Patterns of Tobacco Use in the United States. Outline

Patterns of Tobacco Use in the United States Gary A. Giovino, PhD, MS Professor and Chair Department of Community Health and Health Behavior University at Buffalo, School of Public Health and Health Professions Surveillance and Evaluation Net Conference Series CDC Office on Smoking and Health June 27, 212 Outline Per capita consumption of various tobacco products Prevalence estimates from survey comparisons Current smoking Indicators of quitting CPD/DPM Cigarettes and other tobacco products Indicators of hardening International 1

Trends in Per Capita Consumption of Various Tobacco Products United States, 188 26 16 14 12 Cigarettes Cigars Pipe/Roll your own Chewing Snuff POUNDS 1 8 6 4 2 188 1885 189 1895 19 195 191 1915 192 1925 193 1935 194 1945 195 1955 196 1965 197 1975 198 1985 199 1995 2 25 Source: Tobacco Situation and Outlook Report, U.S. Department of Agriculture, U.S. Census Note: Among persons > 18 years old. YEAR Beginning in 1982, fine-cut chewing tobacco was reclassified as snuff. Source: US Department of Agriculture Small cigars weigh less than or equal to 1.36 grams Features common to cigarettes, such as shape, length (7 to 1 mm), and use of filter tips Large Cigar weigh > 1.36 grams Wide variety of cigar products Cigarillo Considered a large cigar for taxation purpose Source: Cristine Delnevo, UMDNJ School of Public Health 2

Adult Per Capita Cigarette Consumption and Major Smoking and Health Events United States, 19 21 5 1 st Surgeon General s Report Broadcast Ad Ban 1 st Great American Smoke-out Number of Cigarettes 4 3 2 1 1 st Smoking- Cancer Concern Fairness Doctrine Messages on TV and Radio Non-Smokers Rights Movement Begins First Surgeon General s Report on ETS Master Settlement Agreement Great Depression 19 191 192 193 194 195 196 197 198 199 2 YEAR Source: United States Department of Agriculture; Centers for Disease Control and Prevention; Alcohol and Tobacco Tax and Trade Bureau 25 Per Capita Consumption of Cigarettes and Cigars (Number of Sticks) 2 21 2 15 Cigarettes Cigars Small Cigars Large 1 5 Source: US Department of Treasury; Alcohol and Tobacco Tax and Trade Bureau 3

Unintended tax disparities from S CHIP (effective April 1, 29)? Product Pre SCHIP tax SCHIP tax Cigarettes (pack of 2) $.39 $1.1 Roll Your Own (per ounce) $.69 $1.549 Small Cigars (pack of 2) $.4 $1.1 Large Cigars (single) $.5 maximum $.4 maximum 2.72% of sales price but not to exceed $.5 per stick 52.75% of sales price but not to exceed $.4 per stick Snuff (per ounce) $.37 $.94 Little Chewing cigars Tobacco now taxed (per at ~$1/carton, ounce) whereas $.12 a carton of cigarillo cigars $.32 with wholesale cost of $1 would have FET liability of $5.28/carton Pipe Tobacco (per ounce) $.69 $.177 Source: Cristine Delnevo, UMDNJ School of Public Health Per Capita Consumption of Cigars (Number of Sticks) 2 21 6 5 4 3 Cigars Small Cigars Large Cigars Total 2 1 Source: US Department of Treasury; Alcohol and Tobacco Tax and Trade Bureau 4

Per Capita Consumption of Smokeless, Pipe, and Roll Your Own Tobacco Products (in pounds) 2 21.6.5 Total Smokeless.4.3 Snuff.2 Chewing Tobacco.1 Roll Your Own Pipe Source: US Department of Treasury; Alcohol and Tobacco Tax and Trade Bureau Trends in Per Capita Consumption of Various Tobacco Products United States, 188 26 16 14 12 Cigarettes Cigars Pipe/Roll your own Chewing Snuff POUNDS 1 8 6 4 2 188 1885 189 1895 19 195 191 1915 192 1925 193 1935 194 1945 195 1955 196 1965 197 1975 198 1985 199 1995 2 25 Source: Tobacco Situation and Outlook Report, U.S. Department of Agriculture, U.S. Census Note: Among persons > 18 years old. YEAR Beginning in 1982, fine-cut chewing tobacco was reclassified as snuff. Source: US Department of Agriculture 5

