Tobacco

1. Tobacco Health Effects, Costs, WHO Treaty, Academia, and Control Measures Martin Donohoe

3. Tobacco – Weapon of Mass Destruction • 1.1 billion smokers worldwide (40% of men, 9% of women) • 80% in low and middle income countries • Almost 6 trillion cigarettes smoked/yr worldwide

4. Tobacco – Weapon of Mass Destruction • 38 million (15% of adults) in U.S. • 18% of men; 14% of women • 7% of pregnant women • 8% of adolescents (down from 18% in 2002)

5. Tobacco – Weapon of Mass Destruction • 38 million (15% of adults) in U.S. • 9% of Asians • 11% of Hispanics • 16% of African-Americans • 17% of whites • 32% of American Indians/Alaska Natives

6. Tobacco – Weapon of Mass Destruction • 38 million (15% of adults) in U.S. • 33% of mentally ill • 24% of active duty military (38% start after enlisting) • Costs billions (lost productivity, health care) • Concerns re effects on performance

7. ETS Exposure (most recent studies from 2015 and before) • 25% prevalence of among non-smokers • 40% of school-aged children and 33% of adolescents • Courts beginning to use in custody/parental rights decisions

8. How Tobacco Companies Make Cigarettes More Addictive, Attractive and Deadly to Kids • Nicotine • Addictive* • Immunosuppressive • Possibly carcinogenic • Interferes with some chemotherapy • Linked to cardiovascular, respiratory, and GI disorders

9. How Tobacco Companies Make Cigarettes More Addictive, Attractive and Deadly to Kids Bronchodilators (expand airways for nicotine delivery) Ventilated filters (cause smoker to breathe deeper) Menthol (cools and numbs throat) Flavorings (e.g., liquorice, chocolate)

10. How Tobacco Companies Make Cigarettes More Addictive, Attractive and Deadly to Kids Sugars and acetaldehyde (make inhalation easier, enhances nicotine’s addictive effects) Tobacco-specific nitrosamines (carcinogenic, higher concentration in US cigarettes) Ammonia compounds (increase speed of nicotine delivery to brain) Levulinic acid (reduces harshness of nicotine, makes smoke smoother, less irritating

11. Tobacco – Weapon of Mass Destruction • 7 million deaths/yr worldwide (11% of male deaths; 6% of female deaths) – 1 million from passive smoking • More deaths than from malaria, TB, and AIDS combined • Tobacco industry makes over $9,000 for each of the direct deaths • Estimated 8-10 million by 2030

12. Tobacco – Weapon of Mass Destruction • Leading cause of death in U.S. • 440,000 deaths/yr from smoking • 42,000 from environmental tobacco smoke (ETS) • Sum exceeds number of US soldiers who died on the battlefields of WWI, WWII, Korea, and Vietnam combined • Smokers die 10 years earlier than non-smokers

13. Tobacco – Weapon of Mass Destruction • Numerous health consequences (21 diseases) • Heart disease, cancer (12 types; 25% of all cancers), stroke, COPD, suicide, preterm birth, LBW, infant/fetal mortality, etc. • Daily cannabis use increasing with legalization; occurs predominantly among cigarette smokers

14. Tobacco – Weapon of Mass Destruction Tobacco smoke contains over 7,000 chemicals, including numerous toxins, carcinogens, air pollutants, chemicals classified as hazardous waste, and radioactive pollonium

15. Tobacco – Weapon of Mass Destruction • Grown in almost 125 countries on over 4.3 million hectares of arable land (China, Brazil, and India main producers) • Which could otherwise feed 10-20 million people • 1 tree cut down for to cure every 300 cigarettes • Heavily fertilizer- and pesticide-dependent crop • Tobacco industry has lobbied to weaken environmental regulations

16. Cigarette Litter • The most littered item in the world • 4.5 trillion butts (1.7 billion lbs)/yr • 38% of all street litter • Most common trash item on world’s shorelines • Comprised largely of filters made from cellulose acetate, a non-biodegradable plastic • Filters trap toxins, heavy metals which can leach into environment • 1/3 of e-cigarettes and refills single use, spent capsules and replacement plastic pods contain numerous hazardous substances

17. Tobacco – Weapon of Mass Destruction • Direct medical costs = $170 billion/yr (worldwide $1.4 trillion) • Lost productivity = $156 billion/yr • Combined total would require tobacco tax of $25/pack • Actual tax = $1.18 to $5.36 per pack • Medical care and lost productivity due to tobacco use costs each U.S. citizen approximately $1,020/yr

18. Tobacco – Weapon of Mass Destruction • Smoking costs the average smoker at least $1.1 million over a lifetime • Includes cost of tobacco, health care costs, income loss, and other costs (e.g., homeowner’s insurance, etc.)

