Epidemiology of Tobacco-Related Health Disparities

Epidemiology of Tobacco-Related Health Disparities Gary A. Giovino, PhD, MS Professor and Chair Department of Health Behavior School of Public Health and Health Professions University at Buffalo, SUNY SOC W 598, HSERV 59 A Integrative Seminar on Health Disparities: The Case of Tobacco April 1, 29 Overview of Today s Talk Disparities Consequences of tobacco use and exposure to tobacco smoke pollution Patterns of use Epidemiologic Model of Tobacco Control and Nicotine Addiction Tobacco Products Agent Environment Familial, Social, Cultural, Political, Economic, Historical, Media Vector Host Tobacco Product Smoker/Chewer Manufacturers; Incidental Host Involuntary Smoker Other Users Source: Orleans & Slade, 1993; Giovino 22 1

Consequences of Use Global Burden of Tobacco Tobacco killed 1 million people worldwide in the 2th Century Leading preventable cause of death - kills up to half of people who use it Unless urgent action is taken By 23 tobacco will kill >8 million people each year - 8% in developing countries Tobacco could kill 1 billion people during the 21st Century - unless we act now 2

Cardiov ascular Cancer Stroke B rochitis/emphy sema Unintential injuries Diabetes Influenza/pneumonia Alzehimer's disease Nephritis/nephrotic Septicemia Chronic Disease and Related Factors Leading Causes of Death, United States, 2* Actual Causes of Death, United States, 2* 5 1 15 2 25 3 35 Percentage (of all deaths) Tobacco Poor diet/lack of exercise Alcohol Microbial agents Pollutants/tox ics Motor Vehicles Firearms Sex ual B ehav iors Illicit drug use Source: Mokdad et al. JAMA 24; 291:1238-1245 5 1 15 2 Percentage (of all deaths) Smoking and Tobacco Smoke Pollution Damage Every Part of the Body Tobacco Smoke Pollution Smoking Source: WHO, Report on the Global Tobacco Epidemic, 28. The MPWOER Package; page 11. 8 132,332 (3%) 147,9 (33%) Source: CDC. MMWR; November 14, 28 3

Smoking and Tobacco Smoke Pollution Damage Every Part of the Body Tobacco Smoke Pollution Smoking Source: WHO, Report on the Global Tobacco Epidemic, 28. The MPWOER Package; page 11. 1 The Health Consequences of Involuntary Exposure to Tobacco Smoke Major Conclusions: 1) Secondhand smoke causes premature death and disease in children and in adults who do not smoke. 2) Children exposed to secondhand smoke are at an increased risk for sudden infant death syndrome (SIDS), acute respiratory infections, ear problems, and more severe asthma. Smoking by parents causes respiratory symptoms and slows lung growth in their children. Source: USDHHS; A Report of the Surgeon General (26) The Health Consequences of Involuntary Exposure to Tobacco Smoke 3) Exposure of adults to secondhand smoke has immediate adverse effects on the cardiovascular system and causes coronary heart disease and lung cancer. 4) The scientific evidence indicates that there is no risk-free level of exposure to secondhand smoke. 5) Many millions of Americans, both children and adults, are still exposed to secondhand smoke in their homes and workplaces despite substantial progress in tobacco control. Source: USDHHS; A Report of the Surgeon General (26) 4

The Health Consequences of Involuntary Exposure to Tobacco Smoke 6) Eliminating smoking in indoor spaces fully protects nonsmokers from exposure to secondhand smoke. Separating smokers from nonsmokers, cleaning the air, and ventilating buildings cannot eliminate exposures of nonsmokers to secondhand smoke. Source: USDHHS; A Report of the Surgeon General (26) Moist snuff Fine cut Chewing Tobacco Loose leaf Long cut Moist plug Twist Roll Dry snuff Other products Disease Caused by Tobacco Use Tobacco smoke pollution (secondhand smoke, environmental tobacco smoke) is a cause of: Lung cancer and coronary heart disease in nonsmokers - 49,4 annual deaths (11% of SAM) Respiratory infections and symptoms in the children of parents who smoke Smokeless tobacco causes: Oral cancer Oral leukoplakia Dental caries (possibly) Cigars cause: Cancers of the mouth, larynx, and lung Coronary heart disease COPD 5

