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Tobacco Atlas: Big tobacco is targeting the world's most vulnerable to increase profits

The sixth edition of The Tobacco Atlas and its companion website finds the tobacco industry is increasingly targeting vulnerable populations in emerging markets, such as Africa, Asia, and the Middle East, where people are not protected by strong tobacco control regulations. The report was released at the 17th World Congress on Tobacco OR Health in Cape Town, South Africa.

The Atlas, co-authored by ACS and Vital Strategies, graphically details the scale of the tobacco epidemic around the globe. It shows where progress has been made in tobacco control, and describes the latest products and tactics being deployed by the tobacco industry to grow its profits and delay or derail tobacco control efforts. In response to an evolving tobacco control landscape, the Sixth Edition includes new chapters on regulating novel products, partnerships, tobacco industry tactics and countering the industry. 

In 2016 alone, tobacco use caused more than 7.1 million deaths worldwide (5.1 million in men, 2.0 million in women). Most of these deaths were attributable to cigarette smoking, while 884,000 were related to secondhand smoke. The increase in tobacco-related disease and death has been outpaced by the increase in industry profits. The combined profits of the world's biggest tobacco companies exceeded $62.27 billion in 2015, the last year on record for all the major companies. This is equivalent to $9,730 for the death of each smoker, an increase of 39% since the last Atlas was published in 2015, when the figure stood at $7,000.  

"Every death from tobacco is preventable, and every government has the power reduce the human and economic toll of the tobacco epidemic," said Jeffrey Drope, PhD, co-editor and author of The Atlas and our vice president, Economic and Health Policy Research. "It starts by resisting the influence of the industry and implementing proven tobacco control policies." (Jeffrey is pictured in the top image.)

"Tobacco causes harm at every stage of its life cycle, from cultivation to disposal," said Dr. Neil Schluger, Vital Strategies' senior advisor for science and co-editor and author of The Atlas. "It is linked to an ever-increasing list of diseases, burdens health systems, and exacerbates poverty, especially when a breadwinner falls ill and dies from tobacco use. . . The only way to avert this harm is for all governments to vigorously implement the Framework Convention on Tobacco Control and to enforce the proven strategies that reduce tobacco use."

Tobacco use and exposure to secondhand smoke costs the global economy more than two trillion dollars every year – equivalent to almost 2% of the world's total economic output. Low- and middle-income countries represent more than 80% of tobacco users and tobacco-related deaths, placing an increased share of tobacco-related costs on those who can least afford it. A growing proportion of that burden will fall on countries across Africa in the future, if governments do not implement tobacco control policies now.

Africa is at a tipping point

The Sixth Edition of The Tobacco Atlas reveals that the tobacco industry deliberately targets countries that lack tobacco control laws and exploits governments, farmers, and vulnerable populations across Africa. In Sub-Saharan Africa alone, consumption increased by 52% between 1980 and 2016 (from 164 billion to 250 billion sticks). This is being driven by population growth and aggressive tobacco marketing in countries like Lesotho, where prevalence is estimated to have increased from 15% in 2004 to 54% in 2015. Economic growth has increased consumers' ability to afford tobacco products and there is a lack of tobacco control interventions to deter tobacco use. Furthermore, in countries like Ethiopia, Nigeria, and Senegal, smoking is now more common among youth than adults – potentially increasing the future health and economic burden of tobacco in these countries. 

Yet Africa has seen real successes recently. Ghana and Madagascar have introduced comprehensive bans on tobacco advertising, promotion, and sponsorship. Burkina Faso, Djibouti, Kenya, and Madagascar have implemented graphic warnings on cigarettes, an important intervention in countries with multiple dialects and for citizens in those countries who have low levels of literacy. South Africa has implemented consecutive tobacco tax increases to deter consumption, and Kenya has implemented a highly effective track-and-trace system to track and reduce illicit trade. These countries are setting an example to others across the world.

