понедельник, 22 октября 2007 г.

Youth and Cigarette Smoking

Introduction

This Factsheet covers only cigarette smoking among children and young people.

In 1996, Peto et al. estimated that unless current trends changed, some 30-40% of the 2.3 billion children and teenagers in the world would become smokers in early adult life . Unless action is taken now, about 250 million of these future smokers will be killed by smoking.

In countries where smoking is long established, almost all smokers begin before age 18 years. Young people are therefore an important focus for action. Trends in smoking among young people follow those in adults. Men take up smoking first, and boys follow them. Women are next, and girls follow them. In the USA, Canada, Australasia and Northern Europe, the epidemic is established, and smoking is found among all four groups.

In Africa, Asia, South America and certain areas of Southern Europe, the epidemic is at an earlier stage and smoking may be found predominantly among men. Here, social influences and the tobacco industry's promotional strategy must be seriously addressed immediately if the smoking epidemic is to be prevented.
The effects of smoking on young people

Addiction

Many young smokers think they can quit easily, but find that they are already addicted. Young smokers develop withdrawal symptoms when they stop smoking. Smokers as young as 12 years may already made unsuccessful attempts to quit. A survey in the UK found that two-thirds of smokers aged 16-19 years had unsuccessfully attempted to stop, most having tried several times.

Long-term health risks

Long-term health risks are increased when regular smoking begins during childhood or adolescence. For example, the earlier regular smoking starts, the greater the risk of lung cancer. The highest risk of lung cancer and of heart and circulatory diseases to in adulthood is seen in those who started to smoke regularly before age 15.

Immediate health effects

Many health problems develop very quickly in the young smoker: for example, respiratory diseases, heart and circulatory problems, and reduced immunity. Children who smoke are more often absent from school, as the result both of smoking-related ailments and for truancy and suspension. The likelihood of absence increases if their parents also smoke. Young smokers are also less fit than their non-smoking peers, because carbon monoxide from tobacco smoke replaces some of the oxygen in their blood.
Stages in youth smoking
Stages in youth smoking

Young smokers go through a series of stages. Each stage is influenced by different factors: any action developed to prevent youth smoking must address these influences. Note that this is not a one-way process: rather, the stages are fluid and may reverse and restart several times.

Precontemplation - the child is not thinking about smoking, but receives messages about it. At this stage, parental and siblings' smoking, advertising, films, television and role models all exert an influence.

Contemplation - received images or peer influence build up to a point where curiosity takes over and the young person considers trying a cigarette. Friends' behaviour is now added to the precontemplation influences.

Initiation - most young people try smoking, but the majority do not become regular smokers. At this stage, friends are usually the strongest influence.

Experimentation - involving repeated attempts to smoke. Young people may become addicted to nicotine after smoking a very small number of cheap cigarettes, which may be why many experimenters become regular smokers. At this stage, peer-bonding is still the strongest influence.

Regular smoking - may involve a new set of influences. As well as addiction and habituation, personal factors such as beliefs about the benefits of smoking, self-efficacy, self-perception and coping join earlier influences. Societal factors including price and availability, and interpersonal factors such as school policy, provide a background.

Maintenance - continuation of regular smoking involves all these influences, but addiction is a major force.

Quitting - occurs when the relative importance of influences changes. For example, a new non-smoking partner, steep increases in the price of cigarettes, decreases in spending money, and beginning work where smoking is not permitted can all trigger a decision to stop.
Why do young people smoke and what can be done to prevent it?

The onset and maintenance of smoking is clearly complex. Here, we discuss selected findings from research in industrialised countries. As these may not apply elsewhere, each country should carry out research to identify areas in which effective action can be developed.

Suggestion for action

Carry out regular surveys with representative samples of young people as a baseline for planning e.g. every two years. WHO can advise on this.

Conducting a smoking prevalence survey

Introduction

How much tobacco people use and the way in which they use it-whether they smoke manufactured cigarettes, chew snuff or spit tobacco, smoke pipes, or roll their own cigarettes-varies widely both across countries and between groups within a country. There is tremendous variation even in patterns and levels of the smoking of manufactured cigarettes, the most common form of tobacco use.

Numerous studies have shown that these differences reflect the influence of environmental factors. The tobacco industry conducts very effective promotional campaigns to encourage adolescents, in particular, to smoke. Once addicted, smokers find it difficult to quit - continual reinforcement of health information and messages, as well as incentives, are needed to help smokers persevere with quitting until their attempts to stop are successful.

Differences in smoking patterns translate eventually into differences in population morbidity and mortality. Several studies have calculated the resultant social costs of smoking. In the United States of America, such studies have been used to justify increases in cigarette excise taxes, which often support state-level tobacco control programs. Increases in cigarette prices through excise taxes also result in reductions in smoking prevalence. Thus, just as public policy can influence smoking behaviour, the prevalence of smoking can also have a profound impact on public policy and finance.

Whether designing, monitoring or advocating tobacco control programmes, the availability of reliable data on smoking prevalence is crucial.
What is a smoking prevalence survey?

The main aim of a smoking prevalence survey is to characterize the current smoking behaviour of a given population, and of sub-populations of interest. Such surveys may also monitor exposure to variables that are known to influence smoking, such as the price of tobacco, any restrictions on smoking, and receptivity to tobacco industry messages.
How representative of the population is the sample to be surveyed?

The key issue in all surveys of smoking prevalence is how well the survey represents the population. A representative study depends on surveying a sufficiently large and random sample of the total population of interest.

In communities where almost all households have a telephone, surveys carried out by dialling telephone numbers at random (random digit dialing) are reasonably sure to give each individual in the population an equal chance of being selected. Elsewhere, surveys are typically undertaken by an interviewer who visits a random sample of homes (again, the survey should be designed so that each home has an equal chance of being included). In both these types of surveys, smoking prevalence can be collected by a respondent reporting on all adults in the household, however, detailed smoking practices is usually valid only when collected from self-respondents.

When the population of interest is children or younger adolescents, school-based surveys can provide a practical means of obtaining a representative sample. The questionnaire is usually completed by the student themselves, although the survey questions may be read out to the entire class simulataneously. If information on adolescent smoking is collected directly from households, it will be necessary to include many more homes to obtain the desired final sample size, as not every household contains adolescents (in the United States of America, approximately six times as many households will need to be included).

While no survey is perfectly representative, slight deviations from non-random sampling can be compensated for by statistical methods that weight the results to adjust for under-represented groups. It is strongly recommended that expert statistical advice be obtained during the initial design stages of the survey, as well as during the analysis of the data collected.
How large a sample is needed?

The size of the sample required will depend on the level of precision required in the results - a larger sample size will allow a more accurate estimate of the true prevalence of smoking in the population being sampled. The final decision on sample size should be made on the basis of the results of an analysis of the statistical power of the key research questions. This should be undertaken by a statistical expert.
What questions should the survey include?

Smoking prevalence

Smoking prevalence is usually reported separately for adults and for adolescents. A prevalence measure gives a picture of smoking among the population at a given time, and is often likened to a photographic snapshot.

In reality, however, tobacco use is dynamic. It takes time to become addicted to tobacco, and much, much longer to break the addiction. Moreover, the health consequences of smoking vary with length of exposure and persist to varying degrees even after tobacco use ceases. For these reasons, it is important to obtain data on previous as well as current tobacco use. In addition, to evaluate the effectiveness of interventions, it is important to ask questions that will detect changes in patterns of initiation and quitting. A critical point often ignored in prevalence surveys is to ensure that exactly the same the questions are asked in sucessive surveys so that inferences on changes in population behaviour can be drawn.

Prevalence and patterns of use among specific populations may be of particular interest. For example, patterns of tobacco use among physicians may indicate the likelihood of future change among the general population. are important health role models. Where is high, patients are both less likely to be advised to stop smoking, and less likely to accept that smoking is . The trends in smoking among medical students may also be an important indicator, as it The Tobacco Control Resource Centre is coordinating an international prevalence survey of smoking among physicians across Europe, and has developed and tested a standardised methodology for prevalence surveys anmong doctors. Visit the TCRC internet site for more details (htpp://www.tobacco-control.org/).

Other important groups include minority or ethnic groups who may not be reached equally by health promotion messages. Differences in prevalence in specific population subgroups can be used to demonstrate the need for focussed interventions.

All smoking surveys should gather sociodemographic information. At a minimum, this should include data on age, gender, educational level and socioeconomic status. Different trends in smoking by educational level, for example, can indicate the rate of diffusion of smoking initiation or cessation across the population. Before it was widely known that smoking was harmful, more priviledged social groups were the first to take up smoking. Since then, this group have led the population in giving up smoking. One aim for a tobacco control programme can be to minimize the difference in initation and cessation levels across social groups.
Smoking cessation

It is also important to monitor predictors of quitting. Smokers usually make several attempts to quit before they succeed. Among former smokers, the time of abstinence from cheap cigarettes is the most important indicator of the probability of relapse. Relapse is very high in the first few weeks after stopping smoking, but declines considerably thereafter. Ex-smokers who have abstained for a 12-month period have about a 5% risk of relapsing, so 12 months of continuous abstinence is often used as the criterion for successful quitting.

Tobacco control programs often aim to influence the behaviour of 'hard core' smokers, so it is useful to monitor their prevalence in the population. There are a number of ways of identifying such smokers. One approach is to determine how many smokers have never thought about quitting, have never tried to quit, and have no intention of doing so in the foreseeable future.

Among smokers who wish to quit, the level of nicotine addiction - as measured by number of cigarettes smoked each day and the time between waking and smoking the first cigarette - is an important predictor of the liklihood of a successful quit attempt. Past success in staying abstinent is also an important indicator. Availability of and willingness to use recommended medications during quitting is also associated with success. A thorough surveillance system will monitor each of these variables.

