tobacco 101 part 1 lesson 1 - emory university...introduction to tobacco 101 welcome to ttac’s...

Tobacco101PartOne,LessonOne

2016

ASELF-GUIDEDE-BOOKINEIGHTLESSONS

©2016EmoryCentersforTrainingandTechnicalAssistance2

IntroductiontoTobacco101WelcometoTTAC’sTobacco101!Tobacco101isaself-guidedtutorialthatprovidestheinformationandresourcesnecessarytounderstandwhytobaccouseisconsideredthe#1preventablecauseofdeathintheUS,aswellastheevidence-basedandpromisingstrategiesthatcanreducetobacco’stoll.Youcanbenefitfromthiscoursewhetheryouarenewtotobaccocontrolandneedanintroductiontokeytopics,orareanexperiencedprofessionallookingtorefreshandupdateyourknowledge.

Tobacco101wasrevisedinthespringof2013tocontainthelatestinformation,resources,andtoolsavailable.Theuser-friendlyself-guidedformatallowsyoutocompletethetutorialatyourownpaceandexplorethevariousexternalresourcesandtoolsasneeded.Tobacco101isorganizedintotwopartscomprisedoffourlessonseach.Optionalreviewquestionsareofferedattheendofeachlessontoallowyoutocheckyourunderstandingofthecontent,trysomeoftheresources,andreflectonhowtheinformationappliestoyourroleintobaccocontrol.

Youcanstartatthebeginningandreadthroughthecoursefrombeginningtoendorsimplyselectthosesectionsthatareofgreatestinterest.

Part1:IntroductiontoPreventionandControlofTobaccoUse• Lesson1:TheEvolutionofTobaccoControl• Lesson2:TobaccoUseintheUnitedStates• Lesson3:ImpactofTobaccoUse• Lesson4:FactorsthatDetermineTobaccoUse

Part2:ReducingtheProblemofTobaccoUse• Lesson1:CredibleTobaccoControlResourcesandKeyPartners• Lesson2:TobaccoControlModels• Lesson3:EffectiveTobaccoControlPolicies• Lesson4:StrategiesforSuccess

TTACalsoprovidestailored,on-siteTobacco101trainingsfororganizationswhowanttoincludeitinconferencesandworkshops.Tolearnmore,visitourwebsitewww.tacenters.emory.eduorcontactusattacenters@emory.edu.


TableofContentsPART1: INTRODUCTIONTOPREVENTIONANDCONTROLOFTOBACCOUSELESSON1

TheEvolutionofTobaccoControl Page4

CheckforUnderstanding Page15

Sources Page17


Tobacco101PartOne,LessonOneTheEvolutionofTobaccoControl

LessonOneLearningObjectivesLessonOneisabouttheevolutionofthefieldtobaccocontrol.Attheendofthislesson,youshouldbeableto:

1. Describetheevolutionofthetobaccocontrolmovement.Themovementdidnothappenovernight,butevolvedovertime.Wewilltakeacloselookathowthathappenedduringthepastcentury.

2. ExplainhoweventsinU.S.historyaffectedtobaccouse.

Certaineventshadaprofoundeffectontobaccoproduction,tobaccoadvertising,tobaccoprevalence,andsocialnormsrelatedtotobaccouse.

3. Describehowtobaccouseemergedasapublichealthproblem.

Asresearchintotheeffectsoftobaccousegrew,sotoodidawarenessoftheadversehealtheffectsoftobaccoonthebody.Wewilllookathowresearchexpandedandknowledgeincreasedduringthelastcentury.


EarlyHistoryofTobaccointheAmericasTobaccohasbeeninAmericaforcenturies.ThetobaccoplantisnativetoCentralandSouthAmericaandwasbroughttoNorthAmerica–toVirginia-inthe16thand17thcenturiestobegrownforcommercialtobaccoproducts,includingcigarettes,pipetobacco,andcigars.NativeAmericansviewedtobaccoassacred.Traditionally,tobaccowasofferedasagifttothespiritsinceremoniesandprayers.Tobaccowasalsousedformedicalpurposes.TheMayanssmokedtobaccoforsuchvariedconditionsasasthma,bitesandstings,bowelcomplaints,chills,fever,convulsions,nervousailments,soreeyes,skindiseasesandurinaryailments.Today,thetobaccoplantisoneofthemostprofitablecommercialproductsofalltime,anditisusedinallregionsoftheworld.

