Smoking and Health in the Americas Smohg md Health in the Ameticas A 1992 Report of the Surgeon General, in collaboration with the Pan American Health Organization U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Public Health Service Centers for Disease Control National Center for Chronic Disease Prevention and Health Promotion Office on Smoking and Health PAN AMERICAN HEALTH ORGANIZATION Pan American Sanitary Bureau, Regional Office of the WORLD HEALTH ORGANIZATION Suggested Citation U.S. Department of Health and Human Services. Smoking and Health in the Americas. Atlanta, Georgia: U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 1992; DHHS Publication No. (CDC) 92-8419. THE SECRETARY OF HEALTH AND HUMAN SERVICES WASHINGTON. O.C. 20201 FLY i + 1~32 The Honorable Thomas S. Foley' Speaker of the House of Representatives Washington, D.C. 20515 Dear Mr. Speaker: It is my privilege to transmit to the Congress the 1992 Surgeon General's report on the health consequences of smoking as mandated by Section 8(a) of the Public Health Cigarette Smoking Act of 1969 (Pub. L. 91-222). The report was prepared by the Centers for Disease Control's Office on Smoking and Health in conjunction with the Pan American Health Organization. The topic of this report, Smokina in the Americas, reflects a concern for the broader problems posed by tobacco consumption. The report explores the historical, social, economic, and regulatory aspects of smoking in the Western Hemisphere. It defines the current extent of tobacco control activities in the countries of the Americas and stresses the need for regional coordination and cooperation in our efforts to create a smoke- free society. The countries of North America --the United States and Canada--are in the midst of a major epidemic of smoking-related disease, including cancer, heart disease, disease, chronic obstructive lung and adverse outcomes of pregnancy. The countries of Latin America and the Caribbean now show evidence of a rising prevalence of smoking, particularly among young people, and in the absence of efforts to decrease tobacco use, are likely to be swept by a similar epidemic. I believe that we in the United States must provide leadership through continued efforts to control tobacco consumption and prevent the uptake of smoking by young people. In addition, I believe that we must participate fully in regional efforts to develop effective smoking-control programs. Sincerelv. Enclosure THE SECRETARY OF HEALTH AND HUMAN SERVICES WASHINGTON. O.C. 20201 The Honorable Dan Quayle President of the Senate Washington, D.C. 20510 Dear Mr. President: It is my privilege to transmit to the Congress the 1992 Surgeon General's report on the health consequences of smoking as mandated by Section 8(a) of the Public Health Cigarette Smoking Act of 1969 (Pub. L. 91-222). The report was prepared by the Centers for Disease Control's Office on Smoking and Health in conjunction with the Pan American Health Organization. The topic of this report, Smokino in the Americas, reflects a concern for the broader problems posed by tobacco consumption. The report explores the historical, social, economic, and regulatory aspects of smoking in the Western Hemisphere. It defines the current extent of tobacco control activities in the countries of the Americas and stresses the need for regional coordination and cooperation in our efforts to create a smoke- free society. The countries of North America --the United States and Canada--are in the midst of a major epidemic of smoking-related disease, including cancer, heart disease, disease, chronic obstructive lung and adverse outcomes of pregnancy. The countries of Latin America and the Caribbean now show evidence of a rising prevalence of smoking, particularly among young people, and in the absence of efforts to decrease tobacco use, are likely to be swept by a similar epidemic. I believe that we in the United States must provide leadership through continued efforts to control tobacco consumption and prevent the uptake of smoking by young people. In addition, I believe that we must participate fully in regional efforts to develop effective smoking-control programs. Sincerely, Louis W. Sullivan, M.D. Enclosure Foreword By the mid-1980s, an estimated 526,000 people in the Americas were dying each year of diseases that are directly attributable to smoking. The number contin- ues to increase. Most of these deaths occur in Canada and the United States, where smoking has been a widespread, entrenched habit for over 60 years. However, approximately 100,000 deaths occur annually in the countries of Latin America and the Caribbean. We are in the unfortunate position of watching an epidemic-like the one we are currently living with in the United States-begin to gather momentum among our neighbors. The determinants of smoking are complex. Many forces are brought to bear on the young person who is deciding whether or not to smoke. The current overall prev- alence of smoking in a population-a general measure of its social acceptability- plays a large role. The frequency with which peers or role models smoke may be even more important. The current laws and regulations that govern smoking may influence the decision, as do the price of cigarettes and the ease with which they can be purchased. The extent to which tobacco products are advertised and the forms and mechanisms for tobacco promotion are also likely to have a major influ- ence on a young person's decision. All of these combine in an intricate way to create a social norm; the individual decision is hardly an isolated and independent event. Considerable gains have been made against smoking in Canada and the United States in recent years. As documented in previous Surgeon General's reports, the prevalence of smoking in the United States has been falling at a rate of approximately 0.5 percentage points per year. But millions continue to smoke, and the current rate of decline will not reduce smoking prevalence to the goal of 15 percent set for the year 2000. It is clear that the efforts under way in the United States and Canada are important in maintaining the momentum of smoking abate- ment, but it is equally clear that they are insufficient. More sectors of society must be brought into the nonsmoking coalition, and the tools at our disposal must be further strengthened. Other countries of the Americas face different circumstances. For some, still in the process of economic development, the prevalence of smoking is still low, and the problem may have a lower priority than more acute public health concerns. For others, further along in their development, diseases associated with smoking are already major causes of death, and the prevalence of smoking is high among young people in urban areas. Overall, the impact of smoking-related illness is not yet as evident in the other countries of the Americas as in Canada and the United States. However, the high prevalence among young people in many of these countries is ominous. Each country must deal with its problem in its own political, economic, and cultural context. Nonetheless, the countries of the Americas face a common threat, even