In keeping with the broader understanding that tobacco is not merely a threat to individual health but to the cause of social and environmental justice, the theme for World No-Tobacco Day this year is Tobacco: A threat to development. Here it is important to first differentiate the type of development that advances the health of individuals, communities and ecosystems versus the type of development that exploits and harms them. The term ‘development’ as it has been used historically in the social sciences is itself fraught with ambiguity and inconsistency.1
Traditionally, the term has usually included an element of maturation of economies and economic industries so people can move out of the non-wage sector into more productive and prosperous wage sectors. Over time, ‘development’ has been broadened to address human development, including health, literacy, democracy, human rights and other non-economic domains. Nevertheless, the dominant, often implicit, interpretation of ‘development’...
One of the images of women in technical roles at BAT, posted on International Women’s Day. BAT, British American Tobacco.
A tweet extolling BAT’s commitment to diversity as part of International Women’s Day. Source: Twitter
Celebrated globally on 8 March, International Women’s Day (IWD) honours the social, economic, cultural and political achievements of women. The day also serves as a call to action for greater gender equality and is an opportunity to highlight the continued discrimination women face in areas such as education and employment.
The theme for IWD 2017 was ‘Be Bold For Change’, and IWD event organisers and participants were urged to embrace ‘bold pragmatic action to accelerate gender parity.’ The tobacco industry, true to form, issued corporate social responsibility messages...
Heterogeneity in the measurement and reporting of outcomes in studies of electronic cigarette use in adolescents: a systematic analysis of observational studies
To examine consistency between cross-sectional studies of conventional and electronic cigarette use among adolescents in terms of the measurement, analysis and reporting of parameters.Design
A systematic analysis of cross-sectional studies of conventional and electronic cigarette use in adolescents, to identify measured and reported parameters.Data sources
Studies examining use of electronic and conventional cigarette use in adolescents were identified by searching the SCOPUS database in August 2015.Study selection
The selection criteria for studies were: cross-sectional studies, in English, on e-cigarette use in adolescents. Two reviewers independently selected relevant studies from the search. 60 abstracts were identified, from which 31 papers were eligible for review (23 unique studies).Data extraction
Measured and reported parameters were identified and tabulated. These included the prevalence of cigarette and/ or electronic cigarette use, and the definitions of terms. Data were extracted independently by two reviewers.Data synthesis
With regards basic parameters of ‘ever’ or ‘current’ use of electronic or conventional cigarettes, there were 31 unique measured parameters across 23 studies. Of 16/23 studies in which authors collected information on dual current use, prevalence was reported in 11/16, with six different definitions of ‘dual use’.Conclusions
There are substantial differences in measurement and reporting of parameters across observational studies of electronic and conventional cigarette use in adolescents. These studies are at risk of reporting bias, and results are difficult to interpret. A core outcome set that should be measured and reported in all observational studies is required, using structured consensus techniques.
Tobacco use among members of the US military service is unacceptably high, resulting in substantial healthcare and personnel costs. Support of military command is critical to the success of tobacco control policies because line commanders are responsible for implementation and enforcement. This study is the first to examine US military line commanders’ perspectives about current tobacco control policies and the impact of tobacco on readiness.Methods
We conducted key-informant interviews with 20 officers at the US Army's Command and General Staff College about military tobacco use and tobacco control policy.Results
Participants identified the long-term impact of tobacco use on military members, but were unaware of proximal effects on health and readiness other than lost productivity due to smoke breaks. Officers also discussed nicotine addiction and the logistics of ensuring that an addicted population had access to tobacco. Regarding policy, most knew about regulations governing smoke-free areas and were open to stronger restrictions, but were unaware of current policies governing prevention, intervention and product sales.Conclusions
Findings suggest that strong policy that takes advantage of the hierarchical and disciplined nature of the military, supported by senior line and civilian leadership up to and including the secretaries of the services and the Secretary of Defense, will be critical to substantially diminishing tobacco use by military personnel.
