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 smokefree 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 smokefree 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 continues 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 prevalence of smoking in a population-a general measure of its social acceptabilityplays 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 influence 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 abatement, 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 information 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 Americas. It focuses on cultural antecedents and trends, on social and economic structure, 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 smoking. 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 increased 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 knowledge, 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 ramifications 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 especially 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 unfortunate that while the transnational conglomerates in control of almost all tobacco 

production and marketing have directed their efforts toward penetrating developing 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 Scientific 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 Organization, 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 Epidemiologist, 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 Biostatistics, 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 Technologies, 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 WriterEditor, 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 Prevention 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 Program, 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 departments 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, unabridged, 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 personal risks are amenable to social solutions is an important 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 focused primarily, although not exclusively, on the epidemiologic, clinical, biologic, and pharmacologic 

aspects of smoking. With the twenty-fifth anniversary 

report (U.S. Department of Health and Human Services 1989), in which considerable attention was devoted 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 Services, 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 Collaborating 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 collaborative 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 identified 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 status 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 reviews written by experts in the historical, sociodemographic, 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 Agriculture, the Centers for Disease Control, The World Bank, 

the World Health Organization, the Economic Commission for Latin America and the Caribbean, the 

Caribbean Community Secretariat, the Latin American 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 information on tobacco cultivation, cigarette consumption, legislation, taxation, government and nongovernment 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 (February 1990), and Port of Spain, Trinidad and Tobago 

(March 19901, before incorporation into PAHO’s countryby-country status report. 

Infroducfion 9 
Major Conclusions 

Five major conclusions have emerged from review 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 smokingattributable 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 dominated 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; morbidity and mortality; knowledge, attitudes, and practices; tobacco consumption and production; and 

taxation and legislation-is crucial to the development 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 indigenous 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 tobacco was grown. Despite antitobacco movements, 

the popularity of tobacco increased dramatically after 

the U.S. Civil War, and by the early part of the twentieth 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 manufacturing 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 accompanied 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 creation 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 cigarettes produced by the transnational companies. 

During the 198Os, several divergent forces influenced the consumption of tobacco in Latin America 

and the Caribbean. Changing demographics (primarily 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 potential market for tobacco. Although systematic surveillance 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 countries of Latin America and the Caribbean during the 

1980s. The result was that despite the increasing prevalence 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 widespread, 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 consistency and comprehensiveness, establishing overall 

trends for morbidity and mortality is difficult. Nonetheless, 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 mortality is high and increasing because of high consumption levels in the past, but prevalence of smoking is 

declining. In Latin America and the Caribbean, prevalence of smoking is high in some sectors, but smokingattributable 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 medical 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 increasing development and industrialization. Nonetheless, early evidence suggests that smokingprevention 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 control through taxation and other disincentives. Revenues 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 responsiveness 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. Furthermore, the extent to which such legislation is enforced is not fully known. Nonetheless, the pace of 

enactment suggests a growing awareness of the potential 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 comprehensive control, including (in addition to legislation and taxation) the development of national 

coalitions, the promotion of education and mediabased 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 smokingrelated 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. Furthermore, the importance of tobacco manufacturing and 

production to local economies is undergoing considerable 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 spiritual 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 coincided 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 consumption 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 countermeasures, an economic recovery is likely to instigate a resurgence of tobacco consumption. 

Chapter 3. Prevalence and Mortality 

1. 

2. 

3. 

73 

Certain sociodemographic phenomena-such as 

change in population structure, increasing urbanization, increased availability of education, and 

entry of women into the labor force-have increased 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 comprehensive control efforts. Available information 

reflects a variety of survey methods, analytic 

schemes, and reporting formats. 

Available data indicate that the median prevalence of smoking in Latin America and the Caribbean 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 cohorts (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 smokingattributable 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 conservative and is best viewed as the first point on a 

continuum of such estimates. However, it provides 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 foreboding. In North America, a high prevalence of smoking, now declining, has been followed by an 

increasing burden of smoking-attributable morbidity 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 countries 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 control and prevention programs has increased. In 

Brazil, for example, the cost of public information 

and personal smoking-cessation services is estimated 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 percent of per capita GNP per year of life gained. 

In Latin America and the Caribbean, as GNP increases, cigarette consumption increases, particularly at lower income levels. This effect is 

attenuated at higher income levels. 

Advertising tends to increase cigarette consumption, although the relationship is difficult to quantify precisely. Advertising restrictions are 

generally associated with declines in consumption and, hence, are an important component of 

tobacco-control programs. 

The case for promoting increased tobacco production on economic grounds should be reconsidered. Although tobacco is typically a very 

profitable crop, much of the advantage of producing 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 industry 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 smoking, 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 influenced 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 examples of an immediate change in tobacco consumption 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 enforcement is unknown. 

Chapter 6. Status of Tobacco Prevention 

and Control Programs in the Americas 

1. 

2. 

3. 

4. 

5. 

A basic governmental and nongovernmental infrastructure for the prevention and control of tobacco 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 tobacco 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 Americas are often available through church and community organizations. Private and govemmentsponsored cessation programs are uncommon. 

Media and public information activities for tobacco 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 Directing 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 American 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 available 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 following discussion reviews but does not attempt to 

trace the history of tobacco use in the region’s indigenous societies. Some of the practices discussed are 

rare or extinct; others are in current use, but all contribute 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. tahacumproduce 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 changing food supply forced a major shift from hunting and 

gathering to land cultivation. At that time, populations migrated from the open savannas of southern 

South America, which were largely unsuited for agriculture, 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 tobacco 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 followed also recorded tobacco use among the Indians, 

and these accounts, along with the observations of 

missionaries, soldiers, travelers, and scholars, are integral 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 purposes, such as sealing friendships; augmenting palavers, war councils, and dances; and strengthening 

warriors. Small amounts of tobacco were also used 

during ceremonies to ensure fertility; to forecast propitious weather; to predict successful fishing, lumbering, 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 discovery 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 themselves 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 council 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 Antilles. 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 Caribbean coast of South America at the arrival of the Europeans, 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 ethnographic 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 discussion focuses on South American practices. The information 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, smoking, inhaling airborne tobacco smoke, and applying 

tobacco products to the skin and the eyes. 

Tobacco Chewing 

The chewing or, more precisely, sucking Of tobacco quids is widely practiced in South America and 

the West Indies. The widespread distribution of tobacco chewing is considered indicative of the antiquity of this method (Zerries 1964). The practice has 

been observed in the Lesser Antilles and eastern Venezuela 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 America, tobacco chewing was practiced by Indians of the 

Pacific Northwest. With periodic fluctuations, tobacco chewing has found wide acceptance in nonIndian societies as well (U.S. Department of Health 

and Human Services [USDHHSI 1986; National Cancer 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 Scientific Publishers) (Wilbert 1990) and in the proceedings 

published by Birkhtiuser Verlag (Wilbert 1991). 

20 Historical Context 
drinking is similar to that of tobacco chewing, although 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, northwestern Colombia, and a few scattered places in Bolivia 

and Brazil. Tobacco drinking has found little acceptance 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 Guianese 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 concentrate may also be squirted directly from mouth to 

mouth. Tobacco drinking is often accompanied by the 

consumption of tobacco in other forms, alcoholic beverages, 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 region. 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 Shipibo 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 American 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 middle 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 sometimes administered by a partner. 

Tobacco Smoking 

Smoking is the most prevalent form of tobacco 

consumption in native South America and is particularly common in greater Guiana, the upper Amazon, 

the Montaiia, Las Yungas, Mato Grosso, and the Gran 

Chaco. Smoking has also been reported in many intervening 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 smoking 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 onemeter long and two-centimeters wide (Wallace llSS91 

1972). 

Certain customs may be associated with smoking. 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 beverages, such as guarana (Pudliniu cupunu var. sorbilis) 

and cassiri. 

Tobacco is prepared for smoking by sun- or airdrying the leaves and crushing them; some societies 

alter the product with additives. To give cigar or pipe 

tobacco a pungent odor similar to frankincense, Indians of Guiana and Amazonia add the resin of Protim 

heptuphy~lum, a tree of the myrrh or Burseraceae family. Cararia powder or granules are mixed with tobacco 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 Indians 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 enhance the narcotic effect (Weyer 1959). 

Inhaling Airborne Smoke 

The intentional inhalation of environmental tobacco 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 funnelshaped 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 America and includes the following practices: general and 

directed smoke blowing; spit blowing of tobacco juice, 

nicotine-laden saliva, or tobacco powder; and administration of saliva massages, juice ablutions, and snuff 

and leaf plasters or compresses. Some of these practices may serve therapeutic purposes. Tobacco smoke 

and juice may also be applied to the eyes for absorption of nicotine by the conjunctiva. 

Transcendental Purpose of Native 

Tobacco Use 

Tobacco is traditionally used as a vehicle for 

transcendental experience by South American indigenous 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. Tobacco 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 perception 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 depression (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 biotransformation 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 cigars while simultaneously chewing tobacco during 

ceremonies. Participants in certain rituals and shamanit curing seances on the Guapore River (Brazil) have 

been observed taking dozens of insufflations of tobacco powder and ingesting up to 60 doses of rap6 

(snuff). Aguaruna vision seekers of Ecuador use tobacco 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 preganglionic fibers of the sympathetic nervous system to stimulate 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 interpreted 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 increasingly consumed for the social enjoyment of the stimulant rather than for the toxic and organoleptic effects 

of nicotine sought by the Indians. Acute intoxication, 

and its attendant immediate threat to health, has given 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 practices 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 tobacco trade had been established by the Spaniards 

between the Caribbean and India, and trade later developed with Japan, China, and the Malay peninsula 

(Robert 1967). Spanish tobacco, grown mostly in the 

Caribbean, dominated the market in the early sixteenth 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 monopolize the tobacco trade, many growers smuggled the 

leaf to Dutch and English ships. To curtail the contraband 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 muchneeded cash crop for the struggling Jamestown settlement, was exchanged for imported manufactured 

goods, and the colony soon became economically viable. 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 compete 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 encouraged 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 exported 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 government because it created both a trade imbalance and an 

outflow of currency (Jacobstein 1907). In 1621, as the 

supply of Virginia tobacco increased, Parliament terminated 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 purposes, perhaps in imitation of South American Indians, but other Europeans believed that the use of 

tobacco was a heathen practice to be strongly discouraged. Many people claimed that smoking and chewing tobacco were harmful to health. The most famous 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, tobacco 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 Colony was low, increased prices encouraged a proliferation of small farms in North America and, eventually, 

large tobacco plantations. The shortage of workers for 

these plantations spurred the slave trade, which increased the labor supply. 

Annual tobacco shipments from the colonies increased 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 imported by England from other areas, including Europe, Turkey, Africa, and the Caribbean. During the 

next 75 years, imports from other areas declined, despite 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 tobacco 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 enormously, including those that provided banking and 

related services to planters. 

In the 158Os, the Spaniards developed and expanded the plantation system in the Caribbean but 

emphasized sugar production (Brooks 1952). Foreigners began to enter the sugar industry, which required 

extensive capital, but tobacco production was dominated 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 plantations (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 nicotine than did the Bright leaf grown in the Chesapeake 

Bay area. 

During shipping, tobacco lost much of its moisture, 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 additives 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 manufactobacco 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 between 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 contemplated abandoning tobacco in favor of wheat, and 

some did stop cultivating tobacco (Breen 1985). 

Because of their increasing indebtedness to British 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, annexed to certain merchants in London” (Heimann 

1960, p. 76). The American Revolution terminated the 

Navigation Acts but did not alter the adverse circumstances that many planters still faced. 

Latin America and the Caribbean 

Historicnl Corztext 25 
effect on business, the tobacco trade continued to prosper (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 obligated 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 relented 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, despite condemnation by the Roman Catholic Church 

and early Portuguese demands to use the land to grow 

food. However, these obstacles were overcome because 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 monopoly 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 estimated at 1.9 million crusades (Randall 1977). 

The Expansion of Tobacco Manufacturing 

During the American Revolution, tobacco exported from the British Colonies declined sharply-to 

approximately 15 million pounds per year. Subsequent wars also contributed to the loss of foreign 

markets. Sales declined significantly during the Napoleonic 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 manufactured 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 million pounds (Jacobstein 1907). 

During the American Revolution, Europeans accelerated 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 production was estimated at 137 million pounds, compared 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 approximately 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 producer, with no competition from Europe. Yet, several 

factors contributed to the perpetuation and evolution 

of tobacco cultivation, curing, and trade. By law, before 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 addition to capturing the domestic market, became increasingly 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 America 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 southern colonies, and the practice soon moved north. 

