“They’ll Drink Bucket Loads”

The subtle subterfuge of alcohol advertising.

“To own all routes to sociability; football, music, and everything else that brings the lads together, is to dominate the beer market.”

--Ad agency Mobious in Carling strategy document, 2006.

“Carling Commandments: Thou shalt never abandon your mates in favour of a girl… though shall never desert thy mates in drunken distress, thou shalt always welcome a mate’s mate.”

--Slide presentation by Hill & Knowlton advertising agency, pitching Coors for sports advertising, 2006.

“Shot used to crank up the evening, accelerate the process of getting drunk with less volume of liquid. Sense of danger. For a pleasure ride or to get blasted.”

--Slide presentation by ad agency Cheethambell JWT, 2003.

When the U.K.’s House of Commons Health Select Committee ordered up a report on alcohol last year, the resulting paper once again put the alcohol industry in the spotlight, after researchers at the University of Stirling gained access to a treasure trove of documents from four alcohol companies and their ad agencies. 

The title of the report—“They’ll Drink Bucket Loads of the Stuff”—comes from a “creative brief” prepared by the Cheethambell JWT ad agency in 2005 for the makers of Lambrini, a sparkling pear drink with a kick (7.5 % alcohol by volume) that is popular with young women:

Drinking starts early! Early afternoon at the weekend or straight after work Monday to Friday meeting your girly mates and getting on it is the only way forward…. A light, easy to drink, affordable ‘wannabe’ wine that gets their nights out or in off to a good start. They’ll drink bucket loads of the stuff and still manage to last the duration.

As in the U.S., the U.K. government has a love-hate relationship with the alcohol industry. The flashpoint for disagreement, in many cases, is advertising. Druglink (PDF), a magazine for drug treatment professionals and the criminal justice community, published its analysis of the report in the January/February 2011 issue. Editor Max Daly argues that the alcohol industry in the U.K. is adopting “a similar strategy to that used amid mounting regulation of cigarette advertising 30 years ago.”  Under increasing regulatory pressure, cigarette ads “became more and more elliptical and imaginative as the codes on content were tightened.” The supposedly restrictive advertising codes imposed on cigarette manufacturers simply “honed the advertiser’s skills—either in camouflage or creativity.”

Daly also points to a report on the use of social networking sites to promote alcohol use, prepared by Scottish Health Action on Alcohol Problems, an independent medical advocacy group. Facebook and other sites, the report warned, are being colonized by alcohol promoters “due to the youth appeal of these sites, the difficulties associated with enforcing age restrictions, the relative lack of regulation and the sheer volume of promotional messages. The extensive use of new media to market alcohol represents a proliferation of alcohol branded messages directed at consumers.” 

 In the U.S., Bacardi-branded Mojito Party apps were installed by more than 100,000 Facebook users in 2008. Brewing giant Anheuser-Busch hosts a “VIP micro-site” on Facebook as well. 

A few months earlier, the British Medical Association called for a thoroughgoing ban on alcohol advertising more in line with restrictions on tobacco advertising.

 The Health Select Committee’s report was met with a “furious response” by the alcohol industry, according to Daly. Simon Litherland, managing director of alcohol maker Diageo GB, claimed that “inappropriate consumer views and early proposals” were part of early marketing consultations and were subsequently rejected.

Perhaps because there were no outright examples of law breaking, or perhaps due to a change in U.K. government four months after the report was made public, “They’ll Drink Bucket Loads of the Stuff” has evidently disappeared, leaving few tracks for others to follow. As Daly concludes in the Druglink feature, “whichever political party is at Number 10, there will not be the stomach for a fight with such a powerful adversary as the British drinks industry.”

Photo Credit: http://weblogs.jomc.unc.edu

Drug Czar “Deeply Concerned” About Synthetic Stimulants

“Bath salts” come under federal scrutiny.

The Director of the Office of National Drug Control Policy issued a warning about the new synthetic stimulants now being clandestinely marketed as bath salts or insecticide.  Admitting that “we lack sufficient data to understand exactly how prevalent the use of these stimulants are,” Drug Czar Gil Kerlikowske nonetheless announced that the marketing of such drugs as mephedrone and MDPV was “both unacceptable and dangerous.”

A growing list of states, now including Michigan, Hawaii, Louisiana, Kentucky, North Dakota, and, recently, Florida, have introduced measures to ban the designer drugs, currently being sold under names like “Ivory Wave” or “Purple Wave.” The United Kingdom has already put mephedrone and related drugs under a blanket ban. The drugs are considered addictive, primarily because they are chemically similar to amphetamine and ephedrine. But users often refer to effects more commonly associated with Ecstasy (MDMA), both the good (euphoria, empathy, talkativeness) and the bad (blood pressure spikes, delusions, drastic changes in body temperature).

