WHELAN, E.M. A Smoking Gun: How the Tobacco Industry Gets Away With Murder. Philadelphia, Pennsylvania: George F. Stickley Co., 1984. WORLD HEALTH ORGANIZATION. Smoking Control Strategies in Developing Countries: Report of a WHO Expert Committee. WHO Technical Report Series, No. 695. Geneva: World Health Organization, 1983. WORLD HEALTH ORGANIZATION. Tobacco or health. Forty-third World Health Assembly. Handbook of Resolutions and Decisions of the World Health Assembly and the Executive Board. Geneva: World Health Assembly, May 17, 1990a. WORLD HEALTH ORGANIZATION. Tobacco or health: Tobacco smoking in the Americas. Weekly Epidemiological Record/Relevé Epidémiologique Hebdomadaire 65(21):157-164, May 25, 1990b. Legislation 177 Chapter 6 Status of Tobacco Prevention and Control Programs in the Americas Preface 161 Introduction 183 National Programs for Tobacco Control 183 United States 183 Canada 1854 Regional Activities for Tobacco Control in Latin America andthe Caribbean 185 Elements of Prevention and Control Programs 186 Surveillance and Analysis 186 Education, Public Information, and Cessation Programs 187 Taxation 190 Legislation 191 Coalitions 194 Summary 196 Conclusions 196 Appendix 1. Antitobacco Activities in Latin America and the Caribbean 197 Appendix 2. Antitobacco Organizations in Latin America and the Caribbean 202 References 204 Preface The Americas comprise diverse countries that have not developed synchronously. The impact of many of the factors of development discussed in the previous chapters—the transition to an industrialized economy, the changing population structure, the consolida- tion of the tobacco industry, the growing prevalence of cigarette smoking, and the emerging burden of smoking-attributable mortality—has differed among countries. Almost all coun- tries have some form of antismoking activity, but the nature and extent of that activity are shaped by historical, epidemiologic, economic, and legal factors specific to each country. The current antismoking activities of governments and other agencies are described in this chapter. These activities illustrate the diversity of the public health response to tobacco use. The emphasis here is on the types of activities, rather than specific content and detail. Surveillance, monitoring of prevalence, taxation, and legislation are revisited to provide a comprehensive overview of the current antismoking movement. Prevention and Control 181 Introduction Elements essential tothe prevention and control of tobacco use, described in reports on developing and developed countries,! include surveillance, education, taxation, legislation, and coalition building. These elements must be developed in the sociodemographic and economic context of each country in the Americas, and they must account for the unique nature of the epidemic of tobacco use in each country. Some ele- ments, such as taxation, are beyond the responsibility of ministries of health, and all the elements require the National Programs for Tobacco Control collaboration of other ministries, professional organi- zations, the media, church groups, and community coalitions. Concerted efforts of both government agencies and private or nonprofit organizations are necessary for successful tobacco control (Jamison and Mosley 1991). The current, documented tobacco- control activities of governments and other agencies are reviewed here to provide an overview and summary of content described in detail in previous chapters. United States In the United States, the public health practice of tobacco control has evolved during the past 25 to 30 years as federal, state, and local governments have joined voluntary health agencies in prevention activi- ties. The 1964 advisory committee report to the Sur- geon General on the health consequences of smoking provided the scientific information needed to launch an effective, sustained, national public health cam- paign against tobacco use (Public Health Service 1964). As the national effort matured, the actions of state and local health departments became more im- portant, since municipalities have more opportunities for aggressive control. Funding and technical assis- tance for state and local efforts has come from volun- tary agencies and, more recently, from the Public Health Service—primarily the National Institutes of Health (the National Cancer Institute [NCI] and the National Heart, Lung, and Blood Institute), and the Centers for Disease Control (CDC). The CDC Office on Smoking and Health (OSH) was designated the lead organization for tobacco issues, and the lead spokesperson is the Surgeon General—largely be- cause of the federally mandated annual report of the Surgeon General on the health consequences of smoking. The Department of Health and Human Services (USDHHS) has periodically set national goals for the reduction of tobacco use among residents of the United States, but no coordinated program represents all departments of the federal government. In 1990, the Secretary of Health and Human Services released the year 2000 health objectives for the nation, and tobacco use was addressed by these objectives (USDHHS 1990a). The objectives call for (1) a reduc- tion (to 15 percent) in the prevalence of adult smoking, (2) a reduction (to no more than 15 percent) in the rate of initiation of smoking by persons less than age 20 (as measured by the prevalence of smoking among 20 to 24 year olds), (3) an increase (to 50 percent) in the proportion of smokers who quit smoking for at least one day each year, (4) an increase (to at least 60 per- cent) in smoking cessation beginning in early preg- nancy, (5) a reduction (to 20 percent) in the proportion of children aged 6 or younger who are exposed to tobacco smoke at home, and (6) a reduction (to no more than 4 percent) in smokeless tobacco use among males aged 12 through 24. Additional objectives call for the following: e For all schools to be tobacco-free and to include prevention of tobacco use within the basic curriculum. ¢ For an increase to 75 percent in the proportion of worksites that prohibit or severely restrict smoking. ¢ For enactment and enforcement of bans on the sale of tobacco to minors. ¢ For the development of state tobacco-control plans. 1 Gray and Daube 1980; Pan American Health Organization 1989a; World Health Organization 1979, 1983a,b; Chap- manand Wong 1990; Pierce 1991; Novotny et al., in press; Choi et al., 1991; Davis, Monaco, Romano 1991; Centers for Disease Control 1991. Prevention and Control 183 ¢ For a ban or severe restriction on advertising and promotion of tobacco to which youths are likely to be exposed. ¢ For an increase to 75 percent in the proportion of health care providers who provide smoking cessa- tion advice and assistance to their patients. NCI has encouraged the integration of effective cancer control technology (including tobacco control) into existing health care delivery systems. Interven- tions include school-based programs, testing and dis- semination of minimal interventions (such as self-help programs), training of health care providers, mass media efforts, programs for groups at high risk for tobacco use, and programs to control the use of smoke- less tobacco (Cullen 1988; USDHHS 1990b). Additional support for state activities has been achieved through state cigarette excise taxes dedicated to tobacco-control programs (Bal et al. 1990) and through ASSIST (American Stop Smoking Interven- tion Study), a seven-year project sponsored jointly by NCI and the American Cancer Society. ASSIST, which began in 1991, will provide about $120 million to 20 states or large metropolitan areas for tobacco control (McKenna and Carbone 1989). The goal of ASSIST is to reduce by 43 percent the prevalence of smoking in the participating areas by 1998. ASSIST is expected to help achieve the year 2000 health promotion objectives for tobacco use. The 1989 report of the Surgeon General, Reducing the Health Consequences of Smoking: 25 Years of Progress (USDHHS 1989), details the accomplishments of U.S. tobacco-control efforts. For the United States, the re- port documented a yearly decline, since 1979, of 0.5 percentage points in the prevalence of smoking among persons 20 years old or older and a mean yearly percent decrease of 2.4 percent in the adult (218 years old) per capita consumption of cigarettes. As a result of these trends, three-quarters of a million fewer smoking-related deaths occurred between 1964 and 1985 than would have occurred had prevalence not diminished (USDHHS 1989). Canada The Canadian tobacco prevention and control movement began over two decades ago when educa- tional activities were stimulated by the British Royal College’s 1962 report on smoking and health (Royal College of Physicians 1962). In 1985, the National Strategy to Reduce Tobacco Use was launched; its mission statement resolved to “produce a generation of nonsmokers by the year 2000” (McElroy 1990, p. 2). Twenty-two national health agencies created a joint steering committee whose 1987 directional paper 184. = Prevention and Control presented a framework for the national program. Three principal goals were enumerated: protection of the health and rights of nonsmokers, prevention of smoking among young persons, and availability of cessation programs. To accomplish these goals, seven strategies were identified: legislation, access to in- formation, availability of services and programs, message promotion, support for citizen action, inter- sectoral policy coordination, and research and knowl- edge development (McElroy 1990). Current participants in the national strategy are Health and Welfare Canada, provincial and territorial ministries of health, the Canadian Cancer Society, Ca- nadian Nurses Association, Canadian Council on Smoking and Health, Canadian Medical Association, Physicians for a Smoke-Free Canada, Heart and Stroke Foundation of Canada, Canadian Lung Association, and the Canadian Public Health Association. Health and Welfare Canada, through its Tobacco Programs Unit, is the coordinating agency. The Non-smokers’ Rights Association is not a participating member of the national strategy but plays a major role in tobacco control in Canada. Legislation has been a particularly strong com- ponent of the national strategy. The Tobacco Products Control Act, which came into force January 