During the American Revolution, cigar manufacturing facilities were established in Philadelphia, 

Trenton, and New York, which became the centers for 

American cigar manufacturing. In 1800, cigar factories 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 factories became widespread throughout the Northeast 

26 Historical Context 
(Heimann 1960). In 1831,50 Cuban cigar rollers relocated 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 expensive were the Havanas, made either in Cuba or in 

American factories that imported Cuban leaf. La Corona 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 Colorado, 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, Connecticutgrown 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 cigars, 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 approximately 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, respectively). 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 tobaccos for chewing and pipe smoking was $21 million 

(Heimann 19601. 

The popularity of tobacco, combined with increasing urbanization, encouraged some merchants to 

enlarge their manufacturing activities and aggressively market their products. The first center of activity 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 Richmond 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 manufacturing 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 production 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, flavorings, and varieties of tobacco (Robert 1967). 

Because financial centers were located in the 

North, tobacco financing was easier to obtain by manufacturing firms concentrated in that part of the country. 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 defaulted 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 remained. During the war, tobacco production in Kentucky surpassed that in Virginia. Some southern 

tobacco was smuggled through the lines, but Confederate 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 Danville, 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 warehouses and, during lulls in the fighting, traded their 

food and coffee for tobacco from the Confederate 

troops. Some Union soldiers looted a Durham warehouse 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 sixteenth-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 focused 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 farmers and dealers in the Durham area. The family’s 

patriarch, Washington Duke, was a Confederate veteran 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 difficult 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 combination of shrewd merchandising and aggressive pricecutting 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 effectively. 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 advertised 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 increased dramatically (Wagner 1971). 

Even before Duke turned his attention to the 

manufacturing process, several inventors had been 

working to produce a cigarette-manufacturing machine that would replace the workers who rolled cigarettes by hand. But most manufacturers believed 

that the future of cigarettes was doubtful; they questioned whether a machine capable of producing tens 

of thousands of cigarettes was truly needed. 

In 1881, James Bonsack, announced the invention of his cigarette-making machine, which was rejected by several firms. Duke, however, was 

interested and, with his engineer, helped Bonsack perfect 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 payments 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 incorporated 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 accelerate 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 cigarette, 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 manufactured tobacco, and in order to enter this lucrative 

market, Duke established the American Cigar Company in 1901 with an investment of $10 million. The 

firm controlled several significant factories, including 

Havana Tobacco, American Stogie, and Havana Commercial, 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 market (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, respectively). 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 tobaccos, 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 onefourth of tota 1 federal government tax revenues, excIusi\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 partially responsible for the effort, which concentrated on 

eliminating that particular form of tobacco use. Advertisements of “cures” for smoking appeared in 

newspapers, and in 1880, the General Conference of 

the Methodist Episcopal Church resolved that its ministers would abstain from tobacco (Robert 1967). 

In 1899, Lucy Page Gaston, who had been active 

in the Temperance Movement, established the Chicago 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 antismoking 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 following 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, making it illegal to manufacture, sell, or smoke cigarettes, 

and in 1907, Illinois passed similar legislation. By 

1909, 11 states (Iowa, North Dakota, Tennessee, Arkansas, Indiana, Kansas, Minnesota, Nebraska, Oklahoma, 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 Midwest than in the West and weakest in the East (Wagner 

1971; Sobel 1978). Most of the state laws were rescinded by the middle to late 1920s. 

ATC and several other tobacco companies responded in the 14 states that banned cigarette smoking. One strategy was to sell “the makings” (i.e., 

smoking tobacco and cigarette paper) because cigarettes, not the materials themselves, were prohibited. 

In states where the sale of cigarettes was illegal but 

smoking was permitted, tobacco companies suggested 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 efforts were effective. At the turn of the century, the 

price of plug tobacco declined drastically, and many 

cigarette smokers may have switched to plug. Conversely, the economic boom that began in 1897 may 

have motivated former cigar smokers, who had converted 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 manufacturers 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 popularity 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 cigarettes cost less than other tobacco products, smokers 

may have given little thought to lighting up a cigarette. 

Chewing tobacco, which posed few aesthetic problems 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 representatives 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, Germany, and Australia) (U.S. Bureau of Corporations 

[USBOC] 1909). Britain’s cigarette industry also expanded 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 mid189Os, 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 depression 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 worldwide. 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 markets; and a new London-based company, BritishAmerican Tobacco Company Ltd. (BAT), was organized 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 operations 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 manufacturer. 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 tobacco 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. American 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 longterm 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 stimulated 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 increased significantly (from 10 billion to 393 billion), 

while per capita consumption increased nearly twentyfold (Tennant 1950; Nicholls 1951). Sands (1961) 

concluded that the cigarette industry had the highest 

growth rate in physical output of all U.S. manufacturing industries for 1904 to 1947 and was second only to 

motor vehicles for 1904 to 1937. The average quinquennial growth rate for output was 88 percent for 

cigarettes versus only 15 percent for all U.S. manufacturing 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 exports (Shepherd 1983). 

During this same period, the dilution of ATC’s 

two-thirds holding in BAT meant that the concentrated 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 absence of British antitrust action, ITC continued to dominate the U.K. domestic market, while BAT controlled 

markets outside the United States. Even after the European 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 because 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 predominant international force outside theunited States 

and United Kingdom well into the 1960s. Thus, U.S. 

cigarette firms enjoyed relative protection in expanding sales in the large, rapidly growing U.S. market. 

World War II provided the opportunity for significantly increased exports for U.S. firms. European 

production facilities had been destroyed, and American 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 future growth. The long period of expansive domestic 

growth made overseas markets pale in comparison. A 

near doubling of sales during the war and the reemergence of the overwhelming dominance of R.J. Reynolds, 

Liggett & Myers, and ATC made the struggle for domestic 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 consumption (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 decline in sales. The two smallest, Philip Morris Companies Inc. and Lorillard, began to explore the possibility 

of expansion into international markets and of increased 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 cigarette. The first ventures abroad, including those in 

Latin America (Shepherd 1983), in the 1950s were 

tentative and coincided with increased tariffs in several 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. producers did not take advantage of the potential international 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. government initiated an inquiry into the health hazards of 

smoking (Eritschler 1975). In the resulting report of 

the Surgeon General, which received considerable attention, smoking was linked to several serious diseases (Public Health Service 1964). The publication of 

the report had immediate impact on U.S. cigarette 

sales (USDHHS 1989). The expression of public concern 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 operations 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 probably 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 motivations-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 immediate 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 operations by using established national brands and working 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 pursuits (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, during the 198Os, BAT spent US$7 billion on nontobacco 

acquisitions, the same amount as the company’s market 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 acquisitions. Diversification was not well received by investors-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 Consultancy, 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 (Anonymous 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) because 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 & Company in 1989 (Burrough and Helyar 1990). BAT narrowly 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 Corporation (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 liability suits, and advertising and press coverage of health 

hazards (McGill 1988), and it broadened political coalitions 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 competitors. Liggett & Myers was almost wholly unsuccessful 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 acquiring Gallaher Tobacco Ltd. in the late 1960s (Corina 

1975). Nevertheless, as U.S. firms continued to expand in the 1960s and 197Os, it became apparent that the 

Anglo-American understanding on separate development 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 became 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 patterns 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, Canada, and Latin America have been areas of fairly competitive activity (Shepherd 1985). But on the whole, 

oligopolistic competition, market allocation, and restraint have characterized TNC operations. 

In general, the normal pattern has not been aggressive, although several markets have been contested. 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 equilibrium 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 & Company, 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 development which contributed to the period of consolidation 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, including 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 operations of these firms are included in Table 4; however, 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 industry (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 International has acquired economically troubled national 

tobacco firm-mostly in Western Europe. The latest 

Rothmans International acquisition is The Carroll Tobacco 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 International 19901, and Philip Morris merged its Canadian 

and U.K. businesses with Rothmans International 

(Harman 1988). 

Four major TNCs (BAT, Philip Morris, R. J. Reynolds, and Rothmans International) account for 31 percent of total world production of cigarettes (5,245 

billion in 1988) (Table 6). If socialist-planned economies 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 enterprise markets worldwide. This percentage may actually 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 approximately 60 percent of world cigarette sales (Table 6), the 

primary avenues of expansion for the major TNCs are 

now through entry into state monopolies, socialistplanned 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 expanding markets of Japan, South Korea, Taiwan, and Thailand, where state monopolies had long prevailed 

(Zimmerman 1990; Chadha 1989; Heise 1988; Connolly 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; Tobacco Reporter 1989a). During the 198Os, France lost 

nearly 50 percent of its market to cigarettes imported 

by TNCs (Manus 1988; Stefani 1990b). Despite considerable difficulty, U.S. and European TNCs are attempting 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). Nontransnational 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 increased TNC market control. 

TNCs do not compete against each other in the 

world commodity market, except through exportation; only 10 percent of the total world cigarette production 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 socialistplanned 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 economies at the time. Philip Morris’s Marlboro was the 

best-selling brand (293 billion cigarettes). This volume 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, Volume 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 largescale production), and (3) consumer preference for the 

products of existing firms. The last fact& is probably 

the most important. 

Several factors ensure sustained consumer preference for the existing products: the location of plants 

or sales outlets, the provision of exceptionally good 

service by the firms, the technology to produce physical 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 networks, 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 differences in products or packaging, has permitted 

TNCs to gain a foothold in the foreign market. However, 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 established 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 control and change or, in effect, transcend the market. 

The consumer loyalty that existing brands have 

gained from previous and current promotional activities 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 competitor must spend more than the established firms do 

on advertising. Thus, cigarette advertising is an investment (although it is not treated as such by accounting 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 considerations led to an inquiry into concentration, pricing, 

and excess profit in Britain (U.K. Monopolies Commission 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 include the small tobacco firms that do not make cigarettes, 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 characterized as “far above competitive levels and [it] bespeaks 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 business. Because of the long history of antitrust concerns, 

tobacco companies avoided for decades any obvious 

price-setting patterns, even as they continued to regularly raise prices. In the deregulated business climate 

of the 1980s (Burrough and Helyar 19901, however, the 

cigarette firms started raising prices regularly, beginning 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 tobacco (about one-third of U.S. cigarettes in the mid198Os), 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 market power in the 1980s. 

The high and increasing profitability of the industry 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 political, 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 America 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 political 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 marketing of tobacco under the Crown monopoly (Leonard 

1951). Eventually, the deep-seated hatred of the colonial 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 became increasingly linked to the international system 

of trade, they experimented with various commodities 

in which they might enjoy some advantage. Leaf tobacco was one of these products, and several countries 

experienced sporadic surges in tobacco exportation. 

Tobacco production was crucial to government revenue in almost all Latin American and Caribbean countries 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 already 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 because tobacco products were logical commodities for 

local industrialization. Tobacco products were a luxury to import, domestic raw materials were readily 

available, scale requirements were not large, technology was not unduly difficult to acquire or adapt to 

local conditions, and leaf production was labor intensive. Because tobacco manufacturing provided tax 

revenue for the state and reduced nonessential imports, 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 opposition from owners of national firms, economic nationalists, and other groups that feared foreign control of 

the local economy. In some countries, such as Colombia, 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 official 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 consumption 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 examples 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 several popular TNC brands. The local firms, which constituted 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 government , 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, contraband increased, to 15 percent, in 1966; all the nationally 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 European TNC in the region. Denationalization has been 

pursued more aggressively in Argentina, Brazil, Mexico, 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 region. 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 Caribbean 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 concentration and consolidation (Shepherd 1983,1985). 

Several factors have contributed to high levels of 

market concentration in the Latin American and Caribbean 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, successive mergers reduced the industry to only two firmsa 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 tobacco 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 cigarettes; 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 producers. 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 antitrust case (see comments earlier in this section), the 

Philip Morris product cannot be sold in Canada. 

In Latin America and the Caribbean, the popularity 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 demand creation, primarily through advertising and distribution, larger sales forces, and other promotional 

techniques. Figured on the basis of constant 1960 

prices in Argentina, the average annual cigarette advertising 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 subsidiary, 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 promotional 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 decreased by nearly 15 percent (Economic Commission 

for Latin America and the Caribbean 1989; InterAmerican 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 somewhat 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 harmful effects of smoking (LJSDHHS 1989). In Latin America and the Caribbean, the widespread economic 

depression almost certainly reduced consumption, although 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 governments throughout Latin America and the Caribbean 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 consumption was level or declined in 19 of 20 Latin American and Caribbean countries and declined overall in 

the region by 17 percent in the 1980s. (This reported 

decline, however, does not consider the potential effect 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, especially those in Asia (Zimmerman 1990). 

