Classifying European cigarette consumption trajectories from 1970 to 2015

ObjectivesTo systematically code and classify longitudinal cigarette consumption trajectories in European countries since 1970.DesignBlinded duplicate qualitative coding of periods of year-over-year relative increase, plateau, and decrease of national per capita cigarette consumption and categorisation of historical cigarette consumption trajectories based on longitudinal patterns emerging from the data.Setting41 countries or former countries in the European region for which data are available between 1970 and 2015.ResultsRegional trends in longitudinal consumption patterns identify stable or decreasing consumption throughout Northern, Western and Southern European countries, while Eastern and Southeastern European countries experienced much greater instability. The 11 emergent classes of historical cigarette consumption trajectories were also regionally clustered, including a distinctive inverted U or sine wave pattern repeatedly emerging from former Soviet and Southeastern European countries.ConclusionsThe open-access data produced by this study can be used to conduct comparative international evaluations of tobacco control policies by separating impacts likely attributable to gradual long-term trends from those more likely attributable to acute short-term events. The complex, regionally clustered historical trajectories of cigarette consumption in Europe suggest that the enduring normative frame of a gently sloping downward curve in cigarette consumption can offer a false sense of security among policymakers and can distract from plausible causal mechanisms among researchers. These multilevel and multisectoral causal mechanisms point to the need for a greater understanding of the political economy of regional and global determinants of cigarette consumption.

Examining Twitter Discourse on Electronic Cigarette and Tobacco Consumption During National Cancer Prevention Month in 2018: Topic Modeling and Geospatial Analysis

Background Examining public perception of tobacco products is critical for effective tobacco policy making and public education outreach. While the link between traditional tobacco products and lung cancer is well established, it is not known how the public perceives the association between electronic cigarettes (e-cigarettes) and lung cancer. In addition, it is unclear how members of the public interact with official messages during cancer campaigns on tobacco consumption and lung cancer. Objective In this study, we aimed to analyze e-cigarette and smoking tweets in the context of lung cancer during National Cancer Prevention Month in 2018 and examine how e-cigarette and traditional tobacco product discussions relate to implementation of tobacco control policies across different states in the United States. Methods We mined tweets that contained the term “lung cancer” on Twitter from February to March 2018. The data set contained 13,946 publicly available tweets that occurred during National Cancer Prevention Month (February 2018), and 10,153 tweets that occurred during March 2018. E-cigarette–related and smoking-related tweets were retrieved, using topic modeling and geospatial analysis. Results Debates on harmfulness (454/915, 49.7%), personal experiences (316/915, 34.5%), and e-cigarette risks (145/915, 15.8%) were the major themes of e-cigarette tweets related to lung cancer. Policy discussions (2251/3870, 58.1%), smoking risks (843/3870, 21.8%), and personal experiences (776/3870, 20.1%) were the major themes of smoking tweets related to lung cancer. Geospatial analysis showed that discussion on e-cigarette risks was positively correlated with the number of state-level smoke-free policies enacted for e-cigarettes. In particular, the number of indoor and on campus smoke-free policies was related to the number of tweets on e-cigarette risks (smoke-free indoor, r49=0.33, P=.02; smoke-free campus, r49=0.32, P=.02). The total number of e-cigarette policies was also positively related to the number of tweets on e-cigarette risks (r49=0.32, P=.02). In contrast, the number of smoking policies was not significantly associated with any of the smoking themes in the lung cancer discourse (P>.13). Conclusions Though people recognized the importance of traditional tobacco control policies in reducing lung cancer incidences, their views on e-cigarette risks were divided, and discussions on the importance of e-cigarette policy control were missing from public discourse. Findings suggest the need for health organizations to continuously engage the public in discussions on the potential health risks of e-cigarettes and raise awareness of the insidious lobbying efforts from the tobacco industry.

Classifying the comprehensiveness of flavoured tobacco sales restrictions: development and application of a tool to examine US state and local tobacco policies