ForFurtherInformation…aboutsacredtobaccouseamongNativeAmericans,visit:

• TheNationalNativeNetwork’sKeepItSacredwebsitehttp://www.keepitsacred.org/network/

• TheSouthDakotaNativeAmericanCommunityToolkithttp://doh.sd.gov/Tobacco/PDF/NAtoolkit_CommWEB.pdf


OverviewofTobaccoUseintheUnitedStates

ThisgraphshowsthepercapitacigaretteconsumptionamongadultsintheUnitedStatesforeachyearfrom1900to2011.ThepercapitaconsumptionrepresentstheamountofcigarettessmokedeachyeardividedbythetotalpopulationoftheUnitedStatesthatyear,givinganaveragenumberofcigarettessmokedperadultforeachyear.Clearly,adultsmokinghasgoneupanddownduringthepastcentury.Thereisanobviousoverallincreasefrom1910until1970,andthenadeclineeversincethen.Ifyoulookclosely,youcanseethatinsomeyearssmokingdroppeddramatically.ManyhistoricaleventsduringthelastseveraldecadesinfluencedtobaccouseintheUnitedStates,shapingthisgraph.Wewilltakeacloserlookateacheventandhowitaffectedtobaccoconsumptionthroughouttheremainderofthislesson.

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AdultPerCapitaCigaretteConsumption,1900-2011

Sources:CentersforDiseaseControlandPreventionandUnitedStatesDepartmentofAgriculture

In1900,percapitacigaretteconsumptionwas54cigarettesperyear.

Morerecently,in2011,percapitacigaretteconsumptionis1232cigarettesperyear.

Attheheightofthetobaccoepidemicintheearly1960s,thepercapitaconsumptionwas4166cigarettesperyear.

ForFurtherInformation…aboutadulttobaccouseintheUnitedStates,readthisMorbidityandMortalityWeeklyReportfromtheCentersforDiseaseControlandPreventionthatdescribestobaccouseamongadultsuptotheyear2005:http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5542a1.htm


EvolutionofTobaccoControl:1910-1945Fromtheearly1900’sthrough1945,severaleventsoccurredthatincreasedtheconsumptionoftobaccointheUnitedStates.Someoftheseevents,andhowtheyaffectedtobaccoconsumption,aredescribedbelow:

UnitedStatesentersWorldWarI(1917)Warusuallycausesasharpupsurgeintobaccouse,andWorldWarIwasnoexception.Partoftheremarkablegrowthincigarettesmokingfrom1910to1930,whichincludesthewaryears,wasbecausewomenbegansmoking.

GreatDepression(1929–early1940s)ThetobaccoindustrywasoneoftheonlyindustriestomakeaprofitduringtheGreatDepression.Tobaccowascheaptoproduce,andthedemandfortobaccoproductsincreasedaspeoplelostworkorcamebackfromwar.

UnitedStatesinvolvementinWorldWarII(1941-1945)AspartoftheWorldWarIIwareffort,PresidentRooseveltmadetobaccoaprotectedcrop.CigaretteswereincludedinGIsC-rations,andtobaccocompaniessentmillionsoffreecigarettestoGIs.Tobaccousewassofiercethatashortagedevelopedand,bytheendofthewar,cigarettesaleswereatanall-timehigh.

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EvolutionofTobaccoControl:1946-1970Startingin1950,researchregardingtobacco’shealtheffectsbegantoemerge,justifyingthebeginningsoftobaccocontrolpoliciesinthe1960sand1970s.ReadaboutsomeoftheeventsthataffectedtobaccoconsumptionintheUnitedStatesfrom1946through1970below:

Firstreportslinkingsmokingandcancer(1950)Threeimportantepidemiologicstudiespublishedinleadingmedicaljournalsshowedthefirstpowerfullinksbetweensmokingandlungcancer.

SurgeonGeneral’sReport(1964)Thereleaseofthe1964SurgeonGeneral’sReportlinkingsmokingandlungcancerisasignificanteventintobaccocontrol.Ithadconclusivedataonthehealthrisksofsmoking,anditclearedthewaytoraisethepublic’sawarenessofthedangersoftobaccouse.However,behaviorchangetakestime,andwedidnotseeasignificantdeclineintobaccouseuntil1973.ClickhereforanoverviewoftheReport’sfindings,orclickheretodownloadtheReportinitsentirety.

