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채원 독고
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3 ? How do we understand tobacco smoking behavior?

4 History of Tobacco

5 Mackay & Eriksen, The Tobacco Atlas, WHO, 2002

6 Within 150 years of Columbus s finding strange leaves in the New World, tobacco was being used around the globe. Its rapid spread and widespread acceptance characterise the addiction to the plant Nicotina Tobacum. Only the mode of delivery has changed. In the 18 th centry, snuff held sway; the 19 th century was the age of the cigar; the 20 th century saw the rise of the manufactured cigarette, and with it a greatly increased number of smokers. At the beginning of the 21 st century about one third of adults in the world, including increasing numbers of women, used tobacco. Despite thousands of studies showing that tobacco in all its forms kills its users, and smoking cigarettes kills non-users, people continue to smoke, and deaths from tobacco use continue to increase. Mackay & Eriksen, The Tobacco Atlas, WHO, 2002

7 : ( ) 1600 : 1603 : 1858 : 1900 : 1950 : 1600 : ( ) 1981 : ( )

8 1500: 1558 :, 1566 : (Jacques Nicot) 1614 : Virginia 7, : 1833 :, 1840 : Baroness de Dudevant 1901 : Imperial Tobacco Company British American Tobacco 1604 : : 1761 :, (John Hill), Nasal cancer

9 BC 6000 : BC 1 :, 1492 : 1531 : 1612 : 1800 : 1881 : 1913 : RJ Reynolds Camel 1994 : CEO 1882 :, (Federal tax) 1939 :, (Ochsner) 1950 :, (Wynder and Graham) 1953 :,

11 Epidemiologic Study on Harmful Effect of Tobacco Smoking on Population Health

13 Health Risks of Cigarette Smoking Smoking Kills: A White Paper on Tobacco. UK (1998)

16 Emphysema

17 Berger s Disease

19 Lung Cancer

20 Relation between Smoking and Smoking Related Death

21 ( ) '10 '20 '30 '40 '50 '60 '70 '80 '90 '00 : Intern Herald Tribune, May 18,

22 Cigarette Consumption and Lung Cancer Deaths in South Korea (both sexes combined) Jee et al, Int J Epidemiol (1998)

23 Smoking and Cardiovascular Risk in South Korean Men Jee et al, JAMA (1999)

24 Mortality in Relation to Smoking: 40 Years Observations on Male British Doctors Doll, Peto, et al, BMJ (1994)

25 Mortality in Relation to Smoking: 40 Years Observations on Male British Doctors Doll, Peto, et al, BMJ (1994) Subjects : British male doctors who replied to a postal questionnaire in 1951, of whom had died during the first 20 years and another have died during the second 20 years. Results : Excess mortality associated with smoking was about twice as extreme during the second half of the study as it had been during the first half. The death rate ratios during (comparing continuing cigarette smokers with lifelong non-smokers) were approximately threefold at ages and twofold at ages The excess mortality was chiefly from diseases that can be caused by smoking. Positive associations with smoking were confirmed for death from cancers of the mouth, oesophagus, pharynx, larynx, lung, pancreas, and bladder; from chronic obstructive pulmonary disease and other respiratory diseases; from vascular diseases; from peptic ulcer; and (perhaps because of confounding by personality and alcohol use) from cirrhosis, suicide, and poisoning. A negative association was confirmed with death from Parkinson's disease. Those who stopped smoking before middle age subsequently avoided almost all of the excess risk that they would otherwise have suffered, but even those who stopped smoking in middle age were subsequently at substantially less risk than those who continued to smoke. Conclusion : Results from the first 20 years of this study, and of other studies at that time, substantially underestimated the hazards of long term use of tobacco. It now seems that about half of all regular cigarette smokers will eventually be killed by their habit.