Other examples of effective tobacco control policies

In spite of the tobacco industry's efforts to impede progress, global cigarette consumption and tobacco use prevalence have declined recently thanks to an overall increase in the adoption of proven and innovative tobacco control measures. Tobacco taxes alone could deliver a 30% relative reduction in smoking prevalence by 2025. This would save 38 million lives and $16.9 trillion, just from former smokers becoming healthier.

  • In 2013, the Philippines implemented one of the largest tobacco tax increases in a low- and middle-income country, leading more than 1 million smokers to quit.
  • Turkey's comprehensive tobacco control strategy reduced smoking prevalence from 39.3% in 2000 to 25.9% in 2015.
  • Analysis by Australia's government found that plain packaging alone resulted in 108,228 fewer smokers between December 2012 and September 2015.
  • Brazil has banned all tobacco additives such as flavors used to attract children. WHO predicts that there will be 3 million fewer smokers in Brazil between 2015 and 2025.


Tobacco Atlas - Tobacco Use in Africa

Tobacco Atlas - Tobacco Industry's Actions 

Tobacco Atlas - Successful Policies

Photos courtesy of Photo©Marcus Rose/The Union

  • ACS teams up with medical innovation company to shorten bench-to-bedside time

    The American Cancer Society is partnering with the Atlanta-based Global Center for Medical Innovation (GCMI) to more rapidly bring groundbreaking research from the lab to the clinic. ACS and GCMI plan to jointly raise $5 million to sustain the program. 

    While ACS conducts research and funds research through grants to hundreds of scientists and health professionals nationwide, bridging the gap between early research and actual treatment can often be very challenging. 

    In its role, GCMI will bring together members of the medical device community, including universities, research centers, hospitals, clinicians, and investors, to accelerate commercialization of innovative medical technologies that come out of ACS-funded research, while reducing the time and cost of bringing new ideas to market. 

    “Fostering efficient, rapid innovation from the bench to the bedside in cancer care is a high priority for the ACS,” says Bill Chambers, PhD., our senior vice president, Extramural Research. “This new partnership will allow GCMI and the ACS to identify, develop, and promote technology innovation from among projects within the ACS portfolio of funded research.” 

    Bill noted: “We will initially focus on medical device research which we have previously funded and which is poised for further development in partnership with GCMI.  For instance, things like imaging tools for real time monitoring of tumor growth or response to treatment.” 

    The ACS has funded more than 24,000 investigators through its Extramural Research program, and this provides a wealth of opportunities which may benefit patients as a result of this partnership.

    Three to five projects will be identified and launched each year with the goal of initiating one project each quarter. 

    Project duration will be assessed during the kick-off phase, which includes the identification of resource needs, e.g., external experts, time and materials, and the creation of a timeline for the innovators to reach key developmental milestones.

    More about the Global Center for Medical Innovation 

    GCMI is the Southeast’s first and only comprehensive medical device innovation center dedicated to accelerating development, building businesses, and improving health. It opened in April 2012, and to date has worked with more than 50 different startups, clinician innovators, university tech transfer offices, and academic researchers to design, engineer, prototype, and facilitate commercialization of a broad range of innovative medical devices. It is an independent, 501(c)(3) non-profit organization.

  • Vote for ACS in the STAT Madness research competition!

    Remember the ACS research study that found rates of colorectal cancer increasing in younger people? 

    Well, we have entered that study into the STAT Madness competition, a bracket-style tournament to find the best innovations in science and medicine in 2017.

    To vote for ACS, find our logo and click on it. Make sure to use Chrome, not Explorer, when doing this. We're matched up with Yale University right now, and its leading, so please let's all vote! 

    Rounds of voting

    Unlike some brackets, where you fill in your picks all at once, this goes round by round. The round of 64 vote starts on Feb. 26, and the championship round finishes on March 30, at 5 p.m. ET. The full schedule is here

    STAT’s team of award-winning journalists chose the 64 discoveries from a field of almost 150 entries. Vote for ACS, round by round. The winner we be named on April 2. While the crowd voting is going on, STAT will be determining its Editors’ Pick.

    If you don't want to miss a round, sign up for STAT Madness alerts. You will get notified every time a new round opens. You can also keep track of the competition on social media via #statmadness2018. 