FairnessDoctrinemessagesonbroadcastmedia(1967)In1967,theFederalCommunicationsCommission(FCC)ruledthattheFairnessDoctrineappliedtocigarettecommercials,andthatradioandtelevisionstationsmustdevotehundredsofmillionsofdollars’worthofbroadcasttimetofreeantismokingmessages.Thedoctrinerequiredequaltimeforantismokingcommercialsasforpaidpro-tobaccocommercials,whichcausedaboomincompelling,free,publicserviceantismokingcommercials.

UnitedStatesbansbroadcastadvertisementsforcigarettes(1970)InApril1970,theU.S.CongresspassedthePublicHealthCigaretteSmokingAct,whichbannedallradioandtelevisionadvertisingofcigarettes.Thebanonadvertisingisbelievedtohavecontributedtothedeclineintobaccouseduringtheearly1970s.

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EvolutionofTobaccoControl1971-1990 TobaccocontrolintheUnitedStatesbegantotakeoffafter1970,withfederallawsandadvocacymovementscreatingmomentuminthefield.Seebelowforafewmajoreventsbetween1971and1990thathadaneffectontobaccoconsumption:

AmericansforNonsmokers’Rightsformed(1976)In1976,theorganizationAmericansforNonsmokers’Rightswasformed,beginningthemovementtoprotectnonsmokersfromtobaccosmoke.Shortlyafter,a1978RoperReportpreparedfortheTobaccoInstituteconcludedthatthenonsmokers'rightsmovementwas"themostdangerousdevelopmentyettotheviabilityofthetobaccoindustrythathasyetoccurred."

Federalcigarettetaxdoubles(1983)FederaltaxesontobaccohavebeenpartofthefederaltaxsystemsincetheCivilWar.Thefederalcigarettetaxhadincreasedslowlyuntil1983whenitwasdoubledto16centsperpack.Clickheretolearnmoreaboutthehistoryoffederaltobaccotaxes.

Coalescenceofmodernadvocacymovement(early1980s)Untiltheearly1980s,thescienceandgrassrootsbranchesoftobaccocontrolworkedseparately.Themodernadvocacymovementwasbornwhenthesetwobranchesjoinedtogethertohaveamorecredibleandpowerfuleffect.

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EvolutionofTobaccoControl1991-2000

The1990’swerecrucialyearsinthetobaccocontrolmovement,withseverallandmarkpoliciesandreportsoccurringbetween1991and2000thataffectedtobaccouseinthecountry:

SynarAmendmentenacted(1992)In1992,CongressadoptedtheSynarAmendment,whichrequiresstatestoenactlawsestablishingminimumagesatwhichanyonecanbuytobacco.Statesmustalsoenforcethoselawsandshowprogressivereductionsintheavailabilityoftobaccoforsaletominors.ClickheretoreadmoreabouttheSynarProgram.

Environmentaltobaccosmokelistedasaknownhumancarcinogen(1992)InaJuly1992meeting,theEnvironmentalProtectionAgency(EPA)ScienceAdvisoryBoardendorsedtheconclusionsofamajorreportassessingthehealthrisksofsecondhandsmoke.Thisincludedunanimousendorsementoftheclassificationofenvironmentaltobaccosmoke(ETS)asaGroupA(knownhuman)carcinogen.Soonafter,smokingwasbannedonalldomesticflights,apivotalvictoryforsmoke-freeadvocates.

TheMasterSettlementAgreement(1998)TheMasterSettlementAgreement(MSA)isahistoricmilestoneintobaccocontrol.InNovember1998,AttorneysGeneralof46states,theDistrictofColumbia,andfivecommonwealthsandterritoriessettledlawsuitswithtobaccocompaniestorecouphundredsofbillionsofdollarsinMedicaidexpensesresultingfromsmoking-relatedillnessanddisease.Thislawsuitresultedina$206billionsettlement,payableover25years.Mississippi,Florida,Texas,Minnesotahadsettledseparatelawsuitspreviously.

Marylandbanssmokinginprivateworkplaces(1998)Marylandwasthefirststatetobansmokinginworkplaces.Previously,Californiaenactedrestrictionsthatrequiredworkerstosmokeonlyinventilatedareas.By1998,twentyotherstatesrequireddesignatedsmokingareasinworkplaces.Clickheretolearnmoreaboutchangesinstatesmokingrestrictionsthattookplacefrom1998-2004.