The Future of Tobacco Control 

In developed, industrialized countries, the decline 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 (Figure 1). A similar recent downward trend in consumption 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 indirect taxes, such as excise taxes on cigarettes, is typical 

of economic austerity programs recommended by 

some international financial institutions. This emphasis might force governments of the region to rely even 

more on the tobacco industry for revenue, thus reinforcing 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 smokingstands at the center of complex and changing economic forces. The TNCs have successfully established 

market dominance and created demand for their 

products. In recent years, the overall economic picture has been one of diminished consumption. However, 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 conamalgamation 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 countermeasures, an economic recovery is likely to instigate 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 estimates 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 America 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 factors have contributed to the potential of the population 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 primarily by changes in the birthrate and death rate; with 

some regional exceptions, migration and emigration 

have been less important. Changes in fertility, natality, and mortality have been dramatic (Table 1). 

In 1930, overall mortality was high in Latin 

America, and life expectancy was only 35 years, although in several countries, such as Argentina, Uruguay, and Cuba, life expectancy was greater because 

an export-driven economy (Merrick 1986) had encouraged environmental and sanitary improvements. 

Most Latin American countries, however, did not introduce widespread methods for control of endemic 

diseases until after World War II. Between 1950 and 

1970, improved methods for the control of major infectious diseases of children and adults may have 

accounted for 30 percent of the increase in life expectancy (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 years of 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 countries (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 Argentina 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 experienced 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 increased 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). Although 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 percent smaller than that in the United States; in 1990, it 

was 32 percent larger. 

These population shifts have created a large potential market of tobacco consumers in Latin America. 

Further, the trend in the birthrate ensures that a substantial 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 region 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 Salvador, remain primarily rural. 

The urban lifestyle-which includes social differentiation, 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 proportion 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 tobacco 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 education 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 number 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 complexalthough sophisticated consumers may be more exposed 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 prevalence 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 increased (4.5 percent and 3.3 percent per year, respectively) (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 stratification in six countries found a large increase in nonmanual 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 America accounted for a larger percentage of total income 

than did the corresponding groups in the United 

States. Conversely, the lowest income group accounted 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, however, 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 selected 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 increasing 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 disposable income, a group in which women figure prominently. 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 significance 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 developed (see Chapter 6). Available information on prevalence 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 Organization for the American Cancer Society in 1988 (Gallup 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 Disease 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 surveys compiled have been formally published, and 

they differ widely by sampling strategy, target population, method of weighting and adjustment, and reporting 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 examined (number of smokers divided by number of persons 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 summary 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- PostPrimarv arv 

Women 

Second- Postsecondary 

school 

No 

schooling 

Primary ary 

school school 

secondary 

City schooling school 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 Caracas, Venezuela, the prevalence of smoking for 

women was approximately half that for men. However, in Lima, Peru, the prevalence of smoking for 

women was one-fifth that for men. Furthermore, in 

almost all sample populations, the age-adjusted prevalence of cigarette smoking increased with educational 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 schoolingevidence 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 (defined 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 percent 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 conducted 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 methodology 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 survey focused exclusively on urban areas; the 1988 Gallup 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 comparisons 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 legitimate, although they must still be interpreted with 

caution. In the 1988 Gallup survey, the overall prevalence of smoking was higher in countries that underwent early modernization, such as Chile (39 percent), 

Brazil (38 percent), Argentina (35 percent), and Uruguay (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 produced weighted prevalence estimates representative 

of the area studied. The overall results have not been 

age-adjusted, but age-specific results are directly comparable. These surveys are discussed together because of the general uniformity of the methods used; 

other surveys of women of reproductive age are discussed 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 prevents 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 moredeveloped 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 prevalence 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 sampled, although the sample size varied for specific questions. 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 (nonHispanic) 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 percent 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 cigarettes per day). The prevalence of smoking as a function 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 effect 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 pregnant 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 generalizable to Latin America as a whole, but they support 

the supposition that smoking is common among 

young people in some of the more-developed countries and that the quantity smoked is not great. Although 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 development 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)--displayed 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 prevalence for women were from less-developed, predominantly 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 Jamaica. For Trinidad and Tobago, a 42 percent prevalence 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 smoking exceeds 50 percent; for rural women in lessdeveloped 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 moredeveloped 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 percent, 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 knowledge 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). Collection 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 probability 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 prevalence 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 prevalence 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 prevalence of smoking has declined among Hispanic men 

and women, uptake of smoking is increasing among 

young Hispanic women. In general, persons of Hispanic 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 University 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 Respiratory 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 

1986 Department of Health 

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 

1 l-19 Trinidad and Tobago 23 12 17+ 

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 

Country Number Sponsor Prevalence (%) 

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 standard measure of the health status of a population. 

Mortality has traditionally been used as an indicator 

of socioeconomic status and standard of living, especially in countries for which measures of economic 

productivity are inappropriate. 

Mortality is a useful measure when setting 

health priorities, communicating health-related information, 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 immunodeficiency syndrome, cocaine, heroin, alcohol, fire, automobile 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 disease have limitations as well. For example, life expectancy, which can express the health status of a 

population, may be misleading. For developing countries, 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 complicated by the need to estimate and adjust data to 

compensate for missing or insufficient data. A stepby-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 Comment on the Methodology”). 

Mortality Data 

The data in this section are from the PAHO 

Technical Information System, a data base that includes mortality information. PAHO collects mortality data (by age, sex, and cause of death) from source 

jurisdictions by using questionnaires, national publications, and other methods. Most of the data are from 

civil registries, which rely on death certificates completed by health personnel in the field. These mortality 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 collection questionnaire limit comparability with other 

data. 

Coverage 

PAHO has estimated that the underregistration 

of mortality is more than 20 percent in Brazil, Colombia, Dominican Republic, Ecuador, EI Salvador, Honduras, Panama, and Peru (PAHO 1990b). The diverse 

reporting standards from various countries necessitated 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 underreporting 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 representative 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 sociodemographic 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 demographic 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 countryspecific 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 “symptoms, signs, and illdefined conditions” (Manual oflnternational 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 estimates), 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 determining 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 diseasespecific rates for middle-aged rather than elderly populations (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 identical 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 pancreas (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, cannot be isolated in the PAHO grouping. The relevant 

PAHO categories are “bronchitis (chronic and unspecified), emphysema, and asthma” fICD-9 490-493). 

Thus, unlike the grouping for COPD used in the calculation 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 America 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 countries, 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 Caribbean countries are at the low end of the range. Currently, 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 expectancy 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 current 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 parameters is illustrated by data for four countries (Guatemala, 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 contains national mortality data suitable for this analysis 

for all but 10 jurisdictions in the Americas: Antigua 

and Barbuda, Bermuda, Bolivia, Guadaloupe, Grenada, Haiti, Montserrat, Netherlands Antilles, Nicaragua, and Saint Pierre and Miquelon. 

To determine the number of deaths in the Americas attributable to smoking, the number of deaths for 

these 10 jurisdictions had to be estimated. The United 

Nations (1989) population estimates for these jurisdictions 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 consumption 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 structure. 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 mortality 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 America, 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 gradient of economic development is associated with 

increased life expectancy. In general, the death rate 

for children is lower in more highly developed countries, 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 disease, 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 deathdiseases 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 improves, the epidemiologic profile of a country 

changes. Countries with a lower life expectancy tend 

to have a younger population, and the greatest mortality 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 increases, 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, cerebrovascular disease, COPD, and cancers of the lung, lip, oral 

cavity, pharynx, larynx, esophagus, pancreas, bladder, 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 smokingattributable 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 spectrum 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 lowest 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 subcategories 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 percent of deaths. 

To estimate the number of deaths from smokingrelated conditions for subregions of the Americas 

(Table 27), both the reported mortality data (Table 25) 

and synthetic mortality estimates for the 10 jurisdictions without data were used. For these jurisdictions, 

the mortality distribution patterns from the four selected countries (Table 24) were applied, as described. 

Substantially more deaths in North America 

than in Latin America and the Caribbean were attributed to coronary heart disease, lung cancer, and bladder cancer. The number of deaths was similar in 

North America and in Latin America and the Caribbean for cerebrovascular disease, COPD, and oral cancer. Using these estimates, 81 percent of lung cancer 

deaths in the Americas occur in North America. When 

accounting for underreporting, the proportion is probably 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 smokingrelated factors, such as person-years of smoking contributed by heavy smokers, age at initiation, and cigarette 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 relatively 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 patterns 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 populations, 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, Caraballoso 1983). In Colombia, the relative risk for lung 

cancer among current smokers was 10.3 in one casecontrol 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/ hypopharynx 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 snlokers 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- Cerebroheart 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 esophageal 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 investigate the factors associated with esophageal cancer 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 esophageal 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 development 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 prevalence 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 estimate is 3 million smoking-attributable deaths per year. 

The methodology described earlier for calculating 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. Unfortunately, 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: 

l 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. 

l 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 mortality 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 correlated 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 industrialized 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 calculated at over 90 percent for countries that have populations 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 mortality rates for the population aged 55-64. This index, a 

measure of smoking maturity in a population, contains population risk factor information related to the 

l 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 Caribbean. 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 populations 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 directly available to a country are used, and adjustment 

that might be necessary for cross-country comparisons 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 intermediate 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 besumption (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 underestimates for several reasons: (1) COPD was undercounted 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 postnatal 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 Caribbean, 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 trajectory 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 empirical 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, synthetic 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 benchmark for adjusting the estimates derived in this analysis. 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 difficult 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 underestimate can be approximated by comparing the estimate 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 mortality of about 55 percent, the number of smokingattributable deaths might be as high as 155,000. The 

more conservative estimate of 100,000 smokingattributable deaths was deemed more appropriate because 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 increasingly credible estimates of SAM to be made as 

better mortality data become available and the estimates 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 apparently 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 transformation. Many transformations are available; the 

square root was used because of properties appropriate 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 proportionately 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 smoking in countries with lung cancer rates less than those 

for U.S. never smokers. Since smoking is not uniformly 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 smoking is the dominant risk factor for lung cancer, this 

effect is probably negligible. In cardiovascular disease, 

however, smoking interacts with hypertension, hypercholesterolemia, 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 conservative. 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 considerable 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 

Cerebrovascular 

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 

Cerebrovascular 

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 pulmonary 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 smokingattributable 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 urbanization, increased availability of education, and 

entry of women into the labor force-have increased 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 comprehensive control efforts. Available information 

reflects a variety of survey methods, analytic 

schemes, and reporting formats. 

3. Available data indicate that the median prevalence of smoking in Latin America and the Caribbean is 37 percent for men and 20 percent for 

women. Variation among countries is considerable, 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 cohorts (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 smokingattributable deaths were occurring each year in all 

the countries of the Americas; 100,000 of these 

deaths occurred in Latin American and the Caribbean countries. 

The estimate of 526,000 deaths annually is conservative and is best viewed as the first point on a 

continuum of such estimates. However, it provides 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 foreboding. In North America, a high prevalence of smoking, now declining, has been followed by an 

increasing burden of smoking-attributable morbidity 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 consequences of smoking was released by the Surgeon 

General’s Advisory Committee on Smoking and 

Health (Public Health Service 19641, extensive research has assessed the disability, morbidity, and premature mortality attributable to tobacco use. The 

many effects of smoking on health were documented 

in the Surgeon General’s twenty-fifth anniversary report on smoking and health (U.S. Department of 

Health and Human Services IUSDHHSI 1989). A 

detailed examination of smoking-attributable mortality (SAM) in the United States summarizes these associations (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 diseases 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 infectious and parasitic diseases have been brought under 

control. Many cases of lung cancer are now anticipated in Brazil (The World Bank 1989a). Cardiovascular 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 significantly. 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 mortality rate for men did not begin to level off until 1985 

(USDHHS 1989). For women, deaths from lung cancer have not yet peaked, and lung cancer has become 

the most common cause of cancer mortality, surpassing 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 consumption (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 estimates 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): 

l An attempt to identify an increased incidence of 

smoking-related illness in current or former smokers and attribution of that increase to smoking. 

l An application of these attribution ratios to estimates of the direct (health care) costs of caring for 

persons with smoking-related illness-to obtain an 

estimate of the direct costs of smoking. 

l An estimate of the indirect costs of smokingrelated 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 obthe 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 estiof 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 approach has been criticized for placing a high value on 

losses sustained by young adults, men, and moreFigure 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 

soSource: Doll and Pete (1981). 