“I am deeply concerned  about the distribution, sale, and use of synthetic stimulants—especially those that are marketed as legal substances,” Kerlikowske said. “I ask that parents and other adult influences act immediately to discuss with young people the severe harm that can be caused” by such drugs.

Kerlikowske, who will convene a panel of experts on the subject,  said he was acting in response to recent data from the American Association of Poison Control Centers, which showed that poison control units have received 251 calls related to “bath salts” so far this year, compared to a total of 236 calls in all of calendar year 2010.

An earlier post of mine on mephedrone can be found HERE. Some of the best coverage has come from the anonymous NIH researcher who blogs on science topics as DrugMonkey.  See also coverage of alleged mephedrone deaths by David Kroll HERE.


Photo Credit: http://www.astantin.com/

Smoking and the Slave Trade

To Africa and back again.

[Queen Nzinga (smoking a pipe) with Her Entourage, Kingdom of Kongo, 1670s]--------->

In the 17th Century, tobacco, the prototypical New World stimulant, was introduced to Africa by European traders. By 1607, tobacco was being cultivated in Sierra Leone, and in 1611 a Swiss doctor commented on how the soldiers of the “Kingdom of Kongo” fought hunger by grinding up tobacco leaves and setting them on fire, “so that a strong smoke is produced, which they inhale.”

It did not take long for the true motivations behind this botanical boon to be revealed. Tobacco served two crucial functions for the slave traders of the Middle Passage: Once Africans had acquired the smoking habit, tobacco could be used in lieu of cash as payment for purchasing slaves. In addition, tobacco was frequently handed out to slaves during the horrific Atlantic voyage. This was not done out of altruism, or common decency, of course. In an article for Slavery and Abolition Journal, Jerome S. Handler writes: “European slavers apparently believed that such measures were useful in their efforts to control their ‘cargo’ and avoid or minimize social unrest and revolts—or even put the enslaved in a better mood prior to their being sold or transshipped from one American port to another."

How did the slaves smoke the tobacco enroute? With clay pipes supplied by the slave traders. The Europeans had introduced an easily grown, highly addictive plant drug, so it was inevitable that white traders would use that addictive property to their advantage. And they were happy to create an additional market in paraphernalia.

Handler, writing in the African Diaspora Archaeology Network Newsletter, notes that, while Africans produced their own pipes, “white clay pipes of Europeans manufacture, particularly English and Dutch, were commonly used to purchase slaves…. In general it appears that European pipes were often preferred to African ones.” The pipes came in long and short versions, the long “elbow bend” pipes being preferred on shore, with the short pipe being preferred for use onboard. Jean Barbot, an agent for the French Royal African Company, reported that the slaves onboard were occasionally given “short pipes and tobacco to smoak upon deck by turns.”

However humane the practice might sound, the motivations of the traders “were the same as those which prompted them to distribute beads and allow African board games aboard the ships, that is, an attempt to mollify or placate the captives in situations that were always fraught with tension and possibilities of insurrection.” Presumably, it also diminished hunger and helped keep the slaves on their feet during auction in the New World.

Not every ship’s captain went along with the pipes. A French slave ship captain wrote that “for fear of fire, tobacco should be grated and given as a powder.”  Handler, a Senior Scholar at the Virginia Foundation for the Humanities, notes that “there are no data on whether the enslaved were allowed to keep the pipes they received aboard the slave ships. “

Probably not. “Chances are that pipes were collected by the ship’s crew after each use to be re-used at another time,” according to Handler. But it is likely enough that at least some pipes were successfully smuggled ashore. And while most of the white clay pipes found in African descendant archaeological sites in America were probably local in origin, “it may be that an occasional pipe was brought by some enslaved African via the Middle Passage.”

Handler, J. (2009). The Middle Passage and the Material Culture of Captive Africans Slavery and Abolition, 30 (1), 1-26 DOI: 10.1080/01440390802673773

Graphics Credit: Virginia Foundation for the Humanities and the University of Virginia Library,
www.slaveryimages.org.

Khat to the Chase

Of mephedrone, bath salts, and impaired driving.

 Automobile accidents are the ninth leading cause of death worlwide, according to the World Health Organization (WHO). More than a million people are killed on roads annually, and that number could rise to 2.5 million by 2020. WHO estimates that traffic accidents cost developing countries an astonishing 1-2 % of their gross domestic product (GDP).