    About STAT

    STAT is a national publication focused on finding and telling compelling stories about health, medicine, and scientific discovery. Its web address is It is produced by Boston Globe Media and its editorial team is led by Richard Berke, a longtime reporter and editor at The New York Times.

    Feel free to spread the word through your social media channels, and please use the hashtag #statmadness2018. 

    More about the study

    If you recall, ACS researchers led by Rebecca Siegel, MPH, strategic director of Surveillance Information Services in our Intramural Research Department, partnered with the National Cancer Institute to analyze 30 years of colorectal cancer data to better understand the trend. One key finding? Compared to people born around 1950, people born around 1990 have twice the risk of getting colon cancer, and four times the risk of getting rectal cancer. Read the full study here.

  • Standing desks: are they worth it?

    According to a report from the Society for Human Resource Management, standing desks are the fastest growing employee benefit in U.S. workplaces. 

    Companies that sell standing desks claim they provide a variety of health benefits, but according to a study published in the Journal of Physical Activity and Health, standing burned 88 calories an hour, not much more than the 80 calories an hour burned while sitting.

    One thing many studies have been clear about is that long hours of sitting are linked to obesity, diabetes, heart disease, some types of cancer, and shorter life. So it makes sense that standing would counteract these risks. However, studies have not yet been done to either prove or disprove these assumptions.

    According to Alpa Patel, PhD, our strategic director, Cancer Prevention Study 3, “Sitting time research is still in its infancy, and we are trying to understand whether it’s the total amount that you sit or how frequently you break up those bouts of sitting that are related to disease risk. While we continue to learn what is driving this relationship, it’s clear that cutting down on the time you spend sitting is good for your health.”

    Many people who use standing desks say it’s helped them with shoulder and back pain. But it’s also true that standing for long periods of time may cause back, leg, or foot pain, instead of relieving it. Experts advise that if you do try a standing desk, start slowly (stand for just 30 minutes to an hour a day) and increase gradually.

    NOTE:  A longer version of this story by Stacy Simon first appeared on

  • New ACS grant opportunity for early career clinicians who want to move into research

    ​The American Cancer Society has launched a new grant program to support early career clinicians aiming to become clinician scientists. Please help spread the word, and direct any clinicians who might be interested to to learn more. The application deadline is April 2.

    The Clinician Scientist Development Grant (CSDG) will provide funding for clinical faculty who see patients to be mentored and to participate in research training to aid their development as independent clinician scientists.

    "These grants were created to support the ACS's commitment to fostering the careers of clinician scientists," said William Chambers, PhD., senior vice president, extramural research. "Grantees will be free to pursue research questions across the cancer research continuum."

    • Applicants must be full-time clinicians who are within the first six years of their initial faculty appointment.
    • Awards range from three to five years for a maximum $135,000.
    • The grants cover direct costs plus 8% allowable indirect costs per year.

  • ACS takes a new position on e-cigarettes

    ​Over the past year and a half, the American Cancer Society has been reviewing the evolving landscape for tobacco control, and this month the ACS Board approved a new position statement on e-cigarettes.

    You can read a statement about our position on, but here are the key points:

    • No one should smoke cigarettes, and every effort should be made to get smokers off all forms of tobacco and to prevent everyone – especially youth – from starting to use any tobacco product.
    • Smokers are strongly advised to use proven cessation methods, such as prescription medications and counseling, to quit smoking.
    • We don't know the long-term effects of e-cigarettes, but we do know the current generation of products is less harmful than cigarettes. Smokers who choose to quit using e-cigarettes should be supported. They should not use both cigarettes and e-cigarettes, a combination that continues the harm of cigarettes.

    Tobacco remains the leading cause of cancer deaths, so we need urgent action to reduce suffering and save the most lives. Tobacco control has grown more complex in recent years, as e-cigarettes and other new tobacco products have emerged and evolved rapidly. A great deal of research on these products is being conducted, but it will be many years before we have the kind of long-term research that will ultimately be needed.