Oral Cancer in a 2 Year-Old Man Who Used ST 6

Smoking Attributable Mortality Rate Lung Cancer Mortality (1,) Ischemic Heart Disease Mortality (1,) State-Specific Estimates of Current Smoking Prevalence (1) and Ischemic Heart Disease Mortality (2) among Persons 35 to 64 Years in the United States, 1998-2 12. MS r 2 =.548 ß =3.929 1. 8. OK AR KY P <.1 N = 51 6. CA 4. UT 16 2 24 28 32 Current Smoking Prevalence 1. Source: NCI-sponsored Tobacco Use Supplement to the Current Population Survey, 1998-99; 2. Source: NCHS mortality data from CDC Wonder System, 1999-2. Note: Mortality data were age-adjusted to the 2 U.S. population. Prevalence of Current and Former Smoking Quit Less than 15 Years (1) and Lung Cancer Mortality (2) among Persons 35 Years or Older in the United States, 1998-2 16. 15. 14. 13. 12. 11. 1. 9. 8. 7. 6. CA 5. UT 4. 22 26 3 34 38 42 46 Current + Former Smoking Prevalence 1. Data from Current Population Survey, 1998-99; 2. Data from CDC Wonder System, 1999-2. Note: Smoking and mortality estimates were age-adjusted to the 2 projected U.S. population HI WV ME KY r 2 =.52 ß =4.161 P <.1 N = 51 State-Specific Estimates of Cigarette Smoking Prevalence (1) and Smoking-Attributable Mortality Rate (2) among U.S. Adults 39. 365. 34. 315. 29. 265. 24. 215. 19. 165. 14. CA UT 8 12 16 2 24 28 Current Smoking Prevalence 1. Among persons age 3 years and older; Source: NCI Tobacco Use Supplement to the Current Population Survey, 23 estimates 2. Source: MMWR 25;54:625-628. MN HI NV WV KY r 2 =.49 ß = 1.36 P <.1 N = 51 9

Death Rate Age-adjusted Lung Cancer Mortality Rates among Women > 35 years old: 1979-22 1 75 5 KENTUCKY CALIFORNIA ARKANSAS USA 25 1979 1981 1983 1985 1987 1989 1991 UTAH 1993 1995 1997 1999 Age-adjusted to the 2 US population 21 Racial/Ethnic Differences in Lung Cancer The Multiethnic Cohort Study Among persons smoking < 3 CPD lung cancer was: Highest among African Americans and Native Hawaiians Intermediate among Whites Lowest among Japanese Americans and Latinos Consistent by sex and by histological type Among persons smoking > 3 CPD: No significant differences Source: Haiman et al. Ethnic and Racial Differences in Smoking-Related Risk of Lung Cancer. NEJM 26.354(4):333-342. Source: MMWR, July 11, 28 1

The Health Consequences of Smoking: Nicotine Addiction Major Conclusions: 1) Cigarettes and other forms of tobacco are addictive. 2) Nicotine is the drug in tobacco that causes addiction. 3) The pharmacologic and behavioral processes that determine tobacco addiction are similar to those that determine addiction to drugs such as heroin and cocaine. Source: USDHHS; A Report of the Surgeon General (1988) Patterns of Use 11

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 POUNDS Total Sales (million packs Real Cigarette Price PERCENT Conceptual Model of Factors Influencing Trends in Adolescent Smoking United States, 1975-21 45 4 35 3 25 2 15 1 5 1975 1977 1979 1981 1983 1985 1987 1989 1991 1993 1995 1997 1999 21 YEAR Data Source: Institute for Social Research, University of Michigan, Monitoring the Future Surveys 3 28 26 24 22 2 Total Cigarette Sales and Cigarette Prices, US, 197-25 $4.2 $3.7 $3.2 $2.7 $2.2 $1.7 18 197 1973 1976 1979 1982 1985 1988 1991 1994 1997 2 23 Fiscal Year Cigarette Sales (million packs) Real Cigarette Price $1.2 Source: Tax Burden on Tobacco, 26, and author s calculations Trends in Per Capita Consumption of Various Tobacco Products United States, 188-24 16 14 12 1 8 6 4 2 Cigarettes Cigars Pipe/Roll your own Chewing Snuff YEAR Source: Tobacco Situation and Outlook Report, U.S. Department of Agriculture, U.S. Census Note: Among persons > 18 years old. Beginning in 1982, fine-cut chewing tobacco was reclassified as snuff. Estimates for 22 and 23 are preliminary. 12

