CALL TO ACTION FIFTH EDITION

The tobacco control movement must grow its base of Revised, Expanded, and Updated
support to achieve ever-larger and more ambitious policy
and public health successes.

C
ompletely revised, updated, and
specially created to be used by students,
teachers, researchers, journalists,
advocates, and policymakers, the new
Fifth Edition of The Tobacco Atlas and its
EQUA L I T Y
companion website tobaccoatlas.org aims
to be the most comprehensive, informative,
and accessible resource on the most
important and current issues in the
evolving tobacco epidemic. This edition also
presents an invitation to join the tobacco
control movement for partners from other
communities—including environment,
equality, development, and non-communicable “We want this document to be used,
disease—whose interests are also
dramatically affected by the tobacco
DE V E L OP ME N T

epidemic and its human toll. to persuade the unconvinced about

NEW TOPICS INCLUDE:

• Environmental harms of tobacco

• E-cigarette use, product
development and marketing
• Trends in the use of water pipes
• Tobacco’s exacerbation of
poverty and development
• Tobacco’s contribution to
tuberculosis, HIV/AIDS, alcohol
abuse, and mental illness
NON- C OM
MUNI C A B L E DISE A SE S
• The lifecycle of tobacco regulation
• Integrating tobacco control into
the global non-communicable
disease agenda
• The endgame to the tobacco epidemic

Product Code: 9674.05

$39.95 (CAN $43.95) Michael Eriksen
ISBN: 978-1-60443-235-0
Judith Mackay
53995 Neil Schluger
Farhad Islami Gomeshtapeh
9 781604 432350 > cancer.org/bookstore tobaccoatlas.org Jeffrey Drope
FIFTH EDITION
Revised, Expanded, and Updated

THE
TOBACC0
ATLAS
Michael Eriksen
Judith Mackay
Neil Schluger
Farhad Islami Gomeshtapeh
tobaccoatlas.org Jeffrey Drope
 Chapters Topics: ENVIRONMENT EQUALITY DEVELOPMENT NCDS Page

HARM
1 DEATHS = t 14

2 COMORBIDITIES = t 16

3 HEALTH CONSEQUENCES t 18

4 SECONDHAND SMOKE = t 20
The tobacco control movement must grow 5 ENVIRONMENT
Published by the American Cancer Society, Inc. wO $ 22
250 Williams Street
its base of support to achieve ever-larger
Atlanta, Georgia 30303 USA and more ambitious policy and public 6 POVERTY = $ 24
www.cancer.org
health successes. PRODUCTS AND THEIR USE
Copyright ©2015 The American Cancer Society, Inc. 7 NICOTINE DELIVERY SYSTEMS t 28
All rights reserved. Without limiting under copyright reserved above, no part of this In this edition of The Tobacco Atlas, we invite colleagues
publication may be reproduced, stored in, or introduced into a retrieval system or tackling closely-related challenges—including protecting 8 CONSUMPTION = $ 30
transmitted in any form by any means (electronic, mechanical, photocopying, recording, the environment, promoting equality, engendering
or otherwise) without the prior written consent of the publisher. 9 MALE SMOKING
development and fighting non-communicable diseases = $ 32
(NCDs)—to explore common interests, ideas, and
ISBN 978-1-60443-235-0 10 FEMALE SMOKING
strategies to find far-reaching solutions. As this table of = t 34

Library of Congress Cataloging-in-Publication Data contents illustrates, every chapter touches meaningfully
11 YOUTH USE = 36
on one or more of these important areas.
Eriksen, Michael P., author. 12 E-CIGARETTES
O ENVIRONMENT t 38
The tobacco atlas / written by Michael Eriksen, Judith Mackay, Neil Schluger,
Farhad Islami, Jeffrey Drope. — Fifth edition. The tobacco industry causes major ecological
13 WATER PIPES = 40
pages cm damage, and at least seven chapters offer solutions
Copyright © American Cancer Society, 2015. to protect the environment from this devastation. 14 SMOKELESS TOBACCO = t 42
Includes index.
ISBN 978-1-60443-235-0 (pbk. : alk. paper) — ISBN 1-60443-235-7 (pbk. : alk. paper) = EQUALITY INDUSTRY
1. Tobacco use—Maps. 2. Tobacco use—Statistics—Maps. 3. Tobacco industry—Maps. In nearly half the chapters, we highlight the tobacco
4. Medical geography—Maps. I. Mackay, Judith, author. II. Schluger, Neil W., 1959- author. industry’s attempts to attract young women and 15 GROWING wO $ 46
III. Islami, Farhad, author. IV. Drope, Jeffrey, author. V. Title. children, while also offering tractable solutions that
G1046.J94M3 2015 instead empower women and protect children. 16 COMPANIES $ 48
362.29'60223—dc23
2014049978 17 ILLICIT TRADE t 50
$ DEVELOPMENT
While many chapters demonstrate that tobacco is 18 MARKETING
Managing Editor: John M. Daniel = $ 52
Contributing Editors: Ellie Faustino, Alex Liber, Michal Stoklosa, Carrie Whitney
inextricably linked to chronic underdevelopment,
Contributor Authors (chapters: Consumption, Illicit Trade, Investing, Prices, evidence emerges throughout the Atlas 19 UNDUE INFLUENCE t 54
Smokeless Tobacco, Taxes, Water Pipes): Alex Liber and Michal Stoklosa demonstrating that it is possible for tobacco growers
and users to free themselves from its yoke. SOLUTIONS
Printed by RR Donnelley
20 WHO FCTC O = t 58
Printed in China t NCDS
Tobacco use is an important risk factor for all
21 TAXES $ t 60
Design: Language Dept. www.languagedept.com major NCDs. More importantly, it is arguably the
526 W26th St., Studio 7B most preventable, and the Atlas offers appropriate 22 PRICES $ 62
New York, New York 10001 USA prevention strategies that are proven effective in
multiple settings. 23 SMOKE-FREE O = 64
Translation: Alboum & Associates www.alboum.com
2219 N. Quantico Street
24 QUITTING t 66
Arlington, Virginia 22205 USA
25 MEDIA CAMPAIGNS $ 68
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 American Cancer
26 WARNINGS & PACKAGING t 70
Society concerning the legal status of any country, territory, city, or area of its authorities,
or concerning the delimitation of its frontiers or boundaries. The mention of specific
27 REGULATIONS wO t 72
companies or of certain manufacturers’ products does not imply that they are endorsed or
recommended by the American Cancer Society in preference to others of a similar nature
28 MARKETING BANS = 74
that are not mentioned. Errors and omissions excepted, the names of proprietary products
are distinguished by initial capital letters. The American Cancer Society does not warrant
29 INVESTING $ 76
that the information contained in this publication is complete and correct and shall not be
liable for any damages incurred as a result of its use. The authors alone are responsible for
30 LEGAL CHALLENGES & LITIGATION O $ t 78
the views expressed in this publication.
31 NCD GLOBAL AGENDA $ t 80
The fifth edition of The Tobacco Atlas can be found online at www.TobaccoAtlas.org.
The online version of the Atlas provides additional resources and information unique to Sources, methods and data for all chapters are
32 THE ENDGAME O $ t 82
the online interactive version. available at tobaccoatlas.org.
 4 5
DR. MARGARET CHAN
Director-General, World Health Organization
T I
his fifth edition of The Tobacco Atlas celebrates
a decade since the WHO Framework Convention
on Tobacco Control (WHO FCTC) came into
force in 2005. The treaty’s usefulness is clear
throughout these pages. Further, this edition
of the Atlas covers the broad spectrum of non-
communicable diseases and important issues that
influence them, especially gender, development,
and the environment.
The WHO FCTC is the first international treaty
negotiated under the auspices of WHO. It is an
evidence-based treaty that represents a milestone
for the promotion of public health, and it provides
new legal dimensions for international health
cooperation. Since the treaty entered into force
in 2005, it has become one of the most rapidly
and widely embraced treaties in the history of the
FOREWORDS
United Nations.
Some extraordinary advances in tobacco control
have taken place since the publication of the
previous Atlas in 2012. Highlights of these are:
• The adoption, in 2012, by the Conference of the
Parties, of the first protocol to the Convention,
THE PROTOCOL TO ELIMINATE ILLICIT TRADE IN TOBACCO
PRODUCTS. This protocol is currently open for
ratification, acceptance, approval, or accession
by the Parties to the WHO FCTC.
• By October 2014, 179 PARTIES, covering 90% of
the world’s population, had committed
themselves to its full implementation. And,
over the past decade, more than 130 Parties
that have ratified the Convention had either
strengthened their tobacco control legislation
before they ratified the treaty, or have
adopted new, treaty-compliant legislation
(see Chapter 20: WHO FCTC).
All five editions of The Tobacco Atlas have used
data from WHO sources, especially the WHO
Reports on the Global Tobacco Epidemic and
information from implementation reports of the
Parties to the WHO FCTC. The Atlases also contain
data from surveys conducted as part of the Global
Tobacco Surveillance System, which comprises
data from the Global Youth Tobacco Survey and
the Global Adult Tobacco Survey. WHO and
Member States are joined in these efforts by the US
Centers for Disease Control and Prevention and
the Bloomberg Initiative—examples of successful
partnerships for monitoring the tobacco epidemic.
As implementation of the Framework Convention
intensifies, the tobacco industry fights back,
harder and through every possible channel. The
industry continues to attempt to derail tobacco
control measures by adopting tactics that range
from corporate social responsibility programs to
legal and trade challenges to government tobacco
control legislation. We cannot permit the industry
to shape in any way our public health efforts to end
the tobacco epidemic.
This fifth edition of The Tobacco Atlas provides
a good example of the interrelatedness of health
issues, and how we need to work together, across
diseases and conditions, to improve public health.
JOHN R. SEFFRIN, PHD
Chief Executive Officer, American Cancer Society
PETER BALDINI
Chief Executive Officer, World Lung Foundation
n the three years since the publication of the
previous edition of The Tobacco Atlas, much has
shifted in the landscape of tobacco control. Some
of these changes show great promise: one hundred
and eighty parties have now ratified or acceded
to the WHO Framework Convention on Tobacco
Control, and more countries than ever are now
adopting and implementing protective tobacco
control policies. Encouragingly, these nations
include those with enormous populations, and a
number of low- and middle-income countries where
the epidemic is hitting the hardest.
Notable achievements in the past three years include
Australia’s move to implement the world’s first plain
packaging policy for tobacco products, and Russia’s
and Vietnam’s passage of comprehensive national
laws, including strict prohibitions on smoking in all
public places. As we go to press, China has just made
historic progress: a law that will make all indoor
public places in Beijing 100% smoke-free, paving the
way for a national smoke-free law in China. Such
a development in the world’s most populous and
highest tobacco-using nation would be a game-
changing global health achievement.
We also continue to see an unwavering
commitment to tobacco control from Bloomberg
Philanthropies, which since 2007 has dedicated
more than 600 million dollars to supporting
anti-tobacco policies in more than 90 low- and
middle-income countries. Significant support also
comes from the Bill and Melinda Gates Foundation,
which has focused on preventing the epidemic
from taking hold in Africa and on supporting policy
efforts in China and Southeast Asia. These two
major donors drive momentum and buoy much of
the world’s tobacco control policy efforts. These
efforts are complemented by organizations such as
the American Cancer Society and the World Lung
Foundation and their many partners and colleagues
around the globe who continue to provide financial,
material, technical, and programmatic support.
Tobacco control is also increasingly important
in development conversations, occupying a
central spot in noncommunicable disease (NCD)
discussions in the United Nations and other fora.
Tobacco use has rightly been recognized as one of
the leading NCD risk factors that must be addressed
systematically, and is critical to the Sustainable
Development Goals that will be unveiled this year.
This is the good news. However, major challenges
lie ahead.
Although we are seeing smoking rates drop in
many high-income countries, the tobacco epidemic
continues to ravage low- and middle-income nations,
who are facing the brunt of the industry’s tactics.
This focus on addicting hundreds of millions in
“emerging markets” has led to alarming trends
in tobacco use in some countries. Unless we
redouble our efforts to fight the spread of tobacco,
100 million people will die from tobacco-related
disease between now and 2030—and up to one
billion could die this century. Notably, worrying
developments are occurring in Africa, where
current prevalence of tobacco use is still relatively
low. As a recent American Cancer Society report
stated, by 2100 “without action [against tobacco],
Africa will grow from being the fly on the wall to the
elephant in the room.”
We continue to confront an industry that constantly
changes and adapts its marketing strategies. The
burgeoning of new products, likely new portals
to tobacco use, is a salient example. Electronic
Nicotine Delivery Systems such as e-cigarettes
and “cigalikes” are challenging the tobacco
control community. Researchers have only just
started to measure their harm reduction potential
for individual smokers, and their public health
impact at the population level is still unclear. With
the aggressive marketing of these products in
yet-unregulated contexts in many countries, it is
unsurprising and concerning to see rapid uptake
among youth and emerging evidence of a “gateway”
effect to smoking conventional cigarettes. Prompt
regulation of these and other new products would
protect decades of progress in public health.
The industry also increasingly seeks to use
international economic agreements (e.g. the
World Trade Organization) and its near-unlimited
resources to deter countries from taking action
to protect their citizens’ health. With titanic legal
battles being waged on pack warnings from
Australia to Uruguay, and relentless tobacco
industry interference around the world, with this
Atlas we seek to involve new partners beyond our
traditional public health allies—not only from the
NCD community, but also experts on tax policy,
development, and human rights—whose interests
are dramatically affected by the tobacco epidemic
FOREWORDS
and its human toll.
Just as we develop a new Atlas every three years to
provide advocates, journalists, and policymakers
with clear, simple, graphic, and up-to-date
information, we seek also to arm these new allies,
not just because tobacco causes more disease and
death than any other agent, but also to shed light
on the industry’s malevolent actions against fair
trade, economic growth, the global climate, and the
overall health of the planet. No one is untouched by
the ravages of tobacco.
We want this document to be used, parsed, quoted,
defended, and debated, and ultimately to open
minds, to persuade the unconvinced about tobacco’s
toll, to spur untraditional allies to action, and to help
create opportunities to reverse the epidemic.
With this fifth edition of The Tobacco Atlas we
hope to reach many more people around the
globe, reinforcing a movement that is making great
strides but that cannot let down its guard for even a
second. The fate of the earth, a world that should be
free of tobacco industry exploitation, depends on it.
 6 7
WE BELIEVE THAT BY ENGAGING
A WIDE-RANGING ARRAY OF HEALTH,
LEGAL, ECONOMIC, DEVELOPMENT
AUTHORS’ PREFACE
AND ENVIRONMENTAL PROPONENTS
AND DEMONSTRATING HOW TOBACCO
USE AFFECTS THEIR ISSUES, WE CAN
AMPLIFY OUR IMPACT.
GET INVOLVED AT TOBACCOATLAS.ORG
$ +
USD1,000,000,000,000
Annual industry revenue
I
n 2000, while at a meeting of the WHO
Framework Convention on Tobacco Control’s
(WHO FCTC) Intergovernmental Negotiating
Body, founding authors Michael Eriksen and Judith
Mackay discussed the need for a global atlas on
tobacco. Having recently authored two health
atlases, Mackay thought it was an intriguing notion,
but was concerned there might not be enough
data for a true global atlas. After years of working
in tobacco control at the US Centers for Disease
Control and Prevention and the World Health
Organization (WHO), Eriksen was confident that
the data existed and that the real need was for
the data to be assembled in one accessible place,
presented in a colorful, graphic and readable
format, and disseminated widely. In 2002, WHO
published the first edition of The Tobacco Atlas.
In the subsequent 13 years, much has changed in
global tobacco control, and yet much has remained
the same. The WHO FCTC was unanimously
approved by the World Health Assembly in 2003
and signed by 168 member states, covering 90%
of the world’s population. WHO also developed
MPOWER, providing evidence-based best
practices. Countries have continued to adopt often
paradigm-shifting policies such as prohibiting
“light” cigarettes, implementing complete public
smoking bans, and introducing plain/standardized
tobacco product packaging. Philanthropists
Michael Bloomberg and Bill and Melinda Gates
have committed hundreds of millions of dollars to
support global tobacco control, which among many
efforts helped implement the Global Adult Tobacco
Survey (GATS) in 2007 to serve as a complement to
the existing Global Youth Tobacco Survey (GYTS).
In the United States in 2006, the tobacco industry
was found guilty of fraud and racketeering in one of
+ =
1,000,000,000 TRILLIONS MILLIONS
Adult smokers worldwide Cigarettes consumed annuallly Preventable deaths each year
the largest civil cases in history. In Europe, member Tobacco control lessons include the importance
countries have twice revised the wide-reaching of strategies that affect populations—not just
Tobacco Products Directive. individuals—such as the powerful role of policies
and litigation in disrupting the status quo. There
What has remained the same is that the tobacco
may be strategies that work in development, climate
industry continues to thrive with revenues
change, environmental protection, or poverty
approaching USD1,000,000,000,000 annually, with
reduction that could be extremely promising for
millions of deaths occurring each year among the
tobacco control. How can we share approaches
one billion adult smokers who consume trillions
and best work together to collectively advance the
of cigarettes annually. And today, after a century
human condition?
of harm, the tobacco industry is trying to re-invent
itself by selling purportedly less harmful products, In the first edition of The Tobacco Atlas, we wrote:
but in such a way as to maintain and expand
AUTHORS’ PREFACE
“The publication of this Atlas marks
nicotine addiction worldwide.
a critical time in the epidemic. We stand at
While progress is being made, the pace is too a crossroads, with the future in our hands.
slow and too many lives continue to be lost. As WE CAN CHOOSE TO STAND ASIDE; OR TO
we planned the fifth edition of The Tobacco Atlas,
TAKE WEAK AND INEFFECTIVE MEASURES;
we were driven not only by our sense of urgency
to continue to vigorously promote these proven OR TO IMPLEMENT ROBUST AND ENDURING
tobacco control strategies, but also to broaden the MEASURES TO PROTECT THE HEALTH AND
base of tobacco control and expand the number of
people who are willing to act.
WEALTH OF NATIONS.”
Four editions later—with the wonderful earlier
We believe that by engaging a wide-ranging array
contributions of Omar Shafey (2nd and 3rd
of health, legal, economic, development, and
editions) and Hana Ross (3rd and 4th editions)—
environmental proponents and demonstrating how
these words are as true today as they were then.
tobacco use affects their issues, we can amplify our
The founding authors, together with new authors
impact. Documenting the impact of tobacco use
Neil Schluger, Farhad Islami, and Jeffrey Drope,
and how it exacerbates mental health conditions,
substance abuse, diabetes, tuberculosis, HIV,
the American Cancer Society and the World
Lung Foundation are proud to present the fifth
poverty, and environmental degradation can help
triennial edition of The Tobacco Atlas, along with
enlist an increasing number of individuals and
the interactive www.tobaccoatlas.org website. We
institutions, thereby expanding our collective
hope this endeavor will accelerate global efforts to
spheres of influence.
reduce the harm caused by tobacco use and will
Not only do we hope to enroll a larger and robust engage new partners that will collectively advance
cadre of proponents concerned about tobacco global health.
control and urge them to action, we also hope to
share best practices and lessons learned.
 TA5_2015_WEB.pdf 1 3/12/15 11:51 AM
8 9
MICHAEL
ERIKSEN, SC.D.
Michael Eriksen is Regents’ Professor and founding
Dean of the School of Public Health at Georgia
State University. He is also director of Georgia State
University’s Tobacco Center of Regulatory Science
(TCORS) and the Center of Excellence in Health
Disparities Research (CoEx). Prior to his current
positions, Dr. Eriksen served as a senior advisor
to the World Health Organization in Geneva and
was the longest-serving director of the Centers
for Disease Control and Prevention’s Office on
Smoking and Health (1992–2000). Previously, Dr.
ABOUT THE AUTHORS
C
Eriksen was director of behavioral research at the
M M.D. Anderson Cancer Center. He has recently
Y
served as an advisor to the Bill & Melinda Gates
Foundation, the Robert Wood Johnson Foundation,
CM
the American Legacy Foundation, and the CDC
MY Foundation. Dr. Eriksen has published extensively
CY
on tobacco prevention and has served as an expert
witness on behalf of the US Department of Justice
CMY
and the Federal Trade Commission in litigation
K against the tobacco industry. He is editor-in-chief
of Health Education Research and has been
designated as a Distinguished Cancer Scholar by
the Georgia Cancer Coalition. He is a recipient of
the WHO Commemorative Medal on Tobacco or
Health, and a Presidential Citation for Meritorious
Service, awarded by President Bill Clinton.
Dr. Eriksen is past president and Distinguished
Fellow of the Society for Public Health Education,
and has been a member of the American Public
Health Association for over 40 years.
JUDITH
MACKAY, MBChB, FRCP
Dr. Mackay is a medical doctor based in Hong Kong
since 1967. She is senior adviser to World Lung
Foundation as part of the Bloomberg Initiative,
to the Bill and Melinda Gates Foundation, senior
policy adviser to the World Health Organization,
and director of the Asian Consultancy on Tobacco
Control. She holds professorships at the Chinese
Academy of Preventive Medicine, the University
of Hong Kong and Chinese University. She is a
Fellow of the Royal Colleges of Physicians of
Edinburgh and of London. After an early career as
a hospital physician, she moved to public health.
She has authored or co-authored ten health atlases,
published 200 papers, and addressed over 460
conferences on tobacco control. She has received
many awards, including the WHO Commemorative
Medal, Royal Awards from the UK and Thailand, the
Fries Prize, the Luther Terry Award for Outstanding
Individual Leadership, the US Surgeon General’s
Medallion, the Founding International Achievement
Award from the Asia Pacific Association for the
Control of Tobacco, and the Lifetime Achievement
Award from the International Network of Women
Against Tobacco. She was selected as one of
Time’s 60 Asian Heroes (2006) and one of Time’s
100 World’s Most Influential People (2007), the
British Medical Journal Lifetime Achievement
Award (2009), and a Special Award of Outstanding
Contribution on Tobacco Control (2014). She has
been identified by the tobacco industry as one of
the three most dangerous people in the world.
NEIL W.
SCHLUGER, MD
Dr. Schluger is Chief Scientific Officer of World
Lung Foundation as well as Chief of the Division
of Pulmonary, Allergy and Critical Care Medicine
at the Columbia University Medical Center,
and Professor of Medicine, Epidemiology and
Environmental Health Science at the Columbia
University College of Physicians and Surgeons
and Columbia’s Mailman School of Public Health.
Dr. Schluger’s career has focused on global
aspects of lung disease. He has written over 150
articles, chapters and books, and his work has
been published in The New England Journal of
Medicine, JAMA, The Lancet, and the American
Journal of Respiratory and Critical Care Medicine,
among other journals. He serves on the editorial
boards of The American Journal of Respiratory
and Critical Medicine, the Annals of the American
Thoracic Society, and Chest. He also currently
serves as the Chairman of the Steering Committee
of the Tuberculosis Trials Consortium (TBTC),
an international research consortium funded
by the United States Centers for Disease Control
and Prevention (US CDC). He is also the founder
and director of the East Africa Training Initiative,
a World Lung Foundation-sponsored project to
train pulmonary physicians in Ethiopia. Under this
initiative, expert faculty are in residence in Addis
Ababa to train Ethiopian physicians in order to
develop a cadre of specialists to care for patients
and develop public health approaches to lung
health. This program is the first of its kind in
East Africa.
FARHAD ISLAMI
GOMESHTAPEH, MD, PhD
Dr. Islami is the director of interventions in the
Surveillance and Health Services Research
group at the American Cancer Society. His work
focuses on investigating the associations between
tobacco or other modifiable risk factors and
cancer and evaluating the effects of interventions
for cancer prevention, including tobacco control,
in reducing cancer morbidity and mortality.
Dr. Islami has published more than 90 articles
in peer-reviewed journals, including studies of
the association of tobacco use with cancer and
other chronic diseases, including cardiovascular
and gastrointestinal diseases. Several of these
publications studied long-term health effects of
tobacco products other than cigarettes, and studies
conducted by Dr. Islami and colleagues in Iran
and India have provided the strongest evidence so
far for associations between waterpipe smoking
and esophageal and gastric cancers. Dr. Islami
was a member of the International Agency for
Research on Cancer (IARC) secretariat in the IARC
Monographs Volume 100: A Review of Human
Carcinogens Part E, Lifestyle Factors, and the
IARC Handbooks volume 14, The Effectiveness of
Tax and Price Policies for Tobacco Control. He is
also involved in studies of cancer disparities and
distribution of risk factors of cancer, including
tobacco use, in various socioeconomic groups.
Dr. Islami is the co-chief editor of Frontiers in
Cancer Epidemiology and Prevention, a specialty
section of Frontiers in Oncology. He earned his MD
from Tehran University of Medical Sciences, Iran,
and a PhD in Epidemiology from the King’s College,
University of London, UK.
JEFFREY
DROPE, PhD
Dr. Drope is the Managing Director of the Economic
and Health Policy Research program at the
American Cancer Society. His research focuses
on the nexus of public health (including tobacco
control, harmful alcohol use, nutrition, and access
to care) and economic policymaking, especially
trade, investment and taxation. His work seeks to
explain rigorously how countries can integrate the
two different policy areas in proactive ways that
engender both improved public health outcomes
and economic prosperity. Recent projects have
ABOUT THE AUTHORS
received support from major funding organizations,
including the National Institutes of Health (National
Institute for Drug Abuse, Fogarty International
Center and the National Cancer Institute), the Johns
Hopkins Bloomberg School of Public Health (with
funds from the Bloomberg Initiative to Reduce
Tobacco Use), the National Science Foundation,
and the International Development Research
Centre. In addition to extensively publishing in
these substantive areas, he continues to participate
actively in capacity-building efforts on these
issues across the globe, working with major inter-
governmental organizations, non-governmental
organizations, national governments and many
institutions of higher learning. Most recently,
Dr. Drope is spearheading a multi-country initiative
to illuminate the economics of tobacco farming in
low- and middle-income countries in Africa and
Asia. He is also an associate professor of political
science at Marquette University, where he regularly
teaches and mentors students on global health and
international development.
 11

The Tobacco Atlas is the product of the

combined effort of many dedicated people.
Four individuals played vital roles as contributing authors and editorial/data coordinators:
Ellie Faustino, Alex Liber, Michal Stoklosa, and Carrie Whitney. Christina Curell, Sun Young Jeong, and Xuanzi Qin
played key roles as primary research assistants. For additional content and editorial support, we thank
Samantha Bourque, Emily Cahill, Lauren Clark, Amanda Gailey, and Sarita Pathak.

We sincerely thank the American Cancer Society and the World Lung Foundation for their unwavering
support for the fifth edition of The Tobacco Atlas. We especially thank Jacqui Drope for her outstanding
organizational role, as well as Sandra Mullin (WLF), Elizabeth Ward (ACS) and Sally Cowal (ACS) for their
leadership. Additionally, without the high-level support from ACS’ Otis Brawley and Greg Bontrager,
the project would not have come to fruition. We thank Ahmedin Jemal for providing overall ideas
about the content of the Atlas in its early stages, and Hana Ross for her early work on the project.
Rebecca Perl provided valuable content input on many parts of the Atlas. We thank Bob Land for his

ACKNOWLEDGMENTS
expert and timely indexing work. We also received crucial organizational support from Chris Frye,
Kerri Gober, Lauren Rosenthal, Melissa Wilks and Shacquel Woodhouse, and relied upon Vanika Jordan for
printing and publication expertise.

We are grateful to Steve Hamill at WLF for spearheading the website, and playing major roles in broader
communication and promotion strategy. We thank Chun-Yu Huang for ongoing support of the online
version and Elizabeth Mendes for helpful input on the website process. Also for communications and
promotion efforts, we thank Tracie Bertaut, Tracey Johnston, and Tara Peters.

For their advice on specific chapters and/or providing data, there are a number of individuals that
we wish to thank. For Consumption, Marie Ng and her IHME colleagues, Michael Thun, Linda Andes,
Krishna Palipudi, and Deliana Kostova; for Smokeless Tobacco, Stephen Stanfill and Pankaj Chaturvedi; for Water
Pipes, Orna Baron-Epel; for Legal Challenges & Litigation, Patricia Lambert and the International Legal
Consortium (ILC) at the Campaign for Tobacco-Free Kids; for WHO FCTC, Vera Luiza da Costa e Silva and
Douglas Bettcher; for Warnings & Packaging, Rob Cunningham; for The Endgame, Mira Aghi, Simon Chapman,
Greg Connolly, Yul Doretheo, Sheila Duffy, J.R. Pinky Few, Becky Freeman, Joe Gitchell, Prakash Gupta,
Marita Hefler, Ei Skye Kimura-Paul, Jon Krueger, Eric LeGresley, Ruth Malone, Wasim Maziak and Martin Raw;
for Health Consequences, Roberta Savli and her colleagues at the European Federation of Allergy and
Airways Diseases Patients' Associations; for Nicotine Delivery Systems, Royal Kai Yee Law; and for Male
Smoking and Female Smoking, IHME. For mapping assistance, we thank Liora Sahar and the Statistics
and Evaluation Center at ACS, and for access to the 2014 WHO FCTC reports, we thank Tibor Szilagyi.

For their superlative creative force to present these important topics in original and effective ways,
we are deeply indebted to the Language Dept. team: Jenn Cash, Tanya Quick, Leah Koransky, Lizania Cruz,
Angela Choi, and Niquita Taliaferro. The project is much richer and better for their contributions.
Similarly, the project has benefitted greatly from the translation team at Alboum & Associates.

Last, and certainly not least, we thank our tireless and exacting managing editor, John M. Daniel.
 BODY AND MIND
People living with
mental illness are nearly
twice as likely to smoke
as other persons.

Tobacco damages not only the whole person

but also the whole planet.

HARM
ENVIRONMENT
Cigarette butts are the
most commonly discarded
piece of waste worldwide.
It is estimated that 1.69
billion pounds of butts wind
up as toxic trash, which is
roughly equivalent to the
weight of 177,895 endangered
African elephants.

DEVELOPMENT
Nearly three-quarters of

T
he harm caused by tobacco use isn’t limited to lung cancer, Brazilian smokers report
spending money on
heart disease, and emphysema. Tobacco use exacerbates cigarettes instead of
other non-communicable diseases, mental illnesses and household essentials.
substance abuse problems, as well as damages the environment
and undermines human development.
 14 MALE DEATHS FEMALE DEATHS 15

Chapter Percent of male deaths due to smoking: 25%+ 15%+ Percent of female deaths due to smoking:

01 all ages, 2010

Male deaths 25%
and greater: 2010
Female deaths 15%
and greater: 2010
all ages, 2010

DPR KOREA 34% DPR KOREA 22%

TURKEY 31% BRUNEI 21% 0.0—4.9%
BOSNIA AND
30% DENMARK 20%
HERZEGOVINA
ALBANIA 19% 5.0—9.9%
ARMENIA 30%
LEBANON 18% 10.0—14.9%
GREECE 30%
BOSNIA AND
MACEDONIA 29% HERZEGOVINA 17% 15.0—19.9%
BELARUS 28% CUBA 17% 20.0—24.9%
RUSSIA 28% UNITED KINGDOM 16%
POLAND 28% USA 16%
25.0—100.0%
UKRAINE 27% SERBIA 16% NO DATA
GEORGIA 27% IRELAND 15%
NETHERLANDS 26% FYR MACEDONIA 15%
LATVIA 26% ICELAND 15%
MONTENEGRO 26%
BELGIUM 25%
HUNGARY 25% From 1964 to 2014,

TOBACCO CONTROL
PREVENTED 8 MILLION
PREMATURE DEATHS
in the United States alone. clipboard: Industry Says

CALL TO ACTION DEATHS BY REGION

G
lobally, tobacco use killed 100 million people in the never smoked or who quit smoking after being diagnosed
20th century, much more than all deaths in World Wars with the disease.
DEATHS

Number of smoking-related deaths in the I and II combined. Tobacco-related deaths will number “Smoking is a cause of real and
Even for those who smoke 10 or fewer cigarettes per day,
As tobacco use is the most common preventable cause of death, governments INSET
World Health 1: DEATHS
Organization regions: allBY WHO
ages, 2010 REGION around 1 billion in the 21st century if current smoking serious diseases, cancer, particularly
life expectancy is on average 5 years shorter and lung
must implement effective policies to prevent tobacco use (reducing initiation MALE DEATHS   
FEMALE DEATHS = 100,000 PEOPLE patterns continue. Among middle-aged persons, tobacco cancer of the lung, stroke, heart
cancer risk is up to 20 times higher than in never-smokers. attack, and respiratory disease such
and promoting cessation) and involuntary exposure to tobacco smoke in order use is estimated to be the most important risk factor for
Those who smoke fewer than 4 cigarettes per day are at up as bronchitis and emphysema.
to save lives. Death registries should collect data on tobacco use status to premature death in men and the second most important
to 5 times higher risk of lung cancer. As there is neither a
For a lifetime smoker, about

help assess and monitor national tobacco-related death rates. risk factor in women (following high blood pressure) in
safe tobacco product, nor a safe level of tobacco use, the HALF CAN EXPECT
2010–2025. To understand better how to address this issue,
1.2 —
best way to prevent tobacco-related deaths is to avoid using TO DIE PREMATURELY
tobacco deaths need to be monitored closely, and this can clipboard:
benefit from Industry Says quote: allies say
DISPARITY IN TOBACCO DEATHS be done best if death registries systematically collect data
it. Current smokers greatly quitting smoking as a result of their cigarette smoking.”
HARM

(see Chapter 24: Quitting). — DAVID O'REILLY, Scientific Director,

1.0 — on tobacco use status. Currently, data on tobacco deaths British American Tobacco, 2014
Percentage of smoking-related deaths in mixed-race and white men in South Africa: by cause of death,
mostly come from individual epidemiological studies.
ages 35–74 years, 1999–2007
 MIXED RACE   WHITE
0.8 —
Tobacco use increases the risk of death from many diseases;
DEATHS BY COUNTRY INCOME
MILLIONS OF DEATHS

cancer, ischemic heart disease, chronic obstructive “Estimates from patients at our
LUNG CANCER pulmonary disease (COPD), and stroke are the most common P
PU
Proportion of O
U O R
RG EEM
MO OCCN NII Y
Gsmoking-related
global B
B SSH
Ydeaths HinTThigh-,
A
AEED D ::3
3 TTEESSN
NII oral cancer ward indicate that

UPPER AERODIGESTIVE CANCER

0.6 — ones. Lung cancer is the leading cause of cancer death middle-, and low-income countries: all ages, 2010 80—90%
worldwide, killing approximately 1.4 million people globally LOW INCOME   
  MIDDLE INCOME   
HIGH INCOME

in 2008. At least 80% of lung cancer deaths are attributable

OF PREVENTABLE CANCERS
TUBERCULOSIS OF THE NECK, HEAD,

MALES
0.4 — to smoking. Even in Africa, where smoking prevalence

COPD
has increased only recently, lung cancer is now the most AND THROAT ARE
common cause of cancer death in men.
TOBACCO-RELATED.

FEMALES
0.2 —
ISCHEMIC HEART DISEASE Not only does tobacco use cause disease, but patients with More than one million Indians die
prematurely from tobacco-related
|

70%
|

60%
|

50%
|

40%
|

30%
|

20%
|

10%
|

0
|

10%
|

20%
|

30%
|

40%
|

50%
|

60%
|

70% coronary heart disease, cancer, or several other diseases disease each year.”
0— who continue smoking are also at significantly higher risk — PANKAJ CHATURVEDI, cancer specialist at
Tobacco-related deaths are more common in people with lower socioeconomic status. In South Africa, More than two thirds of tobacco deaths occur in low- and middle-
mixed-race men tend to be of lower socioeconomic status than white men. AFRO AMRO EMRO EURO SEARO WPRO of death compared to patients with the same disease who income countries.
Mumbai's Tata Memorial Hospital, India, 2014
 16 CALL TO ACTION SMOKING AND TB 17

Chapter
Providers must routinely integrate smoking cessation services SMOKING AND ALCOHOL ABUSE Smoking will prevent countries from meeting their
tuberculosis mortality Millennium Development Goal. Mortality rate goal per 100,000

02 into TB, HIV, alcohol and mental health care. Smoking status for hazardous drinking:
percent of hazardous drinking among different types of smokers,
EUROPE

WITHOUT TOBACCO
MORTALITY RATE GOAL:
6
WITH TOBACCO
and estimated year of achievement
with/without tobacco.

SMOKING AND HIV

USA, 2002
2024 2048
HAZARDOUS DRINKING
DEFINITIONS
Life years lost due to smoking: Danish cohort, ages 35–80, 1995–2000
> 14 drinks per week or
MEN
5+ drinks per day at least once in the past year

LOST YEARS OF LIFE WOMEN 5.1

> 7 drinks per week or
4+ drinks per day at least once in the past year AMERICAS MORTALITY RATE GOAL: EASTERN MORTALITY RATE GOAL: WESTERN MORTALITY RATE GOAL:
NEVER SMOKERS WITH HIV 4 MEDITERRANEAN 17 PACIFIC 17
5.1 WITHOUT TOBACCO
2006
WITH TOBACCO
2029
WITHOUT TOBACCO
2014
WITH TOBACCO
2062
WITHOUT TOBACCO
2009
WITH TOBACCO
NEVER
NEVER-SMOKERS WITH HIV
12.3 12.3
SMOKERS WITH HIV
SMOKERS WITH HIV

| | | | | | | | | | | | | | | |

65 70 75 80
clipboard: Industry Says quote: allies
80 say
SOUTH-EAST
| | | | | | | | | | | | | | | |
AVG. LIFE EXPECTANCY
65 70 75 AFRICA MORTALITY RATE GOAL: MORTALITY RATE GOAL:
16 ASIA 24
Smokers lost more than twice as many yearsAVG.
of life
LIFE than did non-smokers.
EXPECTANCY WITHOUT TOBACCO WITH TOBACCO WITHOUT TOBACCO WITH TOBACCO
clipboard: Industry Says quote: allies say NEVER NEVER 2007 2033

Although the high smoking rates among HIV-infected patients worsen mortality outcomes,
COMORBIDITIES

THE TOBACCO INDUSTRY BOASTS ABOUT ITS HISTORY AND SUPPORT FOR THE
Never-smoker Former smoker Daily smoker
NUTRITIONAL NEEDS OF THE HIV-INFECTED COMMUNITY “Tobacco control is
through providing grants to HIV/AIDS organizations. 19.2% 22.0% 43.4% tuberculosis control.’’
“It is with great pride that we have partnered with numerous organizations within the
HIV/AIDS community to bring attention and additional resources to bear in this terrible disease.”
Current smokers are more likely to be hazardous drinkers than ­—STANTON A. GLANTZ, PhD,
Professor of Medicine, University of California, San Francisco,
are both never-smokers and former smokers, and at higher risk of USA, 2011
—PHILIP MORRIS, HIV/AIDS Grantmaking program, 1997
adverse effects of both smoking- and alcohol-related diseases.

