The latest medical research on Addiction Medicine

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Smoke-free legislation and neonatal and infant mortality in Brazil: longitudinal quasi-experimental study.

Tobacco Control

To examine the associations of partial and comprehensive smoke-free legislation with neonatal and infant mortality in Brazil using a quasi-experimental study design.

Infant and neonatal mortality.

Implementation of partial smoke-free legislation was associated with a -3.3 % (95% CI -6.2% to -0.4%) step reduction in the municipal infant mortality rate, but no step change in neonatal mortality. Comprehensive smoke-free legislation implementation was associated with -5.2 % (95% CI -8.3% to -2.1%) and -3.4 % (95% CI -6.7% to -0.1%) step reductions in infant and neonatal mortality, respectively, and a -0.36 (95% CI -0.66 to-0.06) annual decline in the infant mortality rate. We estimated that had all smoke-free legislation introduced since 2004 been comprehensive, an additional 10 091 infant deaths (95% CI 1196 to 21 761) could have been averted.

Strengthening smoke-free legislation in Brazil is associated with improvements in infant health outcomes-particularly under comprehensive legislation. Governments should accelerate implementation of comprehensive smoke-free legislation to protect infant health and achieve the United Nation's Sustainable Development Goal three.

The taste of smoke: tobacco industry strategies to prevent the prohibition of additives in tobacco products in Brazil.

Tobacco Control

The tobacco industry (TI) uses several strategies to attract new consumers, including using additives in tobacco products, which makes tobacco especially attractive to youth. Based on scientific evidence and the principles of the WHO Framework Convention on Tobacco Control, the Brazilian Health Regulatory Agency (ANVISA, for the name in Portuguese), published the Collegiate Board Resolution (RDC, for the name in Portuguese) 14/2012 in 2012, prohibiting the addition of substances that enhance the flavour and taste of tobacco products in order to make them more attractive. In response, the TI used various strategies to prevent RDC 14/2012 from entering into force. At the time, the Brazilian additive ban was the most comprehensive in the world as it included a ban on menthol.

This paper analyses the arguments and strategies used by the TI to prevent the implementation of the additives ban.

Review of published articles, reports, legislation and legislative activity, internal TI documents, media stories and other documents to describe TI's reaction to the ban.

The results show that the TI used some well-known strategies to delay or cancel the entering into force of the resolution. For example, the TI attempted political interference, used litigation and commissioned studies with findings that questioned the resolution's rationale. The TI strategies used in Brazil are similar to those used at the global level to oppose other tobacco control measures.

TI successfully delayed the most comprehensive additive ban in the world using its usual tactics, despite the fact that none of the arguments presented by the TI had an acceptable scientific basis or evidence.

Cross-country comparison of cigarette and vaping product marketing exposure and use: findings from 2016 ITC Four Country Smoking and Vaping Survey.

Tobacco Control

To compare exposure to and use of certain cigarette and vaping product marketing among adult smokers and vapers in four countries with contrasting regulations-Australia (AU), Canada, England and the USA.

Self-reported exposure to cigarette and vaping product advertising through point-of-sale, websites/social media, emails/texts, as well as exposure to and use of price offers were assessed for country differences using logistic regression models adjusted for multiple covariates.

Reported exposure to cigarette advertising exposure at point-of-sale was higher in the USA (52.1%) than in AU, Canada and England (10.5%-18.5%). Exposure to cigarette advertising on websites/social media and emails/texts was low overall (1.5%-10.4%). Reported exposure to vaping ads at point-of-sale was higher in England (49.3%) and USA (45.9%) than in Canada (32.5%), but vaping ad exposure on websites/social media in Canada (15.1%) was similar with England (18.4%) and the USA (12.1%). Exposure to vaping ads via emails/texts was low overall (3.1%-9.9%). Exposure to, and use of, cigarette price offers was highest in the USA (34.0 % and 17.8 %, respectively), but the use rate among those exposed was highest in AU (64.9%). Exposure to, and use of, price offers for vaping products was higher in the USA (42.3 % and 21.7 %) than in AU, Canada and England (25.9%-31.5 % and 7.4%-10.3 %).

Patterns of cigarette and vaping product marketing exposure generally reflected country-specific policies, except for online vaping ads. Implications for research and policy are discussed.

Strategies and barriers to achieving the goal of Finland's tobacco endgame.