1, 1989, phased out all forms of tobacco advertising in print and broadcast media, on billboards and mass transit posters, and on point-of-sale signs. The act prohibits the free distribution of tobacco products, prohibits the display of tobacco trademarks on nontobacco items, restricts tobacco company sponsorship to events sponsored before 1987, and requires tobacco product packages to prominently display health messages and to list toxic constituents of tobacco smoke (Kyle 1990). The Non-Smokers’ Health Act (effective December 29, 1989) bans smoking or restricts it to just a few areas in conveyances, public places, and workplaces under federal jurisdiction. About 900,000 workers, or 8 per- cent of the Canadian work force, are affected (Kyle 1990). Retail taxes average US$3.70 for a pack of 20 cigarettes (Claiborne 1991). Using the slogan “Break Free for a New Genera- tion of Non-Smokers,” the national campaign has brought together key groups and individuals and has encouraged cooperation, coordination, and compre- hensiveness. Between 1980 and 1989, the prevalence of smoking among teenagers in Canada decreased by almost 50 percent (Stephens 1991), while it remained constant among high school seniors in the United States (Johnston, O'Malley, Bachman 1987). Tobacco prevention and control in Canada, along with that of the French overseas departments and territories (see Chapter 5), is the most comprehensive in the Americas. Regional Activities for Tobacco Control in Latin America and the Caribbean In 1984, the Pan American Health Organization (PAHO) held a meeting in Punta del Este, Uruguay, on programs for control of noncommunicable diseases (PAHO 1988a). This effort was followed by an advi- sory group recommendation to hold subregional workshops to identify strategies and obtain political commitment for tobacco control in member countries. Workshops on control of smoking were subsequently held for the Southern Cone and Brazil in 1985 (PAHO 1986), the Andean Area in 1986 (PAHO 1987a), the English-speaking Caribbean in 1987 (PAHO 1988b), and Central America in 1988 (PAHO 1989b). At these workshops, representatives of each subregion re- ported on activities related to tobacco control, includ- ing surveillance, regulatory policies, educational programs, and media activities. PAHO emphasized the need for plans of action to include efforts from government health and education agencies and from cultural, sports, communications, trade, legislative, and agricultural programs. PAHO also encouraged member countries to set up a central office for tobacco control in each ministry of health (PAHO 1988a). The World Health Organization (WHO) requested that each country identify a focal point for tobacco or health activ- ities (WHO 1986). In 1989, a Regional Plan of Action for the Preven- tion and Control of Tobacco Use was released by PAHOat the thirty-fourth meeting of its Directing Council (PAHO 1989a). The plan was accompanied by a resolu- tion urging member governments to institute the plan and encouraging the PAHO Director to mobilize extrabudgetary resources for implementing the plan. Elements of the plan are as follows: Promotion of policies, plans, and programs. Provide information on control strategies to various agencies; collaborate in the formulation of national policies; and develop workshops and meetings, demonstration projects, guidelines for national programs, legislative strategies and enforcement, and minimum indicators essential for program evaluation. Mobilization of resources. Identify government and nongovernment organizations and individuals that can contribute to the plan; involve WHO collabo- rating centers in mobilizing resources; collaborate with professional associations and political leaders; and collaborate with educational, health, and trans- portation services in providing smoke-free facilities. Management and dissemination of information. Identify agencies that provide tobacco-related educational material, involve mass media in dissemination of such information, and evaluate its dissemination through a regional information network. Training. Identify training needs and train pro- gram managers and health professionals. Research. Conduct applied research on overall program efficacy, on smoking among adolescents and other high-risk groups, and on effectiveness of cessa- tion programs. Technical advisory services. Provide direct advice from PAHO staff or consultants to requesting countries. Because this regional action plan is so recent, its implementation and impact have not yet been evalu- ated in depth. Nonetheless, the plan is commendable for having identified the factors important to tobacco control and for having encouraged participating coun- tries to develop coordinated programs. The Caribbean Community (CARICOM), an or- ganization of heads of governments from the Carib- bean area, recommended in 1987 that all members participate in a Regional Program for Drug Abuse Abatement and Control. Tobacco is included in the program, and education is the main focus of interven- tion activities. Other components include treatment, data collection, and the establishment of national councils on drug abuse. Many Caribbean countries have established these councils (Appendix 2), which bring national attention to tobacco as a gateway drug and to the need for education to prevent tobacco use by young persons. No evaluation studies or reports on these councils are available. Since 1980, the International Union Against Can- cer has joined public and private health leaders in 18 countries of the Americas in organizing national workshops on smoking and health. International vol- untary agencies have provided assistance to these workshops, in which 6,000 physicians, educators, health officials, and community activists have partici- pated. Several countries have established national plans for tobacco control, which include research on prevalence of smoking and smoking-related diseases, educational campaigns on the health consequences of smoking, and comprehensive smoking-related health policies. In January 1985, leaders of tobacco-control activ- ities formed the Latin American Coordinating Com- mittee on Smoking Control (LACCSC) (American Cancer Society [ACS] 1988), which has the following goals: ¢ To help coordinate smoking-control efforts throughout Latin America. Prevention and Control 185 ¢ To provide a clearinghouse for information sup- portive of national smoking-control initiatives. ¢ To provide a forum for planning multinational strategies. ¢ To provide guidance and training in smoking- control advocacy skills. * To adopt resolutions calling for action by govern- ments throughout the region. By using funding from the International Union Against Cancer and the American Cancer Society (ACS), LACCSC, in partnership with PAHO, has dis- tributed a newsletter several times a year, has devel- oped a model smoking-education curriculum, and has developed guidelines for smoking-control coalitions and media advocacy. Workshops on working with the media, fostering advocacy, and calculating smoking- attributable mortality have been held in conjunction with LACCSC annual meetings. LACCSC has sup- ported national coordinating committees, national plans of action, and World No-Tobacco Day (May 31 of each year). In 1991, the Association of Latin American Women for the Control of Smoking was formed at the seventh annual LACCSC meeting to help prevent smoking among women and to combat tobacco adver- tising directed toward women. Initial goals include data collection and reporting on smoking among women and coordination with other multinational organizations concerned with smoking among women (ACS 1988). Elements of Prevention and Control Programs The information presented here derives from joint work of PAHO and the CDC Office on Smoking and Health. In 1988, a questionnaire was developed, and an in-country investigator identified for each Latin American and Caribbean country completed the questionnaire (PAHO 1992). Information and docu- mentation about the overall prevention and control of tobacco use were requested, along with specific data on the main control elements. The findings are pre- sented in detail in a companion report (PAHO 1992). The overview of the findings presented here empha- size the diverse nature of tobacco-control activities in Latin America and the Caribbean. Surveillance and Analysis A comprehensive system for surveillance of tobacco-related events would include surveillance of the following: (1) adult, adolescent, and special popu- lations (such as women and physicians) to determine current and former use of tobacco, rate of smoking initiation, and rate of smoking cessation; (2) public knowledge, attitudes, and beliefs about tobacco use; (3) interventions, such as the prevalence of restrictions onsmoking at worksites and the extent of antismoking education in schools; (4) legislative and regulatory activity, both proposed and enacted (Novotny et al., in press); and (5) trends in tobacco products. Many Latin American and Caribbean countries have some elements of a surveillance system, but none appears to have all elements (PAHO 1992). 