SMOKING AND MENTAL ILLNESS

MENTAL ILLNESSES SURVEYED
Smoking prevalence among people with lifetime mental
BIPOLAR DISORDER
illnesses or psychological distress: USA, 2007
SCHIZOPHRENIA
C
quote:ertain
alliespopulations smoke at higher rates than the Smokers are more likely to consume excessive amounts
clipboard: Industry Says say
general population, including those who use alcohol to of alcohol, and smoking may independently affect an
excess, or have mental illness, or who are affected by individual’s propensity to abuse alcohol and vice versa
DEMENTIA
other diseases such as tuberculosis (TB) and HIV/AIDS. As SMOKING AND ALCOHOL ABUSE . These people are at risk of adverse
PHOBIAS/FEARS
harm 1 harm 2

 NEVER SMOKER  FORMER SMOKER  CURRENT SMOKER a result, smoking has a tremendous impact on several other effects of both tobacco and alcohol-related diseases.
ATTENTION DEFICIT/HYPERACTIVITY SERIOUS PSYCHOLOGICAL DISTRESS grave public health crises.
Mental health disorders are also tied closely to tobacco use.
IN ITS EFFORTS Most cases of TB occur in places where tobacco use is Persons with mental illness have high smoking rates, and
HARM

INDIA
TO UNDERMINE extremely common or rising rapidly. China and India alone, for certain illnesses, such as anxiety disorders, tobacco use
Smoking increases
18 . 3 % 31 . 9 % 41.8% 6 1 . 4% AND DIMINISH THE which have high smoking rates, account for 40% of all cases may cause or worsen the problem SMOKING AND MENTAL ILLNESS.
the risk of poor
7%
harm 1 harm 2

10.
of tuberculosis in the world. A recent study showed that 21% Additionally, smoking is associated with increased severity
DEVASTATING EFFECTS OF of tuberculosis cases in adults were attributable to tobacco. of symptoms of schizophrenia and bipolar disorder.
outcomes from
SMOKING ON HEALTH, As most patients with TB are relatively young, excess
TB infection. In
Persons with mental illness die disproportionately from
India, TB is the
21 . 0 %

British American Tobacco has

morbidity and mortality from tobacco-related tuberculosis smoking-related diseases. In California, USA, approximately
argued that “there are other
takes a toll on persons in their most economically- half of deaths among people with mental illness were due leading cause of
3 2 . 4%

issues [besides smoking &

health] which we believe should productive years SMOKING AND TB. to diseases caused by smoking. smoking-associated
be of greater significance to harm 1 harm 2
excess deaths.
%

27.

%
3 .4

2 the PRC [China] and the WHO HIV-infected persons are even more susceptible to the
AMONG INDIAN MEN
9

% 4 4.
7%
6 0.6 25. 8 %
including hepatitis which is dangers of tobacco than are persons without HIV infection.

NO MENTAL ILLNESS 1 MENTAL ILLNESS 2 MENTAL ILLNESSES 3+ MENTAL ILLNESSES

very prevalent in China and a
major health concern.” In settings where treatment for HIV infection has become AGES 30–69,
—British American Tobacco, 1997 widely available, HIV-infected tobacco smokers are losing more 38% OF TB DEATHS ARE
life-years to smoking than to HIV infection itself SMOKING AND HIV.
Current smoking prevalence increased with greater numbers of mental illness, ranging from harm 1 harm 2 ATTRIBUTED TO SMOKING.
18.3% for people with no illness to 61.4% for people with three or more mental illnesses.
 18 CALL TO ACTION
Chapter
Governments should strive to prevent people from
03 starting tobacco use because it is the best way to avoid
the consequences tobacco inflicts on human health.
HARM FROM TOBACCO
Tobacco causes disease and
disability to almost every organ.
5 TEETH
Periodontal disease
(gum disease, gingivitis,
periodontitis)
Loose teeth, tooth loss
Root-surface caries, plaque
Discoloration and staining
HEALTH CONSEQUENCES
Gastric, colon and pancreatic cancer
Abdominal aortic aneurysm
Peptic ulcer (esophagus, stomach,
upper portion of small intestine)
Possible increased risk of breast cancer
Infertility (sperm deformity, loss of
15
Peripheral
vascular disease,
poor circulation
HARM
(cold fingers)
19 LEGS AND FEET
Peripheral vascular disease,
cold feet, leg pain
and gangrene
Deep vein thrombosis
Cataracts
Blindness (macular degeneration)
Stinging, excessive tearing and blinking
6 MOUTH AND THROAT
Cancers of lips, mouth,
throat, larynx and pharynx
Sore throat
Impaired sense of taste
Bad breath
10 CHEST AND ABDOMEN
Esophageal cancer
11 LIVER
Liver cancer
12 MALE REPRODUCTION
motility, reduced number)
Impotence
Prostate cancer death
HANDS 16 SKIN
Psoriasis
Loss of skin tone,
wrinkling,
premature aging
18 WOUNDS AND SURGERY
Impaired wound healing
Poor postsurgical recovery
Burns from cigarettes and
from fires caused by cigarettes
20 CIRCULATORY SYSTEM
Buerger's disease
(inflammation of arteries,
veins and nerves
in the legs)
Acute myeloid leukemia
BRAIN CELLS 19
SMOKING DURING PREGNANCY SMOKING AND THE LUNG
Tobacco smoke can affect brain cells adversely. Several studies have shown
ATROPHY OF GREY MATTER IN SMOKERS’ BRAINS,
which may make them more susceptible to dementia. Also, children born to
mothers who smoked during pregnancy have neural alterations similar to those
in children with attention-deficit/hyperactivity disorder.
Health risks to mothers and children associated
with maternal smoking CONSTITUENTS OF TOBACCO SMOKE HAVE MANY
ADVERSE EFFECTS ON THE LUNG
MOTHER FETUSES, INFANTS, CHILDREN
For example, as scavenger cells engulf
1 EYES 2 BRAIN AND PSYCHE 3 HAIR 4 NOSE
Placental abruption
Placenta previa
Stunted gestational
development
particles of impurities and debris from
tobacco smoke, the color of smokers’
3
Premature rupture Stillbirth lungs becomes gray-black over time.
Stroke Odor and Cancer of nasal cavities
2 (cerebrovascular accident) discoloration and paranasal sinuses of membranes Sudden infant death
Premature birth syndrome (SIDS)
Addiction/withdrawal Chronic rhinosinusitis
1 7 7 EARS Reduced lung function and HEALTHY TOBACCO
Altered brain chemistry Impaired sense of smell Spontaneous abortion/ HUMAN LUNG SMOKER’S LUNG
4 Hearing loss miscarriage impaired lung development
Anxiety about tobacco’s
health effects Ear infection Ectopic pregnancy Asthma and bronchitis
5
exacerbation
6
8 LUNGS 9 HEART Acute lower respiratory CLEFT PALATE/LIP
infection (bronchitis and
Lung, bronchus and Coronary thrombosis Maternal tobacco use and cleft palate/lip
pneumonia)
tracheal cancer (heart attack)
Respiratory irritation
Chronic obstructive Atherosclerosis (damage
8
pulmonary disease (COPD) and occlusion of coronary (cough, phlegm, wheeze) MATERNAL SMOKING INCREASES RISK OF
9
CLEFT PALATE AND CLEFT LIP IN BABIES
and emphysema vasculature) Childhood cancers
Chronic bronchitis Orofacial cleft Risk of cleft lip is approximately
30% higher in children born to women who
Respiratory infection Possible increased risk
smoke during pregnancy. Heavy maternal
11 (influenza, pneumonia, of allergic diseases
10 tuberculosis) smoking (≥25 cigarettes/day) can increase risk
Possible increased risk of bilateral cleft palate in newborns four-fold.
Shortness of breath, asthma of learning disability
Due to their limited resources for surgical
Chronic cough, excessive and attention-deficit/
repairs, children born with cleft palate/lip in low-
sputum production hyperactivity disorder
and middle-income countries can be at higher
14 risk of death for not being adequately treated in
a timely manner. Surgeries at older ages can be
12 13
13 FEMALE REPRODUCTION 14 URINARY SYSTEM
associated with worse outcomes. clipboard: Industry Says
Cervical and ovarian cancer Bladder, kidney, and
Premature ovarian failure, ureter cancer
early menopause
T
15 Reduced fertility obacco smoke has more than 7000 chemicals, hundreds Several tobacco products have been introduced that
Painful menstruation of which are toxic and negatively affect almost all organ claim to reduce harm, but some of them have already
systems HARM FROM TOBACCO. Children born to women who shown harmful effects. The World Health Organization has PHILLIP MORRIS
harm 1 harm 2 “Philip Morris USA agrees with
smoke during pregnancy are at higher risk of congenital classified smokeless tobacco as an established cause of the overwhelming medical and
16 17 SKELETAL SYSTEM disorders, cancer, respiratory disease, and sudden death cancers of the mouth, esophagus, and pancreas. Smokeless scientific consensus that
17 Osteoporosis harm 1
SMOKING DURING PREGNANCY
harm 2
CLEFT PALATE/LIP . Smokers and
harm 1 harm 2
tobacco, water pipes, and low-tar cigarettes expose CIGARETTE SMOKING
non-smokers who are exposed to secondhand smoke are users to carcinogens that are present in cigarette smoke.
Hip fracture CAUSES LUNG CANCER,
at higher risk of a long list of serious health conditions, Preliminary studies have shown that e-cigarette smokers
Susceptibility to
back problems including cancer and pulmonary and cardiovascular may be exposed to some harmful compounds or suffer HEART DISEASE, EMPHYSEMA
and other serious diseases in smokers.
Bone marrow cancer diseases. Both active and secondhand smoking increase some acute symptoms, but overall, e-cigarettes appear to Smokers are far more likely to
develop such serious diseases
be less harmful than traditional cigarettes as they do not
18
Rheumatoid arthritis cardiovascular disease risk by promoting atherosclerosis, clipboard: Industry Says quote: allies say
than non-smokers.”
blood clot formation, and several other mechanisms. There involve combustion. Nevertheless, their overall impact on ­— Philip Morris USA Website, 2014
Exposure to secondhand
smoke or active smoking
are at least 69 carcinogens in tobacco smoke, which can public health is unclear (see Chapter 12: E-cigarettes).
IMMUNE SYSTEM causes the cause many types of cancer. Smoking increases risk of death As there is no safe tobacco product, the best way to
19
Impaired resistance to infection
THICKENING OF from ischemic heart disease by more than 2.5-fold and prevent tobacco-associated harms is to avoid starting
Possible increased risk of death from lung cancer and chronic obstructive pulmonary use (or for tobacco users to quit).
allergic diseases ARTERIAL WALLS disease by 20-fold. “I felt that I only really had the
(an early stage of Due to limited access to care for early detection and
20
atherosclerosis) starting as Smoking also causes common health problems that may treatment of tobacco-related diseases, individuals
CHOICE BETWEEN GIVING
OTHERS young as 15 years of age.
not be associated with immediate serious danger, but that with low socioeconomic status or in low- and middle- UP SMOKING AND GIVING
Diabetes
Sudden death
carry substantial costs at the population level. For example, income countries are likely to suffer more from the UP BREATHING.”
among 18–64-year-olds in the USA in 2008, 16% of current harms of tobacco. ­— MICHAEL WILKEN, a COPD patient,
European Federation of Allergy and Airways
smokers had self-reported poor oral health status, which was Diseases Patients Associations’
4 times greater than for never-smokers. COPD Working Group, 2011
 20 CALL TO ACTION work rest home
21

SECONDHAND SMOKE PREVALENCE EXPOSURE BY

China 2010 63.3 88.5 67.3 Based on a survey in 15 low- and middle-
Chapter Bangladesh 2009 62.2 79.7 54.9 income countries in 2008–2011, people are
Smoke-free legislation must be enacted to reduce involuntary exposure to tobacco smoke,
04
Egypt 2009 59.9 72.7 62.5

especially
clipboard:in children.
Industry People
Saysshould be informed about the
quote: allies sayrisks of secondhand smoke and
Viet Nam 2010
Greece 2013
55.9
52.3
84.9
72.2
73.1
Secondhand
65.7 smoke exposure (%): in adults age ≥ 15, 61% MORE LIKELY TO MAKE THEIR SOCIOECONOMIC
the potential harms of thirdhand smoke. Indonesia 2011
Malaysia 2011
51.3
39.8
85.4
71
78.4 Adult Tobacco Survey, 2008–2013
Global
38.4
HOMES SMOKE-FREE VOLUNTARILY STATUS
Turkey 2008 37.3 55.9  56.3
WORK Among those who work outside of the home who usually work indoors or both indoors and outdoors if smoking in workplace and
Russian Federation 2010 34.9 78.6  34.7
RESTAURANTS Among those who visited restaurants in the past 30 days public place is banned.

HARMS Romania 2011

Poland 2010
China 2010
Ukraine 2010
work 34.2
33.6
63.3
33.1
rest 86.6 home 35.4
52
88.5
64.1
 HOME
44.2
67.3
23.5
Somebody smokes in the home at least monthly
Voluntary smoking ban at home
by education level:
Bangladesh2009
Philippines 2009 62.2
32.6 79.7
33.6 54.9
54.4
WORKPLACE 80%— Guangdong, China, 2010
One of the statements that Level of evidence for harms caused by secondhand smoke in children and adults Egypt 20092012
Argentina 59.9
31.6 72.7
23.2 33
80%­—
62.5 NO BAN   
  PARTIAL BAN*   
FULL BAN
Viet Nam 2010
Thailand 2011 55.9
30.5 84.9
46.9 73.1
36 60%— 60%—
tobacco companies were required *Partial ban: smoking was allowed in certain
to publish in the United States
SUFFICIENT EVIDENCE SUGGESTIVE EVIDENCE Greece
India 2013
2009 52.3
29.9 72.2
47.8 65.7
40 areas and/or at certain times only.
Indonesia
Brazil 20082011 51.3
23.3 85.4
31.7 78.4
27.9
40%­— 40%—
(newspapers, TV, their websites, Malaysia2009
Mexico 2011 39.8
18.6 71
29.6 38.4
17.3
and on cigarette packs) after a Turkey 2008
Nigeria 2012 37.3
17.3 55.9
29.3 56.3
6.620%— 20%—
6% 81%
federal court in 2012 concluded Russian Federation
Uruguay 2009 2010
work 34.9
16.5 rest 78.6 home 34
4.4 34.7
Romania 2011 34.2 86.6 35.40%— 0%—
that the companies “deliberately Qatar 2013 12 25.9 16.8
Poland
China 2010
2010 33.6
63.3 52
88.5 44.2
67.3

13 %
deceived the American public:” Panama 2013 5.6 12.4 4.4 RESTAURANTS
| | | | | | | | | | | | | | | | | | | | | |
Ukraine
Bangladesh20102009 33.1
62.2 64.1
79.7 23.5
54.9

RUSSIAN FED.
2010

2009

2012

2009

2008

2012

2009

QATAR
2013

PANAMA
2013
CHINA

BANGLADESH

EGYPT
2009

VIET NAM
2010

GREECE
2013

2011

MALAYSIA
2011

TURKEY
2008

2010

ROMANIA
2011

2010

2010

2009
INDONESIA

POLAND

UKRAINE

PHILIPPINES

ARGENTINA

THAILAND
2011

INDIA

BRAZIL

MEXICO
2009

NIGERIA

URUGUAY
“THERE IS NO SAFE Philippines
Egypt 2009 2009
Argentina
Viet Nam 20102012
32.6
59.9
31.6
55.9
33.6
72.7
23.2
84.9
54.4
62.5
33
80%­—
73.1
80%—

PREVALENCE (%)
ADULTS Coronary Lung cancer Reproductive Chronic Atherosclerosis
LEVEL OF EXPOSURE TO artery disease effects in women obstructive
Thailand
Greece
India
Indonesia
2011
2013
20092011
30.5
52.3
29.9
51.3
46.9
72.2
47.8
85.4
36
65.7
40
60%—
78.4
60%—

40%—
Brazil
Malaysia2008
2011 23.3
39.8 31.7
71 27.9
38.4

y Says
SECONDHAND SMOKE.”
quote: allies say
pulmonary Mexico
Turkey 2008
2009 18.6
37.3 29.6
55.9
40%­—
17.3
56.3
20%— 20%—
disease, chronic Nigeria
Russian 2012
Federation 2010 17.3
34.9 29.3
78.6 6.6
34.7
Breast cancer, respiratory
Uruguay
Romania 2009
Qatar
Poland2013
2011
2010
16.5
34.2
12
33.6
4.4
86.6
25.9
52
34
35.4
16.8
44.2
0%— WORK 0%—
preterm delivery symptoms, Panama 2013
Ukraine 2010 5.6
33.1 12.4
64.1 4.4
23.5 PRIMARY SCHOOL OR LESS
Philippines 2009 32.6 33.6 54.4 HOME 80%—
asthma, 80%­— | | | | | | | | | | | | | | | | | | | | | |

Cancer2012
Argentina of the nasal 31.6 23.2 33

RUSSIAN FED.
2010

2009

2011

2010

2010

2009

2012
CHINA

BANGLADESH

EGYPT
2009

VIET NAM
2010

GREECE
2013

MALAYSIA
2011

TURKEY
2008

2010

ROMANIA
2011
INDONESIA

POLAND

UKRAINE

PHILIPPINES

ARGENTINA

THAILAND
2011

2009
INDIA

BRAZIL
2008

MEXICO
2009

2012
NIGERIA

URUGUAY
2009

QATAR
2013

PANAMA
2013
impaired lung 70 %
SECONDHAND SMOKE

Thailand 2011 30.5 46.9 3660%— 60%—

8%
Stroke Nasal irritation sinus, pharynx,
function India 2009 29.9 47.8 40
and
Brazil larynx
2008 23.3 31.7 27.9
40%­— 40%—
In 2007, South Australia
Mexico 2009 18.6 29.6 17.3
became the first Australian state Nigeria 2012 17.3 29.3 6.620%—
20%—
to ban smoking in cars in which Uruguay 2009 16.5 4.4 34
children were traveling. Qatar 2013 12 25.9 16.8
0%—
| | | | | | | | | | | | restaur | | | | | | | | | |
0%—

22%
“While it is an adult's right to Panama 2013 5.6 12.4 4.4

RUSSIAN FED.
CHINA

BANGLADESH

EGYPT

NAM

GREECE

INDONESIA

MALAYSIA

TURKEY

ROMANIA

POLAND

UKRAINE

PHILIPPINES

ARGENTINA

THAILAND

INDIA

BRAZIL

MEXICO

NIGERIA

URUGUAY

QATAR

PANAMA
| | | | | | | | | | | | | | | | | | | | | |

RUSSIAN FED.
2010

2009

2010

2010

2009

2012
CHINA

BANGLADESH

EGYPT
2009

NAM
2010

GREECE
2013

2011

MALAYSIA
2011

TURKEY
2008

2010

ROMANIA
2011
INDONESIA

POLAND

UKRAINE

PHILIPPINES

THAILAND
2011

2009

2012

QATAR
2013

PANAMA
2013
ARGENTINA

INDIA

BRAZIL
2008

MEXICO
2009

NIGERIA

URUGUAY
2009
choose to smoke and expose

VIET
themselves to all the associated

VIET
and well-known health risks,
Learning
disability and
THIS BAN AIMS TO PROTECT CHILDREN Sudden Infant
Death Syndrome
Impaired lung
function; lower
Middle ear
disease
attention deficit/
Asthma,
tuberculosis
Smoking bans in public places have a major effect on reducing exposure to secondhand smoke (see Chapter 23: Smoke-Free).
ATTENDED SECONDARY SCHOOL
For example, Uruguay adopted comprehensive smoke-free national legislation in 2006. Air nicotine concentrations in public
CHILDREN WHO COULD (SIDS), low birth respiratory illness;
hyperactivity
places dropped by 90% in Uruguay from 2002 to 2007.
disorder Allergic diseases home
NOT OTHERWISE PROTECT weight respiratory
(including rhinitis,
56%

E
symptoms, e.g.
THEMSELVES.” cough, wheeze, dermatitis, xposure to secondhand smoke can cause many of the multiunit buildings—even if nobody smokes in one's own

19 %
breathlessness food allergy), same diseases as active smoking. It increases the risks of apartment but people smoke elsewhere in the building.
—KATY GALLAGHER, Chief Minister
of the Australian Capital Territory lymphoma contracting lung cancer by 30% (small cell lung cancer The health effects of exposure to vapor from e-cigarettes are
leukemia
by 300%) and coronary heart disease by 25%. Exposure to currently unknown, but several countries have included or
secondhand smoke killed more than 600,000 non-smokers are considering the inclusion of e-cigarettes in smoke-free
in 2010. Ischemic heart disease, lower respiratory tract regulations to prevent abatement of smoke-free laws by
UNDERESTIMATED EXPOSURE infections, asthma, and lung cancer are the most common e-cigarette smoking. This inclusion would prevent any 2 5%
HARM

162,200
causes of deaths related to secondhand smoke. Women potential harm from exposure to e-cigarette vapor. HIGH SCHOOL GRADUATE
Exposure to secondhand smoke in children brought to a hospital for asthma or breathing problems: Cincinnati, USA, 2010–2011 suffer the greatest number of deaths among non-smoking
Nicotine and other tobacco compounds accumulate on
adults. In 2010, 740 million women were exposed to 28%
various surfaces (such as clothes, furniture, walls, and
Each year, secondhand secondhand smoke in China alone.
vehicles) and can stay there several months after smoking
PARENTS’
REPORT 35% smoking in the United Although most health effects of active smoking appear in has stopped, even after the surfaces have been washed.
Kingdom causes over older ages, many victims of exposure to secondhand smoke These residues, or thirdhand smoke, contain several toxic
20,000 cases of lower are children or even unborn babies HARMS. Because these compounds and have shown harmful effects on human
LAB TEST
(Saliva cotinine) 80% respiratory tract infection, effects occur at early ages, the number of years of healthy
harm 1

cells and animals in laboratory studies, but the nature

3 8%
3 4%
| | | | | 120,000 cases of middle life lost due to sickness, disability or early death related to and magnitude of any health effects in humans needs
0% 20% 40% 60% 80%
ear disease, 22,000 new secondhand smoke in children is much higher than in adults. further investigation. Nevertheless, measures to eliminate
cases of wheeze and Laboratory tests revealing exposure to smoke suggest that secondhand smoke, such as banning smoking in public
COLLEGE OR ABOVE
While only one third of parents reported that their children were exposed to secondhand smoke, laboratory tests asthma, and 200 cases harmful effects of exposure to secondhand smoke in children places, houses, and vehicles (see Chapter 23: Smoke-Free),
confirmed that, in reality, 80% of children brought to a hospital (Cincinnati Children’s Hospital Medical Center) of bacterial meningitis in may even be vastly underestimated UNDERESTIMATED EXPOSURE . can also reduce thirdhand smoke. Families with low socioeconomic
harm 1

in the United States for asthma or breathing problems were exposed to secondhand smoke. These findings children alone. People can be exposed to secondhand smoke in homes, status may be more likely to be
indicate that many respiratory diseases that might not be linked to secondhand smoke based on self-reports exposed to secondhand smoke
indoor work and public places, cars, outdoor places, and in
may in fact be related to the exposure. at home.
 clipboard: Industry Says quote: allies say

22 CALL TO ACTION 2003 2009 WILDFIRE CAUSE 23

Chapter
Governments should legislate safe, environmentally- FARMING & VEGETATION LOSS BRITISH COLUMBIA, CANADA SIBERIAN REPUBLIC
OF BURYATIA Cigarette butts are a common

05
One of the most
In 2001, a senior manager A man discarded a cause of wildfires, and a threat
sustainable tobacco farming practices and hold the Tobacco farming contributes to vegetation loss and climate change. destructive wildfires
at Philip Morris observed,
cigarette butt into dry to life, property, and forest lands.
in Canadian history.
tobacco industry accountable for the costs their “Creating social value
Destroyed more grass, causing a fire,
starts with the product. Clearing of land for cultivation and the large amounts of wood
products inflict on farmers and the environment. Yet, except to the smoker, needed for curing tobacco cause massive deforestation at a than 26,000 hectares, which destroyed 2000
70 homes and hectares of forest.
THERE IS NO rate of approximately 200,000 ha per year, and the subsequent
9 businesses. Caused He was fined USD19.6
CIGARETTE-CAUSED
DANGEROUS PESTICIDES
release of greenhouse gases contributes to climate change. WILDFIRE
PERCEIVED SOCIAL USD40 million in million in damages.
damage.
Common pesticides used in growing tobacco, and their potential harms
VALUE TO DECREASE IN VEGETATION
  1996
1987
HINGGAN FOREST, CHINA
As a monocrop, tobacco plants are vulnerable to a variety of pests and
OUR PRODUCT…” CHERNOBYL, UKRAINE (GREAT BLACK DRAGON FIRE)
Tobacco companies tout A cigarette was Part of the largest
diseases, prompting many farmers to apply large quantities of chemicals 2002
their Corporate Social suspected of starting a
and pesticides, which harm human health and the environment. Responsibility and take
LAKE TAHOE, wildfire of all time.
up environmental causes
CALIFORNIA, USA wildfire that destroyed Destroyed 3 million
ALDICARB such as the “Keep America 2007 A discarded cigarette evacuated villages. acres of forest reserve,
Affects brain, immune and reproductive system in animals and
Beautiful” campaign, but
1990–2010 KULA FOREST RESERVE, from a gondola caused killed 220, injured
in reality this stance is
CORONEL MOLDES, SALTA, ARGENTINA HAWAII, USA a wildfire, which burned 2010 thousands, and left
humans; highly toxic even at low doses; soil and ground water designed to protect the KERALA FOREST, INDIA
contaminant. A 7-day fire destroyed 673 acres of forest 34,000 homeless.
value of their business.
USA, PHASING OUT BY 2018. EU MEMBER STATES, HIGHLY RESTRICTED USE. 2300 acres. and resulted in A wildfire destroyed
USD3 million in damage. 60 hectares of lush
CHLORPYRIFOS forest.
Affects brain and respiratory system at high doses; found widely in soil,
water, air, and food.
USA, BANNED FOR HOME USE IN 2000.

1,3-DICHLOROPROPEN “…an estimated 4.5

Highly toxic effects on skin, eye, respiratory and reproductive system; trillion of the estimated
leaches readily into groundwater; probable cancer-causing agent in annual 6 trillion 2013 2006 2009
humans. globally consumed MELIPILLA, CHILE TABLE MOUNTAIN, SOUTH AFRICA VICTORIA, AUSTRALIA
EU MEMBER STATES, PHASED OUT IN 2009.
cigarettes [are]
1975–2010 A wildfire destroyed A wildfire destroyed A wildfire destroyed
ENVIRONMENT

deposited as butts
IMIDACLOPRID somewhere KASUNGU, CENTRAL REGION, MALAWI 6900 acres. 700 hectares, including 450,000 hectares
into the environment nearly 50% of the world’s including several towns,
Affects brain and reproductive system; highly toxic to bees and each year. This silverleaf tree population. killing 208 and leaving
other beneficial insects and certain bird species; persistent in the material comprises
10,000 people homeless.
environment in soil, water, and as a food contaminant; contains
naphthalene and crystalline quartz silica, which are cancer-causing THE LARGEST
agents; used in large volumes in agriculture. PERCENTAGE

T
EU MEMBER STATES, TWO-YEAR BAN FOR USE ON CROPS ATTRACTIVE TO BEES IN 2013.

METHYL BROMIDE
OF WASTE he tobacco industry damages the environment in biodegradeable) are the single most collected item in
… collected globally many ways, and in ways that go far beyond the effects beach cleanups. Material that leaches out of these filters is
Affects skin, eye, brain and respiratory system; may cause fluid in during the coastal
cleanups each year.” of the smoke that cigarettes put into the air when they toxic to aquatic life. To combat this, a bill to ban the sale of
lungs, headaches, tremors, paralysis or convulsions; volatile, ozone-
—THOMAS E. NOVOTNY and
are smoked. The harmful impact of the tobacco industry single-use filtered cigarettes was submitted to the California
depleting agent.
clipboard: Industry Says
PHASING OUT BY 2015 UNDER MONTREAL PROTOCOL OF THE UNITED NATIONS
quote: allies say
ELLI SLAUGHTER, on deforestation, climate change, litter, and forest fires is Legislature in 2014.
San Diego State University, “I will quit if plastic sachets are no
ENVIRONMENT PROGRAMME.
2014
1975–2010 enormous and growing. more available.”
NENO, SOUTHERN REGION, MALAWI Damage to people and the environment by fires caused by
CHLOROPICRIN Tobacco farming is a complicated process involving heavy cigarette smoking is considerable and deadly WILDFIRE CAUSE .
—SATYABIPRA PATRA, 9-year gutka user, 2011
HARM

Lung-damaging agent; high-level exposures cause vomiting, fluid

PLASTIC BANS
harm 1

use of pesticides, growth regulators, and chemical fertilizers According to data from the United States Fire Administration,
in lungs, unconsciousness and even death; toxic to fish and other DANGEROUS PESTICIDES . These can create environmental health cigarette smoking is the first or second-leading cause of
organisms; used as a tear gas in WWI. “Cigarette butt waste is
harm 1

problems, particularly in low- and middle-income countries fire-related deaths every year in the USA. Young and elderly
EU MEMBER STATES, BANNED SINCE 2011.
India banned plastic wrapping for

CARBARYL
THE LAST SOCIALLY with lax regulatory standards. In addition, tobacco, more persons are among the most commonly affected, and data tobacco products in 2011.
than other food and cash crops, depletes soil of nutrients, from CDC indicate that fire and burns are annually among the 10
Affects brain, and immune and reproductive system; likely cancer- ACCEPTABLE FORM 1990–2010
including nitrogen, potassium, and phosphorus. As a result, leading causes of unintentional death in the United States.
ENVIRONMENTAL & PUBLIC HEALTH BENEFITS
• Passed in an effort to decrease plastic
causing agent, linked with cancer among farmers; linked with low OF LITTERING URAMBO, TABORA, TANZANIA
in many low- and middle-income regions of the world, new litter and toxic environmental waste
sperm counts among exposed men; toxic to bees and other beneficial in what has become an In 2010-2011,
increasingly health areas of woodlands are cleared every year for tobacco • Paper packaging increased prices and
insects and aquatic life; contaminant in air and water. subsequent to this
crops (as opposed to re-using plots) and for wood needed decreased sales and consumption of

20¢
EU MEMBER STATES, BANNED SINCE 2007. and environmentally
image, Urambo District cigarettes, bidi, and chewing tobacco
conscious world.”
in Tanzania lost for curing tobacco leaves, leading to deforestation
—CHERYL G. HEALTON in Jaipur, Rajasthan
1.3 million m3 trees FARMING & VEGETATION LOSS. This deforestation can contribute to
(American Legacy Foundation) et al, • Decreased consumption could confer
worth USD10.5 million,
harm 1

Commentary in Tobacco Control,
USA, 2011 which would occupy an
area of 145 km2, the
equivalent of 2½ times
the size of Manhattan.
climate change by removing trees that eliminate CO2 from health benefits such as decreased
In 2009, San Francisco implemented a 20-cent per
the atmosphere. pack Cigarette Litter Abatement fee to help recover cancer rates
the cost of cleaning up cigarette litter. • Lack of plastic packages may
Litter from cigarettes fouls the environment as well.
discourage customers
Internationally, cigarette filters (which are not generally
 24 CALL TO ACTION INCOME UP IN SMOKE 25

Chapter Sweden Finland Percentage of median

Governments should strengthen tobacco control programs to prevent tobacco
06 household income needed
Norway
consumption from impoverishing citizens and impeding economic development. Estonia
to buy 10 of the cheapest
United Denmark
Latvia
brand of cigarettes per day:
Kingdom Lithuania—

TOBACCO IMPOVERISHES COUNTRIES Russian Federation 2012

Netherlands
Ireland Belarus
Canada Belgium Germany
Poland
10.00—100.00%
—Lux.
TANZANIA UNITED STATES BRAZIL Czech Rep.
Ukraine
Slovakia
7.50—9.99%
$40M $6000 100M Austria Rep.
Hungary Moldova
France
Slovenia— —Croatia
OF $50M EXCESS COST REALS Bosnia &
Romania
Mongolia
5.00—7.49%
Herzegovina Serbia Kazakhstan
REVENUE PER SMOKER “[In 2004-2005], Montenegro— Bulgaria

tobacco consumption Albania

—FYR
Macedonia
2.50—4.99%
Tanzania earns $50 million per US smokers cost their The cost to Brazil due to Spain
Italy Georgia Kyrgyzstan

[IMPOVERISHED]
Portugal
United States of America Greece
year from tobacco but spends employers an excess of tobacco is approximately Armenia— —Azerbaijan
Tajikistan Korea
0.00—2.49%
$40 million for tobacco- $6000 a year per smoker 100 million reals per thousand
ROUGHLY 15 MILLION
Turkey Rep. Japan
related cancers alone. due to lower on-the-job smokers in lost productivity.
productivity, higher absences,
—Malta
Cyprus—
Syrian
Arab Rep. Afghanistan China NO DATA
and excess healthcare costs. PEOPLE IN INDIA.” Tunisia Lebanon—
Jordan Iraq
Isl. Rep.
of Iran
­ Morocco —Israel Pakistan Nepal
Kuwait—
­ RIJO M JOHN et al,
—
Algeria Libya
Productivity loss and healthcare cost burdens Tobacco Control, 2011 Egypt Bahrain—
—Qatar Bangladesh
undermine economic development in many countries. Mexico —Hong Kong
Saudi Arabia
Dominican Rep.
India LAO
Haiti PDR

CHILD LABOR VICIOUS CYCLE

Mauritania
Mali
Honduras Thailand Philippines
Guatemala Niger Yemen
Senegal Viet Nam
El Salvador Chad Sudan
Nicaragua Cambodia
Burkina Faso
Working in tobacco fields affects Disadvantage increases smoking likelihood, and smoking increases likelihood Benin
Costa Rica
school attendance and retention rates. of disadvantaged circumstances. Venezuela Sierra Leone— Ghana Nigeria
Panama Sri Lanka
Togo
Liberia—
Suza in Kasungu district Cameroon
Colombia Malaysia
and Katalima in Dowa Adverse circumstances Uganda
district of Malawi: 2008 (unemployment, Congo Kenya |
Singapore Indonesia
As a means of Ecuador —Rwanda
single parenthood) 1 Dem. Rep.
—Burundi
coping with different of Congo
Stress SOCIAL circumstances United Republic

Isolation
DISADVANTAGE AND 2 of Tanzania

DEPRIVATION CREATES As an "affordable"

63% Smoking as “normal” VULNERABILITY recreation Peru Brazil
Angola
—Comoros
POVERTY

of children of tobacco-growing families Unsafe neighborhoods TO SMOKING As a response to Zambia

were involved in child labor. stress and exclusion Bolivia

Limited recreation Madagascar
VICIOUS CYCLE OF SMOKING
10–14% AND DISADVANTAGES Paraguay
Botswana

of children from tobacco-growing families are out

Less money for 4 Australia
of school because of working in tobacco fields. essentials
S. Africa
AND MAKES 3
Increased smoking
—Lesotho

SMOKING
16% Greater financial stress CIRCUMSTANCES
WORSE PREVALENCE Less quitting
Chile
Uruguay
of parents said their children were out of school Poorer health and INCREASES

T
wellbeing Higher relapse Argentina
because of an inability to pay educational fees
and buy uniforms and shoes.
here is an inextricable and pernicious relationship between afford health coverage. As a result, in places where clipboard: Industry Says
HARM

tobacco and poverty. In many ways, tobacco and poverty are part individuals purchase health insurance, those costs
ry Says Lack ofquote:
education allies say
drives individuals of the same vicious cycle VICIOUS CYCLE . Across the globe, smoking are proportionately much higher than they are for
New Zealand

further into poverty. harm 2

is generally common among the poorest segments of the population.

harm 3 products 1

non-smokers. Smoking-related illness takes workers out of

These groups, already under financial stress, have little disposable the work force, adding to the indirect costs of tobacco and

FINANCIAL STRAIN HIGH INCOME MIDDLE INCOME

73% 76%
income to spend on cigarettes. Consumption of tobacco adds
directly to financial stress FINANCIAL STRAIN. For example, in a city such
harm 2 harm 3 products 1
creating further downward pressure on the economy, especially
in LMICs TOBACCO IMPOVERISHES COUNTRIES.
harm 2 harm 3 products 1
BURKINA FASO
In Burkina Faso in 1998,
“…when child and Percentage of male smokers who spent money on 65% as New York, a pack-per-day smoker living at the poverty level spends a Rothman's
Furthermore, working in the tobacco industry can trap people in representative said,
maternal mortality are falling as much as 20% of his household income in supporting his smoking
cigarettes instead of household essentials poverty. In LMICs, many small tobacco farmers are often forced
universally around the world, “the average life expectancy
habit. In lower-income countries, the World Health Organization here is 40 years,
THE THREAT OF A RISE IN 31% 30% estimates that as much as 10% of household income can be spent on
to sell their crop at a low, fixed price and have few choices but
to over-pay the tobacco companies for fertilizer, seeds, technical
infant mortality is high,
25%
TOBACCO IS HEADING IN THE 15% 21% 22% 21% tobacco products, leaving less money for food, education, housing,
advice, and other items. Trapped in a type of indentured servitude, THE HEALTH PROBLEMS
11%
WRONG DIRECTION… and clothing.
they are added to the lists of those victimized directly or indirectly WHICH SOME SAY ARE
The developing world is about to enter There are costs to smokers that go far beyond the money that by the tobacco economy.
a phase of rapid growth in tobacco at
CANADA FRANCE
2006–2007 FRANCE
CANADA
IRELAND NETHERLANDS
2012 IRELAND2006NETHERLANDS
NEW
2013 NEW ZEALAND
REPUBLIC OF
ZEALAND REPUBLIC
UNITED
KINGDOM
KOREAOF KOREA
BRAZIL MALAYSIA MEXICO
UNITED KINGDOM2009 BRAZIL2006–2007MALAYSIA
2012
THAILAND
MEXICO
2006 THAILAND they pay to buy cigarettes. Smokers develop many more illnesses
CAUSED BY CIGARETTES
a time when it can least afford it.” 2006–2007 2012 2006 2013 2008–2009
2008–2009 2010 2010 2006–2007
2006–2007 2009 2006–2007 2012 2006
than non-smokers, which places enormous cost stresses on any JUST WON'T BE A
Smokers spend money on cigarettes instead of on household essentials such as food and education.
­— KEITH HANSEN, The World Bank Group, 2012
This could exacerbate the poor’s disadvantaged circumstances and standard of living.
country’s health care expenditures, and makes it more difficult to PROBLEM HERE.”
 POVERTY
Tobacco companies view vulnerable populations The poorest smokers
in Uruguay smoke twice
as many cigarettes as

as market opportunities, not as human beings. the wealthiest smokers.