Tobacco Control

Finland boldly legislated the end of tobacco use in its 2010 Tobacco Act, and subsequently expanded the goal in 2016 to eradicate other nicotine-containing products. This study explored stakeholders' perceptions about the strengths, barriers, solutions and rationale for Finland's comprehensive but conventional strategy to achieve its nicotine-free goal.

Study participants were selected based on expertise in policy or practice of tobacco control (n=32). Semi-structured interviews, conducted in 2017 and 2018, covered topics ranging from consensus among stakeholders to Finland's ranking on the 2016 Tobacco Control Scale. The framework method was chosen for analysing interview transcripts.

A perceived strength of Tobacco-Free Finland 2030 was the consensus and cooperation among members of the tobacco control community. The objective of becoming a nicotine- versus smoke-free society had almost unanimous support, challenged by a small minority who argued for greater discussion of harm reduction approaches. The need for maintaining legitimacy and historical successes in tobacco control were reasons for using a conventional strategy. Barriers to achieving the endgame goal included insufficient funding and over-reliance on non-governmental organisations, political/legal constraints, impact of institutional practices on tobacco disparities, ambivalence about the role of mass media and lack of prioritising smoking cessation.

Stakeholders' broad confidence in reaching the goal of Finland's tobacco endgame suggests that future policy initiatives will reflect the current, conventional strategy. If the Finnish government chooses to continue this approach, then it should designate separate funds for Tobacco-Free Finland 2030 and implement structural changes that will facilitate tobacco control initiatives.

Exploiting a low tax system: non-tax-induced cigarette price increases in Taiwan 2011-2016.

Tobacco Control

This study aims to analyse the non-tax-induced price increasing strategies adopted by tobacco industry in Taiwan, a high-income country with comprehensive tobacco control policies but low tobacco taxes and a declining cigarette market.

Using governmental tax, price and inflation data, we analysed cigarette sales volume, affordability, affordability elasticity of demand, market share, pricing and net revenue of the top five tobacco companies in Taiwan from 2011 to 2016 when no tax increases occurred.

Total revenue after tax grew significantly for all the major transnational tobacco companies between 2011 and 2016 at the expense of the state-owned Taiwan Tobacco and Liquor Corporation. In terms of market share, Japan Tobacco (JT) was the leading company, despite experiencing a small decline, while British American Tobacco and Imperial Brands remained stable, and Philip Morris International increased from 4.7% to 7.0%. JT adopted the most effective pricing strategy by increasing the real price of its two most popular brands (Mevius and Mi-Ne) and, at the same time, doubling the sales of its cheaper and less popular brand Winston by leaving its nominal retail price unaltered.

Low and unchanged tobacco taxes enable tobacco companies to use aggressive pricing and segmentation strategies to increase the real price of cigarettes without making them less affordable while simultaneously maintaining customers' loyalty. It is crucial to continue monitoring the industry's pricing strategies and to regularly increase taxes to promote public health and to prevent tobacco industry from profiting at the expense of government revenues.

Evolving IQOS packaging designs change perceptions of product appeal, uniqueness, quality and safety: a randomised experiment, 2018, USA.

Tobacco Control

Globally, the tobacco industry is promoting heated tobacco products. These products may represent a strategy to promote dual use of tobacco products. One product, IQOS from Philip Morris International, is being proposed in the USA for marketing as a less harmful product. The visual design of tobacco products can influence consumers by implying product characteristics. Thus, we sought to test the impact of IQOS packaging designs on cognitive, affective and behavioural intention responses.

From existing IQOS packages used globally, we developed three IQOS packages that decreasingly linked the product to the Marlboro brand. In September to October 2018, we assigned participants randomly to one package in an online experiment. All participants (n=954) were US adults reporting current smoking and no colour blindness. The experiment used quota sampling to ensure diversity by gender, sexual orientation, race, ethnicity and education. Measures were informed by the Context of Consumption Framework. To assess differences in ratings, we conducted non-parametric Kruskal-Wallis tests with post hoc comparisons using Dunn's test.

We found significant differences in cognitive indicators including appeal (H=6.87, p=0.03), uniqueness (H=15.68, p<0.01), brand equity-quality (H=122.35, p<0.01) and perceived safety compared with other tobacco products (H=14.27, p<0.01). Participants rated packages similarly on affective and behavioural intention measures. All were rated low for talking to others about the product and high for interest in trying with a coupon.

Linking or separating IQOS products with a well-established cigarette brand changes how adult smokers respond to the product. Regulators should consider the visual design of packaging.

Heated tobacco product use among Korean adolescents.