Adult Per Capita Cigarette Consumption and Major Smoking and Health Events United States, 19 21 5 1 st Surgeon General s Report Broadcast Ad Ban 1 st Great American Smoke-out Number of Cigarettes 4 3 2 1 1 st Smoking- Cancer Concern Fairness Doctrine Messages on TV and Radio Non-Smokers Rights Movement Begins First Surgeon General s Report on ETS Master Settlement Agreement Great Depression 19 191 192 193 194 195 196 197 198 199 2 YEAR Source: United States Department of Agriculture; Centers for Disease Control and Prevention; Alcohol and Tobacco Tax and Trade Bureau 6

6/27/212 ~193 8

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Jan. 4, 1954 1952 11

1953 1953 12

1952 Adult Per Capita Cigarette Consumption and Major Smoking and Health Events United States, 19 21 5 1 st Surgeon General s Report Broadcast Ad Ban 1 st Great American Smoke-out Number of Cigarettes 4 3 2 1 1 st Smoking- Cancer Concern Fairness Doctrine Messages on TV and Radio Non-Smokers Rights Movement Begins First Surgeon General s Report on ETS Master Settlement Agreement Great Depression 19 191 192 193 194 195 196 197 198 199 2 YEAR Source: United States Department of Agriculture; Centers for Disease Control and Prevention; Alcohol and Tobacco Tax and Trade Bureau 13

Brown & Williamson on Nicotine. Moreover, nicotine is addictive We are, then, in the business of selling nicotine, an addictive drug. Addison Yeaman; General Counsel to the Brown & Williamson Tobacco Company; July 17, 1963. Source: U.S. Food and Drug Administration, 1996. Cigarette smoking is a health hazard of sufficient importance to warrant remedial action 1964 Report of the Advisory Committee to the U.S. Surgeon General 15

Philip Morris on Nicotine. Think of the cigarette pack as a storage container for a day s supply of nicotine. Think of the cigarette as a dispenser for a unit dose of nicotine Think of a puff of smoke as a vehicle of nicotine Smoke is beyond question the most optimized vehicle of nicotine and the cigarette the most optimized dispenser of smoke. Dr. William Dunn; Philip Morris Tobacco Company, 1972. Source: U.S. Food and Drug Administration, 1996. R. J. Reynolds chimes in. In a sense, the tobacco industry may be thought of as being a specialized, highly ritualized, and stylized segment of the pharmaceutical industry. Tobacco products uniquely contain and deliver nicotine, a potent drug with a variety of physiological effects. Claude Teague, R.J. Reynolds Tobacco Company, 1972. Source: U.S. Food and Drug Administration, 1996. 16

Adult Per Capita Cigarette Consumption and Major Smoking and Health Events United States, 19 21 5 1 st Surgeon General s Report Broadcast Ad Ban 1 st Great American Smoke-out Number of Cigarettes 4 3 2 1 1 st Smoking- Cancer Concern Fairness Doctrine Messages on TV and Radio Non-Smokers Rights Movement Begins First Surgeon General s Report on ETS Master Settlement Agreement Great Depression 19 191 192 193 194 195 196 197 198 199 2 YEAR Source: United States Department of Agriculture; Centers for Disease Control and Prevention; Alcohol and Tobacco Tax and Trade Bureau Our lack of greater progress in tobacco control is more the result of failure to implement proven strategies than it is the lack of knowledge about what to do. Former U.S. Surgeon General David Satcher, M.D., Ph.D. 2 21

US Consumption of Cigars 195 22 Billions of cigars 1 9 8 7 6 5 4 3 2 1 SGR Begin advertising little cigars Ban advertising of little cigars 195 1954 1958 1962 1966 197 1974 1978 1982 1986 199 1994 1998 22 Year Cigar Aficionado Large cigars Small cigars Source: USDA Tobacco Yearbook 22; Tobacco Outlook 23 TBS 254 22

Outline Per capita consumption of various tobacco products Prevalence estimates from survey comparisons Current smoking Indicators of quitting CPD/DPM Cigarettes and other tobacco products Indicators of hardening 24