186 Prevention and Control Most Latin American and Caribbean countries have conducted some form of an adult survey on tobacco use (Chapter 3, Table 16), but the methods, sample size, target groups, sampling methodology, and questions of these surveys have varied consider- ably. The survey questions used have been recom- mended by the International Union Against Cancer (Gray and Daube 1980), used for the U.S. National Health Interview Survey (USDHHS 1989), or derived from other sources. Small, non-population-based samples of adults were generally drawn for one-time surveys. In some countries, including Colombia, Jamaica, and Mexico, questions on tobacco use were included in surveys of drug use (PAHO 1990). In the U.S. Virgin Islands, CDC’s Behavioral Risk Factor Surveillance System (BRFSS) has been used each year since 1988 to survey adults aged 18 years or older about smoking, lack of exercise, contraceptive use, lack of seatbelt use, and other risk factors (PAHO 1992). The BRFSS permits trend analyses of behaviors over time and helps iden- tify population risk patterns. No Latin American or Caribbean country other than the U'S. Virgin Islands has periodically monitored tobacco use in the general population. The diverse methodologies limit analysis and conclusions for specific countries and the region as a whole. For example, if occasional smokers were in- cluded in the category for current daily smokers, the reported prevalence of current smoking may have been increased. Furthermore, samples were often drawn from urban areas, and since the prevalence of smoking is higher among urban than nonurban dwell- ers (Chapter 3, “Prevalence of Smoking in Latin Amer- ica and the Caribbean”), national inferences cannot be drawn. Several countries have also surveyed groups at high risk for tobacco-related disease. Because of the well-documented effects of maternal tobacco use on infant health (Malloy et al. 1988), women of reproduc- tive age (15 to 44 years old) have often been surveyed (Chapter 3, Tables 11-18). Women of reproductive age in the Americas were asked about tobacco use in eight surveys conducted with assistance from CDC and in 10 surveys performed by PAHO’s Latin Amer- ican Center for Perinatology and Human Develop- ment (PAHO 19875). Several Latin American and Caribbean countries have surveyed youths about cigarette smoking (Chap- ter 3, Table 17), but the definitions used for categories of smokers were again quite variable. Furthermore, the surveys may have missed an important segment of the young population because most of them were performed in schools. In many of these surveys, ques- tions about tobacco use were part of drug-use surveys; because tobacco is addicting, it is considered a sub- stance that can lead to the use of other drugs (Fleming et al. 1989). In the United States, school-based surveil- lance of behavioral risk factors is accomplished through a uniform survey instrument, the Youth Risk Behavior Survey (Harel et al. 1990). Standard ques- tions on ever use of cigarettes, use of cigarettes in the last 30 days, and current daily use of cigarettes are included in this survey. Persons aged 12 to 18 are surveyed because, in the Americas, initiation of smok- ing generally occurs in this age group. Physicians are generally educated about the health consequences of smoking, and their health- related behavior may set an example for other persons (Adriaanse and Van Reek 1988). Prevalence of smok- ing among physicians may bean indicator of diffusion of the nonsmoking norm and of a society’s willingness to combat the health consequences of smoking (Pierce 1991). In several Latin American countries, the prev- alence of smoking among physicians and physicians- in-training has generally been similar to or only slightly lower than that in the general population (Chapter 3, Table 16). Surveys in Latin America and the Caribbean have often not included questions on knowledge, attitudes, and beliefs regarding tobacco (Chapter 3, Table 18). This information is important for monitor- ing the effect of public information campaigns (Pierce 1991) and in tracking public support for legislative and policy interventions. Data from youth surveillance may be extremely helpful when establishing school- based educational programs. But data on tobacco use must be collected in a standardized way to allow for planning and evalua- tion of national programs and comparison of trends within and between countries. Furthermore, the key variables of a surveillance system should not be mod- ified significantly over time. In 1990, WHO convened an internal working group to update standard mea- sures of tobacco use. Standard definitions for world- wide surveillance have not yet been agreed upon, but WHO continues to pursue consensus for worldwide surveillance (WHO 1983a, 1988). A recent example of surveillance of tobacco products serves to demonstrate the value of a coordi- nated, regional approach. Under the sponsorship of PAHO, the Health Protection Branch of Health and Welfare Canada measured the tar, nicotine, and car- bon monoxide yield from popular cigarette brands in 20 countries (Table 1). The results suggest that smok- ers in most Latin American and Caribbean countries are exposed to levels of toxic constituents similar to those to which North American smokers are exposed (e.g., 14 to 18 mg of tar per cigarette). Continued monitoring of product characteristics is an important component of surveillance of tobacco-related disease. More than half the world’s deaths due to cancers and cardiovascular disease and 85 percent of deaths due to chronic obstructive pulmonary disease occur in developing countries. To assess the cost and effective- ness of intervention strategies against several chronic diseases, The World Bank commissioned a series of studies that incorporated economic, epidemiologic, and clinical data for developing countries Jamison and Mosley 1991), most of which lacked empirical data about many of the major chronic diseases of adults. The lack of data systems that enable analyses of mor- tality trends and of trends in determinants of chronic diseases now hampers meaningful policy and pro- gram development. Education, Public Information, and Cessation Programs School-based educational activities against to- bacco are uncommon in Latin America and the Carib- bean, but through the efforts of LACCSC, ministries of health and education, and nongovernment organiza- tions, several countries have begun to include anti- tobacco education in school curricula (see Appendix 1). Few of these programs have been evaluated; how- ever, a 1988 antitobacco education program in Chile, initiated with the assistance of WHO, has been evalu- ated by the Ministry of Health in Chile. This evaluation Prevention and Control 187 Table 1. Selected data for popular brands of cigarettes in 20 countries Carbon Tar Nicotine monoxide Filter Market Brand name* Country (mg/cig) (meg/cig) (mg/cig) type share (%) Derby KS FT Argentina 13.44 0.90 15.46 Acetate 14.0 Jockey Club KS FT Argentina 14.16 0.96 16.85 Acetate 5.3 L&M KS FT Bolivia 14.82 1.07 17.38 Acetate 48.4 Astoria Bolivia 21.79 1.60 17.56 None 16.6 Belmont KS FT Brazil 19.93 1.48 19.51 Acetate 19.1 Mustang KS FT Brazil 14.44 0.85 18.20 Acetate 4.1 Players Light RS FT Canada 14.86 1.34 15.21 Acetate 12.9 Export A RS FT Canada 15.03 1.27 15.91 Acetate 5.7 Derby Superlongs PS FT Chile 14.64 1.36 18.80 Acetate 24.7 Advance Superlongs PS FT Chile 8.69 0.70 10.75 Acetate 11.9 Pichoja RS P Colombia 23.79 1.58 16.31 None 21.7 Delta KS FT Costa Rica 16.20 1.24 19.04 Acetate 53.7 Derby KS FT Costa Rica 16.08 1.35 15.98 Acetate 21.6 Marlboro RS FT Dominican Republic 15.45 1.17 15.88 Acetate 51.1 Cremas KS P Dominican Republic 21.77 0.98 18.77 None 3.5 Lark KS FT Ecuador 14,90 1.06 17.31 Acetate/ 36.1 charcoal Lider Suave KS FT Ecuador 13.01 0.90 16.32 Acetate/ 31.3 charcoal Delta PS FT El Salvador 18.02 1.12 18.67 Acetate 57.3 Diplomat deLuxe 100s PSFT EI Salvador 18.60 1.14 20.10 Acetate 15.6 Rubios KS FT Guatemala 14.99 0.85 15.90 Acetate 28.6 Belmont KS FT Guatemala 14.28 0.64 16.62 Acetate 16.9 Royal KS FT Honduras 13.39 1.05 14.48 Acetate 39.0 Belmont KS FT Honduras 13.65 1.07 15.73 Acetate 23.0 Craven A RS FT Jamaica 17.68 1.51 14.12 Acetate 76.7 Raleigh RS FT Mexico 15.87 0.85 17.44 Acetate 22.9 Delicados Oscuros RS FT Mexico 14.33 0.73 17.66 Acetate 8.4 Viceroy KS FT Panama 15.15 1.05 15.04 Acetate 32.7 Marlboro KS FT Panama 14.78 0.96 15.02 Acetate 19.3 188 Prevention and Control Table1. Continued Carbon Tar Nicotine monoxide Filter Market Brand name* Country (mg/cig) (mg/cig) (mg/cig) type share (%) Union Club PS FT Paraguay 18.15 1.00 17.77 Acetate — Clayton 100s PS FT Paraguay 21.39 1.87 20.10 Acetate — Broadway Extra RS FT Trinidad and Tobago 14.53 1.20 13.26 Acetate — du Maurier RS FT Trinidad and Tobago 15,29 1.38 14.34 Acetate — Nevada KS FT Uruguay 15.55 1.41 14.10 Acetate 76.8 Casino KS FT Uruguay 16.06 1.34 20.43 Acetate 23.2 Marlboro KS FT United States 17.00 1.20 17,00 Acetate 12.3 Winston KS FT United States 17.00 1.10 16.00 Acetate 4.0 Belmont Extra Suave RS FT Venezuela 15.43 0:92 16.01 Acetate / 45.7 charcoal Astor Super Suave RS FT Venezuela 15.09 0.85 16.37 Acetate / — charcoal Source: Collishaw, unpublished data (1991 ). *Codes refer to product types, where KS = king size, FT = filter tip, RS = regular size, PS = premium size, and P = plain. suggested that school-based education was effective in preventing the uptake of smoking by younger adolescents but was ineffective in persuading adoles- cents who were already smokers to stop smoking (Sepulveda 1990). By the end of the intervention, 3.2 percent of students in the intervention group were daily smokers, versus 10 percent of students in the nonintervention group. Programs in a few Latin American and Carib- bean countries rely on physicians to provide informa- tion to patients visiting government facilities. In Cuba, the National Program to Reduce Cancer Deaths uses the islandwide system of primary-care providers. An 18 percent decrease in smoking prevalence was reported in communities with intervention sites and a 4 percent decrease at nonintervention sites (Sudrez- Lugo 1988). Public information campaigns focus attention on tobacco asa serious health issue and help craft preven- tion and cessation messages for target audiences. For- mal public information programs train public health professionals in communications, and these persons can then build working relationships with local media (Erickson, McKenna, Romano 1990). In 1990, most coun- tries in the Americas reported some public information activity on tobacco use. In many Latin American and Caribbean countries, public information activities have revolved around a “smokeout” day similar to the ACS’s Great American Smokeout held on the third Thursday in November each year in the United States (CDC 1990a). Many countries have promoted the WHO-sponsored World No-Tobacco Day, held on May 31 each year (CDC 1991). WHO has distributed press packets and video messages in several lan- guages, including Spanish, for this event. Further- more, public information announcements broadcast in the United States may be viewed in Caribbean coun- tries on cable networks. Education and public information activities in the Americas have increasingly focused on use of drugs, including tobacco. Efforts have included both school-based education and public information cam- paigns. Many organizations in the Americas that ad- dress tobacco use