Contribution of smoking to socioeconomic inequalities in mortality: a study of 14 European countries, 1990-2004
Smoking contributes to socioeconomic inequalities in mortality, but the extent to which this contribution has changed over time and driven widening or narrowing inequalities in total mortality remains unknown. We studied socioeconomic inequalities in smoking-attributable mortality and their contribution to inequalities in total mortality in 1990–1994 and 2000–2004 in 14 European countries.Methods
We collected, harmonised and standardised population-wide data on all-cause and lung-cancer mortality by age, gender, educational and occupational level in 14 European populations in 1990–1994 and 2000–2004. Smoking-attributable mortality was indirectly estimated using the Preston-Glei-Wilmoth method.Results
In 2000–2004, smoking-attributable mortality was higher in lower socioeconomic groups in all countries among men, and in all countries except Spain, Italy and Slovenia, among women, and the contribution of smoking to socioeconomic inequalities in mortality varied between 19% and 55% among men, and between –1% and 56% among women. Since 1990–1994, absolute inequalities in smoking-attributable mortality and the contribution of smoking to inequalities in total mortality have decreased in most countries among men, but increased among women.Conclusions
In many European countries, smoking has become less important as a determinant of socioeconomic inequalities in mortality among men, but not among women. Inequalities in smoking remain one of the most important entry points for reducing inequalities in mortality.
Although numerous studies have documented the prevalence and increasing use of little cigars and other cigar products, the present study is the first direct, head-to-head laboratory comparison of little cigar and cigarette smoking. The study addressed a fundamental objective to compare exposure and use characteristics of little cigar and cigarette smoking.Methods
Smoking patterns, toxicant exposure and subjective measures were collected and analysed in 21 adults after smoking a little cigar (Winchester) and a cigarette (own brand). Participants were dual users of little cigars and cigarettes.Results
Similar to cigarettes, little cigars delivered substantial nicotine and relatively more carbon monoxide. Puff volume, puff duration and time to smoke were significantly greater after cigarettes, but the temporal pattern of smoking more intensively at the beginning was similar in little cigars and cigarettes. Both little cigars and cigarettes reduced urge to smoke. Participants consistently mentioned that the lower cost of little cigars was a reason for initiation and continuation of their use.Conclusions
The results support the notion that regulation of little cigars is appropriate in light of public health considerations.
Firm strategy and consumer behaviour under a complex tobacco tax system: implications for the effectiveness of taxation on tobacco control
The current tobacco taxation scheme in Turkey, a mix of high ad valorem tax and low specific tax, contains incentives for firms and consumers to change pricing and consumption patterns, respectively. The association between tax structure and price and tax revenue stability has not been studied in detail with micro data containing price segment information.Objectives
In this study, we analyse whether incentives for firms and consumers undermine the effectiveness of tax policy in reducing consumption.Methods
We calculate alternative taxation scheme outcomes using differing ad valorem and specific tax rates through simulation analysis. We also estimate price elasticity of demand using detailed price and volume statistics between segments via regression analysis.Findings
A very high ad valorem rate provides strong incentives to firms to reduce prices. Therefore, this sort of tax strategy may induce even more consumption despite its initial aim of discouraging consumption. While higher prices dramatically reduce consumption of economy and medium price segment cigarettes, demand for premium segment cigarettes is found to be highly price-inelastic.Conclusions
The current tax scheme, based on both ad valorem and specific components, introduces various incentives to firms as well as to consumers which reduce the effectiveness of the tax policy. Therefore, on the basis of our theoretical predictions, an appropriate tax scheme should involve a balanced combination of ad valorem and specific rates, away from extreme (ad valorem or specific dominant) cases to enhance the effectiveness of tax policy for curbing consumption.