For years now, police and public health officials have puzzled over the alarming number of traffic accidents in East Africa. In terms of sheer numbers, Asian countries have the highest total traffic fatalities, according to figures compiled by the Global Road Safety Partnership (GRSP), a consortium including the World Bank, the Red Cross and other aid agencies (PDF HERE). That is not surprising, since these nations contain the majority of the world’s drivers.

However, beyond the picture of traffic fatalities in terms of sheer numbers, or on a per population basis, there is another revealing measure—traffic deaths per motor vehicle. And when the GRSP measured nations by that yardstick, the four worst countries in the world for traffic deaths—judging by the number of fatalities per 10,000 licensed vehicles—were Ethiopia, Tanzania, Lesotho, and Kenya—all East African nations.

Moreover, these are all African countries in which the use of khat--an amphetamine-like plant drug that is the natural precursor of the designer drug known as mephedrone--is legal and common. The major khat-using countries in Africa are commonly listed as: Somalia, Kenya, Yemen, Ethiopa, Tanzania, Lesotho. Note the overlap. Khat, as one online article put it, is “the legal high of east Africa.”

On the tiny island nation of Mauritius, just off the southeast African coast, Touria Prayag writes at allAfrica.com that drivers “zoom past you, zigzag on the roads, nervously changing to the left lane to swiftly veer back on your side without any warning…. brazenly flouting the Highway Code in every imaginable dangerous manner…. And the carnage continues….”

In Ethiopia, annual road crash fatalities account for 114 deaths per 10,000 vehicles, compared to one death per 10,000 vehicles in Great Britain, and an average of 60 deaths per 10,000 vehicles across 39 sub-Saharan African countries. A report in the Bulletin of the World Health Organization (PDF HERE)  notes that Ethiopian truck drivers “are regarded as so dangerous that their trucks are commonly referred to across Ethiopia as ‘al Qaeda.’” Anecdotally, Ethiopians told WHO officials that khat “increased driver confidence and vehicle speed while also making drivers irritable and impairing concentration,” and that high levels of khat could lead to hallucinations.

A Kenya forum on TripAdvisor asks: Are matatus [local taxes piloted by khat-chewing Kenyans] safe?” 

Since khat is legally available in most of East Africa, and comprises a significant part of the social fabric of local cultures, the use of khat is similar to the use of alcohol in higher-income nations. But does khat present the same threat of driving impairment as alcohol? Bolivia is now arguing its right to allow citizens to chew coca leaves in the traditional manner. Is it safe to drive and chew coca leaves? In all of these cases, the challenge is to determine what constitutes a “safe” dose of the drug; a dose that does not endanger people on or near the highway. There is not enough research on khat to answer that question. Nor is there a way to administer roadside tests for khat. The best evidence, African police officers say, is green teeth.

The active ingredients in khat—cathine and cathinone—are similar in structure to amphetamines, and chemically similar to the ingredients used in the manufacture of mephedrone powder. Mephedrone is sold as 4-MMC, Meow Meow, M-Cat, and other nicknames. Cathine and cathinone ramp up dopamine, serotonin and noradrenaline levels in a manner very similar to amphetamine, with many of the same positive effects (mild euphoria, reduced hunger, increased energy) and the same negative effects (depression, fatigue, lack of appetite, drug craving). It is thought that chronic use of khat results in dopamine D2 depletion in areas of the brain involved in goal-directed action.

The current fervor over mephedrone being disguised as bath salts or plant food for black market sales purposes in the U.S and U.K. demonstrates that this question is not academic for developed western nations. Sold as Ivory Wave, or Bliss, or White Lightning, mephedrone and other products containing cathinone are increasingly available across the U.S. states. In 2008, police seized 600 pounds of fresh khat—in Fargo, North Dakota.

A recent paper published in Frontiers in Psychology, authored by a group of Dutch and Spanish psychologists, appears to show that khat users exhibit a specific cognitive deficit: On stop-signal tasks, stop signal reaction time (SSRT) was significantly slower for the khat users. Such tests typically involve rapidly pressing a green “go” button upon seeing an arrow in certain positions, or abruptly aborting the response when the arrow turns red. The test measures “individual ability to stop a planned or ongoing motor response in a voluntary fashion.” For example, someone with Parkinson’s disease would score at the very high end of the SSRT scale.