19. Smoking and the Military • 24% of active US military smoke • Cigarettes tax-free • Costs $1.6 billion annually for lost productivity and healthcare expenses • Veteran smoking rates/health care costs high • Federal law requires smoking facilities at VA hospitals

20. Smoking Prevention and Cessation • Only 3.2% of state revenues from tobacco taxes and settlement money spent on prevention and cessation • Financial institutions convinced many state governments to divert settlement funds into capital appreciation bonds, in order to borrow money for routine expenses • Bankers, consultants, and lawyers have pocketed over $500 million in fees

21. Smoke-Free Legislation • 1975: Minnesota passes first clean indoor air law • By 1999: All 50 states and D.C. have some public smoking restrictions • Health benefits for smokers and non-smokers • Do not hurt economic bottom line of bars or restaurants • 2016: ALA gives majority of states “F” for tobacco control

22. Tobacco Control Measures Associated with avoidance of estimated 8 million deaths and estimated extended mean life span of 19-20 years since first surgeon general’s report in 1964 Ever $1.00 a state spends on smoking cessation treatments saves an average of $1.26 Additional savings from other tobacco control measures

23. Tobacco Control Measures • Only 16% of the world’s population lives in jurisdictions with comprehensive smoke-free laws • 10% live in areas with comprehensive bans on advertising, promotion, and sponsorship

25. Smokescreen • Cigarettes most marketed products in the world • Over $9 billion spent on marketing in the U.S. in 2016 ($26 million/day) • U.S. Tobacco industry profits over $117 billion in 2016 ($78 billion in 2001) • 2017: Tobacco giants, to comply with 2006 civil racketeering case, required to launch a national advertising campaign to rectify its previous “false, deceptive, and misleading public statements about cigarettes and smoking.”

26. TOP 10 CIGARETTE MARKETS BY VOLUME (billions of cigarettes)(Euromonitor International, 2017) China: 2,350.5 Indonesia: 316.1 Russia: 278.4 USA: 263.4 Japan: 173.9 Turkey: 105.5 Egypt: 90.0 Bangladesh: 86.1 India: 84.9 Philippines: 79.1

27. Smokescreen • U.S. leading exporter of cigarettes • U.S. tax money used to assist corporations in their marketing efforts overseas • Top 3 tobacco companies received almost $190 million in government subsidies in 2013, now phased out

28. Smokescreen • Tobacco manufacturers pay governments U.S. $133 billion/yr, but less than $1 billion/yr spent on tobacco control (and only 3% of this spent on low- and middle-income countries)

29. Smokescreen • Tobacco companies spend approximately $9 billion on marketing in the U.S. (not including e-cigarettes) • $20 on marketing for every $1 that states spend to fight tobacco use • States spend less than 2% of tobacco revenue to fight tobacco use • Recent state funding cuts

30. Smokescreen • Reynolds American and Phillip Morris International are the 2 largest donors to the American Council on Science and Health (a corporate front group promoting e-cigarettes) • See slide show and article on ACSH on “Science and Pseudoscience” page of phsj website

31. WHO Framework Convention on Tobacco Control Treaty • Finalized 2/27/05 • Ratified by 180 nations • Including Russia, Canada, Australia, Mexico, and the UK • Another 7 have signed but not yet ratified/approved

32. WHO Framework Convention on Tobacco Control Treaty • Exempts tobacco control from free trade challenges • Limits tobacco advertising • Cracks down on tobacco smuggling • Bans tobacco sales to and by minors

33. WHO Framework Convention on Tobacco Control Treaty • Promotes agricultural diversification and alternative livelihoods for tobacco farmers • Standardizes packaging • Bans deceptive terms such as “light” and “mild” • Improves warning labels

34. Tobacco Advertising Worldwide • 24 countries with 694 million people have introduced complete bans • Banned in European Union, China, etc. • 100 more countries are close to a complete ban • 67 countries currently do not ban any tobacco advertising