To evaluate the safety and effectiveness of e-cigarettes, by comparing users of only e-cigarettes, smokers of only tobacco cigarettes and dual users.Design
Prospective cohort study. We update previous 12-month findings and report the results of the 24-month follow-up.Data sources
Direct contact and questionnaires by phone or via internet.Methods
Adults (30–75 years) were classified as: (1) tobacco smokers, if they smoked ≥1 tobacco cigarette/day, (2) e-cigarette users, if they inhaled ≥50 puffs/week of any type of e-cigarette and (3) dual users, if they smoked tobacco cigarettes and also used e-cigarettes. Carbon monoxide levels were tested in 50% of those declaring tobacco smoking abstinence. Hospital discharge data were used to validate possibly related serious adverse events in 46.0% of the sample.Main outcome measures
Sustained abstinence from tobacco cigarettes and/or e-cigarettes after 24 months, the difference in the number of tobacco cigarettes smoked daily between baseline and 24 months, possibly related serious adverse events.Results
Data at 24 months were available for 229 e-cigarette users, 480 tobacco smokers and 223 dual users (overall response rate 68.8%). Of the e-cigarette users, 61.1% remained abstinent from tobacco (while 23.1% and 26.0% of tobacco-only smokers and dual users achieved tobacco abstinence). The rate (18.8%) of stopping use of either product (tobacco and/or e-cigarettes) was not higher for e-cigarette users compared with tobacco smokers or dual users. Self-rated health and adverse events were similar between all groups. Among those continuing to smoke, there were no differences in the proportion of participants reducing tobacco cigarette consumption by 50% or more, the average daily number of cigarettes and the average self-rated health by baseline group. Most dual users at baseline abandoned e-cigarettes and continued to smoke tobacco. Those who continued dual using or converted from tobacco smoking to dual use during follow-up experienced significant improvements in the 3 outcomes compared with those who continued or switched to only smoking tobacco (p<0.001).Conclusions
E-cigarette use alone might support tobacco quitters remaining abstinent from smoking. However, dual use did not improve the likelihood of quitting tobacco or e-cigarette use, but may be helpful to reduce tobacco consumption. Adverse event data were scarce and must be considered preliminary.Trial registration number
Effectiveness of a hospital-initiated smoking cessation programme: 2-year health and healthcare outcomes
Tobacco-related illnesses are leading causes of death and healthcare use. Our objective was to determine whether implementation of a hospital-initiated smoking cessation intervention would reduce mortality and downstream healthcare usage.Methods
A 2-group effectiveness study was completed comparing patients who received the ‘Ottawa Model’ for Smoking Cessation intervention (n=726) to usual care controls (n=641). Participants were current smokers, >17 years old, and recruited during admission to 1 of 14 participating hospitals in Ontario, Canada. Baseline data were linked to healthcare administrative data. Competing-risks regression analysis was used to compare outcomes between groups.Results
The intervention group experienced significantly lower rates of all-cause readmissions, smoking-related readmissions, and all-cause emergency department (ED) visits at all time points. The largest absolute risk reductions (ARR) were observed for all-cause readmissions at 30 days (13.3% vs 7.1%; ARR, 6.1% (2.9% to 9.3%); p<0.001), 1 year (38.4% vs 26.7%; ARR, 11.7% (6.7% to 16.6%); p<0.001), and 2 years (45.2% vs 33.6%; ARR, 11.6% (6.5% to 16.8%); p<0.001). The greatest reduction in risk of all-cause ED visits was at 30 days (20.9% vs 16.4%; ARR, 4.5% (0.4% to 8.7%); p=0.03). Reduction in mortality was not evident at 30 days, but significant reductions were observed by year 1 (11.4% vs 5.4%; ARR 6.0% (3.1% to 9.0%); p<0.001) and year 2 (15.1% vs 7.9%; ARR, 7.3% (3.9% to 10.7%); p<0.001).Conclusions
Considering the relatively low cost, greater adoption of hospital-initiated tobacco cessation interventions should be considered to improve patient outcomes and decrease subsequent healthcare usage.