PRODUCTS
AND THEIR USE
EQUALITY
There are only two countries
in the world where more
women smoke than men,
but there are 24 where more
girls smoke than boys.

T
he tobacco industry has invested billions of dollars marketing
new products to new people in new markets, often purporting
that their sole goal is to reduce harm to their customers.
We know, however, that their real aim is simply to sell more
products and create more addiction, with little concern for who
or what is harmed.
DEVELOPMENT
Without effective policy
interventions, Africa’s share
of the world’s smokers will
triple by the end of the century.
 clipboard: Industry Says quote: allies say
28 CALL TO ACTION TYPES OF NICOTINE DELIVERY SYSTEMS 29

Chapter Continuum of harm

Because nicotine is not a benign drug, products containing
07 nicotine must be regulated in a manner commensurate with “It’s not a matter CLINICALLY APPROVED UNCERTAIN SAFETY  ESTABLISHED HARMS

CH3
the harm that they cause.

0
of if a child will

N
be seriously NICOTINE REPLACEMENT Many popular tobacco products SNUS SMOKELESS TOBACCO COMBUSTED TOBACCO

CH3
THERAPY (NRT)

0
N
exist in a research and regulatory A smokeless tobacco product The use of smokeless Cigarettes kill at least half of
DANGEROUS POISON poisoned or killed
[by e-liquid], it’s a
A typical vial (10mL)
of liquid nicotine contains
NRT is highly regulated and
if used as recommended
vacuum. It is uncertain if these
products are dangerous to users
originally from Sweden. Due
to manufacturing and storage
tobacco, with the possible
exception of snus, increases
all lifetime users. There are
thousands of toxic chemicals

N
matter of when.” A LETHAL DOSE for cessation, there are few and how much exposure must the risk of oral, head, in cigarette smoke, and

CH3
E-cigarettes and liquid nicotine poisoning calls on the rise in the USA processes (see Chapter 14:
CIGARETTES   
  E-CIGARETTES AND LIQUID NICOTINE — LEE CANTRELL, Director of the if ingested. adverse outcomes. NRT occur for harm to be detected. Smokeless Tobacco), snus has and neck cancers. 69 cancer-causing agents.
San Diego division of the California Labeling a vial of nicotine is not recommended for Examples include: lower concentrations of harmful Other dangerous combusted
Poison Control System, 2014 with pictures of Gummi certain populations, such as chemicals and cancer-causing WATER PIPES products include cigars, little
Bears and candy can be
500— pregnant women, but most E-CIGARETTES agents, yet is still harmful, The risk from using cigars and cigarillos.

CH3
APPEALING TO
N
would agree NRT is safer Traditionally sold by entrepreneurial although less so than other forms water pipes is similar to that
than smoking. companies, but increasingly from smoking cigarettes, and
400— Both poison control centers CHILDREN. of smokeless tobacco.
H

e-cigarette companies are owned the volume of smoke inhaled

and emergency rooms in the
by tobacco companies. These DISSOLVABLE TOBACCO PRODUCTS while using water pipes can
NUMBER OF CALLS

300—
N USA are receiving
products contain an atomizer that Products such as wafers, be substantially more than
INCREASED CALLS AND
NICOTINE DELIVERY SYSTEMS

heats liquid nicotine and other lozenges, sticks, strips and orbs that inhaled while smoking
200—
VISITS REGARDING flavors and additives, creating a often resemble candy or are cigarettes (see Chapter 13:

100— E-LIQUID POISONINGS NICOTINE AND CAFFEINE vapor that is then inhaled. flavored. Water Pipes).

AND EXPOSURES. Some claim that nicotine is as benign as caffeine, HEAT-NOT-BURN PRODUCTS
These new products are similar
0— Nicotine is a poison and but studies show that nicotine is more likely to cause
SEPT–DEC JAN–DEC JAN–DEC JAN–DEC JAN–FEB e-liquid is absorbed through dependence, may help cancers grow, and is considered to e-cigarettes but contain
2010 2011 2012 2013 2014 inhalation, ingestion and skin lethal at a much smaller dose than caffeine. tobacco. The external heat source
contact. Colorful product for heat-not-burn products, such
packaging makes e-liquid
The number of poison center calls involving e-cigarettes and liquid nicotine rose from as Philip Morris’s Heat Stick,
bottles attractive NICOTINE CAFFEINE vaporizes nicotine from tobacco,
one per month in September 2010 to 215 per month in February 2014 in the USA. to toddlers and children,
Approximately 50% of the calls to poison centers involving e-cigarettes and liquid who are at a considerable CH3 purportedly avoiding the toxic
nicotine were for children under age 6. risk for e-liquid poisoning. N N 0 compounds from combusted
H
cigarettes.
N
N
N CH3

VARIATIONS IN NICOTINE LEVELS

CH3 CH3
N 0

WITHDRAWAL SYMPTOMS
Daily nicotine consumption illustrated through select product and usage examples Nicotine withdrawal caused Caffeine withdrawal symptoms,

N
a more intensive degree of
irritability, restlessness and
including headache, fatigue and
difficulty focusing, are common icotine is the addictive agent in cigarettes. Cigarettes Acute exposure to nicotine through the skin or through clipboard: Industry Says
236mg difficulty concentrating after consuming large quantities kill at least half of lifetime users, and tobacco ingestion can also be harmful. If ingested, nicotine is
IN HALF A 34g CAN compared with caffeine withdrawal. of caffeine at a time. Typically, companies continue to look for “safer” or less harmful rapidly absorbed by the small intestine, and typically
86mg these symptoms are short-term
and users of caffeine, alcohol ways to provide nicotine to consumers. While the smoke produces symptoms between 15 minutes and 4 hours
IN 12 POUCHES
and tobacco report feeling most that results from combustion is the deadliest aspect of after exposure. Death may occur within one hour of
dependent on tobacco. smoking, this does not mean that nicotine is benign. severe exposure. Numerous cases of nicotine poisoning
PSYCHOLOGICAL EFFECT have been documented since the early twentieth century
“NICOTINE IS ADDICTIVE
Nicotine affects the nervous system and the heart. The
PRODUCTS

Nicotine produces a Caffeine is a stimulant. It

effects of nicotine on the body include decreased appetite,
when nicotine was used as a pesticide. Exposure to liquid AND VERY HABIT
psychoactive, stimulant effect. induces alertness, elevates
27mg Nicotine increases the speed of mood, facilitates thinking, and mood elevation, increased heart rate, increased blood
nicotine was relatively rare until the newfound popularity FORMING, AND IT IS
of e-cigarettes DANGEROUS POISON.
IN 9 PIECES 24mg 24mg sensory information processing,
and induces a feeling of
increases feelings of motivation.
pressure, nausea, and diarrhea. Symptoms of nicotine products 1 products 2 products 3 VERY TOXIC
IN 1 PACK OF IN 1 DISPOSABLE
relaxation and reduced stress. withdrawal include intense craving, anxiety, depression, The risk of nicotine addiction depends on the dose by inhalation, in contact
20 CIGARETTES E-CIGARETTE
with the skin, or if
headache, increased appetite, and difficulty concentrating of nicotine delivered and the method in which it is
POSSIBLE EFFECTS ON CANCER swallowed. Nicotine can
NICOTINE AND CAFFEINE . delivered VARIATIONS IN NICOTINE LEVELS. There are a variety increase your heart rate
In cell and animal studies, In cell and animal studies,
14mg 12mg and blood pressure and
products 1 products 2 products 3 products 1 products 2 products 3

SMOKELESS TOBACCO/
US-STYLE MOIST SNUFF
nicotine helps cancer grow caffeine prevents some events of ways to consume nicotine, and some methods are
The level of harm from nicotine is based on how nicotine cause dizziness, nausea, and
IN 1 PATCH
and spread and may weaken that may help cancer grow. currently regulated, such as nicotine replacement therapy.
IN 1 PACKAGE chemotherapy. is delivered to the body. Combustion is the most efficient stomach pain. Inhalation
OF 12 ORBS Other methods, such as e-cigarettes and other novel of this product may
method of delivering nicotine to the brain, and because of
LETHAL DOSE nicotine products, are currently unregulated in most aggravate existing
the tars and carcinogens in smoke is also the most harmful respiratory conditions.”
50–60mg 10g method of consuming nicotine.
countries, yet these products are growing in popularity.
— Altria's MarkTen e-cigarette
oral dose of liquid nicotine oral caffeine dose Because of its addictiveness and the other known warning label, 2014
harms of nicotine, a framework is needed to regulate all
nicotine delivery systems in a manner consistent with
SNUS NRT: GUM CIGARETTES E-CIGARETTES NRT: PATCH DISSOLVABLES the harm that they cause TYPES OF NICOTINE DELIVERY SYSTEMS.
products 1 products 2 products 3
 30 CALL TO ACTION Iceland
CIGARETTE CONSUMPTION 31

Chapter Sweden Finland Number of cigarettes smoked

Our largest objective is to dramatically reduce
08 per person per year:
Norway
the consumption of combustible cigarettes. Estonia­
Russian
age ≥ 15, 2014*
Inset 2: Top 10 United
Latvia­­ Fed.
Denmark
Kingdom Lithuania—

TOP 10 CONSUMERS 2. RUSSIA

Canada
Ireland Netherlands Belarus
Russian Federation

3. USA
Belgium
Germany
Poland
0—499

5.8
Distribution of cigarette 4. INDONESIA —Lux. Czech Rep.
Ukraine
Slovakia
consumption: 2014 5. JAPAN
Switz.
Austria Hungary
Rep.
Moldova
500—999
France
6. GERMANY Slovenia— Romania
7. INDIA
Bosnia &
Croatia
Serbia Kazakhstan Mongolia 1,000—1,499
8. TURKEY
9. KOREA REP.
TRILLION: Herzegovina—
Montenegro—
Bulgaria
—FYR
Macedonia DPR 1,500—1,999
1. CHINA 10. VIETNAM number of United States of America Portugal Spain
Italy
Albania

Greece
Georgia
—Azerbaijan
Uzbekistan
Kyrgyzstan Korea

More cigarettes cigarettes Turkey

Armenia—
Turkmenistan Tajikistan Korea
2,000—3,500
Rep. Japan
are now smoked smoked —Malta
Cyprus—
Syrian
Arab Rep. China NO DATA
Tunisia Afghanistan
in China than in worldwide Lebanon—
Jordan Iraq
Isl. Rep.
of Iran Nepal
the next top 29 in 2014. Morocco —Israel
Kuwait—
Pakistan
| Bhutan
|
INTENSE SMOKING
cigarette-consuming Libya
Countries where the average smoker
Algeria
countries combined. REST OF THE WORLD —Bahamas Egypt Bahrain—
—Qatar Bangladesh smokes more than 30 cigarettes
UAE
Mexico Cuba Saudi Arabia
—Hong Kong (pack and a half) a day
Dominican Rep.
India Myanmar
LAO
Haiti Oman PDR
Jamaica— Mauritania
Belize Antigua & Barbuda— Mali

CONSUMPTION BY REGION
Honduras Thailand Philippines
Guatemala Niger Eritrea Yemen
St. Lucia— —Cape Senegal Viet Nam
El Salvador St. Vincent &— —Barbados Verde Chad Sudan
—Gambia Cambodia
Nicaragua the Grenadines —Grenada Burkina Faso
Guinea-Bissau— —Djibouti
—Trinidad & Tobago Guinea
Benin
Global cigarette consumption by WHO region: 1980–2013, in trillions Costa Rica
Sierra Leone— Côte Ghana Nigeria Ethiopia
Panama Venezuela —Guyana
D’Ivoire Central Sri Lanka
Togo
Many of the nations which CHINA Suriname
Liberia—
Cameroon
African Rep. Somalia Brunei Dar.—
Colombia Maldives—
significantly reduced their 2.0— Equatorial Guinea—
Malaysia
Uganda
smoking prevalence during Sao Tome and Principe—
Congo Kenya |
Singapore Indonesia |
Gabon
the last decade, including
CONSUMPTION

Ecuador —Rwanda Kiribati

Dem. Rep.

44+6+5+4+3+2+2+2+1+1+30+z
1.5— —Burundi Papua New Guinea
Canada, Denmark, Iceland, of Congo

���
—Seychelles
EURO
New Zealand, and Uruguay, United Republic
of Tanzania
have seen that their 1.0—
remaining smokers are AMRO Solomon Islands
SEARO Peru Brazil —Comoros
those who smoke the most WPRO (excluding China) Angola Malawi
0.5—
cigarettes per day. Increased EMRO Zambia
tobacco control efforts must AFRO Bolivia Mozambique Vanuatu—
be targeted at those diehard 0— Zimbabwe Madagascar
Samoa—
Namibia —Mauritius
users, who are often | | | | | | | | | | | |
Botswana
Fiji—
1980 1983 1986 1989 1992 1995 1998 2001 2004 2007 2010 2013

THE MOST VULNERABLE Paraguay

—Swaziland
The disproportionate increase in the number of cigarettes smoked in China is a combined effect of Australia
MEMBERS OF SOCIETY. clipboard:
China’s population growth and an increase in smoking intensity. In 2013, an average smoker inIndustry
China Says quote: allies say
S. Africa
—Lesotho
*These estimates are of legally sold machine-made
Tonga—

smoked 22 cigarettes a day, nearly 50% more than in 1980. Chile and roll-your-own cigarette consumption.
Uruguay

A
Argentina

SMOKING AND WEALTH bout 5.8 trillion (5,800,000,000,000) cigarettes were smoked Patterns of cigarette consumption vary widely within
PRODUCTS

worldwide in 2014. The significant reductions in smoking rates in countries. Cigarette consumption displays large New Zealand

Disparities in cigarette consumption in selected Global Adult Tobacco Survey countries “The underlying business continues to perform well […] the United Kingdom, Australia, Brazil, and other countries that disparities and is associated with lower socioeconomic
China and
implement increasingly tight tobacco control laws have been offset status, even in low- and middle-income countries
by wealth group: LOWEST  LOW  MIDDLE  HIGH  HIGHEST OUR GROWTH STRATEGY by the growing consumption in a single nation: China. The Chinese SMOKING AND WEALTH . These inequalities can be reduced by the
Eastern and Southern
Europe consume the
1,673 1,456 CONTINUES TO DELIVER.”
MEAN NUMBER OF CIGARETTES PER PERSON IN 2009

2,000— market now consumes more cigarettes than all other low- and
products 1 products 2 products 3

use of targeted tobacco control measures. For example, revenue most cigarettes per
1,817 853 clipboard: Industry Says quote: allies say
­— NICANDRO DURANTE, CEO, British American Tobacco, 2013 person. This is not only
middle-income countries combined TOP 10 CONSUMERS. from cigarette tax increases could be directed to fund tobacco because of the high
products 1 products 2 products 3

1,500— prevention and cessation programs for disadvantaged groups. smoking prevalence
Other regions are increasingly playing larger roles in the growing (see Chapter 9: Male
1,198 493 1,136 520 global smoking epidemic. The WHO Eastern Mediterranean Region Consumption of other combustible tobacco products is also on Smoking and Chapter 10:
813 730
1,000— (EMRO) now has the highest growth rate in the cigarette market, the rise. Since 2000, global consumption of cigarette-like cigarillos Female Smoking)
833 560 but also
with more than a one-third increase in cigarette consumption since has more than doubled, while consumption of roll-your-own
500—
“THE MARKET COMPETES ON ADDICTION 2000 CONSUMPTION BY REGION. Due to its recent dynamic economic tobacco and pipe tobacco both increased by more than a third. HIGH SMOKING
—the most addictive products win out.
INTENSITY
products 1 products 2 products 3

development and continued population growth, Africa presents This increase is partly because these other tobacco products are
With research, they [firms], like the cigarette companies,
may find out which of their ingredients is most effective the greatest risk in terms of future growth in tobacco use. Without often taxed at lower rates than cigarettes and are, therefore, —the large number of
0— cigarettes smoked
in increasing sales/addiction. […]they are loath to give up appropriate prevention policies across the continent, Africa will lose more affordable.
URUGUAY POLAND THAILAND PHILIPPINES BRAZIL EGYPT these profit opportunities, no matter the costs to society.” by average smoker
hundreds of millions of lives in this century due to tobacco smoking. per day.
Lower socioeconomic groups smoke more not only in high-income but also in low- and ­—JOSEPH E. STIGLITZ,
middle-income countries. Recipient of the Nobel Memorial Prize in Economic Sciences, 2008
 32 CALL TO ACTION Iceland
PREVALENCE 33

Chapter Sweden Finland Percentage of adult males

All countries need to fund and implement more effective tobacco
09 who smoke daily:
Norway
control policies to increase cessation and reduce initiation. Estonia
age ≥15, 2013
Latvia
United Denmark
Lithuania—

10M+
Kingdom

TRENDS BY INCOME LEVEL Canada

Ireland Netherlands
Belgium Germany
Poland
Belarus
Russian Federation

0.0—9.9%
Change in number of daily male smokers: Countries with 10,000,000 or more daily male —Lux. Czech Rep.
Ukraine
age ≥15 in high-, middle-, and low-income countries, smokers: age ≥15, in millions, 2013 Austria
Slovakia

Hungary
Rep. 10.0—19.9%
France Switz. Moldova
in millions, 1980—2013 Slovenia— —Croatia

= 50 MILLION MALES CHINA 264.0 JAPAN 18.9 Bosnia &

Romania
Mongolia
20.0—29.9%
Andorra­
| Herzegovina Serbia Kazakhstan
Bulgaria
Montenegro—
INDIA 106.0 PAKISTAN 17.2 FYR
—Macedonia DPR 30.0—39.9%
Albania Uzbekistan Korea
Italy
609M INDONESIA 50.6 VIET NAM 14.2 United States of America Portugal Spain
Greece
Georgia Kyrgyzstan
Armenia— —Azerbaijan
Turkmenistan Tajikistan 40.0—49.9%
600 — RUSSIAN FEDERATION 27.7 PHILIPPINES 12.9 Turkey Korea
Rep. Japan
BANGLADESH 24.5 BRAZIL 12.2 Tunisia
—Malta
Cyprus—
Lebanon—
Syrian
Arab Rep. Afghanistan China 50.0—100.0%
Isl. Rep.
West Bank/—
UNITED STATES
21.6 TURKEY 10.6 Gaza Strip
Israel—
Jordan
Iraq of Iran
Nepal Bhutan NO DATA
500 — OF AMERICA Morocco Kuwait—
Pakistan
EGYPT 10.1
—Bahamas
Algeria Libya
Egypt Bahrain—
—Qatar Bangladesh
DECLINE
UAE Countries with significant
Mexico Cuba Saudi Arabia
India Myanmar
LAO decline in male smoking
400 — Dominican Rep. PDR

SMOKING TRENDS
Oman
Jamaica—
Haiti
Mauritania prevalence from 1980 to 2013
Belize Antigua & Barbuda— —St. Kitts & Nevis Mali
Honduras Thailand Philippines
Guatemala —Dominica Niger Eritrea Yemen
St. Lucia— —Cape Senegal Viet Nam
El Salvador St. Vincent &— —Barbados Verde Chad Sudan
—Gambia Cambodia
300 — Adult male age-standardized daily smoking prevalence Nicaragua the Grenadines —Grenada
—Trinidad & Tobago Guinea-Bissau—
Guinea
Burkina Faso —Djibouti

in select middle-income countries (%): 1980­—2013 Costa Rica

Benin
Sierra Leone— Côte Ghana Nigeria Ethiopia —Palau
Panama Venezuela —Guyana
D’Ivoire Central Sri Lanka |
Togo |
Marshall Islands
Liberia— African Rep. Somalia Fed. States of
Cameroon Brunei Dar.— Micronesia
60% —
INDONESIA Colombia
Suriname Maldives— Singapore
Malaysia
200 — Equatorial Guinea—
|
Nauru
Uganda |
Sao Tome and Principe—
MALE SMOKING

Congo Kenya
Indonesia |
Gabon
Ecuador —Rwanda Kiribati
Dem. Rep.
—Burundi Papua New Guinea
of Congo —Seychelles
United Republic
100 — THAILAND of Tanzania
40% — —Timor-Leste Solomon Islands
EGYPT Peru Brazil —Comoros
JAMAICA Angola Malawi Tuvalu—
Zambia
ALGERIA
1983
1988
1993
1998
2003
2008
2013
1983
1988
1993
1998
2003
2008
2013
1983
1988
1993
1998
2003
2008
2013

Bolivia Mozambique Vanuatu—

Zimbabwe Madagascar
LOW INCOME MIDDLE INCOME HIGH INCOME 20% —
CUBA Namibia —Mauritius Samoa—
Fiji—
Botswana
Paraguay
Middle-income countries have seen the
greatest increase. clipboard: Industry Says In these threequote: allies say
—Swaziland
S. Africa
Australia Niue—

different regions, neighboring countries had —Lesotho Tonga—

Cook Islands—
comparable male smoking prevalence in 1980 and diverged over time.
Chile
Uruguay

G
Argentina

REGIONAL FORECAST lobally, nearly a third of men ages 15 years or older, or tobacco trends continue, smoking prevalence in men
PRODUCTS

around 820 million people, are current smokers. In the last 30 and women combined in Africa will increase from 16% New Zealand
INDONESIA years, the global age-standardized prevalence of daily smoking in 2010 to 22% in 2030, most of which is expected to be
Estimated proportion of the world's adult smokers (men and women combined)
“If we stop selling cigarettes here living in each WHO region, with current tobacco control policies: 2010-2100 among men has decreased approximately 10%. However, the trend in among men REGIONAL FORCAST. Because the African population
someone else is going to do it instead.” smoking prevalence in men varies substantially worldwide, from
products 2 products 3 industry 1

is growing much more rapidly than the rest of world, Africa

ard: Industry Says quote: allies say
—ANNE EDWARDS, Director External Communications, 100% —
AFRO a 24% decrease in Canada to a 16% increase in Kazakhstan from will see a much higher number of male smokers in the future if
Philip Morris International, on Sex, Lies and Cigarettes, 2011
80% — 1980 to 2013. no additional tobacco control policies are implemented.
AMRO
Although most of the countries with the greatest reductions in male China has one third of all male smokers worldwide. Although
60% —
EMRO Since 1980, although
smoking are high-income countries, smoking prevalence has also awareness about the importance of tobacco control appears to be
smoking rates in
40% — EURO substantially decreased in many low- to middle-income countries increasing, and several tobacco control policies have recently been men have not
SUCCESSFUL INTERVENTIONS
Uruguay has been quite successful in tobacco control. (LMICs) SMOKING TRENDS. However, many other LMICs have made only established in China, simulation models suggest that additional substantially changed
20% — SEARO
in several Southeast
products 2 products 3 industry 1

Adult male current smoking prevalence rates have slight reductions or have even experienced an increase in their tobacco control programs could reduce smoking rates in China by
Asian countries,
DECLINED FROM 39% TO 31% IN ONLY SIX YEARS 0% —
2010 2020 2030 2040 2050 2060 2070 2080 2090 2100
WPRO smoking prevalence TRENDS BY INCOME LEVEL . Most of these countries are
products 2 products 3 industry 1
more than 40% and potentially save more than 12.7 million lives
THE RATES
(2003–2009). located in Southern and Central Asia, Eastern Europe, and Africa. by 2050. Countries with limited tobacco control policies could see
“What is happening today in Uruguay could happen to any
country that implements very effective tobacco control measures.” The majority of the predicted increase in the AFRO region is attributed to men.
For example, with no reduction in smoking prevalence from 1980 comparable or even greater reductions in smoking prevalence if HAVE HALVED
to 2013, Indonesia has more than 50 million male daily smokers, they were to establish more effective policies. in Hong Kong (China),
­ DR. EDUARDO BIANCO, president of Uruguay’s
— Japan, and Singapore.
leading tobacco control organization, CIET, 2010 and ranks third globally for the number of male smokers. If current
 34 CALL TO ACTION Iceland
PREVALENCE 35

Chapter Sweden Finland Percentage of adult

One of the largest public health opportunities available to
10 females who smoke daily:
Norway
governments in the 21st century is to prevent an increase in Estonia
age ≥15, 2013

���
smoking among women in low- and middle-income countries. United Denmark
Latvia
Lithuania—
Kingdom

3M+
Russian Federation
Belarus

TREND, USA
Ireland Netherlands
Canada Belgium Germany
Poland
0.0—9.9%
—Lux.
Countries with Czech Rep.
Ukraine
Estimated smoking prevalence and smoking-attributable mortality: 3,000,000 Austria
Slovakia

Hungary
Rep. 10.0—19.9%
France Switz. Moldova
USA, 1900–2010 or more daily Slovenia— —Croatia
20.0—29.9%
—— 
Romania
MALE   
  FEMALE  % PREVALENCE  % OF DEATHS CAUSED BY SMOKING female smokers: Andorra­
Bosnia &
Herzegovina Serbia Kazakhstan Mongolia
|
Montenegro— Bulgaria
age ≥15, in —FYR DPR 30.0—39.9%
–35% Albania Macedonia Uzbekistan
60%– millions, 2013 Portugal Spain
Italy Georgia Kyrgyzstan Korea
United States of America Greece
–30% UNITED STATES 17.7
Armenia— —Azerbaijan
Turkmenistan Tajikistan Korea
40.0—49.9%
Turkey Rep. Japan
50%– —Malta
50.0—100.0%

% OF DEATHS CAUSED BY SMOKING

CHINA 12.2 Cyprus—
Lebanon—
Syrian
Arab Rep. Afghanistan China
MALE –25% Tunisia Isl. Rep.
SMOKING PREVALENCE

INDIA 12.2 West Bank/— Iraq of Iran

40%–
Morocco
Gaza Strip Jordan
—Israel Pakistan Nepal
Bhutan NO DATA
9.9 Kuwait— |
–20% RUSSIA
—Bahamas
Algeria Libya
Egypt Bahrain— DECLINE
30%— BRAZIL 8.6 —Qatar Bangladesh
Countries with a significant
–15% UAE
FEMALE Mexico Cuba Saudi Arabia
GERMANY 6.9 India Myanmar
LAO decline in female smoking
—— 

Dominican Rep. PDR

Haiti Oman
20%– Jamaica— Mauritania prevalence from 1980 to 2013
–10% FRANCE 6.4

 
Belize Antigua & Barbuda— —St. Kitts & Nevis Mali
Honduras Thailand Philippines
Guatemala —Dominica Niger Eritrea Yemen
10%— –5%
JAPAN 5.4 El Salvador
St. Lucia—
St. Vincent &— —Barbados
—Cape
Verde
Senegal
—Gambia Chad Sudan
Viet Nam

Nicaragua the Grenadines —Grenada Cambodia

Burkina Faso
ITALY 5.2 —Trinidad & Tobago Guinea-Bissau—
Guinea
Benin
—Djibouti

Costa Rica
0%— –0% UNITED KINGDOM 4.9 Panama Venezuela —Guyana Sierra Leone— Côte
D’Ivoire
Ghana Nigeria
Central
Ethiopia
Sri Lanka
—Palau |
| | | | | | | | | | | | Togo |
Marshall Islands
Liberia— African Rep. Somalia Fed. States of
4.2
FEMALE SMOKING

1900 1910 1920 1930 1940 1950 1960 1970 1980 1990 2000 2010 SPAIN Cameroon Brunei Dar.— Micronesia

clipboard: Industry Says quote: allies say

Suriname
Colombia Maldives— Malaysia
POLAND 3.9 Equatorial Guinea—
Sao Tome and Principe—
Uganda
|
Nauru
|

In high-income settings, smoking and smoking-related deaths in women follow Gabon

Congo Kenya
Singapore Indonesia |

the patterns in men by about three decades—but this is not inevitable.

TURKEY 3.9 Ecuador
Dem. Rep. —Rwanda Kiribati
—Burundi Papua New Guinea
of Congo —Seychelles
United Republic
of Tanzania

TREND, JAPAN “As globalization brings iPhones, movies, and

Peru Brazil
Angola Malawi
—Comoros
—Timor-Leste Solomon Islands

Tuvalu—
Zambia
Age-standardized smoking prevalence and lung cancer mortality: fashion to the developing world, it also brings…
Japan, 1950–2010
THE LIES OF TOBACCO COMPANIES Bolivia Mozambique Vanuatu—

MALE   
  FEMALE  ——  % PREVALENCE  LUNG CANCER MORTALITY RATE
in need of new female customers. I know these
Namibia
Botswana
Zimbabwe Madagascar
—Mauritius Samoa—
Fiji—

lies because I heard them all—smoking makes Paraguay

you stylish or attractive or independent. No on —Swaziland
Australia Niue—
MALE all counts—smoking kills, plain and simple.” S. Africa
Tonga—
—Lesotho
80%­— —40 Cook Islands—
—NANCY G. BRINKER, founder of the
MORTALITY RATE (DEATHS PER 100,000)

Susan G. Komen for the Cure Foundation, 2010 Chile

Uruguay

IN JAPAN, FEMALE

A
60%— —30 Argentina
SMOKING PREVALENCE

pproximately 176 million adult women worldwide are daily The example of Japan shows that this second stage of the
SMOKING HAS clipboard: Industry Says
PRODUCTS

smokers. Smoking rates in women significantly decreased from epidemic (the increase in female smoking prevalence) is
NOT FOLLOWED 40%— —20 New Zealand
1980 to 2013 in several high-income countries. However, smoking not inevitable TREND, JAPAN.
THE GLOBAL
products 2 products 3 industry 1

among women is still more common in high-income than in low- and

 

20%—
FEMALE
—10 Tobacco companies attempt to link smoking to women’s
——

middle-income countries.
EPIDEMIC MODEL. rights and gender equality, as well as glamor, sociability,
 

0%— —0
Although smokeless tobacco use by South Asian women is relatively enjoyment, success, and slimness. They use various strategies to
“One [hypothesis] is
| | | | | | |
common (see Chapter 14: Smokeless Tobacco), female cigarette promote the social acceptability of smoking in women, including
1950 1960 1970 1980 1990 2000 2010 the greater concern
smoking in most Asian and African countries is uncommon. product development (e.g. flavors and aromas), product design women have that
No single institution owns the copyright for beauty. Furthermore, smoking rates decreased in several Asian and African (e.g. packs that are more appealing to women) and advertising, if they stop smoking
—Virginia Slims advertisement they will gain weight.
countries from 1980 to 2013. However, appropriate tobacco control involvement in social responsibility programs, and using the
programs must be in place to prevent an increase in smoking rates influence of popular media. THIS FEAR
UNDERREPORTING OF USE CHEMICALLY VERIFIED SMOKERS UNDERREPORTING LEADS TO UNDERESTIMATION OF IMPACT ON WOMEN
Of 1,620 chemically-verified smokers, 12% of men and 59% of women
among women in the future to ensure that low- and middle-income
countries will not follow the pattern of the global smoking epidemic.
Some people, especially women, smoke in order to lose or control UNDOUBTEDLY
Underreporting of tobacco use among FEMALE SELF-CLASSIFIED MALE classified themselves as non-smokers. In societies such as South Korea, In this model, first the male smoking prevalence substantially
weight. Healthy diet and exercise have shown to be more efficient PREVENTS
women in South Korea: 2008 59% NON-SMOKER 12% where it is generally not socially acceptable for women to smoke in public,
increases, and over the following 3–5 decades smoking rates
and less harmful ways to control weight or obesity, with additional
benefits beyond weight control alone.
MANY WOMEN
smoking in private may still occur and stay hidden to survey researchers. from desiring
This underreporting will lead to the underestimation of the impact tobacco increase among women TREND, USA . to stop smoking.”
products 2 products 3 industry 1

use has on women in such societies. — Lorillard, 1973

 clipboard: Industry Says
clipboard: Industry Says quote: allies say

36 CALL TO ACTION 37

Chapter
In order to prevent youth tobacco use, comprehensive regulations to reduce the affordability E-CIGARETTE USE
11 and accessibility of tobacco products must be implemented or enforced, including taxation, bans
on tobacco advertising, promotion and sponsorship (TAPS), and the minimum legal sale age.
In October 2013,
a German court banned the
“Be Marlboro” campaign, finding
that in violation of Germany’s
Prevalence of e-cigarette use in youth by age or school grade (%): 2011–2013
EVER   
  CURRENT/FREQUENT refers to e-cigarette use during last month (United States and Korea Rep.) or at least monthly (United Kingdom)
“IT’S A SHAME FOR OUR
FAMILY LINE THAT YOU AND
YOUR BROTHER ARE
These regulations must include all tobacco products. tobacco advertising law it
encouraged children to smoke. 12% 12% NOT SMOKING
“THE FACT THAT PMI [PHILIP —all the men in our family smoke—
STUDENT TOBACCO USE PURCHASING CIGARETTES MORRIS INTERNATIONAL]
12% —
your father, your grandfather.
You are breaking the chain of our

Prevalence of current use of tobacco products: by World Health Organization region, Percentage of current smoker students CONTINUES WITH THE 10% family’s smoking history.”
Although data on youth —A young Indonesian man
in students ages 13–15 in select countries (%), 2010–2011 who usually get their cigarettes by purchasing
CIGARETTES   
  OTHER PRODUCTS them in a store: ages 13­–15, 2010­–2011 MARLBORO CAMPAIGN IN 10% — e-cigarette smoking
from national surveys
recounting his uncle’s shame that
he does not smoke, 2009

AFRICA SOUTH 13%

53% ASIA DESPITE BEING FOUND are sparse, available
AFRICA 14%
GUILTY IN GERMANY data show that current
e-cigarette smoking
UGANDA
5%
23%
only goes to show they want Asia’s 8% —
among high school 7% In 2009,
16% children no matter what. We have
to stop them and protect our students in the United
41% OF INDONESIAN BOYS
ages 13–15 were current
6% children using stringent laws.” States tripled from 2011
ZAMBIA 23% cigarette smokers.
24% —MARY ASSUNTA, senior policy advisor, to 2013. Of teens in the same age range
Southeast Asia Tobacco Control Alliance, 2014 6% —
who bought cigarettes in a store,
AMERICAS 15% 59% were not refused purchase
MEXICO
10%
39% 4% 6% because of their age.

TRINIDAD
AND TOBAGO
9%
12%
29% 4% — 3% 5%
6%
VENEZUELA 26%
5%
2% — 3%

5.6M
EASTERN LIBYAN
4%
MEDITERRANEAN ARAB 28%
JAMAHIRIYA
6%
2%
SAUDI 9%
21% 0% — 1% 1%
YOUTH USE

ARABIA 11% Although youth smoking rates

in the United States halved AGES 11–15 AGES 16–18 GRADES 6-8 GRADES 9–12 GRADES 7–9 GRADES 10–12
SYRIAN
7% during 1997–2011, one out of
ARAB 34% UNITED KINGDOM UNITED STATES KOREA REP.
23% every 13 American children 2013 2013 2011
REP.
under age 18 alive today

G
(around 5.6 million children)
EUROPE CZECH 31% lobally, cigarette smoking is common among youth. commercials; having depression, anxiety, or stress; and
REPUBLIC 17%
48% WILL DIE PREMATURELY Another serious concern is that other tobacco higher accessibility and lower prices of tobacco products.
In the United Kingdom in 2011,

ITALY* 21% 49%

from smoking-related diseases
unless current smoking rates products—including pipes, hookahs, smokeless
Tobacco pricing and stronger regulations are crucial
EVERY DAY AROUND
clipboard: Industry Says quote: allies say
drop further. tobacco, or bidis—are also commonly used by youth
to addressing the youth tobacco epidemic. Teens are 600 BOYS AND GIRLS
17% worldwide. In fact, prevalence of use of these products ages 11–15
UKRAINE 54% particularly sensitive to tobacco pricing; higher prices
10% (over 200,000 a year)
*Other product data not available is higher than that of cigarettes in many countries,
prevent many of them from becoming regular tobacco
SOUTHEAST ASIA
particularly in Southeast Asia, the Eastern Mediterranean,
users. Tobacco regulations are also important. As water pipe
TOOK UP SMOKING.
PRODUCTS

4%
MALDIVES 34% and sub-Saharan Africa STUDENT TOBACCO USE . These rates
10% products 1 products 2 products 3
smoking may be exempt from smoking bans in public
are even higher than the corresponding rates in adults in
NEPAL
3%
27% “VULNERABLE POPULATIONS many countries. This indicates the necessity for tobacco
places, more young people may smoke water pipes in social
gatherings in hookah (water pipe) lounges. The percentage In contrast to
19%
ARE MORE SUSCEPTIBLE regulations for adolescents to include tobacco products
of youth smokers who usually obtain tobacco products in
scientific evidence,
there is still an
SRI
LANKA
2%
10%
20% AND HIGHLY RECEPTIVE other than cigarettes, and the need to increase awareness
about their harms.
a store is high in many countries, but it can be reduced by
INCORRECT BELIEF
TO MARKETING. banning tobacco product sales to minors or enforcing the
THAT SOME TOBACCO
WESTERN PACIFIC Predatory tobacco industry retail Most regular smokers initiate smoking before 20 years of existing bans PURCHASING CIGARETTES. The minimum legal sale
25%
GUAM
24%
5% marketing practices aimed at
the culture and lifestyle of youth
age. Youth may have several reasons for starting tobacco
products 1 products 2 products 3

age for tobacco products in several countries is now 21 PRODUCTS ARE SAFE.
use, including looking ‘cool’, ‘mature’, or ‘sociable’, or years, which is more effective in reducing youth exposure “Our parents don’t
and low socioeconomic status
LAO 8% mind us smoking ‘shisha’
PDR
51% communities undermine the public believing that tobacco use is good for coping with stress to tobacco products than is the 18-years limit in effect in [a local water pipe] and
7%
health benefits of US and global and weight control. The factors increasing youth tobacco many other countries. it is not dangerous.”
9% tobacco control efforts.”
initiation may vary across countries, but some common “I play sports and would
PHILIPPINES 50%
7% —LA TANISHA C. WRIGHT, never smoke a cigarette
an anti-tobacco activist and a former trade factors are: tobacco use by parents or peers; exposure to because it harms the body
In addition to cigarette smoking, other tobacco products The percentage of youth smokers who usually marketing manager at Brown & Williamson tobacco advertising; acceptability of tobacco use among and you get cancer,
tobacco company, 2013
are commonly used by youth: in some regions, the rates get tobacco products by purchasing them in a peers or in social norms advertised in movies or tobacco but ‘shisha’ is quite safe.”
are even higher than cigarette smoking rates. store is high in many countries. —Two Pakistani young adults, 2009
 —

CALL TO ACTION THE VARYING STATE OF E-CIGARETTES WORLDWIDE

luxembourg
lithuania
denmark
bulgaria

the netherlands
germany

slovenia
portugal
romania
belgium

slovakia
hungary

sweden
estonia

ireland
finalnd
austria

poland
greece
cyprus

france

malta
czech

latvia

spain
italy
38 39

UK
Chapter
E-cigarettes should be regulated in such a PREVALENCE & USE
12 way as to reduce smoking of combusted tobacco
products to the greatest extentAustria
possible.
Belgium
AUT 13.7% 4.2%
BEL 11.5% 3.2%
Bulgaria BGR 31.1% 4.6%
E-cigarette prevalence and use as a cessation aid
in 27 European Countries, 2012
 EVER USED   
USED AS CESSATION AID
In a 2012 survey of 27 European
countries, 20.3% of all current
smoker respondents had ever used
e-cigarettes, and 3.7% had used 80%
PREVALENCE
GREAT BRITAIN
Approximately 2.1 million MANUFACTURING &
PREVALENCE
Cyprus CYP 23.6% 5.4% adults in Great Britain use
Czech Republic CZE 34.3% 6.6%
them as a cessation aid. CHINA
“The World Health e-cigarettes. Of these, about
Denmark DNK 36.3% 5.3%
40%–40%­— 700,000 are ex-smokers, while
E-CIGARETTE MECHANICS
Estonia EST 22.3% 2.8% Organization reckons Despite manufacturing 95%
Finland FIN 20.5% 3.2%
France FRA 22.6% 3.9%
30%—
that of the one billion 1.3 MILLION ARE DUAL REGULATION
of the world’s e-cigarettes in
Germany DEU 20.2% 2.8% 30%— smokers globally, Shenzhen, China, e-cig use
Greece GRC 22.4% 8.8%
80% live in low- &
USERS OF TOBACCO UAE in the country is very small.
How does an e-cigarette work? Hungary HUN 22.3% 4.7%
Ireland
Italy ITA
IRL
8.8%
12.1%
2.9%
2.7%
20%—
20%—
middle-income AND E-CIGARETTES. The UAE Ministry of Health In 2013, Smoore, a Chinese
e-cigarette manufacturer,
E-CIGARETTES are battery-powered devices that resemble
Latvia LVA 23.9% 1.7% 20%—
countries, most of
BANNED E-CIGARETTE USE
Lithuania
cigarettes and heat liquid nicotine, producing a vapor
Luxembourg LUX
LTU 11.8%
28.0%
0.6%
3.7%
10%­—
which are markets that
GROWTH REGULATION throughout UAE nations due SHIPPED MORE THAN
that is inhaled.
Malta MLT 16.7%
Poland POL
3.6%
31.0% 5.2%
10%— HAVE NOT YET IRELAND EUROPEAN UNION to health concerns. 100 MILLION E-CIGARETTES
Portugal
Romania
PRT
ROU
17.0%
22.2%
0.4%
5.1% 0% 0%— BEEN PENETRATED PREVALENCE E-CIGARETTE SALES By May 2016, all 28 European TO OTHER COUNTRIES,
E-CIGARETTE COMPONENTS Slovakia SVK 7.9% 1.3%
USA Union Member States will primarily Europe and the USA.
GREW BY 478%
| | | | | | | | | | | | | | | | | | | | | | | | | | |

Slovenia SVN 20.3% 2.3%

BY E-CIGS.”