Current Use Among Middle and High School Students by Type of Tobacco Product National Youth Tobacco Survey, 24 3 25 28. 22.3 Middle School High School PERCENT 2 15 1 5 11.7 12.8 8.1 5.2 6. 2.9 2.6 3.1 2.3 2.6 1.5 2.3 Any Use Cigarettes Cigars Smokeless Pipes Bidis Kreteks Note: Used tobacco on > 1 of the 3 days preceding the survey Source: American Legacy Foundation, National Youth Tobacco Survey Past Month Cigarette Use among Persons Aged 12 or Older, by Age: 26 Percent Using in Past Month 5 4 3 2 19.9 35.6 4.2 36.4 32. 28. 29.4 29.6 26.7 22.7 18.6 1 1.7 9.1 12-13 14-15 16-17 18-2 21-25 26-29 3-34 35-39 4-44 45-49 5-54 55-59 6-64 65+ Age in Years Source: National Survey on Drug Use and Health, SAMHSA 9.5 25

Trends in Cigarette Smoking Anytime in the Past 3 days by Grade in School United States, 1975 21 12 th Grade 1 th Grade 19.2% in 21 8 th Grade 13.6% in 21 7.1% in 21 Source: Institute for Social Research, University of Michigan, Monitoring the Future Surveys Trends in Prevalence of Past Month Cigarette Smoking Among High School Seniors by Gender United States, 1975 21 PERCENT 45 4 Female 35 3 25 Male 2 15 1 5 1975 1978 1981 1984 1987 199 1993 1996 1999 22 25 28 YEAR Source: Institute for Social Research, University of Michigan, Monitoring the Future Surveys 26

Trends in Prevalence of Past Month Cigarette Smoking Among High School Seniors by Race United States, 1977 21 PERCENT 45 4 White 35 3 25 2 Hispanic 15 1 Black 5 1977 198 1983 1986 1989 1992 1995 1998 21 24 27 21 YEAR Source: Institute for Social Research, University of Michigan, Monitoring the Future Surveys; for racial subgroups, data for the current year and the previous year are combined Trends in cigarette smoking* - United States, 1974-21 Percent 4 35 3 25 2 15 1 5 1974 1976 1978 198 1982 1984 1986 1988 199 1992 1994 1996 1998 2 22 24 26 28 21 Year NHIS *Before 1992, current smokers were defined as persons who reported having smoked >1 cigarettes and who currently smoked. Since 1992, current smokers were defined as persons who reported having smoked >1 cigarettes during their lifetime and who reported now smoking every day or some days. Source: various National Health Interview Surveys from 1974 21, National Center for Health Statistics, CDC 27

Average Annual Rates of Change in Various Surveys NHIS 1974 (37.1%) 199 (25.5%) =.73% 199 (25.5%) 1997 (24.7%) =.11% (1992 Definition Δ) 199 adj. (26.2%) 1997 (24.7%) =.21% 1997 (24.7%) 24 (2.9%) =.54% 24 (2.9%) 21 (19.4%) =.25% 199 adj. (26.2%) 21 (19.4%) =.34% TUS CPS (self respondents) 1995/96 (23.7%) 26/7 (18.5%) =.47% BRFSS (Median of all states + D.C.) 1997 (23.2%) 21 (17.3%) =.45% Trends in cigarette smoking* - United States, 1974-21 4 35 3 Percent 25 2 15 1 5 1974 1976 1978 198 1982 1984 1986 1988 199 Year 1992 1994 1996 1998 2 22 24 26 28 21 NHIS *Before 1992, current smokers were defined as persons who reported having smoked >1 cigarettes and who currently smoked. Since 1992, current smokers were defined as persons who reported having smoked >1 cigarettes during their lifetime and who reported now smoking every day or some days. Source: various National Health Interview Surveys from 1974 21, National Center for Health Statistics, CDC 28