26 Time for a smoke? One cigarette reduces your life by 11 minutes We derived the difference in life expectancy for smokers and non-smokers by using mortality ratios from the study of Doll et al of male doctors over 40 years. The relative death rates of smokers compared with non-smokers were threefold for men aged and twofold for those aged 65-84, as corroborated elsewhere. Average life expectancy from birth for the whole population or subgroups can be derived from life tables. Applying the rates of Doll et al to the latest interim life tables for men in England and Wales, with adjustment for the proportion of smokers and non-smokers in each five year age group, we found a difference in life expectancy between smokers and nonsmokers of 6.5 years. We used the proportion of smokers by age group, the median age of starting smoking, and the average number of cigarettes smoked per week in the 1996 general household survey. We calculated that if a man smokes the average number of cigarettes a year (5772) from the median starting age of 17 until his death at the age of 71 he will consume a total of cigarettes in his lifetime. If we then assume that each cigarette makes the same contribution to his death, each cigarette has cost him, on average, 11 minutes of life: 6.5 years=2374 days, hours, or minutes 5772 cigarettes per year for 54 years= cigarettes / =11 minutes per cigarette. Shaw et al, BMJ (2000)

27 Environmental Tobacco Smoking (ETS) and Health

28 Environmental Tobacco Smoking Side stream smoke Main stream smoke

29 5% 75% 20%

32 Age-adjusted Mortality for Lung Cancer in Korea, Jee et al, Int J Epidemiol (1999)

33 Relationship between Educational Attainment and Lung Cancer Mortality in Korea RII=7.3 RII=4.2 RII=2.2 RII=2.3 RII=1.5 RII=1.1 Rate Ratio Male Female Khang et al, Int J Epidemiol 2004

34 ETS and Lung Cancer in South Korea Jee et al, Int J Epidemiol (1999)

35 Smoking smuggling Smoking

36 Tobacco Smoking in South Korea

44 (2001)

45 '45 '55 '00 (2001)

46 ,

47 20 (2001)

48 (2001)

49 , (2001)

50 (%) (2001)

51 (%) (2001)

52 % Comparison of Smoking Rates among Males and Females Aged 15+ by Countries Male Female Korea, 1998 Japan, 1996 US, 1998 UK, 1996 Germany, 1995 France, 1992 Singapore, 1998

53 ,

54 1988, ,,, ,000

55 ( ) (2001)

56 ( )

57 (1995, 1997, 1999 ) (2001)

58 - % (2001)

59 :, (2001) %

60 International Comparison of Smoking Rates in Adolescents, High School 3 rd Grade Students % Male Female Kore a, 1997 Japan, 1991 US, 1997 UK, 1994 Russia, 1994 Israel, 1994

61 How Can We Reduce Smoking Rates?

63 Childhood and Adult Socioeconomic Positions and Their Effect on Current Smoking Habits in Korea Labor and Income Panel Study (Odds ratios and their 95%CI) 2922 Males aged females Father's socioeconomic status 1.26 ( ) 1.24 ( ) 1.13 ( ) 0.94 ( ) 0.86 ( ) 0.75 ( ) Equivalized houshold income 1.20 ( ) 1.18 ( ) 1.11 ( ) 1.90 ( ) 1.93 ( ) 1.84 ( ) Education 1.74 ( ) 1.65 ( ) 1.71 ( ) 1.68 ( ) Khang, 2004

65 Distribution of Powerelites (Area-based Socioeconomic Indicator) and Their Effects on Current Smoking among 26,022 Males in 522 Dongs of Seoul City (Odds ratios and 95% CI) Age adjusted Age, income adjusted Age, income, education, occupational class adjusted LQ level 1 (highest) LQ level ( ) 1.14 ( ) 1.09 ( ) LQ level ( ) 1.23 ( ) 1.16 ( ) LQ level ( ) 1.24 ( ) 1.15 ( ) LQ level 5 (lowest) 1.46 ( ) 1.36 ( ) 1.25 ( ) Khang, 2004

66 , (2003) (1)

67 , (2003) (2)

68 , (2003) (3)