    Amid this evolving landscape, the American Cancer Society must be the source for credible information and provide the best guidance based on available evidence. And most importantly, the American Cancer Society must provide leadership and action to get people off all tobacco products.

  • Updated cell phone study findings still inconclusive

    The U.S. National Toxicology Program (NTP) has released the remaining results of a large study it conducted in rats and mice to try to determine whether the radiofrequency radiation (RFR) used by cell phones might cause cancer. The main findings of the study have not changed since partial results were released in 2016: It’s still not clear whether RFR, the type of low-energy radiation given off by cell phones while they’re in use, can cause harmful health effects in people.

    To conduct the studies, the NTP built special chambers that exposed rats and mice to different levels of RFR. The exposure began while the rodents were still in the womb, and continued for about two years, which is all or most of their life. Two years of age for a rat is similar to 70 years of age for a person, according to John Bucher, PhD, NTP senior scientist. The rodents were exposed for about nine hours a day, and received levels of radiation that ranged from about the upper limit of what is allowed by law for cell phones, to about four times higher than what is allowed.

    The part of the NTP study released in 2016 suggested that male rats exposed to heavy RFR to their whole body for long periods of time were more likely than a control group of rats to develop certain types of brain tumors (gliomas), as well as a rare type of heart tumor (malignant schwannoma). The NTP focused on these two tumor types because some studies in people have also found possible links between cell phone use and these types of tumors. There was no significant difference in tumor rates among the female rats in the study.

    The draft of the final report, released Feb. 2, still noted a significantly higher (although still relatively low) rate of heart schwannomas in the male rats but not female rats. Bucher noted that the gender difference might be due to male rats’ larger size, which led to greater absorption of radiation.

    However, there are other findings from these studies that make this finding hard to explain. For example, the newly released results show little indication of an increased risk of tumors or any other health problems in mice exposed to RFR. Also, the male rats exposed to RFR in the study lived, on average, significantly longer than the male rats who were not exposed. The reasons for this are not clear.

    The study has not yet been peer reviewed by outside experts, which is typically part of the scientific process before studies are released in their final form. Peer review is expected in March, following a public comment period.

    In response to the study’s findings, the U.S Food and Drug Administration has released a statement saying, “Based on this current information, we believe the current safety limits for cell phones are acceptable for protecting the public health.”

    Otis W. Brawley, MD, our chief medical officer, said in a statement, “These draft reports are bound to create a lot of concern, but in fact they won’t change what I tell people: the evidence for an association between cell phones and cancer is weak, and so far, we have not seen a higher cancer risk in people. But if you’re concerned about this animal data, wear an earpiece.”

    Should you change your cell phone use?

    In a conference call with reporters, Bucher said he has not changed his own personal cell phone use as a result of the study, nor has he recommended his children make any changes to their cell phone use.

    Still, people who are worried about RFR from cell phones can take steps to limit their exposure:

    • Keep the antenna away from your head by using the speaker mode on the phone or a hands-free device such as a corded or cordless earpiece.
    • Text instead of talk. But remember only to text while it’s safe to do so, and never text while driving. According to the Centers for Disease Control and Prevention, any cell phone use can cause distracted driving, which increases the risk of motor vehicle crashes.
    • Limit your (and your children’s) cell phone use. This is one of the most obvious ways to limit your exposure to radiofrequency waves from cell phones. You may want to use your cell phone only for shorter conversations, or use it only when a conventional phone is not available. Parents who are concerned about their children’s exposure can limit how much time they spend on the phone.
    This story by Stacy Simon first appeared on

  • Vulnerable populations still smoking at high rates

    Although tobacco control measures have reduced overall smoking rates in the United States (from 42% in 1965 to 15% in 2015), a new ACS report says the high prevalence of cigarette smoking among vulnerable populations is one of the most pressing challenges facing the tobacco control community. 

    Those populations includes individuals in lower education and/or socioeconomic groups; American Indians and Alaskan Natives; people with mental illness, particularly schizophrenia; military personnel, particularly among those in the lowest pay grades; and lesbian, gay, bisexual, and transgender (LGBT) men and women.