Number of manufactured cigarettes consumed 

f Rate based on over 100 deaths. 

q 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 probability of death or disease. Although several attempts 

have been made to estimate willingness-to-pay for 

non-smoking-related illness (Viscusi 19901, this approach has not been applied to cost-of-smoking studies. In addition, no value has been assigned to 

intangible items, such as pain and suffering, premature death, and loss experienced by relatives; accordingly, 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 Thompson 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. However, discussions of smoking-control policies have frequently asked whether smokers in economically 

advanced societies (with well-developed public or private health care financing, disability, and pension systems) 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”), although several Latin American and Caribbean countries 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 influences the degree to which smoking-related illness becomes manifest. Since many smoking-related 

illnesses do not have an important impact on persons 

under age 50, such illnesses do not significantly contribute 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 different 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 applied 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 characteristics, including diet and level of alcohol consumption, exercise, and education KJSDHHS 1990), all of 

which may be associated with differences in health 

outcomes. Leu and Schaub (1983) developed the hypothetical construct of the “nonsmoking smokertype,” 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 diseases 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 proportion 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 frequently 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) smo l! er (billions) smo K 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 smokingrelated deaths during the year. However, these studies do not address other issues that most concern 

policymakers, including the economic impact of decreased prevalence of cigarette smoking, the length of 

time before economic effects are realized, the economic benefits of not smoking, and a comparison of 

the lifetime illness costs of smokers with those of 

nonsmokers (Hodgson 1990). Health care expenditures 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 adjusted for the altered temporal pattern, exceed costs 

incurred by never smokers. 

Most cost-of-illness studies are based on estimates 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 economic costs of smoking are estimated as the average 

additional costs per smoker, due to smoking-related 

illnesses, incurred over the smoker’s lifetime. Estimates can be made of direct (medical care expenditures) 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 anticipated lifetime costs has been estimated for smokingrelated 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 smoking 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 individual 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 beginning at age 17. Because expenditures are higher for 

persons who die than for those who survive, the analysis 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, noninstitutionalized 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 percent) 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 estimates 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 history 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 estimates 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 willingnessto-pay. Moreover, even for economically advanced 

countries, including the United States, the incidencebased 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 technologically advanced, and access to sophisticated 

therapy is frequently limited to residents of large metropolitan 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 smokingrelated illness in Latin American and Caribbean countries. 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 medical care and employee absenteeism associated with 

smoking-related illness in Venezuela increased significantly 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 derived 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 reported 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 burden imposed on nonsmokers by smokers is as much a 

function of the institutional arrangements for financing 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 premiums. These types of programs are limited to persons who participate in the formal economy. 

Although national health insurance systems are mandated in some countries, a Iow level of funding may 

limit the scope of public systems and lead to the creation of private markets for health services. Information on the formal health care system may be 

inadequate for measuring the external costs of smoking-related illness; data may be needed on the actual 

source and disposition of funds. 

The U.S. health care system is financed by various government and private payment sources. In the 

United States in 1985, direct payments accounted for 

24 percent and private insurance-principally provided by businesses for their employees-accounted 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 contributions to the Medicaid program. Government health 

programs are financed by various mechanisms, including 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 services accounted for 8.6 percent of the total gross domestic 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, accounted for 27 percent of public expenditures on 

health in 1986. Private health care is financed by individual persons, who directly pay fees for services, and 

private insurance, largely financed by employers, 

which features various capitation and reimbursementfor-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 twothirds of the country’s physicians are employed by the 

Ministry in some capacity. In addition, largely unregulated 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 concentrated 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 diseases 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 smokingassociated 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 advertisements, 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 programs, lobbying efforts of smoking-control advocates, 

and enforcement of restrictions on cigarette sales, advertising, and smoking in public places-use resources 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 advertising, strengthen product warnings, restrict smoking ir public places, and help tobacco growers 

diversify and produce other crops (Collishaw, Kaiserman, Rogers 19901. Except for the program to discourage 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 collectively (as the Canadian Council on Smoking and 

Health). Such advocacy activities, although rarely 

costed-out, consume resources that should be included 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 formally 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 reviewed. In contrast, treatment for lung cancer cost 200 

percent of per capita GNP per year of life gained. This 

comparison suggests that public information programs designed to control smoking in Brazil are extremely 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 satisfaction from smoking and other forms of tobacco use 

and (2) income to producers in excess of the cost of 

resources for tobacco production. Tobacco production also generates costs-principally the value of resources used to manufacture tobacco products. 

Confusion about the costs and benefits of tobacco production has been spawned by tobacco industry analysts who label the value of the land, labor, and capital 

used in tobacco production as a benefit of such production (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 allocated to tobacco production is a measure of the opportunity costs of producing tobacco. A tobacco industry 

may also generate tax revenues, which are neither 

benefits nor costs to a society. Rather, taxes are transfers 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 evidence of tobacco’s net contribution to growers’ incomes. Although tobacco production may be very 

profitable for the individual producer, it is not necessarily beneficial economically. Subsidies and externalities associated with the production of tobacco may 

lead to a divergence between what is best for producers and what is best for society as a whole. 

Demand for Tobacco 

Worldwide consumer demand for tobacco products drives the market for tobacco. In the economist’s 

view, this demand originates from consumer efforts to 

satisfy exogenously determined wants, which are subject to constraints on consumer resources. Such constraints include limits on time and disposable income. 

By using information about products and prices, each 

consumer purchases a mix of goods to maximize consumer 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 security, affihation with other smokers, and perhaps in 

certain cultures, a sense of being modern or progressive. However difficult these attributes are to measure, 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 consumption 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, including taxes, tariffs, and import quotas decrease consumption. 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 consumption through the market price: as supply increases, 

price tends to decrease, which stimulates consumption until the additional sales clear the market. Factors 

other than price that influence the demand for cigarettes 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 quantity demanded divided by the percent change in income that caused the demand change. The relation of 

consumption to income can be observed for individuals, groups, and countries, for which income and consumption fluctuate over time, and for variations in 

income and consumption among groups at a particular 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 

. 

. 

q 

. 

l m 

. 

. 

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 percentage of the population that smokes and in the 

amount each smoker smokes and to a shift from 

homemade and roll-your-own cigarettes to moreexpensive, 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). However, elasticity tends to fall as income rises, and nearzero estimates have been reported for developed 

countries (Table 6). In the model that compared 

consumption to the logarithm of GNP (Figure 41, estimated 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 smoking is permitted make smoking more difficult. These 

restrictions raise the total effective price of cigarettes 

for consumers and reduce cigarette consumption. Increased 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 filters, 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, qualitycontrolled, flavored cigarettes made from blends of 

tobacco, including fabaco rubio, a flue-cured tobacco. 

Some authorities have suggested that the development of filter-tipped cigarettes and long, slim cigarettes has increased smoking among women (see 

Chapter 2, “The Emergence of the Tobacco Companies”). 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 demand for cigarettes by operating on retail price, product 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 monopoly markets, because of competition. In addition, oligopoly markets are characterized by greater variety as 

firms attempt to capture market niches for specific 

products. 

Cigarette advertising and the sponsorship of entertainment, 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, public policy toward cigarette advertising and promotional 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 advertising and promotion has changed over time. Cigarette 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, billboards, and point-of-sale posters) and 25 percent toward promotional activities, such as coupons, free 

samples, public entertainment, and allowances to retailers (CDC 1990). By 1988, when total expenditures 

reached $3.27 billion, promotional activities accounted 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 heavily 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 sponsorship of sporting and cultural events be phased out 

(Collishaw, Kaiserman, Rogers 1990). This advertising ban is currently being contested by Canadian 

tobacco companies in a protracted court case (Collishaw, 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 Statistics 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). Advertising attempts to associate smoking with attributes generally considered positive, such as high-style 

living, healthful activities, and economic, social, and 

political success; it fails to voluntarily provide information on the substantial hazards of cigarette consumption. 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 advertising restrictions on consumption. An extensive study 

of this issue was performed by the New Zealand Toxic 

Substances Board (1989) in support of its recommendation 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 controls 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 percent in 1986 in countries without a total ban at that 

time. 

However, these studies have limitations-primarily 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 consumption may be inappropriate. 

Supply of Tobacco 

Tobacco, which is grown in more than 120 countries, is the most widely grown nonfood crop. It is 

grown in most developing countries, and the share of 

tobacco production in developing countries has increased 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 Companies”). 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 Americas 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 increasing more rapidly in developing than in developed 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 decline 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 alternatives are few. Millions of persons are involved in or 

dependent on some stage of the tobacco-production 

process for a portion of their livelihood (Agroeconomic 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 depend 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 employment 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 destemming the raw tobacco leaves. In most countries, these 

activities occur in agricultural areas and are included 

in statistics for the agricultural sector. In other countries, 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 tobacco particularly attractive to growers in many countries. 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 substantially 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 unexpected price fluctuations that plague other crops by 

negotiating sales prices for crops before planting; 

growers are paid in cash immediately upon sale (Economist 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 tobacco 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 tobacco 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 tobacco growing. In addition to being labor intensive, 

tobacco cultivation requires large amounts of fertilizers and pesticides, and in many areas, fuel (wood, gas, 

or oil) is needed for tobacco curing. The U.S. Department 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 alternative activities is the most important factor in determining 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 required 7.5 times as many man-hours of labor as manioc did and 5.3 times as many man-hours as potatoes 

did. Accordingly, all of the apparent additional returns 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 fluecured and processed on the farms. Tobacco is then 

manufactured into cigarettes, cigars, smokeless tobacco 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 substantial employment in many countries, but the labor 

intensity of cigarette manufacturing varies considerably 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, cigarette 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. Cigarettes 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 distribution 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 component of larger distribution activities in most economies. Although attributing some proportion of 

employment to tobacco distribution activities is statistically appropriate, such attribution may be inappropriate 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, however, may be affected by shifts in consumption patterns; 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 demand 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 countries, but the net aggregate effect of shifts in demand 

into or out of specific industries is small, except perhaps for some transitional costs. Exceptions may 

occur, however, for factors that receive higher-thannormal returns (called “rents” by economists) from a 

specific activity. Such factors are particularly disadvantaged 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 cigarettes 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 develop 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 companies 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 tobaccogrowing 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 develop 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 percent 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 financial and technical aid from the companies, along with 

guaranteed prices for crops. As a result, the companies 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 (Collishaw, Kaiserman, Rogers 1990). But in a unique turn 

of events, the Canadian government developed a subsidy program to downsize the Canadian tobacco industry (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 establishment 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 tobacco 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 encourages a shift of resources from other crops to tobacco. In competitive markets, such a resource shift 

would lead to an expansion in supply and an equilibrating 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 increases in supply, falling prices, and government campaigns 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 regulatory 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 Emergence of the Tobacco Companies”). Cigarettes smuggled from the United States have been a problem in 

several Latin American countries over the years, most 

recently in Colombia (Nares 1984). Cigarette smuggling 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 cigarettes 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 estimated 1 to 4 percent of total Canadian cigarette consumption in 1990 (Collishaw, personal communication 

1991). 

The United States is the world’s second largest 

tobacco producer (after China) and the largest exporter 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 pricesupport program affect the development of tobaccogrowing sectors in many developing countries. 

Higher-than-free-market prices, received by U.S. tobacco 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 domestic and foreign consumers. These high prices also 

create opportunities for foreign producers to profitably 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 increase 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 (Sumner 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 substituted 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 tobacco production. The vulnerability of tobacco exportation 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 opportunity 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 concentrated in developing countries and consumers are 

concentrated in the developed world, this transfer 

tends to raise incomes and stimulate growth and investment 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 subsidy programs in other countries, and profits from this 

exportation. 

Because tobacco is readily marketable, investments in agricultural projects supporting tobacco 

production are usually self-liquidating, and in the 

past, such investments may have been thought attractive by international development agencies, which 

financed projects designed to enhance tobacco production in Latin America and the Caribbean (Chapman and Wong 1990). Such financing is currently 

under review by some international lenders because 

of concerns about the long-term health effects of encouraging tobacco-industry growth in developing 

countries. 

