Consumption (Demographics)

In 1753, Carl Linnaeus, a Swedish botanist, officially named a well-known plant Nicotiana tabacum. The name honored Jean Nicot de Villemain, France's ambassador to Portugal in 1560, who wrote of the new herb's wonderful medicinal properties and sent some ground-up leaves to Catherine de Medici, the Queen of France, to cure her son's migraine headaches. Catherine and her court became enamored of the product. However, the herb had already been used widely in Europe and elsewhere before this event. The word "Tobago" or "tobacco" appears to be the Native American name for the pipe or cylinder used by many to inhale smoke from the burning leaves of this plant—leaves that contain nicotine, a psychoactive and addictive drug.

Ways of Consuming Tobacco

The main ways of consuming tobacco have involved inhalation of smoke from burning tobacco leaves or the use of smokeless tobacco products (snuff and chewing tobacco), where nicotine from ground tobacco leaves is absorbed through membranes in the mouth or nose.

PIPES. In earliest times, tobacco smoke was inhaled through a long tube or pipe. American Indians used communal smoking of long, decorated clay pipes as a ceremony indicating good will. Long clay pipes were also used in Europe. British author Alfred Lord Tennyson liked to smoke clay pipes and kept handy a basket filled with them. He could only smoke one pipe for a few minutes because it soon became too hot and he would have to throw it away. Lord Tennyson would sit in this way all day: filling, smoking, breaking-up, and discarding pipes. Shorter wooden pipes such as briar pipes date mainly from the nineteenth century but there is some mention of earlier wooden pipes that closely resembled the long clay pipes.

In India and Arabia, smokers preferred water pipes (also known as hookahs, gozas, narghiles, and sheeshas), where the smoke cooled by passing through water before inhalation. These water-cooled pipes were typically used for social gatherings where the mouthpiece, at the end of the long, flexible snake-like pipe, was passed around. The lips would not touch the mouthpiece, but the smoke would be captured in cupped hands. Many British people in India engaged in this type of smoking, and it was given the nickname "hubble-bubble."

CIGARS. The Mayan term for smoking was sik'ar, which is probably the derivation of the word "cigar." Early cigars were a long thick bundle of twisted tobacco leaves wrapped in a dried palm or maize leaf. Cigars were produced in tabacerias in Spain in the seventeenth century and became the predominant form of tobacco use in Europe during the nineteenth century. Twenty-first-century cigars consists of filler, binder, and wrapper, all of which are made of air-cured and fermented tobacco. The modern cigar has a characteristic aroma and flavor that comes mainly from the fermentation process. However, the word "cigar" refers to a wide range of products that are wrapped in tobacco leaf, reconstituted tobacco, or paper treated with tobacco extract. A small cigar made of heavy-bodied tobacco is called a cheroot in many parts of the world and a chutta in parts of Asia, especially India.

SMOKELESS TOBACCO. Prior to the invention of the phosphorous match in the mid-nineteenth century, two forms of smokeless tobacco were popular: snuff and chewing tobacco. Snuff became the preferred nicotine delivery system for the upper class in Europe in the seventeenth and eighteenth centuries, becoming popular in England after 1660 when the court of Charles II introduced it upon returning to London from exile in Paris. The tobacco leaf was ground up with a rasp into a fine powder that could be inhaled through the nose. An instruction manual from this Rococo period (c. 1750) laid out fourteen steps for the genteel use of snuff, including the manner for extracting snuff from the box and bringing it to the nose. Two of the final steps included "Take in the snuff evenly with both nostrils without making a grimace" and "Sneeze, cough, expectorate" (Schivelbusch, p. 13). Elegant habitués prided themselves on being able to stuff their noses with snuff without sneezing. An indication of snuff's popularity can be seen from Marie Antoinette's wedding presents; there were more than fifty gold snuff boxes, making them an even more popular gift than gold watches.

The preferred forms of smokeless tobacco among Americans of European decent were chewing tobacco and snuff used as a moist dip. To use snuff, a small instrument was needed to deposit moist dip on the gums or to place a pinch inside the cheek. Chewing tobacco needed no instrument and was a favorite of sailors and men who worked outdoors for use while working. Early on, chewing tobacco was sold in loose bulky bags. Later, sweeteners were added, and it was molded into lumps to fit into a pocket. Chewing, in particular, led to the mouth becoming filled with tobacco juice that could either be swallowed (often causing stomach problems) or, preferably, spat out. When the Catholic pope banned smoking in church in 1642, some prelates sought to maintain their nicotine habit by changing to chewing tobacco. British writer Sir Compton Mackenzie noted with amazement that he had encountered one particular prelate in Seville who would chew tobacco during his sermon and then "spit over the heads of pious women seated on the floor under his pulpit and each time hit the same flagstone with his tobacco juice" (Kiernan 1991).