Number of Cigarettes pounds of tobacco Per Capita Consumption (in pounds) of Tobacco Products Other than Cigarettes -- United States, 1992-25.4.3.2 Snuff Chew Large Cigars Small Cigars RYO/Pipe.1 1992 1994 1996 1998 2 22 24 Source: US Department of Agriculture; Cristine Delnevo, UMDNJ Adult Per Capita Cigarette Consumption and Major Smoking and Health Events United States, 19-25 5 4 3 Broadcast 1 st Surgeon Ad Ban General s Report End of WW II Fairness Doctrine Messages on TV and Radio 1 st Great American Smoke-out OTC Nicotine Medications Master Settlement Agreement 2 1 1 st Smoking-Cancer Concern Non-Smokers Rights Movement Surgeon Begins General s Report on ETS Federal Cigarette Tax Doubles 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 13

Number of Cigarettes Adult Per Capita Cigarette Consumption and Major Smoking and Health Events United States, 19-25 5 4 3 Broadcast 1 st Surgeon Ad Ban General s Report End of WW II Fairness Doctrine Messages on TV and Radio 1 st Great American Smoke-out OTC Nicotine Medications Master Settlement Agreement 2 1 1 st Smoking-Cancer Concern Non-Smokers Rights Movement Surgeon Begins General s Report on ETS Federal Cigarette Tax Doubles 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 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. 17

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. 18

Billions of cigars Number of Cigarettes Adult Per Capita Cigarette Consumption and Major Smoking and Health Events United States, 19-25 5 4 3 Broadcast 1 st Surgeon Ad Ban General s Report End of WW II Fairness Doctrine Messages on TV and Radio 1 st Great American Smoke-out OTC Nicotine Medications Master Settlement Agreement 2 1 1 st Smoking-Cancer Concern Non-Smokers Rights Movement Surgeon Begins General s Report on ETS Federal Cigarette Tax Doubles 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 US Consumption of Cigars 195-22 1 8 6 4 2 SGR Begin advertising little cigars Ban advertising of little cigars Cigar Aficionado 195 1954 1958 1962 1966 197 1974 1978 1982 1986 199 1994 1998 22 Year Large cigars Small cigars Source: USDA Tobacco Yearbook 22; Tobacco Outlook 23 TBS-254 21

Ariva Cigaletts Medical Packaging; Claim-For when you can t smoke New Non-Combusted Products Face the Future; Join the Movement Electronic Cigarettes A battery-powered device that provides inhaled doses of nicotine by delivering a vaporized propylene glycol/nicotine solution (Wikipedia) http://en.wikipedia.org/wiki/e-cigarette 23

1965 1967 1969 1971 1973 1975 1977 1979 1981 1983 1985 1987 1989 1991 1993 1995 1997 1999 21 23 25 27 Percent % CURRENT SMOKERS PERCENT Current Use Among U.S. Adults of Various Tobacco Products, by Sex National Health Interview Survey, 2 35 3 25 2 15 1 5 31.3 21.3 25.7 21. 4.5.2 1..1 2.5 Males Females Any Use Cigarettes Cigars Pipes Snuff Chewing Tobacco.2 2.5.1.1.1 Bidis Note: Current users report using either every day or on some days Source: National Center for Health Statistics Trends in cigarette smoking* among adults aged >18 years, by sex - United States, 1955-27 6 5 4 Men 3 2 1 Women 22.3% 17.4% 1955 196 1965 197 1975 198 1985 199 1995 2 25 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 or some days. Source: 1955 Current Population Survey; 1965-27 National Health Interview Surveys (NCHS, CDC). Trends in cigarette smoking* by age - United States, 1965-27 6 5 4 3 2 1 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 1965-27, National Center for Health Statistics 24