Tobacco Control

Heated tobacco products (HTPs) may compromise decades-long efforts to marginalise the tobacco industry. Their appeal to adolescents imposes a risk of a new tobacco epidemic. Empirical evidence on the behavioural patterns of HTP use among adolescents is required. We investigated the prevalence of HTP use and the association between use of HTPs and e-cigarettes and attempts to quit smoking cigarettes.

Nationally representative cross-sectional survey data of South Korean adolescents aged 12-18 years (mean age: 15 years) were used. The survey was conducted 1 year after the introduction of HTPs in Korea. A total of 59 532 adolescents were identified. Descriptive statistics and multiple logistic regression results are presented.

In all, 2.8% of South Korean adolescents were ever HTP users. Among these, 75.5% were current cigarette users, 45.6% were current e-cigarette users and 40.3% were concurrent users of cigarettes and e-cigarettes. Unlike ever use of e-cigarettes, which was associated with a higher likelihood of cigarette quit attempts (adjusted OR (aOR)=1.35, 95% CI: 1.16 to 1.58), no difference in cigarette quit attempts was found for ever use of HTPs (aOR=1.07, 95% CI: 0.91 to 1.26).

Considering the recent introduction of HTPs to the Korean market and less than 1% prevalence of e-cigarette when first introduced, the prevalence of ever HTP use among Korean adolescents is an important concern. The results showing high polytobacco use and the lack of an association between HTP use and cigarette quit attempts call for a ban on HTP advertisements with modified harm claims.

Impact of e-cigarette and cigarette prices on youth and young adult e-cigarette and cigarette behaviour: evidence from a national longitudinal cohort.

Tobacco Control

Understanding the impact of prices for tobacco and nicotine products is critical for creating policies to prevent use among young people. This study examines the impact of electronic cigarette (e-cigarette) and cigarette prices on current e-cigarette and cigarette use among youth and young adults.

Data were from a national probability-based sample aged 15-21 collected in 2014 and followed every 6 months for 2.5 years through 2016. We conducted separate conditional likelihood logistic regression models with past 30-day e-cigarette use and past 30-day cigarette use outcomes on the sample of individuals who participated in at least two survey waves (n=11 578) with linked Nielsen market-level price data for rechargeable e-cigarettes and cigarettes. Models controlled for time-varying variables at the individual and state policy levels, and fixed effects at the individual, wave and market levels.

Higher cigarette prices were associated with increased past 30-day e-cigarette use, indicating e-cigarettes may serve as a substitute for cigarettes. We did not find a statistically significant relationship between rechargeable e-cigarette prices and past 30-day e-cigarette use; neither did we find a significant relationship between rechargeable e-cigarette prices and past 30-day cigarette smoking.

This is the first study to examine e-cigarette and cigarette prices on e-cigarette and cigarette behaviour longitudinally among young people. Findings suggest the need for better measuring the costs associated with e-cigarette use among this population, as well as a careful assessment of price and tax policies that takes into account cross-product impact to sufficiently discourage e-cigarette and cigarette use among young people.

US young adults' perceived effectiveness of draft pictorial e-cigarette warning labels.

Tobacco Control

Future research should assess perceptions and the appropriateness of pictorial imagery for e-cigarette warnings and test their efficacy against text-only warnings experimentally.

Participants were 876 young adults (ages 18-29) recruited through Amazon Mechanical Turk who completed an online e-cigarette survey in 2018. Participants viewed and ranked five versions of the same e-cigarette nicotine addiction warning message-four pictorial and one text-only-on their perceived noticeability, likelihood of capturing young people's attention, memorability, relevance to the addiction warning text and overall effectiveness in warning people about e-cigarette risks. For each outcome, presentation of the five warning versions was randomised. Pictorials included symbolic images of risk and addiction, and of priority audiences for the warning (ie, young people).

For all outcomes, pictorial warnings were ranked higher than the text-only warning, and the warning using a yellow triangle caution icon was ranked highest for all outcomes. The text-only warning was ranked as the least likely to be effective for all four outcomes in which it was assessed. Trends were similar for current e-cigarette users and non-users.

Effect of menthol cigarette and other menthol tobacco product bans on tobacco purchases in the RTI iShoppe virtual convenience store.

Tobacco Control

To test how a potential US ban of menthol products or replacement with 'green' products and ads could influence tobacco purchases.

US adult menthol smokers (N=1197) were recruited via an online panel and randomly assigned to complete a shopping task in one of four versions (experimental conditions) of the RTI iShoppe virtual store: (1) no ban, (2) replacement of menthol cigarettes and ads with green replacement versions, (3) menthol cigarette ban and (4) all menthol tobacco product ban. Logistic regressions assessed the effect of condition on tobacco purchases.