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Since2000,wehaveseenmoresignificanteventstakeplacethathaveaffectedtobaccoconsumption,includingpoliciesatthebusiness,state,national,andinternationallevels.DepartmentofTransportationbanssmokingonallinternationalflights(2002)U.S.DepartmentofTransportationbanssmokingonallflightsbetweentheUnitedStatesandothercountries.

WorldHealthOrganizationadoptsFrameworkConventiononTobaccoControl(2003)TheFrameworkConventiononTobaccoControl(FCTC)istheworld’sfirstinternationalpublichealthtreaty.Thetreaty,adoptedbytheWorldHealthOrganizationin2003,recognizestobaccouseasaglobalepidemic.Ithassince

becomeoneofthemostwidelyembracedtreatiesinUnitedNationshistoryand,asofNovember2009,has168partiessignedontoit,establishinginternationalcooperationandstandardstoreducetobaccouse.Asofyet,theUnitedStateshasnotratifiedthetreaty.VisittheFCTCwebsitetolearnmore.

NewYorkStatepassescomprehensivesmoke-freeairlaw(2003)NewYorkStatepassedanear-totalstatewidesmokingbanin2003,banningsmokinginallbars,restaurants,andclubs.NewYorkalsobeganenforcingabanonInternetcigarettesalesandadoptedtheUnitedStates’firstfire-safecigaretteregulations.ACDCarticleinMMWRshowsasignificantdeclineintobaccouseinNewYorkCityfrom2002to2006.

Businessesreacttochangesinsocialnormssurroundingtobacco(2004-2005)In2004,NASCARendeditslongstandingsponsorshipdealwithR.J.ReynoldsTobaccoCo.,citedtobearesultof“changingbusinessdynamics.”Clickheretolearnmoreabouttheterminationofthe33-yearoldsponsorship.In2005,WestinHotelsandResortsannouncedthatitwouldnolongerallowsmokinginanyrooms,restaurants,bars,orpublicareasatits77propertiesintheUnitedStates,Canada,ortheCaribbean,makingitthefirstmajorsmoke-freehotelchain.ClickheretoreadmoreaboutWestin’spolicychange.

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Inmorerecentyears,smokingrateshavecontinuedtodeclineslowly,andthefederalgovernmenthastakenstepstofurtherreducetheserates:

Adultsmokingprevalencedropsbelow20%(2007)In2007,theadultsmokingprevalencedippedbelow20%intheUnitedStatesforthefirsttimeindecades.Thedroptoaprevalencerateof19.8%smokingamongadultsisreportedintheMarch2009MorbidityandMortalityWeeklyReport(MMWR)fromtheCentersforDiseaseControlandPrevention.

Federaltobaccotaxesincrease(2009)Inearly2009,thefederalgovernmentsignificantlyraisedtobaccotaxes,withcigarettetaxesincreasingfrom$0.39to$1.01perpack.Federaltaxesonothertobaccoproducts,likecigarsandsmokelesstobacco,werealsoincreased.ThemainpurposeofthetaxincreasewastofundanexpansionoftheStateChildren’sHealthInsuranceProgram(SCHIP).Thisincreasecameatatimewhentobaccocompanieswerealsoincreasingtheirpricesduetotheslowingeconomyandrisingproductioncosts.ClickheretoreadafactsheetaboutthetaxincreasesfromtheCampaignforTobacco-FreeKids.

FamilySmokingPreventionandTobaccoControlActispassed(2009)InJune2009,theFoodandDrugAdministration(FDA)wasgrantedtheauthoritytoregulatetobaccoproducts.TheU.S.Senatevoted79to17toapprovethebill(H.R.1256/S.982),knownastheFamilySmokingPreventionandTobaccoControlAct.Implementationoflawbeganinfollowingyearandcontinues.Laterinthiscourse,wewilltalkaboutthepurposeofthislegislationandthepotentialbenefitfortobaccocontrolintheUnitedStates.