    Geography also plays a role in smoking rates, due to culture, policy, and the strong and persistent influence of the tobacco industry. Those states, called "Tobacco Nation" by the Truth Initiative, are Alabama, Arkansas, Indiana, Kentucky, Louisiana, Michigan, Mississippi, Missouri, Ohio, Oklahoma, Tennessee, and West Virginia. (The Truth Initiative® is  America’s largest non-profit public health organization dedicated solely to making tobacco use a thing of the past. It was previously known as American Legacy Foundation.)

    "Who's Still Smoking? Disparities in Adult Cigarette Smoking Prevalence in the United States" appeared online January 31, in CA: A Cancer Journal for CliniciansThe lead author is Jeffrey Drope, PhD, vice president, Economic and Health Policy Research.


    Although smoking prevalence in the U.S. has decreased in all education groups over the last one-half century, the largest decrease has been among those who are college-educated. Fifty years ago, smoking prevalence for all education groups was fairly clustered, with nearly 40% of college-educated individuals smoking, along with approximately 45% of individuals in all other education groups. Today, five decades later, 6.5% of college-educated individuals continue to smoke, while 23.1% of those with a high school education or less smoke.


    Although all income groups experienced overall declines in smoking over the last few decades, the largest relative decreases have been in higher socioeconomic groups. In 2015 and 2016, current tobacco use prevalence was about 10% for adults in higher income households (greater than 400% of the Federal Poverty Level) compared with almost 25% for adults in households below the poverty line.


    Among all racial and ethnic groups, there has mostly been a downward trend for both men and women, but there also remains considerable variation. Individuals who are of American Indian or Alaskan Native descent exhibit the highest smoking prevalence (24.3% male and 23.4 female), and women in this group also experienced a recent upward trend after a nearly two-decade downward trend. Individuals of Asian and Hispanic/Latino descent have the lowest prevalence of smoking (12.6% male and 3.5% female).

    Mental Illness

    The burden from smoking has been particularly high on individuals struggling with mental illness. Past 30-day cigarette smoking prevalence among people with a past year serious mental illness was more than double those without a past-year mental illness (27.9% versus 12.9%).  There is also significant variation among different mental illnesses. Smoking prevalence was highest among those with schizophrenia, at nearly 60%. Individuals with such disorders may also experience additional risk factors, such as the easy availability of tobacco in some treatment centers.

    A recent analysis found smoking among individuals with a serious psychological distress accounted for two-thirds of the difference in life expectancy relative to nonsmokers without a serious psychiatric disorder. Evidence suggests that some individuals with mental illness may have a genetic predisposition toward addiction and/or may self-medicate using nicotine.

    Sexual Orientation

    Smoking prevalence rates among lesbian, gay, bisexual, and transgender (LGBT) men and women in the U.S. are significantly higher than those among heterosexuals. Studies show the social stresses of living in a society that can be hostile to individuals in the LGBT community contribute to the higher prevalence. Furthermore, the authors say, the tobacco industry has for many years marketed specifically to the LGBT community, placing advertisements in community media outlets, attending pride festivals to hand out coupons for discounted cigarettes, and promoting their products in LGBT bars.


    Smoking in the military has trended significantly downward in recent decades, mirroring trends in the general population. In 1980, more than one-half of military personnel reported smoking. By 2011, smoking prevalence had dropped to less than one-quarter. Smoking rates are still significantly higher in the military than in the general population (24% in 2011, the most recent reliable survey). And disparities by pay grade within the military persist.  For service members in the lowest 4 pay grades of enlisted members (E1-E4), smoking prevalence remained around 30% in 2011. In contrast, smoking prevalence in the highest 6 pay grades of commissioned officers (O4-O10) had dropped below 5%.


    Smoking prevalence varies considerably across states, from 8.7% in Utah to 26.2% in Kentucky. There is a smoking belt leading from Michigan to Mississippi, including several adjacent states in the Midwest and Appalachia, where smoking prevalence is substantially above the national average. 

    The authors say: "More attention to and support for promising novel interventions, in addition to new attempts at reaching these populations through conventional interventions that have proven to be effective, are crucial going forward to find new ways to address these disparities."

