Chapter 4
Ecuador, smoking and health organization   194
Education, tobacco  287, 297-202
Educational attainment   63-64
Eight-city survey, smoking prevalence   66-67
Enema, tobacco 22

107

Environmental tobacco smoke, restrictions on   153-157
Epidemiologic transition   205
Esophageal cancer, mortality from  86-89, 91-92
Excise taxes
  effect on consumption   129-233
  manufactured cigarettes   191
  post-Civil War   29-30
  United States, nineteenth century   29-30
Exportation of tobacco during American Revolution   26
Externalities, economic   125

F

Farming, tobacco   220-221
Foreign investments, tobacco companies   33-34
France, model legislation   261

G

Gallaher Tobacco Ltd.   35
Gallup Organization, prevalence surveys   67-68
Gaston, Lucy Page   30

H

Hanson Trust Ltd.   35
Havana Commercial 29
Havana Tobacco   29
Hawkins, Sir John   23
Health and Nutrition Examination Survey
  Hispanic   71-72
   National   131
Health care financing   11-7.114,135-236
Health care systems
   Latin America and the Caribbean   123-214
   North America   113
Health consequences
  latent, of smoking   105
   taxation   133-13`4
Health economics, see Chapter 4
Health education, legislation for   158-161
Health objectives for the nation, year 2000   183-284
Health warning
  legislation for   292-294
   statements of   150-152

I

Imperial Tobacco Company  32.33,36
Import substitution   226
Import tariffs   127
Importation and exportation  222,224, 225, 226
Income distribution   64-65
Income elasticity   116
Indigenous societies, tobacco use in, see Chapter 2
Indirect cost estimates, smoking-related diseases   207-108

210


Initiation of smoking  68,69,72
Insurance, health  1%114,135136
International competition, tobacco companies   35
International growth, tobacco companies   33-34
International Union Against Cancer  185,186
Interventions, legislative, see Chapter 5

1

James I, King   24

Knowledge of smoking   77,78-79
Kohlberg Kravis Roberts & Company   35
Kress, Dr. D.H.   30

L

Labeling requirements   150-152
Labor force   64-65
Laryngeal cancer, mortality from  86.89,91-93
Latency of health consequences of smoking   205
Latin America
  advertising-control legislation   250
   health education   161
  prevalence of smoking, see Chapter 3
  product labeling requirements   152
  pubIic smoking restrictions   154
  tobacco industry   42-48
  tobacco manufacturing and trade   25-26
   tobacco taxation  128,131,133,134
  workplace smoking restrictions   157
  youth smoking regulations   258
Latin American Coordinating Committee on Smoking
Control  185-286, 187,196
Legislation
  antitobacco, impact of   161
   health education   158-161
   purposes   147
  tobacco-control programs   191-193
  tobacco-control, see Chapter 5
   see also Restrictions
Licensing agreements, transnational tobacco
corporations   35-36
Licensing, tobacco retailers   158
Licking, tobacco 21
Life expectancy  61-62,83-84
Lifetime costs, smoking-related illness   112-212
Liggett & Myers Tobacco Company   32
Local taxes   128
Loews Corporation 35
Lorillard  27,33,35
Lorillard, Pierre 27

Lung cancer
  mortality from  86-89,91-93
  mortality index  89.91,93

M

Manufacturing, tobacco   121
   Caribbean   25-26
   Latin America   25-26
   North America  24-25,26-29
Market entry 40
Market penetration, Latin America and
the Caribbean   43-45
Mass media advertising, legislation on   248-150
Methodologic issues, prevalence and mortality   93-96
Methodology, smoking-attributable mortality
calculations   81-83
Mexico, smoking and health organization   194
Migration, internal   62-63
Minors, tobacco access laws   157-158
Model legislation, French law   261
Mortality estimates   84-85
Mortality index  89.91,93
Mortality, smoking-attributable, see Chapter 3
Municipal taxes   128
Municipal workplace smoking restrictions   156-157

N

Nabisco Inc. 35
National Cancer Institute   183, 184
National control programs, see Chapter 6
National Health Interview Survey   229
Native tobacco use   19-23
  transcendental purpose   22-23
Navigation Acts 24
New Zealand, tobacco promotion bans   129
Nicotine yield, cigarette brands   188-189
Non-smokers' Health Act, Canada  153,156,184
Nonsmoking smoker-type   109
North America
  advertising-control legislation   149
  cigarette manufacturing   28-29
   health education   159-161
  product labeling requirements   151-152
  public smoking restrictions   153-154
  tobacco manufacturing and trade  24-25,26-28
  workplace smoking restrictions   256-157
  youth smoking regulations   157-158

0

Ogden's Imperial Tobacco, Ltd.   32
Oligopoly markets   227-219
Omnibus Budget Reconciliation Act, United States   132-133
Oral cancer, mortality from  86-89,91-93

