Tobacco Documents Online

The educational level of the population, for example, illustrates the complexity. Data from selected sources indicate that smoking is more prevalent among highly educated women than among less-educated women. One would think that in- creased education would be linked to a greater awareness of and concern about the health consequences of smoking, but this assumption appears incorrect. It may be that a higher educational level, especially in developing countries, imparts greater susceptibility to messages that promote positive associations with smoking. Only through systematic monitoring of smoking prevalence as well as of the knowl- edge, attitudes, and behaviors of the population can we appreciate the underlying reasons for the current epidemiologic configuration. Such appreciation, in turn, is the basis for a rational prevention and control program. Another area in which surveillance is critical is in the monitoring of the tobacco sector of the economy. Such monitoring should include production, consumption, price structure, and taxation policy as well as advertising and promotion of tobacco products. The structure of the industry in any country will have important ramifi- cations for the growth and "success" of the commodity. One of the fundamental paradoxes of market-oriented societies is that some entrepreneurs-even acting completely within the prescribed rules of business practice-will come into conflict with public health goals. The market structure of the tobacco industry constitutes a major threat to public health simply because the product is tobacco. In the tobacco industry, attempts to control a large market share, marketing to target groups, widespread use of innovative promotional techniques, and corporate growth, development, and consolidation-in short, the traditional elements of successful entrepreneurial activity-are ultimately inimical to the public health. Each country faces its own resolution of this paradox, but recognizing and monitoring it is fundamental to the prevention and control of tobacco use. Most countries of the Americas have begun to face these complex issues. Several have taken major steps, others tentative ones, but all should recognize the crucial role of international coordination and cooperation. It is clear that although most countries can have significant impact on their own smoking-related problems, the international community can become smoke-free only by acting in concert. The process is an arduous one that begins with multifaceted efforts to change social norms regarding smoking and that moves ultimately to a disappearance of demand for tobacco products. I hope that the current report will serve as an impetus for continuing activity in the control of smoking and for mobilization of international resources toward the goal of a smoke-free society. Antonia C. Novello, M.D., M.P.H. Surgeon General `v TIMN 380723

Preface from the Director, Pan American Health Organization Diseases related to smoking are an important cause of premature deaths in the world, both in developed and developing countries. Eliminating smoking can do more to improve health and prolong life than any other measure in the field of preventive medicine. Developing countries, including those of Latin America and the Caribbean, are not behind their neighbors in the north with regard to the tremendous growing problem of noncommunicable diseases related to tobacco consumption. Over the last three decades, the countries of Latin America and the Caribbean have experienced important changes in their demographic, socioeconomic, and epidemiologic profiles. Increasing numbers of the older, more urban, and espe- cially the poorer populations of the region, are dying of diseases related to lifestyle determinants. Consumption of tobacco is one of these harmful threats to the health and well-being of our populations. Despite that, in most of the developing countries of our region, not enough attention has been given to generate actions and the kind of information needed for policy and program formulation with regard to tobacco control. It is also unfortun- ate that while the transnational conglomerates in control of almost all tobacco production and marketing have directed their efforts toward penetrating develop- ing economies, many governments, given the urgent needs created by other health problems, and in some cases due to financial or economic reasons, consider tobacco control a low priority. The United States Government and the Pan American Health Organization (PAHO) have been working in a joint effort to generate the information included in the Surgeon General's report, and the PAHO country report, which hopefully will bring more awareness and promote action against smoking in the region of the Americas. Our collaboration with the Office of the Surgeon General has been highly satisfactory, and it will encourage the development of a regional network for implementing research and exchange of successful experiences in the control of tobacco addiction. • Carlyle Guerra de Macedo, M.D., M.P.H. Director v TIMN 380724