CIGARETTES. Cigarettes are made from fine-cut tobacco and are wrapped in paper or some type of organic leaf. They typically measure between 60 and 120 millimeters in length and between 20 and 30 millimeters in circumference and have a weight that ranges from 500 to 1,200 milligrams. Cigarettes originated as cigaritos in Spain and Portugal in the seventeenth century and were made from the leftovers from cigar manufacturing. Significant improvements in cigarette paper were introduced in Barcelona around the end of the eighteenth century.

Cigarettes had advantages over other types of tobacco in that they could be consumed within a relatively short period of time. The lack of accompanying instruments or paraphernalia meant that they could be smoked easily even while working, and they were less likely to soil clothes. Cigarettes became popular in France during the French revolution, and the French government began licensing cigarette manufacturing about 1840. Cigarettes started to be popular in England after the Crimean War (1854–1856). Mass production of cigarettes, however, was limited before the invention of the first successful cigarette manufacturing machine in 1884.

Despite the availability of manufactured cigarettes, hand-rolled cigarettes are popular in some parts of the world. For example, Indian bidis are slim, unfiltered cigarettes wrapped in tendu leaves instead of paper, the leaves being less permeable to air and requiring the smoker to inhale more deeply. Cheap labor in India has enabled these handmade cigarettes to be sold at a competitive price as a prerolled cigarette. However, in other places, some smokers appear to prefer the time-consuming ritual of rolling their own cigarettes from bulk tobacco that is sometimes perceived to have less additives.

Origins of Tobacco Consumption

Archeological studies of clay pipes and pottery indicate that there was widespread tobacco use in the Americas before explorer Christopher Columbus arrived. Clay pipes and Mayan pottery depicting smoking have been dated before the eleventh century. In 1492, Columbus mentions in his journal seeing a man carrying "dried leaves which are in high value among them for a quantity of it was brought to me at San Salvador" (Borio). When Hernan Cortez conquered the Aztec capitol in 1519, he found Mexican natives smoking tobacco stuffed inside perfumed reeds. A few years later in 1536, Jacques Cartier wrote of the Iroquois who lived near the St Lawrence River:

They have a plant of which a large supply is collected in summer for the winter's consumption. They hold it in high esteem, though the men alone make use of it in the following manner. After drying it in the sun, they carry it around their necks in a small skin pouch in lieu of a bag, together with a hollow bit of stone or wood. Then at frequent intervals, they crumble this plant into powder which they place into one of the openings of the hollow instrument, and laying a live coal on top, suck at the other end to such an extent that they fill their body so full of smoke that it streams out of their mouths and nostrils as from a chimney. (von Gernet, p.)

Similar behaviors were reported among Native-American tribes from differing parts of the Americas in the early years of European settlement.

Worldwide Spread of Tobacco Consumption

It is clear from the writings of the time as well as from archaeological excavations that Europe did not consume tobacco prior to Columbus's voyage to the Americas. In the early years after the explorers and sailors introduced tobacco along trading routes and to home countries, most tobacco was smoked with a clay pipe. While there is much evidence that such pipes and other instruments related to smoking (for example, tongs used for obtaining embers from a fire to light a pipe) were found in Europe after Columbus's voyage, there are no such artifacts dated before the voyage. The rapid and widespread diffusion of tobacco consumption around the world has been attributed particularly to Portuguese sailors:

Before the end of the sixteenth century the [Portuguese] had developed these small farms to a point where they could be assured of enough tobacco to meet their personal needs, for gifts, and for barter (Brooks).

The Spanish from Mexico introduced tobacco to the Philippines, where it was cultivated before 1600. Around 1600, Asia and the Ottomans had begun to smoke. The Portuguese brought it to Japan before 1590, and by 1643 it was grown widely in both China and Japan. The Portuguese also introduced tobacco to West Africa by the early seventeenth century. Several Englishmen have been credited with introducing it to England, including explorers James Hawkins, Sir Francis Drake, and Sir Walter Raleigh, but historians agree that Raleigh was the first to make tobacco use fashionable in England, after he smoked at the execution of the Earl of Essex in 1601. In the 1790s, the Scottish explorer Mungo Park, during his attempts to find the source of the Niger River, found tobacco in demand wherever he went in Africa.

