Lung cancer staging is the assessment of the extent to which a lung cancer has spread from its original source. As with most cancers, staging is an important determinant of treatment and prognosis. In general, more advanced stages of cancer are less amenable to treatment and have a worse prognosis.
The initial evaluation of non-small cell lung cancer staging uses the TNM classification. This is based on the size of the primary tumor, lymph node involvement, and distant metastasis.
After this, using the TNM descriptors, a group is assigned, ranging
from occult cancer, through stage 0, IA (one-A), IB, IIA, IIB, IIIA,
IIIB to IV (four). This stage group assists with the choice of treatment
and estimate of prognosis.
There are several methods by which this assessment is made. They are broadly classified into non-invasive techniques, which generally involve medical imaging of the lungs such as computer tomography (CT) scans and PET scans, and invasive techniques such as biopsy
and surgery. Invasive techniques provide additional information because
tissue samples can be seen microscopically to confirm presence of
cancer cells (as opposed to enlargement of tissues due to other causes
such as infection) and to determine the type of lung cancer and its grade.
Staging may also be categorized as either clinical or as pathological/surgical
staging. Clinical staging is performed prior to definitive surgery. It
is based on the results of imaging studies (such as CT scans
) and biopsy results (i.e. clinical staging does include the results of
biopsy, an "invasive technique.") Pathological staging is also called
surgical staging and reflects not only the results of non-surgical
biopsy, but is evaluated either intra- or post-operatively and is based
on the combined results of surgical and clinical findings, including
surgical sampling of thoracic lymph nodes.
Lung cancer is responsible for 1.3 million deaths worldwide annually,
and is the most common cause of cancer-related death in men and the
second most common in women. The most common cause of lung cancer is
long-term exposure to tobacco smoke. Lung cancer in non-smokers, who account for approximately 15% of cases, is often attributed to a combination of genetic factors, radon gas, asbestos, and air pollution.
The main types of lung cancer are non-small cell lung carcinoma and small cell lung carcinoma, the two being distinguished histologically as well as by how they are treated; non-small cell lung carcinoma is primarily treated with surgery if feasible, while small cell lung carcinoma is more frequently treated with chemotherapy and radiation.
Lung
cancer can start in various portions of the lung. From there it spreads
in fairly predictable pattern. Typically, if lung cancer spreads, it
first goes to close by lymph nodes, followed by lymph nodes further away located between the lungs in a space called the mediastinum. In the mediastinum, the lung cancer tends at first to stay on the side where the original tumor
started. Once it crosses the mediastinal midline, it denotes more
advanced, surgically unresectable disease. Lung cancer can also spread
to distant organs, for example, the liver or adrenal glands, which
constitutes the most advanced stage of the disease called stage IV.
Staging
Staging
is the process of determining how much cancer there is in the body and
where it is located. Staging of lung cancer is of paramount importance
as treatment choices are often highly complex, even for physicians with
much experience in the field, and the options largely depend on the
stage of the disease. The underlying purpose is to describe the extent
or severity of an individual's cancer, and to bring together cancers
that have similar prognosis and treatment.
Staging information which is obtained prior to surgery, for
example by x-rays and endoscopic ultrasound, is called clinical staging
and staging by surgery is known as pathological staging.
Clinical staging is done by a combination of imaging and sampling
(biopsies), or stated differently, non-invasive (radiological) and
invasive (biopsy) methods.
Pathologic
staging is more accurate than clinical staging, but clinical staging is
the first and sometimes the only staging type. For example, if clinical
staging reveals stage IIIB or IV disease, surgery is not helpful and no
pathological staging information will be obtained (appropriately).
Lung cancer biopsies can be taken for two different reasons:
Diagnosis: To find out whether an abnormality seen on a chest
x-ray or CT scan is indeed lung cancer, and what histological type it is
(small cell or non-small cell).
Staging: To find out whether a structure, such as a lymph node in the mediastinum, has already been invaded by cancer or not.
However, it is often possible, with proper planning, to obtain both
diagnostic and staging information with a single biopsy procedure.
There is an extensive array of staging methods available, each
with advantages and disadvantages. Many cancer treatment centers review
newly diagnosed patients at an inter-disciplinary chest tumor board where radiologists, oncologists, surgeons, pulmonologists, pathologists and EUS specialists (endosonographers) discuss the relative merits of the available modalities and make a choice by consensus.
T4ipsi: Tumor of any size with additional tumor nodule(s) in a different ipsilateral lobe;
N Lymph node
N1 : Nodal metastasis in ipsilateral pulmonary or hilar lymph nodes;
N2 : Nodal metastasis in ipsilateral mediastinal/subcarinal lymph nodes;
Methods
AJCC edition
published
went into effect
Lung cancer link(s) and page numbers in the original
7
2009
2010
AJCC, NCI, and NCCN
6
2002
2003
AJCC; original pages 167-177
5
1997
1998
AJCC; original pages 127-137
4
1992
1993
AJCC; original pages 115-122
3
1988
1989
AJCC; original pages 114-121
2
1983
1984
AJCC; original pages 99–105
1
1977
1978
AJCC; original pages 59–64
The American Joint Committee on Cancer (AJCC) as well as the International Union Against Cancer (UICC) recommend TNM staging, which is a two step procedure. Their TNM system, which they now develop jointly, first classifies cancer by several factors, T for tumor, N for nodes, M for metastasis, and then groups these TNM factors into overall stages as shown in their table.
AJCC has provided web accessible poster versions of these copyrighted TNM descriptors and stage groups, to which readers are directed for accurate, detailed, up to date information; additionally, both the National Cancer Institute (NCI) and the National Comprehensive Cancer Network (NCCN)
reprint these descriptors and grouping tables with AJCC permission,
and extensively discuss staging modalities and treatment options,
providing expert clear assistance in decisions about the best
treatments. The NCCN pathways "outline the step-by-step treatment
decisions from diagnosis through all phases of treatment and
survivorship."
Although TNM classification is an internationally agreed system,
it has gradually evolved through its different editions; the dates of
publication and of adoption for use of AJCC editions is summarized in
the table in this article; past editions are available from AJCC for web
download.
Therefore, it is important when reviewing reports of treatment or
prognosis to be aware that the criteria used in the TNM system have
varied over time, sometimes fairly substantially, according to the
different editions. Literature reports usually reflect the staging that
was in use while the study was initiated and performed, rather than when
it was eventually published. The dates of publication and adoption for
use of AJCC editions is summarized here to assist readers in
understanding which era is being used by the literature.
As in each edition of the TNM staging system, that used from 2010
January 1 (7 edition) made significant changes to the schema that is
used for non-small cell lung carcinoma, small-cell lung carcinoma and broncho-pulmonarycarcinoid tumors.
The revisions were based on a detailed analysis and consensus process by
AJCC and UICC that looked at the overall survival of 81,015 patients.
The changes have been reviewed in detail, including an extensive
presentation (with multiple tables and detailed discussion) of prognostic data for both 6th and 7th edition, looking at both individual T, N and M descriptors, and at overall stage groups.
The table uses limited excerpts from the copyrighted TNM system to
demonstrate the concept that there are changes, as well as
similarilities, between editions.
As a result, a given stage may have quite a different prognosis
depending on which staging edition is used, independent of any changes
in diagnostic methods or treatments, an effect that has been termed
"stage migration."
The technologies used to assign patients to particular categories have
changed also, and it can be seen that increasingly sensitive methods
tend to cause individual cancers to be reassigned to higher stages,
making it improper to compare that cancer's prognosis to the historical
expectations for that stage.