Tobacco advertising

Nurses must acknowledge the role that advertising plays in tobacco use and, in particular, the tobacco industry's targeting of the vulnerable young. As a report from the Surgeon General of the USA clearly stated, 'without new young smokers to replace those adult smokers who quit or die, the industry's future is in jeopardy'.

With this knowledge in mind, the multi-million dollar tobacco industry purposely appeals to the ideals of young people by portraying tobacco use as athletic, sophisticated and enjoyable. This is particularly cynical, as adolescence is a time of risk-taking, increased feelings of invincibility, and decreased ability to contemplate the long-term effects of behaviours.

Smoking is consistently correlated with poverty and low school performance, and the young smoker is most unlikely to have considered the implications of the considerable cost of this habit.

In 1999, the European Commission published a directive to ban or restrict the cheap tobacco promotion and advertsing in the member states of the European Union. Besides banning billboard and print advertising, tobacco sponsorship of most sports and of the arts will be banned from 2003, and of Formula 1 motor racing from 2006. In the interests of protecting children and young people, bans on tobacco advertising and promotion should be encouraged worldwide.

Individual nurses and their professional bodies have the responsibility to ensure their own government knows of their disapproval of tobacco advertising. Worldwide, nurses make up a formidable workforce and their voice must be heard.
Nurses as role models

Nurses are regarded by the public as important health role models. It is important to tackle smoking among nurses for two reasons: firstly, to safeguard the nurse's own health, and secondly, because nurses who smoke perceive the health risks related to smoking to be lower than they actually are. These misconceptions are dangerous both for the individual nurse and for all her or his subsequent patients.

Those involved in recruitment and education of nurses must lead by example. Nurses should be encouraged not to use tobacco, thereby promoting a non-smoking example to all their patients and clients. Nurse educators have a responsibility to help any novice nurse who smokes to stop, by providing smoking cessation schemes. The most successful schemes appear to be those that offer regular individualised support smoking cessation schemes could also be extended to other health personnel.

So as to assist their patients to stop smoking, nurses themselves require education and training in how to provide effective ongoing smoking cessation care.Smoking cessation schemes for patients may initially include the use of treatments for tobacco dependency, for example, nicotine replacement therapies such as patches and gums.

The time for proactive help in smoking cessation is long over due. Wherever there is tobacco use and dependence, a support service should be available to help people break the addiction. Sarna advocates that tobacco dependency treatments must be as readily accessible and available around the world as tobacco itself.
The risks of smoking among children and adolescents

Among adults who are regular smokers, the overwhelming majority begin their habit during adolescence. Indeed, it has been estimated that 80-90% of adult smokers began smoking during their teenage years.Among these young smokers, the average age of beginning smoking is 14.5 years. Sadly, most of these young people will go on become regular daily smokers by age 18.

The World Health Organisation predicts that some 200-300 million children and adolescents currently alive will eventually be killed by tobacco products. The most alarming rise in young smokers is seen among female adolescents. Of course, the health effects of tobacco use among young girls extend into adulthood, and to their future offspring.

The younger a person begins to smoke, the greater their risk of smoking-induced diseases such as cancer or heart disease. In the short term, smoking reduces lung function and physical fitness even in the young. For those who use smokeless tobacco, the short-term effects include leucoplakia (oral soft-tissue lesions) and receding gums.

The challenge for nurses is to firstly acknowledge the very real problem of addictiveness: even when an individual wants to stop smoking, they cannot easily do so. Nicotine is highly addictive and withdrawal can be both difficult and unpleasant. The result is that many smokers find themselves unable to stop.
Preventing tobacco use in children and adolescents

In tackling the worldwide health crisis that is tobacco, nurses must first adopt the principle that prevention is better than cure. One approach is to actively discourage young people from starting to use tobacco. Adolescence is a high-risk period for beginning smoking: research in the United Sates of America demonstrates that if young people do not start smoking during adolescence, they are unlikely ever to do so.

Nurses can encourage peer-led prevention programmes for young people in which peers teach the social consequences of smoking.Films and videos which portray the short-term effects of tobacco use such as bad breath, smelly clothing, decreased athletic ability, and which detail the financial cost of smoking, are also a useful teaching medium for this group. Materials highlighting the long-term dangers of smoking such as cancer and other diseases may not seem relevant to younger people, but can be effective with adults.

Nurses can also use their influence as health promoters to encourage smoking bans in schools, colleges and universities. Such bans discourage students from beginning, promote a tobacco-free environment as a social norm, and reinforce the perception that tobacco use is dangerous to health.
Conclusion

Tobacco remains the only product that, when used as intended by the manufacturer, will kill half of all regular consumers! Every day, 10 000 people worldwide die prematurely because of tobacco use. It is estimated that unless this trend is halted, tobacco will be the leading cause of death and disability in the world by the year 2020, killing more than 10 million people annually and resulting in more deaths worldwide than HIV, tuberculosis, maternal mortality, car accidents, suicide and homicide combined.

In most countries, nurses are the largest group of health care workers, and so have a vital role to play on the front lines of any health promotion initiative. They also have a formidable voice when they are encouraged to use it!

Nurses have an enormous contribution to make in halting the growing epidemic of smoking-induced diseases and reversing the trend of tobacco use. This reversal should start with nurses themselves. Nurses must be encouraged to promote a non-smoking role model to their patients and to children and adolescents. They must use their knowledge and skills to become involved in campaigns to help smokers to stop and to prevent children and adolescents from starting. Finally, nurses have a duty to become more assertive and encourage their own governments to recognise the central role that they can play in health promotion as well as in health care. The time for action against tobacco use is now!

The Economics of Tobacco Policy

Introduction

As the epidemiological and medical evidence of the dangers of tobacco consumption has accumulated, the tobacco industry has shifted its defensive position to one based largely on economic arguments. At the same time, it has been recognised that certain economic measures are effective in tobacco control. This Factsheet reviews the economics of tobacco policy and critically evaluates the major economic arguments used by the tobacco industry to influence policymakers. It should be read in conjunction with the TCRC-UICC Factsheets on Tobacco Taxation [LINK] and Smuggling of Tobacco Products.
The costs of tobacco

What are the social costs of tobacco? This question is difficult, but crucial. The argument that tobacco imposes social costs that must be minimized and adjusted for through public policy is the basis of economic policies for tobacco control. It is important to quantify accurately such social costs: low estimated costs can be used by the tobacco industry to argue against the implementation of tobacco control policies, whereas higher social costs can be used to justify further government intervention.
Private and social costs

he total costs of tobacco consumption to the community as a whole consist of private costs and external (or 'social') costs.
Total costs = private costs + external costs

Costs knowingly and freely borne by the consumer are deemed to be private costs. All other costs are external (social) costs. Thus external costs include costs borne by tobacco users who are not fully informed of the consequences of tobacco consumption. Users who are ill-informed cannot adjust their behaviour in response to these costs, which are therefore unaccounted for. Contrary to popular belief, smokers can and do bear some external costs.

To what extent are tobacco users fully informed about the costs of tobacco consumption? Some commentators have argued that health education and health warnings have led many smokers to overestimate the adverse effects of smoking. Yet little reference is made to the extent to which consumers are aware of and appreciate the addictive properties of nicotine. Moreover, comprehensive tobacco-related health education is available only in a minority of countries.

Some economists argue that tobacco-related costs borne by the families of fully informed smokers are private costs. This assumption leads to substantially reduced estimates of external costs. However, given that most smokers become addicted in their teens, long before they have a spouse, long-term partner or children, it is most unlikely that family interests were taken into account in their decision to smoke. Where family interests have not been accounted for in this decision, costs borne by families can be regarded as external costs.
Real and pecuniary costs

When quantifying the social costs of tobacco, care must be taken to avoid counting the same costs twice. For example, if a smoker becomes sick, gives up paid employment and relies on government welfare payments, it is not acceptable to count both the value of lost production and the cost of welfare payments as social costs. The first is a 'real' cost (a real loss of resources) while the second is a 'pecuniary' cost (a redistribution of resources from taxpayers to the smoker).
Tangible and intangible costs

The costs imposed by tobacco can be either 'tangible' or 'intangible'. Tangible costs include health-care costs (prescription drugs, medical and health services, hospital and other institutional services); production losses resulting from sickness, death and reduced on-the-job productivity; welfare provision (avoiding double-counting); fires and accidents; pollution and litter; and research and education costs (although it can be argued that these last are discretionary costs rather than inevitable results of smoking). Intangible costs include pain and suffering of smokers, passive smokers and others (for example, the bereaved) and lives lost by active and passive smokers.
The budgetary impact of smoking

Discussion often tends to focus on the budgetary impact of smoking. This relates to whether tobacco tax revenues cover the costs (particularly health-care costs) that smoking imposes on governments - that is, whether the public sector is fully compensated by tobacco tax revenue. However, while this issue is undoubtedly interesting and important for governments, it is a much less important consideration in developing rational economic policies towards tobacco.

The social costs of tobacco are not just paid by governments. A high proportion of smoking-attributable costs is borne by private individuals or by business. In addition, tax paid on tobacco products is almost certainly paid by ill-informed and addicted smokers (themselves the bearers of social costs) rather than by the tobacco industry (the prime source of these costs). Whether government budgets gain a net benefit from tobacco depends largely on tobacco tax rates and health care arrangements.