The study itself involved 20 regular khat users recruited from the immigrant populations of Leiden and The Hague, and matched against 20 khat-free controls. All of the khat users met four or more of the 7 DSM-IV criteria for addiction, and did not consume alcohol the night before the test. The investigators speculate that this reduced level of inhibitory control “may even be involved in the emergence of addiction: the more a drug is used, the less able users are to prevent themselves from using it.”

The parallels to traffic signals and stop signs are obvious, and apt. The authors state that the findings of their study are “rather worrying because, first, many real-life situations require active inhibition of prepotent actions, as in the case of traffic lights turning red, or of criminal actions.” The obvious conclusion is that the chronic chewing of khat leaves “may indeed lead to a marked deterioration of cognitive functions (as inhibitory control) implicated in driving behavior.” Studies by NIDA director Nora Volkow and others have show that cocaine users suffer similar reductions in dopamine D2 receptors and “need significantly more time to inhibit responses to stop signals than non-users.” In general, stimulant drugs taken regularly at high doses appear to disrupt response inhibition due to alterations in dopamine functioning. (Although some studies have shown a facilitation of inhibitory control at lower doses).

The usual caveats apply: It is impossible to rule out pre-existing propensities for impulsivity, disinhibition, and the like. Some health researchers do not agree that the case for driving impairment on khat has yet been made. In the Bulletin of the World Health Organization, Anita Feigin of the Centre for Population Health in Australia writes that, so far, much of the information is anecdotal, “and, as yet, there is no clear evidence of a causal relationship between the use of khat and traffic accidents.” African taxi drivers who immigrate to Australia use khat “to stay awake and alert.” However, Feigin notes that the use of khat has deeply divided the members of east African migrant communities.

It is an interesting conundrum. The developed West has its entrenched tradition of alcohol as a legal high, despite its side-effects, which frequently result in mayhem on the highways. On the other hand, the drinking nations must now contend with demands from other cultures for the decriminalization of khat and coca leaf, which, along with coffee and tea, make up a category we might call the “soft” stimulants.

Because of the connection with mephedrone and other amphetamine-like designer drugs, these questions will not be going away until more research provides some solid answers. Such research may not be long in coming: The NIH-funded Khat Research Program (KRP) at the University of Minnesota, for example, brings American researchers together with a broad group of scientists from Yemenese and German universities to study the effects of a common plant drug most Americans have never heard of—but a drug they may be dealing with in synthetic form sooner rather than later.

Colzato, L., Ruiz, M., van den Wildenberg, W., Bajo, M., & Hommel, B. (2011). Long-Term Effects of Chronic Khat Use: Impaired Inhibitory Control Frontiers in Psychology, 1 DOI: 10.3389/fpsyg.2010.00219


Photo Credit: http://blogs.citypages.com

Personalizing Addiction Medicine

Gene variants make anti-craving drugs a hit-or-miss affair.

Rather than taking on another broad hunt for the genes controlling the expression of alcoholism, noted addiction researcher Dr. Bankole Johnson and co-workers at the Department of Psychiatry and Neurobehavioral Sciences at the University of Virginia took a different tack. The researchers focused, instead, on investigating whether genetic variations among alcoholics might affect their responses to a specific anti-craving medication.

The result, according to Kenneth Warren, acting director of the National Institute on Alcohol Abuse and Alcoholism (NIAAA), is a study that represents “an important milestone in the search for personalized treatments for alcohol dependence.”

For any addiction, once it has been active for a sustained period, the first-line treatment of the future is likely to be biological. New addiction treatments will come—and in many cases already do come—in the form of drugs to treat drug addiction. Every day, addicts are quitting drugs and alcohol by availing themselves of drug treatments that did not exist fifteen years ago. As more of the biological substrate is teased out, the search for effective approaches narrows along avenues that are more fruitful. This is the most promising, and, without doubt, the most controversial development in the history of addiction treatment.

The researchers were interested in variations in the gene controlling the expression of a serotonin transporter protein. Dr. Johnson’s earlier work had centered on teasing out the influence the serotonin 5-HTT transporter exerts on the development of alcoholism. Previous research had focused attention on the so-called LL and TT variants of this transporter gene. After performing genetic analyses to determine which test subjects were carrying which versions of the gene in question, Dr. Johnson and his colleagues conducted a controlled trial of ondansetron on a randomized group of 283 alcoholics.
The findings were published in the American Journal of Psychiatry.