35. U.S. Efforts to Undermine the Treaty • Despite overwhelming U.S. and international public support for the goals of the treaty… • U.S. government attempted to scuttle the treaty in the name of free trade and free speech • Tobacco industry documents show attempt to create alternative through Project Cerberus

36. U.S. Efforts to Undermine the Treaty • Original U.S. negotiator Thomas Novotny resigned after the Bush administration pressured him to lobby for the deletion of 10 of 11 treaty provisions, as outlined in a Phillip Morris memo

37. Tobacco Companies • Phillip Morris • Parent company = Altria (also owns 85% of Kraft Foods and 28 % of Miller Brewing) • 2008: Phillip Morris International becomes independent company, separates from Phillip Morris USA and Altria • Now world’s largest tobacco company

38. Tobacco Companies • 2017: BAT buys 68% of Reynolds for $49 billion (BAT already owns the other 42%) • Creates the second largest listed tobacco company by sales and profits • 80% of cigarettes sold in US made by BAT and Phillip Morris • 2018: Phillip Morris International announces Foundation for a Smoke Free World • Multiple deans of schools of public health sign letter agreeing not to work with the foundation

39. U.S. Efforts to Undermine the Treaty • U.S. Belatedly signed on 5/3/05 • Senate must ratify AND President must sign • Administration has not submitted treaty to Congress – “studying it”

40. Bush Administration Ties to the Tobacco Industry • Karl Rove (Deputy Chief of Staff and Senior Advisor) – lobbyist/strategist for PM • Kirk Blalock (White House liaison to the business community) – PM public relations official

41. Bush Administration Ties to the Tobacco Industry • Charles Black (informal advisor to Bush during 2000 campaign) – PM lobbyist • Daniel Troy (former FDA Chief Counsel) – represented tobacco industry when it sued the FDA over tobacco ad regulation

42. Bush Administration Ties to the Tobacco Industry • Tommy Thompson (HHS Secretary) • Received $72,000 in campaign contributions from PM executives when he was governor of Wisconsin • Advisor for the primary tobacco lobbying firm in D.C. • Rejected his own advisory panel’s recommendation to increase federal tobacco tax

43. Bush Administration Ties to the Tobacco Industry • British American Tobacco PLC’s Brown and Williamson unit and RJ Reynolds Tobacco Holdings, Inc. represented by Barbour, Griffith and Rogers • Lobbying firm stocked with Republican operatives, including: • Haley Barbour – former GOP Chairman, MS governor • Lanny Griffith – White House aide to GHW Bush

44. Obama Administration and Tobacco • Signed into law $0.94 increase in federal tobacco tax (2009) • US Trade Representative Ronald Kirk • Former PM lobbyist • Opposed smoking ban at Dallas airport when mayor of Dallas in early 1990s • Opposed federal excise tax on tobacco • Opposes special rules for tobacco in international trade agreements

45. Trump Administration and Tobacco • President Trump earned $2.1 million (2013-16) from tobacco holdings • States he has sold his stocks, but no proof • Reynold American gave $1 million and Altria $500,000 for inaugural celebration

46. Trump Administration and Tobacco • Vice-President Pence: • Argued in 2001 that “smoking doesn’t kill” • Received almost $100,000 from tobacco lobby over career • Owned up to $250,000 in stock in family’s chain of convenience stores “Tobacco Road” (company went bankrupt)

47. Trump Administration and Tobacco • Senate Majority Leader McConnell • Has long voted for tobacco interests • From KY, major tobacco producer • 2017: former chief of staff hired by Altria

48. Trump Administration and Tobacco • Former HHS Secretary Tom Price • Voted against 62 cent tax increase that would have helped to pay for health care for public insurance for poor children (2009) • Until 2012, owned at least $37,000 in shares in PMI and Altria

49. Trump Administration and Tobacco • Former HHS Secretary Tom Price • Received over $37,000 in donations from tobacco companies and PACs during career as state legislator and Georgia Congressman • Voted against allowing FDA to regulatge tobacco • 2017: former Deputy Chief of Staff hired as lobbyist for Reynolds

50. Trump Administration and Tobacco • Former FDA Chief Scott Gottlieb • Prior to appointment, worked primarily for investment bank Winston and Company, which helped raise $4.7 million for e-cigarette company Kure in 2016 • Then became director of Kure in 2016