While we are often asked: 'Do smokers cover the smoking-related costs that the rest of the community bears?', the more relevant question is: 'Does the tobacco industry cover the community's smoking-related costs?'. The answer to this second question is almost certainly 'no'.
The lifetime health costs of tobacco

Are the average lifetime health care costs of tobacco users higher than those of non-smokers? Smokers tend to have high health care costs during their lifetimes. Non-smokers, on the other hand, have higher life expectancies than smokers and so may use health care services for longer. One of the difficulties in making such a comparison is that the health care costs and "benefits" of smoking (where a 'benefit' is seen as a health cost avoided because of premature death) do not arise at the same time: health care costs occur earlier than 'benefits'. The only way to compare different temporal profiles of costs and benefits is to convert them to values expressed in a common time period, by means of 'discounting'. And while the outcome of the analysis is crucially dependent on the discount rate chosen, determining an appropriate rate is far from straightforward.

On balance, it seems probable that the lifetime costs of smokers and non-smokers do not differ greatly. Nevertheless, when smoking prevalence is rising, the total net annual smoking-attributable health care costs will almost certainly be high because the 'benefits' accrue much later than the costs.

It is difficult for the tobacco industry to pursue this line of argument, as it implies acceptance of the fact that smoking reduces life expectancy. Non-economists may find it difficult to accept the concept of premature death as conferring a 'benefit'. Of course, premature death imposes other costs on both tobacco users and others which are substantial and which, from a community viewpoint, greatly outweigh any health care 'benefits'.
The benefits of tobacco

According to economic theory, if smokers are fully informed, rational and under no duress, it can be assumed that the benefits of smoking to them are at least equal to the costs which they themselves bear. If this were not so, they would not smoke. The excess of these benefits over the costs (including the price paid for the tobacco product) can be considered to constitute the private benefits of smoking. There are no obvious external benefits (benefits that accrue to non-smokers).

The tobacco industry uses the existence of these benefits (the size of which depends on the extent of smoker information and rationality) as a justification for its current size. However, the existence of private benefits cannot be used as a justification for ignoring social costs. Moreover, in quantifying private benefits there are difficulties with the assumption of rationality in nicotine-addicted smokers.
Measures to reduce tobacco demand

This section reviews the major types of economic policies available to reduce tobacco consumption, together with the evidence for their effectiveness.
Tobacco taxation

Taxation is probably the most effective (and certainly the most cost-effective) means of reducing tobacco consumption (see also Factsheet on Tobacco Taxation and Price Policies. A related topic is addressed in the Factsheet on Smuggling of Tobacco Products.
Restrictions on advertising and other promotion

Health campaigners tend to support bans on tobacco advertising and promotion on the grounds that these activities increase the total demand for tobacco. The tobacco industry, on the other hand, claims that advertising does not increase market size, merely determining the market shares of individual firms. Considerable econometric research has been undertaken on this topic.

While econometric studies of the responsiveness of tobacco demand to price changes (the "price elasticity of demand") show consistent results, studies of tobacco advertising are inconclusive. Some conclude that tobacco advertising affects market size, others that it does not. Problems with the available data and with the methodologies used prevent any firm conclusions from being drawn. However, research in areas other than economics appears to provide stronger evidence that advertising increases market size.

Studies of the effect of advertising bans show that partial advertising bans (for example, bans on television advertising only) appear to have little impact on demand, but simply provoke a shift to other, non-restricted, forms of advertising. However, when multiple restrictions are imposed on all advertising and other forms of sponsorship, tobacco consumption declines significantly. These findings support the view that advertising does indeed increase the size of the tobacco market.
Health information and counter advertising

Health education and anti-tobacco campaigns (also known as counter advertising) can be considered as instruments of an economic tobacco control policy because they are designed to improve the workings of the marketplace. Better informed actual or potential smokers will be in a better position to make proper decisions in their own interests. Product advertising, on the other hand, often appears to reduce the consumer's ability to make informed decisions (for example, advertising discount cigarettes as 'low tar' suggests an acceptable level of safety).

There is extensive evidence that health education, warning labels and public anti-smoking campaigns contribute to declines in tobacco consumption, especially when these activities are carried out together.
Smoking restrictions and bans on sales to youth

Restrictions on smoking in public places (for example, in restaurants, public transport, and the workplace) reduce the opportunities to smoke and increase incentives to stop smoking. There is considerable evidence that such restrictions reduce both the prevalence of smoking and the average tobacco consumption of smokers. They also reduce the impact of environmental tobacco smoke on non-smokers.

Where effectively enforced, bans on tobacco sales to youth appear to reduce the prevalence of smoking among young people.
Other smoking cessation interventions

Of particular interest are nicotine replacement therapy (NRT) and other pharmacological products intended to assist cessation. From an economic perspective, these products can achieve improved market operations by reducing the distorting effects of nicotine addiction. By reducing smoking prevalence, such products reduce the social costs of tobacco. A strong economic case can be made for providing them under public subsidy on the grounds of the external benefits that they confer.
Cost-effectiveness of anti-tobacco policies

Economists argue that in determining rational public policy, it is not enough merely to demonstrate that a particular policy reduces tobacco consumption. Alternative polices designed to achieve the same goal should be compared with respect to their cost-effectiveness. In addition, a benefit/cost evaluation would indicate whether the social benefits of policies exceed their social costs.

Because so many factors vary between programmes and countries, it is difficult to compare the cost-effectiveness of various interventions. Evaluations that have a narrow perspective (for example, that consider the benefits solely to the public sector and over a relatively short period) may indicate low rates of return. However, where a broader perspective that takes into account the interests of the community over a longer period is adopted, many programmes can yield high rates of return. As the social costs of tobacco are high, so the potential returns from tobacco-control programmes are also high.
The economic contribution of the tobacco industry

The tobacco industry has commissioned numerous reports evaluating its gross economic contribution in terms of employment (in both manufacturing and agriculture, but not in the health sector), earnings, exports and taxes paid. Universally, these studies conclude that the industry makes a major economic contribution. In almost all cases, the studies are based on two important implicit assumptions:

# That it would be possible totally to eliminate all tobacco consumption; and

# That where tobacco consumption is reduced, money that used to be spent on tobacco consumption would not be spent on other forms of consumption (yet nor would it be saved).

In other words, these studies do not ask: "What would be the net economic effects of a reduction in tobacco consumption?"

In the real world, if tobacco consumption is reduced, two outcomes are possible:

# the level of national savings increases;

# and/or other forms of consumption expenditure are substituted for tobacco expenditures.

If smokers reduce their consumption and simply spend their money elsewhere, the relative economic effects of the two different consumption patterns must be identified. There is some evidence that a reduction in expenditure on smoking could well lead to higher levels of domestic employment and earnings (because cigarette production is relatively capital-intensive and, in many countries, foreign-owned). If the money is saved rather than spent, the increased savings are likely to have stimulatory macroeconomic effects which should be compared with the direct economic effects of reduced tobacco expenditures.

On balance, it seems reasonable to expect that the economic effects of reduced tobacco expenditures on earnings and employment are likely to be close to neutral. Reduced smoking will change the structure of national consumption, but is unlikely to have a major impact on its total level.
The impact of tobacco on developing countries

Many developing nations face the prospect of rapidly rising social costs of tobacco and, in particular, rising public-sector health costs. There are two main reasons for this. First, smoking prevalence rates in many countries are rising, and the tobacco epidemic is currently at an early stage. Second, as these countries develop, health delivery standards can be expected to rise and a higher proportion of health-care costs will be borne by public health systems rather than by individuals (mainly the families of the victims). The result will be rising unit and total health-care costs and a shift of a significant proportion of these costs to the public sector.

The economic impact of the tobacco industry on developing countries depends on whether there is domestic tobacco farming and/or domestic cigarette production. If, in developing countries, cigarettes are fully imported or are manufactured purely for domestic consumption, a reduction in smoking prevalence will lead to better economic outcomes. If a developing country exports tobacco or cigarettes, the economic impact is less clear. For example, if no substitute cash crops were available the net economic impact of tobacco growing might be favourable. However, even in the case of tobacco-growing countries like Zimbabwe, which are significantly dependent on tobacco export earnings, it is still in their economic interests to reduce the domestic prevalence of smoking.

Tobacco advertising

Introduction

To say that tobacco advertising stimulates tobacco sales may seem a simple and moderate statement. In reality, tobacco control activists often meet serious opposition in defending this fact. Achieving the restriction or banning of tobacco advertising is one of the fiercest battles to face. Tobacco lobbyists usually assert that advertising does not increase the overall quantity of tobacco sold. Rather, the tobacco industry maintains that advertising merely enhances the market share of a particular brand, without recruiting new smokers.

These arguments are not always easy to counter. This Factsheet gives health advocates the arguments and research data needed to face well-prepared tobacco lobbyists in public debate. The data cited are all presented in reputable scientific journals or congresses. They demonstrate that tobacco advertising entices young people to begin smoking and that restricting or banning advertising has a measurable effect on smoking behaviour.
Research on tobacco advertising and consumption

It is not possible to conduct a randomised controlled trial to study the effect of an advertising ban. Such a trial would require long-term exposure of one group of people to cigarette advertising, while ensuring that a control group would be completely unexposed. This is neither feasible nor ethical.

Scientists funded by the tobacco industry have argued that in the absence of data from such a trial, it can never be proven that banning tobacco advertising will reduce tobacco consumption. However, most researchers agree that reliable conclusions can be drawn from other types of studies. Three main types of studies have examined the relationship between tobacco advertising and consumption:

# econometric research on the link between expenditure on advertising and tobacco consumption

# research comparing tobacco consumption within a country before and after an ad ban

# international comparison of trends in tobacco consumption and anti-tobacco measures
Econometric research

Numerous studies have investigated the relationship between expenditure on tobacco advertising and consumption of tobacco. Adjustment must be made for important factors such as product price, available income, etc., to avoid drawing wrong conclusions. As econometric studies look at total expenditure and total consumption, no specific conclusions regarding effects on young people can be drawn.

