Tobacco Consumption in the Twentieth Century

44฀recorded฀for฀women฀in฀the฀1960s.฀The฀number฀of฀smokers฀fell฀only฀in฀response฀to฀the฀ massive฀ anti-smoking฀ campaigns฀ of฀ the฀ 1970s,฀ with฀ a฀ greater฀ decline฀ among฀ men฀ than฀ among฀women฀ [26] .฀Smoking฀prevalence฀in฀Germany฀was฀conirmed฀in฀the฀latest฀Microcen- sus฀Study฀Fig.฀ 2.2 .฀The฀national฀Youth฀Risk฀Behavior฀Survey฀YRBS฀2003฀of฀the฀United฀ States฀indicates฀that฀the฀prevalence฀of฀current฀cigarette฀use฀has฀declined฀substantially฀since฀ the฀late฀1990s฀and฀is฀at฀the฀lowest฀level฀since฀YRBS฀was฀initiated฀in฀1991฀ [28] .

2.2 Cigarette Smoking in the USA Since 1965

Over฀the฀period฀from฀1965฀to฀1993,฀smokers฀in฀the฀USA฀and฀their฀tobacco-use฀behaviour฀ were฀monitored฀in฀a฀survey฀of฀all฀smokers฀above฀the฀age฀of฀18฀years฀with฀a฀minimum฀annual฀ consumption฀of฀100฀cigarettes฀ [6] .฀With฀effect฀from฀1991฀and฀1992,฀the฀survey฀included฀all฀ those฀who฀smoked฀daily฀ [29,฀30] .฀Deined฀in฀these฀terms,฀the฀annual฀prevalence฀of฀cigarette฀ smoking฀in฀the฀USA฀was฀42฀in฀1965฀and฀25฀in฀1993฀ [6,฀30] .฀Smoking฀cessation฀was฀ achieved฀by฀24฀in฀1965฀compared฀with฀50฀in฀1993฀ [30] .฀In฀the฀30–39-year-old฀category,฀ 89฀irst฀tried฀smoking฀before฀the฀age฀of฀18฀and฀71฀became฀regular฀smokers฀ [21] .฀The฀ average฀age฀at฀which฀smoking฀was฀irst฀tried฀was฀14.6฀years฀and฀the฀age฀at฀which฀survey฀ respondents฀became฀regular฀smokers฀was฀17.7฀years฀ [21] .฀In฀contrast,฀after฀1980,฀the฀survey฀ revealed฀that฀the฀transition฀to฀regular฀smoking฀did฀not฀occur฀until฀after฀the฀age฀of฀20฀ [31] . Smoking฀was฀initially฀a฀male฀preserve;฀however,฀from฀1965฀to฀1993,฀smoking฀prevalence฀ among฀men฀declined฀from฀52฀to฀28.฀Smoking฀prevalence฀among฀women฀was฀34฀in฀1965,฀ falling฀to฀22฀in฀1993.฀Overall,฀the฀prevalence฀of฀cessation฀among฀ex-smokers฀in฀1993฀was฀ 52฀for฀men฀and฀47฀for฀women฀ [30] .฀Nevertheless,฀the฀prevalence฀of฀male฀pipe฀and฀cigar฀ smoking,฀chewing฀tobacco฀and฀using฀snuff฀rose฀continuously฀ [3,฀32] .฀Among฀adolescent฀ smokers,฀there฀was฀gender฀equality.฀From฀1967฀onwards฀in฀particular,฀there฀was฀an฀increase฀ in฀the฀number฀of฀female฀smokers฀following฀the฀introduction฀of฀“female฀cigarettes”฀ [31] ,฀ whereas฀smoking฀prevalence฀among฀young฀women฀with฀a฀college฀education฀declined฀over฀ the฀period฀from฀1983฀to฀1991฀ [6] . 50 Male Smokers Female Smokers Frequency [] 45 40 35 30 25 20 15 10 5 15 16- 20 21- 25 26- 30 31- 35 36- 40 41- 45 46- 50 51- 55 56- 60 61- 65 66- 70 71- 75 75 Fig. 2.2 ฀฀฀Smoking฀prevalence฀ among฀men฀and฀women฀as฀a฀ function฀of฀age.฀Data฀from฀ the฀Microcensus฀Study฀1999฀ [27] ,฀by฀kind฀permission฀of฀ the฀German฀Federal฀ Statistics฀Ofice Differences฀in฀educational฀level฀are฀also฀apparent฀among฀smokers:฀37฀of฀individuals฀ in฀education฀for฀9–11฀years฀were฀smokers฀compared฀with฀only฀14฀of฀those฀who฀were฀in฀ education฀for฀16฀years฀ [30] .฀Higher฀educational฀levels฀were฀correlated฀with฀a฀willingness฀ to฀quit฀smoking฀ [6,฀33] .฀Willingness฀to฀quit฀smoking฀also฀increased฀with฀age,฀with฀educa- tional฀level฀also฀being฀a฀decisive฀factor฀in฀this฀context฀ [21,฀34,฀35] . Smoking฀prevalence฀was฀highest฀among฀people฀living฀below฀the฀poverty฀line฀ [30] ,฀blue- collar฀workers฀ [2,฀36] ,฀single฀or฀divorced฀people฀ [13] ฀and฀military฀personnel฀ [37,฀38] .฀Tobacco฀ use฀declined฀most฀rapidly฀among฀the฀medical฀professionals;฀at฀the฀beginning฀of฀the฀1990s,฀ only฀3฀of฀doctors฀in฀the฀USA฀were฀smokers฀ [35] ,฀compared฀with฀some฀20฀of฀doctors฀in฀ Germany฀ [27] .฀However,฀there฀seems฀to฀be฀a฀rethinking฀of฀smoking฀habits฀in฀the฀United฀States.฀ The฀prevalence฀of฀cigarette฀smoking฀among฀US฀adults฀has฀declined฀by฀almost฀half฀since฀ 1965,฀with฀positive฀trends฀observed฀among฀people฀in฀almost฀all฀sociodemographic฀groups฀ and฀efforts฀to฀reduce฀disparities฀recognized฀as฀an฀important฀goal฀in฀public฀health฀ [39] .