Trends in Cigarette Smoking Among Adults and High School Seniors United States, 1974-27 *Adult data are from the National Health Interview Surveys., ages > 18 year olds. Before 1992, current smokers were defined as persons who reported having smoked >1 cigarettes and who currently smoked. Since 1992, current smokers were defined as persons who reported having smoked >1 cigarettes during their lifetime and who reported now smoking every day or some days. High School Senior data are on daily smoking. Source: University of Michigan, Institute for Social Research, Monitoring the Future Trends in cigarette smoking* by age - United States, 1965-29 6 5 Percent 4 3 2 1 1965 1967 1969 1971 1973 1975 1977 1979 1981 1983 1985 1987 1989 1991 1993 1995 1997 1999 21 23 25 27 29 Year 18-24 25-44 45-64 >=65 *Before 1992, current smokers were defined as persons who reported having smoked >1 cigarettes and who currently smoked. Since 1992, current smokers were defined as persons who reported having smoked >1 cigarettes during their lifetime and who reported now smoking every day or some days. Source: various National Health Interview Surveys from 1965 29, National Center for Health Statistics, CDC 29

% Former Smokers Percentage of Ever Smokers* Who Have Quit, by Age United States, 1965-29 8 7 6 5 4 3 2 1 Year 18-24 25-44 45-64 >=65 Source: various National Health Interview Surveys, 1965 29; *Ever smoked 1 + Cigarettes Also known as the quit ratio, estimates since 1992 incorporate same day smoking. Prevalence (%) of cigarette smoking among US adults as estimated by various surveys 22 29 35 3 25 2 15 * * NSDUH 1 * NSDUH NHIS BRFSS 1 5 NSDUH w/o 1 cigarette criterion; NSDUH 1 with 1 cigarette criterion * TUS CPS; 3

Average Annual Rates of Change (%) Survey 1997 24 24 29 24 21 22 29 NHIS.54.6.25.27 NSDUH (w/o 1 cigarette criterion) NA.3 NA.37 NSDUH 1 (with 1 cigarette criterion) NA.32 NA.37 BRFSS.33.6.6.76 2 18 16 14 12 1 Prevalence (%) of daily and less than daily smoking among U.S. adults (ages 18+ years old) 22 29 NHIS, BRFSS, and NSDUH 8 6 4 2 DAILY SMOKING * * LESS THAN DAILY SMOKING NHIS NSDUH BRFSS * Confidence intervals around 22 and 29 estimates do not overlap. 31

2 18 16 14 12 1 Prevalence (%) of daily and less than daily smoking among U.S. adults (ages 18+ years old) 22 29 NHIS, BRFSS, and NSDUH 1 8 6 4 2 DAILY SMOKING * * LESS THAN DAILY SMOKING NHIS NSDUH 1 BRFSS * Confidence intervals around 22 and 29 estimates do not overlap. NSDUH, NSDUH 1 and NHIS (during 22 29, on average) NSDUH was 5.35 percentage points (PP) higher than NHIS. NSDUH 1 was 3.56 PP higher than NHIS. NSDUH was 1.79 PP higher than NSDUH 1. Essentially all of that difference was between estimates of less than daily smoking. Why NSDUH still higher than NHIS? Would Not at all NHIS ever smokers of 1+ lifetime cigarettes who were abstinent <3 days have responded that they smoked during the previous 3 days in NSDUH? If so, prevalence estimate would be raised only by approximately.4 PP, thus not explaining much of the difference. Design issues? Something else? 32

Trends in cigarette smoking* among adults aged >18 years, by sex - United States, 1955-21 6 % CURRENT SMOKERS 5 4 3 2 1 Female Male 21.9% 17.4% 1955 196 1965 197 1975 198 1985 199 1995 2 25 21 YEAR *Before 1992, current smokers were defined as persons who reported having smoked >1 cigarettes and who currently smoked. Since 1992, current smokers were defined as persons who reported having smoked >1 cigarettes during their lifetime and who reported now smoking every day day or some days. Source: 1955 Current Population Survey; 1965 21 National Health Interview Surveys. 21 estimates are for January September 21. Trends in cigarette smoking* among adults aged >25 years, by education- United States, 1974-29 Percent 5 45 4 35 3 25 2 15 1 5 Year <8 years 9-11 years 12 years 13-15 years >=16 years *Before 1992, current smokers were defined as persons who reported having smoked >1 cigarettes and who currently smoked. Since 1992, current smokers were defined as persons who reported having smoked >1 cigarettes during their lifetime and who reported now smoking every day or some days. Source: various National Health Interview Surveys from 1974 29, National Center for Health Statistics 33

