industry remains alive and well. Figure 1.3 outlines the current state of the industry in the United States. We are still surrounded by cigarette advertising. Governments have difficulty in reconciling the huge tax revenues they receive from cigarette sales and the outlay on health care that results from these sales. High-profile sports such as Formula One racing could not exist without cigarette advertising. The World Health Organization recently launched a counter-campaign with large posters in the style of 'Marlboro Man' proclaiming 'Bob—I've got emphysema'.

Even if the health message is beginning to have an impact in wealthy countries, cigarettes are heavily promoted in the Third World. The numbers of cigarette exports from the USA has doubled in the last 20 years. The WHO estimates that the number of smokers worldwide will increase from current numbers of 1.1 billion to 1.6 billion by 2025. Much of this growth will be in poorer countries. China in particular appears to have a grim future. Total cigarette consumption there has risen almost 10-fold in the last 50years (Fig. 1.4), and the country will be reaping the whirlwind of subsequent respiratory disease for years to come.

The mortality figures discussed above describe a lower incidence of COPD in women than men. Recent large cross-sectional population-based studies in the US confirm this, but show a changing pattern emerging, with the prevalence of COPD almost equal in men and women [31,35]. This probably re-

fleets the changing pattern of exposure to the most important risk factor, tobacco smoke.

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