Tobacco Control Health Article

THE MAGNITUDE OF THE USE OF TOBACCO PRODUCTS

In the United States, tobacco products have been used for hundreds of years. Early consumption of tobacco products was predominantly ceremonial use by Native Americans, followed by more widespread use of tobacco for pipes, hand-rolled cigarettes, cigars, and chewing. Cigarette smoking as we know it today—as a highly addicting and habituated behavior—is a function of the twentieth century. The introduction of blended tobacco that allowed for inhalation, the invention of the safety match, the ability to mass produce cigarettes, coupled with sophisticated distribution systems and unprecedented marketing efforts led to the rapid adoption of cigarette smoking during the first half of the twentieth century, peaking in the mid-1960s. Annual per capita cigarette consumption increased from 54 cigarettes in 1900 to a high of 4,345 cigarettes in 1963. The release of a landmark report by the Surgeon General in 1964, which detailed the health effects of smoking, has led to a series of social and behavioral changes associated with a nearly 50 percent decline in annual per capita consumption, to a level of 2,136 cigarettes in 1999.

In addition to the reduction in per capita cigarette consumption, the United States has also experienced a reduction in adult smoking prevalence, decreasing from about 43 percent in 1965 to 24 percent in 1998, meaning there are tens of millions of fewer smokers than if earlier rates of smoking had continued. The reduction in the proportion of the adult population who smoke has not been as great as the reduction in per capita consumption, indicating that those who continue to smoke are also smoking fewer cigarettes.

While the U.S. reduction in adult smoking rates has been substantial when compared to the level of smoking in 1964, there has been relatively little progress in the 1990s, when adult smoking rates appeared to have plateaued at about 25 percent. In addition, the progress that has been achieved since 1964 has not been experienced equally by all U.S. population groups. Smoking rates appear to vary by race and ethnicity, level of education, age, poverty status, and region of the country. Contrary to other parts of the world, there is a relatively small difference in smoking rates based on gender. In 1998, there was a nearly threefold difference in the likelihood of smoking based on race and ethnicity, with the highest smoking rates occurring among American-Indian and Alaska Native populations (40.0%), and the lowest occurring among Asian and Pacific Islander groups (13.7%). A similar differential is seen in relation to level of education, with high school drop outs at least three times more likely to smoke than college graduates (36.8% vs. 11.3%, respectively), and the difference between the two groups appear to be increasing. Additionally, state of residence seems very important, with the lowest smoking rates in Utah (13.9%) and the highest in Nevada (31.5%). Lastly, smoking rates vary by age and poverty level, but not as greatly as for race and ethnicity, educational level, or state of residence. For example, those sixty-five years of age and older, and those whose income is at or above the poverty level, are less likely to smoke than those under sixty-five years of age and those living in poverty.

The 1994 Surgeon Generals Report Preventing Tobacco Use among Young People focused intense interest on smoking among young people. This report emphasized the fact that smoking onset, and nicotine addiction, almost always begin in the teen years, and it provided an early warning of an increase in the use of tobacco products among young people. In fact, after more than a decade of relatively stable youth smoking rates in the 1980s, cigarette smoking began increasing among high school students in the early 1990s, peaking in 1997.

One of the most interesting observations about youth-smoking rates is the difference in likelihood of smoking between black and white youth. In the late 1970s, there was virtually no difference between smoking rates based on race. However, over the subsequent two decades, white youth continued relatively high smoking rates, while smoking rates among black youth plummeted. Unfortunately, this difference between black and white youth in high school is beginning to erode, and there is no difference in cigarette smoking rates between black and white middle school students.

While cigarette smoking rates among young people may have peaked, there is a disturbing increase in the use of alternative or novel tobacco products, notably in cigars, bidis, and kreteks. Because of the harm caused by all tobacco products, it is important to monitor total tobacco consumption. When this is done, tobacco use rates typically are in the 30 to 40 percent range for all demographic subgroups, and actually exceeds 50 percent for white, high school boys.

Broadly speaking, other developed countries are experiencing changes in smoking rates similar to that observed in the United States. These changes can be characterized by gradual declines in adult smoking, contrasted with increases in the early and mid-1990s among young people. The situation in the developing world, however, is quite different and somewhat difficult to characterize due to less systematic attention to monitoring patterns of tobacco use over time in a manner that allows for inter-country comparisons. However, it can be said that global tobacco consumption is increasing, with over one billion smokers, but with large differences in tobacco use by gender, type of product consumed, and intensity of tobacco use. For example, in many countries in the Far East, the majority of men smoke, but relatively few women do. In India, relatively few women smoke, but smokeless tobacco use is common. In many countries, smoking intensity (the number of cigarettes smoked per day) is much lower than in developed countries. However, all of these parameters are likely to change as the multinational tobacco companies increase marketing and promotion efforts in developing countries.

In an effort to systemize and standardize the collection of tobacco data, the World Health Organization (WHO), in collaboration with the Centers for Disease Control and Prevention (CDC), have developed the Global Youth Tobacco Survey (GYTS), which is an effort to collect in-depth data on tobacco use patterns and attitudes from adolescents throughout the world. By the end of 2001, over seventy countries are expected to have collected standardized data on tobacco use among young people as part of the GYTS project. Clearly, more is needed to standardize the global collection of tobacco data, not just tobacco-use rates, but country-specific data on the effect of tobacco use on public health, the presence of tobacco-control legislation, and the cost of cigarettes. Accordingly, the American Cancer Society, in collaboration with WHO and CDC, has recently published Tobacco Control Country Profiles, which is a summary of the existing tobacco-related data for each country of the world.