Externalities 

Several positive externalities, or technologic spillover effects, have been associated with both tobacco 

growing and manufacturing. Improvements in farming practices, for example, have increased yield from 

not only tobacco but other crops as well because many 

of the modern farming procedures introduced for tobacco growing can also be applied to other crops 

grown in rotation with tobacco (Sofranko, Fliegel, 

Sharma 1976; Economist Intelligence Unit 1983). Producing 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, manufacturing and marketing of tobacco products may 

require highly trained workers to maintain and support modern factories in developing countries (Philip 

Morris International Inc. 1988). The training, except 

for that specific to tobacco production, helps to increase the supply of sophisticated managers and technicians. These positive externalities, however, could 

probably be achieved for many other commodities as 

well. 

One potentially negative externality is deforestation associated with curing tobacco. Several early reports 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 tobacco. 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 commissioned by the International Tobacco Information Centre (an industry-sponsored group) and was performed 

by the International Forest Science Consultancy (Fraser 1986). For the few countries examined, the researchers 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. Overall, the report estimated that in tobacco-growing, developing countries, only 0.7 percent of trees cut for all 

purposes are cut for tobacco curing. Because no available data question these findings, deforestation associated 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 export allows a country to participate in a subsidized 

international market and capture some of the economic transfers between consumers and producers 

that occur in such markets. Such participation may 

benefit a country’s net income, provided that no serious externalities are associated with tobacco production. When tobacco is produced for domestic 

consumption, however, most subsidies enjoyed by 

domestic producers are financed by domestic consumers, 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 consumption and restrain policies designed to discourage consumption 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 popular 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 employment, and shifts the subsidy paid by consumers 

from foreign suppliers to domestic producers. The 

development of a domestic tobacco sector almost certainly results in increased tobacco use because of a 

decline in tobacco’s real price. In addition, development of a domestic sector makes it more difficult for a 

country to mount successful antitobacco campaigns 

because domestic producers rather than foreign suppliers are affected. Because of these conflicting interests, the measurement of the net costs or benefits 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, alternatives 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. Increased production of alternative crops may lead to a 

fall in their prices, which not only makes them lessattractive substitutes for tobacco, but also harms traditional producers of these crops. Similarly, a decline 

in tobacco production by established producers may 

merely produce opportunities for competitors to initiate or increase production. Given the potential excess 

supply of tobacco in many countries, programs that 

encourage production of alternative crops will probably require strict controls to successfully reduce tobacco 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 tobacco diversification plan, and by 1990, about C$80 

million had been allocated to the plan. One component of the plan, the Alternative Enterprise Initiative 

Program, focuses on the development of alternative 

crops and production technologies to benefit tobaccogrowing regions (predominantly Ontario). A second 

part of the program offers cash incentives to encourage 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 tobacco 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 designed to underwrite downsizing, tobacco agricultural 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 competitive 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 determinant of the price of tobacco in international markets, 

were abolished or radically altered, foreign tobacco 

producers might have to contend with a massive increase 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 consumption in China, which has a self-sustaining market, 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 countries, 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 international 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 markets for U.S.-manufactured cigarettes in Japan, South 

Korea, and Taiwan (Council on Scientific Affairs 

1990). Previously, sales of U.S.-manufactured cigarettes and, to a lesser extent, U.S. tobacco were restricted 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 domestic demand slackens, domestic health concerns increase, 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 instituted to constrain the supply of tobacco and support 

current prices. Increased demand for excess tobacco 

is likely to come from developing countries, but demand will depend on rates of growth in income and 

on government tobacco policies. 

Tobacco Taxation 

Almost all countries levy taxes directly on tobacco 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 countries, 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 tobaccos. 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 premiumwhen compared with domestically produced cigarettes, including domestically produced versions of 

international brands licensed by the large multinational tobacco companies. In addition to import duties, 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 locations (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 monopoly 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 Argentina, 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 operations 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 finance 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 inflation, 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 levies, 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 mechanism, little impact on cigarette prices may result because 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, approximately 10 percent of the revenue of provincial governments is derived from levies on Colombian cigarette 

sales (Nares 1984). 

Differences in cigarette tax rates among countries 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. Various tax-evasion activities have been identified: buying cigarettes in neighboring lower-tax areas for 

personal consumption; organized smuggling of cigarettes 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 distribution system (forged tax stamps and underreporting) 

(Advisory Commission on Intergovernmental Relations 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 Cigarette Contraband Act was enacted. Law enforcement 

problems, stemming from organized interstate cigarette smuggling, contributed to the deceleration of 

state tax increases in high-tax states (Advisory Commission on Intergovernmental Relations 1985). Because the range of real prices has declined among 

states, interstate smuggling has become less profitable. This decline in profitability and increased federal 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. cigarettes 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 smugglers now control 35 percent of the national cigarette 

market (Nares 1989). In Canada, citizens cross the 

U.S.-Canadian border to purchase Canadian cigarettes 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 quantity of a commodity demanded declines as the price 

for that commodity increases. Numerous econometric studies have confirmed that this law holds for 

cigarettes, even though they are addictive, and the 

relation has also been demonstrated for various addictive 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 quantity 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 percent the quantity of cigarettes demanded. To determine 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 attempt to explain differences in cigarette consumption 

as a function of price, income, and demographic variables. 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 procedures 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 estimates are frequently unstable because the independent 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 because some cigarettes sold in low-tax areas are consumed 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. surveys 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 suggested that increased prices primarily reduced the 

number of smokers (measured as prevalence, or the 

participation rate) (Lewit and Coate 1982). The estimated effects on the number of cigarettes consumed 

per smoker were not statistically significant. Differences 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 Commission’s Fairness Doctrine), these researchers were 

also able to investigate the effect of that policy on 

teenage smoking. They reported that elasticity of demand 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 smoking, 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 substantially 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 compensate 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 demand for cigarettes in Latin America and the Caribbean 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 Caribbean 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-yourown” 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 consumption 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 developed models of rational addiction that distinguish 

between the consumption of addictive and nonaddictive goods and that allow for economic analysis. The 

Becker-Murphy models recognize that current consumption 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 nonaddictive 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 cigarette demand. In particular, the authors found that a 

10 percent permanent increase in the price of cigarettes 

would reduce current consumption by 5 percent initially 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 estimates 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 cigarette demand. 

The application of the rational addiction model 

to cigarette consumption is a recent development; further 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 cigarette demand derived from the model are not inconsistent 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 declined (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 beginning in August 1982 (see also Chapter 2, “The Emergence 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 mid1970s. The very rapid acceleration in the rate of decline-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 further 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* 

4poo3w3,60@ 

3poo3#200- 

3poo-, 

1982 1983 1984 1985 1986 1987 1988 

l 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 additional 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 cigarette 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 determining smoking behavior. A decline in per capita 

cigarette consumption in Peru and Bolivia in the 1980s 

has been attributed to falling incomes in both countries (Chandler 1986). 

Health Consequences of Tax Changes 

In some countries, a policy of aggressively increasing 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 provided 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 calculated upper-bound estimates of the impact on mortality 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 consumption, 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 disability 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 morbidity and mortality in the region. This supposition is 

reinforced by the latency of the health effects of tobacco 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 revenuegenerating 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 manufacturers 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 incidence 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 Wohlgenant 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 distribution 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 consumption has become more concentrated in lower socioeconomic groups, and tobacco tax increases, as a share 

of income, would fall most heavily on these groups. 

Sammartino (1987) analyzed the distributional effects 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 Brazil, Uruguay, and Venezuela, prevalence of smoking 

is also higher for lower socioeconomic groups (Chapter 3, “Prevalence of Smoking in Latin America and 

the Caribbean”). In these countries, tobacco tax increases might also be regressive. In most other countries of the Americas, however, cigarette smoking is 

positively correlated with income. Moreover, in most 

Latin American and Caribbean countries, high-income smokers are more likely than low-income smokers to consume more cigarettes and purchase 

expensive brards of cigarettes. When increased revenues from tobacco taxes reflect expenditures on tobacco, the taxes may be proportional relative to 

income even in countries in which smoking is more 

common among the lower socioeconomic groups. Tobacco 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 systems are a mix of many different taxes, and fairness 

can be achieved by increasing progressiveness elsewhere in the tax system to balance tobacco tax increases 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 attributable to smoking in a particular year. These estimates 

(described earlier in this chapter) cannot be used to 

establish the appropriate level of tobacco taxation because, in addition to several methodological limitations, the estimates do not explicitly distinguish 

between costs borne by smokers (e.g., the cost of premature death) and costs shifted to others (i.e., external 

costs). Moreover, these estimates do not adequately 

account for the social insurance benefits that nonsmokers 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 pension claims revert to nonsmokers by increasing the 

ratio of benefits to contributions that nonsmokers receive. 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 nonsmokers 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 government 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 examination 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 benefits (pensions and Social Security) of never smokers. 

Manning and associates (1989) reported that their estimates of the net external economic costs of smoking 

are quite sensitive to two parameters: the rate of discount 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 estimates of the external economic costs of smoking fell 

below the average excise tax (state plus federal) imposed at the time of their analysis, which suggested 

that, at that rate of taxation, smokers probably compensated for the costs of smoking imposed on never 

smokers. Since the publication of their analysis, evidence of additional hazards of passive smoking has 

been reported (Glantz and Parmley 1991). Such evidence 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 imposed on never smokers by smokers. However, uncompensated financial externalities may be substantial 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 excess 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 medical care is inexpensive. 

Economics 135 
The essence of the argument for tobacco taxes is 

that tobacco-related illnesses may impose an uncompensated burden on never smokers regardless of their 

income class. If, however, smoking is positively correlated 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 undesirable 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 improve health by discouraging tobacco use among persons who would not have used tobacco if they were 

fully informed. The effect would be particularly beneficial 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 experiencing an epidemiologic transition, the economic impact 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 control and prevention programs has increased. In 

Brazil, for example, the cost of public information 

and personal smoking-cessation services is estimated 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 increases, cigarette consumption increases, particularly 

at lower income levels. This effect is attenuated at 

higher income levels. 

5. Advertising tends to increase consumption of cigarettes, although the relationship is difficult to 

quantify precisely. Advertising restrictions are 

generally associated with declines in consumption and, hence, are an important component of 

tobacco-control programs. 

6. The case for promoting increased tobacco production on economic grounds should be reconsidered. Although tobacco is typically a very 

profitable crop, much of the advantage of producing 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 industry is a significant source of employment, production 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 smoking, 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 influenced by local economic factors. 

136 Economics 
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WITT,‘S.F., PASS, C.L. The effects of health warnings and 

advertising on the demand for cigarettes. Scottisk \ozcrnal of 

Political Ecorzonry 28(1):86-91, February 1981. 

WOMACH, J. Tobacco Programs of the U.S. Department of 

Agriculture: Tkeir Operatiorl and Cost. Washington, DC: 

Congressional Research Service, 1989. 

WORGOTTER, G.F., KUNZE, M. Cigarette prices and cigarette consumption in Austria 1955-1983. Neul York State 

]outxal of Medicirw 86(9):478-479, September 1986. 

WORLD HEALTH ORGANIZATION. Report of a WHO 

consultation on statistical aspects of tobacco-related mortality. Report prepared by World Health Organization, Geneva, WHO/TOH/CLH 90.2, October 9-13,1989. 

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 Americas, and their laws vary in scope and rigor. Comprehensive laws, which provide a wide range of 

control, are rare; most laws in the Americas are categorical and deal with one or another aspect of tobacco 

promotion and use. Restrictive legislation has generally 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 Americas 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 landmark 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 become clear. In 1990, the 43rd World Health Assembly 

reaffirmed the effectiveness of tobacco-control strategies and, in particular, legislation and policies to 

(1) protect against exposure to environmental tobacco 

smoke in workplaces, public places, and public transportation; (2) increase the real price of tobacco; and 

(3) control direct and indirect advertising and promotion of tobacco products (World Health Organization 

[WHO] 1990a,b). 

Purposes of Legislation 

Law is a powerful tool for closing the gap between social policy and scientific knowledge about 

tobacco. The purposes of such legislation are as follows: 

l To set forth government policy on production, 

promotion, and use of tobacco, and to place the 

government squarely on the side of health. 

l To encourage smokers to stop smoking, and to 

dissuade young people from starting to smoke or 

from using smokeless tobacco. 

l To provide protection against the dangers of exposure to environmental tobacco smoke in enclosed 

public places. 

l To monitor and control the content of manufactured tobacco products. 

l To contribute to the development of a social climate 

in which smoking and other forms of tobacco use 

are unacceptable. 

l To provide for the allocation of resources to support 

effective programs to combat smoking. 

l 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 (demand). 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 nonsmokers from the health effects of exposure to environmental 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 countries (Bahamas, Barbados, Bermuda, Grenada, Guyana, Jamaica, Saint Lucia, and Trinidad and Tobago). 

