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'Roadfood' Warriors  

Spirits were high as they drove south toward Kentucky. "That's exactly the kind of place we look for," said Jane Stern, a plus-size woman who favors mandarin jackets and velvet opera slippers. "There were old coots in overalls smoking at a communal table," she added, as if this were a good thing. . . .

The Sterns, who are married and both 59 years old, talk like this while they drive, and much of what they say ends up in their writing. They've published 40 books on various subjects. Their memoir, "Two for the Road" (Houghton Mifflin), comes out this month. But their magnum opus is "Roadfood," an oft-updated book, Web site and Gourmet magazine column devoted to down-home eateries, diners, fish camps, barbecue pits, hot-dog stands and the like. Since their first book in 1976, they've spent some 200 days a year on the road, and they claim to average 12 meals a day. and velvet opera slippers. "There were old coots in overalls smoking at a communal table," she added, as if this were a good thing. . . .

Although they poke gentle fun at the places they write about, there's nothing phony about their admiration for "sleeves-up" culture. They shun cities, preferring to live in a pet-filled home in rural Connecticut, where Michael smokes cigars on horseback

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Daly's book a walk on the wild side 

Typical of how he plays, John Daly holds nothing back in his new book.

There are stories of how he lost 60 pounds in college by drinking a fifth of whiskey and smoking three packs of cigarettes a day. . . .

"John Daly: My Life In and Out of the Rough" will be in bookstores Monday, and no one will mistake it for Ben Hogan's book on the fundamentals of modern golf. . . .

- Forced to lose 60 pounds at Arkansas if he wanted to play on his college team, he once went three days without hardly any food, drinking four bottles of whiskey until he passed out in his room and had to be taken to the emergency room.

"But you know what? My cigarettes-popcorn-whiskey diet worked," Daly wrote. "The pounds just peeled right off. By Christmas, I'd lost 65 pounds. I probably ought to have written a diet book or something."

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Book Review Symposium on the Politics of Tobacco  

The salience of tobacco in American politics during the past two decades is hard to underestimate. That much, these two books and their companions in this special set of topical reviews, clearly establish. But exactly what are the questions to which these books provide answers? And, to the extent there are international and comparative dimensions to the discussion of tobacco, how are those considerations to be understood? . . .

Criminally Gifted 

But the real endurance test for any hero is how attuned he is to his own native turf. Loren D. Estleman's hard-boiled private eye, Amos Walker, is so much a part of Detroit they should name a car after him. He's already built like a small truck, the better to take the physical punishment he gets in NICOTINE KISS (Forge/Tom Doherty, $23.95). ("I have one of those faces guys want to push in when they feel like pushing in a face," he explains.) In an attempt to repay a debt to a cigarette smuggler, Walker follows his route along a desolate shore of Lake Huron, where he runs across enough mean-spirited hunters, snowmobilers, counterfeiters and government agents

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References 

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Acknowledgements 

We thank Allison Gilbert for help with the cost-effectiveness analyses and Helen Gelband, Andra Ghent, and Dhirendra Sinha for comments.

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Conclusion 

Worldwide, only two large and growing causes of death exist. One is HIV-1 infection, and the other is tobacco. On current consumption patterns, about 1 billion people in the 21st century will be killed by their addiction to tobacco. Strong evidence shows that tobacco tax increases, the dissemination of information about health risks from smoking, restrictions on smoking in public places and workplaces, comprehensive bans on advertising and promotion, and increased access to cessation therapies are effective both in reducing tobacco use and in improving the health of populations. Despite this evidence, these policies, especially higher taxes, have been applied aggressively only in a few high-income countries, covering a small proportion of the world's smokers. Limited implementation of effective tobacco control in developing countries is due to political constraints as well as the lack of awareness of the unique effectiveness and cost-effectiveness of these interventions.

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Constraints to Effective Tobacco-Control Policies 

Although substantial evidence exists concerning the effectiveness of numerous policy interventions to reduce tobacco use, the use of these interventions globally is uneven and limited (see a more formal analysis in Chaloupka and others 2001). World Bank data reveal that ample room exists to increase tobacco taxes. In 1995, the average percentage of all government revenue derived from tobacco tax was 0.63 percent. Middle-income countries averaged 0.51 percent of government revenue from tobacco taxes, while lower-income countries averaged only 0.42 percent. An increase in cigarette taxes of 10 percent globally would raise cigarette tax revenues by nearly 7 percent, with relatively larger increases in revenues in high-income countries and smaller increases in revenues in low- and middle-income countries (Sunley, Yurekli, and Chaloupka 2000). Despite this evidence, price increases have been underused. Guindon, Tobin, and Yach (2002) studied 80 countries and found that the real price of tobacco, adjusted for purchasing power, fell in most developing countries from 1990 to 2000.

Why does so much variation exist in tobacco-control policies? The political economy of tobacco control has been inadequately studied. A few plausible areas of interest are outlined here. First, the recognition of tobacco as a major health hazard appears to be the impetus for most of the tobacco-control policies in many high-income countries. . . .

A key tool for addressing political opposition is earmarking tobacco taxes.