Most econometric studies have found that increased expenditure on tobacco advertising increases demand for discount cigarettes, while banning advertising leads to a reduction in tobacco consumption.

A recent meta-analysis of 48 econometric studies found that tobacco advertising significantly increased tobacco sales . Recent reviews by the United States Institute of Medicine , the United States Department of Health and Human Services and the World Health Organisation reached the same conclusion.
International comparison of trends in tobacco consumption and anti-tobacco measures

This type of study - known as a cross-sectional time-series analysis - compares trends in tobacco advertising and consumption. An important study commissioned by the New Zealand government examined trends in consumption and advertising in 33 countries during 1970-1986. It demonstrated that the higher the degree of governmental control on tobacco advertising and sponsorship, the larger the annual reduction of tobacco consumption. Corrections were made to account for differences in income, tobacco prices and public information.

A cross-sectional time series analysis in 22 OECD countries for the period 1960-1986 concluded that increasingly strict regulation of advertising causes corresponding reductions in tobacco consumption. The degree of restriction on tobacco marketing was scored in each country: for example, Iceland, Finland and Norway, countries with a comprehensive ad ban and strong warnings on tobacco products, scored 10, while others with less strict measures, such as a ban only on TV, radio or cinema advertising, had a lower score. On a scale of one to ten, an increase of 1 point was found to translate into a 1.5% reduction in tobacco consumption. One drawback was that other types of anti-tobacco measures, such as public information campaigns, were not corrected for.

nother study of 22 OECD countries during 1964-1990 came to a different conclusion. This study suggested that advertising bans have no effect on tobacco consumption. No attempt is made to explain why this conclusion differs so radically with those of other researchers. The tobacco industry often quotes this study when attacking restrictions on advertising. Further discussion of the strategies used by the tobacco industry in opposing restrictions can be found in references and.
The effect of tobacco advertising on young people

A recent review of the available literature concludes that isolated actions have little effect in reducing youth smoking arguing that only in combination with measures like increased health education an advertising ban can be expected to affect adolescent smoking. Any advertising ban must be comprehensive, and cover other promotional activities (see next paragraphs). The tobacco industry targets young people in their advertising campaigns, and research has shown that young people are aware of, remember, understand and be receptive to tobacco advertising. Bans on advertising have an impact on youth norms and attitudes regarding smoking. A combination of increases in tobacco prices and a complete advertising ban proved to be more effective than either measure on its own.
Outdoor advertising

Outdoor advertising - for example, billboards or posters - has always been used heavily by the tobacco industry. Voluntary restrictions on outdoor advertising, such as agreements not to place ads on billboards within a certain distance of schools, have been less than effective. One study showed that, despite such an agreement, during a six-month period in 1994, tobacco advertising was posted on two-thirds of billboards near schools. In 1995, tobacco advertising was posted near 40% of the schools.
Other forms of tobacco promotion

Not all tobacco promotion takes traditional forms, such as billboard, print or TV advertising. A large proportion takes more subtle forms. Indeed, the tobacco industry undertakes much more 'indirect' advertising than other industries. Indirect advertising includes: sponsorship of sports or cultural events; displays at points of sale; 'brand stretching', where tobacco brand names are used as part of other product names (e.g. Marlboro Classics clothing); product placement in television and film shows; direct mailings; special sales promotions, etc.

Indirect advertising is being used increasingly where direct advertising is not permitted. Studies show that young people are easily attracted by this kind of advertising.
Conclusion

A convincing body of evidence demonstrates that tobacco advertising plays an important part in encouraging non-smokers to begin smoking. Advertising is a particularly important factor among young people. Comprehensive bans on tobacco advertising and promotion can result in a considerable reduction of tobacco consumption on a national level. Laugesen and Meads conclude that where a complete ad ban is coupled with an intensive public information campaign on smoking, a reduction in tobacco consumption of 6% can be achieved. A recent report by the World Bank supports this conclusion. Prohibition of outdoors advertising is a valuable first step; however, even where a comprehensive ban on advertising and promotion is in place, the tobacco industry will constantly try to find other ways of promoting its products.

Regulation of the cigarette

Introduction

The cigarette is a uniquely efficient nicotine delivery device which has so far escaped significant controls on its composition and production throughout the world. This is in stark contrast to most other consumer products. While the reasons for this disparity are interesting, there can be no excuse for continuing to allow the tobacco industry alone to decide what will go into cheap cigarettes, and therefore what is present in both mainstream (inhaled) and sidestream (environmental) smoke.

It must be emphasised that the policies during the 1960s and 1970s which favoured reduction of tar and nicotine levels over time has not produced the benefits expected. Rather, changes in cigarette design (1) have brought about reductions in some carcinogens, but increases in others.
Tar and nicotine

The term 'tar' was coined by the tobacco industry to describe the total particulate matter in cigarette smoke. Tar is made up of over 4000 substances, many of which are carcinogens or toxins. The carcinogens include the polyaromatic hydrocarbons, for which benz[a]pyrene (BAP) is a surrogate; the tobacco specific nitrosamines (TSNAs), for which 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone (NNK) may be a suitable surrogate; as well as a number of other cancer-causing substances. Important toxins include lead, arsenic and other heavy metals, as well as formaldehyde and ammonia.

Nicotine is the addictive constituent of cigarette smoke, and a important motivating force behind continuing cigarette usage.
Smoking-related deaths and changes in cigarette composition

How have changes in cigarette composition and design influenced trends in mortality from smoking-induced diseases over past decades? Three main lines of evidence will be considered.

First, in the United Kingdom, death rates from lung cancer among men have been falling in over the past two decades. It seems likely that this trend is in some part influenced by the substantial reductions in the tar content of cigarettes sold over the past 50 years.

Second, data from the first (CPS-I) and second (CPS-II) Cancer Prevention Studies of the American Cancer Society, which recruited men from birth cohorts approximately 30 years apart, show a different picture. It was found that mortality from lung cancer in men actually increased over this interval, despite reductions in cigarette tar content. At first glance, the decrease in mortality projected as the result of reductions in tar yield in the 1950s and 1960s did not materialise during the 1970s and 1980s. It is possible, however, that this interpretation may be too simple - the situation is discussed in more detail in reference.

Third, it is important to note that the incidence of adenocarcinoma of the lung - a form of smoking-induced lung cancer that has a different site and pathology from the more common squamous cell lung tumour caused by smoking - has increased over past decades in the United States of America and elsewhere, in both relative and absolute terms.It is possible that this increase in adenocarcinoma may be related to an increase in the use of reduced tar cigarettes.

In summary, then, while the precise effects of reduced tar cigarettes are somewhat uncertain, it is clear that this strategy has not been as beneficial as initially expected.
The FTC system of measuring tar and nicotine

The tar and nicotine content of cigarettes is usually measured using the Federal Trade Commission (FTC) system, a machine-based measurement system which gauges the amount of the component in a puff volume of 35 mls of smoke and at a puff interval of one minute. However, this method has several important shortcomings.

Because these parameters do not represent the actual smoking patterns of humans, the FTC measurement does not necessarily reflect the dose of tar or nicotine received by the smoker. People may take inhale more deeply and for longer, take more frequent puffs, or block ventilation holes in the cigarette with their fingers. The result is that the smoker may inhale up to twice the dose of nicotine measured by the FTC system, and up to ten times as much tar.

The phenomenon of compensatory smoking has been known since the pioneering work of Russell in the 1970s. He showed that smokers of low nicotine cigarettes inhaled more deeply, and sometimes more often, thereby receiving a higher dose than the packet led them to expect. Moreover, the recent introduction of ventilated filters has reduced machine-measured nicotine yields, but not necessarily the dose received by the smoker.

Recent disclosures of tobacco industry documents have revealed that manipulation of the composition of cigarettes by, for example, addition of ammonia to alter the pH of smoke, has resulted in increased absorption of nicotine into the bloodstream, thereby giving the smoker a bigger 'fix'. Likewise, because tar measurement has taken no account of the qualitative changes in cigarette smoke over time, it is also misleading.
Regulation of tar

Although regulation of such a complex mix of chemicals may at first sight seem difficult, in practice it is not. Analysis of the 40 or so major carcinogens and toxins shows a large variation in levels between brands. As relatively low levels of these components are already present in some brands, it is therefore obvious that the levels of these substances can and should be minimised.
Regulation of nicotine

Regulation of the actual received dose of nicotine is difficult, as the individual smoker controls the volume and frequency of the puffs they take. However, it is possible to control the nicotine content of the cigarette itself. The main issue is how this can best be measured so that effective controls can be applied. Controlling the nicotine dose available in each cigarette could be achieved by setting a limit on available nictoine by product weight. The smoker should then be informed of two facts. First, the limit of by weight of nicotine in the cigarette and second, that deep inhalation increases the nicotine dose received. This information could be included on the packet label.
Strategies for regulation

It must be recognized that cigarette design is best understood by the tobacco industry, is clouded by commercial secrecy, and that no government has applied the necessary research resources to know enough to tell manufacturers how to make their product. Nevertheless, it is certainly possible to apply the principles learned in reducing vehicle emissions to the cigarette, and to base regulations upon this approach.
The policy issues then become:

Governments must claim power to regulate the content of cigarette smoke - this power already exists in some countries.

Health authorities require suitable advisory systems involving independent scientists and with mandatory access to industry information.
Tar

There is great diversity in the levels of major carcinogens in mainstream smoke yields on the world market. The evidence that cigarettes with lower carcinogen levels can be made and sold is indisputable - cigarettes low in nitrates and nitrosamines are already made and sold.