are responsible primarily for drug-abuse prevention. Cessation programs, an important component of tobacco-control programs (Novotny et al., in press), have been regularly provided by the Seventh-Day Adventist Church in many countries of the Americas. The church has strong tenets against several health Prevention and Control 189 risk-factors, including smoking, using alcohol, and eating meat. The standard five-day classes, which are open to the public, include a spiritual approach to health issues (Proctor 1985). A few countries report that other private smoking-cessation programs are sporadically offered. No information is reported on widely available, self-help cessation programs, such as those used effectively in the United States (Glynn, Boyd, Gruman 1990). But most smokers quit without the aid of formal programs and may rely on minimal interventions (e.g., those that provide the skills and information necessary for persons who want to quit smoking) (Fiore et al. 1990). Because smoking behav- ior patterns in many Latin American and Caribbean countries differ from those in the United States, mini- mal interventions may have to be adapted to specific cultures. More information is needed on public knowledge, behavior patterns, and methodologies effective for developing such interventions. Taxation The World Health Assembly has recognized the potential of taxation as a tool for the control of tobacco use (WHO 1986). Among the countries of the Ameri- cas for which data are available, variability is wide in the type of taxes levied, their contribution to the price of tobacco and cigarettes, and the proportion of gov- ernment revenue they generate (see Chapter 4, “Eco- nomics of the Tobacco Industry”). In Peru, for example, cigarette taxes are only 16 percent of the price of cigarettes, but in Colombia, taxes are 120 percent of the price (Table 2). Tariffs vary from 14 percent to 130 percent of the price of manufactured cigarettes. Tax as a percentage of total central government revenue also varies substantially; however, assessment is complicated because different revenue generating and collecting systems are used by Latin American and Caribbean countries. Table 2. Tobacco tax and tariff in selected countries of the Americas, 1988 or earlier Tariff (as % Tax (as % of price of of total Tax (as % manufactured government Country of price)* cigarettes)t revenue)” North America Canada 75 20 2.4 United States 35+ 14 1.9 Latin America . Argentina 755 36 22.5 Brazil 76 105 7A Chile 15 5.6 Colombia 120 50 13.2 Cubal 1.8 Ecuador 90 El Salvador 80 Guatemala 80 4.7 Haiti 130 41.3 Mexico 57 20 1.1 Peru 16 1104 2.8 Venezuela 45 35 2.7 Caribbean Suriname 50 Trinidad and Tobago 20 Source: ment of Health and Human Services (1989). “1983. 11988. fncludes state taxes. 81987. iGovernment tobacco monopoly. Includes 24% surcharge; import of cigarettes is banned. 190 ~=Prevention and Control U.S. Department of Agriculture (1984, 1989); Agro-economic Services Ltd. and Tabacosmos Ltd. (1987); U.S. Depart- Tobacco taxes may be dedicated for specific health purposes. Several states in the United States have used cigarette tax revenues to finance tobacco- related health programs, and the most substantial pro- gram of this kind is in California. In November 1988, the state’s cigarette tax was increased from 10 cents to 35 cents per pack. Three-quarters of the revenues from this tax increase are used for health education, re- search, medical treatment, and environmental conser- vation programs (Tobacco Tax and Health Protection Act of 1988; Bal et al. 1990). But the level of taxation is not necessarily an indicator of concern for health. For example, in Can- ada, where taxes add an additional 75 percent to the price of cigarettes, health concerns and a concerted antismoking movement have strongly influenced pol- icy. Butin several Latin American countries where the level of taxation is as high or higher (Table 2), health concerns may not have been a strong influence. Throughout Latin America, the influence of health concerns on level of taxation has varied (PAHO 1992). Data regarding tobacco taxation for 1989 or later (Table 3) differ somewhat from the information re- ported earlier (Table 2). These differences may reflect short-term changes in taxation policy, but they may also reflect differences in the methods used to calcu- late the proportion of tobacco price and the proportion of government revenue contributed by tobacco tax. Legislation The legislative efforts to control tobacco use in the Americas are extensive (see Chapter 5), but how well the written laws are enforced in day-to-day life is unclear. In the United States, for example, laws in most states ban cigarette sales to minors, but these laws are rarely enforced (CDC 1990b). Systematic information on enforcement in the Americas is not available. Table 4 summarizes tobacco-control legislation in the Americas—the base on which continued efforts are expanding. Some key points about the legislation are given below. (The French overseas departments and territories are counted as Caribbean countries, as in Chapter 5.) e Fifteen Latin American and four Caribbean coun- tries have either a total ban on or some type of legis- lation restricting advertising and cigarette promotion. ¢ Three countries prohibit all advertising of tobacco. ¢ Bolivia limits advertising to the tombstone format, which allows print and a picture of the package. e Two countries—Argentina and Bolivia—prohibit advertising associated with sports. e Sixteen countries restrict advertising that influ- ences young people. Table 3. Excise taxes on manufactured cigarettes as percentage of total retail price and of total national tax revenue, 1989 or most recent year available Retail Tax Country price revenue Andean Area Bolivia 61° 1.4 Perut 558 0.1 Venezuela 50 2.5 Southern Cone Argentina 75 22.0 Chile 75 10.0 Paraguay 10/35! 8.6 Uruguay 60 5.0 Brazil 73 5.0-7.0 Central America Costa Rica 75 5.0 EI Salvador 43 21.0 Guatemala 3.0 Panama 60 2.0 Mexico 1.7 Latin Caribbean Dominican Republic 13 2.3 Haiti 41 Puerto Rico 39 3.0 Caribbean Aruba 64 Bahamas 48 Barbados 41 British Colonies** Tax free French overseas depart- ments and territories** 75 French Guiana 52H Guyana 50 35.04 Jamaica 42 4.0 Netherlands Antilles Tax free Organization of East Caribbean States St. Lucia 18 0.5 Dominica 35 1.0 St. Vincent and the Grenadines 4] 1.0 Suriname 55 Trinidad and Tobago 15 1.1 US. Virgin Islands 4 Source: Pan American Health Organization (1992). “1987. 17% surtax on imports. 11988. 87% of taxes allocated to cancer hospital. Average 1978-1988. Tight tobacco/ dark tobacco. “Includes Anguilla, Bermuda, British Virgin Islands, Cayman Islands, Montserrat, and Turks and Caicos Islands. “Except French Guiana. For this table and associated text, the French overseas departments and territories are counted with the Caribbean countries. tor consumption taxes. Prevention and Control 191 Table 4. Principal legislative measures’ for control of tobacco in the Americas, by type of measure and country Health warning Statement of tar A Restrictionon Advertising Rotating and nicotine Country advertising ban __orstrong — Standard yield North America Canada x x Xx United Statest x Latin America ~*~ Argentina ~~ Bolivia Brazil Chile Colombia Costa Rica Cuba xX Ecuador El Salvador Guatemala ~~ KK KOK x ~ xX ~*~ ~~ Honduras Mexico Panama Paraguay Peru Uruguay ~ KK KK XK ~~ KM mK KO Venezuela Caribbean Bahamas x X Barbados x Bermuda xX Xx xX French overseas departments B and territories° Xx x X Trinidad and Tobago x x Xx Source: Copies of national legislation provided by individual countries to the Pan American Health Organization. “Provisions of the legislation are summarized in Chapter 5, Appendix 1, notes to Tables 2, 4, 5, and 6. tThe countries listed are those in the Americas that have any type of legislative control of tobacco use. tDoes not necessarily imply federal legislation, but acknowledges activities of several states. For this table and associated text, the French overseas departments and territories are counted with the Caribbean countries. 192 Prevention and Control Restriction on smoking Prevention of In public In the smoking among Health piaces workplace ——-young people education xX xX xX x xX xX Xx X X xX x xX x Xx x x Xx Xx x xX xX X xX X x Xx xX Xx xX Xx Xx x Xx xX xX Xx xX xX Xx X x Xx x xX Xx Xx x Xx Xx X x xX xX x Xx xX X Xx Prevention and Control 193 * Nearly all countries that have legislation on adver- tising require health warnings in advertisements. * Two countries specify the frequency and duration of health warnings required on the broadcast media. * Fourteen Latin American and five Caribbean coun- tries require health warnings on cigarette packages. ¢ Two Latin American countries require strong health warnings, but none requires multiple warn- ings used in rotation, as do Canada, the United States, and the French overseas departments and territories. e Only three Latin American countries, three Carib- bean countries, and Canada require a statement of tar and nicotine yield on cigarette packages. * Restrictions on where cigarettes can be sold are generally not found in Latin American and Carib- bean countries. ¢ The State of Rio Grande do Sul, Brazil, prohibits the sale of cigarettes in any establishment subsidized by the government and recommends that tobacco not be sold in hospitals and health services institutions. e Nineteen countries restrict smoking in public places. * Seven countries ban smoking on work premises, and thirteen ban smoking in health establishments. ¢ In the United States, a major statement on the haz- ards of smoking in the workplace has been issued (National Institute for Occupational Safety and Health 1991). ¢ Nineteen countries have laws that control smoking by young people. e Thirteen Latin American countries restrict cigarette advertising that influences young people, but only five of these countries prohibit the sale of tobacco products to minors. e Argentina and Ecuador prohibit free distribution of samples of cigarettes to minors, and Uruguay pro- hibits the sale of loose cigarettes. e Nine Latin American and Caribbean countries pro- hibit smoking and sales of tobacco in schools and places frequented by young people, although many schools may prohibit smoking on school property. e Eleven Latin