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TheEvolutionofTobaccoControl–WhereWeAreNow

Recenteventsshowthatsignificantprogresshasbeenmadeinreducingtobaccouseandprotectingpeoplefromtobaccosmoke,buttheneedfortobaccocontrolprogramsandpoliciesremains:2012SurgeonGeneral’sReportisreleasedThe2012SurgeonGeneral’sReport,PreventingTobaccoUseAmongYouthandYoungAdults,summarizesresearchontheepidemiology,causes,andhealtheffectsofsmokingamongyoungpeople.Thereportfindsthatover600,000middleschoolstudentsandmorethanthreemillionhighschoolstudentssmokecigarettes,andthatyouthandyoungadultshavehighratesofcigaruseanduseofmultipletobaccoproducts.

TobaccoindustrybringsnewproductstothemarketThetobaccoindustryhasintroducedseveralnoveltobaccoproductstothemarketoverthepastfewyears.Clickheretolearnmoreabouttheseproductsandhowtheyattractyouthtotobaccouse.

ResearchshowschangesincombustibletobaccousepatternsThesteadydecreaseincigaretteconsumptionhasbeencounteredbyarecenttrendofusingothercombustibletobaccoproducts.ClickheretoreadaMorbidityandMortalityWeeklyReportabouttheincreaseuseofcigarsandpipetobacco.

Comprehensivesmoke-freelawscontinuetobeadoptedAsofOctober2012,23states,WashingtonDC,PuertoRico,andtheU.S.Virgin

Islandshadenactedcomprehensivesmoke-freelawsthatincludeallbars,restaurants,andworkplaces.Theselawsprotect48.7%oftheU.S.populationfromsecond-handsmoke.VisittheAmericansforNonsmokers’Rightswebsiteformoreinformation,smoke-freelists,andmaps.

ForFurtherInformation…onhistoryoftobacco,checkoutTheTobaccoTimelinebyGeneBorio:http://archive.tobacco.org/resources/history/Tobacco_History.html


TheEvolutionofTobaccoControl:PolicyMattersManyhistoricaleventshaveaffectedtobaccouseintheUnitedStates,causingbothincreasesanddecreasesoverthepastcentury.AlloftheeventsmentionedinthislessonhaveinfluencedtobaccouseandshapedtobaccocontrolintheUnitedStatesasweknowittoday.Throughouttheevolutionofthetobaccocontrolmovement,thegreatestreductionsintobaccousehaveoccurredthroughpolicychanges.Youcanseehowsomepoliciesenactedovertheyearshaveaffectedtobaccouseinthegraphbelow.Governmentsupportforpoliciesandprogramsthatreducetobaccousearegenerallywelcomedbythegeneralpublic.NowthatyouhavesomebackgroundinformationonthehistoryoftobaccocontrolintheUnitedStates,wecanmoveontotalkingaboutcurrentissuesandchallenges.


LessonOneCheckforUnderstandingBeforemovingontothenextlesson,pleaseanswerthefollowingquestionstoreviewwhatyoulearnedinLessonOne:

1. Thinkaboutit:Whattwoorthreeeventspresentedinthislessonwereyousurprisedtolearnaffectedtobaccouse?Whatsurprisedyouabouttheconnection?

2. Whendidscientistsbeginpublishingreportsaboutthehealtheffectsoftobacco?

a. 1930sb. 1950sc. 1970sd. 1990s

3. WhichofthefollowingbestdescribestheMasterSettlementAgreement?

a. Theresultofa1998lawsuitbroughtagainsttobaccocompaniesbythe46AttorneysGeneraltorecoupMedicaidexpensesresultingfromsmoking-relateddisease.

b. 2003WorldHealthOrganizationtreatyrecognizingtobaccouseasaglobalepidemic.c. 2012publicationsummarizingresearchontheepidemiology,causes,andhealtheffectsofsmoking

amongyoungpeople.d. Noneoftheabove.

4. WhichofthefollowingbestdescribestheFamilySmokingPreventionandTobaccoControlAct?a. 1970lawbanningallradioandtelevisioncigaretteadvertising.b. 1992lawrequiringstatestosetminimumagestobuytobacco.c. 2009lawgivingtheFoodandDrugAdministration(FDA)authoritytoregulatetobaccoproducts.d. Noneoftheabove.

5. AfterexaminingthehistoricsuccessesandchallengesofchangingtobaccocontrolpolicywithinUnitedStateshistory,whattacticsseemtobemostsuccessfulandmightserveasmodelsforcurrenttobaccocontrolpolicyproblems?