Acknowledgments This report was prepared by the Department of Health and Human Services and under the general direction of the Centers for Disease Control, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health. William L. Roper, M.D., M.P.H., Director, Centers for Disease Control, Atlanta, Georgia. Jeffrey P. Koplan, M.D., M.P.H., Director, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control, Atlanta, Georgia. Virginia S. Bales, M.P.H., Deputy Director, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control, Atlanta, Georgia. Michael P. Eriksen., Sc.D., Director, Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control, Atlanta, Georgia. The editors of the report were Richard B. Rothenberg, M.D., M.P.H., Senior Scien- tific Editor, National Center -for Chronic Disease Prevention and Health Promotion, Centers for Disease Control, Atlanta, Georgia. Gwendolyn A. Ingraham, Managing Editor, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control, Atlanta, Georgia. Barbara Sajor Gray, M.Ln., Senior Writer-Editor, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control, Atlanta, Georgia. Judith Navarro, Ph.D., Consulting Editor, Chief, Editorial Services, Pan American Health Orga- nization, Washington, D.C. Senior contributing editors were Aloyzio Achutti, M.D., Professor, Discipline of Promotion and Protection of Health, School of Medicine, Federal University of Rio Grande do Sul, PSrto Alegre, Brazil. Neil E. Collishaw, M.A., Chief, Tobacco Products Section, Environmental Health Directorate, Health and Welfare Canada, Ottawa, Canada. Ronald M. Davis, M.D., Chief Medical Officer, Michigan Department of Public Health, Lansing, Michigan. vtt Eric Nicholls, M.D., Regional Advisor in Chronic Diseases, Pan American Health Organization, Washington, D.C. T~omas E. Novotny, M.D., M.P.H., Liaison Officer, School of Public Health, University of California, Berkeley, California. Sylvia C. Robles, M.D., Department of Public Health, School of Medicine, University of Costa Rica, San Jose, Costa Rica. Margarita Ronderos Torres, M.D., M.Sc., Head of Epidemiology and Prevention Division, National Cancer Institute, Bogoti, Colombia. Contributing authors were Jorge BalAn, Ph.D., Director, Center for the Study of State and Society, Buenos Aires, Argentina. Luis G. Escobedo, M.D., M.P.H., Medical Epidemi- ologist, Surveillance and Research Branch, Division of Adolescent and School Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control, Atlanta, Georgia. Eugene M. Lewit, Ph.D., Director of Research and Grants, Economics, David and Lucile Packard Foundation, Los Altos, California. Thomas E. Novotny, M.D., M.P.H., Liaison Officer, School of Public Health, University of California, Berkeley, California. Ruth Roemer, J.D., Adjunct Professor, School of Public Health, University of California, Los Angeles, California. Philip L. Shepherd, Ph.D., Associate Professor, Department of Marketing and Environment, Florida International University, Miami, Florida. Robert Sobel, Ph.D., Professor of Business History, Hofstra University, Hempstead, New York. Kenneth E. Stanley, Ph.D., Department of Biosta- tistics, Harvard School of Public Health, Boston, Massachusetts. Johannes Wilbert, Ph.D., Emeritus Professor of Anthropology, University of California, Los Angeles, Pacific Palisades, California. Reviewers were Francisco Lbpez Antunano, M.D., Director, Health Program Development, Pan American Health Organization, Washington, D.C. TIMN 380725

