1. Welcome to Tobacco & Health: from Cells to Society Roberta Ferrence, PhD Ontario Tobacco Research Unit Sept 11, 2013

2. Ontario Tobacco Research Unit History of the Course Early1990s: module of Non-communicable Diseases Became so popular, developed full half course 1998 Joanna Cohen and I first co-instructors Michael Chaiton involved for several years - now Course lead Added sites in second year; now across Canada

3. Ontario Tobacco Research Unit Uses of Epidemiological Data on Tobacco Use Identify target groups for prevention Evaluate policies and interventions Impact of industry marketing and promotion Basis for predicting disease outcomes Data for testing causal hypotheses Expert testimony for litigation

4. Ontario Tobacco Research Unit Key Messages Dynamic Model Observations are deceiving Sex differences Effects of bans Tourist effect Level of smoking: not just prevalence Latent period for health effects

5. Ontario Tobacco Research Unit Diffusion Process Diffusion of Innovation Model (Rogers & Schumaker) New behaviours & products tend to follow a predictable curve after introduced into a population “S-shaped” curve slowly at first, then sharply finally slows and levels off or declines Same as epidemic curve that describes the spread of infectious diseases

6. Ontario Tobacco Research Unit The “S” Shaped Curve Early Adopters Late Adopters DIFFUSION DISCONTINUANCE

7. Ontario Tobacco Research Unit Diffusion of Tobacco Use WWI prime event in diffusion to widespread use Early adopters: men, high SES, urban, developed countries Early adopters also early quitters BC, ON Rates may decrease faster in late adopter groups at certain points

8. Ontario Tobacco Research Unit International Trends in Cigarette Consumption An example of diffusion: Developed Countries Peaked in 1980s, subsequent decline Small sex differences Developing Countries Steady increase in prevalence and #/day for several decades Large but decreasing sex differences Net Effect: Little change in Global consumption over time

9. Ontario Tobacco Research Unit Trends in Tobacco Use among Canadian Adults After leveling off in the early 90s, cigarette use has continued its long-term decline Both prevalence and level of smoking are decreasing in the long term Increasing proportions of smokers smoke less than daily Significant but declining differences by province Increase in use of alternative nicotine products (e.g., e-cigarettes, Hookah)

10. Ontario Tobacco Research Unit Trends in Tobacco Use among Canadian Youth Substantial decreases in youth prevalence (while marijuana use increasing) No significant sex differences Males more likely to be daily smokers and to smoke more cigarettes per day

11. Ontario Tobacco Research Unit The Future of Smoking Depends on many factors: Taxes, availability, acceptability, restrictions, disincentives, cessation support, stability of industry due to litigation FCTC Further declines likely among all groups in developed world Experience in developing world will vary depending on tobacco controls, industry marketing and other factors Other forms of nicotine increasing in marketplace