LessonOneCheckforUnderstandingAnswersBeforemovingontothenextlesson,pleaseanswerthefollowingquestionstoreviewwhatyoulearnedinLessonOne:

1. Thinkaboutit:Whattwoorthreeeventspresentedinthislessonwereyousurprisedtolearnaffectedtobaccouse?Whatsurprisedyouabouttheconnection?

CorrectAnswer:Answerswillvary.

2. Whendidscientistsbeginpublishingreportsaboutthehealtheffectsoftobacco?

a. 1930sb. 1950sc. 1970sd. 1990s

Correctanswer:b.Needtoreview?Gobacktoslide5,“EvolutionofTobaccoControl:1946–1970.”

3. WhichofthefollowingbestdescribestheMasterSettlementAgreement?

a. Theresultofa1998lawsuitbroughtagainsttobaccocompaniesbythe46AttorneysGeneraltorecoupMedicaidexpensesresultingfromsmoking-relateddisease.

b. 2003WorldHealthOrganizationtreatyrecognizingtobaccouseasaglobalepidemic.c. 2012publicationsummarizingresearchontheepidemiology,causes,andhealtheffectsofsmoking

amongyoungpeople.d. Noneoftheabove.

Correctanswer:a.“Needtoreview?Gobacktoslide7,“EvolutionofTobaccoControl1991-2000.”

4. WhichofthefollowingbestdescribestheFamilySmokingPreventionandTobaccoControlAct?a. 1970lawbanningallradioandtelevisioncigaretteadvertising.b. 1992lawrequiringstatestosetminimumagestobuytobacco.c. 2009lawgivingtheFoodandDrugAdministration(FDA)authoritytoregulatetobaccoproducts.d. Noneoftheabove.

Correctanswer:c.“Needtoreview?Gobacktoslide9,“EvolutionofTobaccoControl2006-2010.”

5. AfterexaminingthehistoricsuccessesandchallengesofchangingtobaccocontrolpolicywithinUnited

Stateshistory,whattacticsseemtobemostsuccessfulandmightserveasmodelsforcurrenttobaccocontrolpolicyproblems?

CorrectAnswer:Answerswillvary.


LessonOneSourcesResourcesUsed

1. HamiltonJL.TheDemandforCigarettes:Advertising,theHealthScare,andtheCigaretteAdvertisingBan.TheReviewofEconomicsandStatistics.1972;54(4):401-411.

2. Bernstein,MA.TheGreatDepression:DelayedRecoveryandEconomicChangeinAmerica,1929-1939.NewYork:CambridgeUniversityPress,1988.

3. Seldon,BJ,Doroodian,K.Asimultaneousmodelofcigaretteadvertising:Effectsondemandandindustryresponsetopublicpolicy.TheReviewofEconomicsandStatistics.1989;71(4):673-677.

4. U.S.DepartmentofHealthandHumanServices.SurgeonGeneralReport:ReducingTobaccoUse.Atlanta,Georgia:CentersforDiseaseControlandPrevention;2000.pp405-406.

Images

1. Slide2:CultivationandharvestoftobaccobyAmericanIndiansbyBarthelemyVincentLyon.FromImagesfromtheNationalLibraryofMedicine’sHistoryofMedicineCollection:http://www.nlm.nih.gov/hmd/ihm/

2. Slide4:ChesterfieldCigarettesAd,1940.FromTrinketsandTrashwebsite:http://www.trinketsandtrash.org3. Slide5:KentCigarettesAd,1960andPhilipMorrisCigaretteAd,1969.FromTrinketsandTrashwebsite:

http://www.trinketsandtrash.org4. Slide8:FrameworkConventionforTobaccoControllogo.FromWorldHealthOrganization’sFramework

ConventiononTobaccoControlWebsite:http://www.who.int/fctc/about/en/index.html.5. Slide10:CamelDissolvablesAd,2009.FromTrinketsandTrashwebsite:http://www.trinketsandtrash.org6. Slide11:AnotherCivil-ServiceOutrage:LessSmokeandMoreFirebyThomasNast.FromImagesfromtheNational

LibraryofMedicine’sHistoryofMedicineCollection:http://www.nlm.nih.gov/hmd/ihm/

tobacco 101 part 1 lesson 1 - emory university...introduction to tobacco 101 welcome to ttac’s...

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