American and Caribbean countries mandate health education about the hazards of tobacco use. * Five Latin American countries mandate anti- tobacco education in schools, but many schools undoubtedly provide such education voluntarily. Coalitions A comprehensive tobacco-control program calls for a national smoking and health organization dedicated to the development of policy and the coordination of government and voluntary efforts. The organization 194 Prevention and Control may be an official government agency, or it may bea voluntary agency with or without government sup- port. Nongovernment coalitions or commissions may function outside of the government structure but may include representatives from various ministries, usually health and education. In several countries, medical societies, often a part of a larger coalition, have sus- tained activities against tobacco use. Several countries in Latin America have estab- lished national commissions with a wide range of functions regarding tobacco control: promotion of research, development of policy, provision of educa- tion and information, coordination of intergovern- ment actions, and evaluation of the effects of tobacco-control programs. These national bodies have the capacity to mobilize support from many departments of government and the private sector. Most national commissions are concerned with measures to control tobacco use rather than the pro- duction of tobacco. The Permanent National Advisory Commission on the Control of Smoking is a govern- ment agency created in Argentina to advise on and assist with the production, processing, and exportation of tobacco. The commission, which is composed of government officials and representatives of the em- ployers and employees engaged in tobacco production and processing, does not control the use of tobacco. In the absence of a national smoking and health organization, the tobacco-control effort is usually han- dled by the ministry of health. In two Latin American countries, legislation sets forth this responsibility. In Bolivia, a 1978 decree makes the Ministry of Social Welfare and Public Health the only agency that can regulate all aspects of the promotion and sale of to- bacco that affect health. The decree specifically recog- nizes that tobacco is harmful to health. In Brazil, legislation enacted in 1986 provides that the Ministry of Health shall promote week-long activities in con- nection with National No-Smoking Day, observed an- nually on August 29. In seven Latin American countries, legislation creates a national smoking and health organization. A 1986 decree in Chile established the National Commis- sion for the Control of Smoking, which includes the Minister of Health as chairperson and the undersecre- taries of interior, economic affairs, agriculture, labor, transport and telecommunications, and justice. The commission (1) continually reviews the situation on smoking and assesses the place of the tobacco industry in the economy; (2) coordinates monitoring of the prevalence of smoking; (3) determines the effects of smoking on mortality and morbidity; (4) identifies public and private resources for information, education, and health care; (5) analyzes legal texts concerning antismoking measures; (6) proposes smoking-control policies; and (7) designs and evaluates medium- and long-term smoking-control activities. In Ecuador, a 1989 resolution of the Ministry of Public Health created the Interinstitutional Anti- smoking Committee under the National Bureau for Epidemiological Control and Surveillance. The com- mittee, which comprises representatives from the public and private sectors and is chaired by a repre- sentative of the Ministry of Public Health, plans, ad- vises on, and carries out the national program against smoking. The General Health Law of 1983 in Mexico pro- vides that the Secretariat of Health, the governments of the federated entities, and the Council on General Health in each geographic area shall coordinate activ- ities for the Antismoking Program. The program aims to prevent and treat the illnesses caused by smoking; to educate citizens, especially families, children, and adolescents, about the health effects of tobacco use; and to promote research on the causes of smoking. The federal government of Mexico has entered into agreements with the various states to coordinate smoking-control activities of the National Council Against Addictions. These activities include the fol- lowing: (1) encouraging legal measures to control smoking, (2) promoting cooperation between federal and state agencies, (3) integrating government activi- ties with those of the private sector, (4) establishing a government center for information and documenta- tion, (5) strengthening surveillance, (6) promoting re- search, (7) undertaking epidemiologic studies, and (8) undertaking other studies for early identification of persons with smoking-related problems. In Panama, a 1989 decree created the National Commission to Study Tobacco Use, which was charged with producing a report on the harmful ef- fects of tobacco use and gathering statistical data on progress in combating smoking. The report is to in- clude information on legislation and on progress at the international level on tobacco and health. A 1988 Ministerial Resolution in Peru created the Permanent National Commission Against Tobacco, which provides information and formulates recom- mendations on the health risks of smoking. The com- mission determines the role of the Ministry of Health and other health institutions in combating tobacco use. These agencies provide support and facilities for the commission, which includes representatives from different sectors of society. In Uruguay, legislation enacted in 1970 provides for a special commission of the Ministry of Public Health, acting in collaboration with the Ministry of Education and Culture, to study the effects of smoking and to disseminate information on the health risks of tobacco use. Legislation proposed in 1988 would cre- ate the Bureau for the Control of Smoking, within the Ministry of Public Health, with broad power to (1) conduct epidemiologic studies, (2) coordinate preven- tive strategies, (3) conduct public education programs (with cooperation from the National Administration of Public Education, the University of the Republic, and other educational organizations), (4) establish maximum levels of tar and nicotine in tobacco prod- ucts, and (5) develop actions to reduce smoking. In Venezuela, a 1984 decree of the Ministry of Health and Social Welfare established a permanent national council under the jurisdiction of the Division of Chronic Diseases. The council studies the health problems related to smoking and formulates policies for preventing smoking and smoking-related dis- eases. The multidisciplinary council is composed of two representatives from the Ministry of Health and Social Welfare (the Chief of the Division of Chronic Diseases, who serves as president, and the Director of Oncology) and representatives from the ministries of agriculture, labor, transportation and communica- tions, justice, environment and natural resources, information and tourism, and youth affairs; the Vene- zuelan Social Security Institute; the National Acad- emy of Medicine; the Venezuelan Cancer Society; and the Venezuelan Medical Federation. A technical unit, composed of physicians, epidemiologists, political sci- entists, sociologists, academicians, publicists, and social communicators, supports and coordinates the devel- opment of antismoking actions. The Ministry of Health and Social Welfare coordinates educational programs among the agencies represented on the council. No legislation that establishes national organiza- tions for tobacco policy development is available from Caribbean countries. Although national efforts may occur in other countries as well, they lack the critical support that government sanction provides. Yet the lack of such support does not necessarily vitiate anti- smoking efforts. In the Americas, nongovernment groups, such as citizens’ coalitions, voluntary agen- cies, and special-interest groups, have effectively pro- moted good health. This compendium of legislation and coalitions does not indicate the extent to which tobacco-control activities are implemented. Many of the recently es- tablished government and nongovernment commis- sions on tobacco may still be rudimentary, but some efforts are well established. For Latin America and the Caribbean, a listing of national organizations, sponsors, and activities of these organizations is pro- vided in Appendix 2. Prevention and Control 195 Summary Activities critical to controlling tobacco use in- clude surveillance of tobacco consumption, collection of excise taxes, and coordination of local, national, and regional efforts. Surveillance data can be used to mon- itor trends in tobacco use and to provide a basis for targeting populations. The collection of tobacco tax revenue can be used for monitoring tobacco consump- tion, and such revenue can be dedicated to health- related programs, as has been done in Peru. The coordination of tobacco-control activities augments the scarce resources that any single jurisdiction might Conclusions have available to it. Communication networks, such as the LACCSC and the Advocacy Institute’s GLOBALink electronic bulletin board (ACS 1990), can assist joint efforts. In many countries of the Americas, the frame- work for effective tobacco control is in place. As PAHO’s Regional Plan of Action for the Prevention and Control of Tobacco Use is implemented, all tobacco-control efforts in the Americas are likely to become increasingly effective. 1. A basic governmental and nongovernmental in- frastructure for the prevention and control of to- bacco use is present in most countries of the Americas, although programs vary considerably in their degree of development. 2. The need is now recognized, and work is under way, for developing a comprehensive, systematic approach to the surveillance of tobacco-related factors in the Americas, including the prevalence of smoking; smoking-associated morbidity and mortality; knowledge, attitudes, and practices with regard to tobacco use; tobacco production and consumption; and taxation and legislation. 