Special comment is made on the French overseas departments and territories in the Americas. The principal 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 environment 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 promotion 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 advertising and promotion in increasing sales and consumption is difficult to quantify precisely (U.S. Department 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 dependence of newspapers and magazines on advertising 

revenue from the tobacco industry may hinder the 

publication of information about the hazards of tobacco use (Whelan 1984; USDHHS 1989). As prevalence of smoking has declined in Canada, the United 

States, and other industrialized countries, transnational tobacco corporations have intensified their promotion 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 tobacco. 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 offered for sale in Canada. 

The statute and the regulations, however, provide the tobacco manufacturing, importing, and advertising 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 unconstitutional 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 enactment 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 smokeless tobacco in 1986. Health warnings are required in 

cigarette and smokeless tobacco advertisements (see 

next topic). 

State and local legislation to control tobacco advertising 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 advertisement 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; restrictions on the imagery, content, and format of tobacco advertisements; bans on certain types of 

promotion, such as targeting of children and sponsorship of sports and cultural events; and economic disincentives (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 legislation 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 tobacco 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, Ecuador, El Salvador, Mexico, and Peru have statutes of 

this type. 

Virtually all Latin American countries that control 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 regulations that restrict the advertisement of cigarettes and 

tobacco products. Regulations of the Bureau of Standards 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 advertisements 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 advertising, but the Carreras Group Ltd., which has a 

monopoly on the Jamaican cigarette market, has voluntarily withdrawn advertising from television, 

radio, billboards, print media, and cinemas. The Carreras 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. television programs; thus, the U.S. ban on advertising tobacco products on television applies to the U.S. and 

British Virgin Islands. 

None of the Caribbean countries restrict the tobacco 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 tobacco advertisement. 

Requirements for Health Warnings and 

Statement of Tar and Nicotine Yield 

Mandatory warnings on packages and in advertisements of tobacco products are a form of health 

education; these warnings alert the public to the dangers 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 tobacco 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 Uruguay, the Commission for the Control of Smoking, 

under legislation enacted in 1988, is authorized to set 

maximum allowable levels of tar and nicotine for tobacco products. 

North America 

The Tobacco Products Control Act of Canada 

prohibits the sale of a tobacco product unless it displays one of the required health messages, lists the 

toxic constituents of the product and, when applicable, 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 display 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 environmental tobacco smoke, lung disease, and stroke. 

Canada is introducing an innovative way to distribute 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 occupy 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 

Tobago X X 

*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 constituents 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 regulations 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, Premature 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, although the Departme:.t of Health and Human Services and the Federal Trade Commission have 

recommended such requirements. The tobacco industry 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 displayed 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 cigarette 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 warnings 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 diseases.” 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 cigarettes 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 cigarettes have 18 mg of tar or more. These standards 

apply to cigarettes manufactured in Trinidad and Tobago only. Average nicotine yield and tar group are 

requested by Bureau of Standards regulations; however, 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 cigarettes 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 common, perhaps because legislation to control smoking 

in public places is considered a better approach. Also, 

many educational and health institutions have voluntarily 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 socially unacceptable. The effectiveness of tobaccocontrol 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 mission statement of the Canadian tobacco company, Imperial Tobacco Ltd. (ITL) (Imperial Tobacco Ltd. v. 

Attorney General of Canada, 1990): 

The following philosophies have effectively governed 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, positive 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 example 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 disseminated, 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 airlines and other forms of transportation subject to national 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 sections. 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 governments and multiple municipalities within the 10 provinces had enacted legislation to control smoking in 

public places and the workplace (Calgary Health Services 1988). Both the types of public places and the 

degree of restrictiveness vary. The public places include 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, hospitals, retail stores with more than 10 employees, service 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 ordinances (Pertschuk and Shopland 1989). 

Although the federal government has not enacted 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 airlines 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 Islands; within the states of Alaska and Hawaii; and 

between Alaska or Hawaii and a point in the contiguous 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 restrictiveness, 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 restrict smoking in indoor cultural and recreational facilities, such as libraries, museums, theaters, galleries, 

arenas, and auditoriums. In 31 states, smoking in 

schools and on school grounds is restricted for students, 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 public 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 transportation vehicles, health establishments, schools, cinemas 

and theaters, and government buildings, but legislation 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 smoking in public places is rare. The Ministry of Transport 

of the Bahamas issued regulations prohibiting smoking 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 hospitals, 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 important 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+ 

transportation 

Country Govem- Health 

and selected ment estabjurisdiction 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+ 

transportation 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 jurisdiction. 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 ensure that workers refrain from smoking in any workplace under their control, except in designated 

smoking areas for which size, ventilation, and other 

characteristics are prescribed. 

Legislation in several provinces in Canada, including 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 smoking in all areas of the workplace, except designated 

smoking areas, public areas, and areas used for lodging and private dwellings. 

Municipal bylaws, enacted by 22 municipalities 

in Canada as of 1988, have been the major legal mechanism for controlling smoking in the workplace. This 

legislation generally requires employers to have written smoking policies that attempt to accommodate 

both smokers and nonsmokers in the workplace (Calgary Health Services 1988). The most stringent legislation bans smoking when the concerns of smokers 

and nonsmokers cannot be accommodated. Bylaws 

may also set forth requirements for compliance, posting 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 promotion 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 Services 1988). 

In the United States, policies of federal agencies 

generally restrict but do not ban smoking in the workplace; most federal employees are covered by such 

policies. The General Services Administration has issued 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 nonsmoking employees; a work area for smoking, if all employees assigned to the area agree to the designation; and 

contiguous nonsmoking areas in employee cafeterias, 

lunchrooms, and lounges sufficient to meet the demand. The policy must prohibit smoking in auditoriums, 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. Violation 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 employers 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 exercise their rights under a smoking ordinance. 

Latin America 

In Latin America, restrictions on smoking in the 

workplace are generally included in legislation prohibiting 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 smoking 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 possible. 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 specifically 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 development 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 cigarettes from retailers and vending machines, banning 

or restricting the sale of tobacco through vending 

machines is critical (USDHHS 1989). Prohibiting cigarette 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 statesMinnesota 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 countries 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 revocation 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 Saskatchewan, New Brunswick, and Newfoundland. The provinces 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 Comprehensive 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 supervised areas so that minors cannot use them. Wisconsin 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 license 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 Tobacco 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 making sales to minors; sets a graduated schedule of 

penalties-from monetary fines to license suspension; provides separate penalties for failure to post a 

sign stating that sales to minors are illegal; places 

primary responsibility for investigation and enforcement 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. Legislation in 15 states bans smoking in schools, and in 17 

additional states, smoking is restricted to designated 

areas (USDHHS 1989). Smoking by teachers has customarily 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 legislation 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 prohibits 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 cinemas, 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 Control 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 introducing 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 smoking 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 enacted. 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 cohesive coalition of national voluntary and health organizations-particularly the Non-Smokers’ Rights 

Association, the Canadian Cancer Society, the Canadian Council on Smoking and Health, Physicians for 

Legislation 159 
a Smoke-Free Canada, and the Canadian Medical Association (Lachance, Kyle, Sweanor 1990). These and 

other organizations have banded together as the Canadian 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 personnel 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 federal government, each of the 10 provinces, the two 

northern territories, and eight nongovernment organizations meets regularly to coordinate activities 

(McElroy 1990). The National Clearinghouse on Tobacco and Health was established to increase public 

access to current information on tobacco issues. The 

national strategy has created a strong partnership between the government and the voluntary groups for 

an organized, targeted campaign against the use of 

tobacco. 

In the United States, one of the federal government’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 addition, the Office on Smoking and Health publishes 

annual and cumulative bibliographies of publications 

on tobacco. Other agencies of the Public Health Service have also made major contributions to education 

and information (USDHHS 1989; see also Chapter 6). 

From 1967 to 1970, the federal government mandated that messages about the health hazards of tobacco use be broadcast through the media to balance 

commercial cigarette advertisements. This use of the 

Federal Communications Commission’s fairness doctrine had a substantial effect on tobacco use. Per capita 

consumption decreased in 1967 and continued to decline each year through 1970. When cigarette advertising 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 tobacco, 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) mandatqpublic education on the health hazards of tobacco 

use. In Uruguay, a special order of the Ministry of 

Health requires hospitals and special services, particularly maternal and child health clinics, to provide 

intensified education on tobacco use. Only Bolivia 

and Mexico have enacted national legislation requiring 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 education in all sectors of the community, with special emphasis 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 education on tobacco use, but the school systems in some 

Caribbean countries voluntarily include such education (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 legisla tion bans smoking in all public places. 

This new law provides the French overseas departments and territories, together with Canada, with 

the most comprehensive tobacco-control legislation in 

the Americas. The effectiveness of this model program 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 evidence indicates that specific legislative interventions 

do have positive effects: 

l A decline in cigarette consumption is associated 

with the required airing of antismoking messages 

in the U.S. broadcast media (Warner 1979,1986b). 

l A decline in smoking is associated with price increases (Townsend 1990; Lewit 1989; Warner 1986a; 

USDHHS 1989). 

l Of 15 European countries, those with legislative 

programs made more progress in reducing smoking than did those that used a voluntary agreement 

(Cox and Smith 1984). 

l In Norway, in the five years following enactment of 

the Tobacco Law of 1975, which banned advertising, 

raised tobacco taxes, and stimulated strong educational programs, cigarette sales declined by 15 percent, particularly among young people (Tye, 

Warner, Glantz 1987). 

l In Finland, a decline in total consumption of tobacco products has been related to antismoking 

measures (Advisory Committee on Health Education [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 evaluation. Determining the extent to which statutes are 

enforced and obeyed is an important first step in evaluating their impact. 

Legislation 161 
Conclusions 

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. 

2. Although the direct effects of legislation are often 

difficult to specify because of interaction with a 

variety of other factors, there are numerous examples of an immediate change in tobacco consumption 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 enforcement is unknown. 

162 Legislatio7i 
Appendix 1. Notes to Tables 

Details are provided below on selected legislation 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 television 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 promotion of samples at colleges and universities are prohibited. Advertising associated with the practice of 

sports is prohibited. Young persons may not be 

shown as models in tobacco advertising, and the representation of persons smoking excessively is prohibited. Low-nicotine cigarettes may not be represented 

as beneficial to health. 

Bolivia 

Advertising of tobacco is restricted to the tombstone 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 products. Persons inhaling or exhaling cigarette smoke, 

adolescents, pregnant women, and children may not 

be shown. Tobacco advertisements may not be associated with sporting, domestic, or occupational activities. Labels and advertisements for tobacco must be 

licensed by the health authority to prevent indiscriminate promotion of tobacco consumption. 

Brazil 

Advertising of tobacco products is permitted on 

television between 9:00 p.m. and 6:00 a.m. only. Advertising in theaters before 800 p.m. is prohibited if 

persons under 18 are admitted. Tobacco advertisements 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 warnings are prescribed. Announcement of sponsorship of 

events by tobacco companies is limited to the presentation 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 manufacturer or importer may contribute to cultural or 

sporting activities or events, at which brand names of 

tobacco products are used, to the value of contributions 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 reference 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 prohibited. 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 warning 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. Advertising 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 broadcast of tobacco advertisements before 7:30 p.m., the 

insertion of such advertisements in programs for children, 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 literature and history of Ecuador. 

El Salvador 

Tobacco advertising on radio or television and in 

cinemas during programs directed to children is prohibited, 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 tobacco 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 femininity 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 preparation 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 representing 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 international 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 Advertising Standards Authority and other agencies. These 

standards require a health warning on tobacco advertisements, 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 cigarettes, little cigars, and smokeless tobacco on television and radio. Health warnings are required in print 

advertisements and on billboards. 

Uruguay 

Legible health warnings, required on written tobacco 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 tobacco products. No promotion of tobacco products, 

direct or indirect, may be undertaken in schools or 

other educational institutions, whether public or private. Legislation proposed in 1988 would set forth 

standards for advertising tobacco products, including 

a prohibition on advertisements directed to or depicting young people. Low-tar and low-nicotine cigarettes could not be depicted as beneficial to health, and 

advertising could not associate smoking with sports, 

physical strength, social prestige, virility, or femininity. 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 consumption of cigarettes and tobacco products is 

prohibited. 

Restrictions on Smoking in Public Places (Table 4) 

Bolivia 

Smoking is prohibited in schools, health premises, 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 municipalities 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 prohibited 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 rejected 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 governments 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 restaurants of more than 100 square meters must reserve 50 

percent of the space for nonsmokers. 