Prevalence (%) of current cigarette smoking among US adults (ages 18+ years old) 1995 27 TUS CPS 28 26 24 22 2 18 16 14 12 1 8 6 4 2 MALES * FEMALES * Past month tobacco use among adults aged 18 or older, by education United States, 29 Source: National Survey on Drug Use and Health 34

Percent Trends in cigarette smoking* among adults, by poverty status - United States, 1983-29 45 4 35 3 25 2 15 1 5 1982 1984 1986 1988 199 1992 Year 1994 1996 1998 At/above Below Unknown 2 22 24 26 28 *Before 1992, current smokers were defined as persons who reported having smoked >1 cigarettes and who currently smoked. Since 1992, current smokers were defined as persons who reported having smoked >1 cigarettes during their lifetime and who reported now smoking every day or some days. Source: various National Health Interview Surveys from 1983-29, National Center for Health Statistics, CDC. Percent Cigarette Smoking Trends among Adults, by Race/Ethnicity, 1978-29 7 6 5 4 3 2 1 Hispanic African American White Asian American Indian Year Source: National Health Interview Surveys, 1978 29, selected years, aggregate data 35

Median Household Income and Current Smoking Prevalence United States, 26/7 Source: US Census Bureau and 26/7 TUS-CPS. Median Household Income and Quit Ratio United States, 26/7 Source: US Census Bureau and 26/7 TUS-CPS. 36

Marketing Factoids Percent of smokers who were male in: 1974 53%; 29 55%. Percent of smokers by race/ethnicity: Non Hispanic White: 1983 82%; 29 75% Hispanic: 1983 5%; 29 1% Asian/Pacific Islander: 1983 1%; 29 3% Percent of smokers by education: Less than HS: 1974 41.1%; 29 18.6% Some College: 1974 13%; 29 31% Percent of smokers below poverty line in: 1983 1%; 29 18% Outline Per capita consumption of various tobacco products Prevalence estimates from survey comparisons Current smoking Indicators of quitting CPD/DPM Cigarettes and other tobacco products Indicators of hardening 37

% Former Smokers Percentage of Ever Smokers* Who Have Quit, by Age United States, 1965-29 8 7 6 5 4 3 2 1 Year 18-24 25-44 45-64 >=65 Source: various National Health Interview Surveys, 1965 29; *Ever smoked 1 + Cigarettes Also known as the quit ratio, estimates since 1992 incorporate same day smoking. Quit Ratio (%) among US adults, by age, 22 29 NSDUH 9 8 7 6 5 4 3 2 1 18 25 26 34 35 64 65+ 38

Quit Ratio (%) among US adults, by age, 1992/93 26/7 TUS CPS 9 85 8 75 7 65 6 55 5 45 4 35 3 25 2 15 1 5 18 24 25 44 45 64 65+ Recent Quit Ratio (%)* among US adults aged 35 64 22 29 NSDUH 2 15 1 5 35 64 % abstinent among adults who smoked during the previous year 39

Recent Quit Ratio, Adults aged 45 64, NHIS, 1978 29 2 18 16 14 12 1 8 45 64 6 4 2 6 3+ Month abstinence for US adults (ages 25+) who were daily smokers 12 months previously 1992/93 26/7 TUS CPS 5 4 3 2 % abstinent 1 4

Outline Per capita consumption of various tobacco products Prevalence estimates from survey comparisons Current smoking Indicators of quitting CPD/DPM Cigarettes and other tobacco products Indicators of hardening 6 Prevalence (%) of Smoking < 15, 15 24, and 25+ CPD by Current Adult Cigarette Smokers United States, NHIS, 1985 29 5 4 3 2 1 <15 15 24 25+ 41

Mean CPD for all current smokers United States, 1974 21, NHIS 25 2 19.8 15 1 12.8 Mean CPD 5 25 2 Mean CPD for all current smokers, daily and less than daily smokers United States, 1995 21, NHIS 2.2 17.6 15 1 5 5.4 15.1 12.8 All Smokers Daily Less than Daily 4.3 42

