1.2 billion smokers globally 83% of global smokers (956 million) live in developing countries Prevalence rate (in 90s) MaleFemale Bangladesh4010 Turkey5926 Vietnam734 Pakistan369 China634 Indonesia632 Russia6314 Philippines7518 Egypt435 Prevalence rates in selected developing countries 1990s

Smoking- the epidemic of the 20 th C 100 million people died of tobacco-related causes during the 20th century The WHO predicts that, without intervention, tobacco will kill more than 8 million people every year by 2030, and 1 billion this 21 st century; 80% of those deaths will occur in developing countries The WHO proposes six policies to reduce global tobacco deaths: the FCTC  Monitor tobacco use and prevention policies  Protect people from tobacco smoke  Offer help to quit tobacco use  Warn about the dangers of tobacco  Enforce bans on tobacco advertising, promotion, and sponsorship  Raise taxes on tobacco

Unless current smokers quit, smoking deaths will rise dramatically over the next 50 years Source: Peto and Lopez, 2001

Famous Issues in Epidemiology A second year medical student Ernst Wynder 1948, attended the autopsy of a two-pack-a-day smoker who had died from lung cancer collected case histories of lung cancer victims Captured the interest of thoracic surgeon Evarts Graham. He was a sceptical smoker Wynder and Graham published a large case-control study that had used standardised interviews linking smoking and lung cancer In the following decade, hundreds of reports were published linking lung cancer and smoking Doctors were convinced of the health risks of smoking. Many doctors quit, including Graham, who quit in 1952, but died of lung cancer in 1957

TOBACCO and LUNG CANCER The 1950 Large Case Control Studies* Author Cases Controls OR % of Non-Smokers Doll & Hill Wynder & Graham *More than 600 Men per group. Smokers were all life-long smokers, and ex-smokers were carefully excluded Conclusion: Life-long Smokers are times as likely to get lung cancer as life-long never smokers

Cancers associated with smoking Major cause Lip Mouth Pharynx Oesophagus Larynx Lung Pancreas Kidney, pelvis BladderAssociated Nose Stomach Kidney, body Liver Colorectal Cervix uteri Childhood cancer TobNutr AD164 From: Doll, 1988

Cardiovascular disease, mainly heart disease and stroke Cancer Chronic respiratory diseases Diabetes Chronic Non-communicable Diseases-NCD

Adult per capita consumption of tobacco products in the 20th Century in Australia Year Annual amount of tobacco dutied per adult over 15 years ( kg) Depression World War II Uptake by women Early research on health effects of smoking Report of the US Surgeon General Broadcast of tobacco advertising phased out Commencement of Quit Campaigns Tobacco Taxation Workplace smoking bans introduced New health warnings Introduction of manufactured cigarettes

Trends in lung cancer mortality and smoking prevalence in Australia

AD145 Impact of lung cancer on male cancer mortality trends in Australia : 1910– Age standardised mortality per 100,000 males Year of Death 1910 All cancer All cancer without lung Anti-Cancer Council of Victoria Epidemiology Centre, TobNutr

Taxation is the most effective measure around the globe –As taxes/prices increase, consumption falls A 10% increase in price reduces cigarette consumption by: –4% in developed countries, –8% in developing countries –People with low incomes (including youth) are more price-sensitive A 10% price increase reduces smoking as much as 10% among youth and poor groups Deters youth from taking up smoking

How Price/Tax Measure Work Price Elasticity Evidence As price/ tax increases, consumption decreases

Prevalence of Tobacco Use in China: Taxation Works CURRENT ADULT SMOKING:PERCENTAGES Year Total Adults Men Women 1996 Yang et al Yang et al st BRFS

Tobacco advertising: Most effective way of gaining market share and attracting new smokers Evidence show that: Smokers often associate smoking imported-cigarettes with: –Glamour –Economic independence –High social status –Smoking healthier cigarettes with low tar and nicotine level and “light” brands –Better taste and easy inhale “quality” –Competitive prices with domestic brands

Countries that support advertising ban with comprehensive TC measures are more successful on reducing consumption Banning Tobacco Advertising Works

Smoking Rates: California Anti Tobacco Mass Media Works Packs smoked (billions) Proposition 99 Media campaign suspended and reinstated Historical trend Stan Glanz Tobacco Wars-Media impact

Government Responsibilities WHO Framework Convention on Tobacco Control (FCTC) 2005, Signed by Most Countries and Ratified by Many: includes  Monitor tobacco use and prevention policies  Protect people from tobacco smoke  Offer help to quit tobacco use  Warn about the dangers of tobacco  Enforce bans on tobacco advertising, promotion, and sponsorship  Raise taxes on tobacco