In the state of Rio de Janeiro, smoking is prohibited 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, museums, schools, garages, and taxis. 

Port0 Alegre prohibits smoking in businesses, 

cinemas, theaters, schools, elevators, buses, and places 

where explosives or flammable materials are processed 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 circular requiring teachers and professors to refrain, whenever 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 smoking 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 entertainment, including cinemas and theaters, throughout 

the country. The owners or managers of these facilities are responsible for enforcement. 

Smoking is also prohibited in all means of public 

transportation. Drivers are responsible for enforcement; 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 ministerial resolution prohibits smoking on all means of 

public transportation. 
Guatemala 

Guatemalan Government Accord No. 681 (August 3, 

1990) prohibits smoking in public transportation vehicles and in public places in government and private 

offices. 

Honduras 

Comprehensive legislation enacted in 1989 prohibits smoking in public and private schools; cinemas 

and theaters; collective ground, air, and sea transportation; public and private hospitals; government offices 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, restricts smoking in a wide range of indoor public 

places, including public transportation vehicles; kindergartens; primary, secondary, and high schools; 

waiting rooms of health facilities, hospitals, and clinics; libraries; cinemas, theaters, and auditoriums; government 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 compliance with the ban on smoking. 

Trinidad and Tobago 

Although no national legislation restricts smoking on aircraft, British West Indian Airways Ltd., in 

compliance with regulations of the International Airline Transport Association, prohibits smoking on 

flights of less than one and one-half hours. 

Uruguay 

Since 1976, the School of Medicine of the University of the Republic of Uruguay has prohibited smoking 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 applies to patients, visitors, physicians, students, and 

technical and administrative personnel while on duty 

and in contact with patients and their visitors. Smoking is prohibited in plenary sessions and working 

committee sessions of the Chamber of Deputies. Legislation 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, although 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 prohibits 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 transportation 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 Cigarettes 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 advertising 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 publications 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 people 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 resistance to the polluting effects of tobacco and because 

minors are susceptible to example. Tobacco advertising must not depict children or adolescents, nor may 

it associate tobacco with sports. In 1984, the Minister 

of Education and Culture prohibited students, professors, and parents of students from smoking in public 

and private educational institutions. 

Brazil 

Legislation enacted in 1988 specifies that no reference 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 municipalities of Rio de Janeiro, SBo Paulo, and P&-to Alegre 

prohibit smoking in schools. 

Chile 

Tobacco advertising on radio or television is prohibited 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. Administrators or managers of the establishments must ensure 

compliance with the decree. Violators are sentenced 

under the General Health Law, which provides a penalty 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 advertisements may not be presented on television before 

7:30 p.m. nor be included in programs intended exclusively 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 adolescents about the effects of tobacco on health through 

individual methods and mass communication. The 

statute contains no specific ban on advertising directed 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 adolescents 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 products 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 programs 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 advertising 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 antismoking education, for systematic and programmed 

teaching of health education. 

Brazil 

Legislation enacted in 1986 provides for a national 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 Smoking, established by a 1986 decree, is charged with 

designing and evaluating a program for smoking control that includes education, information, and regulation. The Commission is required to identify 

resources in the public and private sectors for informational, educational, and smoking-cessation activities. The function of the Intersectoral Commission for 

Primary Prevention of Alcoholism in Schools, established 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 modified 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 programs on the effects of consumption of drugs and 

tobacco and to encourage cultural and sports activities 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 adolescents through individual methods and mass communication. Emphasis is on education of the family to 

prevent tobacco use by children and adolescents. Coordination 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, organized No Tobacco Day, which involves educational 

councils at the primary, secondary, and teacher training levels. Legislation proposed in 1988 would authorize a commission for the control of smoking to coordinate educational programs on tobacco with the National 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 Digest of Health Legislation (IDHL), edited by the Health 

Legislation Office, World Health Organization, Geneva, and the LEYES database produced in the WHO 

Regional Office for the Americas, or Pan American 

Health Organization (PAHO), by the Health Legislation Project (HLE), Health Policies Development Program. Several state and local statutes were provided 

by PAHO. The list contains related laws not specifically 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 Policies Development Program, December 1989 (in Spanish and English). 

Argentina 

Order No. 33.266 prohibits drivers of school 

buses from smoking and prohibits smoking on vehicles transporting dangerous substances. 

Order No. 22.900 prohibits smoking on public 

transportation vehicles. 

Order No. 09-12-910 prohibits smoking in theaters, 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, legislative, 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, hospitals 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 enclosed 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) Regulations 1988 requires health warnings on cigarette packages. (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 smoking in any educational establishment, private or public, 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 smoking in public places, requires a health warning on 

tobacco packages, and restricts advertising. (IDHL, 

1989,40(2):406) 

The Brazilian Political Constitution of 1988 stipulates 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 smoking 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 secondary 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, Revised 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 institutions, and restrictions on tobacco sales in health institutions. (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 advertising 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 Education, da ted May 11,1981, restricts smoking by teachers 

and in the schools. 

Law No. 9.032 of March 27,1980, concerns educational 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 Ministry of Health prohibits smoking by health professionals, 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 elepublic 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 campaign in the community and in schools of the municipal education system. 

Circular 27 of July 4,1989, of the Ministry of the 

Interior, recommends restrictions on smoking in government 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 broadcast 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 campaigns aimed at, among other topics, preventing tobacco 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, requires 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, television, 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, concerns restrictions on sales to minors. (IDHL, 1989, 

40(1):101) (LEYES database) 

Decree No. 17.969-S of February 4, 1988, concerns tobacco information programs. (IDHL, 1989, 

40(1):101) (LEYES database) 

Decree No. 18.216-S-TSS of June 23, 1988, concerns 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 beverages. (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, advertising restrictions, and health warnings on packages. (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 Prevention 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 various 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 beverages and tobacco. (IDHL, 1974,25:123-141) 

Regulations of December 16, 1974, on advertising 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 private 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, creates 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 advertising 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, theaters, 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 forbids 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 commission 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 protection 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 packages, evaluation of smoking-control programs, and 

advertising restrictions. (IDHL, 1985,36(3):649652) 

The Comprehensive Smokeless Tobacco Health 

Education Act of 1986 concerns information programs, smokeless tobacco, restrictions on sales to minors, health warnings on packages, advertising 

restrictions, levels of toxic constituents, and evaluation of smoking-control programs. (IDHL, 1987, 

38(1):67-70) 

Regulations under the Comprehensive Smokeless Tobacco Health Education Act of 1986. (IDHL, 

1987,38(3):547) 

Smoking Regulations. Part 101-20 (Management 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 Annotated, Title 49, Appendix, Section 1374(d), Prohibition 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 Governor: 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 technical and administrative personnel; requires inclusion of smoking history in patient charts; establishes 

smoking-cessation programs in the hospital; intensifies 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, prohibits 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 cigarettes, 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 advertising and marketing of cigarettes and tobacco products. (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 intensified education on tobacco, especially in the maternal 

and child health clinics, and requires inclusion of information 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. (Provided by HLE/PAHO) 

Decree No. 19.067 of March 1979 concerns requirements for theatrical performances, including 

authorization for the sale of nonalcoholic drinks, cigarettes, and other items in theaters. (Provided by 

HLE/PAHO) 

Decree 407/981 of August 12, 1981, concerns 

smoking on interdepartmental passenger transportation. (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 prescribing 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 commercial advertising that directly or indirectly encourages 

the consumption of cigarettes and other products derived 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 associated 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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May 25,199Ob. 
Chapter 6 

Status of Tobacco Prevention 

and Control Programs in the Americas 

Preface 181 

Introduction 183 

National Programs for Tobacco Control 183 

United States 783 

Canada 184 

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

Elements of Prevention and Control Programs 186 

Surveillance and Analysis 186 

Education, Public Information, and Cessation Programs 287 

Taxation 190 

Legislation 191 

Coalitions 194 

Summary 196 

Conclusions 296 

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

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

References 204 
Preface 

The Americas comprise diverse countries that hazje not dezyeloped synchronously. The 

impact of many of the factors of dezlelopment discussed in the previous chapters-the 

fransition to an industrialized economy, the changing populafion sfructure, the consolidation of the tobacco industry, thegrozoing prez~alence of cigarette smoking, and the emerging 

burden of smoking-attributable mortality-has differed among countries. Almost all countries 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 elements, 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 organizations, 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 tobaccocontrol 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 activities. The 1964 advisory committee report to the Surgeon General on the health consequences of smoking 

provided the scientific information needed to launch 

an effective, sustained, national public health campaign against tobacco use (Public Health Service 

1964). As the national effort matured, the actions of 

state and local health departments became more important, since municipalities have more opportunities 

for aggressive control, Funding and technical assistance for state and local efforts has come from voluntary 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 because 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 reduction (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 percent) in smoking cessation beginning in early pregnancy, (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: 

l For all schools to be tobacco-free and to include 

prevention of tobacco use within the basic curriculum. 

l For an increase to 75 percent in the proportion of 

worksites that prohibit or severely restrict smoking. 

l For enactment and enforcement of bans on the sale 

of tobacco to minors. 

l For the development of state tobacco-control plans. 

1 Gray and Daube 1980; Pan American Health Organization 

1989a; World Health Organization 1979, 1983a,b; Chapman and Wong 1990; Pierce 1991; Novotny et al., in press; 

Choi et al., 1991; Davis, Monaco, Roman0 1991; Centers 

for Disease Control 1991. 
l For a ban or severe restriction on advertising and 

promotion of tobacco to which youths are likely to 

be exposed. 

l For an increase to 75 percent in the proportion of 

health care providers who provide smoking cessation 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. Interventions include school-based programs, testing and dissemination 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 smokeless 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 Intervention 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 report 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 educational 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 information, availability of services and programs, 

message promotion, support for citizen action, intersectoral policy coordination, and research and knowledge development (McElroy 1990). 

Current participants in the national strategy are 

Health and Welfare Canada, provincial and territorial 

ministries of health, the Canadian Cancer Society, Canadian 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 component 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 percent 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 Generation of Non-Smokers,” the national campaign has 

brought together key groups and individuals and has 

encouraged cooperation, coordination, and comprehensiveness. 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 advisory 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 reported on activities related to tobacco control, including 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 activities (WHO 1986). 

In 1989, a Regional Plan of Action for the Prevention 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 resolution 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 collaborating centers in mobilizing resources; collaborate 

with professional associations and political leaders; 

and collaborate with educational, health, and transportation 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 program 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 cessation 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 evaluated in depth. Nonetheless, the plan is commendable 

for having identified the factors important to tobacco 

control and for having encouraged participating countries to develop coordinated programs. 

The Caribbean Community (CARICOM), an organization of heads of governments from the Caribbean 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 intervention 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 Cancer has joined public and private health leaders in 18 

countries of the Americas in organizing national 

workshops on smoking and health. International voluntary agencies have provided assistance to these 

workshops, in which 6,000 physicians, educators, 

health officials, and community activists have participated. 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 activities formed the Latin American Coordinating Committee on Smoking Control (LACCSC) (American Cancer 

Society [AC‘31 1988), which has the following goals: 

l To help coordinate smoking-control efforts 

throughout Latin America. 

Pree7etltion and Control 185 
l To provide a clearinghouse for information supportive of national smoking-control initiatives. 

l To provide a forum for planning multinational 

strategies. 

l To provide guidance and training in smokingcontrol advocacy skills. 

l To adopt resolutions calling for action by governments throughout the region. 

By using funding from the International Union 

Against Cancer and the American Cancer Society 

(ACS), LACCSC, in partnership with PAHO, has distributed a newsletter several times a year, has developed 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 smokingattributable mortality have been held in conjunction 

with LACCSC annual meetings. LACCSC has supported 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 advertising 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 documentation about the overall prevention and control of 

tobacco use were requested, along with specific data 

on the main control elements. The findings are presented in detail in a companion report (PAHO 1992). 

The overview of the findings presented here emphasize 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 populations (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 considerably. The survey questions used have been recommended 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 identify 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 included 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 dwellers (Chapter 3, “Prevalence of Smoking in Latin America 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 reproductive 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 American Center for Perinatology and Human Development (PAHO 1987bj. 

Several Latin American and Caribbean countries 

have surveyed youths about cigarette smoking (Chapter 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, questions about tobacco use were part of drug-use surveys; 

because tobacco is addicting, it is considered a substance that can lead to the use of other drugs (Fleming 

et al. 1989). In the United States, school-based surveillance of behavioral risk factors is accomplished 

through a uniform survey instrument, the Youth Risk 

Behavior Survey (Hare1 et al. 1990). Standard questions 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 smoking generally occurs in this age group. 