The rapidity with which tobacco consumption diffused across the world was fueled by the rapid expansion of its cultivation on large tracts of previously wild lands in the Americas. In 1614, the Spanish king acted to ensure an adequate supply of tobacco by mandating that all tobacco grown in the Spanish-controlled New World be shipped to Seville in Spain. Tobacco plantations in the English colonies of Virginia and Maryland, manned by a flourishing slave trade, were able to expand their tobacco exports sixfold to meet growing demand between 1663 and 1699. This success led to further expansion of tobacco growing into the new territories as the new nation expanded following the American Revolution.

Advertising Helps Cigarettes Become Dominant Mode of Consumption

In the United States and elsewhere, the Industrial Revolution created a wide range of economical mass-produced products, signaling the start of the consumer age. In the mid-1880s, James Duke assisted in perfecting the Bonsack machine for manufacturing cigarettes and negotiated a 25 percent lower price than any other cigarette manufacturer. He used the cost savings to start a marketing war (involving product packaging, advertising, promotional activities, and price), to build consumer demand and to consolidate the entire U.S. tobacco industry into a monopoly. However, it was not until the tobacco monopoly was dissolved through antitrust court action in 1911 that cigarette advertising started in earnest. In that year, U.S. annual per capita consumption (the average number of cigarettes smoked per member of the population above a specified age) was still less than 0.5 cigarettes per person (fourteen years of age and older), and cigarettes made up only 5 percent of the tobacco consumption market.

The changes in tobacco consumption over the first fifty years of the twentieth century are presented in Figure 1. R.J. Reynolds, founder of the R.J. Reynolds Tobacco Company, understood the possibilities of cigarettes and introduced a new cigarette (Camel) made from a sweeter tobacco leaf, which he promoted with an innovative and well-funded advertising campaign aimed at men. Reynolds' advertising campaigns and business prowess were so effective that the company has been credited with the rapid increase in per capita consumption—more existing consumers switched to cigarettes and new consumers preferred them. Between 1911 and the start of World War I, cigarette consumption increased by a factor of 2.3, while total tobacco consumption declined.

This conversion to cigarettes increased during the war when nicotine was seen as helpful for handling stress and maintaining attentiveness, and because manufactured cigarettes were easy to carry and were the quickest way to get a nicotine effect. The nation responded when General "Black Jack" Pershing (then commander of the American Expeditionary Forces) indicated that in his view, to win the war, fighting men needed to be supplied with cigarettes as well as bullets. Organizations such as the Red Cross and the Young Men's Christian Association started a drive to provide free cigarettes to the troops. By 1920 cigarettes represented 23 percent of the total tobacco market, though the total market for tobacco products had increased by only 4 percent since before the war.

In the mid-1920s, the American Tobacco Company, with the lowest market share of the three major companies (ATC, R.J. Reynolds, and Liggett and Myers), was the first to successfully target women with its innovative Lucky Strikes advertising campaign. The slogan "Reach for a Lucky instead of a sweet" was associated with a major increase in the number of young women starting to smoke. Because the market leader, Camel cigarettes, was slow to follow this lead, by 1930 Lucky Strikes had become the leading cigarette brand in the United States. The large increase in smoking among women was associated with a doubling of per capita cigarette consumption between 1920 and 1930. By then cigarettes had captured 43 percent of the total tobacco consumption market. However, the weight of all tobacco sold in the United States grew by only 2 percent over this period, suggesting that the manufactured cigarette led to a lot less wastage than other methods of consumption.

Huge advertising campaigns for cigarettes continued throughout the 1930s, and the decade ended with little change in the overall weight of tobacco sold but with cigarettes sales at 56 percent of the total tobacco market. This situation changed with World War II when the provision of free cigarettes to the armed forces led to a marked 40 percent increase in the overall weight of tobacco consumed. By the end of the war, cigarettes accounted for almost 75 percent of the weight of all tobacco consumed.