Percent 1965 197 72 1974 76 78 198 82 84 86 88 199 92 94 96 1998 2 22 24 26 Percent Trends in cigarette smoking* among adults aged >25 years, by education- United States, 197-26 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 197-26, National Center for Health Statistics Cigarette Smoking Trends among Adults, by Race/Ethnicity, 1978-24 7 6 5 Hispanic African American 4 White 3 Asian 2 American Indian 1 1978-198 1983-1985 1987-1988 199-1991 Year 1992-1993 1994-1995 1999-23- 2 24 1997-1998 Source: National Health Interview Surveys, 1978-24, selected years, aggregate data Percentage of Adults Who Smoke Cigarettes by Race/Ethnicity - United States, 27 4 35 3 25 2 15 1 5 White Afr Amer Hispanic Native Asian/PI Males Females Source: National Center for Health Statistics, 27 National Health Interview Survey 25

% Former Smokers % Former Smokers 1982 1984 1986 1988 199 1992 1994 1996 1998 2 22 24 26 Percent Trends in cigarette smoking* among adults, by poverty status - United States, 1983-27 45 4 35 3 25 2 15 1 5 28.8% 2.3% Year At/above Below *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 1983-27, National Center for Health Statistics, CDC. 8 7 6 5 4 3 2 1 Percentage of Ever Smokers* Who Are Former Smokers, by Age United States, 1965-26 1965 69 73 77 1981 1985 89 93 97 21 25 Year 18-24 25-44 45-64 >=65 Source: various National Health Interview Surveys, 1966-26 *Ever-smoked 1 + Cigarettes Also known as the quit ratio, estimates since 1992 incorporates same-day smoking 8 7 6 5 4 3 2 1 Percentage of Ever Smokers* Who Are Former Smokers, by Education, Adults Aged > 25 Years United States, 197-26 69 73 77 1981 1985 89 93 97 21 25 Year <8 9-11yrs 12 13-15 > = 16 Source: various National Health Interview Surveys, 197-26 *Ever-smoked 1 + Cigarettes Also known as the quit ratio, estimates since 1992 incorporates same-day smoking 26

1982 1984 1986 1988 199 1992 1994 1996 1998 2 22 24 26 Percent 1978 198 1982 1984 1986 1988 199 1992 1994 1996 1998 2 22 24 26 Percent Percentage of Ever Smokers* Who Are Former Smokers, Adults Aged 18 Years, by Race/Ethnicity-United States, 1978-26 6 5 4 3 2 1 White African American Hispanic Asian American Indian Year Source: National Health Interview Surveys, 1965-26; Centers for Disease Control and Prevention: National Center for Health Statistics and Office on Smoking and Health. *Ever-smoked >1 cigarettes, Also known as the quit ratio. Note: estimates since 1992 incorporate same-day smoking Percentage of Ever Smokers* Who Are Former Smokers, Adults Aged > 18 Years, by Poverty Status - United States, 1983-26 6 5 4 3 2 At/above poverty line Below poverty line 52.2% 3.9% 1 Year Source: National Health Interview Surveys, 1983-26; Centers for Disease Control and Prevention: National Center for Health Statistics and Office on Smoking and Health. *Ever-smoked >1 cigarettes, Also known as the quit ratio. Note: estimates since 1992 incorporate some-day smoking 27

Percent Former Smokers Current Smoking Prevalence (%) Median Household Income and Current Smoking Prevalence, Ages 25+, by State United States, 26/27 3. 2. 1.. 35, 45, 55, 65, Median Household Income ($) Source: Tobacco Use Supplement to the Current Population Survey, U.S. Census Bureau Median Household Income and the Prevalence of Ever Smokers Who ve Quit, Ages 25+, by State United States, 26/27 65. 6. 55. 5. 45. 4. 35, 45, 55, 65, Median Household Income ($) Source: Tobacco Use Supplement to the Current Population Survey, U.S. Census Bureau 29