AUSTRIA

BELGIUM

BULGARIA

CYPRUS

CZECH REPUBLIC

DENMARK

ESTONIA

FINLAND

FRANCE

GERMANY

GREECE

HUNGARY

IRELAND
italyITALY

LATVIA

LITHUANIA

LUXEMBOURG

MALTA
the NETHERLANDS

POLAND

PORTUGAL

ROMANIA

SLOVAKIA

SLOVENIA

SPAIN

SWEDEN

UK
regulate e-cigarettes as part
CARTRIDGE that contains liquid nicotine and/or other
Spainingredients

luxembourg
ESP 10.9% 2.3%

lithuania
denmark
bulgaria

netherlands
germany

slovenia
portugal

romania
belgium

slovakia
hungary
in 2013, generating €7.3

sweden
estonia

ireland
finalnd
austria

poland
greece
cyprus

france

malta
czech

latvia

spain
of the EU Tobacco Products
Sweden SWE 12.4% 2.5%
90% OF US ADULTS

UK
HEATING MECHANISM to vaporize nicotine
The Netherlands NLD 21.9% 2.5% ­— DEREK YACH, million in revenue, while Directive. Manufacturers will REGULATION REGULATION
UK GBR 26.9% 4.8% were aware of e-cigarettes
clipboard: Industry Says
SENSOR to detect when a smoker puffs
quote: allies say clipboard: Industry Says quote: allies2014say
SVP & Executive Director of
Vitality Institute, in a 2014 survey.
tobacco sales dropped 6%. be required to disclose all SINGAPORE AUSTRALIA
ingredients and toxicological
In Singapore, the
REGULATION &
PREVALENCE
data, and also provide a
importation, distribution and
BY LAW, LIQUID NICOTINE
description of the production
BATTERY LED light
FRANCE process. Additionally, the SALE OF E-CIGS IS CONSIDERED A POISON
MICROPROCESSOR to control heat and light in Australia and the retail sale
As of January 2014,
In 2013, the French amount of nicotine in IS PROHIBITED of liquid nicotine is allowable
e-cigarettes and refill
“There is ongoing debate within the nicotine and tobacco “We’re trying to bring
there were more than HEALTH MINISTER containers will be limited,
and carries a fine up to only by permit.
TANK SYSTEMS function similarly as e-cigarettes but have PROPOSED A BAN ON $5000 Singapore dollars.
larger atomizers, batteries and nicotine cartridges, or
research community concerning whether electronic cigarettes back the chic attitude, 7700 E-CIGARETTE products will be required to

WILL OFFER A WAY OUT OF THE SMOKING THE SEXINESS E-CIGARETTE USE. carry health warnings, and
tanks. Users are able to add different concentrations of FLAVORS AVAILABLE, 88% of French survey E-CIGARETTE ADVERTISING
liquid nicotine to tank systems resulting in varying, and
typically higher, doses of nicotine delivery.
EPIDEMIC OR A WAY OF PERPETUATING IT. IN SMOKING.” with approximately
200+ new flavors being
respondents were aware
of e-cigarettes, and one in
WILL BE BANNED.
Robustly designed, implemented and accurately reported —OLIVER GIRARD, introduced monthly. five had used e-cigarettes
E-CIGARETTES

scientific evidence will be the best tool we have to help Chief Executive of
us predict and shape which of these realities transpires.” Smarty Q E-Cigarettes,
at least once.
2013
—SARA HITCHMAN, ANN MCNEILL & LEONIE BROSE,

E BIG TOBACCO & E-CIGS

Editorial in Addiction, 2014 lectronic cigarettes, also known as e-cigarettes or
electronic nicotine delivery systems, were introduced
to the market by Chinese entrepreneurs in 2004 and
USA E-CIG REGULATION E-CIGARETTE MARKETING CONCERNS have skyrocketed in awareness, use, and controversy over
smoking, delay or prevent cessation attempts, promote
youth use, and draw former smokers back into nicotine
addiction USA E-CIG REGULATION. Additionally, this booming
harm 1

industry is increasingly run by tobacco companies —the

All major tobacco companies have
e-cigarette products on the market
the past decade PREVALENCE & USE . E-cigarettes represent a same companies that have long promoted dangerous or under development.
E-cigarette concerns & implications for policy Marketing in the absence of regulation resembles traditional cigarette advertising. harm 1

booming industry, estimated at USD2.5 billion in the USA products over consumer health. On the other hand,
COMPANY E-CIG
ISSUES & CONCERNS POLICY RECOMMENDATIONS in 2014. many believe that e-cigarettes represent the best hope
for a disruptive technology that can begin the end of
YOUTH Initiation doubled in one year. Implement minimum age of E-cigarettes mimic traditional cigarettes in design and are
purchase laws. traditional smoking, saving millions of lives. Lorillard Blu Skycig
often assumed to be “safer” than traditional cigarettes, or
CURRENT Most e-cig users continue to Discourage long-term dual use. to help smokers quit E-CIGARETTE MECHANICS. While these health Currently, there is a significant focus on e-cigarettes and
SMOKERS smoke, although some may
PRODUCTS

harm 1

claims are implied, they are not usually stated explicitly, as much research is underway to determine health impacts Imperial Puritane
quit completely.
this might trigger additional regulation. and help inform regulations. For now, this multi-billion
UNSUBSTANTIATED CLAIMS
EX- Returning to “safe” nicotine Restrict marketing targeted dollar industry continues to grow as more people use
SMOKERS may be attractive to former at ex-smokers (e.g. “Welcome Unsubstantianted health and wellness claims are a Many governments, organizations, companies and
smokers (potential relapse to Back” campaign). concern in e-cigarette marketing. Nutri Cigs purports to
consumers are uncertain how e-cigarettes should be
e-cigarettes out of curiosity, a desire to quit smoking, or a BAT Vype
smoking). help users lose weight, sleep better and increase energy. safer way to continue a nicotine addiction.
regulated. E-cigarettes deliver nicotine, and their health
NON- Companies are advocating Regulate vaping in indoor areas “WELCOMING BACK” EX-SMOKERS MARKETING TO YOUTH effects are unknown; yet they are assuredly less harmful
SMOKERS’ e-cigs be used anywhere to so that it does not undermine Altria Mark Ten
RIGHTS
E-cigarettes are being marketed to Lorillard's claim that than traditional tobacco products that burn tobacco.
increase their acceptance existing clean indoor air laws.
“Welcome Back” smokers who have “responsible e-cigarette Tobacco companies recognize the potential of this
and use. Nearly 48% of US adult e-cigarette users have used
previously quit. manufacturers, including
growing market and are investing heavily in e-cigarette combustible cigarettes and e-cigarettes on the
NICOTINE Upsurge in calls to poison Require child-proof packaging “Though the primary message is blu e-cigs, do not market to
same day. Dual use of e-cigarettes and traditional
Reynolds Vuse
POISONING control centers for children and appropriate labelling of that people can smoke e-cigarettes youth” is clearly false. brands BIG TOBACCO & E-CIGS. cigarettes is a public health concern, as
harm 1

under 6 years from liquid liquid nicotine. indoors, FIN’s choice of a diner
nicotine poisoning. from the 1950’s—a time when On an individual level, e-cigarettes are likely less harmful SMOKERS COULD BE EXPOSED TO EVEN JTI E-Lites
smoking was perfectly acceptable— to a user than traditional cigarettes, but additional research
DRUG E-cigs are being used for Consider regulating e-cigs as is the ad's booster engine, a is needed about the effects of e-cigarettes, long-term
HIGHER AMOUNTS OF NICOTINE.
DELIVERY other drugs, particularly drug delivery devices, or even subtle but powerful underlying sell CELEBRITY ENDORSEMENTS
DEVICES hash oil. as drugs (like nicotine that runs on pure nostalgia.” E-cigarette companies are using famous spokespeople, consequences of use, and ingredients. Public health experts
replacement therapy), to allow for PMI Nicolite
—Adweek, May 2012
such as Jenny McCarthy, to market their products. are concerned that e-cigarette use could renormalize
possible future health claims.
 40 CALL TO ACTION WATER PIPE USE 41

Chapter
Governments should regulate water pipes and their use in the same ways as all other NAMES FOR WATER PIPES Percentage of adults currently using

13 combustible tobacco products, and the use of water pipes in public places should not
be exempted from smoke-free laws.
English and native script and the countries where
a name predominates A SINGLE PUFF
FROM A WATER PIPE
water pipes in Middle Eastern countries

HOOKAH हुक्का / ‫حُقّة‬

(450mL) is nearly equal 12.5%
MA'ASSEL IN SYRIA India, Pakistan, United Kingdom, USA
to the volume of smoke
clipboard: Industry Says
inhaled from an entire
cigarette (500mL).
quote: allies say Syrian
Arab Rep.
LESS THAN 2%
Afghanistan
Most water pipe smokers in Syria started smoking in the early 1990s, NARJILA ‫نرجيلة‬ Tunisia 2—10%
after the introduction of ma’assel. Morocco 22.4% Turkey
Armenia, Azerbaijan, Cyprus, Greece,
Lebanon
Isl. Rep. MORE THAN 10%
Iraq, Israel, Italy, Jordan, Lebanon, of Iran Pakistan
40 —
Palestine, Syria, Turkey, Uzbekistan Algeria —­­­Israel
Kuwait
| NO DATA
The promotion of water Bahrain—­­­
35 —
pipe use is rooted in wilful Egypt —Qatar
(N) ARGHILE НАРГИЛЕ ongoing misinformation that Saudi UAE
30 — hookah water can magically Arabia
Bosnia and Herzegovina, Bulgaria, Croatia,
NUMBER OF SMOKERS

clean up tobacco smoke.

25 — Republic of Macedonia, Serbia
Nothing could be further
from the truth.
20 —
MA'ASSEL QALYAN ‫قلیان‬ “WATER… HAS ONLY A
INTRODUCED
Iran
15 —
SMALL EFFECT ON THE
10 — ÐIÊU CÀY ĐIẾU CÀY REMOVAL OF TAR AND
Viet Nam
5— TOTAL NICOTINE.”
0—
| | | | | |
SHISHA ‫شيشة‬ —British American Tobacco
Research & Development, 1967
1950 1960 1970 — %05 1980 1990 2000 Egypt,
YEAR OF INITIATION South Africa

In a 2002 survey of water pipe cafés in Aleppo, most water pipe smokers reported initiating smoking after 1990,
— %04
a date marked by the introduction of ma’assel smoking tobacco.
WATER PIPES

INCREASING PREVALENCE WOMEN AND WATER PIPES

T
he water pipe is a tobacco smoking device with roots in studies on the long-term health effects of water pipes are
— %03
52% India, Africa, and the Middle East. Water pipes have been still forthcoming. However, health scientists confidently
Evidence from Jordan and USA Proportion of all tobacco users who used water pipes: by sex, 2011 used for centuries, but the introduction of ma‘assel in the predict that water pipe smoking will cause large-scale
 FLORIDA BOYS AND GIRLS   
JORDANIAN GIRLS   
JORDANIAN BOYS — %02
 WOMEN   MEN — %05 early 1990s, a molasses-soaked smoking tobacco, triggered sickness and death similar to other forms of tobacco.
a surge in use outside the traditional water pipe user base of
Water pipe use has spread beyond the Middle East and is
Water pipe use is especially difficult to confront older males MA'ASSEL IN SYRIA . Water pipes employ an indirect
products 1 products 2 products 3
becoming integrated into the global tobacco market
because it often happens in homes, away from where heat source (such as lit charcoal) to slowly burn tobacco
— %01 NAMES FOR WATER PIPES . In 2012, Japan Tobacco International

70% —
traditional social pressures and policy interventions
like smoking bans can have an impact.
33%
— %04 leaves while users draw smoke down through a water
chamber and into their mouths through hoses. Along with
products 1 products 2 products 3

purchased Al Nakhla, then the world’s largest water

pipe tobacco manufacturer. Other transnational tobacco
MA’ASSEL
the sugary molasses, ma‘assel is flavored heavily with apple, Ma’assel, the molasses-soaked smoking
— %0 companies have explored moving into the water pipe
banana, orange, vanilla, and other fruit or candy tastes. tobacco commonly burned in water pipes
PRODUCTS

60% — tobacco market. Otherwise-strong smoking bans in Europe

23% 34%
%03
Water pipe smokers often falsely believe that their form of and North America sometimes have specific exemptions
in the Middle East, Europe, and North
America, was introduced to the world in
50% — tobacco use is safer than smoking cigarettes, a notion which allowing the smoking of water pipes in cafés, enabling
the early 1990s.
EVER USE OF WATER PIPE (%)

must be dispelled by thorough, aggressive educational public smoking in otherwise smoke-free areas. Water pipe
40% — Up to 77% of ma’assel packages
efforts. When hot smoke passes through water at the base use is also on the rise among adolescents and young adults
— %02 indicate the percentage of ‘tar’ in the
30% —
13% of the water pipe, the smoke cools, and is then easily and on college campuses and beyond, even among people who product as 0.0%.
deeply inhaled by even first-time tobacco smokers. The explicitly refuse to smoke cigarettes WOMEN AND WATER PIPES,
9% heavily flavored and cooled water pipe smoke is inhaled in
products 1

INCREASING PREVALENCE . Researchers must quantify the harms

products 2 products 3
THE TOBACCO INDUSTRY DELIBERATELY
20% —
massive quantities. The water’s cooling effect may actually
products 1 products 2 products 3

to health of this method of tobacco use and determine MISREPRESENTS THE HARM POSED BY
4% 13%
— %01
be increasing harm by enabling water pipe smokers to inhale the best methods to stem the rise of water pipe use around SMOKING WATER PIPE TOBACCO.
10% —
smoke deeper into their lungs. the globe.
0% — 9% 8% Water pipe smoking is associated with elevated risks of lung,
— %0
lip, mouth, and esophageal cancers. As widespread water
2008
2009
2010
2011

2008
2009
2010
2011

2008
2009
2010
2011

pipe use is a recent phenomenon, large-scale high-quality

The prevalence of water pipe use among students has 2% 2%
increased dramatically in Jordan and the USA. MOROCCO ALGERIA JORDAN UAE PAKISTAN SAUDI
ARABIA
 42 CALL TO ACTION Iceland
ADULT USE 43

ndustry
Chapter
SaysBecause smokeless
quote: allies
tobaccosay
products are not harmless, their regulation
Sweden Finland Prevalence of adult

14 smokeless tobacco use:

Norway
should be tightly integrated into tobacco control policies. 2013 or most recent
Latvia
United Denmark
Kingdom

PROCESSING IMPACTS CARCINOGENS Canada

Ireland Netherlands
Poland
Russian Federation

LESS THAN 1.0%

By using existing laws,
Effect of processing on a key group of carcinogens Czech Rep.
tobacco control proponents were able to Ukraine
ban gutkha sales in India: in smokeless tobacco products from around the world: Austria Rep.
1.0—4.9%
Switz. Hungary Moldova
France
“Product not to contain any substance Tobacco-Specific Nitrosamines (TSNAs) in ng/g
which may be injurious to health:
—Croatia Romania
Mongolia
5.0—9.9%
Kazakhstan
PASTEURIZATION FACTORY COMPOST PILE
TOBACCO AND NICOTINE SHALL SWEDEN FERMENTATION FERMENTATION Albania
Bulgaria

Uzbekistan
DPR
Korea
10.0—19.9%
NOT BE USED AS INGREDIENTS IN USA SUDAN United States of America Portugal Spain
Italy
Greece
Georgia
Armenia— —Azerbaijan
Turkmenistan
Kyrgyzstan

Tajikistan
20.0% AND ABOVE
ANY FOOD PRODUCTS.” Syrian NO DATA*
­— Food Safety and Standards Authority of India, 2011 Tunisia
Arab Rep. Afghanistan China
Iraq
SNUS SNUFF TOOMBAK Pakistan
Nepal
| Bhutan
|
FEMALE MAJORITY
Libya
Countries where female prevalence is
Algeria

EDUCATION AND USE MIN

601
MIN
1,520
MIN
295,000
Mexico
Egypt

Saudi Arabia
—Qatar

India | Myanmar
LAO
higher than male prevalence

Dominican Rep. Bangladesh

Haiti PDR
Adult male tobacco use by level of education Mauritania
—St. Kitts & Nevis Mali
in Madagascar: ages 15–59, 2009 5,850 20,500
Honduras
—Cape Senegal
Niger Eritrea Yemen
Thailand
Viet Nam
Philippines

SMOKELESS TOBACCO   
  SMOKING TOBACCO
  MAX Verde Sudan
MAX —Barbados —Gambia Chad Cambodia
SMOKELESS TOBACCO

—Grenada Burkina Faso

Costa Rica —Trinidad & Tobago Guinea
Benin
Sierra Leone— Côte Ghana Nigeria Ethiopia
Panama Venezuela —Guyana
D’Ivoire Sri Lanka |
Togo |
NO EDUCATION Liberia— Fed. States of Marshall Islands
Cameroon Micronesia
Tobacco leaves, when processed
differently, can create products with
OVER 50% OF Equatorial Guinea— Uganda
Maldives— Malaysia

PRIMARY vastly different carcinogens levels. ORAL CANCERS IN Sao Tome and Principe—
Gabon
Congo

Dem. Rep. —Rwanda

Kenya
Indonesia

The levels of TSNAs (a major group

of carcinogens) vary dramatically
SUDANESE MEN *70 countries have never
of Congo
—Burundi

United Republic
—Seychelles

SECONDARY are caused by the of Tanzania

as a consequence of manufacturing use of collected smokeless —Timor-Leste

processes that increase microbial smokeless tobacco Brazil tobacco use data, leaving —Comoros
Malawi
production of nitrite, which reacts products. them with an incomplete Zambia
HIGHER EDUCATION
| | | | | | | to form TSNAs. picture of tobacco use Mozambique Madagascar
30% 20% 10% 0 10% 20% 30%
in their country. Such Namibia
Zimbabwe Samoa—

Smokeless tobacco use in Malagasy men decreases information needs to be

Paraguay
as they become more educated, making smokeless collected in future tobacco
—Swaziland
surveillance efforts. Australia Niue—
the burden of the poor. By contrast, smoking tobacco S. Africa
—Lesotho
is used equally by men of all education levels. 992,000
clipboard: Industry Says quote: allies say MAX

O
Argentina

YOUTH USE ver 300 million people around the world, the vast majority of dissolvable products failed in the United States, and snus
PRODUCTS

whom live in South Asia, use smokeless tobacco products brand extensions were commercial failures in Canada and South
YOUTH USE . In over a dozen countries, more women than men Africa. By contrast, in 2012, the Indian Supreme Court disrupted
Prevalence of smokeless tobacco use among youth: products 2 products 3 industry 1

Aged 13 to 15 years, by WHO region, 2013 or most recent use smokeless tobacco, reflective of the differing norms in each the world’s largest smokeless tobacco market when it ruled that
Flavored smokeless tobacco products
have consistently been perceived… as
HIGHEST   
  MEDIAN   
LOWEST culture of smokeless use. Smokeless tobacco use definitively causes gutkha and pan masala were dangerous food products, the sale of
“for beginners” or a way to recruit cancers of the head and neck. More than 40 types of smokeless which could be temporarily banned under Indian food safety laws. Smokeless tobacco
30% — Palau
PREVALENCE OF SMOKELESS TOBACCO USE

younger men to try the product. tobacco products are ingested by nose or mouth around the world. India’s manufacturers responded by producing smokeless tobacco products are often sold
A former [US Tobacco] 25% — with more flavorings
sales representative revealed that
An ongoing chain of chemical reactions during the preparation of products that are not classified as food. The reaction of India’s
Gambia than candy.
smokeless tobacco products between bacteria and tobacco leaves smokeless tobacco users to the bans remains unclear.
AMONG YOUTH (%)

20% —
“CHERRY SKOAL IS Nepal makes up the chemical-microbial dynamic PROCESSING IMPACTS CARCINOGENS.
Wintergreen smokeless
tobacco products
15% — Bringing smokeless tobacco products into tobacco control
FOR SOMEBODY WHO LIKES THE Botswana
Djibouti Norway This dynamic influences the concentration of the same deadly
products 2 products 3 industry 1

regulatory frameworks is essential to managing the harms caused

have been found to have

TASTE OF CANDY, IF YOU KNOW

10% — Barbados
Syrian
Sri Lanka
Korea Rep.
chemicals in smokeless tobacco that cause disease in combustible
by these products. Research will inform future policy action on
6 TIMES MORE
5% — Swaziland Belize tobacco users. flavoring than
WHAT I'M SAYING.” Arab Rep.
Oman
Tajikistan
Montenegro
Indonesia
Malaysia smokeless tobacco. The question of whether using smokeless wintergreen candies.
0% — Canada The size of the smokeless tobacco market in high-income countries tobacco changes the likelihood of a person to use cigarettes Without these flavorings,
­—Wall Street Journal, 1994
AFRO AMRO EMRO EURO SEARO WPRO remains relatively stable. The 2014 European Union Tobacco is hotly debated EDUCATION AND USE . There is more to learn about
smokeless tobacco use
products 2 products 3 industry 1
would be much more
Smokeless tobacco use among youths ensures that the health harms caused by smokeless tobacco Products Directive left a ban on snus sales in place in every EU opportunities to regulate product flavorings, health warnings, and difficult to initiate.
are not likely to soon fade. country except Sweden. In recent years, the test marketing of novel products.
 DECEPTION
The tobacco industry often
facilitates illicit trade,

The tobacco industry profits on the harm exaggerates the scope of

the problem, and makes
unsubstantiated claims about

caused to their customers.

new tobacco control measures’
impacts on illicit trade levels.

INDUSTRY
T
he tobacco industry, driven only by profit, seeks to manipulate
consumers to buy more of their products with no regard
for the consequent harms. Governments and societies must
not only seek to end the industry’s deplorable behaviors, but
VULNERABLE
POPULATIONS
“So ladies and gentlemen,
this is the kind of tobacco
industry tactic. They just
want more and more market
share. They could not care less
if they are killing children.”
—DR MARGARET CHAN,
Director-General of the WHO, 2014 DEVELOPMENT
Over 85% of all cigarettes
smoked globally are being
produced by only six
also using the lessons from fighting this epidemic — particularly transnational companies, each
effective population-level policy interventions — they can make having gross revenue that
is comparable to the gross
certain that something similar does not happen with other domestic product of a small
industries that potentially harm our well being. country. In the battle for
public health, few low- and
middle-income countries
have the experience and
resources that could match
those of the transnational
tobacco industry.
 46 CALL TO ACTION “The hardest of all the crops we’ve worked in is tobacco. You get tired. No patterns
LAND DEVOTED TO GROWING TOBACCO 47

Chapter It takes the energy out of you. You get sick, but then you have Production by country:
International organizations and national governments must help tobacco
15
to go right back to the tobacco the next day.”
area in hectares, 2012
farmers to ease the transition to alternative crops beyond tobacco. ­— DARIO A., 16-year-old tobacco worker in Kentucky, USA, 2013

TOBACCO AND UNDERNOURISHMENT LAND USE

3/4
Countries who NO TOBACCO GROWN
Countries that are among the top 25 tobacco leaf producing countries dedicated 1% or
AND have more than 10% undernourishment more of arable land
Rep.
LESS THAN 1,000
to growing tobacco:
= 10,000 TONNES A US study found that Moldova
Kyrgyzstan 1,000—4,999
nearly three quarters of 2011 Albania
Turkey Tajikistan
Greece
children aged 7-17 who
COUNTRY TONNES (2012) UNDERNOURISHMENT (2011–13)
were laboring in tobacco LEBANON 7.5% 5,000—9,999
fields in the USA
Lao PDR 40,600 27% FYR MACEDONIA 4.8% 10,000—99,999
Philippines 48,075 16%
EXPERIENCED MALAWI 4.5%
Cuba

SYMPTOMS OF GREEN DPR KOREA 2.3%

Honduras 100,000 OR MORE
Mozambique 54,450 37%
TOBACCO SICKNESS. ZIMBABWE 2.3% NO DATA
Zambia 61,500 43% This is ironic as it is illegal ZAMBIA 1.7% Malaysia
for children under 18 to 50% REDUCTION
UNITED REPUBLIC Countries that have
DPR Korea 80,000 31% purchase cigarettes, yet
OF TANZANIA 1.5%
they can be employed reduced the percent
Bangladesh 85,419 16% in tobacco fields and JORDAN 1.3% of arable land for
experience illness from tobacco by 50% from
Pakistan 98,000 17% their labors.
CHINA 1.3% 2001 to 2011
MOZAMBIQUE 1.3%
Zimbabwe 115,000 31% ST. VINCENT AND
According to a US Department THE GRENADINES 1.1%
United Rep. of Tanzania 120,000 33% of Labor 2012 report,

Malawi 151,500 20% 16 COUNTRIES USE

CHILD LABOR IN THE
India 875,000 17%
PRODUCTION OF TOBACCO. PRODUCTION TRENDS 5—
 CHINA– BRAZIL– INDIA– USA– ARGENTINA

Trends in tobacco production (in metric tonnes) — CHINA GROWS

GROWING

4— 1980
by the major tobacco-producing countries — TOBACCO ON MORE
3—
AGRICULTURAL LAND

MILLIONS
In 1980, China’s tobacco —
production was similar to the 2—
than that of India, Brazil,
China 3,201,850 11% other major producers. Since ­—
Indonesia, Malawi and
United Republic of
that time, China has tripled its 1—
Tanzania combined.
—
tobacco production.
The populations in many of the top tobacco-growing nations suffer from undernourishment. 0—
| | | | | |
1961 1971 1981 1991 2001 2011

clipboard: Industry Says

ALTERNATIVE CROP CASE STUDIES
T
Crop substitution is a viable and lucrative alternative to growing tobacco. obacco leaf is grown in at least 124 of the world’s countries. farmers and government officials believe that tobacco is a
However, while some countries have had success, others are struggling.
INDUSTRY

CHINA’S ALTERNATIVE CROP EXPERIENCE KENYA’S ALTERNATIVE CROP EXPERIENCE
In 2008, a tobacco crop substitution pilot project began among more than 450 The Tobacco To Bamboo Project, which
families in the Yuxi municipality of the Yunnan Province in China. In 2010, farmers began in Kenya in 2006, has shown that
increased their annual profit per acre by up to 110% by growing other crops. shifting to bamboo growing is possible due
to farmer willingness and training at the
CROPS AVG. REVENUE – COST = AVG. NET PROFIT (PER ACRE) INCREASE IN PROFIT community level. It is estimated that annual
income from bamboo farming will be 4–5
times higher than tobacco at farm gate
ROOM FOR IMPROVEMENT WITH
ALTERNATIVE CROPS
Only 15% of WHO FCTC parties that
completed a 2014 implementation report
and that grow tobacco reported the
presence of support for viable alternatives
for tobacco growers. Five percent
reported alternatives being promoted for
In 2012, nearly 7.5 million tonnes of tobacco leaf was grown cash crop essential to their economic success. The short-
on almost 4.3 million hectares of agricultural land, an area term benefits of a crop that generates cash for farmers are
larger than Switzerland. China is the world’s leader in tobacco offset by the long-term consequences of increased food
production, with 3.2 million tonnes of tobacco leaf grown in 2012. insecurity, frequent sustained debt, environmental damage,
“R.J. Reynolds doesn’t employ
and illness and poverty among farm workers. farm workers or grow its own
In the same way that consumers are addicted to nicotine,
tobacco. Because
tobacco farmers are trapped in a vicious cycle of growing Food insecurity and poverty is a concern in many of
tobacco, which tobacco companies exploit. Tobacco the world’s largest tobacco-growing countries FARM WORKERS ARE NOT
companies are often the major buyers in countries, setting the TOBACCO AND UNDERNOURISHMENT. In October 2013, an expert OUR EMPLOYEES,
price and process of selling tobacco and requiring enormous
industry 1 industry 2 Solutions 1

meeting of the Conference of the Parties to the WHO we have no direct control over
Tobacco $9,940 $5,106 $4,834 prices, and 10 times higher when processed tobacco workers, and only 3% reported their sourcing, their training, their
at the community level to make products labor and land inputs. Moreover, the tobacco companies FCTC discussed economically sustainable alternatives pay rates, or their housing and
alternatives being promoted for tobacco
typically supply inputs very readily, but at above-market prices to growing tobacco ALTERNATIVE CROP CASE STUDIES. Because the
White Mushroom $12,877 $4,173 $8,704 80% such as baskets, furniture, etc. sellers. Much progress is needed
worldwide in promoting and providing and on poor credit terms that are unfavorable to the farmers.
industry 1 industry 2

transition from growing tobacco to growing healthful

Solutions 1
access to human services.”
—R.J. Reynolds Tobacco Company, 2014

the resources for countries to transition food products can be difficult and complex, support from
Over the past 50 years, tobacco farming has shifted from high-
Grapes $15,255 $5,080 $10,175 110% to economically viable alternatives to
to low- and middle-income countries PRODUCTION TRENDS. During
governments and international organizations is necessary
tobacco growing. industry 1 industry 2 Solutions 1
to break the cycle of poverty and illness resulting from
ALL FIGURES IN USD this time, Africa has seen a significant increase in tobacco
growing tobacco.
farming. More than 20 African countries grow tobacco. Many
 48 CALL TO ACTION Iceland
MARKET SHARE LEADERS 49

Chapter
clipboard: Industry Says quote: allies say By volume:
Sweden Finland
Tobacco companies should be strictly regulated in ways that minimize
16 2013 or latest available
Norway
the harm caused by their products. Estonia

Latvia
United Denmark Lithuania—
Kingdom
388B
REVENUE AND COUNTRY GDP Ireland Netherlands 151B Belarus

“We have developed

Canada Belgium 181B Poland
Russian Federation
China National Tobacco Corp
Revenue of top tobacco companies in comparison to the GDP in select countries: in USD Lux.—
Germany
Czech Rep.
Ukraine
TOBACCO COMPANY GROSS REVENUE: 2012 (2011 DATA FOR CNTC)
 
COUNTRY GDP: 2013
 
A CLEAR France Switz.
Austria
Slovakia

Hungary
Rep.
Moldova
Philip Morris International/Altria

$96.0
COMPETITIVE EDGE Slovenia— —Croatia
Bosnia & Serbia
Romania

Kazakhstan Mongolia
British American Tobacco
when it comes to Herzegovina

100— $78.1
$84.0 $95.2 reduced-risk products.
We believe that 304B Italy
Albania
Bulgaria
—FYR
Macedonia
Uzbekistan
DPR
Korea
125B Imperial Tobacco Group
148B Georgia Kyrgyzstan
Portugal Spain Japan

80— $76.4 $80.0 these products may

provide us with a
United States of America
Greece —Azerbaijan
—Armenia
137B Japan Tobacco International
unique opportunity —Malta
Turkey
2551B Korea Rep.
Other
BILLIONS USD

Cyprus— Syrian
60— for accelerated Tunisia Lebanon— Arab Rep.
Isl. Rep. China
$45.7
profitability growth Iraq of Iran
40—
$45.8 over the longer term.” Morocco
Jordan
—Israel
Kuwait—
Pakistan
Nepal
| NO DATA
$20.0 $23.9
Algeria Libya
$20.1 $24.5 ­—ANDRÉ CALANTZOPOULOS,

B
Egypt
20— Chief Executive Officer,
UAE
Bangladesh
—Hong Kong
LARGEST MANUFACTURERS
Philip Morris International,
2014
Mexico Cuba
Dominican Rep.
Saudi Arabia
India Myanmar
LAO
OF CIGARETTES
0— PDR Number of sticks produced:
Jamaica—

112B
JAPAN TOBACCO
INTERNATIONAL
UGANDA

ALTRIA/PHILIP
MORRIS USA
EL SALVADOR

IMPERIAL
TUNISIA

BRITISH AMERICAN
TOBACCOO
OMAN

PHILIP MORRIS
INTERNATIONAL
ECUADOR

CHINA NATIONAL

MOROCCO
TOBACCO CORP.
Honduras
in billions (B), 2013
Thailand Philippines
Guatemala Eritrea Yemen

NICOTINE MARKET
Senegal
El Salvador —Gambia Sudan Cambodia Viet Nam
Nicaragua Burkina Faso
—Trinidad & Tobago Guinea
Costa Rica
Ghana Nigeria Ethiopia
Recent moves by tobacco companies Panama Venezuela —Guyana Côte
D’Ivoire Togo Sri Lanka
to consolidate the nicotine market Cameroon
Colombia Maldives— Malaysia
Uganda

$44.1B
The 2013 profits of the top six tobacco companies are
251B
|
Kenya
2009 ALTRIA Singapore

EQUIVALENT TO THE COMBINED PROFITS Acquired U.S. SMOKELESS TOBACCO, the

Ecuador
Dem. Rep.
of Congo Indonesia
Papua New Guinea
of The Coca-Cola Company, Walt Disney, General Mills, FedEx, world’s leading moist smokeless tobacco United Republic
AT&T, Google, McDonald’s and Starbucks in the same year. of Tanzania
COMPANIES

manufacturer, for USD11.7 billion.