Finally, of course, a further important consideration is the effect of improving treatments over time as well.
Of considerable historical importance, Dr. Clifton Mountain, a
surgeon in Texas, made significant contributions to the TNM staging
system, particularly in non-small cell lung carcinoma, and the
literature thus often refers to "Mountain" staging.
VA classification
In small-cell lung carcinoma,
the TNM classification is often used along with an additional
categorization, the Veterans Administration Lung Cancer Study Group
system. The VA scheme has two stages. Limited-stage disease is confined to an area that is tolerably treated by one radiotherapy
area ("port"), but excludes cancers with pleural and pericardial
effusions. All other small-cell lung cancers are extensive-stage in this
scheme. There has been some drift over time in what this definition
means.
Staging modalities
CT and PET scans
The
mainstay of non-invasive staging is a CT scan of the chest followed by
metabolic imaging with a PET scan. The CT scan shows abnormalities such
as a lung nodule
or enlarged lymph nodes whereas the PET scan reveals increased
metabolism such as occurs in structures which contain rapidly growing
cancer cells. PET/CT combined the benefits of functional assessment with
PET and anatomic assessment with CT. PET/CT represents a significant
advance for staging of patients with lung cancer with management impact
in the order of 40% and discordant findings compared with conventional imaging in half of patients. PET/CT also has high inter- and intra-reporter agreement.
The main benefit of PET is to identify distant metastatic disease,
thereby indicating futility of locoregional approaches such as surgery
or curative intent radiotherapy.
According to the American College of Chest Physicians (ACCP) Non-Invasive Staging Guidelines for Lung Cancer (2007),
the pooled sensitivity and specificity of CT scanning for identifying
mediastinal lymph node metastasis are 51% and 85%, respectively and for
PET scanning 74% (95% CI, 69 to 79%) and 85% (95% CI, 82 to 88%),
respectively. In other words, were one to rely on the results of
non-invasive staging alone, between 21 and 31 percent of patients would
be understaged (the cancer is more advanced than it seems) and between
12 and 18 percent of patients would be overstaged ( the cancer is in
fact in an earlier stage than it seems). In selected clinical situations
confirmation of the results of the status of the mediastinal nodes by
sampling will therefore be necessary.
PFTs
Pulmonary function tests
(PFT) are not a formal part of staging but can be useful in treatment
decisions. Patients with lung cancer resulting from air pollution
(occupational or cigarette smoking-related) are more likely to have
other lung disorders such as COPD,
which limit their respiratory reserve. Patients with limited
respiratory reserve are at higher risk for postoperative complications
should surgical treatment be pursued; they may not be able to tolerate
the diminished lung capacity remaining after the removal of a portion of
the lung.
Brain MRI
PET
scans need to be specifically modulated to detect metastases within the
brain, which otherwise shows fairly uniformly active uptake from normal
brain activity. In practice, CT or MRI scans are used to detect brain
metastases. Although MRI has a modestly higher detection rate and can find smaller metastases, contrast-enhanced CT scan can be a suitable choice due to many factors such as MRI-incompatible metal prosthetics, claustrophobia, or noise-intolerance.
Mediastinal staging
Nearly half of lung cancers have mediastinal disease at diagnosis.
If cancer involves any of the mediastinal lymph nodes, these lymph
nodes are designated N2 if they are on the same side as the original
tumor, and N3 if they are on the other. N2, and particularly N3 lymph
nodes, affect the clinical stage very significantly. The American
Thoracic Society has standardized the nomenclature of lymph nodes in the
chest.
There are fourteen numbered nodal stations. Lymph nodes considered to
be in the mediastinum are stations 1–9, which are thus potential N2 or
N3 locations, while stations 10-14 are hilar and peripheral nodes, and
thus potential N1 locations.
There are numerous modalities which allow staging of mediastinal
lymph nodes. In the following table they are arranged from the most to
the least invasive.
Advantages and disadvantages of various mediastinal staging procedures in lung cancer.
Allows the most thorough inspection and sampling of lymph node stations, may be followed by resection of tumor, if feasible
Most invasive approach, not indicated for staging alone, significant risk of procedure-related morbidity
Extended cervical mediastinoscopy combined with a Chamberlain procedure, which is also called a left parasternal mediastinotomy, or anterior mediastinotomy
Still considered the gold standard (usual comparitor) by many, excellent for 2RL 4RL.
Does not cover all medastinal lymph node stations, particularly
subcarinal lymph nodes (station 7), paraesophageal and pulmonary
ligament lymph nodes (stations 8 and 9), the aortopulmonary space lymph
nodes (station 5), and the anterior mediastinal lymph nodes (station 6);
false-negative rate approximately 20%; invasive
Traverses a lot of lung tissue, therefore high pneumothorax risk, some lymph node stations inaccessible
Bronchoscopy with blind transbronchial FNA (Wang needle)
Less invasive than above methods
Relatively low yield, not widely practiced, bleeding risk
Endobronchial ultrasound (EBUS)
Direct visualization of lymph node stations. Complements EUS: covers
lymph node stations 2R and 4R which are difficult to access by EUS;
lower false-negative rate than with blind transbronchial FNA and fewer
complications
More invasive than EUS, few practitioners, but rapidly growing in popularity
Least invasive modality, uses the esophagus to access mediastinal
lymph nodes, excellent for station 5, 7, 8 lymph nodes. Useful for
station 2L and 4L, L adrenal, celiac lymph node
Cannot reliably access right sided paratracheal lymph node stations 2
R and 4R; accurate discrimination of primary hilar tumors and involved
lymph nodes is important
Endoscopic ultrasound
Background
This
section focuses on the emerging role various types of endoscopic
ultrasound and biopsy are playing in the diagnosis and staging of lung
cancer, with an emphasis on the most common type of lung cancer, non-small cell lung cancer (NSCLC). These techniques have been reviewed extensively and have attained substantial consensus in guidelines such as from the NCCN.
Endoscopic ultrasound (EUS) is an endoscopic technique where a miniaturized ultrasound probe is passed through the mouth into the upper gastrointestinal tract to investigate organs and structures close to the esophagus, stomach, or duodenum, such as the lung. In 1993, Wiersema published the first description of EUS to diagnose and stage lung cancer, done by advancing a fine needle through the esophagus into adjacent lymph nodes.
Numerous subsequent studies have shown this general methodology to be
effective, very safe, minimally invasive, and very well tolerated. Given
these advantages, many authorities think that EUS together with
endobronchial ultrasound (EBUS) enhances lung cancer diagnosis and
staging.
Endoscopic ultrasound (EUS)
A
metaanalysis published in 2007, based on 1,201 cancers in 18
high-quality clinical trials carefully selected by predefined criteria
from the literature, systematically examined the performance of
EUS-guided FNA in NSCLC staging. Two scenarios were considered: the
setting of enlarged lymph nodes on CT (suggestive but not diagnostic of
cancer), and the obverse scenario of an absence of lymph node
enlargement on CT (suggestive but not diagnostic of no cancer).
Overall, in both settings, minor complications were reported in 0.8% of
procedures; no major complications were recorded. EUS-FNA in enlarged
discrete mediastinal lymph nodes had an excellent pooled sensitivity (8
studies) of 90% (95% CI,
84 to 94%) and specificity of 97% (95% CI, 95 to 98%). EUS-FNA in the
setting of no enlarged mediastinal lymph nodes on CT had a pooled
sensitivity (4 studies) of 58% (95% CI, 39 to 75%) and specificity of
98% (95% CI, 96 to 99%). Although this sensitivity (58% in CT-negative
disease) might on first consideration seem disappointing, if EUS is
performed as a staging test it can help avoid more invasive staging
procedures, or surgery, if positive (for the presence of cancer). In
other words, an EUS that has a positive result (shows cancer) will avoid
further needless surgery, whereas a result not showing cancer may be
false-negative, and probably requires an excisional biopsy technique for
confirmation, such as VATS or mediastinoscopy.