As presented in Figure 1, the amount of tobacco sold per capita grew by 61 percent in this fifty-year period. However, the most important change was the emergence of cigarettes as the dominant form of tobacco consumption. At the start of the century only 2 percent of U.S. tobacco sales by weight were for cigarettes; at the half-century mark, this proportion had risen to nearly 80 percent. However, not all countries had the same advertising-driven rise in consumption of manufactured cigarettes. India is perhaps the best example, where even as late as the 1990s an estimated 40 percent of tobacco consumption came from chewing tobacco, another 40 percent from hand-rolled bidi cigarettes, and less than 20 percent from manufactured cigarettes.

In the second half of the twentieth century advertising campaigns were also demonstrated to influence consumption behavior, although during this period overall per capita consumption was declining because of the public health campaign against smoking. Three important examples illustrate the effect of advertising on consumption. In the late 1960s, the tobacco industry introduced a group of cigarettes that were made for and advertised specifically to women, Virginia Slims being the most popular. The introduction of these brands was associated with a major increase in smoking initiation by adolescent girls, particularly those who were not college bound. There was no increase in initiation by young adult women or by adolescent or young adult males.

In the late 1970s, the tobacco industry launched a major promotional campaign for smokeless tobacco that was specifically targeted at young baseball players. Between 1978 and 1985, sales of moist snuff increased dramatically. By 1985, 40 percent of male college baseball players were using smokeless tobacco regularly compared to only 3 percent who were smoking cigarettes, in marked contrast to the consumption pattern in the 1950s and 1960s.

The third example is the "Joe Camel" character campaign of the R.J. Reynolds tobacco company introduced in 1987. Reynolds' internal documents demonstrate the company was worried about declining market share and therefore was increasingly excited about the effect of this campaign on adolescents. That effect was a general surge in U.S. adolescent smoking from the start of this campaign until it was halted as part of a legal settlement between states attorneys general and tobacco companies in 1998. During the campaign, adolescent receptivity to tobacco marketing was a major predictor of who started smoking.

Tobacco and Health

Throughout history, the willingness of people to experiment with tobacco and to continue to consume at high levels has been influenced by beliefs about its medicinal properties and adverse health consequences. From the beginning, tobacco was seen as more than just a recreational drug. For example, the Peruvian natives limited tobacco use to medicinal purposes, generally in the form of snuff, and European medicine at the time readily adopted the idea that inhaling smoke could exert a positive influence. Before 1600 there were several treatises by physicians in different parts of Europe attesting to the widespread prescription of tobacco for numerous maladies. One treatise listed it as a cure for toothache, falling fingernails, worms, halitosis, lockjaw, and cancer; another listed it as a cure for colic, nephritis, hysteria, hernia, and dysentery. The first book written solely about tobacco appeared in 1587 in Antwerp, Belgium, and was titled De Herbe Panacea.

While the medical literature occasionally suggested that tobacco use was associated with harmful consequences, it was not until five key research papers were published in 1950 that medical researchers started to become convinced that the sudden rise in lung cancer deaths, beginning in 1920, was caused by the increase in cigarette smoking. Throughout the 1950s, the scientific evidence continued to mount, particularly in the United Kingdom and the United States.

New findings linking smoking to lung cancer received substantial attention in the newspapers of the day and appeared to cause a small but short-lived surge in successful quitting. In response to this threat to cigarette consumption, the tobacco industry introduced filtered cigarettes with advertisements implying that they were less harmful. In addition, beginning in 1953 the industry used its own Tobacco Industry Research Committee (TIRC) to produce and promote scientific critiques of each new piece of evidence.

Public recognition of the dangers of smoking—and its consequent impact on consumption—has been a very gradual process. Even after the release of the 1964 Surgeon General's report, only 66 percent of the population agreed with the statement that cigarette smoking caused lung cancer. In 1978, the tobacco industry introduced "low tar and nicotine" products with the promotional message that they would reduce the harmful effects of cigarette smoking. However, scientists have concluded that neither cigarette filters nor "low tar and nicotine" cigarettes result in any identifiable harm reduction for smokers. The power of this strategy was shown by the slow rise in the general acceptance of the link between cigarette smoking and lung cancer (see Figure 2). It was not until the mid-1980s that over 85 percent of the population agreed that smoking caused lung cancer, nearly twenty-five years after the public health community issued one of the most thorough presentations of evidence ever to indict a product.