Ondansetron is an anti-emetic medication that has shown promise in treating addictions, particularly alcoholism. Ondansetron (trade name Zofran), helps block the nausea of chemotherapy by altering serotonin activity in the GI tract. (Vomiting is a serotonin-mediated reflex.) The scientists found that “individuals with the LL geno-type who received ondansetron had a lower mean number of drinks per day (-1.62) and a higher percentage of days abstinent (11.27%) than those who received placebo.”  This put the ondansetron drinkers under five drinks a day. All of the placebo drinkers continued to exceed the five drinks per day mark.

But the strongest difference was found in the group of alcoholics who possessed both the LL and TT genetic variants. The LL/TT alcoholics taking ondansetron “had a lower number of drinks per drinking day (-2.63) and a higher percentage of days abstinent (16.99%) than all other geno-type and treatment groups combined.” 

The goal here is straightforward. In an email exchange, Dr. Johnson told me: “I agree that it would be great if we could use a pharmacogenetic approach to study other anti-craving drugs. The idea of providing the right drug to the right person is definitely important for optimizing therapeutic effects and minimizing side-effects.” Here is a video of Dr. Johnson discussing the research, courtesy of the University of Virginia:

It won’t be easy. Such genetic testing is still in its infancy, and complications abound. For example, in an earlier study in the Journal of the American Medical Association, Dr. Johnson found that diagnosed patients who received ondansetron over an 11-week period increased their days of abstinence compared to alcoholics on placebo. However, in that study, “The researchers found no differences between ondansetron patients with late-onset alcoholism and those who received placebo.” This suggests that, along with genetic variations, ondansetron’s effectiveness with alcoholics may also depend on the type of alcoholism under consideration: early onset or late onset.

We have a long way to go, but individualized pharmaceutical assistance in the early stages of addiction recovery remains the Holy Grail for many addiction researchers. And hopes are running high.

Johnson, B., Ait-Daoud, N., Seneviratne, C., Roache, J., Javors, M., Wang, X., Liu, L., Penberthy, J., DiClemente, C., & Li, M. (2011). Pharmacogenetic Approach at the Serotonin Transporter Gene as a Method of Reducing the Severity of Alcohol Drinking American Journal of Psychiatry DOI: 10.1176/appi.ajp.2010.10050755

Graphics credit: Sergey Ivanov at http://pn.psychiatryonline.org/content/

Visual Cues and Addiction

Do smoking scenes in movies make smokers want to light up?

Smokers and former smokers will understand what I mean when I say that an addiction to smoking is like a pilot light that is always lit, always ready to whoosh into full flame with the application of a few milligrams of nicotine. And they will also understand that feeling, like a bolt sliding home, of instant identification that comes from seeing someone else smoking. Especially if you are not smoking, but wish to be.

It makes sense that a smoker or former smoker who sees someone smoking might find that image to be a trigger for nicotine craving. But we have to ask whether smokers trying to quit are really endangering their newfound abstinence simply by viewing “smoking content” on TV or in the movies. It seems a bit too prudish to be true. Yet, logic would seem to suggest that some sort of behavioral effect might be expected when a smoker in withdrawal sees an image of someone smoking.  Does, say, viewing scenes of smoking in a movie produce changes in brain function robust enough to trigger relapse in the absence of any other direct cues? Are environmental cues of this nature more dangerous to newly abstinent smokers than we thought?

“Our findings support prior studies that show smokers who exit a movie that had images of smoking are more likely to crave a cigarette, compared with ones who watched a movie without them,” said Dylan Wagner of Dartmouth College, in a Society for Neuroscience Press Release. “More work is needed to show whether brain activity in response to movie smoking predicts relapse for a smoker trying to quit.”

In a small study involving 17 smokers and 17 non-smokers, scientists at Dartmouth College set out to determine what differences might show up in a functional magnetic resonance imaging (fMRI) scan of smokers and non-smokers while they watched 30 minutes of a movie with several smoking scenes. The subjects were not told that the experiment was about smoking. But when they viewed smoking scenes, the brains of smokers showed increased activity in a portion of the parietal lobe of the brain called the intraparietal sulcus. The study was published in the January 19 issue of the Journal of Neuroscience.

What does this brain region do? As it happens, the neurons in the intraparietal sulcus encode information about the position and geometrical properties of objects. This part of the brain coordinates eye movement data and reaching movements.  Using a mouse or a joystick is a good example of an activity that involves the intraparietal sulcus.

The intraparietal sulcus, or IPS, has other functions, but primarily it serves, in the words of one study, as an interface “between the perceptive and motor systems for controlling arm and eye movements in space.”  Apparently, the habitual hand gestures used in lighting and smoking a cigarette, when viewed in a movie or commercial, triggered impulses from that part charged with controlling the routine gestural aspects of smoking--if the viewer were actually smoking.