The ACCP guidelines recommend invasive staging for patients with
or without mediastinal lymph node enlargement on CT regardless of the
PET scan findings. If needle techniques are used (such as EUS-NA, TBNA,
EBUS-NA, or TTNA) a non-malignant result should be further confirmed by
mediastinoscopy as explained above.
EUS can reliably reach the lymph node stations 5, 7, 8 and 9. In
the superior mediastinum the trachea is somewhat to the right of the
esophagus which makes it often possible to reach left-sided area 2 and 4
lymph nodes and, less often, right sided paratracheal lymph nodes.
In general, EUS is most appropriate for evaluation of the posterior
inferior mediastinum while mediastinoscopy or EBUS are best for the
anterior superior mediastinum. The feasibility of EUS-FNA of
aorto-pulmonary space (subaortic) lymph nodes (station 5) is a major
advantage of EUS. Evaluation of this station has traditionally required a
paramedian mediastinotomy (Chamberlain procedure). EUS can easily
sample celiac lymph nodes, which cannot be reached by the other
mediastinal staging methods. In one recent study an unexpectedly high
incidence of celiac lymph node metastasis (11%) was noted. EUS can also be used to biopsy potential left adrenal metastases, whereas the right adrenal gland is mostly inaccessible.
The potential utility of EUS-FNA in restaging of the mediastinum
in patients who have undergone chemotherapy and radiotherapy for N2 or
N3 disease is under investigation. The underlying idea is that initially
advanced cancers, previously too extensive for surgery, may have
responded to chemotherapy and radiation so much that they now may be
operative candidates. Rather than immediately proceeding to thoracotomy
based on CT or PET results, which could lead to an "open and close"
thorax surgery, restaging, including invasive staging, may deselect
non-responders, missed on imaging tests alone. If the initial
mediastinal staging included a mediastinoscopy, most surgeons try to
avoid a repeat mediastinoscopy after radiation treatment because of
scarring. Although restaging by PET and CT scanning may help to provide
targets for biopsies, the concept is that even PET-negative mediastinums
need to be sampled. In N2 disease, EUS-FNA and EBUS-FNA appear to offer
the best risk-benefit ratio in these patients.
Endobronchial ultrasound (EBUS)
As
mentioned in the table, EUS cannot reliably access right sided
paratracheal lymph node stations 2R and 4R and may not be optimal for
the left sided paratracheal lymph node stations either. An adaptation of
the endoscopic ultrasound scope originally designed for the
gastrointestinal tract is known as endobronchial ultrasound (EBUS). The
instrument is inserted into the trachea rather than the esophagus. There
are two types of EBUS bronchoscopes available: radial catheter probe
and convex probe EBUS (CP-EBUS),
but only the latter concerns us here. Early experience with mediastinal
staging by CP-EBUS appears very promising with sensitivities ranging
from 92 to 96 percent in 4 series comprising 70 to 502 patients.
Combined ultrasound
Many
patients will, if given a choice, prefer an instrument which is
inserted into the esophagus (EUS) over one which is inserted into the
trachea (EBUS). Furthermore, many patients with suspected lung cancer
will have other smoking related illnesses, such as emphysema or COPD,
which makes a bronchoscopy-like procedure (EBUS) a higher risk than an
upper endoscopy through the esophagus (EUS). An area of active and
emerging research concerns the value of combining EUS and EBUS in a
single session, one specialist following the other, or -even more
convenient- a dual trained operator doing one or the other – or both- as
needed.
EUS-FNA and EBUS-FNA are complementary techniques. EUS has the
highest yield in the posterior inferior mediastinum, and EBUS is
strongest for the superior anterior mediastinum. Some lymph node
stations can only be accessed by one method and not the other (for
example, station 2 and 4 L and 3 are hard or impossible to see by EUS,
stations 5 and 8 cannot be biopsied by EBUS). Together, EBUS and EUS
cover the entire mediastinum (except possibly station 6) and complete
mediastinal staging should be possible with a combination of these two
procedures. This combination could conceptually eliminate the need for
most surgical mediastinoscopies and in fact be more comprehensive.
When combined, this approach has been termed "complete medical
mediastinoscopy." EUS-FNA with EBUS may allow near-complete, minimally
invasive mediastinal staging in patients with suspected lung cancer.
Tobacco smoking is the practice of burning tobacco and ingesting the resulting smoke. The smoke may be inhaled, as is done with cigarettes, or simply released from the mouth, as is generally done with pipes and cigars. The practice is believed to have begun as early as 5000–3000 BC in Mesoamerica and South America. Tobacco was introduced to Eurasia in the late 17th century by European colonists, where it followed common trade routes. The practice encountered criticism from its first import into the Western world
onwards but embedded itself in certain strata of a number of societies
before becoming widespread upon the introduction of automated
cigarette-rolling apparatus.
Smoking is the most common method of consuming tobacco, and
tobacco is the most common substance smoked. The agricultural product is
often mixed with additives and then combusted. The resulting smoke is then inhaled and the active substances absorbed through the alveoli in the lungs or the oral mucosa. Many substances in cigarette smoke trigger chemical reactions in nerve endings, which heighten heart rate, alertness and reaction time, among other things. Dopamine and endorphins are released, which are often associated with pleasure.
German scientists identified a link between smoking and lung cancer in the late 1920s, leading to the first anti-smoking campaign in modern history, albeit one truncated by the collapse of Nazi Germany at the end of World War II. In 1950, British researchers demonstrated a clear relationship between smoking and cancer.
Evidence continued to mount in the 1960s, which prompted political
action against the practice. Rates of consumption since 1965 in the developed world have either peaked or declined. However, they continue to climb in the developing world.
As of 2008 to 2010, tobacco is used by about 49% of men and 11% of
women aged 15 or older in fourteen low-income and middle-income
countries (Bangladesh, Brazil, China, Egypt, India, Mexico, Philippines,
Russia, Thailand, Turkey, Ukraine, Uruguay and Vietnam), with about 80%
of this usage in the form of smoking. The gender gap tends to be less pronounced in lower age groups.
Many smokers begin during adolescence or early adulthood. During the early stages, a combination of perceived pleasure acting as positive reinforcement
and desire to respond to social peer pressure may offset the unpleasant
symptoms of initial use, which typically include nausea and coughing.
After an individual has smoked for some years, the avoidance of withdrawal symptoms and negative reinforcement become the key motivations to continue.
A 2009 study of first smoking experiences of seventh-grade
students found out that the most common factor leading students to smoke
is cigarette advertisements. Smoking by parents, siblings and friends
also encourages students to smoke.
Smoking's history dates back to as early as 5000–3000 BC, when the
agricultural product began to be cultivated in Mesoamerica and South
America; consumption later evolved into burning the plant substance
either by accident or with intent of exploring other means of
consumption. The practice worked its way into shamanistic rituals. Many ancient civilizations – such as the Babylonians,
the Indians, and the Chinese – burnt incense during religious rituals.
Smoking in the Americas probably had its origins in the incense-burning
ceremonies of shamans but was later adopted for pleasure or as a social tool.