196 Prevention and Control 3. School-based educational programs about to- bacco use are not yet a major feature of control activities in Latin America and the Caribbean. The few evaluation studies reported indicate that such programs can be effective in preventing the initiation of tobacco use. 4. Cessation services in most countries of the Amer- icas are often available through church and com- munity organizations. Private and government- sponsored cessation programs are uncommon. 5. Media and public information activities for to- bacco control are conducted in most countries of the Americas, but the extent of these activities and their effect on behavior are unknown. Appendix 1. Antitobacco Activities in Latin America and the Caribbean The antitobacco activities described here include school-based education, public information cam- paigns, and cessation activities. PAHO (1992) is the source of this summary. School-Based Educational Activities Argentina With help from the Argentine Cancer League, the ministries of health and justice developed an anti- smoking educational program for 561 secondary schools. Bahamas Antitobacco information is minimally included in the antidrug curriculum. Belize The Curriculum Development Unit of the Min- istry of Education and Pride Belize (an antidrug orga- nization) developed a school health education program that includes information on health and on developing skills for resisting substance abuse. Bermuda Antitobacco information is incorporated into the Family Life Education curriculum. Bolivia The Ministry of Education and Culture devel- oped a natural science curriculum for the third and fifth years of primary school. The National Commis- sion Against Tobacco Use (CONLAT) offers classes to primary and secondary schools. Brazil Materials are sometimes included in curricula, as determined by individual schools or states. Educa- tional materials are widely available. British Virgin Islands The health studies curriculum for high school students uses British antitobacco materials. Chile The ministries of health and education, health services, and provincial education departments spon- sor school-based educational prevention programs that include evaluation. Students aged 13 or older are now included. Colombia The Ministry of Education offers a program on preventing smoking and other forms of drug addic- tion. A booklet, E! Placer de No Fumar (The Pleasure of Not Smoking), is included in the compulsory behavior and health section of the school curriculum. Costa Rica Information on the effects of smoking are in- cluded in primary and secondary curricula and in science textbooks. Educational material is provided by the Social Security Fund, and references to smoking have been eliminated from textbooks. The National Antismoking Association sponsors workshops for secondary school students. Cuba Since 1991, antismoking education is offered in all schools islandwide, beginning with the seventh grade. Guatemala The National Antismoking Commission is plan- ning an educational program for schools. The Youth Congress on Smoking, held in 1990, provided instruc- tion and training on prevention activities. Guyana The National Coordinating Council for Drug Ed- ucation includes tobacco in curriculum development. Honduras Lectures on tobacco use are provided to schools by the Institute for the Prevention of Alcoholism and Drug Abuse. Jamaica Antitobacco information has been incorporated into the health education curriculum of primary and secondary schools. Mexico Antitobacco information is to be included in public primary school textbooks. The national anti- smoking program has produced booklets for use in schools by youth groups and by parent groups. Uni- versities include tobacco and health material in schools of medicine, psychology, and social work. Panama The Ministry of Education is required by law to include information on the health aspects of smoking Prevention and Control 197 in school curricula (science courses during the first year of secondary school). Paraguay Antitobacco education is included in some way in grades four through six. An antismoking associa- tion has targeted school-based education as a future activity. Peru Each year, the National Cancer Institute, the Ministry of Health, and the Ministry of Education sponsor programs in Lima for 50,000 students aged nine to 12. Puerto Rico The Puerto Rican Lung Association sponsors contests, nonsmoking day, and an educational cam- paign in secondary schools, vocational schools, and universities. By giving talks to seventh-grade stu- dents, the American Cancer Society reaches 85 percent of public schools and 30 percent of private schools. Suriname The Teachers’ Union collaborates with the Min- istry of Health in training teachers in smoking preven- tion education. Trinidad and Tobago The Ministry of Education includes antitobacco education in the syllabus of the general health educa- tion program for primary, junior high, and senior high school students. Uruguay General education for grades three through six targets health behavior, environmental pollution, clean indoor air, and tobacco use as a risk factor for disease. U.S. Virgin Islands The Department of Education adopted a revised health curriculum that includes a unit on smoking and on prevention of cardiovascular disease. Venezuela The Ministry of Education has an official pro- gram. Parents, teachers, and students are organized into extracurricular groups to help develop educa- tional messages. 198 Prevention and Control Public Information Campaigns Anguilla Television and radio spots, prepared by health care providers, are occasionally aired. Argentina Television and radio campaigns are sponsored by the Public Health Foundation. Campaigns directed toward youths were sponsored by the Argentine Can- cer League in 1978 and 1983 and by the Ministry of Health and Social Action in 1979, 1980, and 1982. Barbados Government and nongovernment agencies focus antitobacco activities around World No-Tobacco Day. Belize Medical and dental associations sponsored a television campaign and bumper stickers in 1989. The National Drug Abuse Advisory Council and Pride Belize distribute pamphlets and sponsor billboards discouraging drug and alcohol use. Smoking-cessation messages are aired on cable television. Bolivia In 1983, CONLAT sponsored a meeting on ciga- rettes and cancer. The biennial Tobacco or Health Day is addressed through mass media and public meet- ings. Children’s poster campaigns have been spon- sored, and Bolivia observes both a smokeout in November and World No-Tobacco Day in May. Brazil On National Antismoking Day, a race is spon- sored by the Ministry of Health in 400 cities. The National Program Against Smoking sponsors a school poster contest each year and publishes a newsletter. The Brazilian Medical Association has an official Anti- smoking Commission. Five million copies of an anti- tobacco comic book have been distributed. British Virgin Islands Print media cover smoking as a risk factor for cardiovascular disease. Public information materials from the United Kingdom are used. Medical associa- tions provide seminars and public information and support World No-Tobacco day. Cable television from the United States provides antismoking messages. Cayman Islands Public information materials from the United Kingdom are used. Medical associations provide seminars and public information and support World No-Tobacco Day. Business and anti-drug-abuse groups are active in smoking control. The Cayman Radio and Government Information Service broadcasts antitobacco messages on the radio. Cable television from the United States provides antismoking messages. Chile The National Cancer Society, in partnership with the pharmaceutical industry, sponsors a television campaign. The Association of Laryngectomy Patients has a mobile presentation for use at schools and work- sites. The Ministry of Health publishes numerous articles, and World No-Tobacco Day is celebrated by diverse activities. Colombia A national no-smoking day, established in 1984, is coordinated by the Colombian Cancer League. Since 1989, the campaign has coincided with World No-Tobacco Day. In 1990, public service announcements from the Public Health Service of the United States were translated and adapted for the Colombian television audience. In 1991, a mass media campaign was begun with the slogan “Smokers: An Endangered Species.” Costa Rica Printed materials are distributed through hospi- tals and clinics. Smoke-free Day is supported by print and elec- tronic media. The Social Security Fund produces tele- vision advertisements, and religious radio stations broadcast tobacco-related information. Journalists have been trained on health topics, including smoking. Cuba A mass media campaign, the backbone of a gov- ernment program, includes television announce- ments, posters, stickers, and T-shirts. Public education, aimed at parents, teachers, physicians, and government employees, emphasizes the effect of smoking on family income. The National Program to Reduce Cancer Deaths has enlisted a large network of family physicians. Ecuador The Lung Association sponsors antitobacco ed- ucation and media messages. A pharmaceutical workers’ union sponsors antitobacco information. El] Salvador The Department of Mental Health (of the Minis- try of Public Health and Social Welfare) occasionally provides television messages and conferences on smoking and health. French overseas departments and territories Posters, pamphlets, and radio and television programs provided by the French government are infrequently used. Guatemala The National Antismoking Commission pro- vides limited public information through the media. The Association of Physicians and Surgeons provides strong antitobacco support. Honduras Radio programs occasionally address scientific information on smoking. World No-Tobacco Day is supported through the National Smoking Control Commission. Jamaica The National Council on Drug Abuse (of the Ministry of Health), the Jamaican Medical Associa- tion, and the Jamaican Cancer Society are active in public information campaigns. Mexico A government program disseminates informa- tion through print and electronic media. World No- Tobacco Day is supported through various media. Panama A prevention program, based on public informa- tion, began in 1990 on the local level. Smoking-related