69 Cigarette Price and Consumption in UK during Townsend et al, BMJ (1994)

70 Results : Price elasticities of demand for cigarettes (percentage change in cigarette consumption for a 1% change in price) were significant at -0.5 (95% confidence interval -0.8 to -0.1) for men and -0.6 (-0.9 to -0.3) for women, were highest in socioeconomic group V (-1.0 for men and -0.9 for women), and lowest (not significantly different from zero) in socioeconomic groups I and II. The gradient in price elasticities by socioeconomic group was significant for men (F=5.6, P=0.02) and for women (F=6.1, P=0.02). Price was a significant factor in cigarette consumption by age for women in every age group and for men aged Cigarette consumption by young men aged increased with income. There was a significant decrease in smoking over time by women in socioeconomic groups I and II and by men in all age and social groups except socioeconomic group V attributable to health publicity. Price significantly affected smoking prevalence in socioeconomic group V (-0.6 for men and -0.5 for women) and for all women (- 0.2). Conclusions : Men and women in lower socioeconomic groups are more responsive than are those in higher socioeconomic groups to changes in the price of cigarettes and less to health publicity. Women of all ages, including teenagers, appear to have been less responsive to health publicity than have men but more responsive to price. Response to health publicity decreased linearly with age. Real price increases in cigarettes could narrow differences between socioeconomic groups in smoking and the related inequalities in health, but specific measures would be necessary to ameliorate effects on the most deprived families that may include members who continue to smoke. The use of a policy to steadily increase cigarette tax is likely to help achieve the government's targets for smoking and smoking related diseases. Townsend et al, BMJ (1994)

71 Experience in California, US In 1988, the state of California passed Proposition 99, the California Tobacco Tax and Health Promotion Act, increasing the tax on each package of cigarettes from 10 cents to 35 cents beginning January In addition, the act earmarked 20% of the revenue raised by this new tax for health educational programs to reduce tobacco use. These programs included statewide anti-smoking multimedia campaigns, tobacco prevention education in the public schools, community intervention programs administered through local health departments, and a network of competitive grant projects targeting high-risk populations. The most visible component of these four programs was the statewide anti-smoking multimedia campaign. According to the California Department of Health Services, between April 1990 and June 1993, the state spent about $26 million for this campaign. Never before had a state government used paid advertising on this large a scale to promote changes in healthrelated behavior. Campaign expenditures, which began in April 1990 and were heaviest between then and March 1991, were temporarily halted in late 1991 and early 1992 when California's governor decided to divert these funds to medical care for the poor. This provoked considerable debate among policymakers and health promotion professionals about the effectiveness of the anti-smoking media campaign vs taxation on cigarettes in California. Hu et al, AJPH (1995)

72 Figure 2. Rates of per Capita Cigarette Consumption and Age-Adjusted Rates of Death from Heart Disease in California Relative to Rates in the Rest of the United States and Predicted Rates If the Tobacco- Control Program Had Not Been Instituted in 1989 and If It Had Not Been Cut Back in The solid lines, which represent the fit of the regression equation to the data (solid circles), show that the program, which was implemented in 1989, was associated with greater reductions in rates of per capita cigarette consumption (Panel A) and mortality from heart disease (Panel B) than the rates predicted on the basis of the relation between the rates in California and those in the rest of the United States before 1989 (broken lines). Had the effectiveness of the program not been reduced starting in 1992, the per capita consumption and death rates would have fallen even faster than they did (dotted lines). Fichtenberg et al, NEJM (2000)

73 How Can We Reduce Smoking Rates among the Poor?

74 Educational Inequalities in Current Smoking Rates from 1989 to 1999 in South Korea: Use of Social Statistics Survey Data RII=2.57 ( ) College+ High Middle Primary RII=2.63 ( ) College+ High Middle Primary RII=2.63 ( ) College+ High Middle Primary RII=2.52 ( ) Khang, 2004 College+ High Middle Primary

75 Smoking Prevalence among UK men 16 years older, by Social Class, Lawlor et al, Am J Public Health 2003

Trends in Male Smoking by Education, USA (1974-95) 50 45 40 35 30 25

76 Trends in Male Smoking by Education, USA ( ) < 12 years (NCHS, 1995)

77 Age-standardized all-cause mortality, men from England and Wales aged years, by social class, Lawlor et al, Am J Public Health (2003)