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Comprehensive Tobacco-Control Programs 

In recent years, several governments, mostly in high-income countries, have adopted comprehensive programs to reduce tobacco use, often funded by earmarked tobacco tax revenues. The programs generally have similar goals for reducing tobacco use:

* preventing initiation among youths and young adults

* promoting cessation among all smokers

* reducing exposure to passive tobacco smoke

* identifying and eliminating disparities among population subgroups (U.S. DHHS 1994).

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Effectiveness and Cost-Effectiveness of Tobacco-Control Interventions 

Using a static model of the cohort of smokers alive in 2000, we estimate the number of deaths attributable to smoking over the next few decades that could be averted by (a) price increases, (b) NRT, and (c) a package of non-price interventions other than NRT. Cost-effectiveness of these policy interventions was calculated by weighing the approximate public sector costs against the years of healthy life saved, measured in DALYs.

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Interventions to Reduce the Supply of Tobacco 

The key intervention on the supply side is the control of smuggling. Recent estimates suggest that 6 to 8 percent of cigarettes consumed globally are smuggled (Merriman, Yurekli, and Chaloupka 2000). Of note, the tobacco industry itself has an economic incentive to smuggle, in part to increase market share and decrease tax rates (Joossens and others 2000; Merriman, Yurekli, and Chaloupka 2000). Although differences in taxes and prices across countries create a motive for smuggling, a recent analysis comparing the degree of corruption in individual countries with price and tax levels found that corruption within countries is a stronger predictor of smuggling than is price (Merriman, Yurekli, and Chaloupka 2000). Several governments are adopting policies aimed at controlling smuggling. In addition to harmonizing price differentials between countries, effective measures include prominent tax stamps and warning labels in local languages, better methods for tracking cigarettes through the distribution chain, aggressive enforcement of antismuggling laws, and stronger penalties for those caught violating these laws (Joossens and others 2000). Recent analysis suggests that, even in the presence of smuggling, tax increases will reduce consumption and increase revenue (Merriman, Yurekli, and Chaloupka 2000).

In contrast to the effectiveness of demand-side interventions, there is much less evidence that interventions aimed at reducing the supply of tobacco products are as effective in reducing cigarette smoking

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Interventions to Reduce Demand for Tobacco 

Numerous studies, mostly from high-income countries, have examined the effect of interventions aimed at reducing the demand for tobacco products on smoking and other kinds of tobacco use. The small but growing number of studies from low- and middle-income countries provide useful lessons about differences in the effect of these interventions between these countries and high-income countries. The following is a review of the effect of price and non-price interventions in reducing demand for smoking, including a discussion of each intervention's effect on initiation and cessation. A more complete study of the effectiveness of various interventions is available elsewhere (Jha and Chaloupka 2000b).

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• Rationale for Government Intervention 

In addition to the public health burden caused by tobacco, an economic rationale exists for government to intervene to reduce tobacco use:

* Consumers have inadequate information about the health consequences of tobacco use (Jha and others 2000; Warner and others 1995). Specifically, the decision to initiate smoking is made primarily by youths, whose ability to make fully informed, appropriately forward-looking decisions is questioned by society in many different contexts (minimum ages for drinking, driving, and voting, for instance). In industrial countries, about 80 percent of adult smokers begin smoking before age 20. Even if children and young adults have information on future risks, they tend to discount that future risk greatly.

* The addictive nature of tobacco is underappreciated and poorly understood.

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Health Consequences of Smoking 

Key Messages for the Individual Smoker

More than 50 years of epidemiology on smoking-related diseases have led to three key messages for individual smokers worldwide (Doll and others 2004; Peto and others 2003).

* The eventual risk of death from smoking is high, with about one-half to two-thirds of long-term smokers eventually being killed by their addiction.

* These deaths involve a substantial number of life years forgone. About half of all tobacco deaths occur at ages 35 to 69, resulting in the loss of about 20 to 25 years of life, compared with the life expectancy of nonsmokers.

* Cessation works: those adults who quit before middle age avoid almost all the excess hazards of continued smoking.

Worldwide, about 80 percent of deaths among the 2.7 billion adults over age 30 involve vascular, respiratory, or neoplastic disease.

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Smoking Trends 

Tobacco use, in both smoked and nonsmoked forms, is common worldwide. This chapter focuses on smoked tobacco, chiefly cigarettes and bidis (tobacco hand rolled in the leaf of another plant, temburi, which is popular in India and parts of Southeast Asia), because smoked tobacco is more common—accounting for about 65 to 85 percent of all tobacco produced worldwide (WHO 1997)—and causes more disease and more diverse types of disease than does oral tobacco use.

A systematic review of 139 studies on adult smoking prevalence (Jha and others 2002) found that more than 1.1 billion people worldwide smoke, with about 82 percent of smokers residing in low- and middle-income countries. Table 46.1 provides an update of these estimates for the population in 2000. Globally, male smoking far exceeds female smoking, with a smaller gender difference in high-income countries. Smoking prevalence is highest in Europe and Central Asia, where 35 percent of all adults are smokers.

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