information is periodically broadcast on radio and television. The staff of health care facilities are trained about smoking. The National Cancer Association and a civic committee sponsor a smoke-free day. Paraguay The Tuberculosis and Lung Disease Associ- ation’s booklet on the health consequences of smoking has been distributed by pharmaceutical companies to 3,000 physicians. Nongovernment organizations’ ac- tivities against drug abuse (including tobacco) receive limited radio and newspaper coverage. Peru World No-Tobacco Day has been celebrated since 1985, with parades and activities for children. Antismoking, posters are displayed in sports centers. A radio campaign against tobacco began in 1989. In- formation is also disseminated by the Center for Infor- mation and Education for the Prevention of Drug Abuse. Prevention and Control 199 Puerto Rico The Puerto Rican Lung Association sponsors a nonsmoking day, as wellas print, radio, and television messages. The local American Cancer Society sponsors community presentations, materials for physicians, and the Great American Smokeout. St. Vincent and the Grenadines The government sponsors print materials. Suriname Public service announcements are made through television and print media. The National Council on Drug Abuse, the Association of Heart Disease Pa- tients, and the Medical Association of Suriname spon- sor a public information campaign. Trinidad and Tobago The Cancer Society sponsors Smokeout Day dur- ing annual Cancer Week, gives lectures to community groups, and offers no-smoking signs to organizations. Uruguay The Office on Smoking Control (of the Ministry of Public Health) produced a program and five-second spots on healthy living for commercial television. Ma- terials were also developed for health care facilities. Community health activities include development of a booklet, Tobacco and Its Consequences. The Cancer Society supports the celebration of Clean Air Day, and the Ecological Party supports clean indoor air policies. U.S. Virgin Islands The Department of Health supports the Great American Smokeout, and local public service an- nouncements use U.S. materials on the risk of smok- ing, especially during pregnancy. The American Lung Association sponsors a weekly 15-minute radio program on lung health and uses the Christmas seal campaign to inform the public about the health conse- quences of smoking. Venezuela The Venezuelan Cancer Society and the Tuber- culosis and Lung Disease Society have sustained pro- grams, including National Smoke-Free Day, World No-Tobacco Day, 10-minute public service announce- ments, and interviews with officials of the Ministry of Health and Social Welfare. 200 Prevention and Control Cessation Activities Argentina Workshops are conducted by the Public Health Foundation and the Argentine Antismoking Union. Cessation classes are offered by the Argentine Cancer League and the Seventh-Day Adventist (SDA) Church. Bahamas Insurance companies offer a nonsmoker life in- surance discount of 35 percent. Barbados The Barbados Cancer Society conducts five- week smoking-cessation clinics based on the Ameri- can Cancer Society model. Bermuda The SDA Church offers smoking-cessation clinics. Bolivia In conjunction with CONLAT, the SDA Church offers cessation programs. Brazil Numerous companies offer classes and semi- nars. Banco do Brasil supports a systematic campaign against smoking that includes a cessation program. British Virgin Islands The SDA Church offers smoking-cessation clinics. Cayman Islands One private clinic and the SDA Church support smoking-cessation activities. Chile Cessation services are offered by the SDA Church, private physicians, and clinics. Primary health care providers are trained in smoking cessation, especially for women of childbearing age (as part of the Women’s Health Plan). Colombia Cessation programs are offered by private clinics in Bogata, Cali, and Medellin. Costa Rica The Institute on Alcoholism and Drug Abuse and the Social Security Fund sponsor cessation programs. Ecuador A pilot project for college-level students was coordinated by the ministries of health and education. The SDA Church offers cessation programs. Honduras The National Smoking Control Commission or- ganizes workshops for community organizations, unions, student groups, and the general public, and the SDA Church offers cessation programs. Jamaica The SDA Church and several private practition- ers offer smoking-cessation clinics. Mexico Cessation programs are offered in university hospitals in Mexico City and in hospitals in other states. Netherlands Antilles Health care providers support cessation activities. Panama Cessation programs are offered by the SDA Church, the Civic Support Committee for No Smoking Day, and the National Cancer Association. Most in- surance companies use a nonsmoker life insurance premium differential of 10 to 25 percent. Paraguay The SDA Church and a Baptist hospital sponsor cessation programs. Peru The Young Men’s Christian Association and the Inca Union (of the SDA Church) support cessation activities. Puerto Rico The Puerto Rican Lung Association sponsors clinics and physician training in smoking cessation. The American Cancer Society and the SDA Church sponsor clinics. Two insurance companies use a non- smoker life insurance discount of one-third. Trinidad and Tobago The SDA Church sponsors clinics and classes. Uruguay The national school of medicine, the SDA Church, and many nongovernment organizations and private clinics offer cessation services. U.S. Virgin Islands The American Lung Association sponsors smoking- cessation clinics. Venezuela The SDA Church and Venezuelan Petroleum support cessation activities. Prevention and Control 201 Appendix 2. Antitobacco Organizations in Latin America and the Caribbean Organizations for the prevention and control of tobacco use are cited below (PAHO 1992). Argentina Coalition or program: Antismoking Action and Health Council (est. 1990) Sponsor: Ministry of Health and Social Action, medi- cal association, Rotary Club, Mainetti Founda- tion, Favaloro Foundation Activities: Promotes community education, research, and legislation Barbados Coalition or program: National Drug Abuse Council Sponsor: Ministry of Health Activities: Includes tobacco in drug-abuse prevention activities and is planning data collection activities Belize Coalition or program: National Drug Abuse Advisory Council Sponsor: Ministry of Health Activities: Includes tobacco in drug-abuse prevention activities Bolivia Coalition or program: National Commission Against Tobacco Use (est. 1983) Sponsor: Bolivian Cancer Foundation Activities: Supports legislation, protects nonsmokers, reduces advertising, conducts research, and co- ordinates with international organizations Brazil Coalition or program: Advisory Group on the Control of Smoking; National Oncology Program (est. 1985) Sponsor: Ministry of Health (National Cancer Insti- tute, Respiratory Diseases Department), non- government organizations, religious groups, legislators, state health departments Activities: Supports legislation, promotes prevention programs, and evaluates the national program by using public information, media, and surveillance Chile Coalition or program: Chronic Disease Program; Na- tional Commission for the Control of Smoking (est. 1986) Sponsor: Government, medical association, nongov- ernment organizations Activities: Sponsors educational planning, data collec- tion, and international linkage 202 = Prevention and Control Colombia Coalition or program: National Council on Smoking and Health (est. 1984) Sponsor: Ministry of Health, National Cancer Insti- tute, Colombian Cancer League, and a press rep- resentative Activities: Conducts studies on tobacco control, taxa- tion, contraband, and advertising restrictions Costa Rica Coalition or program: Costa Rican Social Security Fund; Institute on Alcoholism and Drug Abuse Sponsor: Ministry of Health Activities: Concerned with education, cessation pro- grams, and legislation Cuba Coalition or program: National Program to Reduce Cancer Deaths (est. 1987) Sponsor: Ministry of Health and 15 other government agencies Activities: Develops public information, provincial working groups, legislation, and mass media messages Dominican Republic Coalition or program. Dominican Committee on Smok- ing and Health (est. 1989) Sponsor: Nongovernment organization; Secretariat of Public Health and Social Welfare Activities: Supports media activities and workshops El Salvador Coalition or program: Department of Mental Health Sponsor: Ministry of Public Health and Social Welfare Activities: Supports media campaigns and legislation French overseas departments and territories Coalition or program: French Committee on Health Education Sponsor. French government Activities: Distributes print materials to overseas de- partments and territories Guatemala Coalition or program: Mental Health Department; Na- tional Antismoking Commission Sponsor: Ministry of Public Health and Social Welfare, government and nongovernment organizations, and physicians’ association Activities: Promotes public education and informa- tion, and international and national coordina- tion of data collection, research, and government consultation Guyana Coalition or program: National Coordinating Council for Drug Education Sponsor: Ministry of Health and nongovernment or- ganizations Activities: Develops school curriculum Honduras Coalition or program: Institute for the Prevention of Alcoholism and Drug Abuse (est. 1988) Sponsor: Ministry of Public Health and Social Welfare Activities: Coordinates government and nongovernment organizations, legislation, and school education Coalition or program: National Smoking Control Com- mission Sponsor. Nongovernment organizations Activities: Supports local community action and World No-Tobacco Day Jamaica Coalition or program: National Council on Drug Abuse Sponsor: Ministry of Health and nongovernment or- ganizations (Jamaican Medical Association, Ja- maican Cancer Society) Activities: Promotes school education, public informa- tion, media activities, and legislation Mexico Coalition or program: National Committee for the Study and Control of Smoking (est. 1985) Sponsor: Nongovernment organization Activities: Offers adviceonsmoking and health programs Coalition or program: Antismoking Program (est. 1986) Sponsor: Secretariat of Health and National Council Against Addictions Activities: Supports educational activities, improved treatment for persons with smoking-related ill- ness, legislation, and research Panama Coalition or program: Adult Health Department (est. 1990) Sponsor: Ministry of Health interdisciplinary group of professionals Activities: Promotes prevention program for youths and sets guidelines for local action; reports on and evaluates prevention programs Paraguay Coalition or program: Paraguayan Antismoking Asso- ciation Sponsor: Nongovernment organizations Activities: Encourages legislation and physicians’ actions Puerto Rico Coalition or program: Coalition on Smoking and Health Sponsor: Puerto Rican Lung Association, American Cancer Society, and American Heart Association Activities: Supports legislation, education, media ac- tivities, and cessation programs Suriname Coalition or program: National Council on Drug Abuse Sponsor: Nongovernment organizations, medical association, heart-disease patients, and sports association Activities: Promotes public service announcements and school education Uruguay Coalition or program: Office on Smoking Control (est. 1988) Sponsor: Ministry of Public Health (intersectoral) Activities: Supports media activities, health care and community education, and publications Venezuela Coalition or program: National Antismoking Program (est. 1984) Sponsor: Ministry of Health and Social Welfare Activities: Promotes educational programs, media ac- tivities, and technical information Prevention and Control 203 References ADRIAANSE, H., VAN REEK, J. 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WHO Technical Report Series, No. 695. Geneva: World Health Organization, 1983b. WORLD HEALTH ORGANIZATION. Tobacco or health. Resolution WHA 39.14 of the thirty-ninth World Health Assembly, May 1986. Document No. WHA 39/1986/REC/1, 14, 1986. WORLD HEALTH ORGANIZATION. A5 Year Action Plan. Smoke Free Europe. World Health Organization Regional Office for Europe. Copenhagen, Denmark: World Health Organization, 1988. List of Tables and Figures Chapter 2 The Historical Context Table 1. Tobacco trade in England, 1700-1775 = 25 Table2. Tax revenue from tobacco sales, United States, 1865-1890 30 Table 3. Manufactured tobacco products, United States, 1870-1905 30 Table 4. Economic activity and rankings of major trans- national cigarette producers, 1989 36 Table 5. Transnational cigarette industry: subsidiaries and affiliates (financial interest) or licensing agreements 37-38 Table 6. Estimated cigarette output, by producing group, 1988 38 Table 7. Cigarette market share of major transnational firms and affiliates, selected countries, 1988 39-40 Table 8. Percentage of sales by top cigarette brands in selected countries, 1988-1989 40 Table 9. Income and profitability of tobacco manufactur- ing corporations, United States, 1970-1985 42 Table 10. Expenditures, farm value, marketing bill, and taxes for cigarettes, United States, selected years 43 Table 11. Recorded exportation and importation of ciga- rettes worldwide, selected years, 1951-1960 and 1967-1990 44 Table 12. Subsidiaries, licensing arrangements, and market shares of transnational cigarette firms, selected countries of Latin America and the Caribbean, c.1989 45 Table 13. Market share of Marlboro cigarettes, selected coun- tries, 1975-1989 46 Table 14. Percentage of cigarette sales by type of tobacco blend, selected Latin American countries, 1950-1989 47 Figure 1. Per capita cigarette consumption, United States, 1900-1991 33 Figure 2. Per capita cigarette consumption in the Americas, 1970-1990 48 Chapter 3 Prevalence and Mortality Table 1. Demographic indicators, Latin America and the Caribbean, 1950-1990 61 Table 2. Estimated population, Latin America, the Carib- bean, and the United States, 1950-1990 62 Table 3. Percentage of population living in urban centers, by country in Latin America, 1950-1980 = 63 Table 4. Table 5. Table 6. Table 7. Table 8. Table 9. Table 10. Table 11. Table 12. Table 13. Table 14. Table 15. Table 16. Table 17. Table 18. Table 19. Table 20. Table 21. Table 22. Percentage of population in Latin America and the Caribbean enrolled in school, by age group and sex, 1960-1987 63 Income distribution in Latin America and the United States, 1960 and 1975 64 Income distribution in selected countries of the Americas 65 Prevalence of cigarette smoking among persons aged 15-74 in eight cities in Latin America, ad- justed for age and sex, 1971 65 Standardized ratio of cigarette smoking among persons aged 15-74 in eight cities of Latin Amer- ica, by sex and level of education, 1971 66 Prevalence of smoking in 12 Latin American countries, 1988 67 Male-to-female ratio of smoking prevalence in seven Latin American countries, 1971 and 1988 68 Prevalence of smoking among women of repro- ductive age (15-44 years), selected areas of the Americas, 1979-1989 68 Prevalence of smoking among persons aged 15-24, selected countries of the Americas, 1986-1990 69 Prevalence of smoking and quantity smoked among persons aged 15-24, Santiago, Chile, 1988 69 Prevalence of smoking and quantity smoked among persons aged 15-24, by educational level and sex, Santiago, Chile, 1988 70 Prevalence of smoking among women aged 15-44, by reproductive history and smoking status, Santiago, Chile, 1988 70 Prevalence of tobacco use among adults reported by surveys in Latin America and the Caribbean, 1980s and 1990s 72-75 Prevalence of tobacco use among adolescents reported by surveys in Latin America and the Caribbean, 1980s and 1990s 76-77 Prevalence of smoking among women of child- bearing age, selected Latin American and Carib- bean countries, 1979-1987 78 Public knowledge and attitudes on smoking and health in Latin America and the Caribbean, 1982-1990 78-79 Modified stem-and-leaf display of prevalence of smoking among adults, selected countries of Latin America and the Caribbean, 1980s and 1990s 80 Prevalence of smoking among Hispanic persons in the United States, aged 20-74, by ethnic group and sex, selected years 80 Method used for calculating smoking-attributable mortality in the Americas 82 207 Table 23. Table 24. Table 25. Table 26. Table 27. Table 28. Table 29. Table 30. Table 31. Table 32. Table 33. Life expectancy at birth for persons born during selected periods, by region and country 83 Mortality from defined causes, selected countries, c.1985 84 Mortality from defined causes, regions of the Americas, c.1985 85 Deaths from six major causes as a percentage of all deaths from defined causes, for persons aged 35 or older, selected countries, c.1985 86 Deaths (in thousands) from six major causes, for persons aged 35 or older, selected regions of the Americas, c.1985 88 Smoking-attributable fraction for 10 selected causes of death, United States, 1985 89 Smoking-attributable mortality in the United States 90 Estimated number of deaths due to tobacco use in 27 countries of the World Health Organization (WHO) European Region 91 Smoking-attributable fraction (SAF) and adjusted SAF for lung cancer mortality, selected industri- alized countries, 1978-1981 92 Smoking-attributable mortality for men and women in the Americas, c.1985 94-95 Adjusted estimates of smoking-attributable mor- tality in the Americas, c.1985 96 Chapter 4 Economics of Tobacco Consumption in the Americas Table 1. Table 2. Table 3. Table 4. Table 5. Table 6. Table 7. Table 8. Table 9. Table 10. 208 Relative risks for death attributed to smoking and smoking-attributable mortality for current and former smokers, by disease category and sex, United States,1988 106 Components of the costs of the health effects of smoking 109 Medical care costs for smokers, by study type and author 110 Value of productivity lost due to mortality and morbidity, by study type and author 111 Per capita cigarette consumption and income in the Americas 117 Estimates of income elasticity of demand for cigarettes 118 Estimated advertising expenditures of tobacco in- dustry in selected countries of the Americas 178 Share of world tobacco production, 1990 119 Labor and land use in tobacco growing, processing, and manufacturing in the Americas, 1983 120 International trade in tobacco, 1984 and 1985 = 123 Table 11. Recent estimates of the price elasticity of demand forcigarettes 130 Table 12. Estimates of the price elasticity of demand for cigarettes in the United States, by age group = 131 Figure 1. Correlation between cigarette consumption per person who entered adult life in 1950 and lung cancer rate for that generation as it entered mid- dle age in mid-1970 = 107 Figure 2. Per capita rate of cigarette consumption in Brazil and hing cancer deaths for men in Rio Grande do Sul, Brazil 108 Figure 3. Factors, other than price, that affect the demand for tobacco products 115 Figure 4. Per capita cigarette consumption and annual per capita gross national product in 24 countries of the Americas, 1985 116 Figure 5. Predicted and actual per capita (2 18 years of age) consumption of cigarettes, United States, 1979-1988 132 Figure 6. Per capita consumption and real price of ciga- rettes in Canada, 1982-1987 133 Chapter 5 Legislation to Control the Use of Tobacco in the Americas Table 1. Number of countries that control the production, sale, and promotion of tobacco, by type of legis- lation and region 148 Table 2. Countries that control tobacco advertising and promotion, by type of restriction 149 Table 3. Countries that require health warnings or state- ment of tar and nicotine yield 151 Table 4. Countries that restrict smoking in public places, by typeof place 155-156 Table 5. Countries that attempt to prevent young people from using tobacco, by type of restriction 159 Table 6. Countries that mandate health education on to- bacco use, by type of provision 160 Chapter 6 Status of Tobacco Prevention and Control Programs in the Americas Table 1. Selected data for popular brands of cigarettes in 20 countries 188-189 Table 2. Tobacco tax and tariff in selected countries of the Americas, 1988 orearlier 190 Table 3. Excise taxes on manufactured cigarettes as per- centage of total retail price and of total national tax revenue, 1989 or most recent year available 191 Table 4. Principal legislative measures for control of tobacco in the Americas, by type of measure and country 192-193