'Opt-out referrals after identifying pregnant smokers using exhaled air carbon monoxide: impact on engagement with smoking cessation support
In the UK, free smoking cessation support is available to pregnant women; only a minority accesses this. ‘Opt-out’ referrals to stop smoking services (SSS) are recommended by UK guidelines. These involve identifying pregnant smokers using exhaled carbon monoxide (CO) and referring them for support unless they object.Methods
To assess the impact of ‘opt-out’ referrals for pregnant smokers on SSS uptake and effectiveness, we conducted a ‘before–after’ service development evaluation. In the 6-month ‘before’ period, there was a routine ‘opt-in’ referral system for self-reported smokers at antenatal ‘booking’ appointments. In the 6-month ‘after’ period, additional ‘opt-out’ referrals were introduced at the 12-week ultrasound appointments; women with CO≥4 ppm were referred to, and outcome data were collected from, local SSS.Results
Approximately 2300 women attended antenatal care in each period. Before the implementation, 536 (23.4%) women reported smoking at ‘booking’ and 290 (12.7%) were referred to SSS. After the implementation, 524 (22.9%) women reported smoking at ‘booking’, an additional 156 smokers (6.8%) were identified via the ‘opt-out’ referrals and, in total, 421 (18.4%) were referred to SSS. Over twice as many women set a quit date with the SSS after ‘opt-out’ referrals were implemented (121 (5.3%, 95% CI 4.4% to 6.3%) compared to 57 (2.5%, 95% CI 1.9% to 3.2%) before implementation) and reported being abstinent 4 weeks later (93 (4.1%, 95% CI 3.3% to 4.9%) compared to 46 (2.0%, 1.5% to 2.7%) before implementation).Conclusions
In a hospital with an ‘opt-in’ referral system, adding CO screening with ‘opt-out’ referrals as women attended ultrasound examinations doubled the numbers of pregnant smokers setting quit dates and reporting smoking cessation.
Tobacco companies use colour on cigarette packaging and labelling to communicate brand imagery, diminish health concerns, and as a replacement for prohibited descriptive words (‘light’ and ‘mild’) to make misleading claims about reduced risks.Methods
We analysed previously secret tobacco industry documents to identify additional ways in which cigarette companies tested and manipulated pack colours to affect consumers' perceptions of the cigarettes' flavour and strength.Results
Cigarette companies' approach to package design is based on ‘sensation transference’ in which consumers transfer sensations they derive from the packaging to the product itself. Companies manipulate consumers' perceptions of the taste and strength of cigarettes by changing the colour of the packaging. For example, even without changes to the tobacco blends, flavourings or additives, consumers perceive the taste of cigarettes in packages with red and darker colours to be fuller flavoured and stronger, and cigarettes in packs with more white and lighter colours are perceived to taste lighter and be less harmful.Conclusions
Companies use pack colours to manipulate consumers' perceptions of the taste, strength and health impacts of the cigarettes inside the packs, thereby altering their characteristics and effectively creating new products. In countries that do not require standardised packaging, regulators should consider colour equivalently to other changes in cigarette characteristics (eg, physical characteristics, ingredients, additives and flavourings) when making determinations about whether or not to permit new products on the market.
Analysis of British American Tobacco's questionable use of privilege and protected document claims at the Guildford Depository
Tobacco companies have a documented history of attempting to hide information from public scrutiny, including inappropriate privilege claims. The 1998 Minnesota Consent Judgement created two depositories to provide public access to discovered documents. Users raised concerns about the access conditions and ongoing integrity of the Guildford Depository collection operated until 2015 by British American Tobacco (BAT).Methods
A metadata search of the Legacy Tobacco Documents Library identified inconsistent privilege claims, and duplicates of documents withheld by BAT from public visitors. A review of the validity of claims, for documents obtained through these searches, was conducted against recognised legal definitions of privilege.Findings
BAT has asserted inappropriate privilege claims over 49% of the documents reviewed (n=63). The quantity of such claims and consistency of the stated rationale for the privilege claims suggest a concerted effort rather than human error.Conclusions
There was insufficient attention given to the operation of the Guildford Depository by the original plaintiffs, including to the subsequent use of privilege claims. Appropriate access to these documents, commensurate with the terms of legal settlements creating the collection, was critical given their public interest value for enhancing understanding of industry strategies and activities, informing of policy interventions, and for holding the industry to account. Future legal settlements should prevent defendants from subsequently withholding disclosed documents, aside from those legitimately privileged, from public view. Control of publicly disclosed documents should not be placed back into the hands of defendant tobacco companies. Plaintiffs also need to invest adequate resources into policing claims of legal privilege.