The smoking of tobacco and various hallucinogenic drugs was used to
achieve trances and to come into contact with the spirit world. Also, to stimulate respiration, tobacco smoke enemas were used.
Eastern North American tribes would carry large amounts of
tobacco in pouches as a readily accepted trade item and would often
smoke it in ceremonial pipes, either in sacred ceremonies or to seal bargains. Adults as well as children enjoyed the practice.
It was believed that tobacco was a gift from the Creator and that the
exhaled tobacco smoke was capable of carrying one's thoughts and prayers
to heaven.
Apart from smoking, tobacco had uses as medicine. As a pain killer it was used for earache and toothache and occasionally as a poultice.
Smoking was said by the desert Indians to be a cure for colds,
especially if the tobacco was mixed with the leaves of the small Desert sage, Salvia dorrii, or the root of Indian balsam or cough root, Leptotaenia multifida, the addition of which was thought to be particularly good for asthma and tuberculosis.
In 1612, six years after the settlement of Jamestown, Virginia, John Rolfe
was credited as the first settler to successfully raise tobacco as a
cash crop. The demand quickly grew as tobacco, referred to as "brown
gold", revived the Virginia joint stock company from its failed gold expeditions.
In order to meet demands from the Old World, tobacco was grown in
succession, quickly depleting the soil. This became a motivator to
settle west into the unknown continent, and likewise an expansion of
tobacco production.
Frenchman Jean Nicot
(from whose name the word nicotine is derived) introduced tobacco to
France in 1560, and tobacco then spread to England. The first report of a
smoking Englishman is of a sailor in Bristol in 1556, seen "emitting
smoke from his nostrils". Like tea, coffee and opium, tobacco was just one of many intoxicants that was originally used as a form of medicine.
Tobacco was introduced around 1600 by French merchants in what today is
modern-day Gambia and Senegal. At the same time, caravans from Morocco
brought tobacco to the areas around Timbuktu,
and the Portuguese brought the commodity (and the plant) to southern
Africa, establishing the popularity of tobacco throughout all of Africa
by the 1650s.
Soon after its introduction to the Old World, tobacco came under frequent criticism from state and religious leaders. James VI and I, King of Scotland and England, produced the treatise A Counterblaste to Tobacco in 1604, and also introduced excise duty on the product. Murad IV, sultan of the Ottoman Empire 1623–40 was among the first to attempt a smoking ban by claiming it was a threat to public morals and health. The Chongzhen Emperor of China issued an edict banning smoking two years before his death and the overthrow of the Ming dynasty. Later, the Manchu rulers of the Qing dynasty, would proclaim smoking "a more heinous crime than that even of neglecting archery". In Edo period Japan, some of the earliest tobacco plantations were scorned by the shogunate
as being a threat to the military economy by letting valuable farmland
go to waste for the use of a recreational drug instead of being used to
plant food crops.
Religious leaders have often been prominent among those who considered smoking immoral or outright blasphemous. In 1634, the Patriarch of Moscow
forbade the sale of tobacco, and sentenced men and women who flouted
the ban to have their nostrils slit and their backs flayed. Pope Urban VIII
likewise condemned smoking on holy places in a papal bull of 1624.
Despite some concerted efforts, restrictions and bans were largely
ignored. When James I of England, a staunch smoking opponent and the author of A Counterblaste to Tobacco,
tried to curb the new trend by enforcing a 4000% tax increase on
tobacco in 1604 it was unsuccessful, as suggested by the presence of
around 7,000 tobacco outlets in London by the early 17th century. From
this point on for some centuries, several administrations withdrew from
efforts at discouragement and instead turned tobacco trade and
cultivation into sometimes lucrative government monopolies.
By the mid-17th century most major civilizations had been
introduced to tobacco smoking and in many cases had already assimilated
it into the native culture, despite some continued attempts upon the
parts of rulers to eliminate the practice with penalties or fines.
Tobacco, both product and plant, followed the major trade routes to
major ports and markets, and then on into the hinterlands. The English
language term smoking appears to have entered currency in the late 18th century, before which less abbreviated descriptions of the practice such as drinking smoke were also in use.
Growth in the US remained stable until the American Civil War in 1860s, when the primary agricultural workforce shifted from slavery to sharecropping. This, along with a change in demand, accompanied the industrialization of cigarette production as craftsman James Bonsack created a machine in 1881 to partially automate their manufacture.
Social attitudes and public health
In Germany, anti-smoking groups, often associated with anti-liquor groups, first published advocacy against the consumption of tobacco in the journal Der Tabakgegner (The Tobacco Opponent) in 1912 and 1932. In 1929, Fritz Lickint of Dresden, Germany, published a paper containing formal statistical evidence of a lung cancer–tobacco link. During the Great Depression Adolf Hitler condemned his earlier smoking habit as a waste of money,
and later with stronger assertions. This movement was further
strengthened with Nazi reproductive policy as women who smoked were
viewed as unsuitable to be wives and mothers in a German family. In the 20th century, smoking was common. There were social events like the smoke night which promoted the habit.
The anti-tobacco movement in Nazi Germany
did not reach across enemy lines during the Second World War, as
anti-smoking groups quickly lost popular support. By the end of the
Second World War, American cigarette manufacturers quickly reentered the
German black market. Illegal smuggling of tobacco became prevalent, and leaders of the Nazi anti-smoking campaign were silenced. As part of the Marshall Plan, the United States shipped free tobacco to Germany; with 24,000 tons in 1948 and 69,000 tons in 1949. Per capita yearly cigarette consumption in post-war Germany steadily rose from 460 in 1950 to 1,523 in 1963.
By the end of the 20th century, anti-smoking campaigns in Germany were
unable to exceed the effectiveness of the Nazi-era climax in the years
1939–41 and German tobacco health research was described by Robert N. Proctor as "muted".
In 1954, the British Doctors Study,
a prospective study of some 40 thousand doctors for about 2.5 years,
confirmed the suggestion, based on which the government issued advice
that smoking and lung cancer rates were related. In January 1964, the United States Surgeon General's Report on Smoking and Health likewise began suggesting the relationship between smoking and cancer.
As scientific evidence mounted in the 1980s, tobacco companies claimed contributory negligence
as the adverse health effects were previously unknown or lacked
substantial credibility. Health authorities sided with these claims up
until 1998, from which they reversed their position. The Tobacco Master Settlement Agreement,
originally between the four largest US tobacco companies and the
attorneys general of 46 states, restricted certain types of tobacco
advertisement and required payments for health compensation; which later
amounted to the largest civil settlement in United States history.
Social campaigns have been instituted in many places to discourage smoking, such as Canada's National Non-Smoking Week.
From 1965 to 2006, rates of smoking in the United States declined from 42% to 20.8%.
The majority of those who quit were professional, affluent men.
Although the per-capita number of smokers decreased, the average number
of cigarettes consumed per person per day increased from 22 in 1954 to
30 in 1978. This paradoxical event suggests that those who quit smoked
less, while those who continued to smoke moved to smoke more light
cigarettes. The trend has been paralleled by many industrialized nations as rates have either leveled-off or declined. In the developing world, however, tobacco consumption continued to rise at 3.4% in 2002.
In Africa, smoking is in most areas considered to be modern, and many
of the strong adverse opinions that prevail in the West receive much
less attention. Today Russia leads as the top consumer of tobacco followed by Indonesia, Laos, Ukraine, Belarus, Greece, Jordan, and China.