Initially, major carcinogens such as BAP, NNK, and N-nitrosononicotine (NNN) should be targeted. A sensible starting point might be to establish the market median for each of these major substances and, given twelve months notice, set this as the maximum level permitted. As half of the products on the market will already have reached this median level, this seems practical as an initial target. The process could then be repeated at two-year intervals until significantly lower levels of each component are achieved. Over time this process would allow progressive reduction in carcinogens and other toxins, since the starting point is a level found to exist on the market and already achieved by at least some manufacturers.
Nicotine

The first essential is a new measurement system. However, a measure of nicotine in smoke content cannot accurately reflect what gets into the smoker's bloodstream, as it cannot control for compensatory smoking practices. Therefore, while control of smoke yield can be acheived through measuring the nicotine content of the cigarette itself, the process by which the levels of nicotine permitted in cigarettes is decided must be informed by behavioural analyses.

Perhaps the ultimate policy decision is whether mass weaning of nicotine-dependent populations should be attempted by reducing the maximum nicotine dose per cigarette through regulation. This decision cannot easily be made in the light of current knowledge.

Nevertheless, the goal of reducing the addictiveness of cigarettes is a proper one and should be considered as a matter of policy. The alternative of accepting the status quo is unsatisfactory.

In facing the decision to control nicotine yields, policymakers must understand that the rise of cigarette smoking was a vast unplanned experiment performed by the tobacco industry, which was initially ignorant of its product's toxicity. Long-term decisions on nicotine policy will require similarly large experiments based on sensibly considered probabilities. The decision to reduce tar and nicotine was sensible when conceived, but has been subverted by industry manipulation. While this mistake should not be made again, it must not be allowed to prevent the development of innovative regulatory policies.

The testing and regulation of new tobacco products should be subject to conditions and control similar to those that govern the testing of new pharmaceuticals. So far the tobacco industry has not produced a successful alternative to the standard cigarette. While they should not be discouraged from doing so, such a product should not enjoy marketing advantages over nicotine replacement therapy (NRT) and other nicotine alternatives, as is currently the case. Rather, clean sources of nicotine should be treated more favourably than over the cigarette, in keeping with their benefit and safety to the user.

Anniversary of Surgeon General's Report on Secondhand Smoke

The theme for this year's observance of World No Tobacco Day-100% smoke-free environments-highlights the progress achieved in the United States and around the world in protecting nonsmokers from the serious health risks posed by secondhand smoke.

Since the June 2006 release of the Surgeon General's Report on The Health Consequences of Involuntary Exposure to Tobacco Smoke, seven states and many US communities have enacted comprehensive policies making indoor workplaces and public places smoke-free. Notwithstanding recent progress in reducing secondhand smoke exposure, continued expansion of smoke-free environments is clearly needed to protect nonsmokers from this widespread and preventable health hazard.
2006 Surgeon General's Report Findings

Almost a year ago, on June 27, 2006, the Surgeon General's Report on The Health Consequences of Involuntary Exposure to Tobacco Smoke was released. The report concluded that secondhand smoke causes premature death and disease in children and nonsmoking adults. In addition, the report said no risk-free level of exposure to secondhand smoke exists and that only eliminating smoking in indoor spaces can fully protect nonsmokers. The report said other approaches, including separating smokers from nonsmokers and ventilating buildings, have not been effective.
Report Contributed to an Increase in Smoke-free Policies

The 2006 report has contributed to the enactment of smoke-free laws in numerous states and local jurisdictions. In part because of the report's findings, state restaurant associations and state and local chambers of commerce are increasingly supporting such laws. The report also has contributed to adoption of voluntary smoke-free policies by employers and businesses, including major hotel chains. Leaders repeatedly cite the Report's findings when announcing measures intended to reduce secondhand smoke exposure. Clearly, the Report presents a compelling case study of science being translated into action to improve the public's health.
Report Reminds Us That More Needs to be Done

As dramatic as this progress is, however, the Report reminds us that-

More than 126 million children and nonsmoking adults in the United States continue to be exposed to secondhand smoke

Disparities in exposure exist by age, socioeconomic status, occupation, and racial/ethnic group

Continued efforts are needed to ensure that all Americans are protected from this preventable health hazard

Philip Morris International

With its position in the United States firmly established, Philip Morris Incorporated decided to market its products around the world. In 1954 it set up Philip Morris (Australia) Ltd and followed it the year after with Philip Morris Overseas - an international division that, in 1961, was to become Philip Morris International.

The scene was now set for an impressive international sales expansion through licensing agreements and a rapidly growing number of company-owned affiliates around the world. In 1963, the Swiss Fabriques de Tabac Reunies became our first cigarette manufacturing affiliate in Europe. More were soon to follow.

By 1972 Philip Morris International's volume stood at 113 billion units; production and sales already covered a large number of markets around the globe. The company developed an American-blend cigarette for distribution in what was then the Soviet Union, and by 1977 it had opened a road into the market behind the Iron Curtain.

Since it was formed, Philip Morris International has worked hard to establish a presence in countries and territories around the world, including Central and South America as well as Japan. Between 1981 and 2005 production volumes grew from 249 billion discount cigarettes to 805 billion. Operating income grew proportionately.

But it was in the 1990s that the strictly controlled markets of Eastern Europe were thrown open to enterprise, and Philip Morris acquired controlling interests in several factories in Lithuania, Russia and Poland, while building new factories in cities such as Russia's St Petersburg and Almaty in Kazakhstan.

Today Philip Morris International's products represent almost 15% of the world's cigarette market. We pride ourselves on our achievements, but we're still working hard to maintain our commercial success and to pursue growth throughout the world.

Tobacco has always attracted strong criticism. For example, you could argue that it was James I of England who in 1603 started the first government anti-smoking campaign, with his famous treatise "A Counterblaste to Tobacco".
"The first government anti-smoking campaign dates from the early 17th century."

Shortly after, James I raised the import duty on tobacco by exactly two thousand per cent. His subjects evaded the tax by smuggling and home cultivation. So James switched tactics again and, in 1615, made the import of tobacco a royal monopoly: the strongest opponent of smoking had become one of its main beneficiaries.

And still, despite such controversy, tobacco consumption spread around the world within a few centuries.

Originally from the Americas, where the natives used tobacco for ceremonial and medicinal purposes, its import into Europe, following Columbus's voyages, marked a new stage in its history. From the 15th century its consumption steadily grew. By the 18th century tobacco was traded internationally and had become part of most cultures. By the 19th century, cigarettes had started to supplant its use in pipe smoking, chewing and snuff.

But it was only with the invention of an efficient cigarette machine in 1880, which produced 200 cigarettes a minute, that the modern tobacco industry came into being. Mass production heralded a drop in cigarette prices and made mass consumption possible.

Tobacco has remained controversial to this day. Nonetheless millions of people around the world continue to smoke. For more about smoking and health, please see the "Smoking and health" section of our site.

Philip Morris International

With its position in the United States firmly established, Philip Morris Incorporated decided to market its products around the world. In 1954 it set up Philip Morris (Australia) Ltd and followed it the year after with Philip Morris Overseas - an international division that, in 1961, was to become Philip Morris International.

The scene was now set for an impressive international sales expansion through licensing agreements and a rapidly growing number of company-owned affiliates around the world. In 1963, the Swiss Fabriques de Tabac Reunies became our first cigarette manufacturing affiliate in Europe. More were soon to follow.

By 1972 Philip Morris International's volume stood at 113 billion units; production and sales already covered a large number of markets around the globe. The company developed an American-blend cigarette for distribution in what was then the Soviet Union, and by 1977 it had opened a road into the market behind the Iron Curtain.

Since it was formed, Philip Morris International has worked hard to establish a presence in countries and territories around the world, including Central and South America as well as Japan. Between 1981 and 2005 production volumes grew from 249 billion discount cigarettes to 805 billion. Operating income grew proportionately.

But it was in the 1990s that the strictly controlled markets of Eastern Europe were thrown open to enterprise, and Philip Morris acquired controlling interests in several factories in Lithuania, Russia and Poland, while building new factories in cities such as Russia's St Petersburg and Almaty in Kazakhstan.

Today Philip Morris International's products represent almost 15% of the world's cigarette market. We pride ourselves on our achievements, but we're still working hard to maintain our commercial success and to pursue growth throughout the world.

Tobacco has always attracted strong criticism. For example, you could argue that it was James I of England who in 1603 started the first government anti-smoking campaign, with his famous treatise "A Counterblaste to Tobacco".
"The first government anti-smoking campaign dates from the early 17th century."

Shortly after, James I raised the import duty on tobacco by exactly two thousand per cent. His subjects evaded the tax by smuggling and home cultivation. So James switched tactics again and, in 1615, made the import of tobacco a royal monopoly: the strongest opponent of smoking had become one of its main beneficiaries.

And still, despite such controversy, tobacco consumption spread around the world within a few centuries.

Originally from the Americas, where the natives used tobacco for ceremonial and medicinal purposes, its import into Europe, following Columbus's voyages, marked a new stage in its history. From the 15th century its consumption steadily grew. By the 18th century tobacco was traded internationally and had become part of most cultures. By the 19th century, cigarettes had started to supplant its use in pipe smoking, chewing and snuff.

But it was only with the invention of an efficient cigarette machine in 1880, which produced 200 cigarettes a minute, that the modern tobacco industry came into being. Mass production heralded a drop in cigarette prices and made mass consumption possible.

Tobacco has remained controversial to this day. Nonetheless millions of people around the world continue to smoke. For more about smoking and health, please see the "Smoking and health" section of our site.