78 There is no question that smoking is one of the most prominent causes of morbidity and premature mortality and that the social class gradient in smoking prevalence rates contributes to the social class gradient in health outcomes. The resilience of deprived groups to smoking cessation programs is, however, remarkable. Here we pose the question of whether the poorer life chances of those who continue to smoke in effect constitute a national disincentive to their avoidance or cessation of smoking. If this is the case, then smoking behaviors among members of deprived populations will continue to resist health promotion measures until their general health and well-being show improvements equivalent to those that preceded the earlier abandonment of smoking by more advantaged population groups. The possibility that the resistance of disadvantaged groups to antismoking advice represents a rational response to their particular circumstances should be considered. Lawlor et al, Am J Public Health (2003)

79 SMR for Lung Cancer and Accidents by Social Class in UK Men aged 20-64, Lawlor et al, Am J Public Health (2003)

80 We suggest that the health risks of smoking, and hence the incentives to forgo an otherwise appealing activity, became more evident to segments of the population that could expect to remain healthy. This led to their collective abandonment of smoking as a culturally accepted behavior. Disadvantaged groups are still suffering a substantial burden resulting from nonsmoking-related morbidity and premature mortality, as illustrated, for example, by their increased mortality from accidents (Table 1). Standardized mortality ratios for deaths due to accidents show a social class gradient that has widened over the past century, with members of social class V now facing a risk greater than fourfold that of members of social classes I and II. Accidents account for fewer deaths than lung cancer in the total population, but the close temporal relationship between exposures related to socioeconomic circumstances, such as those arising from poor working and housing environments, and accidents makes the causal nature of the relationship obvious and makes avoidance of such exposures more important and meaningful for members of the groups that exhibit the highest mortality rates from these causes. Among these disadvantaged groups, in which the proportionate gains in life expectancy from smoking are much less pronounced, incentives to quit are far from clear. Lawlor et al, Am J Public Health (2003)

81 The environmental circumstances and clear health advantages of those in high socioeconomic positions push the balance toward focusing efforts on future survival (evidenced, for example, by their long-term investments in education, mortgages, and pensions); thus, quitting smoking in light of evidence of its health-damaging effects is rational. Conversely, among individuals from lower socioeconomic positions, the balance is shifted toward improving the immediate environment and removing hazards. Poor housing conditions, occupational hazards, and environmental dangers are more immediate threats to the health of those in lower socioeconomic positions than is smoking. Smoking cessation may become a priority only when these other hazards have been reduced. This suggestion is reinforced by the fact that the smoking prevalence among homeless individuals in the United Kingdom, those in the most dire material circumstances, is 94%. The hazardous environments faced by individuals from lower social classes affect their likelihood of quitting smoking not only because dealing with such circumstances takes precedence over smoking cessation, but because within these environments smoking is often an important pleasure and coping mechanism. Results of a recent study conducted among smokers and nonsmokers in 3 Glasgow communities at high levels of deprivation indicated that smoking was used as a means of coping with living in a stressful, disadvantaged area. Furthermore, in deprived communities smoking may become a normalized behavior; for example, in the study just described, nonsmokers commented that they often needed legitimate reasons, such as asthma, for not smoking. Lawlor et al, Am J Public Health (2003)

82 The current emphasis on the addictive nature of nicotine has pushed policy away from tackling root causes of disadvantage toward adopting an easier, but clearly less effective, medical model involving such strategies as stop smoking clinics and nicotine substitutes. Smoking prevalence declined among the most advantaged members of society after several decades of greater general health demonstrated by marked and consistent declines in overall mortality and improved material circumstances. To be effective, smoking cessation programs appear to depend on a perceptibly rising tide of general good health among the target population. Efforts to reduce smoking among the most deprived members of society are unlikely to succeed unless they are supported by measures designed to improve the material circumstances of these individuals. Lawlor et al, Am J Public Health (2003)

Vol.259 C O N T E N T S M O N T H L Y P U B L I C F I N A N C E F O R U M

Vol.259 C O N T E N T S M O N T H L Y P U B L I C F I N A N C E F O R U M 2018.01 Vol.259 C O N T E N T S 02 06 28 61 69 99 104 120 M O N T H L Y P U B L I C F I N A N C E F O R U M 2 2018.1 3 4 2018.1 1) 2) 6 2018.1 3) 4) 7 5) 6) 7) 8) 8 2018.1 9 10 2018.1 11 2003.08 2005.08