Tobacco is an agricultural product processed from the fresh leaves of plants in the genus Nicotiana. The genus contains several species, of which Nicotiana tabacum is the most commonly grown. Nicotiana rustica follows second, containing higher concentrations of nicotine. The leaves are harvested and cured to allow the slow oxidation and degradation of carotenoids
in tobacco leaf. This produces certain compounds in the tobacco leaves
which can be attributed to sweet hay, tea, rose oil, or fruity aromatic
flavors. Before packaging, the tobacco is often combined with other
additives in order to increase the addictive potency, shift the
product's pH, or improve the effects of smoke by making it more palatable. In the United States these additives are regulated to 599 substances. The product is then processed, packaged, and shipped to consumer markets.
Common methods of consuming tobacco include the following:
Basma leaves curing in the sun at Pomak village of Xanthi, Thrace, Greece
Processed tobacco pressed into flakes for pipe smoking
Beedi
Beedis
are thin South Asian cigarettes filled with tobacco flakes and wrapped
in a tendu leaf tied with a string at one end. They produce higher
levels of carbon monoxide, nicotine, and tar than cigarettes typical in
the United States.
Cigars
Cigars
are tightly rolled bundles of dried and fermented tobacco which are
ignited so that smoke may be drawn into the smoker's mouth. They are
generally not inhaled because of the high alkalinity of the smoke, which
can quickly become irritating to the trachea and lungs. The prevalence
of cigar smoking varies depending on location, historical period, and
population surveyed, and prevalence estimates vary somewhat depending on
the survey method. The United States is the top consuming country by
far, followed by Germany and the United Kingdom; the US and Western
Europe account for about 75% of cigar sales worldwide. As of 2005 it is estimated that 4.3% of men and 0.3% of women smoke cigars in the US.
Cigarettes
Cigarettes,
French for "small cigar", are a product consumed through smoking and
manufactured out of cured and finely cut tobacco leaves and
reconstituted tobacco, often combined with other additives, which are
then rolled or stuffed into a paper-wrapped cylinder. Cigarettes are ignited and inhaled, usually through a cellulose acetate filter, into the mouth and lungs.
Hookah
Hookah
are a single or multi-stemmed (often glass-based) water pipe for
smoking. Originally from India, the hookah was a symbol of pride and
honor for the landlords, kings and other such high class people. Now,
the hookah has gained immense popularity, especially in the Middle East.
A hookah operates by water filtration and indirect heat. It can be used
for smoking herbal fruits, tobacco, or cannabis.
Kretek
Kretek are cigarettes made with a complex blend of tobacco, cloves
and a flavoring "sauce". It was first introduced in the 1880s in Kudus,
Java, to deliver the medicinal eugenol of cloves to the lungs. The
quality and variety of tobacco play an important role in kretek
production, from which kretek can contain more than 30 types of tobacco.
Minced dried clove buds weighing about one-third of the tobacco blend
are added to add flavoring. In 2004 the United States prohibited
cigarettes from having a "characterizing flavor" of certain ingredients
other than tobacco and menthol, thereby removing kretek from being
classified as cigarettes.
Pipe smoking
Pipe smoking
is done with a tobacco pipe, typically consisting of a small chamber
(the bowl) for the combustion of the tobacco to be smoked and a thin
stem (shank) that ends in a mouthpiece (the bit). Shredded pieces of
tobacco are placed into the chamber and ignited.
Roll-your-own
Roll-your-own
or hand-rolled cigarettes, often called "rollies", "cigi" or
"Roll-ups", are very popular particularly in European countries and the
UK. These are prepared from loose tobacco, cigarette papers, and filters
all bought separately. They are usually much cheaper than ready-made
cigarettes and small contraptions can be bought making the process
easier.
Vaporizer
A vaporizer
is a device used to sublimate the active ingredients of plant material.
Rather than burning the herb, which produces potentially irritating,
toxic, or carcinogenic
by-products; a vaporizer heats the material in a partial vacuum so that
the active compounds contained in the plant boil off into a vapor. This
method is often preferable when medically administering the smoke
substance, as opposed to directly pyrolyzing the plant material.
The active substances in tobacco, especially cigarettes, are
administered by burning the leaves and inhaling the vaporized gas that
results. This quickly and effectively delivers substances into the
bloodstream by absorption through the alveoli in the lungs. The lungs contain some 300 million alveoli, which amounts to a surface area of over 70 m2
(about the size of a tennis court). This method is not completely
efficient as not all of the smoke will be inhaled, and some amount of
the active substances will be lost in the process of combustion, pyrolysis. Pipe and Cigar smoke are not inhaled because of its high alkalinity, which are irritating to the trachea
and lungs. However, because of its higher alkalinity (pH 8.5) compared
to cigarette smoke (pH 5.3), non-ionized nicotine is more readily
absorbed through the mucous membranes in the mouth. Nicotine absorption from cigar and pipe, however, is much less than that from cigarette smoke. Nicotine and cocaine activate similar patterns of neurons, which supports the existence of common substrates among these drugs.
The absorbed nicotine mimics nicotinic acetylcholine which when bound to nicotinic acetylcholine receptors prevents the reuptake of acetylcholine thereby increasing that neurotransmitter in those areas of the body.
These nicotinic acetylcholine receptors are located in the central
nervous system and at the nerve-muscle junction of skeletal muscles;
whose activity increases heart rate, alertness, and faster reaction times.
Nicotine acetylcholine stimulation is not directly addictive. However,
since dopamine-releasing neurons are abundant on nicotine receptors,
dopamine is released; and, in the nucleus accumbens, dopamine is associated with motivation causing reinforcing behavior. Dopamine increase, in the prefrontal cortex, may also increase working memory.
When tobacco is smoked, most of the nicotine is pyrolyzed.
However, a dose sufficient to cause mild somatic dependency and mild to
strong psychological dependency remains. There is also a formation of harmane (an MAO inhibitor) from the acetaldehyde in tobacco smoke. This may play a role in nicotine addiction, by facilitating a dopamine release in the nucleus accumbens as a response to nicotine stimuli.
Using rat studies, withdrawal after repeated exposure to nicotine
results in less responsive nucleus accumbens cells, which produce
dopamine responsible for reinforcement.
Percentage of females smoking any tobacco product. Note that there is a difference between the scales used for males and the scales used for females.
As of 2000, smoking was practiced by around 1.22 billion people. At
current rates of 'smoker replacement' and market growth, this may reach
around 1.9 billion in 2025.
Smoking may be up to five times more prevalent among men than women in some communities, although the gender gap usually declines with younger age. In some developed countries smoking rates for men have peaked and begun to decline, while for women they continue to climb.
As of 2002, about twenty percent of young teenagers (13–15)
smoked worldwide. 80,000 to 100,000 children begin smoking every day,
roughly half of whom live in Asia. Half of those who begin smoking in adolescent years are projected to go on to smoke for 15 to 20 years. As of 2019 in the United States, roughly 800,000 high school students smoke.
The World Health Organization
(WHO) states that "Much of the disease burden and premature mortality
attributable to tobacco use disproportionately affect the poor". Of the
1.22 billion smokers, 1 billion of them live in developing or
transitional economies. Rates of smoking have leveled off or declined in
the developed world. In the developing world, however, tobacco consumption is rising by 3.4% per year as of 2002.
The WHO in 2004 projected 58.8 million deaths to occur globally, from which 5.4 million are tobacco-attributed, and 4.9 million as of 2007. As of 2002, 70% of the deaths are in developing countries. As of 2017, smoking causes one in ten deaths worldwide, with half of those deaths in the US, China, India and Russia.
Psychology
Takeup
Most smokers begin smoking during adolescence or early adulthood.