Strength of Smoke-Free Legislation Cigarette Excise Tax (cents) Median Household Income and the Cigarette Excise Tax Rate, by State United States, 26/27 3. 25. 2. 15. 1. 5.. 35, 45, 55, 65, Median Household Income ($) Source: Tobacco Use Supplement to the Current Population Survey, U.S. Census Bureau Median Household Income and the Strength of State-level Smoke-Free Air Legislation, by State United States, 26/27 4. 3. 2. 1.. 35, 45, 55, 65, Median Household Income ($) Source: Tobacco Use Supplement to the Current Population Survey, MayaTech Corporation Youth Tobacco Use Approximately 9% of adult smokers in the US smoked their first cigarette before age 18 years. Each day in the United States approximately 4, 12-17 year old youths try their first cigarette and another 1,14 become daily cigarette smokers 3

1973 1975 1977 1979 1981 1983 1985 1987 1989 1991 1993 1995 1997 1999 21 23 25 27 Percent PERCENT PERCENT 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 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 Trends in Cigarette Smoking Anytime in the Past 3 days by Grade in School United States, 1975-28 45 4 35 3 25 2 15 1 5 1975 1977 1979 12 th Grade 1 th Grade 2.4% in 28 8 th Grade 1981 1983 1985 1987 1989 1991 YEAR 1993 1995 1997 1999 21 23 25 27 Source: Institute for Social Research, University of Michigan, Monitoring the Future Surveys 12.3% in 28 6.8% in 28 Trends in cigarette smoking among adults and high school seniors -- United States, 1974-27 4 35 3 25 2 15 1 5 Year Adults HS Seniors *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 31

PERCENT PERCENT PERCENT Trends in Prevalence of Past Month Cigarette Smoking Among High School Seniors by Gender United States, 1975-28 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 Trends in Prevalence of Past Month Cigarette Smoking Among High School Seniors by Race United States, 1977-28 45 4 35 White 3 25 2 Hispanic 15 1 Black 5 1977 198 1983 1986 1989 1992 1995 1998 21 24 27 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 Smokeless Tobacco Use Anytime in the Past 3 Days Among High School Seniors by Sex United States, 1992-28 25 2 15 1 Males 11.8% in 28 5 1991 1993 1995 1997 Females 1999 YEAR 21 23 25 27 1.% in 28 Source: Institute for Social Research, University of Michigan, Monitoring the Future Surveys 32

Percent Percent PERCENT Trends in Smokeless Tobacco Use Anytime in the Past 3 Days Among High School Seniors by Population Density United States, 1992-28 2 18 16 14 12 1 8 6 4 2 1991 1993 1995 1997 Other MSA Large MSA 1999 YEAR Non-MSA Source: Institute for Social Research, University of Michigan, Monitoring the Future Surveys 21 23 25 27 11.8% in 28 6.2% in 28 2.6% in 28 Percentage of High School Students Who Currently Used Smokeless Tobacco,* by Sex** and Race/Ethnicity,*** 27 1 8 6 4 2 7.9 13.4 1.3 2.3 1.2 4.7 Total Female Male White Black Hispanic * Used chewing tobacco, snuff, or dip on at least 1 day during the 3 days before the survey. ** M > F *** W > H > B National Youth Risk Behavior Survey, 27 1 Percentage of High School Students Who Currently Smoked Cigars,* by Sex** and Race/Ethnicity,*** 27 8 6 4 2 13.6 7.6 19.4 14.8 1. 12.7 Total Female Male White Black Hispanic * Smoked cigars, cigarillos, or little cigars on at least 1 day during the 3 days before the survey. ** M > F *** W > H > B National Youth Risk Behavior Survey, 27 33

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 POUNDS 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 POUNDS 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 Trends in Per Capita Consumption of Various Tobacco Products United States, 188-24 16 14 12 1 8 6 4 2 Cigarettes Cigars Pipe/Roll your own Chewing Snuff YEAR Source: Tobacco Situation and Outlook Report, U.S. Department of Agriculture, U.S. Census Note: Among persons > 18 years old. Beginning in 1982, fine-cut chewing tobacco was reclassified as snuff. 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 8 6 4 2 YEAR 34

Paradigm for Tobacco Control Access Industry Marketing Individual Price/economic Smoke-free air Anti-Tobacco Mass Media Cessation activities Prevention activities Product Regulation Liability Tobaco Adiction Society 35