U.S. Patterns in Starting and Quitting Cigarette Smoking

The two behavioral processes that influence smoking prevalence are smoking initiation and smoking cessation. Considerable evidence reveals an age window during which people are at much greater risk of starting to smoke. Influences on who starts to smoke are environmental. While the environment also influences desire to quit, successful quitting requires the smoker to overcome considerable physiological, psychological, and behavioral dependencies that are characteristic of smoking behavior. Thus environmental influences are expected to have a much stronger influence on initiation rates than on cessation rates.

MALE AND FEMALE DIFFERENCES IN THE UPTAKE OF CIGARETTE SMOKING. Although cigarette smoking was not very prevalent at the start of the twentieth century and was virtually nonexistent among women, this changed rapidly as the century progressed. The percentage of each U.S. birth cohort (those born during a defined time period, for example 1900–1904) who reported that they had currently or had previously been a smoker (referred to as "ever" smokers and defined as the consumption of at least 100 cigarettes in one's lifetime) is presented in Figure 3.

Among men the highest percentage of ever smokers in a birth cohort was 80 percent. White men born between 1905 and 1929 and African-American men born between 1915 and 1929 reached this peak level. The percentage of ever smokers in a birth cohort started to decline with men in the 1930–1934 birth cohort, that is, those who were under 21 years when the first definitive evidence of smoking and cancer was disseminated. The decline continued with each birth cohort so that among men born between 1955 and 1959 (aged 21 in the late 1970s), just over half (53%) reported ever smoking, one-third less than their parents' generation (1925–1929). Importantly, this decline resulted from a major decrease in the uptake of smoking among adults over the age of 20 years and not from a decrease in uptake among teenagers. Thus, by the year 2000, the vast majority of people who started smoking had had their first cigarette before they were 18 years of age.

Less than 15 percent of women born before the turn of the twentieth century (those turning 21 before 1920) reported ever smoking. This percentage increased dramatically for women born in the first twenty years of the century to around 46 percent for the 1915–1919 birth cohort, coinciding with adolescent exposure to the advertising campaigns that targeted women. African-American women did not catch up to white women until the 1920–1924 birth cohort, after which the patterns were indistinguishable. The proportion of people who reported having smoked at least 100 cigarettes in their lives ("ever" smokers) peaked among women at approximately 55 percent in the 1940–1944 birth cohort and declined slightly to around 50 percent by the 1955–1959 birth cohort. Thus, the large male-female difference in the percentage of people who ever started smoking may have disappeared in cohorts born after 1960.

DEMOGRAPHIC DIFFERENCES IN QUITTING SMOKING. By 1965, of ever smokers, 27 percent of males and 19 percent of females in the United States were former smokers. The lower rate among women

possibly reflects an initial perception that the lung cancer epidemic was peculiar to men and not women, due to the fact that all the early studies on smoking and cancer were completed on men. By 2000, quitting had increased markedly in both genders to 50 percent for men and 47 percent for women.

Differences in quitting are most pronounced between educational groups (see Figure 4). By 1970, almost half of college-graduated U.S. smokers had quit compared to one-third of all other smokers. By 1993, quitting had increased by 13 percent among those who had not attended any college (to 47%) and in 1994, by 21 percent (to 70%) among those who had graduated college. These figures suggest that the higher educated are either more motivated to quit or are more skilled at quitting. However, there were no further increases in quitting in any U.S. group (gender, race, educational) between 1993 and 2000. This halting of the increased trend for successful quitting is a major public health concern and is currently the subject of ongoing research.

WORLDWIDE SMOKING PATTERNS. At the turn of the twenty-first century, lung cancer had become the most common cancer in the world. There are estimated to be 1.2 million new cases each year, about half of which are in the developed countries. The pattern of lung cancer incidence and death follows the pattern of cigarette consumption that occurred about twenty years earlier. Thus, worldwide, lung cancer is three times more common in men than women, because cigarette smoking has historically been much more common in men.

The developed countries with the highest lung cancer incidence are the countries of Eastern Europe, North America, Australia/New Zealand, and South America. In developing countries, the highest rates are seen for countries in the Middle East, China, the Caribbean, and South Africa. For women, the highest incidence rates are in North America and certain European countries such as the United Kingdom, Iceland, and Denmark, with moderate incidence rates found in Australia and New Zealand.