211


Pan American Health Organization
  prevalence surveys  66.67,70-77
  regional tobacco control activities   285
Panama, smoking and health organization   194-195
Pension and disability funds  112-214,135.136
Percutaneous use, tobacco   22
Peru, smoking and health organization   194-195
Philip II, King  23
Philip Morris Companies  33-34,35-40,41
Population configuration, Latin America and the
Caribbean   61-62
Prevalence estimates
  Gallup Organization   67-68
  Pan American Health Organization  66-67, 70-71
  reproductive health surveys   68-70
Prevalence of smoking
   adolescents 71
   adolescents in Latin America and the
    Caribbean   76-77
   adults in Latin America and the Caribbean   72-75
  by sex  66.67,68-69
   Chile  68-70
  country-specific surveys   72-79
   educational attainment   69-70
  eight-city survey   66-67
  Hispanic Americans   71-72
  physicians 71
  pregnant women 70
  reproductive health surveys   68-70
    women  68-70, 71
  women of childbearing age   78
Prevention and control program elements   186-195
Prevention programs, status of, see Chapter 6
Price elasticity   129-131
Price of tobacco products   115
Pro Bono Public0   28
Product technology   40-41
Production and supply   119-121
Production controls   125-126
Profitability of tobacco industry   41-42
Public Health Cigarette Smoking Act, United States   149
Public information campaigns   189

R               _______

R.J. Reynolds Tobacco Company  32,35-40
Raleigh, Sir Walter   23-24
Rational addiction model   131-132
Reemtsma GmbH & Company   35
Regional Plan of Action for the Prevention and Control of
Tobacco   185
Registration of mortality   82
Relative risk due to smoking   87-89
Reproductive health surveys   68-70
Restrictions
  advertising  348-150,191-194

   consumer demand, effect on   116
   sales to adults   152-153
  sales to minors 147, 157-158, 161, 167,168,171,
   173,183,191,194
  smoking in public places   153-154
  smoking in the workplace 154, 156-157
  sponsorship 149,150
  tobacco-control legislation 192-193
Retailers, tobacco licensing   158
Ritual tobacco use   22-23
Rolfe, John 23-24
Rothmans International Tobacco Ltd.   35-40

S

Sales restrictions
   adults   152-153
    minors  747, 157-158, 761,167, 168, 171,173,183,
    191,194
Seventh-Day Adventist Church, cessation programs
189-190
Small, Edward Featherston   28
Smoking-attributable mortality, see Chapter 3
    estimates  89,91-93
Smoking behavior, legislation to control, see Chapter 5
Smoking cessation
   economic benefits   117-112
   programs   189-190
  see also Chapter 6, Appendix 1
Smoking-control policies and programs, costs   114
Smoking restrictions, see Restrictions
Smoking, tobacco   19,20,21-22
Smoking-attributable fraction, index   go,93
Smoking-attributable mortality, calculations   82
Smoking-related deaths   85-89
Smoking-related illness, economics of, see Chapter 4
Smuggling, cigarette  12-1, 128-129
Snuffing, tobacco   21
Socioeconomic factors in Latin America   64-65
Socioeconomic groups, tax burden   134-135
Spanish tobacco trade, sixteenth century  23,25-26
Sponsorship, restrictions on  1`49,150
State taxes   128
Subna tional taxes   128-129
Subsidiaries and affiliates, transnational tobacco
corporations 37
Subsidization, tobacco production   122-125
Substitution   125126
Surveillance
  prevalence of smoking   65-80
  tobacco-control programs   186-187

Tar and nicotine yield   150-252
Tar yield, cigarette brands   188-189

212


Taxation, tobacco   127-136
  control programs   190-191
  government revenue from   128
    increases   132-133
   progressive taxes   134-135
   regressive taxes   134-135
   tax burden   134-135
   see also Excise taxes
Technology, tobacco production   125
Tobacco, cash crop   23-24
Tobacco companies, development and consolidation, see
Chapter 2
Tobacco consumption
  advertising bans   119
  economics, see Chapter 4
    income   115
  per capita, and gross national product   115717
   restrictions, effect on   116
   taxation, effect on   132-133
Tobacco control
   Canada   184
   coalitions   194-l 95
  future developments   48-49
   Latin America and the Caribbean   185-186
   United States   183-184
Tobacco distribution   121-122
Tobacco farming   120-121
Tobacco importation and exportation  122,124,125,126
Tobacco industry
  economics, see Chapter 4
    structure   35-42
Tobacco ingestion, methods of  19,20-22
Tobacco manufacturing   121
   Caribbean   25-26
   Latin America   25-26
   North America  24-25,26-28
Tobacco market
  prices   121
   consumer demand   117-118
Tobacco prevention and control programs, status,
see Chapter 6
Tobacco processing   121
Tobacco production
  legislation   148
   world   119-121
Tobacco Products Control Act, Canada  118,149,151,184
Tobacco trade
   Caribbean   25-26

   international   122,124,125
   Latin America   25-26
   North America  24-25,26-Z
Tobacco use surveys   186-187
Transcendental purpose of tobacco use   22-23
Transfer payments, smoking-related illness   108
Transnational cigarette industry   35-40
Transportation, smoking restrictions  153,154
Trinidad and Tobago, youth smoking regulations   158

Unit taxes   128
United Cigar Stores   29
United States
  advertising-control legislation   149
  health care system  113,135-136
   health education   160-261
  product labeling requirements   152
  public smoking restrictions   154
   tobacco subsidization   123-125
  workplace smoking restrictions   1X-157
  youth smoking regulations   157-158
Urbanization   62-63
Uruguay, smoking and health organization   194-195

V

Vending machines, statutes   157-158
Venezuela
  costs of smoking-related illness   112
  health care system   113
  smoking and health organization   195
   tobacco subsidization   122

W.D. & H.O. Wills   31
Workplace smoking restrictions   156-157
World No-Tobacco Day   172, 186, 289, 198-200,203

Youth, smoking prevention legislation   157-158

213