Elias Anzola, M.D., Medical Officer, Health Promotion Program, Pan American Health Organization, Washington, D.C. Howard Barnum, Ph.D., Senior Economist, The World Bank, Washington, D.C. Glen Bennett, M.P.H., Coordinator, Sn~oking Education Program, Health Education Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland. Mbnica Bolis, Advisor on Legislation, Health Policies Development Program, Pan American Health Organization, Washington, D.C. A. David Brandling-Bennett, M.D., Program Coordinator, Health Situation and Trend Assessment Program, Pan American Health Organization, Washington, D.C. Allan M. Brandt, Ph.D., Associate Professor, Department of Social Medicine, School of Medicine, University of North Carolina, Chapel Hill, North Carolina. David M. Burns, M.D., Professor of Medicine, University of California, San Diego Medical Center, San Diego, California. Peter W. Burr, Agricultural Economist, Tobacco, Cotton, and S'eeds Division, Foreign Agricultural Service, U.S. Department of Agriculture, Washington, D.C. Juan Chackiel, Chief of Demography, Latin American Center for Demography, CELADE, Santiago, Chile. Claire Chollat-Traquet, Ph.D., Scientist, Tobacco or Health Program, World Health Organization, Geneva, Switzerland. Gregory N. Connolly, D.M.D., M.P.H., Director, Office for Nonsmoking and Health, Massachusetts Department of Public Health, Boston, Massachusetts. Joe H. Davis, M.D., M.P.H., Assistant Director for International Health, Centers for Disease Control, Atlanta, Georgia: Ronald M. Davis, M.D., Chief Medical Officer, Michigan Department of Public Health, Lansing, Michigan. Allan C. Erickson, Senior Vice President for Cancer Control, American Cancer Society, Atlanta, Georgia. Sev S. Fluss, M.S., Chief, Health Legislation, World Health Organization, Geneva, Switzerland. William H. Foege, M.D., M.P.H., Executive Director, Carter Center of Emory University, Atlanta, Georgia. M11 Clark W. Heath, Jr., M.D., Vice President of Epidemiology and Statistics, American Cancer Society, Atlanta, Georgia. Thomas A. Hodgson, Ph.D., Chief Economist, Office of Analysis and Epidemiology, National Center for Health Statistics, Centers for Disease Control, Hyattsville, Maryland. Bo Holmstedt, M.D., Director, Department of Toxicology, Karolinska Institute, Stockholm, Sweden. Dean T. Jamison, Ph.D., Department of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, England. C. Everett Koop, M.D., Sc.D., Surgeon General, U.S. Public Health Service, 1981-1989, Bethesda, Maryland. Alan Lopez, Ph.D., Statistician/Demographer, Global Health Situation Assessment and Projections, World Health Organization, Geneva, Switzerland. J. Michael McGinnis, M.D., Director, Office of Disease Prevention and Health Promotion, Department of Health and Human Services, Washington, D.C. Anthony R. Measham, M.D., Chief, Population, Health, and Nutrition Division, The World Bank, Washington, D.C. Anthony B. Miller, M.B., FRC, Professor, Department of Preventive Medicine and Biostatistics, Faculty of Medicine, University of Toronto, Ontario, Canada. W. Henry Mosley, M.D., M.P.H., Professor and Chairman, Department of Population Dynamics, Johns Hopkins University, School of Hygiene and Public Health, Baltimore, Maryland. Eric Nicholls, M.D., Regional Advisor in Chronic Diseases, Pan American Health Organization, Washington, D.C. Donald Maxwell Parkin, Ph.D., Chief, Unit of Descriptive Epidemiology, International Agency for Research on Cancer, World Health Organization, Lyon, France. Mark A. Pertschuk, J.D., Executive Director, Americans for Nonsmokers' Rights, Berkeley, California. Michael Pertschuk, J.D., Codirector, The Advocacy Institute, Washington, D.C. John M. Pinney, Chief Executive Officer, Cooperate Health Policies Group, Washington, D.C. Ranate Plaut, M.D., Epidemiologist, Health Situation and Trend Assessment Program, Pan American Health Organization, Washington, D.C. TIMN 380726