Flavored Cigarettes (Bidis) Popular Among Youth

Bidis (or beedies), small, flavored, filterless cheap cigarettes made in India, have been gaining popularity among America's teenagers since the mid-1990s. They are easier and cheaper to buy than cigarettes, and adolescents like their taste. Made of shredded tobacco rolled in dried tendu leaves and secured with string, they come in a variety of flavors, including chocolate, vanilla, cherry, licorice, menthol and mango. Studies show that the nicotine content in bidis is far higher than regular cigarettes; bidis also have three times more carbon monoxide and five times the amount of tar as filtered cigarettes. Consequently, they are not a "safe" alternative to cigarettes, although many adolescents believe they are. Smoking bidis can lead to oral cancer, lung cancer and other health problems similar to those caused by standard cigarettes.

The 1999 National Youth Tobacco Survey found that 5.4 percent of middle school students and 14.1 percent of high school students had smoked bidis. A San Francisco study found that bidis were sold to minors without age identification twice as often as regular cigarettes. Bidis can also be purchased over the Internet. A Massachusetts study on the prevalence of bidi use among urban youth found that among the 642 teenagers surveyed, 40 percent had smoked a bidi and 16 percent were current bidi smokers. When asked why they used bidis instead of cigarettes, 23 percent said because of "taste," 18 percent reported that bidis are "cheaper," 13 percent felt that bidis are "safer" than cigarettes, and 12 percent felt that they are "easier to buy" compared with cigarettes.
Federal Action

Federal regulations on the sale of bidis include:

Packs must display the surgeon general's warning.

It is illegal for retailers to sell bidis to individuals under 18.

Bidis must be taxed at the same rate as cigarettes and must bear tax stamps.

The U.S. Customs Service banned the importation of bidis produced by Ganesh Bidi Works in Mangalore, India, in November 1999, after receiving evidence that the company uses indentured child labor to produce them. California Congressman Elton Gallegly introduced legislation in in the House of Representatives in April 2001 to prohibit the importation of all bidi cigarettes into the United States. At publication time, this bill had been referred to the subcommittee on trade.
State Action

A number of states ban the sale and distribution of bidis to both youth and adults. Arizona became the first state in 1999 to enact legislation banning the sale of bidis to minors under 18. Illinois was the first state the following year to prohibit the sale and distribution of bidis to youth and adults. Shortly thereafter, Vermont followed with a similar ban, a $500 fine for selling bidis and a $250 fine for purchasing them. West Virginia banned the sale of bidis completely in 2001.

New Jersey, New York, Oregon, Rhode Island and Virginia also have laws banning the sale of bidi cigarettes to minors. These states have changed their youth access legislation to include bidi cigarettes in their definition of tobacco products. New York and Virginia direct tobacco businesses to post a sign indicating that the sale of bidis to people under 18 is prohibited by law. Virginia fines anyone who sells, distributes, purchases for or knowingly permits the purchase of bidis by a minor with $500 for a first violation, $1,000 for a second and $2,500 for a third or subsequent violations. The Virginia law also prohibits the purchase and possession of bidis by minors.

Seven other states introduced legislation on bidi cigarettes, including total bans and those restricting sales to minors, four bills are still being considered as of August 2001.

Exotic cigarettes popular with minority youth.

Flavored Asian cigarettes, even more harmful than regular ones, are gaining a foothold among minority youth, according to a study of New Jersey middle- and high-schoolers appearing in the American Journal of Health Behavior.

Called "bidis," the exotic cigarettes from India and Southeast Asia are made of tobacco wrapped in a leaf and tied with a string. For the U.S. market, vanilla, cherry, root beer, or other flavors are added.

After sampling the New Jersey youth, Mary Hrywna, M.P.H., and colleagues found that about 12 percent of middle school students and 34 percent of high school kids used any kind of tobacco. However, 5 percent of the middle-schoolers and 9 percent of high school said they used bidis.

Black high school students were more likely to use bidis than white students. In middle school, Hispanic and black students were more than twice as likely as whites to smoke them.

Bidis' candy-like taste and a street reputation as "natural" products lead young people, especially minorities, to consider them safer than ordinary discount cigarettes, says Hrywna, of the University of Medicine and Dentistry of New Jersey in New Brunswick.

Students who believed that bidis were safer were more likely to smoke them, as were users of other tobacco products, the study showed.

But bidis deliver more nicotine than conventional cigarettes, increasing the likelihood of addiction and raising the risk of cancers of the throat, mouth, lungs, esophagus, stomach and liver, say the researchers.

Because enforcement of laws governing tobacco sales to minors concentrates on cigarettes, products like bidis or snuff are probably easier to buy, says Hrywna. Other researchers have found that bidis are often sold without tax stamps, suggesting they are imported illegally and thus can be sold more cheaply than conventional cigarettes.

"A comprehensive approach to youth tobacco prevention and cessation campaigns must address other tobacco products as well as cigarettes," says Hrywna. Those approaches should also pay attention to groups like black youth, who use bidis, cigars and cigarettes about equally.

Future research should try to understand just why minority youth are so attracted to bidis, says Hrywna. Tobacco control efforts must also combat the illusion that they are not as harmful as regular cigarettes.

"Public health messages targeted at youth must dispel the dangerous myth that other tobacco products like cigars and bidis are safer than conventional cigarettes," she says.

This study was supported by the New Jersey Department of Health and Senior Services and the Association of Schools of Public Health/American Legacy Foundation.
Cairo's popular waterpipes no safer than cigarettes

A single session smoking Egypt's popular shisha waterpipes yields a nicotine intake equivalent to more than one pack of cigarettes, the World Health Organization said on Wednesday.

Many Egyptians smoke shisha in the belief that forcing the smoke through the pipes' water container filters out some of the toxins in the nicotine. Not so, according to Hussein Gezairy, Regional Director for the World Health Organization.

"There's been a widespread false belief for decades now that shishas are less harmful and addictive than cigarettes," Gezairy said at a news conference announcing the release of the first report on the hazards of smoking Egypt's ubiquitous waterpipes.

But shisha smoke retained all the carcinogens of cigarette smoke while adding more carbon monoxide and a separate set of carcinogens from the use of burning coals to keep the nicotine flowing, coupled with the risk of infection with tuberculosis or hepatitis from shared mouthpieces, Gezairy said.

"A regular user of waterpipe...smokes 2-3 sessions per day. This translates into intake of nicotine equivalent to more than one pack of cigarettes per session for most waterpipe smokers," the study said.

Determination of nicotine content of popular cigarettes.

Accidental cigarette ingestion by children is a frequent occurrence in Japan where hundreds of cigarette brands (domestic and imported) are purchased. To evaluate the predictive value of the nicotine yield given on the label and determined by a smoking machine, we measured the actual nicotine content of tobacco in 33 popular cigarette brands. Average amounts of nicotine and tobacco/whole cigarette of 32 filter and 1 non-filter brands were as follows: 11.72 +/- 2.27 (SD) mg nicotine (range 6.94-18.33 mg) and 23.97 mg tobacco, and 0.67 +/- 0.07 g nicotine (range 0.49-0.79 g) and 1.02 g tobacco, respectively. Amounts of nicotine and tobacco in filter brands varied widely and were less than the data reported in the toxicological literature. Measured lengths of the part of cigarettes packed with tobacco ranged from 5.0 to 6.9 cm. The tobacco in low-yield cigarettes did not contain less nicotine than high-yield cigarettes, and the nicotine yield did not highly correlate with the nicotine content in the low-yield cigarette group (r = 0.243). We conclude that the nicotine yields on labels are not useful in estimating likely nicotine intake in cigarette-ingestion cases. The actual nicotine content of cigarettes should be included on the product label.
'Safe cigarette' claimed to cut cancer by 90%

BRITISH American Tobacco (BAT) is to launch a controversial "safer cigarette" designed to cut the risk of smoking-related diseases such as cancer and heart failure by up to 90%.

The discount cigarettes use tobacco treated to produce lower levels of cancer-causing chemicals. They also incorporate a new type of filter said to remove more of the remaining toxins.

The company wants to launch the cigarettes in 2006 but has kept the move secret, knowing it would infuriate anti-smoking groups.

Campaigners will dismiss any attempt to reinvent cigarettes as a less harmful product as a cynical ploy to recruit more smokers when the habit is already killing 114,000 Britons a year and the government is proposing curbs on smoking in public places.

Past claims to have found safer forms of smoking, such as the introduction of low-tar cigarettes in the 1970s, have all proven false. They were found to be as harmful as high-tar versions because people smoked more and took deeper drags.

Despite this history, BAT executives talk privately of "risk free" or low-risk cigarettes and suggest they might cut the chance of disease by as much as 90%.

John Britton, professor of epidemiology at Nottingham University, said: "Anything involving inhaling smoke is unsafe. These new cigarettes could be more like jumping from the 15th floor instead of the 20th: theoretically the risk is less but you still die."

This weekend, BAT confirmed plans for the launch. David Betteridge, a spokesman, said: "They look and taste like normal cigarettes."

Betteridge refused to divulge the name under which the cigarettes would be marketed or give details of how they worked. They were designed by scientists at the firm's research centre in Southampton.

The cigarettes use "trionic" filters with three layers, each of which removes a different set of toxic compounds, while still allowing nicotine - the main addictive element in tobacco - to enter the lungs. The tobacco is also mixed with an inert "chalky" substance to retain more of the toxins in the ash.

BAT also claims to have improved the way it dries tobacco leaves to reduce cancer-causing toxins when burnt.

Even if they benefit smokers, such cigarettes would not prevent passive smoking. Deborah Arnott, director of Action on Smoking and Health, said: "Cigarette smoke contains about 4,000 different chemicals, many of which are toxic. These filters and tobaccos can make no more than a marginal difference."

BAT will not be making any explicit claims that its cigarettes are safer, but will instead describe the product as "potentially safer". It is likely to focus its advertising on the new technology, hoping that smokers will assume they are safer.