MALE-FEMALE SMOKING RATES AT THE BEGINNING OF THE TWENTY-FIRST CENTURY. In 2000, according to World Health Organization (WHO) data, of the 72 countries selected for review in this chapter, there were 19 in which over 50 percent of men were current smokers (see Table 1). However, many of these countries include those with low annual per capita cigarette consumption levels (see Table 4), suggesting that consumption may be nondaily and even sporadic for many smokers, and the increase in lung cancer may not have been sufficient to galvanize the public health movement against smoking. A further 15 countries had male smoking rates between 40 percent and 50 percent, including South Africa, where there has been a steep decline in annual per capita consumption since the end of apartheid and the change of government to majority rule in 1994. There were only four countries and the U.S. state of California (considered as an autonomous unit since its consumption differs markedly from the rest of the United States) in which male participation was below 20 percent. One of these is Sweden, where there appears to have been a widespread substitution

of smokeless tobacco for cigarettes. California had a well-funded comprehensive tobacco control program throughout the 1990s.

While 52 countries had male smoking rates of 30 percent or greater in 2000 (see Table 2), only 8 countries (mainly in South America or Europe) had comparable female rates. Eight more countries had female smoking rates between 25 percent and 29.9 percent, including the United Kingdom and New Zealand, two countries that, while having

made progress in reducing smoking prevalence, still had rather high rates. While none of the countries on the WHO list had male prevalence rates below 10 percent, in 25 countries the prevalence among women was, in fact, below this level.

In almost all the countries represented, male smoking rates at the turn of the twenty-first century were dramatically higher than female rates. The countries with the closest male-to-female rates consist of those considered closest to equality in other social areas as well (for example,

job opportunity, status within the family), including Switzerland, Denmark, United Kingdom, Ireland, New Zealand, and Norway. There were 22 countries in which the male smoking rate was more than 5 times that of females, including a number with high annual per capita cigarette consumption rates (see Table 4 below) such as Indonesia, Russia, South Korea, and China.

TRENDS IN CONSUMPTION, 1970–2000. Since 1970, WHO has compiled comparable estimates of tobacco consumption from national trade statistics with consumption estimated as locally produced product plus imports minus exports. Yearly census data are then used to estimate per capita cigarette consumption. However, these data can give a biased picture if there are significant population subgroups in which consumption trends are different (such as women). Another factor that can distort estimates is significant cigarette smuggling into or out of the country not reflected in the trade statistics.

PEAK CONSUMPTION. Between 1970 and 2000, annual per capita cigarette consumption in most countries peaked and started to decline. Table 3 presents the year of the highest recorded consumption in 84 countries. Approximately 20 percent of these countries peaked in each five-year period from 1970 through 1985. However, 15 percent of countries with such data available had not peaked before 1995. The United States and the United Kingdom, the countries first credited with identifying the health consequences of cigarette smoking, were among the first to show a decline in consumption.

The magnitude of peak consumption will be affected by whether there are any significant population subgroups that are not consumers (for example, women and some religious groups). However, it can also reflect a different pattern of consumption in a population (for example, nondaily smoking). Thus, differences between countries or a change within a country in per capita cigarette consumption may not correlate strongly with the incidence of disease. While there is very little data on the variation in blood nicotine concentrations in smokers of different countries, there is considerable evidence that different people extract different amounts of nicotine, carbon monoxide, and tar from the same number of cigarettes smoked because of differences in the way they smoke (for example, how many puffs they take or how deeply they inhale). With these caveats, the peak levels of consumption for different countries are presented in Table 4.

There are huge differences in the peak level of annual per capita cigarette consumption reached in differing countries. A total of 18 countries peaked at more than 3,000 cigarettes per capita—an average of approximately 8 to 9 cigarettes per day for every adult resident in the country, defined by the WHO as those aged 15 years and older. These countries include the predominantly English-speaking developed countries (United States, United Kingdom, Canada, and Australia), only a few Western European countries (Greece, Netherlands, Switzerland), and two Asian countries (Japan and South Korea). Most European countries (26) had a peak per capita consumption between 2,000 and 3,000. Of the 27 countries peaking at less than 1,500 cigarettes per capita, most are from the developing world with the exception of Norway, alone among Western European countries in having a very low peak per capita cigarette consumption.