though they may be in differing stages of its evolution. A common approach, characterized by agreement on goals, objectives, and means, can benefit the entire region. The Pan American Health Organization (PAHO) has taken significant steps to establish a forum for the exchange of ideas and for the development of a joint plan of action. As a regional branch of the World Health Organization, PAHO in turn takes part in an international forum for coordinated action against tobacco. The individual decision to smoke-both now and in the future-will ultimately be influenced by these efforts of the global community. This Surgeon General's report is the twenty-second in a series that was inaugurated in 1964 and mandated by law in 1969. The current report looks at the place of smoking in the societies of the Americas and at the current efforts to prevent and control tobacco use. It is perhaps best viewed as a planning document, a portrayal of the current situation in the Americas that will provide the basis for a concerted approach to future prevention strategies. James 0. Mason, M.D., Dr.P.H. William L. Roper, M.D., M.P.H. Assistant Secretary for Health Director Public Health Service Centers for Disease Control Preface from the Surgeon General, U.S. Department of Health and Human Services This 1992 report of the Surgeon General, Smoking and Health in the Americas, is the second on smoking and health during my tenure as Surgeon General. Over the years, the reports have systematically examined the effect of smoking on human health: the biologic effects of substances in tobacco, the risks of disease, the susceptibility of target organs, the addictive nature of nicotine, and the evolving epidemiology of the problem. The reports summarize a massive amount of infor- mation that has accumulated on the untoward effects of tobacco use, now easily designated the single most important risk to human health in the United States. The 1990 report, The Health Benefits of Smoking Cessation, documented the positive impact of quitting and thus furthered the logical argument leading to a smoke-free society. This report is a departure from its predecessors in that it treats the evidence against smoking as an underlying assumption. The issue for the future is how we will go about achieving a smoke-free society, and a consideration of smoking in the Americas is an early step in that direction. The report explores the historical, epidemiologic, economic, and social issues that surround tobacco use in the Amer- icas. It focuses on cultural antecedents and trends, on social and economic struc- ture, and on the local, national, and regional efforts that are currently under way to control tobacco use. One of the striking inferences to be drawn from the report is that the countries of the Americas occupy a continuum of consequences related to smoking. This continuum appears to be related to overall economic development. Countries that are furthest along the path of industrialization have gone through a period of high smoking prevalence and are now experiencing the incongruous combination of declining prevalence and increasing morbidity and mortality from smoking. Other countries, substantially along the path, are entering a period of high prevalence and may also be experiencing some of the disease and disability associated with smok- ing. Still others, less developed industrially, have low prevalences of smoking and relatively lower estimates for smoking-attributable mortality, but must contend with numerous other public health issues. Not all countries fit easily into such a simple classification. Within countries, there is considerable diversity in the pace of industrialization, urbanization, and general development as well as in the manifestation of th'e effects of tobacco use. But the classification is useful in defining the pathway that all countries are likely to take. In the absence of coordinated action, the epidemic of tobacco use is likely to proceed according to a well-defined script: gradual adoption of the smoking habit, long-term entrenchment of tobacco use, and a major loss of human life. The forces that create this script are complex and often difficult to untangle. One of the major findings of the report is the crucial role of surveillance in understanding the intricate interrelationship of the factors that influence smoking. 122 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 iv Preface from the Director, Pan American Healfh 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 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 I'. Eriksen., Sc.D., Director, Office on Smoking and Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control, Atlanta, Georgia. 7'he 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, Port0 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. Eric Nicholls, M.D., Regional Advisor in Chronic Diseases, Pan American Health Organization, Washington, D.C. Thomas 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., MSc., Head of Epidemiology and Prevention Division, National Cancer Institute, Bogota, 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 Lopez Antuiiano, M.D., Director, Health Program Development, Pan American Health Organization, Washington, D.C. vii Elias Anzola, M.D., Medical Officer, Health Promotion Program, Pan American Health Organization, Washington, D.C. Howard Barnum, I'h.D., Senior Economist, The World Bank, Washington, D.C. Glen Bennett, M.P.H., Coordinator, Smoking Education Program, Health Education Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland. Monica 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 Seeds 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, MS., 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. 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. . Vllf Gerard0 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, DSc., 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. 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 Promotion, 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., MS., 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. ix 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. 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. X 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 25 Tobacco Use in Indigenous Societies 2 9 The Emergence of the Cigarette, 1492-1900 23 The Emergence of the Tobacco Companies, 1900 to the Present 32 Chapter 3. Prevalence and Mortality 57 Prevalence of Smoking in Latin America and the `Caribbean 62 Smoking-Attributable Mortality in Latin America and the Caribbean 82 Chapter 4. Economics of Tobacco Consumption in the Americas 202 Economic Costs of the Health Effects of Smoking 205 Economics of the Tobacco Industry 224 Chapter 5. Legislation to Control the Use of Tobacco in the Americas 243 Legislation to Control Production, Manufacture, Promotion, and Sales 248 Legislation to Change Smoking Behavior 253 The Impact of Antitobacco Legislation 262 Chapter 6. Status of Tobacco Prevention and Control Programs in the Americas 2 79 National Programs for Tobacco Control 283 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