Physicians are generally educated about the 

health consequences of smoking, and their healthrelated behavior may set an example for other persons 

(Adriaanse and Van Reek 1988). Prevalence of smoking 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 prevalence of smoking among physicians and physiciansin-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 monitoring 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 schoolbased educational programs. 

But data on tobacco use must be collected in a 

standardized way to allow for planning and evaluation of national programs and comparison of trends 

within and between countries. Furthermore, the key 

variables of a surveillance system should not be modified significantly over time. In 1990, WHO convened 

an internal working group to update standard measures of tobacco use. Standard definitions for worldwide 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 coordinated, regional approach. Under the sponsorship of 

PAHO, the Health Protection Branch of Health and 

Welfare Canada measured the tar, nicotine, and carbon monoxide yield from popular cigarette brands in 

20 countries (Table 1). The results suggest that smokers 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 effectiveness 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 mortality trends and of trends in determinants of chronic 

diseases now hampers meaningful policy and program development. 

Education, Public Information, 

and Cessation Programs 

School-based educational activities against tobacco are uncommon in Latin America and the Caribbean, but through the efforts of LACCSC, ministries of 

health and education, and nongovernment organizations, several countries have begun to include antitobacco education in school curricula (see Appendix 

1). Few of these programs have been evaluated; however, a 1988 antitobacco education program in Chile, 

initiated with the assistance of WHO, has been evaluated 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-lAstoria 

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 adolescents 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 Caribbean countries rely on physicians to provide information 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 (SuarezLugo 1988). 

Public information campaigns focus attention on 

tobacco as a serious health issue and help craft prevention and cessation messages for target audiences. Formal 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 countries 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 languages, including Spanish, for this event. Furthermore, public information announcements broadcast 

in the United States may be viewed in Caribbean countries 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 campaigns. Many organizations in the Americas that address 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 behavior patterns in many Latin American and Caribbean 

countries differ from those in the United States, minimal 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 Americas 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 government revenue they generate (see Chapter 4, “Economics 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. Department 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 tobaccorelated health programs, and the most substantial program 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, research, medical treatment, and environmental conservation 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 Canada, where taxes add an additional 75 percent to the 

price of cigarettes, health concerns and a concerted 

antismoking movement have strongly influenced policy. 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 reported earlier (Table 2). These differences may reflect 

short-term changes in taxation @olicy, but they may 

also reflect differences in the methods used to calculate 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.) 

l Fifteen Latin American and four Caribbean countries have either a total ban on or some type of legislation restricting advertising and cigarette promotion. 

l Three countries prohibit all advertising of tobacco. 

l Bolivia limits advertising to the tombstone format, 

which allows print and a picture of the package. 

l Two countries-Argentina and Bolivia-prohibit 

advertising associated with sports. 

l Sixteen countries restrict advertising that influences 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 
l Nearly all countries that have legislation on advertising require health warnings in advertisements. 

l Two countries specify the frequency and duration 

of health warnings required on the broadcast media. 

l Fourteen Latin American and five Caribbean countries require health warnings on cigarette packages. 

l Two Latin American countries require strong 

health warnings, but none requires multiple warnings used in rotation, as do Canada, the United 

States, and the French overseas departments and 

territories. 

l Only three Latin American countries, three Caribbean countries, and Canada require a statement of 

tar and nicotine yield on cigarette packages. 

l Restrictions on where cigarettes can be sold are 

generally not found in Latin American and Caribbean countries. 

l 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. 

l Nineteen countries restrict smoking in public places. 

l Seven countries ban smoking on work premises, 

and thirteen ban smoking in health establishments. 

l In the United States, a major statement on the hazards of smoking in the workplace has been issued 

(National Institute for Occupational Safety and 

Health 1991). 

l Nineteen countries have laws that control smoking 

by young people. 

l 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. 

l Argentina and Ecuador prohibit free distribution of 

samples of cigarettes to minors, and Uruguay prohibits the sale of loose cigarettes. 

l Nine Latin American and Caribbean countries prohibit 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. 

l Five Latin American countries mandate antitobacco 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 support. 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 sustained activities against tobacco use. 

Several countries in L.atin America have established national commissions with a wide range of 

functions regarding tobacco control: promotion of 

research, development of policy, provision of education and information, coordination of intergovernment 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 production of tobacco. The Permanent National Advisory 

Commission on the Control of Smoking is a government 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 employers 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 handled 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 tobacco that affect health. The decree specifically recognizes that tobacco is harmful to health. In Brazil, 

legislation enacted in 1986 provides that the Ministry 

of Health shall promote week-long activities in connection with National No-Smoking Day, observed annually on August 29. 

In seven Latin American countries, legislation 

creates a national smoking and health organization. A 

1986 decree in Chile established the National Commission for the Control of Smoking, which includes the 

Minister of Health as chairperson and the undersecretaries 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 Antismoking Committee under the National Bureau for 

Epidemiological Control and Surveillance. The committee, which comprises representatives from the 

public and private sectors and is chaired by a representative of the Ministry of Public Health, plans, advises on, and carries out the national program against 

smoking. 

The General Health Law of 1983 in Mexico provides that the Secretariat of Health, the governments 

of the federated entities, and the Council on General 

Health in each geographic area shall coordinate activities 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 following: (1) encouraging legal measures to control 

smoking, (2) promoting cooperation between federal 

and state agencies, (3) integrating government activities with those of the private sector, (4) establishing a 

government center for information and documentation, (5) strengthening surveillance, (6) promoting research, (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 effects of tobacco use and gathering statistical data on 

progress in combating smoking. The report is to include 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 recommendations on the health risks of smoking. The commission 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 create the Bureau for the Control of Smoking, within the 

Ministry of Public Health, with broad power to (1) 

conduct epidemiologic studies, (2) coordinate preventive 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 products, 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 diseases. 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 communications, justice, environment and natural resources, 

information and tourism, and youth affairs; the Venezuelan Social Security Institute; the National Academy of Medicine; the Venezuelan Cancer Society; and 

the Venezuelan Medical Federation. A technical unit, 

composed of physicians, epidemiologists, political scientists, sociologists, academicians, publicists, and social 

communicators, supports and coordinates the development 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 organizations 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 antismoking efforts. In the Americas, nongovernment 

groups, such as citizens’ coalitions, voluntary agencies, and special-interest groups, have effectively promoted good health. 

This compendium of legislation and coalitions 

does not indicate the extent to which tobacco-control 

activities are implemented. Many of the recently established government and nongovernment commissions 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 provided in Appendix 2. 

Prezretltion and Control 195 
Summary 

Activities critical to controlling tobacco use include surveillance of tobacco consumption, collection 

of excise taxes, and coordination of local, national, and 

regional efforts. Surveillance data can be used to monitor trends in tobacco use and to provide a basis for 

targeting populations. The collection of tobacco tax 

revenue can be used for monitoring tobacco consumption, and such revenue can be dedicated to healthrelated 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 framework 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 infrastructure for the prevention and control of tobacco 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 tobacco 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 Americas are often available through church and community organizations. Private and governmentsponsored cessation programs are uncommon. 

Media and public information activities for tobacco 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 campaigns, 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 antismoking educational program for 561 secondary 

schools. 

Bahamas 

Antitobacco information is minimally included 

in the antidrug curriculum. 

Belize 

The Curriculum Development Unit of the Ministry of Education and Pride Belize (an antidrug organization) 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 developed a natural science curriculum for the third and 

fifth years of primary school. The National Commission 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. Educational 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 sponsor 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 addiction. 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 included 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 planning an educational program for schools. The Youth 

Congress on Smoking, held in 1990, provided instruction and training on prevention activities. 

Guyana 

The National Coordinating Council for Drug Education 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 antismoking program has produced book!ets for use in 

schools by youth groups and by parent groups. Universities 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 association 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 campaign in secondary schools, vocational schools, and 

universities. By giving talks to seventh-grade students, the American Cancer Society reaches 85 percent 

of public schools and 30 percent of private schools. 

Suriname 

The Teachers’ Union collaborates with the Ministry of Health in training teachers in smoking prevention education. 

Trinidad and Tobago 

The Ministry of Education includes antitobacco 

education in the syllabus of the general health education 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 program. Parents, teachers, and students are organized 

into extracurricular groups to help develop educational 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 Cancer 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 cigarettes and cancer. The biennial Tobacco or Health Day 

is addressed through mass media and public meetings. Children’s poster campaigns have been sponsored, and Bolivia observes both a smokeout in 

November and World No-Tobacco Day in May. 

Brazil 

On National Antismoking Day, a race is sponsored 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 Antismoking Commission. Five million copies of an antitobacco 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 associations 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 worksites. 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 hospitals and clinics. 

Smoke-free Day is supported by print and electronic media. The Social Security Fund produces television 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 government program, includes television announcements, 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 education and media messages. A pharmaceutical 

workers’ union sponsors antitobacco information. 

El Salvador 

The Department of Mental Health (of the Ministry 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 provides 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 Association, and the Jamaican Cancer Society are active in 

public information campaigns. 

Mexico 

A government program disseminates information through print and electronic media. World NoTobacco Day is supported through various media. 

Panama 

A prevention program, based on public information, 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 Association’s booklet on the health consequences of smoking 

has been distributed by pharmaceutical companies to 

3,000 physicians. Nongovernment organizations’ activities 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. Information is also disseminated by the Center for Information 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 Patients, and the Medical Association of Suriname sponsor a public information campaign. 

Trinidad and Tobago 

The Cancer Society sponsors Smokeout Day during 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. Materials 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 announcements use U.S. materials on the risk of smoking, 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 consequences of smoking. 

Venezuela 

The Venezuelan Cancer Society and the Tuberculosis and Lung Disease Society have sustained programs, including National Smoke-Free Day, World 

No-Tobacco Day, lo-minute public service announcements, 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 insurance discount of 35 percent. 

Barbados 

The Barbados Cancer Society conducts fiveweek smoking-cessation clinics based on the American 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 seminars. 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 organizes 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 practitioners 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 insurance 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 nonsmoker 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 smokingcessation 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 Institute, Colombian Cancer League, and a press representative 

Coalition or program: Antismoking Action and Health 

Council (est. 1990) 

Activities: Conducts studies on tobacco control, taxation, contraband, and advertising restrictions 

Sponsor: Ministry of Health and Social Action, medical association, Rotary Club, Mainetti Foundation, 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 programs, 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 coordinates 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 Smoking 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 Institute, Respiratory Diseases Department), nongovernment 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; National Commission for the Control of Smoking 

(est. 1986) 

Sponsor: Government, medical association, nongovernment organizations 

Activities: Sponsors educational planning, data collection, 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 departments and territories 

Guatemala 

Coalifion or program: Mental Health Department; National Antismoking Commission 

Sponsor: Ministry of Public Health and Social Welfare, 

government and nongovernment organizations, 

and physicians’ association 

Activities: Promotes public education and information, and international and national coordination 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 organizations 

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 Commission 

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 organizations (Jamaican Medical Association, Jamaican Cancer Society) 

Acfivifies: Promotes school education, public information, 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 illness, 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 Association 

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 activities, 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 activities, and technical information 

Prezlenfion arld Confrol 203 
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206 Prevention and Control 
List of Tables and Figures 

Chapter 2 

The Historical Context 

Table 1. 

Table 2. 

Table 3. 

Table 4. 

Table 5. 

Table 6. 

Table 7. 

Table 8. 

Table 9. 

Table 10 

Table 11. 

Table 12. 

Table 13. 

Table 14. 

Figure 1. 

Figure 2. 

Tobacco trade in England, 170@1775 25 

Tax revenue from tobacco sales, United States, 

1865-1890 30 

Manufactured tobacco products, United States, 

1870-1905 30 

Economic activity and rankings of major transnational 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 manufacturing 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 cigarettes 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 countries, 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 Caribbean, 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, adjusted for age and sex, 1971 65 

Standardized ratio of cigarette smoking among 

persons aged 15-74 in eight cities of Latin America, 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 reproductive 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 childbearing age, selected Latin American and Caribbean 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 industrialized countries, 1978-1981 92 

Smoking-attributable mortality for men and 

women in the Americas, c. 1985 94-95 

Adjusted estimates of smoking-attributable mortality 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 industry 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 middle 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 cigarettes 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 legislation and region 148 

Countries that control tobacco advertising and 

promotion, by type of restriction 149 

Countries that require health warnings or statement 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 tobacco 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 percentage 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