Gerardo Reichel-Dolmatoff, Ph.D., Adjunct Professor, University of California, Los Angeles, California. Helena Restrepo, M.D., Coordinator, Health Promotion Program, Pan American Health Organization, Washington, D.C. Laurent Rivier, D.Sc., Director, Drug Analysis Unit, Institute of Forensic Medicine, University of Lausanne, Switzerland. Thomas C. Schelling, Ph.D., Distinguished Professor of Economics and Public Affairs, Department of Economics, University of Maryland, College Park, Maryland. Richard Evans Schultes, Ph.D., Professor Emeritus and former Director, Botanical Museum, Harvard University, Cambridge, Massachusetts. Donald R. Shopland, Coordinator for Smoking and Tobacco Control Program, Division of Cancer Prevention and Control, National Cancer Institute, National Institutes of Health, Bethesda, Maryland. Jesse L. Steinfeld, M.D., Surgeon General, U.S. Public Health Service, 1969-1973, San Diego, California. Daniel A. Sumner, Ph.D., Deputy Assistant Secretary for Economics, Office of the Assistant Secretary for Economics, U.S. Department of Agriculture, Washington, D.C. Cesar A. Vieira, M.D., Coordinator, Health Policies Development Program, Pan American Health Organization, Washington, D.C. Kenneth E. Warner, Ph.D., Professor of Public Health Policy, School of Public Health, University of Michigan, Ann Arbor, Michigan. Ernst L. Wynder, M.D., President, American Health Foundation, New York, New York. Other contributors were Patricia Ardila, Bilingual Editor, The Circle, Inc., McLean, Virginia. Cathy D. Arney, Graphic Artist, The Circle, Inc., McLean, Virginia. John Artis, Courier, The Circle, Inc., McLean, Virginia. Carol A. Bean, Ph.D., Consultant, Artemis Tech- nologies, Inc., Springfield, Virginia. Nowell D. Berreth, Writer-Editor, Public Information Branch, Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control, Atlanta, Georgia. ix Byron Breedlove, M.A., Assistant Branch Chief, Editorial Services Branch, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control, Atlanta, Georgia. Kelly L. Byrne, Desktop Publishing/Word Processing Specialist, The Circle, Inc., McLean, Virginia. Maria Luisa Clark, M.D., Editor, Editorial Services, Pan American Health Organization, Washington, D.C. Gail A. Cruse, Technical Information Specialist, Technical Information Services Branch, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control, Atlanta, Georgia. Alice A. DeVierno, M.L.S., Manager, Technical Information Center, Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control, Atlanta, Georgia. Sue T. Dixon, Secretary, Office of the Director, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control, Atlanta, Georgia. Seth L. Emont, Ph.D., Epidemiologist, Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control, Atlanta, Georgia. Christine S. Fralish, Chief, Technical Information Services Branch, National Center for Chronic Disease Prevention and Health Proniotion, Centers for Disease Control, Atlanta, Georgia. Gary A. Giovino, Ph.D., Chief, Epidemiology Branch, Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control, Atlanta, Georgia. Betty H. Haithcock, Editorial Assistant, Editorial Services Branch, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control, Atlanta, Georgia. Gwendolyn A. Harvey, Program Analyst, Office of the Director, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control, Atlanta, Georgia. Susan A. Hawk, Ed.M., M.S., Program Analyst, Office of the Director, National Center for Health Statistics, Centers for Disease Control, Hyattsville, Maryland. Phyllis E. Hechtman, Editorial Assistant, The Circle, Inc., McLean, Virginia. John Helsel, Senior Systems Analyst, The Circle, Inc., McLean, Virginia. TIMN 380727

Timothy K. Hensley, Technical Publications Writer- Editor, Public Information Branch, Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control, Atlanta, Georgia. Frederick L. Hull, Ph.D., Writer-Editor, Editorial Services Branch, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control, Atlanta, Georgia. Delle B. Kelley, Technical Information Specialist, Technical Information Services Branch, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control, Atlanta, Georgia. Mescal J. Knighton, Writer-Editor, Editorial Services Branch, National Center for Chronic Disease Pre- vention and Health Promotion, Centers for Disease Control, Atlanta, Georgia. Gayle Lloyd, M.A., Editor, Technical Information Center, Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control, Atlanta, Georgia. - Peggy Lytton, Editor, The Circle, Inc., McLean, Virginia. Patricia McCarty, Secretary, Public Information Branch, Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control, Atlanta, Georgia. Rachel R. Merritt, Secretary, Technical Information Center, Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control, Atlanta, Georgia. Jennifer A. Michaels, M.L.S., Technical Information Specialist, Technical Information Center, Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control, Atlanta, Georgia. x Reba A. Norman, M.L.M., Technical Information Specialist, Technical Information Services Branch, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control, Atlanta, Georgia. Cathie M. O'Donnell, Project Director, The Circle, Inc., McLean, Virginia. Richard Ray, Director of Computer Services, The Circle, Inc., McLean, Virginia. Flor M. Rojas-Jaber, Editorial Assistant, Editorial Services, Pan American Health Organization, Washington, D.C. Carlos Rossel, Publications Specialist, Editorial Services, Pan American Health Organization, Washington, D.C. Beverly Schwartz, M.S., Special Advisor, Public Information Branch, Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control, Atlanta, Georgia. Rita Shelton, Senior Editor, Editorial Services, Pan American Health Organization, Washington, D.C. Janete da Silva, Health Manpower Development Pro- gram, Pan American Health Organization, Washington, D.C. Daniel R. Tisch, Director of Publications, The Circle, Inc., McLean, Virginia. Kymber N. Williams, M.A., Public Information Specialist, Public Information Branch, Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control, Atlanta, Georgia. Rebecca B. Wolf, M.A., Program Analyst, Office of Program Planning and Evaluation, Centers for Disease Control, Atlanta, Georgia. TIMN 380728