Other studies point to additional aspects of this event-related change in fMRI scans. Writing in the Journal of Neuroscience in 2006, Hamilton and Grafton offer evidence that the IPS is also “uniquely sensitive to the goals of other people’s hand actions.” The intraparietal sulcus seems to “know” what those hand gestures mean, in a sense. Macaques in the lab were used to demonstrate that “cells in macaque IPL were show to respond selectively to both the performance and observation of an action within a sequence leading to a specific goal and not to the same action when it was part of a sequence achieving a different goal.”

This was a strong suggestion that “the IPS is not just a relay but has a central role in representing and interpreting the goals of observed hand actions.”

Perhaps, then, the idea that strong cues can be produced by images and associations is not so far-fetched. It is, for that matter, the founding theory upon which the modern advertising industry has been built, and while the argument over advertising’s effectiveness is never-ending, cigarette scenes in films might have to be considered a form of indirect advertising beamed directly to the parietal lobe of smokers (and perhaps former smokers as well.)

Hamilton, A. (2006). Goal Representation in Human Anterior Intraparietal Sulcus Journal of Neuroscience, 26 (4), 1133-1137 DOI: 10.1523/JNEUROSCI.4551-05.2006

Graphics Credit: http://aslittleaspossible.blogspot.com/

Update on Smoking Bans Around the World

The noose tightens.

Smoking bans are everywhere. But what does the global picture look like as 2011 gets underway? Herewith, a brief rundown of the smoking situation in assorted countries, courtesy of an analysis late last year by BBC News.

-- Canada. In a nation known as one of the toughest of all when it comes to regulating cigarettes, the Canadian Medical Association Journal says the strict laws have been responsible for “cutting hospital admissions for heart and respiratory problems by about a third.”

-- China. In contrast, 2010 gave observers little reason to think that the Chinese government was actually going to enforce the promised national ban on smoking in public places. Enforcement varied from city to city but in general remained vague at best. Only about 25 % of the adult population believes that smoking is linked to cancer. “The country has an estimated 350 million smokers. For every three cigarettes lit worldwide, one is smoked in China,” according to BBC News.

-- Germany. The smoke-free movement hit some snags in Germany, where a ban on smoking in pubs and restaurants in 2008 has been fiercely resisted in some quarters. Tavern owners complain of lost income, and the bans are also disliked “because of an earlier crackdown on smoking initiated by Adolf Hitler’s Nazi regime,” says BBC News. Nonetheless, cigarettes were banned from Munich’s Oktoberfest for the first time in history.

-- France. Curiously, in a nation that was expected to rise up as one against workplace smoking bans, “correspondents say attitudes to smoking have changed dramatically in France since the 2007 ban, and any fears that people would generally ignore the laws have proved false.”

-- United Kingdom. Smoking is banned almost everywhere—“nearly all enclosed public spaces”—in England, Scotland, Ireland and Wales. This year, England may become the first nation to sell cigarettes in plain brown wrappers—a move government officials hope will make the packages less attractive to younger smokers.

-- Iran. Back in 2003, Iran banned smoking in public buildings. According to the BBC, the measures have had “little effect. However, in July 2010 smokers were banned from taking high-ranking jobs in the Iranian government, the news agency ILNA reported.”

-- Russia. The heavy-smoking Russians continue to astound: “A 2009 survey by the World Health Organization found that Russia has 43.9 million smokers—about 40% of the population.” About 60% of Russian men smoke. 500,000 people die of smoking-related illness each year. The Russian government is considering a blanket no-smoking policy for enclosed spaces—starting in 2015.

-- Uruguay. The host of a recent international summit on tobacco control strategies, Uruguay has adopted some of the toughest anti-smoking laws in the world—so tough that the government was forced to back down on some of its sweeping new restrictions due to tobacco industry pressure.

-- Australia. Starting last September, there was no smoking “in cars carrying children, on sections of beaches, and within 10m (32ft) of playground equipment.” Australia also bans smoking in public workplaces, and plans to follow England’s lead in forcing tobacco companies to use plain wrappers for cigarette packages.

-- United States. California, a state that almost managed to pass a proposition legalizing marijuana, has the strictest and most extensive set of anti-tobacco laws on the planet. Smoking is banned not just within public buildings, but also within 20 feet of public buildings, and on all state beaches.

Graphics Credit: http://www.nicotineedge.com/