25 Mean CPD for all current smokers, daily and less than daily smokers United States, 1995/96 26/7 TUS CPS 2 15 1 5 19.9 17.5 6.7 16.8 14.6 All Smokers Daily Less than Daily 5.2 Change in Mean Cotinine and Number of Cigarettes Smoked Each Day in the Last 5 Days United States, 1988-1994 and 1999-22 National Health and Nutrition Examination Surveys Serum Cotinine (ng/ml) 25 225 2 175 15 125 1 75 5 25 1988-1994 1999-22 Cotinine CPD Among participants aged 25 and older who smoked in the last five days and did not use other nicotine containing products in the last five days. 2 15 1 5 Cigarettes per Day Δ Cotinine = 3.3 t (1, 595) = 4.15 p <.1 Δ CPD = 2.8 t (1,519) = 3.74 p <.2 43

Trends in the percentage of US adult smokers who smoke on some days 1993 21 NHIS 25 2 18.2% 21.8% 15 1 % Some Day 5 Outline Per capita consumption of various tobacco products Prevalence estimates from survey comparisons Current smoking Indicators of quitting CPD/DPM Cigarettes and other tobacco products Indicators of hardening 44

Prevalence (%) of cigarette smoking and use of OTPs among US adult males 2, 25 and 21 NHIS 25 2 * 15 1 5 CIGS + OTP CIGS ONLY OTP ONLY * 22 and 29 confidence intervals do not overlap Prevalence (%) of cigarette smoking and use of OTPs among US adult males 1995/96 26/7 TUS CPS 3 25 2 15 1 5 * * * CIGS+OTP CIGS ONLY OTP ONLY * 22 and 29 confidence intervals do not overlap 45

Prevalence (%) of cigarette smoking and use of OTPs among US adult males 22 29 NSDUH 25 2 * 15 1 5 CIGS+OTP CIGS ONLY OTP ONLY * 22 and 29 confidence intervals do not overlap Outline Per capita consumption of various tobacco products Prevalence estimates from survey comparisons Current smoking Indicators of quitting CPD/DPM Cigarettes and other tobacco products Indicators of hardening 46

Current Cigarette Smoking (%) Among Adults 26/7 Fagerström Test for Nicotine Dependence Score and Cigarette Smoking Prevalence by Country Source: Fagerström & Furberg, Addiction 28; 13:841-845. 47

Percentage of Cigarette Smokers Who Smoke Within 3 Minutes of Waking and Smoking Prevalence, by State US, Ages 25+ Yrs Old, 26/7 Source: Tobacco Use Supplement to the Current Population Survey, 26/7 Percentage of Cigarette Smokers Who Smoke Within 3 Minutes of Waking 26/27 48

Mean Number of Cigarettes Smoked/Day Among Current Smokers and Smoking Prevalence, by State US, Ages 25+ Yrs Old, 26/7 Source: Tobacco Use Supplement to the Current Population Survey, 26/7 Hypothetical Relationship Between Smoking Prevalence and Indicators of Willingness to Quit if Population is Hardening 49

Percentage of Current Smokers Who Have a Strong Interest in Quiting and Smoking Prevalence, by State US, Ages 25+ Yrs Old, 26/7 Source: Tobacco Use Supplement to the Current Population Survey, 26/7 Percentage of Current Smokers Who Believe They Would be Very Likely to Succeed if They Tried to Quit and Smoking Prevalence, by State US, Ages 25+ Yrs Old, 26/7 Source: Tobacco Use Supplement to the Current Population Survey, 26/7 5

Percentage of Persons Who Were Daily Smokers 12 Months Previously Who Were Abstinent for 3+ Months by Prevalence of Daily Smoking 12 Months Ago in 5 States and DC US, Ages 25+ Yrs Old, 26/7 Source: Current Population Survey, 26/7 Percentage of Smokers Aged 25 Years and Older Who Smoked Their First Cigarette of the Day Within 3 Minutes of Awakening, by Sex and Age United States, 1987 and 26/27 Men Women Source: 1987 National Health Interview Survey Cancer Control Supplement and 26/27 Tobacco Use Supplement to the Current Population Survey. Analyses run by Angela Trosclair, Office on Smoking and Health, CDC.. 51

Trends in Recent Quitting Haven t Changed Much Source: Zhu et al., Tobacco Control 212;21:11 118. Assisted Quitting Has Increased but Overall Abstinence Hasn t Source: Zhu et al., Tobacco Control 212;21:11 118. 52