Smoking and Health in the Americas Countries of the Americas 3 Notes on the Text 5 Chapter 1. Introduction, Summary, and Chapter Conclusions 7 Chapter 2 The Historical Context 15 Tobacco Use in Indigenous Societies 19 The Emergence of the Cigarette, 1492-1900 23 The Emergence of the Tobacco Companies, 1900 to the Present 31 Chapter 3. Prevalence and Mortality 57 Prevalence of Smoking in Latin America and the Caribbean 61 Smoking-Attributable Mortality in Latin America and the Caribbean 81 Chapter 4. Economics of Tobacco Consumption in the Americas 101 Economic Costs of the Health Effects of Smoking 105 Economics of the Tobacco Industry 114 Chapter 5. Legislation to Control the Use of Tobacco in the Americas 143 Legislation to Control Production, Manufacture, Promotion, and Sales 148 Legislation to Change Smoking Behavior 153 The Impact of Antitobacco Legislation 161 Chapter 6. Status of Tobacco Prevention and Control Programs in the Americas 179 National Programs for Tobacco Control 183 Regional Activities for Tobacco Control in Latin America and the Caribbean 185 Elements of Prevention and Control Programs 186 List of Tables and Figures 207 Index 209 TIMN 380729

TIMN 380730

Countries of the Americas Latin America Andean Area Bolivia Colombia Ecuador Peru Venezuela Southern Cone Argentina Chile Paraguay Uruguay Brazil Central America Belize Costa Rica El Salvador Guatemala Honduras Nicaragua Panama ~ Mexico Latin Caribbean Cuba Dominican Republic Haiti Puerto Rico I Caribbean Anguilla Antigua and Barbuda Bahamas Barbados Bermuda British Virgin Islands Cayman Islands Dominica French Guiana Grenada Guadeloupe Guyana Jamaica Martinique Montserrat Netherlands Antilles and Aruba Saint Kitts and Nevis Saint Lucia Saint Vincent and the Grenadines Suriname Trinidad and Tobago Turks and Caicos Islands Virgin Islands North America Canada United States of America Data in this report are almost exclusively presented by the above regions. In some instances, however, information is presented separately for the French overseas depart- ments in the Americas (French Guiana, Guadeloupe, and Martinique) and the French territory Saint Pierre and Miquelon, which is in North America. Such instances are noted in the text. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the Secretariat of the Pan American Health Organization or the U.S. Department of Health and Human Services concerning the legal status of any country, territory, city, or area of its authorities, or concerning the delimitation of its frontiers or boundaries. TIMN 380731

Notes on the Text Trade Names Use of trade names is for identification only and does not constitute endorsement by the Public Health Service or the U.S. Department of Health and Human Services. Company Names Current names are used to identify companies throughout the report. In some instances, exact names could not be verified from current sources, and the best available information was used. On tabless reproduced from other sources, the nomenclature used in the original source was retained. Sources used to verify company names included Tobacco International's 57th Annual Directory and Buyer's Guide,1991(Vo1.192, No. 21, New York: Lockwood Trade Journal Co., Inc., 1990) and the following online databases: D&B-Dun's Market Identifiers, ICC British Company Directory, and ICC British Company Financial Datasheets. The complete name is used for the first mention of a company, after which an abbreviated form is generally used. Organizations, Campaigns, and Slogans Names of organizations, coalitions, committees, government agencies, and other groups, as well as names of public information campaigns and health campaigns and their slogans were verified in online sources (Encyclopedia of Associations, MEDLINE, and several news services) and in the files of the Pan American Health Organization (PAHO). Not all such information was verifiable, and translations made into English sometimes varied. Every reasonable effort was made to obtain the official name and/or standard translation; we regret any inaccuracies that may have occurred. Legislation and Health Warnings The legal and the popular names of legislation and the wording of health warnings required on advertisements and packaging of tobacco products were verified in several sources. These included the United States Code Service (online database), PAHO's LEYES database (see Chapter 5, Appendix 2), the International Digest of Health Legislation, copies of legislation, and the files of the Centers for Disease Control's Office on Smoking and Health. W e regret any errors that may have resulted from incomplete files or inaccurate translations. Botanic Substances Names of substances discussed in Chapter 2 are treated as non-English words unless they appear in Webster's Third New International Dictionary of the English Language, un- abridged, Springfield, Massachusetts: G. & C. Merriam Company, 1981. The spelling of non-English words was verified in foreign language dictionaries or used as cited in original sources. 5 TIMN 380732