PER CAPITA CONSUMPTION IN THE YEAR 2000. At the turn of the twenty-first century, only 17 countries had an annual per capita cigarette consumption over 2,000 cigarettes (see Table 5). Seven of these were from Eastern Europe (including Bulgaria, the Russian Federation, Poland, and Hungary) with 6 more from Western Europe (Greece, Netherlands, Spain, Switzerland, Ireland, and Italy). Two Asian countries (Japan and South Korea) and the United States (without California) were at the low end of these high-consuming countries. Sixteen countries and California had per capita consumptions between 1,000 and

1,500 cigarettes, including most of those that had declined the most since their peak (United Kingdom, Finland, Sweden, and California). There were 33 countries with per capita consumption below 1,000. These include Norway, the only developed country to have always had low consumption, and 2 countries with major reductions in consumption, New Zealand and South Africa.

CHANGES IN PER CAPITA CIGARETTE CONSUMPTION, 1990–2000.

Between 1990 and 2000, a total of 31 countries showed an increase in per capita consumption, while 56 countries had a decrease (see Table 6). However, the tobacco business appears to have been very stable. Annual global cigarette consumption increased by less than 1 percent between 1990 and 2000 to a total of 5,572 billion cigarettes (when considering those countries in the WHO Countries Study with data for approximately both time points). However, over this period, the population over the age of 15 years in these countries increased by 17 percent. Thus, the worldwide per capita cigarette consumption decreased from 1,492 sticks per year in 1990 to 1,283 per year in 2000, a 14 percent decline. Thus, while this appears to be a substantial success for tobacco control, the total number of smokers may not have changed.

There were seven countries in which per capita cigarette consumption doubled between 1990 and 2000: Mauritania, Cyprus, Solomon Is, Guinea-Bissau, Russian Fed, United Arab Emirates (UAE), and Myanmar. The per capita consumption rates in Cyprus and the UAE are extremely high (more than 7000 per capita), strongly suggesting that these countries are a source of lower cost smuggled cigarettes for other countries. Three Western European countries, Italy, the Netherlands, and Spain, showed an increase, but only the latter two increased by more than 10 percent. Among the countries that decreased consumption over the decade, 14 experienced a major reduction (less than 40%). These include Finland, Australia, New Zealand, and South Africa, as well as California, all with active tobacco control programs. There were also large drops in per capita cigarette consumption in the United Kingdom and Sweden (less than 30%), with at least part of the Swedish decline attributed to the substitution of snuff for cigarettes among men.

Many of these large reductions in tobacco consumption can be linked to the presence of strong, ongoing tobacco control programs. One of the most successful programs has been conducted in California using numerous strategies to reduce demand for cigarettes, including increasing the price of cigarettes, mass media programs aimed at changing norms on smoking, and restrictions on where people can smoke. The price of cigarettes is comparatively easy to obtain and is one indicator of tobacco control activity. One group of investigators has compared prices between countries by estimating the minutes of labor required to purchase a pack of cigarettes (see Table 7). Cigarettes by this measure were cheapest in a number of the countries with the highest levels of per capita consumption, including Japan, South Korea, Switzerland, the Netherlands, and Greece, underscoring the fact that price is an important tobacco control tool.

See Also Age; Class; Sailors; Soldiers; Women; Youth Marketing; Youth Tobacco Use.

▌ JOHN PIERCE

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psychoactive having an effect on the mind of the user.

snuff a form of powdered tobacco, usually flavored, either sniffed into the nose or "dipped," packed between cheek and gum. Snuff was popular in the eighteenth century but had faded to obscurity by the twentieth century.

briar a hardwood tree native to southern Europe. The bowls of fine pipes are carved from the burl, or roots, of briar trees.

water pipe also called a hookah, a tobacco pipe in which the smoke is filtered through a bowl of water. The smoker inhales through a mouthpiece connected to the pipe by a flexible tube. Water pipes are traditional in the Orient.

air-cured tobacco leaf tobacco that has been dried naturally without artificial heat.

rococo an artistic and architectural style of the eighteenth century (1700s) characterized by elaborate ornamentation.

bidis thin, hand-rolled cigarettes produced in India. Bidis are often flavored with strawberry or other fruits and are popular with teenagers.

plantation historically, a large agricultural estate dedicated to producing a cash crop worked by laborers living on the property. Before 1865, plantations in the American South were usually worked by slaves.

market share the fraction, usually expressed as a percentage, of total commerce for a given product controlled by a single brand; the consumer patronage for a given brand or style of product.

tar a residue of tobacco smoke, composed of many chemical substances that are collectively known by this term.

physiology the study of the functions and processes of the body.