Possible Explanations Hardening of the target Rate of self-quitting without intervention is decreasing over time Unintended consequences Promoting medications might lead smokers to think that they cannot quit without medications, lowering self-efficacy Increased taxes might lead some to reduce consumption and thus feel they ve done enough Smoke-free I m OK as long as I don t bother others; bonding with colleagues Trends in Per Capita Consumption of Various Tobacco Products United States, 188 26 16 14 12 Cigarettes Cigars Pipe/Roll your own Chewing Snuff POUNDS 1 8 6 4 2 188 1885 189 1895 19 195 191 1915 192 1925 193 1935 194 1945 195 1955 196 1965 197 1975 198 1985 199 1995 2 25 Source: Tobacco Situation and Outlook Report, U.S. Department of Agriculture, U.S. Census Note: Among persons > 18 years old. YEAR Beginning in 1982, fine-cut chewing tobacco was reclassified as snuff. Source: US Department of Agriculture 53

Trends in Per Capita Consumption of Various Tobacco Products United States, 188 26 16 14 12 Cigarettes Cigars Pipe/Roll your own Chewing Snuff POUNDS 1 8 6 4 2 188 1885 189 1895 19 195 191 1915 192 1925 193 1935 194 1945 195 1955 196 1965 197 1975 198 1985 199 1995 2 25 Source: Tobacco Situation and Outlook Report, U.S. Department of Agriculture, U.S. Census Note: Among persons > 18 years old. YEAR Beginning in 1982, fine-cut chewing tobacco was reclassified as snuff. Source: US Department of Agriculture Trends in Per Capita Consumption of Various Tobacco Products United States, 188 24 and Linear Projection to 235 16 Cigarettes Cigars Pipe/Roll your own Chewing Snuff 14 12 1 POUNDS 8 6 4 2 188 1885 189 1895 19 195 191 1915 192 1925 193 1935 194 1945 195 1955 196 1965 197 1975 198 1985 199 1995 2 25 21 215 22 225 23 235 YEAR Source: Giovino, American Journal of Preventive Medicine, 27. 54

Trends in Per Capita Consumption of Various Tobacco Products United States, 188 24 and Asymptotic Projection to 26 16 Cigarettes Cigars Pipe/Roll your own Chewing Snuff 14 12 1 POUNDS 8 6 4 2 188 1885 189 1895 19 195 191 1915 192 1925 193 1935 194 1945 195 1955 196 1965 197 1975 198 1985 199 1995 2 25 21 215 22 225 23 235 24 245 25 255 26 YEAR Trends in Per Capita Consumption of Various Tobacco Products United States, 188 24 and Possible Projection to 26 16 Cigarettes Cigars Pipe/Roll your own Chewing Snuff 14 12 1 POUNDS 8 6 4 2 188 1885 189 1895 19 195 191 1915 192 1925 193 1935 194 1945 195 1955 196 1965 197 1975 198 1985 199 1995 2 25 21 215 22 225 23 235 24 245 25 255 26 YEAR 55

Reflections Major reductions in consumption of cigarettes, chewing tobacco. Increased consumption of snuff and cigars Concerns about waterpipes Concerns about industry manipulation marketing to promote dual product use Concerns about OTPs alone or with cigarettes Little population evidence for hardening. Continuing need for detailed surveillance to effectively monitor use and factors influencing use 56

Hardening The hardening hypothesis states that tobacco control activities have mostly influenced those smokers who found it easier to quit and, thus, remaining smokers are those who are less likely to stop smoking. Hughes JR, Drug & Alcohol Dependence 211. Has been used to call for better treatment and in support of harm reduction strategies

The Environment and Drug Use in animal studies, natural behaviors such as eating, drinking palatable substances, social access, and opportunities to exercise reduce the rewarding effects of drugs. Likewise, in humans, an environment enriched with positive reinforcers such as opportunities for learning, personal comfort, and social success serves as a deterrent to drug abuse, while negative aspects of the environment such as stress, poverty, and social isolation contribute to drug abuse. Carroll, Anker & Perry. Drug and Alcohol Dependence 29;14S:S7-S78.