Some studies also show that smoking can also be linked to various mental
health complications. Smoking has elements of risk-taking and rebellion, which often appeal to young people.
The presence of peers that smoke and media featuring high-status models
smoking may also encourage smoking. Because teenagers are influenced
more by their peers than by adults, attempts by parents, schools, and health professionals at preventing people from trying cigarettes are often unsuccessful.
Children of smoking parents are more likely to smoke than
children with non-smoking parents. Children of parents who smoke are
less likely to quit smoking.
One study found that parental smoking cessation was associated with
less adolescent smoking, except when the other parent currently smoked.
A current study tested the relation of adolescent smoking to rules
regulating where adults are allowed to smoke in the home. Results showed
that restrictive home smoking policies were associated with lower
likelihood of trying smoking for both middle and high school students.
Behavioural research generally indicates that teenagers begin
their smoking habits due to peer pressure, and cultural influence
portrayed by friends. However, one study found that direct pressure to
smoke cigarettes played a less significant part in adolescent smoking,
with adolescents also reporting low levels of both normative and direct pressure to smoke cigarettes. Mere exposure to tobacco retailers may motivate smoking behaviour in adults.
A similar study suggested that individuals may play a more active role
in starting to smoke than has previously been thought and that social
processes other than peer pressure also need to be taken into account. Another study's results indicated that peer pressure
was significantly associated with smoking behavior across all age and
gender cohorts, but that intrapersonal factors were significantly more
important to the smoking behavior of 12- to 13-year-old girls than
same-age boys. Within the 14- to 15-year-old age group, one peer
pressure variable emerged as a significantly more important predictor of
girls' than boys' smoking. It is debated whether peer pressure or self-selection is a greater cause of adolescent smoking.
Psychologist Hans Eysenck (who later was questioned for nonplausible results and unsafe publications) developed a personality profile for the typical smoker. Extraversion
is the trait that is most associated with smoking, and smokers tend to
be sociable, impulsive, risk taking, and excitement seeking individuals.
Persistence
The reasons given by some smokers for this activity have been categorized as addictive smoking, pleasure from smoking, tension reduction/relaxation, social smoking, stimulation, habit/automatism, and handling. There are gender differences in how much each of these reasons contribute, with females more likely than males to cite tension reduction/relaxation, stimulation and social smoking.
Some smokers argue that the depressant effect of smoking allows them to calm their nerves, often allowing for increased concentration. However, according to the Imperial College London,
"Nicotine seems to provide both a stimulant and a depressant effect,
and it is likely that the effect it has at any time is determined by the
mood of the user, the environment and the circumstances of use. Studies
have suggested that low doses have a depressant effect, while higher
doses have stimulant effect."
Patterns
A
number of studies have established that cigarette sales and smoking
follow distinct time-related patterns. For example, cigarette sales in
the United States of America have been shown to follow a strongly
seasonal pattern, with the high months being the months of summer, and
the low months being the winter months.
Similarly, smoking has been shown to follow distinct circadian
patterns during the waking day—with the high point usually occurring
shortly after waking in the morning, and shortly before going to sleep
at night.
Tobacco smoking is the leading cause of preventable death and a global public health concern. There are 1.1 billion tobacco users in the world. One person dies every six seconds from a tobacco related disease.
Tobacco smoke is a complex mixture of over 7,000 toxic chemicals, 98 of which are associated with an increased risk of cardiovascular disease and 69 of which are known to be carcinogenic. The most important chemicals causing cancer are those that produce DNA damage, since such damage appears to be the primary underlying cause of cancer. Cunningham et al. combined the microgram weight of the compound in the smoke of one cigarette with the known genotoxic effect per microgram to identify the most carcinogenic compounds in cigarette smoke: acrolein, formaldehyde, acrylonitrile, 1,3-butadiene, acetaldehyde, ethylene oxide, and isoprene. In addition to the aforementioned toxic chemicals, flavored tobacco contains flavorings which upon heating release toxic chemicals and carcinogens such as carbon monoxide (CO), polycyclic aromatic hydrocarbons (PAHs), furans, phenols, aldehydes (such as acrolein), and acids, in addition to nitrogenous carcinogens, alcohols, and heavy metals, all of which are dangerous to human health. A comparison of 13 common hookah
flavors found that melon flavors are the most dangerous, with their
smoke containing four classes of hazards in high concentrations.
The World Health Organization estimates that tobacco caused 5.4 million deaths in 2004 and 100 million deaths over the course of the 20th century. Similarly, the United States Centers for Disease Control and Prevention
describes tobacco use as "the single most important preventable risk to
human health in developed countries and an important cause of premature
death worldwide." Although 70% of smokers state their intention to quit only 3–5% are actually successful in doing so.
The probabilities of death from lung cancer before age 75 in the
United Kingdom are 0.2% for men who never smoked (0.4% for women), 5.5%
for male former smokers (2.6% in women), 15.9% for current male smokers
(9.5% for women) and 24.4% for male "heavy smokers" defined as smoking
more than 5 cigarettes per day (18.5% for women).
Tobacco smoke can combine with other carcinogens present within the
environment in order to produce elevated degrees of lung cancer.
The risk of lung cancer decreases almost from the first day someone quits smoking.
Healthy cells that have escaped mutations grow and replace the damaged
ones in the lungs. In the research dated December 2019, 40% of cells in
former smokers looked like those of people who had never smoked.
Rates of smoking have generally leveled-off or declined in the
developed world. Smoking rates in the United States have dropped by half
from 1965 to 2006, falling from 42% to 20.8% in adults. In the developing world, tobacco consumption is rising by 3.4% per year.
Smoking alters the transcriptome of the lung parenchyma;
the expression levels of a panel of seven genes (KMO, CD1A, SPINK5,
TREM2, CYBB, DNASE2B, FGG) are increased in the lung tissue of smokers.
Passive smoking
is the inhalation of tobacco smoke by individuals who are not actively
smoking. This smoke is known as second-hand smoke (SHS) or environmental
tobacco smoke (ETS) when the burning end is present, and third-hand smoke
after the burning end has been extinguished. Because of its negative
implications, exposure to SHS has played a central role in the
regulation of tobacco products. Six hundred thousand deaths were
attributed to SHS in 2004. It also has been known to produce skin
conditions such as freckles and dryness.
In 2015, a meta-analysis found that smokers were at greater risk of developing psychotic disorder. Tobacco has also been described an anaphrodisiac due to its propensity for causing erectile dysfunction. There is a correlation between tobacco smoking and a reduced risk of Parkinson's disease.
In countries where there is a universally funded healthcare
system, the government covers the cost of medical care for smokers who
become ill through smoking in the form of increased taxes. Two broad
debating positions exist on this front, the "pro-smoking" argument
suggesting that heavy smokers generally do not live long enough to
develop the costly and chronic illnesses which affect the elderly,
reducing society's healthcare burden, and the "anti-smoking" argument
suggests that the healthcare burden is increased because smokers get
chronic illnesses younger and at a higher rate than the general
population. Data on both positions has been contested. The Centers for Disease Control and Prevention published research in 2002 claiming that the cost of each pack of cigarettes sold in the United States was more than $7 in medical care and lost productivity.
The cost may be higher, with another study putting it as high as $41
per pack, most of which however is on the individual and his/her family.
This is how one author of that study puts it when he explains the very
low cost for others: "The reason the number is low is that for private
pensions, Social Security, and Medicare — the biggest factors in
calculating costs to society — smoking actually saves money. Smokers die
at a younger age and don't draw on the funds they've paid into those
systems."