Peru Brazil
2009 REYNOLDS AMERICAN Angola
Zambia

E-CIGARETTE AND VAPOR MARKET Acquired NICONOVUM AB , a Sweden-based nicotine

replacement therapy company. Bolivia
Namibia
Zimbabwe
Mozambique
Madagascar
—Mauritius

The state of the e-cigarette market in the USA: in USD 2010 BAT Paraguay
Established NICOVENTURES to develop and commercialize
Tobacco companies are investing heavily in e-cigarettes Australia
non-nicotine tobacco products. S. Africa
to ensure they are part of this growing market.
2011 JTI Chile
2013 2014 2024 Uruguay
Secured a minority share in PLOOM, a US company which

T
USA MARKET LEADER USA E-CIG AND VAPOR MARKET VALUE FUTURE OF THE MARKET developed a pocket-sized smoking device that heats tobacco Argentina
he big business of tobacco is global in nature, and each part of CNTC contributes 7–10% of the country’s total
Lorillard’s e-cigarette brand, Blu, Projected at $2.5 billion, Wells Fargo analyst to vaporize nicotine and flavor.
clipboard: Industry Says quote: allies say
INDUSTRY

held 47% of the e-cigarette market compared to the nearly $80 billion Bonnie Herzog estimates that the tobacco business, from growing the leaf to manufacturing annual revenue through tobacco tax and profits. The New Zealand
share in the USA. for traditional cigarettes. e-cigs will surpass traditional 2012 LORILLARD products, contributes to the multi-billion dollar tobacco industry. complicated relationship between the Chinese tobacco
cigarettes by 2024. Acquired BLU E-CIGS in 2012 for USD235 million. In 2013,
Six companies lead the world’s tobacco business, but there are industry and tobacco control is best characterized by a
Lorillard acquired British e-cigarette company SKYCIG for GBP30 million.
at least 40 smaller businesses or state-owned monopolies that 2012 report which stated, “China’s top political leadership and
E-CIG AND VAPOR MARKET SIZE: $2.5B IMPERIAL
2013 manufacture cigarettes REVENUE AND COUNTRY GDP. the national tobacco bureaucracy are among the most crucial
Acquired DRAGONITE INTERNATIONAL LTD’S ELECTRONIC CIGARETTE
products 3 industry 1 industry 2

stakeholders in the country’s tobacco development and control.” “Neither nature, human
unit for USD75 million. Each year, the tobacco industry produces six trillion cigarettes, evolution, nor fate
E-CIGARETTES VAPORS/TANKS enough to create a continuous chain from Earth to Mars and In spite of decades’ worth of scientific and medical evidence created the new burdens
$1.4B $1.1B 2014 PHILIP MORRIS INTERNATIONAL back, multiple times. Nearly 500 tobacco factories have been about the dangers of smoking, one billion people continue to of chronic diseases and
injuries. Rather, it was
MARLBORO HEATSTICKS to be released in Japan and Italy in late 2014, documented worldwide, with the location of another 200 suspected smoke worldwide. The decline in smoking rates in high-income
TRACKED NON-TRACKED ONLINE VAPE SHOPS/
and expanded to other markets in 2015.
but unconfirmed. countries is more than offset by increased tobacco use in middle- HUMAN DECISIONS
$300M
made in corporate
CHANNELS CHANNELS* RETAIL 2014 TOBACCO COMPANY MERGERS and low-income countries. Tobacco companies know they must
$700M $700M $800M China grows more tobacco, manufactures more cigarettes, and boardrooms, advertising
In the ultimate market consolidation, Reynolds American has proposed a merger with find replacement smokers, and focus much of their effort in these and lobbying firms, and
also consumes more tobacco than any other country in the world. legislative and judicial
Lorillard, pending regulatory approval. If the deal is finalized as proposed, it will merge the low- and middle-income markets, which have the potential for
second and third largest tobacco companies in the USA. China National Tobacco Corporation (CNTC) posted revenues of chambers.”
ONLINE OTHER* economic and demographic growth, and thus increased profits
$350M $350M USD95.2 billion and profits of USD19 billion in 2011. The Chinese ­— NICHOLAS FREUDENBERG,
E-CIGARETTE AND VAPOR MARKET, NICOTINE MARKET. Lethal But Legal: Corporations,
Most of the major tobacco companies have expanded their product lines government profits financially from the manufacture and sale of products 3 industry 1 industry 2 products 3 industry 1 industry 2
Consumption, and Protecting
*NON-TRACKED CHANNELS include sales from small vapor shops and other channels that are not routinely collected due to size,
and are thus estimates. OTHER non-tracked channels include tobacco-only outlets and other e-cig retail locations. to include non-combustible nicotine products. tobacco, as well as from tobacco taxes collected by the government. Public Health, 2014
 50 CALL TO ACTION 51

Chapter
Governments should not heed tobacco industry threats of rising illicit trade as an excuse EXAGGERATED SCOPE INDUSTRY INVOLVEMENT Illegal Cigarettes:
Who's in Control?, a video

17 to postpone or avoid implementing strong tobacco control measures, but should take active
measures to fight illicit trade, such as employing comprehensive track-and-trace systems.
Tobacco industry estimates of illicit cigarette trade vs. estimates
from two surveys using transparent and rigorous academic methods:
Warsaw, Poland, September –October, 2011
The tobacco industry was, and almost certainly still is, involved in
cigarette smuggling. Cigarette seizures in Italy
created and distributed by British
American Tobacco tries to

LINK GOVERNMENT
REGULATIONS OF THE
22.9% 1800 — LAWSUIT
TOBACCO MARKET TO
EXAGGERATED IMPACT 1600 —

1400 — ILLICIT TRADE, VIOLENCE,

15.6% 1200 —
AND CRIME.

SEIZURES (TONNES)
THE INDUSTRY SAYS THE TRUTH THE PROOF: NO INCREASES IN ILLICIT TRADE
14.6% 1000 —

800 —

600 ­—
TAX INCREASES “THIS TAX RISE IS FURTHER Due to periodic cigarette tax
increases, the inflation-adjusted
CIGARETTE PRICES VS. ILLICIT MARKET SHARE
  AVERAGE PRICE PER PACK, (GBP) INFLATION ADJUSTED   
ILLICIT MARKET SHARE (%) 400 —
GOOD NEWS FOR CRIMINALS £7.5 — — 23%
price of cigarettes in the UK 200 —
who already view the UK as
increased by 37% from 2001 — 19%
0—
a smugglers’ paradise and £6.5 —
to 2012. At the same time the — 15%
do not care what age their 1994
| | |
1996
| |
1998
| |
2000
| |
2002
customers are.” ILLICIT MARKET SHARE DROPPED £5.5 —
— 11%

BY OVER TWO THIRDS. — 7% In November 2000, the European Commission filed a civil action
—Japan Tobacco International, 2010 Survey of littered Survey of packs Survey of littered
£4.5— — 3% against Phillip Morris and RJ Reynolds, accusing the companies of
| | |
packs presented by smokers packs
2002 2007 2012 being involved in smuggling cigarettes. Just after the lawsuit, the
INDUSTRY ESTIMATE TWO ACADEMIC STUDIES inflow of illicit cigarettes to Europe suddenly declined.

PLAIN PACKAGING “At the end of the day

NO ONE WINS FROM PLAIN
NO INCREASE IN AVAILABILITY OF
ILLICIT TOBACCO was observed
PERCENTAGE OF STORES OFFERING ILLICIT CIGARETTES
2.2% EXAGGERATED INDUSTRY'S DESCRIPTION OF THE ILLICIT MARKET
“GROWING
“INCREASED FROM
PACKAGING EXCEPT THE CRIMINALS URGENCY “ALARMING ILLICIT TRADE “EXPECTED “DOUBLED “SIGNIFICANT 7.9% IN 2008 TO

ILLICIT MARKET SHARE*

following the implementation 27.8% IN 2012”
who sell illegal cigarettes 1.3% IN 2010” INCREASE” 25%
of plain packaging in Australia. GROWTH” PROBLEM” TO GROW”
around Australia.” In South Africa, the tobacco industry
ILLICIT TRADE

0.6% 30% — 20% 20% 20% 22.5% 22.5%

—British American Tobacco Australia, 2012 has created the false impression 15% —
that illicit trade was rapidly growing, 0% —
| | | | | |
2012 2012 2013 which according to the industry’s own 2006 2007 2008 2010 2011 2012
PRE- DURING WITH estimates was not the case.
PLAIN PACKAGING IMPLEMENTATION PLAIN PACKAGING *Median from survey of media reports citing the industry
clipboard: Industry Says quote: allies say

DISPLAY BANS “WE BELIEVE THAT PRODUCT DISPLAY
BANS … FOSTER ILLICIT TRADE IN
TOBACCO PRODUCTS, as it is much
SALE
easier to disseminate such
products if they do not need to
be displayed.”
INDUSTRY
NO CHANGE IN PREVALENCE
of illicit cigarettes was
observed following the 2009
implementation of display
bans in Ireland.
T
obacco companies countered policy proposals aimed Tobacco companies are among the main stakeholders
PERCENTAGE OF ILLICIT PACKS IN A SURVEY OF PACKS IN SMOKERS’ POSSESSION to control tobacco use in the past by arguing that benefiting from illicit cigarette trade. Smuggling helps
16% cigarettes were not harming the health of smokers. Few these companies generate higher profits by enabling them
15% 15% people would believe those arguments today. That is why to pay tobacco taxes in jurisdictions with lower levies,
“Illicit is the industry’s
tobacco lobbyists reoriented the debate, and today the or to not pay taxes at all. It has been well documented
primary argument that the tobacco industry uses to oppose that the tobacco industry’s various business strategies
perfect response to
regulation is that new tobacco control measures will cause a to expand tobacco sales facilitated the illicit cigarette
controls on tobacco.”

—ANNA GILMORE, professor of public health

—Phillip Morris International, 2010 massive increase in cigarette smuggling EXAGGERATED IMPACT. trade. Worldwide, transnational tobacco companies have at the University of Bath, UK, 2014
products 3 industry 1 industry 2

2009 2010 2011 been found guilty of organizing illicit tobacco trade, and
PRE-BAN WITH THE BAN Because of the competing interests between profit-
have paid billions of dollars in fines and penalties in
maximizing tobacco companies and public health and
compensation INDUSTRY INVOLVEMENT.
welfare concerns, arguments regarding illicit tobacco trade products 3 industry 1 industry 2

PACK SIZE RESTRICTIONS “The introduction of minimum
pack sizes of 20 for cigarettes…
would ban the sale of 2 in 5
cigarette packs…, thereby
FORCING SMOKERS TO BUY…
MUCH CHEAPER PRODUCTS FROM
that tobacco companies are presenting in public discussions Implementation of tracking and tracing measures, such as
around new tobacco control regulations should be treated unique codes on every pack, would help to combat illicit
While in the mid-2000s
more than 15% of all cigarettes
NUMBER OF CONTRABAND CIGARETTES SEIZED BY FINNISH CUSTOMS
IN MILLIONS OF STICKS with particular caution. Studies paid for and presented by trade. The Protocol to Eliminate Illicit Trade in Tobacco
The UK employs thousands
of well-equipped staff
smoked in Finland were sold 18 cigarette manufacturers are generally not independently- Products, the first Protocol to the WHO FCTC, requires working to detect, investigate,
in packs of less than 16 and stop the illicit tobacco
verified or peer-reviewed and, unlike academic research parties to implement such tracking and tracing systems.
trade. Each year, at a cost of
20 sticks, these packs were studies, are not replicable EXAGGERATED URGENCY. Growing “Codentify,” a track-and-trace system promoted by the under GBP100 million,
banned in 2008. As indicated 10
products 3 industry 1 industry 2

evidence suggests that these industry-commissioned studies tobacco industry, has many limitations, but there are other this strategy
by seizure data, there is
ILLICIT CHANNELS.” NO SIGN THAT THE BAN WAS
overstate the illicit cigarette trade problem EXAGGERATED SCOPE .
products 3 industry 1 industry 2
effective systems for monitoring the supply chain of tobacco PREVENTS A LOSS OF
products that are independent from the tobacco industry.
—Japan Tobacco International, 2012
FOLLOWED BY AN INCREASE IN GBP1 BILLION
2008 2009 2010 in tobacco taxes: A return on
ILLICIT CIGARETTE TRADE. PRE-BAN WITH THE BAN investment of 10 to 1.
 52 CALL TO ACTION MARKETING TO YOUTH 53
clipboard: Industry Says quote: allies say
Chapter
Governments must decide how to regulate the marketing of new MARKETING TO YOUTH Percentage of youth (13–15 years old)

18 products such as e-cigarettes that could potentially reduce harm. Manufacturers of e-cigarettes use the same tactics
long used to market traditional cigarettes to youth.
who reported having an object
with a cigarette or tobacco logo:
2012 or latest available data

MARKETING TACTICS COMPARISON “The ability to attract

0.0—9.9%
new smokers
E-cigarette ads today mirror cigarette ads of the past and develop them
into a young adult
Mazovia, Poland—
10.0—14.9%
VINTAGE CIGARETTE CONTEMPORARY E-CIGARETTE franchise is
15.0—19.9%
KEY TO BRAND
DEVELOPMENT.”
Setif, Algeria—

West Bank—
—Baghdad,Iraq
—Kabul, Afghanistan
—Shanghai, China 20.0—24.9%
—Philip Morris Report, 1999
|
25.0—100%
Karachi,

Tugucigalpa, Honduras—
—Port Au Prince, Haiti
Bobo Dioulasso, Kano,
Burkina Faso Nigeria
Pakistan
NO DATA
Atlantico Puerto Cabezas, | |
Nicaragua Banjul, Gambia—
Addis Abada,
SUBNATIONAL
SEX APPEAL

—Somaliland, Somalia
FRUIT FLAVORS SPORTS SPONSORSHIPS Western Area, Sierra Leone— Ethopia—
Bogota, Colombia— Monrovia, Liberia—

Quito, Ecuador—
|
Atlantique Littora, Benin |
—Bangui,
 Central African Rep. DATA
Central District,

DISCOUNTS DOMINATE
—Macapá, Brazil Cameroon —Kilimanjaro,
 United Republic
|  of Tanzania
Kinshasa,
Tobacco companies Dem. Rep. of Congo
spend more than
Cigarette marketing expenditures by
$900,000 AN HOUR category, USA, 2011: USD, in millions
—Cochabamba, Bolivia
—Manicaland,
 Zimbabwe
in the USA alone to
market their products.
Santiago, Chile—
1938 2013  $7,168 Price discounts, coupons
clipboard: Industry Says quote: allies say $8,366
Million

 $758 Promotional allowances

(retailers and wholesalers)
BILLBOARDS CÔTE
MARKETING

 $130 Public entertainment URUGUAY 93.4% LEBANON 82.4% ARGENTINA 80.6% D'IVOIRE
76.7% VENEZUELA 73.7% WEST BANK 71.9%
$132 (adult only) DOMINICAN BURKINA
“THE EVIDENCE IS All others (including
  $77 P oint-of-sale Countries in which
INDONESIA 89.3% ECUADOR* 82.3% REPUBLIC
80.3% FASO*
76.1% BANGLADESH 73.5% VANUATU 71.3%
TOUGH GUYS

newspapers,
SUFFICIENT magazines,
outdoor, sampling
  $52 D irect mail more than 70% of
youth (13–15 years
PARAGUAY 89.0% KENYA 82.2% NEPAL 79.1% SOMALIA* 76.0% UNITED
REPUBLIC
OF TANZANIA*
73.0%
MOROCCO 70.8%

to conclude that advertising SOLOMON

distribution, and   $50 S pecialty item distribution old) noticed tobacco
BOLIVIA* 85.6% KUWAIT 81.2% CHILE* 78.9% COLOMBIA* 75.8% ISLANDS
70.5%
and promotional activities by (branded and non-branded)
company website) PAPUA NEW LITHUANIA 72.9%
the tobacco companies cause advertising on GUINEA
83.8% GUATEMALA 81.0% BAHRAIN 78.8% SENEGAL 75.0% KYRGYZSTAN 70.5%
the onset and continuation of billboards during the GAZA STRIP 72.7%
smoking among adolescents HONDURAS* 83.4% COSTA RICA 80.8% TUVALU 78.2% MEXICO 74.8% GREECE 70.3%
Largely due to the ban on direct and indirect ads and last 30 days
and young adults.” RUSSIAN MARSHALL
sponsorship in the USA, the tobacco industry spends most of NICARAGUA* 83.2% PHILIPPINES 80.7% 76.8% ARMENIA 74.6% ISLANDS
72.2% QATAR 70.2%
*SUBNATIONAL DATA FEDERATION
­— US Surgeon General’s Report, 2014 its marketing dollars (85.6%) on price discounts and coupons.

T
1958 2013 Advertising and promotional expenditures for cigarettes increased from obacco companies claim publicly that they only market their In 2011, the largest cigarette companies in the USA spent
$8.0 billion in 2010 to $8.4 billion in 2011; however, the total number of
INDUSTRY

cigarettes sold decreased by 8.1 billion units (2.9%). products to influence the behavior of current adult smokers, and USD8.37 billion on marketing, spending the most on
not to attract young people or nonsmokers. However, research discounts to reduce the price of cigarettes to consumers
shows that tobacco marketing contributes substantially to the DISCOUNTS DOMINATE . Tactics include point-of-sale advertisements,
GLOBAL CIGARETTE ADVERTISING smoking behavior of young people MARKETING TO YOUTH. One-third of
industry 1 industry 2 Solutions 1
industry 1 industry 2 Solutions 1

allowances paid to retailers for conspicuous product Japan has hosted each
Volleyball World Cup
youth experimentation occurs as a result of exposure to tobacco placement, and “buy one, get one free” promotions. Globally, since 1997.
Cigarette advertising among adults in selected countries: 2010 or latest available data
advertising, promotion, and sponsorship, and 78% of youth aged the tobacco industry endorses sports teams and public arenas,
PERCENTAGE OF ADULTS WHO NOTICED CIGARETTE ADVERTISEMENTS
13–15 report regular exposure to tobacco marketing worldwide. sponsors concerts and public events, and advertises through
JTI* SPONSORED THE
NIGHTLIFE

ON TELEVISION   IN NEWSPAPERS AND MAGAZINES

Besides the direct marketing of tobacco products, smoking is infused

broadcast and print media GLOBAL CIGARETTE ADVERTISING. 2012 VOLLEYBALL
WORLD CUP,
industry 1 industry 2 Solutions 1

30%—
throughout contemporary culture and adversely influences the behavior In recent years, there has been an explosion in e-cigarette
placing its logo on
of adolescents. Half of all movies for children under 13 contain scenes marketing. In the USA, advertisements for “smoking materials national team uniforms,
20%—
of tobacco use, and images and messages normalize tobacco use and accessories,” including e-cigarettes, increased from courtside digital
in magazines, on the Internet, and at retail stores frequented by USD2.7 million in 2010 to USD20.8 million in 2012. Using billboards, and “gift
10%—
packages” distributed
youth. Moreover, under the guise of corporate social responsibility images of glamour, sex appeal, and high social status, to spectators.
0%— programs—which may include offering scholarships or sponsoring e-cigarette advertisements are often reminiscent of the tactics
*Japan Tobacco International
PHILIPPINES

URUGUAY

RUSSIAN
FEDERATION

UKRAINE

CHINA

INDIA

TURKEY

NIGERIA

POLAND

VIET NAM

THAILAND

EGYPT

1933 2012 schools—the industry preserves its access to the youth market. used by the major cigarette manufacturers before these
practices were banned MARKETING TACTICS COMPARISON.
industry 1 industry 2 Solutions 1
 54 CALL TO ACTION “CHARITABLE” GIVING 55

Chapter
Parties to the WHO FCTC must comply with their obligations under Article 5.3 to GLOBAL EXAMPLES Donations from Philip Morris International (PMI):

19 combat overt and covert tobacco industry interference and undue influence, including
industry attempts to improve their image and create the appearance of being good
Undue influence: examples of tactics used by
tobacco companies
2009–2013, in USD

corporate citizens. CHARITABLE GIVING

TURKEY $1—49,999
FUNDING CHARITIES
Turkey received more money (USD7,651,234) than

1.04%
any other country in donations from Philip Morris $50,000—99,000
International (PMI) in 2013.
US charitable contributions from the Altria Companies: JAPAN $100,000—199,999
in millions USD, 2013 In 2013, Japan received the largest number of
In 2013, Altria topped
donations (16) to various charities from PMI.
$200,000—499,999
charitable giving
among major $500,000—999,999
CATEGORY/ TOTAL NUMBER OF AVERAGE GIFT tobacco companies. LOBBYING
PROGRAM AMOUNT GIFTS PER ORG FACT Altria’s charitable KENYA $1,000,000 AND OVER
donations accounted
MIDDLE SCHOOL $25.40 78 $0.33 78 different educational institutions British American Tobacco (BAT) previously held a
for a mere 1.04%
EDUCATION AND
SUPPORT and programs received funding
of its profits tobacco monopoly in Kenya and developed close ties NO DATA
(E.G. SUCCESS 360°) with political leaders. When a tobacco competitor
ARTS AND CULTURE $4.40 28 $0.16 The Smithsonian Institution (USD47 MILLION), emerged, BAT drafted legislation, that was passed by
BANNED FUNDING
Countries banning
received funding while BAT, Imperial and
the Kenyan government, which encouraged farmers to funding from tobacco
Philip Morris International
CIVIC $2.00 44 $0.05 Two donations were to each donated less sell tobacco leaf to BAT rather than competitors. companies for
healthcare organizations than one half of one SRI LANKA tobacco prevention
EMPLOYEE PROGRAMS $4.40 89 $0.05 88 different organizations received clipboard: Industry SaysIn 2013, Healthquote:
percent of their profits. allies say
Minister Maithripala Sirisena was programs
funding through employee programs offered money from tobacco companies to not introduce
graphic warning labels on cigarette packages. “The
ENVIRONMENT $2.80 15 $0.19 Six charities in Virginia,
a top tobacco-growing state, company representatives continuously tried to approach
UNDUE INFLUENCE

received funding me when I was in Parliament, at home and in office. But

I did not meet them because I do not have anything to
HUMANITARIAN AID
AND MILITARY SERVICE
$1.60 13 $0.12 The American Red Cross and its
Virginia chapter received funding “Let’s be clear about talk with them.”
SUPPORT
one thing. EUROPEAN UNION
BUSINESS- $4.30 390 $0.01 The Texas Conservative Coalition
In 2014, PMI spent more money (GBP5.25 million)
DIRECTED GIVING
Research Institute received funding OUR FUNDAMENTAL on lobbying in the EU than any other corporation.

T
IN-KIND GIVING $1.20 24 $0.05 485 charitable events received wine INTEREST IN THE ARTS obacco companies have a long history of exerting with 23 tobacco companies employing 174 lobbyists. All
donated by Ste. Michelle Wine Estates,
of which Altria is the parent company IS SELF-INTEREST. PUBLIC RELATIONS
AUSTRALIA
influence to promote their own agendas, further
company awareness, or promote goodwill. This is not
major tobacco companies make charitable contributions,
though the amount donated is miniscule in comparison
ARTICLE 5.3
REGIONAL GIVING $1.10 115 $0.01 6 chapters of the Boys & Girls
Club received funding
There are immediate
and pragmatic benefits
to be derived as
From 2010–2012, BAT launched a national campaign
against plain packaging in Australia. The campaign
done innocently or to be good corporate citizens, but to the overall profits of the companies. Additionally, these OF THE WHO FCTC
rather in an effort to achieve “innocence by association” donations often support charities or projects that are in
TOTALS, IN MILLIONS $47.20 796 $0.97 business entities.” created and distributed promotional materials in print, Article 5.3 urges parties to
billboards, on the radio, and through social media. The EXERTING POLITICAL INFLUENCE . Like most major corporations, the best interest of tobacco companies, such as PMI’s 2012
—GEORGE WEISSMAN, actively protect the creation and
clipboard:
Tobacco company charitable giving is small Industry
compared to profits Says
and creates a quote: allies say
Chairman of Philip Morris USA, 1980 two-year campaign was valued at AUS$3,482,247.
products 2 products 3 industry 1

tobacco companies make donations, attempt to influence donation in Spain to support an entrepreneurship program implementation of public
conflict of interest when donated to youth or healthcare organizations. politics and exert undue influence to promote their own for young tobacco growers GLOBAL EXAMPLES. health policies from the interest
PHILANTHROPY brands, companies and profits FUNDING CHARITIES. The
products 2 products 3

Many countries and organizations are working diligently to

industry 1

of the tobacco industry with

the following principles:
products 2 products 3 industry 1

SWITZERLAND difference is that tobacco companies do this to sell

EXERTING POLITICAL INFLUENCE The Red Cross and Red Crescent Museum in Geneva a product that is addictive and deadly.
expose the undue influence of tobacco companies, and the
There is a fundamental and irreconcilable
INDUSTRY

Tobacco company interference:
EU Tobacco Products Directive
In March 2014, the European Union (EU) adopted
the EU Tobacco Products Directive to regulate the
manufacture, presentation and sale of tobacco
products. Leaked Philip Morris International (PMI)
documents prove PMI launched a multi-million Euro
lobbying campaign to undermine the Directive.
A third of the Members of the European Parliament
(233 MEPs) were lobbied. As of June 2012, PMI
had collected information on the position of MEPs
regarding various tobacco regulatory issues. These
data exemplify the research, categorization and
lobbying that tobacco companies undertake to
delay or prevent tobacco control measures.
*
received donations from Japan Tobacco International best way to do this is to follow the WHO FCTC guidelines
conflict between the tobacco industry’s
DATA COLLECTED BY PMI TO TRACK POSITIONS OF MEPs* “Evidence from tobacco (JTI) in 2012. The museum tried to return the funds The global tobacco industry spends tens of billions of and recommendations for Article 5.3, which states, “Parties cointerests and public health policy interests.
industry documents reveals following protest from advocacy groups, but JTI did not dollars (USD) each year on tobacco advertising, promotion should protect the formulation and implementation of
Parties, when dealing with the tobacco industry
PRO-TOBACCO ANTI-TOBACCO that tobacco companies have
MEPs MEPs operated for many years with
accept the repayment and the funds were moved to an and sponsorship. Though tobacco lobbying expenditures public health policies for tobacco control from the tobacco or those working to further its interests, should
account overseen by the museum’s lawyer. be accountable and transparent.
and political contributions are mostly tracked and readily industry to the greatest extent possible.” The influence
GENERIC
PACKAGING 170 33 THE DELIBERATE available in the USA, these practices of formal and informal exerted by tobacco companies is observed worldwide, and
Parties should require the tobacco industry
EXTENDED HEALTH
139 42 PURPOSE OF CORPORATE SOCIAL RESPONSIBILITY tobacco lobbying, building strategic political relationships, it is time for countries to seriously enforce the provisions of
and those working to further its interests to
operate and act in a manner that is accountable
WARNINGS USA
INGREDIENT BAN 126 32
SUBVERTING THE Santa Fe Natural Tobacco Company (SFNTC), a and providing payoffs occur throughout the world. In the Article 5.3 and to stand against the various forms of undue and transparent.
Because their products are lethal, the tobacco
POINT OF SALE
145 36
EFFORTS OF THE WORLD subsidiary of Reynolds American, is a Life Member of USA, over $26 million was spent on tobacco lobbying in 2012, influence exerted by all tobacco companies.
industry should not be granted incentives to
the Carolina Farm Stewardship Association (CFSA),
DISPLAY BAN
HEALTH ORGANIZATION establish or run their businesses.
NEXT GENERATION
PRODUCTS 19 16 to control tobacco use.
The attempted subversion
which promotes sustainable farming. Between 2009
and 2011, SFNTC provided more than USD190,000 WHO DEFINITIONS • Intelligence gathering
• Public relations
• Creating alliances and front groups
• Intimidation (use of legal & economic power)
• Smuggling
• International treaties For specific examples on how to avoid tobacco
• Political funding (campaign contributions) • Philanthropy • Joint manufacturing and licensing
30 31 in funding to help organic tobacco farmers in North industry interference, countries and others
SNUS has been elaborate, well Tobacco companies resist • Lobbying • Corporate social responsibility agreements should review the specific implementation
financed, sophisticated, Carolina grow organic wheat in rotation with organic
MEP: Member of the European Parliament effective tobacco control • Consultancy (use of “independent” experts) • Youth smoking prevention programs • Pre-emption (prohibits localities recommendations in the WHO FCTC Guidelines for
and usually invisible.” tobacco. In 2011, SFNTC purchased USD11 million • Funding research, including universities • Retailer education programs from enacting laws more stringent
measures through a number Implementation of Article 5.3.
—WHO Report of the Committee worth of US-grown, organic flue-cured tobacco, mostly • Smokers’ rights groups • Litigation than state law)
of avenues that have been
of Experts on Tobacco Industry from farmers in North Carolina.
Documents, July 2000 outlined by the WHO.
Through effective policies, governments and DEVELOPMENT
citizens can engender global health success. Tobacco control interventions
are relatively inexpensive

SOLUTIONS
to implement. Only USD600
million per year would deliver
four “best buy” tobacco control
interventions to all LMICs.
This amount is equal to just
less than 0.17% of what citizens
of LMICs spent on tobacco
products in 2013.

NON-COMMUNICABLE
DISEASES
A key target of the WHO
Global NCD Action Plan
is a 30% reduction in tobacco

M
any of the most effective tobacco control solutions are use prevalence by 2025.
population-level policies — a set of approaches that will also
work for addressing other avoidable non-communicable
disease risk factors. But the key to winning these battles
is societies’ successful engagement in advocating for these
policies — governments will need to take the necessary policy
steps, but it is people across broader societies that must demand
change and hold governments responsible.

POVERTY
While only 25% of high-income
countries are covered by
cessation programs at
WHO-recommended levels, not
one low-income country enjoys
the prescribed coverage.
 58 CALL TO ACTION SIGNATORIES AND PARTIES TO WHO FCTC 59

Chapter
Accession to the WHO FCTC is a critical and immediate need BEFORE AND AFTER THE Party or signatory status as of October 2014

20 for all countries that have not yet done so. Following ratification
or accession, adequate funding for and full implementation of
RATIFICATION OF THE WHO FCTC
Adoption of legislative, executive, administrative, and other measures
all articles and protocols are necessary to effectively combat (as per Article 5.2(b)) in relation to ratification of the WHO FCTC, 2014
tobacco use. Moscow, Russian Fed. PARTIES TO CONVENTION
2014, COP 6 (i.e. signed and ratified)
168 PARTIES THAT SUBMITTED REPORTS
Geneva, Switzerland SIGNED BUT NOT RATIFIED
WHO FCTC IMPLEMENTATION 2006, COP 1
NOT SIGNED OR RATIFIED
Seoul, Korea
Progress towards implementation of substantive articles: 2012, COP 5 NO DATA
percent of 126 Parties analyzed, as reported by governments, 2010–2014
103 PARTIES 65 PARTIES COP MEETINGS
HAD LEGISLATION DID NOT HAVE Location of 6 WHO FCTC

60% — 59% LEGISLATION

Bangkok, Thailand
Conference of Parties
(COP) meetings
56% 2007, COP 2
PRIOR TO RATIFICATION
AVERAGE IMPLEMENTATION RATE (%)

55% —
52% AFTER RATIFICATION

50% —
NICARAGUA
1ST COUNTRY TO
45% —
86 PARTIES 17 PARTIES 49 PARTIES 16 PARTIES RATIFY THE Durban, South Africa
STRENGTHENED ADOPTED NO NATIONAL
NATIONAL LEGISLATION
HAVE NOT REVISED
THEIR LEGISLATION LEGISLATION LEGISLATION FCTC PROTOCOL ON Punta del Este, Uruguay 2008, COP 3

0% —
ILLICIT TRADE 2010, COP 4

2010 2012 2014 clipboard: Industry Says

DEATH CLOCK
6
T
152 PARTIES HAVE NATIONAL LEGISLATION
7 4 8 0 4 5 23 7
he WHO Framework Convention on Tobacco Control finance, agriculture, education, labor, the environment,
WHO FCTC

OF WHICH, 135 PARTIES STRENGTHENED OR ADOPTED LEGISLATION

(WHO FCTC), the first treaty negotiated under the law enforcement, and the judicial system.

6
Even though the WHO FCTC has already helped to prevent many
auspices of the WHO, reaffirms the right of all people to
the highest standard of health. Most WHO Member States
An explicit WHO FCTC trade provision on the relation
“The WHO’s proposed
Framework Convention on

7 4 8 0 4 0 5 5
thousands of deaths, the toll from tobacco-related diseases continues to rise.
FCTC 5.2(b) states that each Party shall, in accordance with its capabilities, adopt and implement effective
have ratified the WHO FCTC, making it one of the most
between international trade and public health became
a contentious issue during the negotiations. As a result,
Tobacco Control represents

AN UNPRECEDENTED
MORE THAN 70 MILLION PEOPLE HAVE DIED legislative, executive, administrative and/or other measures and cooperate, as appropriate, with other Parties rapidly embraced international treaties of all time
two conflicting positions emerged—health-over-trade
from tobacco-related diseases since the opening of the
first FCTC working group on 28 October 1999.
in developing appropriate policies for preventing and reducing tobacco consumption, nicotine addiction, and
exposure to tobacco smoke.
PARTIES TO THE WHO FCTC, WHO FCTC IMPLEMENTATION .
and opposition to health-over-trade. Owing to a lack of
CHALLENGE TO THE
TOBACCO INDUSTRY’S
Solutions 1 Solutions 2 Solutions 3 Solutions 1 Solutions 2 Solutions 3

There are several stages in the WHO FCTC in common consensus, a compromise position eliminating any mention
with other UN treaties: first, it needed to be adopted by of trade emerged. This is an important omission, as trade FREEDOM TO CONTINUE
PARTIES TO THE WHO FCTC the World Health Assembly (May 2003); then it became treaties are increasingly being invoked to challenge
clipboard: Industry Says DOING BUSINESS.”
quote: allies say
SOLUTIONS

open for signature until 29 June 2004. During this period, tobacco control policy, as in the introduction of plain/
­— British American Tobacco, 2003
Increase in the number of Parties to the WHO FCTC since the first edition of The Tobacco Atlas, 2002–2015 168 States signed the WHO FCTC. Countries that had not standardized packaging in Australia.
signed could—and still can—accede, a one-step process
PARTIES TO
WHO FCTC 0 109 162 174 179 equivalent to ratification. The WHO FCTC entered into force
on 27 February 2005, 90 days after the 40th Member State had
Contrary to tobacco industry arguments, implementing
tobacco control measures will not harm national
2002 2006 2009 2012 2015 economies. The WHO FCTC has mobilized resources (albeit
The acceded to, ratified, accepted, or approved it BEFORE AND AFTER
still inadequate), rallied hundreds of non-governmental “WHO and its Member States
WHO FCTC
Solutions 1 Solutions 2 Solutions 3

THE RATIFICATION OF THE WHO FCTC. The Protocols have an independent gave birth to the WHO FCTC.
Nearly 20% of the world’s population
smokes cigarettes, including about
800 million men and 200 million women.
organizations, encouraged government action, led to The Convention took on a life
now covers status, qualify as treaties in their own rights, and follow a
An estimated 600,000 individuals died from
Michael Eriksen
secondhand smoke in 2011, and 75% of these
Judith Mackay deaths were among women and children.

understanding of the political nature of health policy, and

Hana Ross

of its own and now gives birth

More than half the countries
of the world have a female smoking
prevalence rate of less than 10%.
Smoking rates between boys and girls

very similar procedure; to date there is only one Protocol, on

differ by less than five percentage points

THE
about
in almost half of the world’s countries.

to another treaty [the first

Smokers consumed nearly

raised tobacco control awareness in many government

5.9 trillion cigarettes in 2009.

TOBACCO
Tobacco is grown in 124 countries, occupying

90%
3.8 million hectares of agricultural land.
China grows 43% of the world’s tobacco,
which is more tobacco than the other top

illicit trade. Protocol]. This is how we build

nine tobacco-producing countries combined.
Annual revenues from the global
tobacco industry are approaching

ministries and departments.

half a trillion dollars.

ATLAS
Cigarettes account for 92% of the
value of all tobacco products sold globally.

ambitions in public health.

The amount of smokeless tobacco
sold globally increased by
59% between 2000 and 2010.
If illicit trade were eliminated, governments
worldwide would gain at least

The Conference of the Parties (COP) is the governing body

$31.3 billion a year in tax revenue.