Integrating the impact of cigarette and waterpipe tobacco use among adolescents in the Eastern Mediterranean Region: a cross-sectional, population-level model of toxicant exposure
Waterpipe smoking is more prevalent than cigarette smoking among adolescents in the Eastern Mediterranean Region (EMR); however, simple prevalence masks complex waterpipe smoking patterns and makes uncertain its contribution to risk of tobacco-related harm. This study aimed to integrate the impact of cigarette and waterpipe tobacco use on toxicant exposure among EMR adolescents.Methods
A cross-sectional model made equivalent individual-level toxicant exposure data for cigarettes and waterpipes, and aggregated it to 23 countries in the EMR using the Global Youth Tobacco Survey. The waterpipe model adjusted for estimated frequency of use, session duration and sharing behaviours. The final model included 60 306 12–17-year olds, and modelled as outcomes nicotine, carbon monoxide (CO) and 14 carcinogens. Sensitivity analyses substantially reduced session duration and proportion of solo use.Results
Our model suggests waterpipe use may contribute a median of 36.4% (IQR 26.7–46.8%, n=16) of the total toxicant exposure from tobacco, and may reach up to 73.5% and 71.9% of total CO and benzene exposure, respectively. Sensitivity analyses reduced all values by 4.3–21.0%, but even the most conservative scenarios suggested over 50% of benzene and CO exposure was from waterpipe use. Between 69.2% and 73.5% of total toxicant exposure derived from dual cigarette and waterpipe users, who smoked cigarettes and waterpipe more frequently and intensely than single users.Conclusions
More research is warranted to refine our model's parameters. Tobacco control researchers should consider a move towards a single unit of measure for cigarette and waterpipe tobacco exposure in order to better inform health policy.
Factors influencing cigarette smoking among soldiers and costs of soldier smoking in the work place at Kakiri Barracks, Uganda
Although Uganda has a relatively low prevalence of smoking, no data exists on cigarette use among military personnel. Studies in other countries suggests military service is a risk factor for tobacco use.Objectives
To assess prevalence and risk factors for and costs of smoking among military personnel assigned to a large military facility in Uganda.Design
A mixed methods study including focus groups, interviews and a cross-sectional survey of military personnel.Setting
Kakiri Barracks, Uganda.Subjects
Key informants and focus group participants were purposively selected based on the objectives of the study, military rank and job categories. A multistage sample design was used to survey individuals serving in Uganda People's Defense Forces (UPDF) from June to November 2014 for the survey (n=310).Results
Participants in the qualitative portion of the study reported that smoking was harmful to health and the national economy and that its use was increasing among UPDF personnel. Survey results suggested that smoking rates in the military were substantially higher than in the general public (ie, 34.8% vs 5.3%). Significant predictors of smoking included lower education, younger age, having close friends who smoked and a history of military deployment. Estimated costs of smoking due to lost productivity was US$576 229 and US$212 400 for excess healthcare costs.Conclusions
Smoking rates are substantially higher in the UPDF compared to the general public and results in significant productivity costs. Interventions designed to reduce smoking among UPDF personnel should be included in the country's national tobacco control plan.
Policies regulating the sale and use of electronic cigarettes (e-cigarettes) vary widely within the USA and worldwide. We assessed support for four proposed policies among a representative sample of California voters (N=1002) and identified latent classes of voters who were likely to support or oppose various policies. Findings showed support for prohibiting e-cigarette use where smoking is banned (70%), taxing e-cigarettes (74%), licensing e-cigarette retailers (74%), and restricting flavourings (57%). Correlates of policy support included smoking status, political orientation, age group and California region. The latent class analysis revealed three classes of voters: Policy Supporters (predominantly college-educated, higher-income, liberal non-smokers), Policy Opposers (predominantly low-educated, low-income, conservative smokers), and Swing Voters (intermediate levels of education, income, and smoking, conservative). Findings provide information to inform segmented state-based communication campaigns regarding regulation of e-cigarettes. If policymakers want to enact prohibitive state-level policies, Opposers and Swing Voters may be important constituents to target.
Numerous epidemiological accounts suggest that waterpipe smoking (aka hookah, shisha, narghile) has become a global phenomenon, especially among youth. The alarming spread of waterpipe and accumulating evidence of its addictive and harmful effects represent a new threat in the global fight to limit tobacco-related morbidity and mortality. In response to waterpipe's alarming trends, major public health and tobacco control organisations have started or are considering systematic collection of data about waterpipe smoking to monitor its trends and assess its harmful effects in different societies. Such plans require coordination and agreement on epidemiological measurement tools that reflect the uniqueness of this tobacco use method, and at the same time allow comparison of waterpipe trends across time and place, and with other tobacco use methods. We started a decade ago our work to develop standardised measures and definitions for the assessment of waterpipe smoking in epidemiological studies. In this communication, we try to expand and update these assessment tools in light of our increased knowledge and understanding of waterpipe use patterns, its context and marketing, as well as the need for evidence-guided policies and regulations to curb its spread. We have assembled for this purpose a group of leading waterpipe researchers worldwide, and worked through an iterative process to develop the suggested instruments and definitions based on what we know currently about the waterpipe epidemic. While the suggested measures are by no means comprehensive, we hope that they can provide the building blocks for standard and comparable surveillance of waterpipe smoking globally.