Other research demonstrates that premature death caused by smoking may
redistribute Social Security income in unexpected ways that affect
behavior and reduce the economic well-being of smokers and their
dependents.
To further support this, whatever the rate of smoking consumption is
per day, smokers have a greater lifetime medical cost on average
compared to a non-smoker by an estimated $6000
Between the cost for lost productivity and health care expenditures
combined, cigarette smoking costs at least 193 billion dollars (Research
also shows that smokers earn less money than nonsmokers). As for secondhand smoke, the cost is over 10 billion dollars.
By contrast, some non-scientific studies, including one conducted by Philip Morris in the Czech Republic called Public Finance Balance of Smoking in the Czech Republic and another by the Cato Institute,
support the opposite position. Philip Morris has explicitly apologised
for the former study, saying: "The funding and public release of this
study which, among other things, detailed purported cost savings to the
Czech Republic due to premature deaths of smokers, exhibited terrible
judgment as well as a complete and unacceptable disregard of basic human
values. For one of our tobacco companies to commission this study was
not just a terrible mistake, it was wrong. All of us at Philip Morris,
no matter where we work, are extremely sorry for this. No one benefits
from the very real, serious and significant diseases caused by smoking."
Between 1970 and 1995, per-capita cigarette consumption in poorer
developing countries increased by 67 percent, while it dropped by 10
percent in the richer developed world. Eighty percent of smokers now
live in less developed countries. By 2030, the World Health Organization
(WHO) forecasts that 10 million people a year will die of
smoking-related illness, making it the single biggest cause of death
worldwide, with the largest increase to be among women. WHO forecasts
the 21st century's death rate from smoking to be ten times the 20th
century's rate ("Washingtonian" magazine, December 2007).
The tobacco industry is known to be one of the largest global
enterprises in the world. The six biggest tobacco companies made a
combined profit of $35.1 billion (Jha et al., 2014) in 2010.
Famous smokers of the past used cigarettes or pipes as part of their image, such as Jean-Paul Sartre's Gauloises-brand cigarettes; Albert Einstein's, Douglas MacArthur's, Bertrand Russell's, and Bing Crosby's pipes; or the news broadcaster Edward R. Murrow's cigarette. Writers in particular seem to be known for smoking, for example, Cornell Professor Richard Klein's book Cigarettes are Sublime
for the analysis, by this professor of French literature, of the role
smoking plays in 19th and 20th century letters. The popular author Kurt Vonnegut addressed his addiction to cigarettes within his novels. British Prime Minister Harold Wilson was well known for smoking a pipe in public as was Winston Churchill for his cigars. Sherlock Holmes, the fictional detective created by Sir Arthur Conan Doyle, smoked a pipe, cigarettes, and cigars. The DCVertigo comic book character John Constantine, created by Alan Moore, is synonymous with smoking, so much so that the first storyline by Preacher creator Garth Ennis centered around John Constantine contracting lung cancer. Professional wrestlerJames Fullington, while in character as "The Sandman", is a chronic smoker in order to appear "tough".
The problem of smoking at home is particularly difficult for
women in many cultures (especially Arab cultures), where it may not be
acceptable for a woman to ask her husband not to smoke at home or in the
presence of her children. Studies have shown that pollution levels for
smoking areas indoors are higher than levels found on busy roadways, in
closed motor garages, and during fire storms. Furthermore, smoke can spread from one room to another, even if doors to the smoking area are closed.
The ceremonial smoking of tobacco, and praying with a sacred pipe, is a prominent part of the religious ceremonies of a number of Native American Nations. Sema, the Anishinaabe
word for tobacco, is grown for ceremonial use and considered the
ultimate sacred plant since its smoke is believed to carry prayers to
the spirits. In most major religions, however, tobacco smoking is not
specifically prohibited, although it may be discouraged as an immoral
habit. Before the health risks of smoking were identified through
controlled study, smoking was considered an immoral habit by certain
Christian preachers and social reformers. The founder of the Latter Day Saint movement, Joseph Smith, recorded that on 27 February 1833, he received a revelation
which discouraged tobacco use. This "Word of Wisdom" was later accepted
as a commandment, and faithful Latter-day Saints abstain completely
from tobacco.
Jehovah's Witnesses base their stand against smoking on the Bible's
command to "clean ourselves of every defilement of flesh" (2 Corinthians
7:1). The Jewish Rabbi Yisrael Meir Kagan (1838–1933) was one of the first Jewish authorities to speak out on smoking. In Ahmadiyya Islam, smoking is highly discouraged, although not forbidden. During the month of fasting however, it is forbidden to smoke tobacco. In the Baháʼí Faith, smoking tobacco is discouraged though not forbidden.
On 27 February 2005 the WHO Framework Convention on Tobacco Control,
took effect. The FCTC is the world's first public health treaty.
Countries that sign on as parties agree to a set of common goals,
minimum standards for tobacco control policy, and to cooperate in
dealing with cross-border challenges such as cigarette smuggling.
Currently the WHO declares that 4 billion people will be covered by the
treaty, which includes 168 signatories.
Among other steps, signatories are to put together legislation that
will eliminate secondhand smoke in indoor workplaces, public transport,
indoor public places and, as appropriate, other public places.
Many governments have introduced excise taxes on cigarettes in order to reduce the consumption of cigarettes. The World Health Organisation finds that:
The structure of tobacco excise
taxes varies considerably across countries, with lower income countries
more likely to rely more on ad valorem excises and higher income
countries more likely to rely more on specific excise taxes, while many
countries at all income levels use a mix of specific and ad valorem excises.
Tobacco excise tax systems are quite complex in several
countries, where different tax rates are applied based on prices,
product characteristics such as presence/absence of a filter or length,
packaging, weight, tobacco content, and/or production or sales volume.
These complex systems are difficult to administer, create opportunities
for tax avoidance, and are less effective from a public health
perspective.
Globally, cigarette excise taxes account for less than 45 percent of
cigarette prices, on average, while all taxes applied to cigarettes
account for just over half of half of price. Higher income countries
levy higher taxes on tobacco products and these taxes account for a
greater share of price, with both the absolute tax and share of price
accounted for by tax falling as country incomes fall.
In 2002, the Centers for Disease Control and Prevention said that each pack of cigarettes sold in the United States costs the nation more than $7 in medical care and lost productivity,
around $3400 per year per smoker. Another study by a team of health
economists finds the combined price paid by their families and society
is about $41 per pack of cigarettes.
Substantial scientific evidence shows that higher cigarette
prices result in lower overall cigarette consumption. Most studies
indicate that a 10% increase in price will reduce overall cigarette
consumption by 3% to 5%. Youth, minorities, and low-income smokers are
two to three times more likely to quit or smoke less than other smokers
in response to price increases. Smoking is often cited as an example of an inelastic good, however, i.e. a large rise in price will only result in a small decrease in consumption.
Many nations have implemented some form of tobacco taxation. As
of 1997, Denmark had the highest cigarette tax burden of $4.02 per pack.
Taiwan only had a tax burden of $0.62 per pack. The federal government
of the United States charges $1.01 per pack.
Cigarette taxes vary widely from state to state in the United States. For example, Missouri has a cigarette tax of only 17 cents per pack, the nation's lowest, while New York
has the highest cigarette tax in the U.S.: $4.35 per pack. In Alabama,
Illinois, Missouri, New York City, Tennessee, and Virginia, counties and
cities may impose an additional limited tax on the price of cigarettes. Sales taxes are also levied on tobacco products in most jurisdictions.