    The cite these examples of novel and innovative interventions and tools that have recently been developed and implemented at the national, state, and community levels in the U.S. to address smoking disparities:

    •  The U.S. Food and Drug Administration’s “This Free Life” campaign aimed at the LGBT community
    • The establishment of strategic partnerships with the 2-1-1 information and referral system to promote smoke-free, low-income homes and to support cessation among 2-1-1 callers who are disproportionally low-income, unemployed, and/or uninsured (Americans in many parts of the country can call 2-1-1- for referrals to social services.)
    • Reducing sales of untaxed or low-tax cigarettes on tribal lands
    • Setting minimum floor pricing policies across states
    • The development of simplified and standardized tobacco-assessment tools for retail settings to allow state and local partners to record their own retail data about product packaging, price, and placement to inform regulation of the retail environment.
    • The development of anti-tobacco media campaigns using nonsmokers and/or former smokers to help smokers to quit, such as the Tips From Former Smokers campaign
    • Expand health care access among low-income adults with attendant smoking-cessation counseling and medication benefits via Medicaid expansion and insurance exchange subsidies
    • The U.S.Department of Housing and Urban Development’s ban on smoking in public housing

  • ACS responds to major report on pros and cons of e-cigarettes

    A comprehensive analysis of existing research on e-cigarettes was released January 23 by the National Academies of Sciences, Engineering and Medicine.

    "Public Health Consequences of E-Cigarettes" cites strong current consensus that the devices are not harmless but are likely to be substantially less harmful than combustible cigarettes, and may help smokers quit, but it also warns that e-cigarettes that contain nicotine can be addictive, and that teenagers who use the devices may be at higher risk of smoking. 

    The report also warns that there are no long-term scientific studies of the devices’ addictive potential or their effects on the heart, lungs, or on reproduction.

    These are similar to findings of a recent comprehensive review conducted by a team of experts at ACS.

    Below is the American Cancer Society's official reaction to the report:

    "In stark contrast to cigarettes and other combustible tobacco products, e-cigarettes do not burn tobacco, a process that yields an estimated 7,000 chemicals, including more than 50 carcinogens. 

    While nicotine is highly addictive, and children and pregnant women should avoid any exposure to nicotine due to its deleterious impact on brain development and fetal health, it is the smoke from combustible tobacco products, not nicotine, that injures and kills millions of users each year worldwide.

    The report correctly finds that the net public health impact of e-cigarettes depends on several factors, including youth initiation and adult cessation of combustible tobacco use, as well as e-cigarettes’ toxicity. The report determines that, “If e-cigarette use by adult smokers leads to long-term abstinence from combustible tobacco cigarettes, the benefit to public health could be considerable. Without that health benefit for adult smokers, e-cigarette use could cause considerable harm to public health in the short- and long-term due both to the inherent harms of exposure to e-cigarette toxicants, and to the harms related to subsequent combustible tobacco use by those who begin using e-cigarettes in their youth.”

    The NAS report comes at a time that the Food and Drug Administration (FDA) is promoting a new, comprehensive approach to address the continuum of risk among different tobacco products, including e-cigarettes, while pursuing the potential reduction of nicotine in combustible tobacco products to less or non-addictive levels. The American Cancer Society Cancer Action Network, the advocacy affiliate of the American Cancer Society, will continue to advocate for the FDA to use its full authority over all tobacco products, including e-cigarettes, in order to save lives and end tobacco-related death and disease in our lifetime."

    Interestingly, one of the scientists on the committee that issued the report on e-cigarettes is ACS grantee Adam Leventhal, PhD, a licensed clinical psychologist and associate professor in the Department of Preventive Medicine - Division of Health Behavior Research within the USC Keck School of Medicine. His grant support studies aligned with his primary research interests: understanding drug use and other health behaviors (e.g., exercise, eating, risk taking) as mood-altering agents; smoking cessation; addiction psychopharmacology and genetics; and addiction among individuals with mental health problems or other populations subject to health disparities.

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