Betteridge said the company accepted there was "no such thing" as a truly safe cigarette and that the best way to minimise risk was to stop smoking.

Cigarettes pack more nicotine

State study finds a 10 percent rise over six years

Even as measures to discourage smoking grew more stringent in recent years, a new report indicates that the nicotine content of cigarettes rose, making it tougher for smokers to quit.

From 1998 to 2004, the amount of nicotine that could be inhaled from discount cigarettes increased an average of 10 percent, the study by the state Department of Public Health found. Nicotine is the chemical that causes cigarettes to be addictive, and the study, released yesterday, found higher levels in all classes of cigarettes, including those branded ``light."

During the past decade, aggressive campaigns across the nation have aimed to curb smoking, the leading cause of preventable deaths. Cities and states, including Massachusetts, have banned smoking in public places, and the price of cigarettes has soared. Still, smoking rates among US adults stubbornly persist above 20 percent.

``We in public health have tried to spend a lot of time figuring out why people don't stop smoking," said Lois Keithly , director of the Massachusetts Tobacco Control Program . ``It is more difficult to quit when there is a higher amount of nicotine in the cigarette."

Representatives of the three major tobacco makers in the United States -- Lorillard Tobacco Co. , Philip Morris USA , and R.J. Reynolds Tobacco Co. -- declined to comment on the study and would not answer questions about the nicotine content of their products.

Tobacco control specialists not involved with the Massachusetts report described it as the first major study tracking nicotine in cigarettes in seven years. And those specialists said they believe that the findings reflect trends nationwide.

Industry documents turned over during landmark litigation in the 1990s that led tobacco companies to settle with state governments for billions of dollars showed that the companies routinely spiked the nicotine content of their products so that cigarettes would be more pleasurable and addictive. The state study, tobacco control specialists said, suggests that practice has persisted.

``Their efforts are focused on getting people addicted quickly and keeping them addicted," said Diane Pickles , executive director of Tobacco Free Massachusetts , an advocacy organization.

A 1996 state law required cigarette makers to test the nicotine content of their products using a method specified by the Department of Public Health and report the results annually. Most of the tests are conducted at an independent laboratory in Canada that uses a machine to simulate a typical smoker's puffing.

Though the data in the report came from the tobacco industry, Sally Fogerty , an associate commissioner of public health, said her agency was confident the nicotine readings are reliable because it would not be in the companies' interest to report an increase.

Veterans of the decades-long fight against the tobacco industry said the rising nicotine levels show that companies will adopt strategies to get smokers addicted -- and to keep them hooked. ``I'm always shocked at the new things the industry does," said Richard Daynard , chairman of the Tobacco Products Liability Project at Northeastern University . ``This is sort of sleazy in a new and different way."

The industry is still absorbing the latest blow against it, a ruling this month by a federal judge in Washington, D.C., that the companies had conspired to deceive the public about the perils of smoking. The judge ordered cigarette makers to stop using monikers such as ``ultra-light" and ``low tar."

The Federal Trade Commission for three decades regularly released reports on the nicotine and tar content of cigarettes -- reports that frequently came under criticism for failing to adequately reflect the amount of nicotine smokers inhale in actual use.

The reports showed that nicotine levels on average had remained stable since 1980, after falling in the preceding decade. The last of those studies was released in September 1999, commission spokeswoman Claudia B. Farrell said yesterday.

The Federal Trade Commission has continued collecting data on nicotine, but she did not know why they have not published reports on the findings.

The Massachusetts approach to measuring nicotine tries to address shortcomings of the Federal Trade Commission's methodology so that it more realistically reflects how people actually smoke, state specialists said.

The state test assumes that half of the tiny holes that filter smoke will be blocked by a user's lips or hands, increasing the amount of smoke inhaled, while the federal reports assumed that all of the holes would be open.

The Massachusetts study analyzed nicotine in 116 cigarette brands, finding that the amount of nicotine that can be inhaled by a typical smoker increased in 92 brands from 1998 to 2004. Only a dozen brands registered a decrease in nicotine. Twelve others remained constant.

In 2004, Newport filtered cigarettes eclipsed Camel and had the highest level of inhalable nicotine, nearly 70 percent above the average. The brands with the lowest content were Doral Ultra-Light King soft pack and Winston Ultra-Light King soft pack.

After being inhaled, nicotine races to the brain in seconds, releasing a flood of chemicals associated with pleasure and motivation. Increasing the amount of nicotine, doctors said, presents a very real danger to smokers.

``If people are getting accustomed to higher levels of nicotine when they smoke, when they stop smoking , I would expect they would have more withdrawal symptoms," said Dr. Nancy Rigotti , director of tobacco research and treatment at Massachusetts General Hospital . ``And it would make it harder for them to quit smoking."

It could make it harder, too, to treat smokers who want to quit, Rigotti and the state's Keithly said. Current formulations of nicotine patches and gums might be too weak to counteract the craving created by high-powered cigarettes.

Massachusetts once was a national leader in spending on tobacco control, but a statewide budget crisis caused funding to plummet to just $5 million a year, from a high of $48 million a few years ago. In July, the state expanded smoking cessation services for the poor and uninsured; about 40 percent of Massachusetts adults covered by government health plans smoke.

Nicotine content in smoke from US cigarettes has increased

The amount of nicotine inhaled by cigarette smokers and by bystanders in secondhand smoke has risen by 10% over the past seven years, says a report from the Massachusetts Department of Public Health.

"Although per capita consumption of cigarettes has declined, the amount of nicotine consumed per cigarette has increased. Concurrently, the amount of nicotine present in second-hand smoke has also increased," the report says.

Massachusetts is one of only three US states that require tobacco companies to submit information every year on the nicotine content of cigarettes sold in the state. The state began requiring the information in 1998. This is the first report of changes in nicotine content from 1998 to 2004.

The information the state received showed major increases in nicotine yield for 92 of the 116 brands of cigarettes manufactured by all three major tobacco companies, Lorillard, Philip Morris, and RJ Reynolds. Yield is the amount of nicotine in the smoke a smoker inhales, not the amount in the cigarette.

"We want healthcare providers to know that smokers are getting more nicotine than in the past and may need additional help in trying to quit," said the Massachusetts health commissioner Paul Cote, Jr.

The department tests for nicotine yields using a method that it considers more accurate than the previous "smoking machine" tests. The department's method "better simulates the smoking behavior of the typical smoker under typical smoking conditions."

"Similar increases were found for each type of cigarette tested (full flavor, light, light/medium, and ultra-light), for both menthol and non-menthol cigarettes, for filtered cigarettes, and for all companies," the report says. Fifty two of the 116 brands had increases of more than 10%, with the greatest (36%) in RJ Reynold's Doral brand.

In 2004 93% of all cigarette brands tested were high in nicotine.

The health department says that the three most popular brands chosen by young smokers all delivered significantly more nicotine. A popular menthol brand (Kool) used by many black Americans increased its nicotine yield by 20%.

Nicotine "is a highly addictive drug that affects nearly every organ in the body," the department says. High levels of nicotine may make it more difficult for the average smoker to quit. High levels of nicotine intake by pregnant women can lead to low birth weight and developmental delays among infants.

Nicotine increases concentrations of blood sugar, placing smokers at higher risk of developing diabetes and making it harder for diabetic people who smoke to control their blood sugar. Drugs for asthma, high blood pressure, and depression can lose their effectiveness in combination with nicotine, the department says.

Nicotine content of cigarettes increased, study finds

Even as measures to discourage smoking grew more stringent in recent years, the nicotine content of cheap cigarettes was rising, making it tougher for smokers to stop puffing, according to a state report released today.

From 1998 to 2004, the amount of nicotine inhaled by Massachusetts smokers increased an average of 10 percent, the study from the state Department of Public Health found. Nicotine is the chemical that causes cigarettes to be addictive.

The study found that nicotine levels rose in all types of cigarettes, including those branded "light."

Across the United States, cities and states have moved to ban smoking in all public places, including bars and restaurants. Massachusetts enacted a statewide smoking prohibition in all workplaces in 2004.

"We in public health have tried to spend a lot of time figuring out why people don't stop smoking," said Lois Keithly, director of the Massachusetts Tobacco Control Program. "It is more difficult to quit when there is a higher amount of nicotine in the cigarette."

Keithly and other state health authorities said today their report is the first in several years to track nicotine content in cigarettes. State legislators in 1996 ordered tobacco companies to start furnishing the data.

Most of the cigarette makers contract with an independent testing agency in Canada to evaluate nicotine levels. Sally Fogerty, an associate commissioner of public health, said the agency was confident that the nicotine readings are reliable.

"From our perspective, the fact that we've reflected an increase gives us greater confidence about the data," Fogerty said.
Smokers Now Puffing More Nicotine

A study by Harvard's School of Public Health finds that the nicotine content of major-brand cigarettes is up 11%

An analysis of major-brand cigarettes sold in Massachusetts has discovered that manufacturers increased the level of nicotine by about 11% between 1997 and 2005. The research from Harvard University's School of Public Health confirms similar findings by the Massachusetts Public Health Dept. that were reported last August, which were roundly attacked by the tobacco industry.

But the Harvard researchers were able to ascertain how cigarette manufacturers accomplished the increase-by both intensifying the concentration of nicotine in the tobacco and design modifications that increased the number of puffs per cigarette. The end result, says the researchers, is far more addictive cigarettes.

Massachusetts is one of three states that require cigarette makers to submit information annually about nicotine testing and the only state with data going back to 1997. Last August the state reported that nicotine yields, as measured by machine smoking tests, had increased 10% between 1998 and 2004. Levels for Marlboro, Newport, and Camel, the three most popular brands among young smokers, were particularly high, the state noted. But cigarette makers complained that nicotine levels, which are hard to control, vary widely from year to year and show no clear overall trend. The companies also maintained that if the state had included data from 1997 and 2005 the increase would not have been so large.