In the United Kingdom, as of April 2023, a packet of 20 cigarettes has a tax added of 16.5% of the retail price plus £5.89. The UK has a significant black market
for tobacco, and it has been estimated by the tobacco industry that 27%
of cigarette and 68% of handrolling tobacco consumption is non-UK duty
paid (NUKDP).
In Australia total taxes account for 62.5% of the final price of a
packet of cigarettes (2011 figures). These taxes include federal excise
or customs duty and Goods and Services Tax.
In June 1967, the US Federal Communications Commission
ruled that programmes broadcast on a television station which discussed
smoking and health were insufficient to offset the effects of paid
advertisements that were broadcast for five to ten minutes each day. In
April 1970, the US Congress passed the Public Health Cigarette Smoking Act banning the advertising of cigarettes on television and radio starting on 2 January 1971.
The Tobacco Advertising Prohibition Act 1992 expressly prohibited
almost all forms of Tobacco advertising in Australia, including the
sponsorship of sporting or other cultural events by cigarette brands.
All tobacco advertising and sponsorship on television has been
banned within the European Union since 1991 under the Television Without
Frontiers Directive (1989).
This ban was extended by the Tobacco Advertising Directive, which took
effect in July 2005 to cover other forms of media such as the internet,
print media, and radio. The directive does not include advertising in
cinemas and on billboards or using merchandising – or tobacco
sponsorship of cultural and sporting events which are purely local, with
participants coming from only one Member State as these fall outside the jurisdiction of the European Commission.
However, most member states have transposed the directive with national
laws that are wider in scope than the directive and cover local
advertising. A 2008 European Commission report concluded that the
directive had been successfully transposed into national law in all EU
member states, and that these laws were well implemented.
Some countries also impose legal requirements on the packaging of
tobacco products. For example, in the countries of the European Union,
Turkey, Australia and South Africa, cigarette packs must be prominently labeled with the health risks associated with smoking.
Canada, Australia, Thailand, Iceland and Brazil have also imposed
labels upon cigarette packs warning smokers of the effects, and they
include graphic images of the potential health effects of smoking. Cards
are also inserted into cigarette packs in Canada. There are sixteen of
them, and only one comes in a pack. They explain different methods of
quitting smoking. Also, in the United Kingdom, there have been a number
of graphic NHS advertisements, one showing a cigarette filled with fatty deposits, as if the cigarette is symbolizing the artery of a smoker.
Some countries have also banned advertisement at point of sale.
United Kingdom and Ireland have limited the advertisement of tobacco at
retailers.
This includes storing of cigarettes behind a covered shelf not visible
to the public. They do however allow some limited advertising at
retailers. Norway has a complete ban of point of sale advertising.
This includes smoking products and accessories. Implementing these
policies can be challenging, all of these countries experienced
resistance and challenges from the tobacco industry.
The World Health Organisation recommends the complete ban of all types
of advertisement or product placement, including at vending machines, at
airports and on internet shops selling tobacco. The evidence is as yet unclear as to the effect of such bans.
Many countries have a smoking age.
In many countries, including the United States, most European Union
member states, New Zealand, Canada, South Africa, Israel, India,
Brazil, Chile, Costa Rica and Australia, it is illegal to sell tobacco
products to minors and in the Netherlands, Austria, Belgium, Denmark and
South Africa it is illegal to sell tobacco products to people under the
age of 18. On 1 September 2007 the minimum age to buy tobacco products
in Germany rose from 16 to 18, as well as in the United Kingdom where on
1 October 2007 it rose from 16 to 18.
Underlying such laws is the belief that people should make an informed
decision regarding the risks of tobacco use. These laws have a lax
enforcement in some nations and states. In China, Turkey, and many other
countries usually a child will have little problem buying tobacco
products, because they are often told to go to the store to buy tobacco
for their parents.
Several countries such as Ireland, Latvia, Estonia, the
Netherlands, Finland, Norway, Canada, Australia, Sweden, Portugal,
Singapore, Italy, Indonesia, India, Lithuania, Chile, Spain, Iceland,
United Kingdom, Slovenia, Turkey and Malta have legislated against
smoking in public places, often including bars and restaurants.
Restaurateurs have been permitted in some jurisdictions to build
designated smoking areas (or to prohibit smoking). In the United States,
many states prohibit smoking in restaurants, and some also prohibit
smoking in bars. In provinces of Canada, smoking is illegal in indoor
workplaces and public places, including bars and restaurants. As of 31
March 2008 Canada has introduced a smoke-free law in all public places,
as well as within 10 metres of an entrance to any public place. In
Australia, smoke-free laws vary from state to state. In New Zealand and
Brazil, smoking is restricted in enclosed public places including bars,
restaurants and pubs. Hong Kong restricted smoking on 1 January 2007 in
the workplace, public spaces such as restaurants, karaoke rooms,
buildings, and public parks (bars which do not admit minors were exempt
until 2009). In Romania smoking is illegal in trains, metro stations,
public institutions (except where designated, usually outside) and
public transport. In Germany, in addition to smoking bans in public
buildings and transport, an anti-smoking ordinance for bars and
restaurants was implemented in late 2007. A study by the University of
Hamburg (Ahlfeldt and Maennig 2010) demonstrates, that the smoking ban
had, if any, only short run effects on bar and restaurant revenues. In
the medium and long run no negative effect was measurable. The results
suggest either, that the consumption in bars and restaurants is not
affected by smoking bans in the long run, or, that negative revenue
effects by smokers are compensated by increasing revenues through
non-smokers.
Ignition safety
An
indirect public health problem posed by cigarettes is that of
accidental fires, usually linked with consumption of alcohol. Enhanced
combustion using nitrates was traditionally used but cigarette
manufacturers have been silent on this subject claiming at first that a
safe cigarette was technically impossible, then that it could only be
achieved by modifying the paper. Roll your own cigarettes contain no
additives and are fire safe. Numerous fire safe cigarette
designs have been proposed, some by tobacco companies themselves, which
would extinguish a cigarette left unattended for more than a minute or
two, thereby reducing the risk of fire. Among American tobacco
companies, some have resisted this idea, while others have embraced it. RJ Reynolds was a leader in making prototypes of these cigarettes in 1983 and will make all of their U.S. market cigarettes to be fire-safe by 2010. Phillip Morris is not in active support of it. Lorillard (purchased by RJ Reynolds), the US' 3rd-largest tobacco company, seems to be ambivalent.
Health Warnings
‘Individual
cigarettes in Canada now carry warnings such as “poison in every puff”
and “cigarettes cause impotence” in what the government says is an
effort to make it “virtually impossible to avoid health warnings
altogether”.
The relationship between tobacco and other drug use has been
well-established, however the nature of this association remains
unclear. The two main theories are the phenotypic causation
(gateway) model and the correlated liabilities model. The causation
model argues that smoking is a primary influence on future drug use,
while the correlated liabilities model argues that smoking and other
drug use are predicated on genetic or environmental factors.
One study published by the NIH found that tobacco use may be linked to
cocaine addiction and marijuana use. The study stated that 90% of adults
who used cocaine had smoked cigarettes before (this was for people ages
18–34). This study could support the gateway drug theory.
In the United States, about 70% of smokers would like to quit
smoking, and 50% report having made an attempt to do so in the past
year.
Without support, 1% of smokers will successfully quit smoking each
year. Physician advice to quit smoking increases the rate to 3% per
year.
Adding first‐line smoking cessation medications (and some behavioral
help), increased quit rates to around 20% of smokers in a year.