2.3 Smoking Habits in Germany

In฀Germany,฀in฀people฀between฀the฀age฀of฀21฀and฀50฀years,฀smoking฀prevalence฀is฀about฀ 33฀in฀women฀and฀44฀in฀men฀Fig.฀ 2.2 .฀Simultaneously,฀as฀direct฀consequences฀of฀ciga- rette฀ smoking,฀ approximately฀ 80,000–90,000฀ new฀ cases฀ of฀ cardiovascular฀ disease฀ and฀ 30,000฀new฀cases฀of฀bronchial฀carcinoma฀are฀recorded฀every฀year.฀Above฀the฀age฀of฀35,฀ tobacco-attributable฀mortality฀rates฀in฀the฀federal฀German฀states฀range฀from฀5.6฀to฀13.2฀ for฀women฀and฀from฀24.3฀to฀29.2฀for฀men.฀The฀highest฀mortality฀statistics฀are฀recorded฀ for฀women฀in฀Hamburg,฀Berlin฀and฀Bremen฀ [27] .฀With฀an฀overall฀mortality฀rate฀in฀Germany฀ of฀17,฀smoking฀represents฀the฀commonest฀avoidable฀and฀exclusively฀behaviour-related฀ cause฀of฀death฀ [40] . According฀to฀the฀Microcensus฀Study,฀a฀representative฀survey฀conducted฀in฀1995฀among฀ the฀ population฀ in฀ Germany,฀ interesting฀ conclusions฀ can฀ be฀ drawn฀ concerning฀ smoking฀ behaviour฀as฀a฀function฀of฀gross฀income฀and฀educational฀level฀see฀Fig.฀ 2.3 .฀Similar฀results฀ are฀also฀evident฀from฀the฀latest฀Microcensus฀Study฀ [27] ฀with฀regard฀to฀the฀postulated฀con- nection฀between฀school฀and฀university฀education฀and฀smoking฀behaviour฀Fig.฀ 2.3 .฀The฀ inluence฀of฀the฀educational฀level฀on฀smoking฀pattern฀in฀different฀social฀classes฀might฀be฀ explained฀by฀the฀eficiency฀of฀anti-smoking฀campaigns฀and฀the฀awareness฀about฀health฀ effects฀of฀smoking฀among฀persons฀with฀different฀educational฀levels฀ [41] . Thus,฀according฀to฀self-reported฀information฀in฀April฀1995,฀30.9฀of฀men฀and฀18.2฀of฀ women฀were฀regular฀cigarette฀smokers.฀In฀both฀sexes,฀smoking฀prevalence฀fell฀with฀increas- ing฀age:฀among฀men฀and฀women฀over฀the฀age฀of฀64,฀smoking฀prevalence฀was฀only฀12.9฀ and฀4.9,฀respectively฀ [42] .฀The฀data฀summarised฀in฀Figs.฀ 2.4 ฀and฀ 2.5 ฀indicate฀that฀the฀ ฀relationship฀between฀monthly฀income฀and฀smoking฀behaviour฀applies฀more฀for฀men฀than฀for฀ women.฀Smoking฀prevalence฀is฀higher฀42.6฀among฀men฀in฀the฀lowest฀income฀category฀ ฀700฀EUR฀than฀among฀those฀with฀a฀high฀monthly฀income฀6,500฀DM,฀though฀the฀rate฀ is฀still฀23.1.฀For฀women,฀the฀most฀pronounced฀income-speciic฀differences฀are฀found฀in฀ the฀youngest฀age฀group฀18–29-year฀olds.฀Here฀too฀there฀is฀a฀considerable฀difference฀in฀ smoking฀prevalence฀41.4฀vs.฀18.5฀for฀the฀lowest฀and฀highest฀income฀groups฀ [42] .