THIS IS HOW WE
Governments collect nearly $133 billion in

FOURTH EDITION tobacco tax revenues each year, but spend

There are discussions of emulating the WHO FCTC for

less than $1 billion on tobacco control.
Completely Revised and Updated WHO recommends that at least 70%
of the retail price of tobacco products
come from excise taxes.
At least 86% of WHO Member States

which regularly reviews and promotes the implementation

imposed a tobacco excise tax, and at least
14% use a portion of tobacco tax revenue
for health purposes.

other health topics, such as global health, diet, and

HEM IN THE ENEMY.”
Some countries are now envisioning an

of the world's
end game for tobacco, with prevalence
targets of under 5%.
The WHO FCTC covers 87.4%
of the world population.

of the Convention, and adopts protocols, annexes, decisions,

Approximately 3.8 billion people are
covered by at least one MPOWER measure
at the highest level of achievement.

alcohol. This speaks to the success of the WHO FCTC

The number of people protected

population.
by comprehensive smoke-free laws has
doubled from 2008 to 2010.
A comprehensive ban on all tobacco
www.TobaccoAtlas.org advertising, promotion, and sponsorship could

and amendments to the Convention. In crafting guidelines ­ DR MARGARET CHAN, Director General,
—
decrease tobacco consumption by about 7%.

and the need for a harmonized global effort for other WHO, addressing COP5 delegates, 2012
First Edition Second Edition Third Edition Fourth Edition Fifth Edition and recommendations, this body reaches well beyond the
major health problems.
domains of medicine and public health, involving trade,
 india
australia poland india
clipboard: Industry Says quote: allies say
60 CALL TO ACTION TAX CHANGES 61

INSET 3
Iceland

Chapter
Tobacco tax increases must, over time, INSET 3 Sweden Finland Average annual percent

21 change in real excise tax

Norway
australia
make tobacco products less affordable. poland india
“Proposals to earmark excise taxes on the most popular price
india
for health programs are by far United Denmark
Latvia
category of cigarettes:
Lithuania—

TAXES AND PREVALENCE THE MOST SERIOUS THREAT Ireland

Kingdom

Belarus
Russian Federation 2008–2012
due to the many health allegations Netherlands

INSET 3
Canada Poland
4.1—75.0%
against cigarettes made Belgium Germany
Cigarette prices and smoking by income group in by anti-smoking groups.” —Lux. Czech Rep.
Ukraine
australia South Africa:
poland 1993–2003 india Year Chamber of Deputies Senate
2009 In favor 135 56 191
Total in favor
—THE TOBACCO INSTITUTE Austria
Slovakia

Hungary
Rep. 1.1—4.0%
France Switz. Moldova

FALL RISE
india
LOW INCOME   
  MIDDLE INCOME   
HIGH INCOME   
PRICE (an industry
42 322 trade group in the USA), 1989
10 40 Against 280 Slovenia— —Croatia Romania
Abstentions 13 5 18
Bosnia & Mongolia
–1.0—1.0%
2010 In favor 430 70 500 Herzegovina Serbia Kazakhstan
—9 Against 11 10 21 Bulgaria
Montenegro—
3535%—
Abstentions 13 3 16 —FYR –1.1— –4.0%

RAND PER PACK (2000 ZAR)

Albania Macedonia Uzbekistan
SMOKING PREVALENCE (%)

Italy Georgia Kyrgyzstan

8 —8 United States of America Portugal Spain
Greece
“ Sugar, rum, and tobacco,
Armenia— —Azerbaijan
Turkmenistan
Korea
–4.1— –20.0%
Turkey
3030%— ­—7 are commodities which are Rep. Japan
india nowhere necessaries of life,
Tunisia
—Malta
Cyprus—
Lebanon—
Syrian
Arab Rep. Afghanistan China NO DATA
6
2525%—
­—6 [but] which are ... objects of INSET 2 Jordan Iraq
Isl. Rep.
of Iran
Year Chamber of Deputies 135
Senate Total in favor
280 almost universal consumption, Morocco —Israel Pakistan Nepal
2009 In favor 135 56 191 Kuwait—
Against 280 42 322 —5 and which are therefore
Algeria Libya

EXTREMELY PROPER
Abstentions 13 5 18 —Bahamas Egypt Bahrain—
—Qatar Bangladesh
4 2020%— 2010 In favor 430 70 500
—4 UAE —Hong Kong
Against 11 10 21 Mexico Saudi Arabia
|
1993
|
1995
|
1997
Abstentions
1999
| 13 3|
2001
16
2003
|
SUBJECTS OF TAXATION.” Jamaica—
Dominican Rep.
Mauritania
Oman
India Myanmar
LAO
PDR
Belize —St. Kitts & Nevis Mali
When taxes raise cigarette prices, —ADAM SMITH, United Kingdom, 1778 Honduras
Antigua & Barbuda—
—Dominica Niger Thailand Philippines
Guatemala St. Lucia— —Cape Senegal Eritrea Yemen
the poor get more health benefits than the rich. El Salvador St. Vincent &— —Barbados Verde
—Gambia Chad Sudan
Viet Nam

Nicaragua the Grenadines Cambodia

Burkina Faso —Djibouti
—Trinidad & Tobago Guinea-Bissau—
Guinea
INSET 2 Costa Rica
Benin

AFFORDABILITY 135 280

ADVOCATING FOR TAXES Panama Venezuela —Guyana

Suriname
Sierra Leone—

Liberia—
Côte
D’Ivoire
Ghana
Togo
Nigeria

Cameroon
Ethiopia
Sri Lanka
Brunei Dar.—
—Palau
|
Fed. States of
Micronesia
|
Marshall Islands

Colombia Maldives— Malaysia

Change in minutes of labor to purchase a pack of The importance of health advocacy in the creation of tobacco Equatorial Guinea—
Sao Tome and Principe—
Uganda
|
Congo Kenya
Singapore
cigarettes: 2009 – 2012 13 tax laws in Mexico Ecuador
Gabon
—Rwanda
Indonesia |
Kiribati
2009 
  2012 INCREASE   
  2012 DECREASE IN FAVOR   
  AGAINST   
  ABSTENTIONS —Burundi Papua New Guinea
—Seychelles
poland
australia india United Republic
south africa
VOTES ON THE TOBACCO TAX INCREASE of Tanzania
100
90
80
60 60
20
60 60
3% 4% 3% Peru Brazil —Comoros
70
Angola Malawi Tuvalu—
POLAND AUSTRALIA
60
50
40 Zambia
+16.2
30
20
+11.3
10
0 Bolivia Mozambique Vanuatu—
Zimbabwe Madagascar
TAXES

Namibia —Mauritius Samoa—

poland Fiji—
australia south africa india 2009 2010 Botswana
poland
australia south africa 13 india 61% TAX FAILED 36% TAX PASSED 93% Paraguay
27
60 60 60 60 S. Africa
Australia Niue—

60 60 60 60 —Lesotho Tonga—
60 60 60 60 Cook Islands—
SOUTH AFRICA INDIA Chile
+9.4 20 +6.9 Uruguay
BEFORE ADVOCACY AFTER ADVOCACY

T
Argentina
obacco excise tax increases that result in higher tobacco product programs are directed to help the poorest members of
poland
australia south africa india
BETWEEN 2009 AND 2010, PUBLIC HEALTH ADVOCATES’ EFFORTS:
SOLUTIONS

prices are among the most effective tobacco control measures society, as was done by the Philippines with new tobacco New Zealand
Equipped
  a political champion, Senator Ernesto Saro Boardman, with all the evidence
  finland israel peru china
available. The bulk of the peer-reviewed evidence from countries taxes implemented in 2013.
60 60 60 60 and support necessary to counter tobacco industry arguments in the media and
60 60 60 60
opponents in the legislature in all stages of economic development confirms that when tobacco
60 60 27 60 60 Article 6 of the WHO FCTC encourages parties to raise prices
FINLAND ISRAEL Released economic reports to counter false industry arguments, inform the public, and
  product prices increase, people use less of these dangerous
+5.6 +5.0 of tobacco products by means of excise tax increases. Excise
maintain positive media coverage products, or quit using them, or never start.
tax levels should be revised often enough to increase the price
Conducted opinion polling to measure public support
 
Tobacco companies often claim tax increases are particularly of tobacco products at a rate above inflation and income growth,
finland israel peru
Partnered
  china
with leaders of congressional health commissions on political forums on tax
finland israel peru china
harmful to the poor, but this claim does not hold up to deeper making tobacco products less affordable over time AFFORDABILITY.
Launched an intensive mass media campaign
 
In 2012, Costa Rica
industry 2 Solutions 1 Solutions 2

scrutiny. In fact, because they are more sensitive to changes in

60 60 60 60 Tobacco tax increases work best when implemented within a earmarked the funds
price than are wealthier people, poorer people get the most health
comprehensive tobacco control program. Tax policies should raised from a tobacco
PERU CHINA benefits from tobacco tax increases by using less or quitting tax increase to be
–6.6 –13 Many health insurance plans in the USA levy tobacco user mandate the use of tax stamps, and set up effective tracking and
surcharges on premiums as an economic disincentive to smoke.
For a ‘pack-a-day’ smoker, an $80 monthly tobacco surcharge industry 2
TAXES AND PREVALENCE . However, people who continue to use tobacco
Solutions 1 Solutions 2
tracing systems for all tobacco products to discourage illicit trade. DEDICATED TO
may suffer financial hardship (see Chapter 6: Poverty) resulting from
finland israel peru china
INCREASES THE COST OF SMOKING BY $2.25 PER DAY. continued purchases of tobacco. The positive impact of tax increases
Government agencies responsible for health should make sure that TOBACCO CONTROL
The relationship between price and income is very important. they participate in the creation of tobacco tax policies alongside efforts, including
In an early study, over 40% of tobacco users reported on public health multiplies when newly generated revenues are
finance and revenue agencies ADVOCATING FOR TAXES. surveillance
When prices increase faster than salaries, people must earn quitting tobacco to avoid the surcharge.
reinvested in health programs (see Chapter 29: Investing). This industry 2 Solutions 1 Solutions 2 and research
more money to afford their cigarettes, which decreases —LIBER et al, Nicotine and Tobacco Research, 2014 capacity building.
cigarette consumption and increases the rate of quitting. can help alleviate societal health inequities, especially when such
 62 CALL TO ACTION
clipboard: Industry Says quote: allies say Iceland
PRICE CHANGES 63

Chapter Sweden Finland Average annual percent

Continuing to increase the price of tobacco products is a cornerstone of tobacco control.
22 change in real price on the
Norway

most popular price category

PRICE GAP
Russian
United Denmark
Latvia Fed. of cigarettes: 2008–2012
Kingdom Lithuania—
Russian Federation
“MY VIEWS AS TO HOW Price difference between a pack of the most popular and
Canada
Ireland Netherlands Belarus
Poland
4.1—75.0%
WE SHOULD PASS ON the cheapest brand of cigarettes: 2013
Brazil BRA 0%
Belgium Germany
—Lux. Czech Rep.

THE PRICE INCREASE 0 BRAZIL 0% Slovakia

Ukraine
1.1—4.0%
10 FINLAND 10% Finland FIN 10% France Switz.
Austria
Hungary
Rep.
Moldova

FALL RISE
in the event of an Romania ROU 21%
Slovenia— —Croatia Romania
–1.0—1.0%
21 ROMANIA 21% Bosnia & Mongolia
increase in the excise Singapore SGP 27%
Herzegovina Serbia Kazakhstan
27 SINGAPORE 27% Montenegro— Bulgaria
–1.1— –4.0%
tax: … suggest that Russia RUS 51%
—FYR

51 RUSSIA 51% Portugal Spain Italy

Albania Macedonia
Georgia
Uzbekistan
Kyrgyzstan
people stock up Thailand United States of America
THA 73% Greece
–4.1— –20.0%
73
Armenia— —Azerbaijan
THAILAND 73% Turkmenistan
to avoid the price
Korea

83 ECUADOR 83% Ecuador ECU 83% Turkey Rep. Japan

increase, and … Azerbaijan AZE 127%

—Malta
Cyprus—
Syrian
China NO DATA
127
Arab Rep.
AZERBAIJAN 127% Tunisia Lebanon—
Isl. Rep.
Afghanistan

when people … 140 NIGERIA 140% Nigeria NGA 140%

West Bank/—
Gaza Strip Jordan Iraq of Iran THE INDUSTRY IS
go to the store to UNITED ARAB United Arab Emirates ARE 165%
Morocco —Israel
Kuwait— Pakistan Nepal
ALSO RESPONSIBLE FOR
165 EMIRATES
165% Algeria Libya
PRICE INCREASES
buy more, they will 205 GEORGIA 205% Georgia GEO 205% —Bahamas Egypt
Bahrain—
—Qatar Bangladesh
Countries where from
UAE —Hong Kong
Mexico
be less likely to 328 CHINA 328% China CHN 328% Dominican Rep.
Saudi Arabia
India Myanmar
LAO 2008 to 2012, increases
remember what they 560%Tunisia TUN 560%
Oman PDR
in cigarette prices
560 TUNISIA
Jamaica— Mauritania
Belize Antigua & Barbuda— —St. Kitts & Nevis Mali exceeded tax increases
last paid.” PRICE OF MOST POPULARCountry GuatemalaISO3 Gap
Honduras Thailand Philippines
—Dominica Niger Eritrea Yemen
PRICE OF CHEAPEST BRAND BRAND St. Lucia— —Cape Senegal Viet Nam
El Salvador St. Vincent &— —Barbados Verde Chad Sudan
—Gambia Cambodia
­­ MYRON E. JOHNSTON,
— Nicaragua the Grenadines Burkina Faso
Philip Morris researcher, 1987 A large price spread provides smokers the opportunity to lessen the impact —Trinidad & Tobago Guinea-Bissau—
Guinea
—Djibouti
Benin
of a price increase by switching to a cheaper brand. Costa Rica
—Guyana Sierra Leone— Côte Ghana Nigeria Ethiopia —Palau
Panama Venezuela Sri Lanka |
D’Ivoire |
Togo Fed. States of Marshall Islands
Liberia— Brunei Dar.—
Cameroon Micronesia

OPPORTUNITY-COST
Suriname

PRICES OF DIFFERENT PRODUCTS

Colombia Maldives— Malaysia
Equatorial Guinea— Uganda
Sao Tome and Principe— Kenya |
Congo Singapore Indonesia

OF CIGARETTES
|
Gabon
Ecuador —Rwanda Kiribati
—Burundi Papua New Guinea
Average prices of equivalent amounts of different tobacco products: —Seychelles
United Republic
20g or 20-stick pack or 6.67 cigarillos, in USD, 2013 of Tanzania
Slices of bread and servings of rice —Timor-Leste
SOUTH that could be bought for the price of an Peru Brazil —Comoros
=$0.10 BOLIVIA EGYPT MALAYSIA SERBIA AFRICA SPAIN SWITZERLAND Angola Malawi
average pack of cigarettes: 2013 Zambia
Tuvalu—

89 35
PRICES

Bolivia Mozambique Vanuatu—

WATER PIPE BULGARIA Namibia
Zimbabwe
Madagascar
—Mauritius Samoa—
Botswana Fiji—
15 38
Paraguay
CAMEROON
Chile —Swaziland
67 44
S. Africa
Australia Niue—
Tonga—
GERMANY —Lesotho
Cook Islands—
ROLL-YOUR-OWN 62 31
INDIA Uruguay

W
156 90 Argentina
IRELAND hether a person decides to buy a tobacco product is greatly Prices of tobacco products are of great interest to the
SOLUTIONS

23 24 dependent on the price of the product and the amount of public health community because they play such a New Zealand
JAPAN money in a person’s pocket. Tobacco prices are central to pivotal role in people’s decisions to use tobacco. The
CIGARETTE 65 83 industry marketing strategies, and it is the tobacco industry that sets overwhelming body of economic evidence confirms that

½
SRI LANKA the prices of its tobacco products. Cigarettes are a largely uniform a 10% increase in cigarette price causes the consumption
47 25
product, easily manufactured at low cost on a global scale. Through of cigarettes to fall between 2% and 8%. Roughly half of this
OMAN
pricing strategies, the tobacco industry regulates its sales volumes fall comes from current smokers cutting back on the number Even in the United
39 92
PANAMA and decides which products and brands will be perceived as of cigarettes they smoke, while the other half results from fewer Kingdom, where almost
“premium” and which will be “economy” brands PRICE GAP. youths starting to smoke as well as current smokers quitting. 90% of the retail price
71 108
industry 2 Solutions 1 Solutions 2 of cigarettes is tax,
PAPUA NEW GUINEA Additionally, less variation in the prices of all tobacco products
Cheap brands help the industry broaden its customer base because half of recent price
CIGARILLO 49 30
these products are more affordable to youth. Conversely, by
can keep people from switching between products to avoid increases (6p of 12p)
POLAND
55 14 increasing the prices of its products, the industry can wring more
price increases PRICES OF DIFFERENT PRODUCTS.
industry 2 Solutions 1 Solutions 2
ARE DIRECTLY
| | | | | |
ZAMBIA
| | | | | | |
money from its addicted customers OPPORTUNITY-COST OF CIGARETTES. When
industry 2 Solutions 1 Solutions 2
Many countries have successfully used tax policies to regulate the ATTRIBUTABLE
regulations successfully increase the price of one product, such price of cigarette products (see Chapter 21: Taxes). Policies beyond
TO INDUSTRY
150 125 100 75 50 25 0 25 50 75 100 125 150
SLICES OF BREAD SERVINGS OF RICE
as cigarettes, the industry is able to set the prices of other tobacco excise taxes also directly and indirectly influence tobacco product
Purchasing the necessities in life is made more difficult with each extra pack of
products to entice consumers to switch products and keep more prices, including bans on discounting and price promotions, PRICING STRATEGIES,
Product prices vary within and among product categories. Tobacco control cigarettes purchased. This matters most for people in low socioeconomic status and not to the tax
should always take care to raise prices across all products and places. groups, who make the greatest financial trade-offs to continue smoking. people buying their goods. minimum retail prices, and minimum package sizes. increases themselves.
 64 CALL TO ACTION CITIES 65

Chapter Smoke-free urban agglomerations, 2012:

Considering the demonstrated health and economic benefits, widespread
23
ry Says
public support, and low cost of implementation, it is vital that governments
act toquote:
initiateallies sayenforce comprehensive smoke-free legislation.
and fully
highest level of achievement in protecting
people from tobacco smoke in the world’s
biggest cities and urban agglomerations
Population covered by:
St. Petersburg NATIONAL
SMOKE-FREE LAWS Moscow
Legislation or Policy

Smoke-free legislation by income level: Montreal Berlin

STATE- OR PROVINCE-LEVEL
London
“100% SMOKE-FREE IS high-, middle-, low-income countries, 2012
Toronto
Detroit Paris Harbin
Legislation or Policy
Istanbul CITY-LEVEL
THE ONLY ANSWER. NUMBER OF PUBLIC PLACES COMPLETELY SMOKE-FREE:
Chicago Boston
Changchun
Shenyang Legislation
Neither  All (or at least 90% of the population covered by San Francisco New York
Barcelona Rome Beijing Qingdao
Seoul
complete subnational smoke-free legislation) Washington D.C. Philadelphia Tianjin NOT COVERED
ventilation nor  Six to seven
Madrid Ankara Jinan
Busan Tokyo by a comprehensive ban
Los Angeles Phoenix Zhengzhou
filtration, alone or  Three to five
Dallas Atlanta Tehran Xi'an Nanjing
Osaka

in combination,  Up to two Alexandria ALLOW SMOKING

Chengdu Shanghai
 Data not reported/not categorized Houston Lahore
Hangzhou ROOMS
can reduce Baghdad Karachi Delhi Wuhan Chongqing
Monterrey
exposure levels Miami
Cairo Hyderabad Shantou
Guangzhou
Dhaka
of tobacco Guadalajara Ahmedabad
Foshan
Riyadh Chittagong Dongguan
smoke indoors Mexico City Surat
Hong Kong Shenzhen
Kolkata
to levels that 51
Jeddah Mumbai
Pune Hyderabad
Yangon
Manila
HIGH INCOME Khartoum
are considered COUNTRIES Chennai Bangkok
Bengaluru
acceptable, even Ho Chi Minh City
Lagos
in terms of Abidjan
Medellin
odor, much less Bogota Singapore
health effects.”
—World Health Organization, 1997
Fortaleza
Kinshasa
SMOKE-FREE

2014 WINTER OLYMPIC GAMES IN Dar Es Salaam Jakarta

Recife Luanda
107
SOCHI, RUSSIAN FEDERATION
MIDDLE INCOME COUNTRIES Smoking was Lima Salvador
forbidden in all Brasilia
enclosed venues
Belo Horizonte
of the Games,
Rio De Janeiro
and on the Sao Paulo
Johannesburg
territory of the
Porto
Olympic Park, Alegre
including all bars Santiago Cape Town
Buenos
and restaurants.

I
Aires Sydney
37
n terms of both countries and population covered, the tobacco are allowed, ventilation is inadequate to eliminate
LOW INCOME COUNTRIES It was the
SOLUTIONS

control measure with the greatest progress since 2007 has been second-hand smoke, due to doorways, leakage, poor Melbourne
14TH CONSECUTIVE protecting people from the dangers of tobacco smoke by enacting maintenance and difficult enforcement, and the reduction
SMOKE-FREE laws that create smoke-free workplaces and public places. Thirty-two in smoking among smokers is smaller.
OLYMPIC GAMES. countries, including 26 low- and middle-income counties, adopted
Elimination of smoking, thus second-hand smoke, also
complete smoking bans between 2007 and 2012. Since 2007, the
eliminates the formation of third-hand smoke from the
population protected by a comprehensive smoke-free law more than
environment. The latter—residual nicotine and other chemicals

16%
quadrupled, as 1.1 billion people (16% of world population) are now
left on surfaces by tobacco smoke—can linger for months, and is
protected from the dangers of second-hand smoke SMOKE-FREE LAWS.
SMOKERS IN CHINA EFFECT OF SMOKING BANS Solutions 1 Solutions 2 Solutions 3
not amenable to normal cleaning. The first three
Most of these newly protected people live in middle-income
Support among smokers in China A ban on smoking in all All combustible tobacco products must be covered for a policy to
countries to
countries, which have taken the lead in passing complete
Only 16% for smoke-free laws in workplaces indoor workplaces
smoke-free laws. be comprehensive. The use of e-cigarettes and water pipes poses BAN SMOKING
of the world’s and bars is greater than it was CAN REDUCE THE PREVALENCE ongoing legislative challenges, with some countries opting to IN VEHICLES
population is among smokers in Ireland before Smoking bans benefit non-smokers and smokers alike: Non-smokers
covered by their initially unpopular but very
OF SMOKING BY 6%, are exposed to significantly less second-hand smoke, while smokers
include these in smoke-free legislation (see Chapter 12: E-cigarettes
CARRYING
and Chapter 13: Water Pipes).
comprehensive and a ban on smoking in all tend to smoke less, have greater cessation success, and experience CHILDREN
SUCCESSFUL100SMOKE-FREE
100 LAW100 100 100 indoor restaurants by 2%. increased confidence in their ability to quit. These effects are were Bahrain,
smoke-free laws.
WAS IMPLEMENTED. greatest under the strongest bans. When indoor smoking areas
Mauritius, and
South Africa.
 66 CALL TO ACTION Iceland
QUITTING RESOURCES 67

Chapter Sweden Finland Availability of nicotine

Governments should subsidize all aspects of individual- and group-level cessation
24 replacement therapy (NRT),
Norway
while simultaneously employing strong population-based cessation strategies. Estonia
cessation programs
United Denmark
Latvia
and quit lines, 2012
Kingdom Lithuania—

SMOKERS WANT TO STOP EFFECTS OVER TIME Canada

Ireland Netherlands
Belgium Germany
Poland
Belarus
Russian Federation
National quit line, and both NRT
Percent of smokers who intend to quit, or have tried to Immediate and long-term health benefits —Lux. Czech Rep.
Slovakia
Ukraine and some cessation services
% of current smokers who intend to quit
  of quitting for all smokers Austria Rep.
COST-COVERED
Hungary
% of current smokers who attempted to quit in the past 12 months
  France Switz. Moldova

BENEFICIAL HEALTH CHANGES INCLUDE: San

Slovenia— —Croatia
Bosnia &
Romania
Mongolia
NRT and/or some cessation services
Andorra­ Marino— Herzegovina Serbia Kazakhstan AT LEAST ONE OF WHICH IS COST-COVERED

74+26+A
Your heart rate
|
WITHIN
Bangladesh
|
BANGLADESH 2009 Monaco Montenegro— Bulgaria

Bangladesh 20 and blood Italy

Albania
—FYR
Macedonia
Georgia
Uzbekistan
Kyrgyzstan
DPR
Korea
NRT and/or some cessation services
China
CHINA 2010 United States of America Portugal Spain
MINUTES pressure drop. Greece Armenia— —Azerbaijan
Brazil Turkmenistan Tajikistan Korea
NEITHER COST-COVERED
Your carbon Turkey
Egypt
EGYPT 2009 Rep. Japan
WITHIN —Malta
China monoxide level in Syrian

12 China
Cyprus— Arab Rep. Afghanistan
Tunisia Lebanon—
India
INDIA 2009 the blood drops West Bank/— Iraq
Isl. Rep.
NONE
Egypt Gaza Strip Jordan of Iran
HOURS Bhutan
to normal. Morocco —Israel
Kuwait—
Pakistan Nepal |

Indonesia

12+40+41+4+3+A
INDONESIA 2011
India WITHIN Your circulation —Bahamas
Algeria Libya
Egypt Bahrain—

Malysia
—Qatar Bangladesh
NO DATA
MALAYSIA 2011
Indonesia 2–12 improves and your lung Mexico Cuba Saudi Arabia
UAE
India Myanmar
WEEKS function increases. Dominican Rep. LAO
Mexico
MEXICO 2009 Jamaica—
Haiti Oman PDR

Malysia
Mauritania
WITHIN
Belize
Honduras
Antigua & Barbuda— —St. Kitts & Nevis Mali
Thailand Philippines
NATIONAL TOLL-FREE
Phillipines
PHILIPPINES 2009 Your coughing and shortness
Guatemala St. Lucia— —Dominica —Cape Senegal Niger
Sudan Eritrea Yemen
QUITLINE
1–9
Viet Nam
Mexico
Verde
El Salvador St. Vincent &— —Barbados Gambia— Chad Cambodia
of breath decrease. Nicaragua the Grenadines —Grenada Burkina Faso
Poland

��� ���
Guinea-Bissau— —Djibouti
POLAND 2009 MONTHS —Trinidad & Tobago Guinea
Phillipines
Benin
Costa Rica
Sierra Leone— Côte Ghana Nigeria Ethiopia —Palau
Venezuela
Romania WITHIN —Guyana
ROMANIA 2011 Your risk of coronary heart Panama D’Ivoire Togo Central Sri Lanka |
|
Marshall Islands
Poland 1 Liberia— African Rep. Fed. States of
Brunei Dar.—
disease is about half that of Suriname
Cameroon
Somalia
Micronesia

Russia
Colombia Maldives— Malaysia
RUSSIA 2009 YEAR a smoker’s. Equatorial Guinea— Nauru
Romania Uganda

96M
|
Sao Tome and Principe— Kenya |
Congo Singapore Indonesia |

Thailand
Gabon
THAILAND 2011 WITHIN Ecuador —Rwanda Kiribati
Russia
Dem. Rep.
Your risk of stroke is reduced to that
5
—Burundi Papua New Guinea
of Congo —Seychelles
Ukraine
UKRAINE 2010 of a nonsmoker’s. United Republic
Thailand YEARS of Tanzania
“Of the 445 million people …
Uruguay
—Timor-Leste
URUGUAY 2009 Your risk of lung cancer falls to about half that Brazil
Solomon Islands

Turkey who live in the world’s 100 largest cities,

WITHIN Peru —Comoros
of a smoker's, and your risk of cancer of the
QUITTING

Angola —Malawi

10 only about 96 million (in 21 cities) Tuvalu—

Vietnam
VIETNAM 2010 mouth, throat, esophagus, bladder, cervix, or
Zambia
Ukraine YEARS HAVE ACCESS TO APPROPRIATE
| | | | | | | | | pancreas decreases. Bolivia Mozambique
Madagascar
Vanuatu—
0% 10% 20% 30% 40% 50% 60% 70% 80% Zimbabwe
Uruguay WITHIN
Your risk of coronary heart disease is that
Namibia
Botswana
—Mauritius
CESSATION SUPPORT.” Samoa—
Fiji—

In many countries,
Vietnam most current smokers would like to give up smoking. 15 of a nonsmoker’s.
Paraguay
—Swaziland
­—World Health Organization, 2013
In Malaysia, up to 71% of current smokers intend to quit smoking, and
| | | | | | | | | YEARS
S. Africa
Australia Niue—
0% 10% 20% 30% | 40% | 50% | 60% 70%
| 80%| | | | |
nearly 50% of smokers made 0% attempts to20%quit in30%2011.40% —Lesotho Tonga—

clipboard: Industry Says

10% 50% 60% 70% 80%
Cook Islands—

BENEFITS OF QUITTING Chile

Uruguay

UNITED STATES

A
Argentina
Former smokers’ risk of death, by age at quitting: t any age, quitting smoking benefits health; smoking cessation is Population-based approaches such as raising prices New Zealand
NEVER QUIT ATTEMPTS WOULD LIKE TO QUIT
  UK Million Women Study, ages 55–63
SOLUTIONS

4% one of the best ways to add years to a smoker’s life. Most smokers (see Chapter 21: Taxes), limiting advertising (see Chapter
ONCE OR TWICE 
  NO 24%
3–10 TIMES 
  40% will make many attempts to quit over a lifetime, and resources 28: Marketing Bans), and restricting public smoking (see
RELATIVE RISK FOR DEATH RELATIVE RISK FOR DEATH FROM
MORE THAN 10 TIMES  
 
41%
YES 74%
FROM LUNG CANCER ANY TOBACCO-RELATED CAUSE
should be more easily available to increase their chances for success Chapter 23: Smoke-Free) have been very effective in reducing “WE DO NOT HAVE
NO ANSWER
 

ard: Industry Says quote: allies say 24.0 industry 2

SMOKERS WANT TO STOP.
Solutions 1 Solutions 2
tobacco use. In New York City, where such measures have A PRODUCT THAT
been aggressively pursued, smoking rates have dropped by
In the USA, 85% of smokers say they have tried to
24 —
Health professionals should always try to get smokers to stop. People
one-third. A recent Australian study found that three-fourths of
MEETS THE NEEDS…
RELATIVE RISK OF DEATH BEFORE AGE 65

quit at least once in their lifetime. Health benefits should be asked if they smoke; they should always be advised to
20 —
the smoking decline there was due to increased taxation, stronger OF EX-SMOKERS.
COMPARED TO A NEVER SMOKER

of cessation emerge stop; and they should be offered assistance in doing so. Several Many…will resume
rapidly and quitting smoke-free laws and mass media campaigns.
16 — interventions are useful as smoking cessation aids, including smoking, and the product
smoking at any age is that they choose could
counseling and support, nicotine replacement therapy, and the use It is also crucial to reach teenagers and other young smokers with
12 —
beneficial to health. cause a swing in market
“Our estimates of China’s burden of mortality attributable to smoking… of medications. smoking cessation messages and aids. The younger someone is
suggest that substantial health gains could be made—a 40% relative Former smokers who share. These quitters…are
stop smoking at about when they stop smoking, the greater the benefit in terms of years dissatisfied with certain
reduction in smoking prevalence and almost 8— 5.9 Most people who successfully quit say that simply stopping (“going aspects of a product
30 and 40 years old of life saved EFFECTS OVER TIME . Smokers lose a decade of life because
13 MILLION SMOKING-ATTRIBUTABLE DEATHS AVERTED AND 4—
3.3 3.0 reduce their risk of dying cold turkey”) was the most effective strategy. Although nicotine industry 2 Solutions 1 Solutions 2

of their habit, and someone who quits before the age of 40 reduces
that previously met their
1.8 1.2 1.6 replacement and treatment with medicines have been shown to needs...a textbook example
MORE THAN 154 MILLION LIFE YEARS GAINED BY 2050 1.6 1.0 1.1 from lung cancer by 97%
lead to higher sustained quit rates, relatively few people use these
their chance of death from tobacco-related illness by 90% of a market opportunity.”
—by extending effective public health and clinical interventions 0— and 90%, respectively.
BENEFITS OF QUITTING . —Philip Morris report, 1988
approaches, and their impact on a population level has been small.
| | | | | | | | | |
to reduce active smoking.” 22 29 39 49 Never 22 29 39 49 Never industry 2 Solutions 1 Solutions 2

—DAVID LEVY et al, British Medical Journal, 2012 AGE OF SMOKERS AT QUITTING
 clipboard: Industry Says quote: allies say

68 CALL TO ACTION ANTI-TOBACCO MASS MEDIA CAMPAIGNS 69

Chapter Number of appropriate characteristics

Governments should fund and/or legislate sustained tobacco “Our objective is to help countries become self-sufficient

25 control mass media campaigns to inform the public about the harm
of tobacco use and to galvanize public support for tobacco control.
in the use of counter-marketing strategies. The sooner governments start
using these tools, the more lives will be saved.”
—SANDRA MULLIN, Senior Vice President, Policy & Communications, World Lung Foundation, 2014
included in national campaigns: 2011–2012

National campaign conducted with:

APPROPRIATE

GRAPHIC ADVERTISEMENTS GLOBAL REACH CHARACTERISTICS

ARE BASED ON: appropriate characteristics including
airing on television and/or radio
AT LEAST 7
• Whether the campaign
TV is the most effective medium for anti-tobacco advertising. In low-income Graphic TV ads such as “Sponge,” produced was part of a 5–6
countries where TV may have more limited reach, radio can be an alternative by Cancer Institute (NSW) Australia, comprehensive tobacco appropriate characteristics or
as well as being less expensive. translate easily and are effectively used in control program with 7 excluding airing
on television and/or radio
many countries. • Whether research

NATIONAL “SPONGE” CAMPAIGN 

 
informed an 1–4
“Lungs are like sponges. If you could wring out the understanding of appropriate characteristics
REGIONAL “SPONGE” CAMPAIGN
  cancer-producing tar that goes into the lungs of the target audience
a pack-a-day smoker every day, this is how much
you would get.”
• Whether materials NO NATIONAL CAMPAIGN
were pretested conducted JAN 2011—JUN 2012
• How the campaign was with duration of at least 3 weeks
AMRO AFRO EURO SEARO WPRO promoted, placed, and
2015—
—
—
publicized NO DATA
— • The extent to which
Testimonial PSA, India: “Sunita” Testimonial PSA, West Africa: “Idrissa” — campaigns were
2010— evaluated
—

Ads with visceral images are the most effective at cutting through smokers’ defenses. — • Whether the campaign
—
was aired on television
—
2005—
and/or radio

SOCIAL MEDIA CAMPAIGNS

—
MEDIA CAMPAIGNS

—
—
—
2000—
“SMOKING KID” VIDEO, THAILAND: 2012
1985—

TV/RADIO IMPACT
—
—
80% —
—
— 60% —
1980—
Percentage of adults who noticed anti-smoking information on 40% —
USA

CANADA

MEXICO

BOLIVIA

SENEGAL

MAURITIUS

NORWAY

TURKEY

RUSSIA

GEORGIA

KAZAKHSTAN

INDIA

BANGLADESH

INDONESIA

CHINA

AUSTRALIA

PHILLIPINES

FIJI

TONGA
TV or radio 20% —
Effectiveness of anti-tobacco campaigns varies widely and depends 0% ­­—

RUSSIAN FED.
GREECE
2013
NIGERIA
2012
BANGLADESH
2009
INDONESIA
2011

2009
CHINA
2010
PANAMA
2013
POLAND
2010
ARGENTINA
2012
INDIA
2009–2010
QATAR
2013
UKRAINE
2010
BRAZIL
2008
THAILAND
2011
URUGUAY
2009
ROMANIA
2011
EGYPT
2009
PHILLIPINES
2009
MALAYSIA
2011
MEXICO
2009
VIET NAM
2010
TURKEY
2012
on the actual content of the advertisements, number of plays
Governments around the world should adapt existing, proven mass they receive on radio or TV, the percentage of the population with
Catch phrase: “If it's so bad, why are you smoking?” media campaigns to implement cost-effective and impactful campaigns. access to radio or TV, and other factors.
When children approached the adult smokers for a light, the adults refused and

M
reminded them that smoking is bad. The children gave each adult a note saying,
“You worry about me. Why not about yourself?” Then almost every adult paused and
threw away their cigarette. This emotional anti-smoking ad led to a 40% increase
NATIONAL SENEGALESE QUITLINE ass media campaigns are among the most effective
ways to warn about the dangers of tobacco use, to
and motivated quit attempts in 59% of people who viewed
the ads GLOBAL REACH, NATIONAL SENEGALESE QUITLINE.
Solutions 1 Solutions 2 Solutions 3 Solutions 1 Solutions 2 Solutions 3

in national quitline calls as well as over 5 million YouTube views within 10 days. Calls to the national Senegalese quitline before and during encourage smoking cessation, and to create support
Broadcast media should be pressed to provide more free
a mass media campaign: 2013 for tobacco control policies TV/RADIO IMPACT. For years, the
SOLUTIONS

Solutions 1 Solutions 2 Solutions 3

time to anti-tobacco ads. Many countries have this option and
“TIPS FROM FORMER SMOKERS” CAMPAIGN, USA: 2012–2014 tobacco industry used mass media to its advantage in order
fail to use it. For instance, all PSAs (not just anti-tobacco) are
80 to present smoking as an attractive and socially-desirable
MASS MEDIA CAMPAIGN TOOK PLACE allotted 3 percent of free broadcast time in China; in Russia
70 behavior. Now governments and advocates are using this tool CHINA
that share is 5 percent. Most notably in Turkey, as part of the Since 2007, the World Lung
to reverse those perceptions and shift behavior.
60 comprehensive tobacco control legislation passed in 2008, Foundation (WLF) has
advocated for the enforcement
On TV, in print, and increasingly through innovative uses of broadcasters are required to give the government 30 minutes
NUMBER OF CALLS

50 of stronger tobacco control

internet-based social media platforms, mass media campaigns a month of prime-time free PSA time for tobacco control. In laws in more than 43 cities in
40
now use graphic, emotional images and messages that starkly countries where tobacco advertising is allowed on television, China. Working in partnership
with national and subnational
30 present the health effects of tobacco use SOCIAL MEDIA CAMPAIGNS. governments should provide equal time, either in the form of
Solutions 1 Solutions 2 Solutions 3
government partners,
Graphic advertisements convince people about the true PSAs or paid ads, for anti-tobacco advertising.
20
dangers of tobacco use, cut through smokers’ defenses, WLF’S CAMPAIGNS
Each year, more countries begin using mass media anti-
10
and illustrate the urgent need for tobacco control policies
tobacco campaigns, but there are still large rural populations,
HAVE BEEN SEEN BY
0
Solutions 1
GRAPHIC ADVERTISEMENTS. Unlike messages that rely on humor or
Solutions 2 Solutions 3
in Africa and Southeast Asia for example, where people MORE THAN 300 MILLION
| | | | |
irony, they translate easily and well across languages and
The 2012–2014 CDC campaign, “Tips from Former Smokers,” included ads on TV, radio,
FEBRUARY–13 MARCH–13 APRIL–13 MAY–13 JUNE–13
cultures. In Senegal, the “Sponge” campagin generated a 63%
are hard to reach. In such areas, innovative strategies using CHINESE CITIZENS.
“Sponge” campaign resulted in a near 600% increase in calls to the national mobile phones, radio, and print should also be pursued,
billboards, YouTube, Twitter, and Facebook, featuring hard-hitting, graphic stories recall and a 144% increase in smokers who intended to quit.
told by former smokers. quitline in Senegal. Campaigns aired in April and May 2013. tested, and refined.
In Norway, the “Sponge” campaign generated a 68% recall
 70 CALL TO ACTION GRAPHIC PACKET WARNING LABELS 71

Chapter
Governments should legislate removal of all trappings
MORE THAN BIGGEST WARNINGS CANADA
Number of rounds of graphic warnings: latest available data

26 1 BILLION PEOPLE 2001: ROUND 1

of tobacco promotion on the packaging of all tobacco now live in countries Top 12 countries in size of graphic labels, 1ST COUNTRY
products, and follow Australia’sclipboard: Industry Says
lead in introducing quote: allies say
with best-practice as a percentage of pack area: 2014
TO INTRODUCE
packet warning labels.
plain/standardized packaging.
GRAPHIC
3 OR MORE ROUNDS
WARNINGS
LABEL CHARACTERISTICS THAILAND
85% covering 50% of
principal display space
2 ROUNDS
“The tobacco industry
Percentage of Parties which have implemented the WHO FCTC labeling provisions under uses all elements of the 2012: ROUND 2 1 ROUND
Article 11 by 2014 (and some have gone above and beyond the FCTC requirements) pack, including the outer Graphic warnings
film, tear-tape, inner
increased to cover
NO GRAPHIC WARNINGS
Health frame and pack inserts to
warnings exist 88% promote the product. 75% of principal NO DATA
[ONLY] STANDARDIZED AUSTRALIA
83% display space
Clear,
visible, legible 85% (PLAIN) PACKAGING
Approved by
WILL STOP
84% THE PACK BEING
15%
relevant authority AUSTRALIA
USED TO PROMOTE 80% 2006: ROUND 1
WARNINGS & PACKAGING

Misleading
URUGUAY Graphic warnings
descriptors
78% THE PRODUCT.”
banned
­— CRAWFORD MOODIE and
DECREASE introduced covering 30%
of front and 90% of back
GERARD HASTINGS, Australian adult smoking
Warnings prevalence fell by 15%,
rotated 78% University of Stirling, Scotland, 2010
from 15.1% to 12.8%, in the
2012: ROUND 2
BRUNEI DAR.
CANADA
second half of 2013, 1ST COUNTRY TO
No less than 30% 75% A YEAR AFTER INTRODUCE
surface area 78% TOBACCO COMPANIES, NEPAL
PLAIN/STANDARDIZED PLAIN/STANDARDIZED
NOT GOVERNMENTS, MAURITIUS
PACKAGING
Includes
50%
MEXICO PACKAGING WAS
pictures/ ARE RESPONSIBLE FOR TOGO Graphic warnings
pictograms
TURKEY INTRODUCED
THE COSTS OF PRINTING TURKMENISTAN in December 2012.
increased to cover 75%
50% or more
surface area 41% PACKET WARNINGS. VENEZUELA 65% of front and 90% of back

clipboard: Industry Says

W
| | | | |
GRAPHIC WARNING
0%
LABELS
25% 50% 75% 100%
arnings on the packaging of all tobacco products
have progressed rapidly from small and weak text
Plain/standardized packaging, with prohibition of all
industry logos and color, is a major battleground between
warnings 40 years ago to the introduction of strong the tobacco industry and governments. Australia was
Examples by region
graphic warnings, first adopted by Canada in 2001. Currently, the first country to adopt legislation to require plain/
2009 2009 2012
graphic warnings have been adopted by about one third standardized packaging, in the face of bitter opposition
AFRICA AMERICAS EASTERN
MAURITIUS CANADA MEDITERRANEAN of countries, with several being in their 3rd round of such from the tobacco industry; in spite of legal threats “IMPERIAL TOBACCO
warnings, so that smokers do not become desensitized to stemming from purported commitments to international
DOES NOT BELIEVE THERE
SOLUTIONS

DJIBOUTI
familiar messages GRAPHIC WARNING LABELS. economic agreements, plain/standardized packaging has
industry 1 industry 2 Solutions 1

been introduced successfully. In contrast to the tobacco IS ANY CREDIBLE OR

Warning messages on cigarette packages deliver important
information directly to smokers. The message is repeated
industry’s initial arguments, consumer transaction times RELIABLE EVIDENCE
to purchase tobacco products and product selection that standardized tobacco
and reinforced every time a smoker reaches for a cigarette. packaging will achieve the
errors have actually decreased or stayed the same. Government's stated objectives
60% front | 70% back 80% front | 80% back 50% front | 50% back In one of its strongest provisions, Article 11 of the WHO of reducing smoking prevalence
Framework Convention on Tobacco Control (FCTC) requires among young people or
assisting smokers who have,
2008 2011 2007 parties, within three years, to require tobacco product
or are trying to, quit.”
EUROPE SOUTH-EAST WESTERN warnings that cover at least 30%, and preferably 50%, of
—Imperial Tobacco response to the
BELGIUM ASIA PACIFIC the visible area on a cigarette pack LABEL CHARACTERISTICS, Chantler Review on standardized
THAILAND HONG KONG
industry 1 industry 2 Solutions 1
packaging of tobacco products, UK, 2014
BIGGEST WARNINGS . Warnings should be extended to all forms
industry 1 industry 2 Solutions 1

of combustible and smokeless tobacco.