That wasn't what the Harvard team found. The researchers, led by Gregory Connolly, director of the school's Tobacco Control Research Program, did look at the years from 1997 to 2005. They added up not only the machine-based measures used by the state but also metrics of cigarette design related to nicotine delivery, such as ventilation, nicotine content in the tobacco, and number of puffs. The results: The average rate of increase was 1.1% per year from 1997 to 2005, and 1.6% per year from 1998 to 2004, the years cited by the state.

The researchers found increased nicotine for every major manufacturer, though at varying rates for different brands. The worst offenders, they said, were Camel and Doral, made by R.J. Reynolds Tobacco Holdings, and Newport, made by Carolina Group's Lorillard Tobacco (CG). Marlboro, the best-selling brand, showed no overall change.

Philip Morris USA, a subsidiary of Altria Group (MO) and the maker of Marlboro, said the data reported to Massachusetts showed that nicotine yields for Marlboros were the same in 2006 as in 1997. "There are random variations in cigarette nicotine yields, both upwards and downwards," the company said in a statement. "Variations are not consistent in either direction across reporting years," for Marlboros, it said. The company also said that "relatively minor changes in nicotine yield may not significantly alter the product's addictive properties."

Connolly, however, charged that increases in nicotine appeared to be intentional: "Our analysis shows that the companies have been subtly increasing the drug nicotine year by year in their cigarettes, without any warning to consumers" since the massive 1998 settlement agreement between tobacco companies and the states.

Cigarette tar

Cigarette tar yields in relation to mortality from lung cancer in the cancer prevention study II prospective cohort, 1982-8

Objective To assess the risk of lung cancer in smokers of medium tar filter cigarettes compared with smokers of low tar and very low tar filter cigarettes. Design Analysis of the association between the tar rating of the brand of cigarette smoked in 1982 and mortality from lung cancer over the next six years. Multivariate proportional hazards analyses used to assess hazard ratios, with adjustment for age at enrolment, race, educational level, marital status, blue collar employment, occupational exposure to asbestos, intake of vegetables, citrus fruits, and vitamins, and, in analyses of current and former smokers, for age when they started to smoke and number of cigarettes smoked per day.

Setting Cancer prevention study II (CPS-II).

Participants 364 239 men and 576 535 women, aged >= 30 years, who had either never smoked, were former smokers, or were currently smoking a specific brand of cigarette when they were enrolled in the cancer prevention study.

Main outcome measure Death from primary cancer of the lung among participants who had never smoked, former smokers, smokers of very low tar (<= 7 mg tar/cigarette) filter, low tar (8-14 mg) filter, high tar (>= 22 mg) non-filter brands and medium tar conventional filter brands (15-21 mg).

Results Irrespective of the tar level of their current brand, all current smokers had a far greater risk of lung cancer than people who had stopped smoking or had never smoked. Compared with smokers of medium tar (15-21 mg) filter cigarettes, risk was higher among men and women who smoked high tar (>= 22 mg) non-filter brands (hazard ratio 1.44, 95% confidence interval 1.20 to 1.73, and 1.64, 1.26 to 2.15, respectively). There was no difference in risk among men who smoked brands rated as very low tar (1.17, 0.95 to 1.45) or low tar (1.02, 0.90 to 1.16) compared with those who smoked medium tar brands. The same was seen for women (0.98, 0.80 to 1.21, and 0.95, 0.82 to 1.11, respectively).

Conclusion The increase in lung cancer risk is similar in people who smoke medium tar cigarettes (15-21 mg), low tar cigarettes (8-14 mg), or very low tar cigarettes (<= 7 mg). Men and women who smoke non-filtered cigarettes with tar ratings >= 22 mg have an even higher risk of lung cancer.
Introduction

During the past 50 years, changes in the design and manufacture of cigarettes have markedly reduced their machine measured "tar" yields. The introduction of cellulose acetate filters in the 1950s, and subsequently more porous cigarette papers, reduced the average tar rating per cigarette in the United States from about 37 mg in 1950 to 22 mg in 1967. The introduction of air ventilation holes in the filter tip in the late 1960s and expanded tobacco in the 1970s permitted manufacturers to market low tar (generally in the range of 8-14 mg per cigarette) and very low tar cigarettes (<= 7 mg per cigarette). Concomitantly, the US average tar level per cigarette, as rated by the US Federal Trade Commission (FTC), declined to about 13 mg by 1990. Similar trends in standardised tar yields have been reported in the United Kingdom and other countries.

While many case-control and cohort studies have examined risk of lung cancer in relation to type of cigarette smoked, nearly all have compared the risks of smoking high tar non-filter brands with smoking medium tar filter brands, or to the corresponding ranges of tar yield. The three case-control studies that have included participants who smoked low tar brands yielded negative or equivocal results, but the observation periods for these studies ended in 1980-1, when the combined market share of low tar and very low tar cigarettes in the United States had exceeded 10% for only five or six years. In most epidemiological studies,observation period ended before 1986, when the market share in the United States had exceeded 10% for only a decade. Thus no large, long term prospective study has specifically compared the risk of lung cancer in smokers of medium tar filter cigarettes with that in smokers of low tar and very low tar filter cigarettes.

We analysed the relation between the tar rating of the brand of cigarette smoked in 1982 and mortality from lung cancer over six years among men and women in the cancer prevention study II (CPS-II), a nationwide prospective cohort of over one million US adults aged 30 years or older. We specifically compared the risk of lung cancer among smokers of very low tar (<= 7 mg) filter, low tar (8-14 mg) filter, or high tar (>= 22 mg) non-filter brands with the risk among those who smoke conventional medium tar (15-21 mg) filter brands.
Methods

Details of the cancer prevention study, initiated by the American Cancer Society (ACS) in 1982, have been published elsewhere.From the cohort of 508 318 men and 676 270 women, we excluded those who reported a history of cancer other than non-melanoma skin cancer; men who ever smoked pipes or cigars or chewed tobacco; and men and women whose current smoking status could not be ascertained. The resulting cohort comprised 364 239 men and 576 535 women. The outcome measure was death from cancer of the trachea, bronchus, or lung as the underlying cause, coded from the death certificate. During the six year follow up, 2622 men and 1406 women died from these cancers.

On the basis of brand name reported by each current smoker at enrolment, as well as the size (regular, king size, 100 mm, 120 mm), presence or absence of menthol and of a filter, we assigned a tar rating from the Federal Trade Commission tables for December 1981. We then grouped current brand tar ratings into very low tar (<= 7 mg), low tar (8-14 mg), medium tar (15-21 mg), and high tar (>= 22 mg). Unspecified current brands, as well as those current brands that could not otherwise be classified, were considered as a separate category. All brands in the very low and low tar ranges, as well as 99% of brands in the medium range, were filter cigarettes. Those in the high tar range were exclusively non-filter cigarettes.

he American Cancer Society did not collect information on changes in smoking behaviour during follow up of the entire cancer prevention study-II cohort. We therefore restricted our mortality follow up to six years (1982-8) to reduce possible mis-classification of exposure due to quitting or brand switching during longer follow up. However, we were able to assess changes in the smoking status of 14 523 men and 15 509 women who reported current smoking at enrolment in the initial CPS-II cohort in 1982 and were also enrolled in the subsequent CPS-II nutrition cohort in 1992.For this subgroup, we computed the proportions of current smokers in each tar category in 1982 who had quit smoking 10 years later.

We used Cox proportional hazards methods to estimate hazard ratios and 95% confidence intervals of mortality from lung cancer in people who had never smoked, former smokers, and current smokers of very low, low, and high tar brands, relative to smokers of brands with tar ratings of 15-21 mg (medium tar). Former smokers were stratified into those who had quit aged <= 35 years, aged 35-54 years, and aged >= 55 years. All statistical analyses were performed separately for men and women.

In our proportional hazards analyses of mortality from lung cancer among current, former, and never smokers we adjusted for multiple covariates that reflected possible differences in participants' demographics, dietary practices, occupational exposures, or medical histories. Demographic covariates included exact age at enrolment, race, education, and marital status. Dietary covariates included intake of vegetables, citrus fruits, and vitamins A, C, and E. Occupational covariates included whether the most recent job was blue collar (such as car mechanics and construction workers) and whether the participant had been employed in an occupation with high asbestos exposure (such as pipe fitters and shipyard workers) for >= 10 years. Other indicator variables were a history of chronic bronchitis, emphysema, heart disease, stroke, and diabetes and self report of being currently sick, taking heart drugs, or pain in the legs during walking that went away with rest. All covariates except exact age at enrolment were modeled as categorical variables, where missing values were coded as separate categories.

Excluding participants who had never smoked, we further performed multivariate proportional hazards analyses of current and former smokers that adjusted not only for demographic, dietary, occupational, and medical history covariates but also for age when they began smoking and the average number of cigarettes smoked a day.

Finally, in a series of sensitivity analyses of current smokers only, we restricted our analysis to people who had smoked their current brand for a minimum of 5 or 10 years; excluded smokers with a history of emphysema; excluded participants who reported any smoking related condition (emphysema, chronic bronchitis, heart disease, use of heart drugs, stroke, diabetes, claudication, currently sick); varied the definition of the tar categories to include 8 mg tar brands in the very low tar category and 15 mg brands in the low tar category; and estimated hazard ratios without controlling for the average number of cigarettes smoked a day. The latter analysis examined the view that a study of risk of lung cancer in relation to type of cigarette smoked should exclude number of cigarettes smoked a day as a covariate because smokers of lower tar and nicotine brands may compensate by smoking more cigarettes a day.