Participants in the menthol cigarette ban (OR=0.67, 95% CI 0.48 to 0.92) and all menthol product ban conditions (OR=0.60, 95% CI 0.43 to 0.83) were less likely to purchase cigarettes of any type than participants in the no ban condition. Participants in the green replacement (OR=1.74, 95% CI 1.13 to 2.70), menthol cigarette ban (OR=3.40, 95% CI 2.14 to 5.41) and all menthol product ban conditions (OR=3.14, 95% CI 1.97 to 5.01) were more likely to purchase a cigarette brand different from their usual brand than participants in the no ban condition.

Our findings suggest that menthol bans could have great public health impact by reducing cigarette purchases. However, tobacco marketing strategies, such as creating green (or other replacement) versions of menthol cigarettes, may undermine public health benefits of a menthol ban by prompting purchases of non-menthol cigarettes. Our findings highlight the importance of taking tobacco marketing tactics into consideration in tobacco product regulation.

Changes to the littered cigarette pack environment in New York City between 2011 and 2015.

Tobacco Control

Imposing policies that increase tobacco prices is a key strategy for reducing smoking prevalence, although it may result in more cigarette trafficking. In 2013, New York City (NYC) passed the Sensible Tobacco Enforcement (STE) law requiring cigarettes be sold for a minimum price of $10.50 per pack. To evaluate whether cigarette price increases changed patterns of behaviour related to cigarette tax evasion, we examined littered pack study data from 2011 and 2015.

Littered cigarette packs were collected from a random sample of NYC census tracts in 2011 and 2015. The proportions of cigarette packs with proper local, known non-local, foreign or unknown, and no tax stamp were calculated. Changes in volume, source and consumption of domestically trafficked cigarettes over time were estimated.

In 2011, 255 packs with cellophane were collected; in 2015, 226 packs with cellophane were collected. Packs without proper local stamp increased from 60.7% in 2011 to 76.3% in 2015 (p<0.05) and those with foreign or unknown stamp increased from 11.6% in 2011 to 31.4% in 2015 (p<0.05). The percentage of domestically sourced packs attributed to domestic trafficking increased significantly from a range of 47.9% to 52.8% in 2011 to a range of 59.4% to 63.2% in 2015.

While the trafficking rate among domestically sourced cigarettes increased between 2011 and 2015 (before and after the STE minimum price floor on cigarette packs was in place), there was a decline in total consumption of domestically trafficked cigarettes due to a significant increase in consumption of foreign-sourced cigarettes. Jurisdictions considering price measures should bolster monitoring and enforcement efforts to maximise public health impact. Given the interstate nature of cigarette trafficking in the USA, Federal intervention would be optimal.

Disparities in current cigarette smoking among US adults, 2002-2016.

Tobacco Control

To assess disparities in current (past 30 days) cigarette smoking among US adults aged ≥ 18 years during 2002-2016.

Nine indicators associated with social disadvantage were analysed from the 2002 to 2016 National Survey on Drug Use and Health: education, annual family income, sex, race/ethnicity, urbanicity, serious psychological distress, health insurance, public assistance, and employment status. Using descriptive and multivariable analyses, we measured trends in smoking overall and within the assessed variables. We also evaluated effect of interactions on disparities and estimated the excess number of smokers attributable to disparities.

During 2002-2016, current cigarette smoking prevalence declined overall (27.5%-20.7%; p trend < 0.01), and among all subgroups except Medicare insurees and American Indians/Alaska Natives (AI/ANs). Overall inequalities in cigarette smoking grew even wider or remained unchanged for several indicators during the study period. In 2016, comparing groups with the least versus the most social advantage, the single largest disparity in current smoking prevalence was seen by race/ethnicity (prevalence ratio = 5.1, AI/ANs vs Asians). Education differences alone explained 38.0% of the observed racial/ethnic disparity in smoking prevalence. Interactions were also present; compared with the population-averaged prevalence among all AI/AN individuals (34.0%), prevalence was much higher among AI/ANs with <high school diploma (53.0%), unemployed (58.0%), or with serious psychological distress (66.9%). The burden of smoking attributable to race/ethnic disparities in smoking prevalence was an estimated 27.6 million smokers.

Overall smoking inequality increased or remained unchanged because of slower declines in smoking prevalence among disadvantaged groups. Targeted interventions among high-risk groups can narrow disparities.