48% front | 63% back 85% front | 85% back 75% front | 90% back GRAPHIC WARNING LABELS IN AUSTRALIA: 2006 VS. 2012
 72 CALL TO ACTION In the Russian Federation, a sweeping anti-smoking bill in 2013,
PACKAGING AND LABELING
TAX POLICIES
MINNESOTA,
PRODUCT USE
UNITED KINGDOM
GLOBAL REGULATORY EXAMPLES 73

Chapter tax increases in 2014, and an economic downturn resulted in a 12% drop in USA In February 2014, Case studies relating to the stages
Countries must establish regulatory frameworks that reduce, CANADA

27
if not eliminate, the harm caused by the use of tobacco products.
These frameworks may require different policies for different
products, depending on the associated risks.
GROWING
Regulate pesticide use
Provide occupational safety
and health safeguards for
farmers, including labor
protections
DISPOSAL
Establish litter and environmental
REGULATIONS
cigarette consumption in what had been the world’s second largest market. PRODUCT USE the UK government
The only US state of tobacco regulation
The Russian Federation demonstrated that In 2012, that considers IRELAND voted to make it a
REGULATIONS, ESPECIALLY WHEN COMBINED, HAVE THE POTENTIAL HEALTH WARNINGS E-CIGARETTES AND The first country to CRIMINAL OFFENSE
on packs of cigarettes institute an outright
TO MAKE BIG DECREASES IN TOBACCO CONSUMPTION. and little cigars E-LIQUID TO BE SUBJECT TO SMOKE IN CARS PRODUCT USE
BAN ON SMOKING BHUTAN
INCREASED FROM TO TOBACCO EXCISE TAX, WHEN CHILDREN ARE
IN WORKPLACES, DECLARED ITSELF
DISPOSAL
50% TO 75% of the
currently 95% of the
wholesale cost of any in March 2004. PASSENGERS.
SAN FRANCISCO, back and front surfaces. product containing or Offenders can face up THE WORLD’S FIRST
USA derived from tobacco. to EUR3000 fines. MARKETING NON-SMOKING NATION
In July 2009, a 20-cent ISLAMIC REPUBLIC in 2005. Violators are fined PACKAGING AND LABELING
MANUFACTURING
fee was imposed on every POINT OF PURCHASE OF IRAN the equivalent of USD232— MALAYSIA
pack of cigarettes sold in NEW YORK CITY, FRANCE more than two months’
One of the first countries A minimum pack size of 20
the city to partially cover USA In 2009, in an effort to in the Eastern Mediterranean salary in Bhutan. cigarettes was implemented
EXPENDITURES In May 2014, the prevent youth smoking, Region to completely in July 2010. This law
ADOPTED A LAW
Protect the environment and
prevent deforestation that MANUFACTURING RELATED TO REMOVING MINIMUM AGE TO
RESTRICTING USE OF
BAN ALL FORMS OF GROWING PROHIBITS SALES OF
14-STICK SO-CALLED
Ensure safe manufacturing CIGARETTE LITTER. TAX POLICIES
BUY CIGARETTES WAS TOBACCO ADVERTISING, BANGLADESH
occurs from tobacco curing COSTA RICA FLAVORING INGREDIENTS
and agricultural practices practices RAISED TO 21. PROMOTION, AND Law prohibits bank loans “KIDDIE PACKS,” which
Passed a comprehensive
IN CIGARETTES. for tobacco cultivation, accounted for over a third
Prohibit all incentives to grow Set product standards, including tobacco control bill that
This law has impacted
SPONSORSHIP. bans subsidies on of the Malaysian market
tobacco, such as subsidies regulating nicotine content and INCREASED TOBACCO MARKETING,
sales of vanilla, orange, and fertilizer to tobacco farms, in 2009.
additives chocolate cigarettes in the and stipulates that the
TAXES BY THE EQUIVALENT PACKAGING AND LABELING
country.
PRODUCT USE government shall provide PACKAGING AND LABELING
BRAZIL
OF USD0.80 PER PACK ZAMBIA EASY-TERM LOANS TO AUSTRALIA
PRODUCT ION
of cigarettes, with all of the The first country to
new tax revenue earmarked BAN MISLEADING 81% OF SMOKERS CULTIVATE ALTERNATIVE Experienced a decline
in smoking after
for tobacco control programs
TERMS SUCH AS “LIGHT” IN ZAMBIA SUPPORT CROPS.
and other health initiatives.
A TOTAL BAN on tobacco REQUIRING PLAIN/
PACKAGING AND LABELING AND “LOW-TAR.” products if government STANDARDIZED PACKAGING
Establish plain/standardized provides help for quitting. FOR CIGARETTES.
packaging as the gold standard
clipboard: Industry Says
Require warning labels, including

clean-up regulations graphic or pictorial images

STAGES OF Disclose ingredients and emissions

R
D I S P L AY
TOBACCO REGULATION Ban “kiddie”-sized packs and sale egulations should guide the use of tobacco products Because it is important to reduce the attractiveness of
US E

of single cigarettes in ways that eliminate or minimize harm. Regulations tobacco, marketing regulations (see Chapter 28: Marketing
At each stage of the life of Require application of tax stamps can effectively do this throughout the lifecycle of the Bans) make it more difficult for the tobacco industry to “While we support effective
to packaging product—from the time tobacco leaves are grown to the communicate a deceptive link between smoking and the evidence-based tobacco
tobacco products, there are many
regulation, we do not support
opportunities to limit the harm disposal of tobacco product waste STAGES OF TOBACCO REGULATION. promise of a more attractive lifestyle. Tax policies regulation that
they can cause. (see Chapter 21: Taxes), along with marketing regulations
industry 2 Solutions 1 Solutions 2

Regulations should correspond to the WHO Framework

Convention on Tobacco Control and other guidance, and that restrict promotional price discounts and coupons,
PREVENTS ADULTS
should be adjusted depending on the customs and political make cigarettes less affordable. Point of purchase FROM BUYING AND USING
PRODUCT USE environments of specific countries. restrictions can limit the availability of tobacco products, TOBACCO PRODUCTS
especially to youth. or that imposes
Enforce smoke-free public Regulatory aspects related to tobacco products are unnecessary impediments
places (indoor and outdoor)
MARKETING
SOLUTIONS

Ban smoking in multi-family PURCHASE Ban or restrict advertising, promotion
dwellings, homes, and cars and sponsorships
with children as passengers
Restrict health claims or language
suggesting reduced risk, including
descriptors such as “mild” or “light”
Ban free samples
Restrict price promotions, including
described in greater detail in many chapters of The Tobacco Regulations on where products can be used (see Chapter to the operation of the legitimate
Atlas. This chapter provides an overview of the regulatory 23: Smoke-Free) protect smokers and those exposed to tobacco market.”
lifecycle and exemplifies how regulations at every level second-hand smoke byclipboard: Industry
prohibiting smoking Says
in certain quote: allies say
­— Philip Morris International,
“Regulating Tobacco Products,” 2014
have the potential to minimize harm. Growing regulations areas. Disposal regulations (see Chapter 5: Environment)
(see Chapter 15: Growing) protect tobacco farmers from the can help ensure that cigarette butts, which are toxic
harms associated with handling tobacco leaves, and limit waste, are disposed of appropriately, or that cigarette
the tobacco industry’s impact on land use, especially in manufacturers are held responsible for collecting and
low- and middle-income countries. Manufacturing disposing of cigarette waste. “Why should society

POINT OF PURCHASE
Require retail licensing
Set a minimum age of purchase
Mandate face-to-face transactions
rather than self-service
Ban vending machines
Ban prominent displays in
retail environments
TAX POLICIES coupons and discounts regulations protect consumers by monitoring the processes
by which products are made, and can restrict additives that
This regulatory framework must evolve with the advent
continue to sanction
companies that create no
Implement higher tobacco of novel nicotine products that purportedly reduce harm. social value and
make smoking more addictive or appealing to youth.
excise taxes New nicotine delivery systems may help people to move CREATE SO MUCH HARM
Earmark taxes for tobacco control Packaging and labeling regulations (see Chapter 26: away from deadly combustible products, but the question
or other public health programs Warnings & Packaging) help to diminish the appeal of remains whether the regulations governing tobacco
FOR SO MANY,
in the process of creating
tobacco and the temptation to use tobacco products products should apply to these alternatives (see Chapter 12: profits for so few?”
by requiring them to be sold in plain packaging and/or E-cigarettes and Chapter 7: Nicotine Delivery Systems). ­— PATRICIA MCDANIEL and
RUTH MALONE, American Journal of
packaging that effectively portrays health warnings. Public Health, 2012
 74 CALL TO ACTION Iceland
ADVERTISING BANS 75

Chapter Sweden Finland Total number of bans on direct

Governments should implement comprehensive TAPS (tobacco advertising,
28 and indirect tobacco advertising,
Norway
clipboard: Industry Says
promotion and sponsorship) bans in order to protect children, youth, non- quote: allies say Estonia
2012: out of a possible 14 bans
smokers, former and current smokers alike. United Denmark
Latvia
Lithuania—
listed in TYPES OF BANS
Kingdom
Russian Federation
Ireland Netherlands Belarus
Canada 12—14
TYPES OF BANS
Poland
Belgium Germany
—Lux. Czech Rep.
Ukraine
“Obviously I am very Austria
Slovakia
Rep.
9—11
Hungary
Number of countries with specific bans on tobacco promotion much against
France Switz. Moldova

anything that tries San

Slovenia— —Croatia
Bosnia &
Romania
Mongolia
6—8
Andorra­ Marino— Herzegovina Serbia Kazakhstan
to reduce |

DIRECT ADVERTISING
|
Bulgaria
consumption of a
Monaco Montenegro—

Albania
—FYR
Macedonia Uzbekistan
DPR 0—5
NUMBER OF Italy Korea
DIRECT TOBACCO ADVERTISING BANS legal product that Portugal Spain Georgia Kyrgyzstan
COUNTRIES United States of America
is used by adults.”
Greece Armenia— —Azerbaijan
Turkmenistan Tajikistan
NO DATA
National TV and radio 144 Turkey
Korea
Rep.
­— GARETH DAVIES,
Chief Executive of
—Malta
Cyprus—
Syrian
China
Japan
GOOD COMPLIANCE
International TV and radio 118 Imperial Tobacco, Tunisia Lebanon—
Arab Rep.
Isl. Rep.
Afghanistan
with more than 7 total
West Bank/— Iraq
commenting on a proposed Gaza Strip Jordan of Iran bans on direct and indirect
clipboard: Industry Says
Local print 129 quote: allies say
advertising ban in the Morocco —Israel
Kuwait—
Pakistan
Nepal
Bhutan
|
advertising in place
United Kingdom, 1997 Algeria Libya
International print 86 —Bahamas Egypt Bahrain—
—Qatar Bangladesh
UAE —Hong Kong
Mexico Cuba Saudi Arabia
Billboards 129 Dominican Rep.
India Myanmar
LAO
Haiti Oman PDR
Jamaica— Mauritania
Point-of-sale 67 Belize
Honduras
Antigua & Barbuda— —St. Kitts & Nevis Mali
Niger Thailand Philippines
Guatemala St. Lucia— —Dominica Senegal Eritrea Yemen
—Cape Viet Nam
Internet 96 “If we do not El Salvador
Nicaragua
St. Vincent &— —Barbados
the Grenadines —Grenada
Verde
Gambia—
Burkina Faso
Chad Sudan
—Djibouti
Cambodia
Guinea-Bissau—
close ranks and Costa Rica
—Trinidad & Tobago Guinea
Benin
Ghana Nigeria Ethiopia
INDIRECT ADVERTISING ban tobacco Panama Venezuela —Guyana Sierra Leone— Côte
D’Ivoire Togo Central
African Rep.
S. Sudan Sri Lanka
—Palau
|
Fed. States of
|
Marshall Islands
Liberia— Somalia
advertising,
MARKETING BANS

Cameroon Brunei Dar.— Micronesia

Suriname
NUMBER OF Colombia Maldives— Singapore
|
Malaysia
promotion and
INDIRECT TOBACCO ADVERTISING BANS COUNTRIES Equatorial Guinea— Uganda Nauru
|
Sao Tome and Principe— Kenya
Congo Indonesia |

sponsorship,
Gabon
Free distribution 102 Ecuador
Dem. Rep. —Rwanda
—Burundi Papua New Guinea
Kiribati

of Congo
Promotional discounts 84 adolescents and United Republic
—Seychelles

young adults will of Tanzania

—Timor-Leste
Tobacco product brands used for non-tobacco products 80 continue to be Peru Brazil —Comoros
Solomon Islands

Angola Malawi Tuvalu—

Non-tobacco product brands used for tobacco products 57 lured into tobacco Zambia

Product placement 104 consumption Bolivia Mozambique

Madagascar
Vanuatu—
Zimbabwe
by an ever- Namibia —Mauritius Samoa—
Fiji—
Appearance of tobacco products in TV and films 45 more aggressive Paraguay
Botswana

Sponsored events 89 tobacco industry.” S. Africa

—Swaziland
Australia Niue—

—Lesotho Tonga—
—DR MARGARET CHAN, Cook Islands—
Director-General of the WHO, 2013
Chile
Uruguay

C
Argentina

GERMANY'S INCOMPLETE TAPS BAN TAPS POLICIES omprehensive TAPS bans on direct and indirect tobacco films and TV programs, event promotion, retailer incentives,
Abb. 2.9
Politische
Meinungsäußerungen
SOLUTIONS

von British American

Tobacco und Reemtsm
im Rahmen von
a advertising, sponsorship and all other forms of promotion are sponsorship and advertising through international media, New Zealand
Imagewerbung.
Quellen: elde 6/2009
(http://www.elde-online.
Number of countries with varying degrees of advertising bans effective at reducing population smoking rates TAPS POLICIES . cross-border advertising, internet advertising, and promotional
ALLOWED BANNED
de/pdf/elde_2009-6.pdf),
Die Entscheidung 9/2009

Partial restrictions are less effective in reducing smoking partly because

harm 2 harm 3 products 1

packaging are some of the ways that the tobacco industry

24 103 1 67 tobacco companies redirect their marketing efforts to available circumvents the intent of simple bans. Legislation should include
venues. Voluntary agreements are also inadequate because they are bans on all forms of direct and indirect advertising, promotion,
unenforceable. Countries that introduced complete bans together with and sponsorship TYPES OF BANS. In 41 countries studied,
harm 2 harm 3 products 1

other tobacco control measures have been able to cut tobacco use smoking prevalence was
Bans deny the tobacco industry one of their tools to recruit new
COMPLETE MODERATE MINIMAL NONE significantly within only a few years.
tobacco users to replace those who have quit or died, to maintain REDUCED 5%
Ban on all forms of direct
and indirect advertising
Ban on national TV, radio,
and print media as well
Ban on national TV, radio,
and print media only
Complete absence of ban,
or ban that does not cover
Tobacco companies have opposed the removal of tobacco retail or increase use among current users, to reduce a tobacco user’s WITHIN 3 YEARS
National promotion/sponsorship TV and radio displays, arguing this would compromise retailers’ safety, increase willingness to quit, and to encourage former users to start using in countries with a
as on some (but not all) national TV, radio, and
ban on direct and
Point-of-sale Print media other forms of direct and/ print media retail crime, reduce retailers’ income, impose additional costs and tobacco again. indirect marketing,
or indirect advertising
be inconvenient. These arguments have successfully delayed policy in contrast to 3%
Outdoor/billboard Internet Abb. 2.10
Großformatige Anzeigen Comprehensive TAPS bans protect youth from the onslaught of
in Die Tabak Zeitung.
development in several jurisdictions. that only banned
tobacco marketing in sports, music venues, the internet, and
Quellen: Die Tabak Zeitung

Brand stretching Cinema before 18:00

37/2009 (Winston) und
advertising, and 1%

10%
18/2010 (Gauloises und
Skavenbeck)

Only 10% of the world’s population is covered by complete Tobacco companies have become ever more creative in their elsewhere, and help reduce the social acceptability of smoking that introduced a
partial ban.
Tabakwerbung in Deutschl
and 13

Incomplete bans allow the tobacco industry to utilize other bans on all tobacco advertising, promotion, and sponsorship attempts to lure new consumers into addiction. New use of media, and tobacco use.
media to continue to promote their product. at the highest level of achievement at the national level. social media, brand stretching, product placement in movies/
 76 CALL TO ACTION FUNDS NEEDED 77

AVAILABLE VS. NEEDED FUNDS IN 2011, ABOUT

$68M
Chapter Per capita annual cost of the four
Since current tobacco control funding is insufficient to arrest the
29 harm caused by tobacco use, all countries should develop new
funding mechanism to support tobacco control efforts.
IN 2011
Governments spend too little on tobacco control:
USD per capita, 2011
HALF OF ALL
CONTRIBUTIONS
made by public or
“best buy” tobacco control measures
in low- and middle-income countries:
in USD

was the total private institutions

LESS THAN $0.10
HEALTH FUNDING international assistance $10.74 from high-income
for tobacco control countries to control
efforts in all low-
1 Row = $0.30
tobacco use in $0.10—$0.49
Development assistance for health in low- and middle-income countries (LMICs) and middle-income LMICs came from just

which includes funding from bilateral and multilateral donors, non-governmental countries. This was also 1 Row = $0.30 two donors:
$0.50—$4.00
organizations, private foundations, and the corporate sector:
the amount spent $10.74 BLOOMBERG
by focus area, in millions USD, 2011 EVERY THREE DAYS $10.74 PHILANTHROPIES
HIGH-INCOME COUNTRIES
by the tobacco industry
and
OR NO DATA
to advertise and promote

$7,696M clipboard: Industry Says

EXPENDITURES BY FOCUS AREA
its products in the
quote: allies say
United States of America. FUNDS 1 Row
COLLECTED = $0.30 THE BILL &
Excise tax revenue MELINDA GATES
from tobacco
$6,130M $10.74
products in LMICs FOUNDATION.
While this assistance
has been critical to
progress in tobacco
$1,788M control, a wider variety
$1,315M $1,266M COST EFFECTIVENESS of funders joining
“With […] these two exemplary
funders would provide
$310M $68M cost-effectiveness a more secure and
rivalled only diverse assistance
environment.
HIV/AIDS Maternal, Malaria Health sector Tuberculosis Non- Tobacco
by basic childhood
newborn, and support communicable
diseases
immunisations, .11
child health Excluding few public .011 + .0078
spending on
FUNDS NEEDED
1.17M 1.16M tobacco control investments $0.11 to deliver four
The four measures include: tobacco tax increases, smoke-free policies, package warnings, and advertising bans.
1.39M The estimates include the human resources and physical capital needed to plan, develop, implement, monitor and enforce the policies.
provide greater “best buy” tobacco .11
dividends.” control measures

T
.011 + .0078
INVESTING

in LMICs he exact global economic cost related to tobacco in all low- and middle-income countries is projected at
4.30M —World Health Organization, 1997
DEATHS IN LMICs IN 2010 consumption is unknown, but it is likely over one trillion
dollars per year. In the United States alone, the estimated
only USD600 million, or USD0.11 per capita, while both
domestic public funding and international development
NEW FINANCING
$0.011 INTERNATIONAL ASSISTANCE
$0.0078 DOMESTIC PUBLIC FUNDING
CURRENT FUNDING
International .11 annual smoking-attributable costs, including direct medical assistance for tobacco control remain at just a fraction of MECHANISMS
96%
assistance and costs as well as the cost of lost productivity due to premature the need AVAILABLE VS. NEEDED FUNDS.
Governments collect nearly USD145 billion in tobacco excise tax revenues each
year, but spend less than USD1 billion combined on tobacco control—96% of this is
.011 + .0078
domestic public
death and illness, amounted to more than USD289 billion
industry 2 Solutions 1 Solutions 2
SOLIDARITY TOBACCO CONTRIBUTION,
funding for tobacco Few low- and middle-income countries have the a concept developed by WHO,
annually on average for the years 2009 to 2012. The global
SPENT BY HIGH-INCOME COUNTRIES. control in LMICs
cost of tobacco use is expected to increase due to increases
experience and resources that could match those of the recommends that countries consider
transnational tobacco industry. Therefore, international dedicating a part of their tobacco
in the number of tobacco-related disease cases, as well as tax revenue toward international
assistance for tobacco control is necessary, especially at
the growing cost of health care. health-financing purposes, including
COST-BENEFIT the initial stages of the epidemic. Countries at later stages
international tobacco control.
SOLUTIONS

Savings created by tobacco
control interventions:
in millions USD, 2013
MISSOURI, USA TAIWAN, CHINA
Tobacco Prevention Outpatient Smoking Cessation
and Cessation Initiative: Services program:
Smoke-free policy change Counseling and nicotine
replacement therapy
UNITED KINGDOM AUSTRALIA GERMANY A great part of these costs can be averted by investing in in the tobacco epidemic can share their tobacco control
Taxation: Australian National Smoke-free Class Competition: tobacco control, which fortunately can bring to bear a set of know-how, and new financing mechanisms could help MANDATORY SOLIDARITY LEVY ON
5% increase in cigarette price Tobacco Campaign: Reward non-smoking classes to
Intensive 6-month mass media prevent students from becoming .0078evidence-based interventions that has proven to be effective the international community to raise the funds required AIRLINE TICKETS in some countries
COST-BENEFIT . Policymakers and international donors can to scale up implementation of the measures set out in the supports scaling-up of treatments
anti-smoking campaign established smokers
for HIV/AIDS and tuberculosis. Similar
industry 2 Solutions 1 Solutions 2

choose from a number of population-wide and individual- MPOWER package. In the long run, knowing the value of
level measures listed in the WHO Framework Convention on investing in tobacco control, each country must learn for airline ticket taxes could support
NET SAVINGS $62M $224M $18,461M $912M $25M Tobacco Control and its guidelines. itself how best to allocate the funds needed to address international tobacco control.
over remaining lifetime of 5761 quitters over 15 years over 50 years over remaining lifetime of 190,000 quitters over 1 year
the tobacco epidemic. TOURISM TAXES and levies on
Annual budget for Taiwan's annual Government annual Australia's annual Government annual
.0078its great return on investment, funding for tobacco
Despite
financial transactions are other ideas
EXAMPLES OF HOW control remains at levels that are inadequate compared to
THESE SAVINGS restoration and government budget spending on industry, governmental spending on helping to consider for financing international
current needs, and far behind the level of funding directed
COULD BE SPENT conservation of for environmental agriculture and investment in early ethnic Germans tobacco control efforts.
Missouri's forests protection. employment. childhood education. living in Eastern Europe. toward addressing other health problems that cause
and wildlife. far fewer deaths HEALTH FUNDING . The total annual cost of
.0078 core population-based tobacco control measures
industry 2 Solutions 1 Solutions 2

delivering
 78 LEGAL CHALLENGES 2012
SCOTLAND
2012
NORWAY
ACRONYMS

FDA FOOD AND DRUG ADMINISTRATION

2012
CANADA
2012–2013
FRANCE
LITIGATION 79

Chapter Resisting legal challenges to tobacco control: IMPERIAL TOBACCO The Court accepted some 2012 ONTARIO V. ROTHMANS INC., NON-SMOKERS RIGHTS ASSOCIATION Litigation against tobacco:

30
WHO WORLD HEALTH ORGANIZATION FRAMEWORK 1998
selected countries 2010–2014 lost its challenge to a ban
of the challenges by PAKISTAN FCTC CONVENTION ON TOACCO CONTROL AMONG OTHERS V. BRITISH AMERICAN TOBACCO selected countries
USA
on vending machines and PHILIP MORRIS Norway, The Lahore High Court WTO WORLD TRADE ORGANIZATION
Several provincial governments
have brought litigation against
The Non-Smokers Rights Association
point-of-sale displays. The but upheld a retail display dismissed a petition by
industry leaders in Canada over
THE MASTER SETTLEMENT AGREEMENT SUCCESSFULLY SUED BAT
Supreme Court stated the ban, deeming it necessary TOBACCO ADVERTISING, PROMOTION (MSA) between attorneys general of 2013
2012
law was designed to protect and that no alternative, less
SHISHA CAFÉ OWNERS TAPS
AND SPONSORSHIP recovery of health care costs and 46 states, 5 territories and the District REGARDING VIOLATIONS OF 2014 PHILIPPINES
USA public health by reducing intrusive measure could
against the smoke-free law. of tax money evaded through of Columbia and five major tobacco ADVERTISING BANS, KOREA REP. There are two ongoing legal cases
FIVE TOBACCO 2012 product attractiveness and produce a similar result. RACKETEERING AND companies, settled litigation brought in promoting tobacco use and enhancing
GOVERNMENT V. THREE TOBACCO COMPANIES cases in which tobacco control
2012 preceding years. It resulted in a its own image by warning about the
COMPANIES challenged BRAZIL availability, not prohibiting
INDIA SMUGGLING ACTIVITY FROM South Korea's National Health advocates have called for the DOH
graphic health warning Brazilian tobacco
their sale. 2013
THAILAND AMERICAN COMPANIES. USD206 BILLION PAYMENT harms of counterfeit tobacco products.
Insurance Service is suing the and FDA (respectively) to articulate
The Delhi High Court
regulations issued by the LOBBYING GROUP 2013 dismissed a petition by an The petition of SINCE 2000
TO LIMIT THE DAMAGE FROM 2000–2014
local arms of PMI and BAT, and local and execute laws regarding graphic
pack warnings and regulation of
market leader KT&G Corp for
FDA. The Court found the
SINDITABACO brought EUROPEAN UNION association of Different Canadian provinces have TOBACCO USE OVER 25 YEARS. EUROPEAN UNION
warnings violated freedom 2012 TOBACCO USD52M IN HEALTH CARE COSTS FOR tobacco and tobacco products. These
of expression and rejected
an action to stop THE INDUSTRY SOUTH AFRICA TOBACCO WHOLESALERS, MANUFACTURERS 2011+ sued the tobacco industry for recovery The MSA also forbids many forms of EU V. RJR NABISCO cases are examples of the utility of
the regulations. The FDA will
the National Health mounted an aggressive which had challenged a PHILIPPINES of billions of dollars in health care tobacco marketing. Court case by the European Community SMOKING-RELATED TREATMENT. litigation as a way to leverage existing
Surveillance Agency, ANVISA, The Constitutional Court to stop the Minister costs caused by tobacco-related 1991 against RJR Nabisco before the US laws in practice. In July 2014,
redesign the warnings. multi-million-euro lobbying ban on selling of tobacco Various legal cases
from implementing a ban dismissed an appeal by of Public Health from disease, alleging that the tobacco court for racketeering and smuggling President Benigno Aquino III
products within 100 yards of BROIN V. PHILIP MORRIS, INC. 2014
LEGAL CHALLENGES & LITIGATION

campaign to weaken the regarding jurisdiction

2012–2014
PERU
The Specialized
Constitutional Court
of Lima rejected the
BRITISH
AMERICAN TOBACCO
Peru case against Congress,
which challenged a ban
on additives and flavorings,
arguing that ANVISA lacked
legal authority and the
rule was not supported by
scientific evidence.
2013
URUGUAY
After several tobacco
control laws, affiliates of
Tobacco Products Directive,
which was only marginally
successful.
BRITISH AMERICAN
TOBACCO over suing the
Minister of Health claiming that
the Tobacco Products Control
Act was unconstitutional.
This case involved person-to-
person marketing techniques
prohibited under a TAPS
ban. The Court found that
the hazards of smoking far
any educational institution.
Many cases have been brought
against gutkha. The Court
of the State of Bihar dismissed
a challenge by
DISTRIBUTORS to the
ban on gutkha or pan
masala containing tobacco.
implementing larger-sized
packet warnings was
ultimately denied.
2012
INDONESIA
The Court accepted some
challenges, but rejected a
constitutional challenge by
Indonesian tobacco farmers
over tobacco regulations,
including graphic health
warnings, TAPS bans and
smoking bans are ongoing.
2011
AUSTRALIA
The Australian government
is fighting challenges to its
companies engaged in a
DECADES-LONG CONSPIRACY
TO MISLEAD ABOUT THE HEALTH
RISKS OF SMOKING
and to suppress information about
the dangers of smoking.
A Florida class action brought by
flight attendants suffering
HARM FROM SECONDHAND
SMOKE, WHICH RESULTED IN A
USD300M SETTLEMENT.
practices. The Court stated "[RJR
officials] at the highest corporate
level [made it] part of their operating
business plan to sell cigarettes to and
through criminal organizations
and to accept criminal proceeds in
PAYMENTS FOR CIGARETTES
BY SECRET AND
SURREPTITIOUS MEANS.”
INDONESIA SIGNED A GRAPHIC PACK
As of July 2014, a class action suit WARNING REQUIREMENT
is being brought against the industry
in Indonesia, where tobacco control INTO LAW.
advocates highlighting
THE ISSUE OF CHILD SMOKERS
will call for more regulations on tobacco
products. The action is currently being
drafted by the National Commission for
Child Protection, a state-established,

on packages of less than
10 cigarettes. The Court
observed that the WHO
FCTC is a human rights
treaty that ratifies the idea
that economic freedoms
should be limited in order
to protect economic and
social rights.
41+24+12+23+z
outweigh the interests of 2013 Tobacco Plain Packaging Act.
and industry workers to
PHILIP MORRIS smokers, and that South Africa SRI LANKA Indonesia’s Health law. One challenge is from
semi-independent organization.
INTERNATIONAL is obliged to observe the The Court of Appeal denied PHILIP MORRIS ASIA
challenged two additional WHO FCTC.
regulations in 2009,
CEYLON TOBACCO using a bilateral investment
treaty between Australia
including 80% graphic COMPANY’S request and Hong Kong. The other
health warnings, as a to delay 80% graphic challenge is from several
violation of a bilateral pictorial health warnings, countries using the World
investment treaty between but the court also ordered Trade Organization.
Switzerland and Uruguay. clipboard: Industry Says
a reduction in the size of quote: allies say
They also challenged and the warnings to 50%—60%
lost in the domestic courts. of the pack.

CALL TO ACTION CALL TO ACTION LITIGATION TOPICS

“In my view,
Governments must resist legal challenges and threats from alleged something is fundamentally wrong in this Governments, organizations and individuals Selected litigation cases by tobacco control topic, up to and including 2014 41%
commitments to international economic agreements to prevent, delay,
world when a corporation can challenge
government policies introduced to should consider taking legal action to support ADVERTISING,
or overturn tobacco control legislation. protect the public from
existing tobacco control laws, and to deal
TOBACCO CONTROL TOPIC # CASES PROMOTION AND
ADVERTISING, PROMOTION AND SPONSORSHIP 245 SPONSORSHIP
A PRODUCT THAT KILLS.” with criminal and civil liability, including

L
SMOKEFREE MEASURES 146
egal challenges by the industry are being launched In November 2010, the WHO Framework Convention ­— DR MARGARET CHAN, Director-General WHO, compensation where appropriate.
around the world to prevent government tobacco on Tobacco Control Conference of Parties adopted the
World Health Assembly, 2014 LIABILITY 69
SOLUTIONS

45

L
CONTENTS AND DISCLOSURES MEASURES
control action. The vast legal resources of the large Punta del Este Declaration in support of WHO FCTC
itigation against the tobacco industry has been
multinational tobacco firms are commonly pitted against Parties who are facing legal attacks for implementing PACKAGING AND LABELING MEASURES 26
sponsored by individuals or groups of individuals,
the often limited legal resources of a low- or middle- the treaty and its guidelines. The Declaration outlined PRICE AND TAX MEASURES 16 23% OTHER
public health advocates, organizations or
income country. These legal challenges, which may concern regarding legal actions taken by the tobacco
governments to recoup the economic harm from tobacco ILLICIT TRADE 13
include invoking economic agreements, are expensive industry that seek to subvert and undermine government clipboard: Industry Says quote: products.
allies say Such litigation has been based on grounds CESSATION 9
to defend and invariably delay implementation of laws policies on tobacco control. The Declaration stated that
such as “health harms, wrongful death, healthcare costs, PROTECTION OF ENVIRONMENT 9
passed in the interest of public health. For example, in Parties have the right to define and implement national
involvement in smuggling, racketeering, conspiracy, SALES TO OR BY MINORS 8
2014 British American Tobacco had 450 people in its public health policies pursuant to compliance with 12% LIABILITY
defective product, concealment of scientific evidence,
regulatory-affairs team involved with aggressive lobbying conventions and commitments under WHO, particularly INDUSTRY INTERFERENCE 8
fraud, deception, misconduct, failure to warn consumers
to prevent plain-packaging regulations within the with the WHO FCTC. ALTERNATIVE ACTIVITIES 2
United Kingdom. The threat of litigation is likely stifling “WE HAVE THE PEOPLE, PATIENCE, adequately of the dangers of tobacco smoke, negligence
EDUCATION 0
Smokers’ rights, neo-libertarian and other front groups, and exposing the public to unreasonable danger.”
legislative and regulatory efforts in many places.
funded by the tobacco industry, are being used globally
PERSEVERANCE AND RESOLVE TOTAL # UNIQUE CASES 596
24%
SMOKE-FREE MEASURES
to work through even the most difficult
to challenge tobacco control legislation. litigation challenges.”
­— LOUIS C. CAMILLERI, Altria/Philip Morris chairman
and chief executive officer at the 2003
Annual Meeting of Stockholders in Richmond, VA
 80 CALL TO ACTION Iceland
TOLL OF NCDs 81

Chapter Sweden Finland Share of deaths due to

The tobacco control community must work closely with the broader movement
31 non-communicable
Norway
addressing the global non-communicable disease (NCD) crisis; moreover, Estonia
diseases (NCDs): 2010
tobacco control proponents must stand together with other public health United Denmark
Lithuania—
Latvia
Kingdom
communities to lift the fight against NCDs to the very top of the global health Netherlands Belarus
Russian Federation
Ireland
and development agendas. Canada Belgium Germany
Poland
15.00—29.99%
—Lux. Czech Rep.
Ukraine
Slovakia
30.OO—49.99%
TRENDS IN MORTALITY SHARING THE TOOLS France Switz.
Austria

Slovenia— —Croatia
Bosnia &
Hungary
Romania
Rep.
Moldova

Mongolia
50.00—69.99%
Andorra­ Herzegovina Serbia Kazakhstan
Packaging regulations, a method
|
Percentage of all deaths by cause, worldwide Montenegro— Bulgaria

 NCDs  employed to control tobacco use, Portugal Albania

—FYR
Macedonia Uzbekistan
DPR
Korea
70.00—89.99%
Italy Georgia Kyrgyzstan
 COMMUNICABLE DISEASES, MATERNAL, NEONATAL, AND NUTRITIONAL DISORDERS United States of America Spain
can also serve to deter people from Greece
 INJURIES consuming other unhealthy products.
Armenia— —Azerbaijan
Turkmenistan Tajikistan Korea
90.00% AND OVER
Turkey Rep. Japan

Tunisia
—Malta
Cyprus—
Lebanon—
Syrian
Arab Rep. Afghanistan China NO DATA
57% 6 5% Isl. Rep.
10%
West Bank/—
9% Gaza Strip Jordan Iraq of Iran
Bhutan INCREASE
Morocco —Israel Pakistan Nepal |
Kuwait—
Countries where share
Algeria Libya
—Bahamas Egypt Bahrain—
—Qatar Bangladesh of deaths due to NCDs
Mexico Cuba
UAE increased by more than
Saudi Arabia
India Myanmar
half from 1990 to 2010
1990 2010 Haiti
Dominican Rep.
Oman
LAO
PDR
Jamaica— Mauritania
Belize
Existence of a global health treaty (WHO FCTC) Honduras
Antigua & Barbuda— Mali
Niger Thailand Philippines
2 5%

Guatemala St. Lucia— —Dominica Senegal Eritrea Yemen

as well as effective national and sub-national El Salvador St. Vincent &— —Barbados
—Cape
Verde
—Gambia Chad Sudan
Viet Nam
Cambodia
legislation make tobacco control a model for Nicaragua the Grenadines —Grenada Burkina Faso
GLOBAL NCD AGENDA

Guinea-Bissau— —Djibouti
34
clipboard: Industry Saysissues that quote: allies say
—Trinidad & Tobago Guinea
% addressing other pressing NCD-related Costa Rica
Benin
Sierra Leone— Côte Ghana Nigeria Ethiopia
Venezuela
require better regulations, including harmful use of Panama —Guyana D’Ivoire Togo Central Sri Lanka |
|
Marshall Islands
NCDs are taking more and more lives each year. alcohol and unhealthy diet.
Liberia—
Cameroon
African Rep. Somalia Brunei Dar.—
Fed. States of
Micronesia
Suriname Maldives—
Colombia Malaysia
Equatorial Guinea— Uganda
Sao Tome and Principe— Kenya |
Congo Singapore Indonesia

LACK OF AWARENESS
|
Gabon
Ecuador —Rwanda Kiribati
Dem. Rep.
—Burundi Papua New Guinea
of Congo —Seychelles
“Mars is concerned that the Smoking accounts for United Republic
of Tanzania
Many people do not realize the degree to which tobacco is linked to introduction of mandatory
other diseases, such as cardiovascular diseases and strokes. plain packaging in the tobacco MORE THAN Peru Brazil —Comoros
—Timor-Leste Solomon Islands

industry would also

20% OF ALL Angola
Zambia
Malawi

SMOKING SECONDHAND SMOKE SET A KEY PRECEDENT CANCER DEATHS Bolivia Mozambique Vanuatu—
% adult smokers who % adult smokers for the application of similar Zimbabwe Madagascar
Samoa—
do not believe or do who do not believe legislation to other industries,
including the food and non-
WORLDWIDE. Namibia
Botswana
—Mauritius
Fiji—
not know that smoking EGYPT or do not know that The total number of Paraguay
causes specific diseases secondhand smoke alcoholic beverage industries tobacco-attributable —Swaziland
causes specific diseases in which Mars operates.” S. Africa
Australia
  LUNG CANCER  cancer deaths in 2010 —Lesotho Tonga—
  HEART ATTACK   LUNG CANCER  —The Mars Corporation was 1,468,950.
  STROKE   HEART DISEASE  to the UK government, 2012 Chile
BANGLADESH
Uruguay