Developing antitobacco mass media campaign messages in a low-resource setting: experience from the Kingdom of Tonga
Tobacco use has become the leading cause of preventable death in Tonga, a small island nation in the South Pacific. One pragmatic and economical strategy to address this worrying trend is to adapt effective antitobacco mass media materials developed in high-income countries for local audiences. Using Tonga as an example, this paper shares the practical steps involved in adapting antitobacco campaign materials for local audiences with minimal resources, a limited budget and without the need for an external production team. The Tongan experience underscores the importance of an adaptation process that draws from evidence-based best-practice models and engages local and regional stakeholders to ensure that campaign materials are tailored to the local context and are embedded within a mix of antitobacco strategies.
An abundance of evidence suggests that the tobacco industry's response to increased regulation imposed on cigarettes has been the development of little cigars and filtered cigars which are tobacco products that are merely cigarettes in disguise. Emphasising these products' physical attributes, the tobacco industry has offered cigar products to its consumers as pseudo-cigarettes. For decades, tobacco manufacturers' response to increased cigarette regulation and taxation has been to exploit policy loopholes by offering these little cigars and filtered cigars pseudo-cigarettes that are exempted from this regulatory oversight. As a result, in spite of increased regulations and taxes on cigarettes, smokers can purchase cigars that are almost physically indistinguishable from their cigarettes at a lower cost. This commentary describes the recent evolution of the cigar market in response to federal regulation, and highlights historical cigar industry attempts to evade taxation, capitalise on product features that are off-limits to cigarettes, and capture the shrinking market of cigarette smokers. We present the case that little cigars and filtered cigars, differing very little physically from cigarettes, are products deserving the same regulatory scrutiny.
Variations of toxic and carcinogenic constituents in nasvai: call for systematic research and regulation
Nasvai (sometimes referred to as naswar or nass) is a smokeless tobacco product used in central Asian countries such as Uzbekistan, Tajikistan, Kyrgyzstan, Turkmenistan and Kazakhstan. It is prepared by mixing locally grown tobacco with slaked lime or alkaline tree ash, and adding various combinations of flavouring and colouring ingredients. Nasvai can be produced in cottage industry settings or be custom made, and is sold either prepackaged in small containers or in bulk. While data on the prevalence of nasvai use in central Asian countries are scarce, the existing reports indicate that it may exceed that of smoking: 22.3% of adult men in Uzbekistan and 40% of rural adult men in Tajikistan reported using nasvai, while smoking prevalence estimates in the same populations were 19.6% and 8.7%, respectively.1 2 The largely unregulated production and accessibility of nasvai suggest that actual consumption may be...
RJ Reynolds has not published a negative randomised clinical trial of Camel Snus for smoking cessation
In 2009, RJ Reynolds Tobacco (RJR) created ‘The Smoker Cessation/Migration Study’, a randomised control trial, to compare Camel Snus to Nicorette nicotine replacement therapy (NRT) for smoking cessation over 1 year. RJR also examined the effect of providing information on the health benefits of switching from cigarettes to smokeless tobacco (ST).1 2
RJR's clinical studies division,3 together with legal, financial, marketing and innovation teams,4 created the earliest protocols.
The study had three arms, with 200 smokers in each: (1) Camel Snus with one-time relative risk ST information; (2) Camel Snus without ST information; and (3) Nicorette lozenges. All participants were given study products for 12 weeks to aid with smoking cessation.5 Biochemically-verified cigarette smoking status (exhaled carbon monoxide and cotinine) was recorded at baseline and at 3, 6 and 12 months, to determine the primary end points of point prevalence and...