A
Argentina

TOBACCO AND NCDs s economic development continues rapidly and as transnational Yet, with strong support from civil society, member states
SOLUTIONS

tobacco, alcohol, food, and beverage companies aggressively unanimously approved a declaration that acknowledges
that fighting these diseasesclipboard: Industry Says quote: allies say New Zealand
THAILAND
Risk factors for the leading non-communicable diseases worldwide promote unhealthy choices, non-communicable diseases is a global priority requiring
(NCDs) such as cardiovascular disease, stroke, diabetes, chronic urgent action. Multiple initiatives evolved after the United
CAUSATIVE Physical Harmful use Diets lung disease, and cancer are becoming more important as causes Nations summit, including formulation of the WHO Global
UKRAINE RISK FACTORS Tobacco use inactivity of alcohol high in salt of global morbidity and mortality TRENDS IN MORTALITY. NCDs have NCD Action Plan, a set of nine specific targets toward preventing
Solutions 1 Solutions 2 Solutions 3

HEART DISEASE surpassed communicable diseases (e.g. HIV, malaria, tuberculosis, major NCDs by addressing their major risk factors. A key target
AND STROKE
diarrhea, pneumonia) as the leading causes of death in all but the is a 30% reduction in tobacco use prevalence by 2025 “NCDs are one of the

VIETNAM CANCER lowest-income nations. Even in low-income countries, deaths from (see Chapter 32: The Endgame).
MAJOR CHALLENGES
NCDs are rapidly approaching those of communicable disease. to sustainable human
The tobacco control community pioneered tools to limit markets
DIABETES Tobacco is a driver of the development of most of the leading NCDs, development in the
for unhealthy commodities. Companies that profit from the sales 21st century, and
including chronic lung disease, cardiovascular disease, stroke,
CHRONIC LUNG
of alcohol, sugary beverages, and foods with high fat, sugar, and therefore must be
POLAND cancer, and diabetes TOBACCO AND NCDs. central to the post-2015
DISEASE salt content—all major NCD risk factors—use strategies similar
development agenda.”
Solutions 1 Solutions 2 Solutions 3

TOTAL DEATHS, 2010 6.3 3.2 2.7 3.1 In 2011, world leaders gathered in New York for a United Nations to those of the tobacco industry. Proven and effective tobacco
—TEZER KUTLUK, President-
(IN MILLIONS) high-level meeting to give NCDs new prominence in the health control measures, such as marketing bans, packaging and labeling Elect, Union for International
CHINA Cancer Control, 2014
and development agendas. Private sector firms and trade associations regulations, and taxation, can also be used in addressing those
Tobacco use is a shared risk factor for the four leading non-communicable diseases
|
80% 60%
| |
40%
|
20%
|
0%
|
20%
|
40%
|
60%
|
80% in the world, causing 6.3 million deaths. tried to undermine strong action, and lobbied for self-regulation. other major NCD risk factors SHARING THE TOOLS.
Solutions 1 Solutions 2 Solutions 3
 82 CALL TO ACTION Iceland 2040 2025 TARGETS 83

Chapter
Policymakers must utilize existing strategies that have been proven 2034 Sweden Finland Adult prevalence needed

32 to meet WHO target of a

Norway
effective in reducing tobacco prevalence, and they must explore bold, Scotland Estonia
30% relative reduction in
innovative tactics to achieve the endgame for tobacco use.
2025 United
Kingdom
Denmark
Lithuania—
Latvia

Russian Federation
prevalence of current tobacco
use from 2010 baseline
Ireland Netherlands Belarus

DEFINITIONS NOVEL IDEAS Canada Belgium Germany

—Lux. Czech Rep.
Poland

Ukraine
0.0—4.9%
Slovakia
Rep.
5.0—9.9%
Some examples of proposals to help reach endgame goals: France Switz.
Austria
Hungary Moldova
Slovenia—
WHO 30% relative reduction in
—Croatia Romania
10.0—14.9%
TARGET each country in prevalence of INGREDIENTS/PRODUCT Bosnia &
Herzegovina Serbia
Bulgaria
Kazakhstan Mongolia

current tobacco use in persons Reduce nicotine to non-addictive levels

Montenegro—

Albania Uzbekistan
DPR 15.0—19.9%
Italy Georgia Kyrgyzstan Korea
Spain
aged 15+ years, by 2025 Eliminate cancer-producing substances United States of America Portugal

(from 2010 baseline)

Greece Armenia— —Azerbaijan
Turkmenistan Tajikistan Korea
20.0—100%
Ban combustibles Turkey Rep. Japan

Make cigarettes less appealing (increase pH level

—Malta
Cyprus—
Lebanon—
Syrian
Arab Rep. Afghanistan China NO DATA
Tunisia Isl. Rep.
“ENDGAME” Prevalence rate
to discourage deep inhalation, remove menthol,
West Bank/—
Gaza Strip Jordan Iraq of Iran
TARGET of 5% or below by an ENDGAME
20XX
Morocco —Israel Pakistan Bhutan
Nepal
remove all ingredients besides tobacco, remove filters) Kuwait— |

announced date Algeria Libya 1st 4 countries or regions to

Ban multiple versions of the same brand —Bahamas Egypt Bahrain—
—Qatar Bangladesh
announce endgame dates
UAE
Ban addition of tobacco to food items (e.g. gutkha) Mexico Cuba Saudi Arabia
Dominican Rep.
India Myanmar
LAO

PROJECTIONS
Haiti Oman PDR
Jamaica— Mauritania
TOBACCO INDUSTRY Guatemala
Belize
Honduras
Antigua & Barbuda—
St. Lucia— Senegal
Mali
Niger Eritrea Yemen
Thailand Philippines
—Cape Viet Nam
Nationalize tobacco companies El Salvador St. Vincent &— —Barbados Verde
—Gambia Chad Sudan
Cambodia
Impact of implementation of existing policies: Nicaragua the Grenadines —Grenada
—Trinidad & Tobago Guinea-Bissau—
Burkina Faso —Djibouti
Guinea
global smoking prevalence, 2010–2030 Reporting standards for WHO FCTC Article 5.3 Costa Rica
Benin
Sierra Leone— Côte Ghana Nigeria Ethiopia
 NO POLICY INTERVENTIONS   POLICY INTERVENTIONS Panama Venezuela —Guyana D’Ivoire Central Sri Lanka
Togo |

AVAILABILITY Suriname
Liberia—
Cameroon
African Rep. Somalia Brunei Dar.—
Fed. States of
Micronesia
Colombia Maldives— Malaysia
Complete prohibition of tobacco Equatorial Guinea—
Sao Tome and Principe—
Uganda
|
Congo Kenya
Singapore Indonesia |
25% — Regulate as a controlled substance Ecuador
Gabon
Kiribati
Dem. Rep. —Rwanda
SINGAPORE
THE ENDGAME

—Burundi Papua New Guinea

of Congo
20% — Make tobacco available by prescription only United Republic
—Seychelles
A 2007 proposal in Singapore
of Tanzania would ban the provision of tobacco
15% — Require a smoker’s license, renewable annually
products to any Singaporeans —Timor-Leste Solomon Islands
Require staggered starting fees to discourage beginners Peru Brazil
BORN IN OR AFTER
—Comoros
10% — Angola Malawi

Ban supply of tobacco to anyone born after a certain year (e.g. Singapore, year 2000) Zambia
5% —
Stronger licensing laws for selling tobacco Bolivia Mozambique THE YEAR 2000; Vanuatu—
Namibia
Zimbabwe Madagascar
—Mauritius
surveys showed a large majority Samoa—
0% —
|

2010
|

2020
|

2030
Limit the number/types of retail outlets Botswana of Singaporeans—including Fiji—

Paraguay current smokers—would support

such a proposal.
MARKET/ECONOMICS S. Africa
—Swaziland
Australia
dustry Says quote:
Existing policies alliespotential
have immense say to Market control measures (e.g. wholesale price floors, import quotas) —Lesotho Tonga—

greatly decrease global smoking prevalence. Chile

$1 tax on all international air travel that goes to departure country’s Uruguay

2025
national tobacco control budget

F
Argentina
ull implementation of proven WHO FCTC & MPOWER policies of cigarettes, or shifting away from smoking combustible
PACK WARNINGS
SOLUTIONS

is capable of reducing tobacco use far below current levels products towards potentially safer ways of delivering
NEW ZEALAND
“Together, experience since 1964 and results
Change label legislation from “health warning” to DEFINITIONS . Tobacco control has already resulted in many nicotine. Some jurisdictions are examining prohibition of
10 specific strategies to
from models exploring future scenarios “package message” industry 1 industry 2 Solutions 1

of tobacco control indicate that the decline
in tobacco use over coming decades
will not be sufficiently rapid to meet targets.
THE GOAL OF ENDING THE TRAGIC
BURDEN OF AVOIDABLE DISEASE
AND PREMATURE DEATH WILL NOT
BE MET QUICKLY ENOUGH WITHOUT
ADDITIONAL ACTION.”
–US Surgeon General’s Report, 2014
remarkable changes in the last 50 years, with the abolition of most possession of tobacco products by all individuals born in or reach 5% endgame by 2025:
Integrate brand name into package message, associating overt tobacco promotion, smoke-free public and workplace laws, after the year 2000, or framing tobacco as a development and
brands themselves with message large graphic warnings on cigarette packs in over 60 countries, and poverty issue in order to attract the attention and thus funding
1. Smoke-free cars
Aim message at party other than the smoker (“Tell Mom to quit”…) plain/standardized packaging initiated in Australia PROJECTIONS. of the development community.
Plain/standardized packaging with no color, brand images; only brand name
industry 1 industry 2 Solutions 1
2. Making cigarettes harder
to purchase
Others believe that the tobacco epidemic is unlikely to be ended by The regulatory framework may differ from country to country.
3. Plain/standardized packs
today’s evidence-based interventions, and question whether new and For both implementing existing measures OR introducing new
QUITTING 4. Smoke-free communities
radical solutions are required, including fundamental reform of the measures, all countries will need to put immediate and much
Make cessation services free to all smokers
tobacco industry—whether commercial or government monopoly. greater emphasis on stronger enforcement, particularly of smoke-
5. Banning duty-free tobacco
Legalize cytosine, as cheaper, safe alternative to other quit pharmaceuticals 6. Tax hikes
Newly-suggested measures include supply-side strategies to curb
free areas and price policies.
7. Mass media shock tactics
OTHER IDEAS the tobacco industry, such as new structures through which Every historical achievement—such as flight, the conquest of 8. Removing all flavor enhancers
Set endgame target date tobacco products would be supplied, removal of the profit incentive Mount Everest, or votes for women—was preceded by many 9. Transparency of all
Frame tobacco use within toxic waste/environmental health context from selling tobacco products, or even the outright abolition of people saying it couldn’t be done, wouldn’t work, or would create tobacco lobbyists’ dealings
commercial tobacco product manufacture and sale NOVEL IDEAS. new problems. But the benefits of envisioning an endpoint for the with government
Target harm of discarded cigarette butts by banning cigarettes with filters industry 1 industry 2 Solutions 1
10. Quit-smoking support
Other ideas include harm reduction by reducing the harmful content tobacco epidemic are far greater than any risks.
 84 85

A chlorpyrifos, 22
chronic obstructive pulmonary disease, 14, 15, 19
F J N S
addiction, market based on, 30 cigalikes, 5 females: and secondhand smoke exposure, 21; smokeless tobacco use Japan: charitable giving in, 54; reduced smoking rates in, 33; smoking in, National Commission for Child Protection (Indonesia), 79 Santa Fe Natural Tobacco Company (SFNTC), 54
advertising, 52; bans on, 74–75; visceral images in, 68 cigarettes: consumption of, 30–31; dual use of, with e-cigarettes, 39; by, 43; smoking by, 27, 34–35; water pipe use by, 40 and lung cancer mortality, 34 National Health Insurance Service (Korea), 79 Saro Boardman, Ernesto, 60
Africa: increased smoking prevalence in, projections for, 33; lung cancer in, harm from, 29; low-tar, 19; national consumers of, 30; opportunity costs fetuses, health risks to, from maternal smoking, 19 Japan Tobacco International, 41, 48, 49, 50, 53, 54 National Health Surveillance Agency (ANVISA; Brazil), 78 schizophrenia, smoking and, 17
15; preventing tobacco epidemic in, 5; tobacco farming in, 47; tobacco of, 62; prices for, 50, 60, 62, 63; smuggling of, 51; taxes on, 31, 50, filters, litter from, 23 John, Rijo M., 24 NCDs. See non-communicable diseases school attendance, 24
market in, potential for, 27, 31 60–61; trash resulting from, 13, 22, 23. See also smoking FIN e-cigarettes, 38, 52 Johnston, Myron E., 62 neck cancer, 15 secondhand smoke: exposure to, 18, 19; harms of, 20, 21; lack of awareness
airline tickets, levy on, 77 cigarillos, 29, 31, 62 fires, cigarette-related, 23 Jordan, water pipe use in, increasing, 40 new products, regulation of, 5 about, 80; prevalence of, 21; protection from, 65
alcohol abuse: cessation and, 16; smoking and, 16, 17 cigars, 29 food insecurity, tobacco growing and, 47 JTI. See Japan Tobacco International New York City, reduced tobacco use in, 67 Senegal: quitline in, 68; “Sponge” campaign in, 69
alidcarb, 22 cities, smoke-free legislation in, 64–65 Freudenberg, Nicholas, 49 New Zealand: reduced smoking prevalence in, 30; tobacco endgame shisha, 37
Al Nakhla, 41 cleft palate/lip, smoking and, 19 K strategies in, 83 Sinditabaco, 78
Altria, 29, 48, 49, 54 climate change, 22, 23 G Kazakhstan, increased smoking prevalence in, 33
Nicaragua, and the FCTC Protocol on Illicit Trade, 59 Singapore: reduced smoking rates in, 33; tobacco ban in, proposal for, 83
American Cancer Society, 5 Codentify, 51 nicotine: accumulating on surfaces, 21, 65; addiction risk from, 29; Sirisena, Maithripala, 54
Gallagher, Katy, 20 Kenya: lobbying in, 54; tobacco crop substitution in, 46
anti-tobacco campaigns: effectiveness of, 69; free air time for, 69 COPD. See chronic obstructive pulmonary disease delivery systems for, continuum of harm, 29; effects of, 28, 29; Skoal, 42
Gates, Bill, 7. See also Bill and Melinda Gates Foundation Korea, Republic of: underreporting of female tobacco use in, 34; youth use
anxiety disorders, tobacco use and, 17 coronary heart disease, 15 levels of, in different tobacco products, 28; poisoning from, 28, 29; Slaughter, Elli, 22
Gates, Melinda, 7. See also Bill and Melinda Gates Foundation of e-cigarettes in, 37
aquatic life, threat to, 23 corporate social responsibility, 54 regulation of, 28, 29; water pipes and removal of, 41; withdrawal from, 29. Smith, Adam, 60
gateway effect, of new tobacco portals, 5 KT&G Corp., 79
Argentina: decrease in vegetation in, 22; tobacco production in, 47 Costa Rica, tobacco control in, 61 See also secondhand smoke; thirdhand smoke smoke-free legislation, 64–65, 72, 73
GATS. See Global Adult Tobacco Survey Kultuk, Tezer, 81
arterial walls, thickening of, 18 counter-marketing strategies, 68–69 nicotine replacement therapy, 29, 66–67 smokeless tobacco: cancer and, 19, 42; female use of, 35, 43; flavoring of,
gender, smoking and, 27. See also females; males; youth
Assunta, Mary, 36 non-communicable diseases, 4; crisis in, 80–81; deaths from, 80–81; 42, 43; harm from, 29; processing of, 42; regulation of, 42, 43; worldwide
atherosclerosis, 19
coupons, 52
culture, tobacco use present in, 53
Germany: “Be Marlboro” campaign in, 36; incomplete TAPS ban in, 74; L discussions about, 5; factors in, 81; tobacco and, 12, 80; trends in, 81 use of, 42–43; youth use of, 37, 42
Smoke-free Class Competition, 76
Australia: Australian National Tobacco Campaign, 76; banning smoking labeling, regulations for, 71, 72, 73 Non-Smokers Rights Association v. British American Tobacco (France), 79 smokers, percentage of, desiring to stop, 66
Gilmore, Anna, 51
in cars, 20; cigarette packaging in, 5, 59, 70, 71; graphic warning
labels in, 71; reduced tobacco use in, 31, 67
D Girard, Oliver, 38
Levy, David, 66
life expectancy, 15
Norway, “Sponge” campaign in, 69
Novotny, Thomas E., 22
smoking: bans on, 5, 21; brain cells and, 18; cleft palate/lip and, 19;
economic effects of, 25; epidemic of, pattern followed, 35; females and,
Davies, Gareth, 74 Glantz, Stanton A., 17
litigation, topics for, in tobacco control, 79 NRT. See nicotine replacement therapy 34–35; global prevalence of, projections on, 82; hazardous drinking and,
Global Adult Tobacco Survey, 4, 7, 21, 30
B death registries, 14, 15
deaths: assessing and monitoring, 14, 15; by country income, 15; Global NCD Action Plan (WHO), 81
litter, 22, 23, 72, 73 Nutri Cigs, 38 16, 17; HIV/AIDS and, 17; intensity of, 31; lung health and, 19; mental
lobbying, 54, 55 illness and, 16, 17; national wealth and, 30; males and, 32–33; quitting,
Bahrain, smoking ban in, for vehicles carrying children, 65 Global Tobacco Surveillance System, 4
BAT. See British American Tobacco
by gender, 14–15; premature, prevention of, 15; preventing, 14;
by region, 14; socioeconomic status and, 14, 15 Global Youth Tobacco Survey, 4, 7
Lorillard, 35, 38, 48 O 15; rates of, 5; TAPS bans on, and rates of, 75; regional forecasts for, 32;
low-income countries: cessation programs lacking in, 57; development trends by income level, 32, 33; tuberculosis and, 17; underreporting of,
“Be Marlboro” campaign, 36 deforestation, 22, 23 governments, tobacco control expenditures of, 76 1,3-dichloropropen, 22
assistance for health in, 76, 77; smoke-free laws in, 64, 65; 20, 34. See also cigarettes
Bianco, Eduardo, 32 dementia, smoking and, 18 Government v. Three Tobacco Companies (Korea), 79 Ontario v. Rothmans Inc. (Canada), 79
smoking-related deaths and, 15; tobacco companies’ targeting of, 49; Smoore, 39
bidis, youth use of, 37 Denmark: reduced smoking prevalence in, 30; smoking and HIV in, 16 greenhouse gases, 22 oral health, smoking and, 19
tobacco harms in, 5, 19 snuff, 42
billboards, 53 developing world, tobacco’s rise in, 24 green tobacco sickness, 46 O’Reilly, David, 15
low-tar cigarettes, 19 snus, 42; harm from, 29; market failures of, 43; regulation of, 42
Bill and Melinda Gates Foundation, 5, 77 diabetes, 7 gutkha, 42, 43 organs, harm to, 18
lung cancer, 14, 15, 19, 21, 34, 41, 66 social media, anti-smoking ads on, 68
bipolar disorder, smoking and, 17 disadvantage, smoking and, 24. See also low-income countries GYTS. See Global Youth Tobacco Survey
lungs, smoking and, 19, 81 socioeconomic status: and secondhand smoke exposure (China), 21;
Bloomberg, Michael, 7 dissolvable products: harm from, 29; US marketing of, 43 P tobacco-related deaths and, 14
Bloomberg Initiative, 4 drinking, hazardous, and smoking, 16, 17 H M packaging, 70–71, 73; regulations for, 71, 72, 73, 80; size restrictions on, 50; Solidarity Tobacco Contribution, 77
Bloomberg Philanthropies, 5, 77 Durante, Nicandro, 30 Hansen, Keith, 24 warnings on, 5, 82 South Africa: cigarette prices in, 60; illicit market in, 51; smoking ban in,
Blu e-cigarettes, 38, 52 ma‘assel, 40, 41
Hastings, Gerard, 70 pan masala, 43 for vehicles carrying children, 65; smoking-related deaths in, 14;
brain cells, smoking and, 18
Brazil: money spent in, on cigarettes, 13; reduced smoking rates in, 31;
E head cancer, 15
Mackay, Judith, 7
Madagascar, adult male tobacco use in, 42
Patra, Satyabipra, 23 snus marketing in, 43
Eastern Mediterranean Region, cigarette consumption growth rate in, 31 health care expenditures, smoking and, 25 pesticides, 22, 23 South Asia, smokeless tobacco use in, 43
tobacco production in, 47; tobacco’s effect on productivity in, 24 Malawi, decrease in vegetation in, 22
e-cigarettes, 5; dual use of, with combustibles, 39; growth of, 39; Healton, Cheryl G., 22 Philip Morris, 16, 29, 51, 52, 67 Southeast Asia, policy efforts in, 5
Brinker, Nancy G., 34 males: money spent by, on cigarettes, 24; smoking among, 27, 32–33
harms from, 29; health impact of, 19; manufacturing of, 39; market for, 48; heat-not-burn products, harm from, 29 Philip Morris Asia, 78 South Korea. See Korea, Republic of
British American Tobacco, 16, 30, 41, 48, 49, 54, 51, 59, 78, 79 Malone, Ruth, 73
marketing of, 38, 52, 53; mechanics of, 38; nicotine poisoning and, 28; Herzog, Bonnie, 48 Philip Morris International, 36, 48, 48, 49, 50, 54, 55, 73, 78, 79 Spain, PMI’s entrepreneurship program in, 55
British American Tobacco Australia, 50 marketing: expenditures on, 52; regulation of, 52, 72
prevalence and use of, 38; regulation of, 38, 39; smoke-free legislation high-income countries: smoke-free laws in, 64; smoking rates in, 5; Philip Morris Norway, 78 “Sponge” campaign, 68, 69
bronchitis, 15 Mars Corporation, 80
and, 65; vapor from, secondhand exposure to, 21; warning label from, 29; smoking-related deaths and, 15 Philip Morris USA, 19 Sri Lanka, lobbying in, 54
Brose, Leonie, 38 Master Settlement Agreement (MSA; US), 79
worldwide status of, 39; youth use of, 37 Hitchman, Sara, 38 Philippines, tobacco taxes in, 61 Stiglitz, Joseph E., 30

INDEX
INDEX

Brown v. Philip Morris Inc. (USA), 79 maternal smoking, 19

economic agreements, international, 5 HIV/AIDS, 7; cessation and, 16; smoking and, 16, 17 pipes, 31, 37 stroke, 15, 80
Burkina Faso, life expectancy in, 25 Mauritius, smoking ban in, for vehicles carrying children, 65
economic development, tobacco’s effect on, 24 homes: secondhand smoke in, 21; voluntary smoking bans in, 21 plain packaging, 5, 50 substance abuse, 7, 12
McCarthy, Jenny, 38
Hong Kong, reduced smoking rates, in, 33 point of purchase, 72, 73 Sudan, oral cancers in, 42
C Edwards, Anne, 32
Electronic Nicotine Delivery Systems, 5 hookahs, youth use of, 37. See also water pipes
McDaniel, Patricia, 73
political influence, 54, 55 Sustainable Development Goals (UN), 5
McNeill, Ann, 38
caffeine, effects of, 28 emerging markets, addiction in, 5 household income, percentage of, cigarette expenditures and, 25 poverty, 7, 24–25; smoking and, 27; tobacco growing and, 47 Switzerland, philanthropy in, 54
media campaigns, 68–69
Calantzopoulos, André, 48 emphysema, 15 human development, tobacco use undermining, 12, 13, 24–25 pregnancy, smoking during, 18, 19 Syria, ma’assel use in, 40
mental illness, smoking and, 7, 12, 13, 16, 17
Camilleri, Louis C., 78 environment: clean-up of, regulations for, 72, 73; degradation of, 7; premature death, tobacco and, 15
methyl bromide, 22
Canada: graphic warning labels in, 71; reduced smoking prevalence in, tobacco use damaging, 12, 13 I Mexico, tobacco tax laws in, 60
price discounts, 52, 53
30, 33; snus marketing in, 43 Eriksen, Michael, 7 product display bans, 50
Iceland, reduced smoking prevalence in, 30 Middle East, water pipe use in, 41
cancer, 14, 15, 19; caffeine’s effect on, 28; deaths from, attributable to EU v. RJR Nabisco (EU), 79 Protocol to Eliminate Illicit Trade in Tobacco Products, 4, 51
Illegal Cigarettes: Who’s in Control (British American Tobacco), 51 middle-income countries: development assistance for health in, 76, 77;
tobacco, 80; nicotine’s effect on, 28; smokeless tobacco and, 42; Europe: e-cigarette use in, 38; Tobacco Products Directive in, 7 Punta del Este Declaration (WHO FCTC), 78
illicit trade, 50–51 smoke-free laws in, 64, 65; smoking-related deaths and, 15; tobacco
water pipe smoking and, 41. See also individual cancer types European Commission, 51 imidacloprid, 22 companies’ targeting of, 49; tobacco harms in, 5, 19
Cancer Institute (NSW) Australia, 68 European Parliament, lobbying of, 54 Imperial Tobacco Group, 48, 49, 54, 71, 78 Millennium Development Goals, 17 Q
Cantrell, Lee, 28 European Union, 54; lobbying in, 54; Tobacco Products Directive, 39, 54, 43 India: banning plastic wrapping for tobacco products, 23; deaths in, 15; Missouri (USA), Tobacco Prevention and Cessation Initiative, 76 quit lines, 66–67
carbaryl, 22 excise tax revenues, 76 ruling smokeless tobacco products as food, 43; tobacco and poverty in, Moodie, Crawford, 70 quitting, 15; benefits of, 66; effects of, 66; proposals for, 82; resources for,
cardiovascular disease: lack of awareness about, 80; risk of, 19
24; tuberculosis in, 17 mortality, trends in, from NCDs, 80 66–67; strategies for, 67. See also cessation
Carolina Farm Stewardship Association (CFSA), 54
Indonesia: male smoking prevalence in, 33; youth smoking in, 37 MPOWER, 7, 77, 83
CDC. See US Centers for Disease Control and Prevention, cessation,
14, 16, 66–67. See also quitting
infants, health risks to, from maternal smoking, 19 Mullin, Sandra, 68 R
initiation, reducing, 14
Ceylon Tobacco Company, 78 Red Cross and Red Crescent Museum, 54
insurance plans, premium surcharges for tobacco users, 60
Chan, Margaret, 45, 59, 74, 78 regulations: establishing, 72–73; global examples of, 73; of smokeless
intense smoking, 31
charitable giving, 54, 55 tobacco, 42, 43
Ireland, smoke-free laws in, 64
Chaturvedi, Pankaj, 15 Reports on the Global Tobacco Epidemic (WHO), 4
ischemic heart disease, 14, 15, 19
child labor, 24 restaurants, secondhand smoke in, 21
Italy, cigarette seizures in, 51
children: health risks to, from maternal smoking, 19; nicotine poisoning and, retail displays, removal of, 75
28; secondhand smoke’s effect on, 21 Reynolds American, 48, 54
China: cigarette consumption in, 30, 31; male smoking rates in, 33; R. J. Reynolds, 47, 51
public service announcements in, 69; secondhand smoke in, 21; RJR Nabisco, 79
smoking prohibitions in, 5, 21, 64; tobacco crop substitution in, 46; roll-your-own tobacco, 31, 62
tobacco production in, 47; tuberculosis in, 17; World Lung Foundation Rothman’s, 25
in, 69 Russia: public service announcements in, 69; smoking prohibitions in, 5
China National Tobacco Corp., 48, 49 Russian Federation, decreased tobacco consumption in, 72
chloropicrin, 22
 86 87

T V
Taiwan, Outpatient Smoking Cessation Services program, 76
tank systems, 38
Tanzania: decrease in vegetation in, 22; tobacco’s economic effects in, 24
TAPS (tobacco advertising, promotion, and sponsorship) bans, 74–75
taxation, 72, 73
tax stamps, 61
thirdhand smoke, harms of, 20, 21, 65
throat cancer, 15
“Tips from Former Smokers” (CDC), 68
tobacco: availability of, proposals for, 82; consumption of, global
economic cost of, 77; deaths resulting from, 7, 15; farming of, 22; health
consequences of, 18; illicit trade in, 50–51; manufacturing of, regulations
for, 72, 73; market control proposals for, 82; marketing of, 26–41; new
portals for, 5; non-communicable diseases and, 80; plastic wrapping for
products, 23; poverty and, 25; pricing of, 37, 62–63; production trends
in (selected countries), 47; product proposals for, 82; regulation of, 37,
72, 83; smokeless. See smokeless tobacco; social value of, 22; taxation
of, 60–61; toxic chemicals in smoke from, 19; use of, preventing, 14, 67,
82–83
Tobacco Atlas, The, 4, 7, 58
Tobacco To Bamboo Project, 46
tobacco companies: consolidating market for nicotine, 48; corporate social
responsibility programs of, 22, 53; e-cigarettes and, 39, 48; goal of, 26;
lies of, 34; litigation against (selected nations), 79; marketing to women,
35; mergers of, 48; profits of, 48; regulation of, 48; resisting tobacco
control measures, 55; revenue of, 48; undue influence by, 54–55
tobacco control, 31–33; companies resisting, 4, 55, 78; development and,
5; expense of, 55, 77; funding mechanisms for, 76, 77; government
expenditures on, 76; legal challenges to (selected nations), 4, 78;
legislation of, 4; as model for fighting non-communicable diseases, 80;
population-level policies, 55; savings resulting from, 76
tobacco farming: alternatives to, 46; child labor and, 46; effects of, 23;
land devoted to, 47; poverty and, 25; regulations for, 72, 73;
undernourishment and, 46
02 COMORBIDITIES
Tuberculosis collage ©World Lung Foundation 2009
vapor, market for, 48
vegetation loss, tobacco farming and, 22
vehicles, children in, smoking ban in, 65 03 HEALTH CONSEQUENCES
Vietnam, smoking prohibitions in, 5 Healthy and diseased lungs National Institute on Drug Abuse, USA
Volleyball World Cup, 53 Child with cleft palate AP Photo / Carlos Jasso
W 05 ENVIRONMENT
Deforestation Satellite imagery from ESRI,
warning labels, 70–71, 73 http://changematters.esri.com ©1987-2014 HERE
water pipes, 19, 40–41; harm from, 29, 41; regulation of, 40; smoke-free Plastic packaging Tahir Turk / World Lung Foundation
legislation and, 65; use of, by gender, 40; tobacco prices for, 62
weight gain, smoking and, 35
Weissman, George, 54
PRODUCTS DIVIDER
Smoking man kalapangha / Shutterstock.com
WHO Framework Convention on Tobacco Control (WHO FCTC), 4, 5, 77;
accession to, 58; Article 5.3, 54, 55; Article 6, 61; Article 11, 70, 71;
Conference of the Parties, 4, 47, 59, 78; deaths from tobacco-related 11 YOUTH USE
Boy smoking ©imageBROKER / Alamy
diseases since first working group, 58; discussing tobacco farming
Indonesian teen smoking AP Photo/Irwin Fedriansyah
alternatives, 47; implementation of, 58, 83; Intergovernmental Governing
Body, 7; labeling provisions, 70, 71; parties to, 58, 59; Protocol to
Eliminate Illicit Trade in Tobacco Products, 51, 59; Protocols, 59; INDUSTRY DIVIDER
Punta del Este Declaration, 78; ratification of, activity following, 58; Philip Morris Netherlands HQ image Peter Braakmann / Shutterstock.com
regulations corresponding with, 73; success of, 59; trade treaties and, 59; RJR plant Bryan Pollard / Shutterstock.com
World Health Assembly approval of, 7 Boy with tobacco leaves See credits for Chapter 15, Growing
WHO. See World Health Organization
wildfires, cigarette-related, 23 15 GROWING
Wilken, Michael, 19 Boy with tobacco leaves Lowell Georgia/National Geographic/Getty Images
Winter Olympic Games (Sochi, 2014), 64
workplace: secondhand smoke in, 21; smoking bans, effectiveness of, 64 18 MARKETING
World Health Assembly, 7, 59 Volleyball sponsorship Christopher Johnson/Globalite Magazine
World Health Organization, 4, 7, 19, 25, 54, 64, 67, 76, 77; Global NCD
Action Plan, 57, 81; goal of, for tobacco use reduction, 82–83
World Lung Foundation, 5, 69
SOLUTIONS DIVIDER
Benigno Aquino See credits for Chapter 30, Legal Challenges & Litigation
World Trade Organization, 5, 78
Margaret Chan See credits for Chapter 30, Legal Challenges & Litigation
Wright, La Tanisha C., 36
Nicola Roxon Rex Features via AP Images

PHOTO CREDITS
tobacco industry: cigarette smuggling by, 51; corporate social responsibility Protesters AP Photo / Tatan Syuflana
programs of, 4; curbing, supply-side strategies for, 83; deception by, Y
45; fighting against Framework Convention implementation, 4; fraud and Yach, Derek, 39 20 WHO FCTC
racketeering by, 7; goals of, 44 ; HIV/AIDS grants and, 16; legal challenges youth: e-cigarette use among, 37; marketing to, 52, 53; smokeless tobacco Tobacco Atlas covers ©American Cancer Society
by, 78; litigation against, 79; malevolence of, 5; marketing strategies of, use among, 42; tobacco initiation of, 37; tobacco use among, 36–37
5; new products from, 7; production of, 49; proposed changes for, 82; YouTube, 68 25 MEDIA CAMPAIGNS
responsibility of, for price increases, 62–63; revenues of, 7; transnational “Sunita” National Tobacco Control Program (NTCP), Ministry of Health
nature of, 45; using international economic agreements, 5 and Family Welfare, India
Tobacco Institute, 60 “Smoke” Ministry of Health and Family Welfare, Bangladesh
Tobacco Plain Packaging Act (Australia), 78
INDEX

“Smoking Kid” Thai Health Promotion Foundation, Thailand

Tobacco Products Control Act (South Africa), 78 “Tips From Former Smokers” Centers for Disease Control and Prevention, USA
Tobacco Products Directive (EU), 7, 78 “Sponge” Cancer Institute NSW, Australia
tobacco-specific nitrosamines (TSNAs), 42
toombak, 42
tourism, taxes and levies on, 77
26 WARNINGS & PACKAGING
All graphic warning labels Courtesy Canadian Cardiovascular Society
track-and-trace systems, 50, 51
tuberculosis, 7, 14; cessation and, 16; smoking and, 17
Turkey: charitable giving in, 54; public service announcements in, 69 27 REGULATIONS
Cigarette vending machine ©Graham Oliver / Alamy
U Hand with warning label packs William West / AFP / Getty Images

undernourishment, tobacco farming and, 46

28 MARKETING BANS
United Kingdom: illicit tobacco trade in, 51; illnesses in, and secondhand
Direct advertising AP Photo / Eckehard Schulz
smoking, 20; price increases in, 63; reduced smoking rates in, 31;
Indirect advertising AP Photo / Dita Alangkara
taxation in, 76; youth tobacco use in, 37
United Nations, 5; addressing non-communicable diseases, 81; treaties of,
59
30 LEGAL CHALLENGES & LITIGATION
Margaret Chan Fabrice Coffrini / AFP / Getty Images
United States: children’s hospital visits in, and secondhand smoke, 20;
Louis Camilleri Daniel Acker / Bloomberg via Getty Images
e-cigarette regulation in, 38; green tobacco sickness, 46; mental illness
Benigno Aquino AP Photo / Aaron Favila
and smoking in, 17; quitting in, 66; smoking and alcohol abuse in, 16;
Norma Broin Roberto Schmidt / AFP / Getty Images
smoking and female mortality in, 34; tobacco control in, 15; tobacco
industry fraud and racketeering in, 7; tobacco marketing in, 52; tobacco
production in, 47; tobacco’s cost to employers in, 24; water pipe use in,
increasing, 40; youth smoking in, 36; youth’s use of e-cigarettes in, 37.
See also US listings
United States Fire Administration, 23
upper aerodigestive cancer, 14
Uruguay: reduced smoking prevalence in, 30; smoke-free legislation in, 21;
smoking in, and socioeconomic status, 27; tobacco control in, 32
US Centers for Disease Control and Prevention, 4, 68
US Food and Drug Administration (FDA), 78
US Surgeon General, 52, 82

tobaccoatlas.org
CALL TO ACTION FIFTH EDITION
The tobacco control movement must grow its base of Revised, Expanded, and Updated
support to achieve ever-larger and more ambitious policy
and public health successes.

C
ompletely revised, updated, and
specially created to be used by students,

Eriksen, Mackay, Schluger, Islami, Drope

teachers, researchers, journalists,
advocates, and policymakers, the new
Fifth Edition of The Tobacco Atlas and its
EQUA L I T Y
companion website tobaccoatlas.org aims
to be the most comprehensive, informative,
and accessible resource on the most
important and current issues in the
evolving tobacco epidemic. This edition also
presents an invitation to join the tobacco
control movement for partners from other
communities—including environment,
equality, development, and non-communicable “We want this document to be used,
disease—whose interests are also parsed, quoted, defended, and

 
dramatically affected by the tobacco debated, and ultimately to open minds,
DE V E L OP ME N T

E N V IR ONME N T

THE TOBACCO ATLAS  

epidemic and its human toll. to persuade the unconvinced about
tobacco’s toll, to spur untraditional
NEW TOPICS INCLUDE:
allies to action, and to help create
opportunities to reverse the epidemic.”
• Environmental harms of tobacco
— JOHN R. SEFFRIN, PhD, Chief Executive Officer, American Cancer Society
• E-cigarette use, product
and PETER BALDINI, Chief Executive Officer, World Lung Foundation
development and marketing
• Trends in the use of water pipes
• Tobacco’s exacerbation of
poverty and development

Fifth Edition
• Tobacco’s contribution to
tuberculosis, HIV/AIDS, alcohol
abuse, and mental illness
NON- C OM
MUNI C A B L E DISE A SE S
• The lifecycle of tobacco regulation
• Integrating tobacco control into
the global non-communicable
disease agenda
• The endgame to the tobacco epidemic

Product Code: 9674.05

$39.95 (CAN $43.95) Michael Eriksen
ISBN: 978-1-60443-235-0
Judith Mackay
53995 Neil Schluger
Farhad Islami Gomeshtapeh
9 781604 432350 > cancer.org/bookstore tobaccoatlas.org Jeffrey Drope