ObjectivesComprehensive tobacco control policies with minimal exemptions can reduce tobacco use and sales. Many states and localities have adopted flavoured tobacco product (FTP) sales restrictions. This study describes the development and application of a schema to characterise the comprehensiveness of these FTP sales restrictions.DesignWe coded state and local FTP sales restrictions enacted June 2007–March 2021 for retailer, tobacco product, and flavour inclusions and exemptions. Guided by FTP literature, legal resources and meetings with FTP policy experts, we developed a six-level classification scheme to characterise coded FTP policies from least to most comprehensive. We present descriptive statistics of FTP policy features and comprehensiveness.ResultsAs of 31 March 2021, 7 state-level and 327 local-level FTP sales restrictions were enacted in the USA. Most state-level policies (71.4%) were categorised in the second lowest comprehensiveness category; local policies most commonly fell within the lowest (48.9%) or highest (26.0%) comprehensiveness categories. Across jurisdictions, adult-only retailers were most frequently exempted from the FTP sales restrictions (state: n=1, 14.3%; local: n=184, 56.3%); and most jurisdictions included electronic cigarettes (e-cigarettes) as a banned product (state: n=6, 87.5%; local: n=227, 100%). While just over half of state (n=4, 57.1%) and local (n=169, 51.7%) sales restrictions included menthol e-cigarettes, most excluded menthol cigarettes and/or menthol smokeless tobacco.ConclusionsComprehensiveness of FTP sales restrictions in the USA varies widely. Current and future FTP policies would be strengthened by including all flavours and all tobacco products—particularly menthol cigarettes—and by avoiding exemptions for certain retailers, particularly adult-only retailers.

Gender, Tobacco Control Policies, and Recalcitrant Smoking Among Older Adults in 20 European Countries

Little is known about sociodemographic and macro-level predictors of “recalcitrant smoking,” defined as persistent smoking when one has developed a health condition that is likely caused by smoking. We aim to investigate the impact of gender, education, and tobacco control policies on recalcitrant smoking among older adults in Europe from 2006 through 2013. Data from 33,839 respondents—aged 50 years and older with a smoking history and at least one smoking-related health condition—were pooled from the 2006–07, 2011, and 2013 waves of three harmonized longitudinal studies on ageing (SHARE, ELSA, and TILDA). We fitted gender-specific logistic regression models with two-way fixed effects and tested interaction terms between gender, tobacco control policies, and education, adjusting for age, marital status, GDP per capita, smoking prevalence, country, and year-fixed effects. Compared to men and individuals with higher levels of education, women and less educated individuals were more likely to be recalcitrant smokers. The association between education and recalcitrant smoking was stronger for women than men. The inverse association between the TCS and recalcitrant smoking was stronger for those having upper secondary education (for men: OR = 0.905, CI = 0.849–0.965; for women: OR = 0.897, CI = 0.834–0.964) and tertiary education (for men: OR = 0.802, CI = 0.717–0.898; for women: OR = 0.739, CI = 0.603–0.907), compared to those having less than upper secondary. As women and less educated individuals are vulnerable to recalcitrant smoking, future policies targeting these marginalized groups are needed to prevent recalcitrant smoking in old age.

Measuring the capacity to combat illicit tobacco trade in 160 countries

Background Illicit trade of tobacco negatively affects countries’ tobacco control efforts. It leads to lower tobacco prices and makes tobacco products more accessible to vulnerable populations. In this study, we constructed an illicit tobacco trade index, which measures the structural and institutional capabilities of 160 countries in addressing illicit tobacco trade. We collected the most recent and best available data on general governance, tobacco control policies, and trade and customs practices. Results Singapore, New Zealand, Finland and Sweden lead countries with the most favorable illicit tobacco trade score. We observed a positive relationship between illicit tobacco trade scores and Gross National Income (GNI) per capita and a negative relationship with the share of illicit tobacco trade to total tobacco consumption. Conclusions The capability to combat illicit trade varies across countries. However, on average, low and middle-income countries (LMICs) are less capable of addressing illicit tobacco trade as suggested by the lower illicit tobacco trade index score. The lower index score in low and middle-income countries was mainly driven by low scores in tobacco control policies and trade and customs practices and conditions. Our study reinforces the importance for LMICs to adopt the WHO’s Protocol to Eliminate Illicit Tobacco Trade Products, particularly committing to treaty obligations and investing on track and trace system and other customs reforms.

Flavour capsule cigarette use and perceptions: a systematic review

ObjectiveThis systematic review on flavour capsule cigarettes aims to examine prevalence, correlates of use, behaviours and perceptions of these products globally.Data sourcesA search of original, peer-reviewed research without restrictions in publication year, population, study design or language, using a combination of cigarette and capsule terms was conducted across four databases (Medline, Embase, Web of Science and Scopus), indexed until 30 April 2021.Study selectionStudies were included if they presented original, human subjects research on flavour capsule cigarettes.Data extractionTwo authors independently extracted data on main outcome results and assessed risk of bias using a validated quality assessment tool (QATSDD).Data synthesisOf 842 unduplicated database records and four studies from citation searching screened, 20 studies were included in the review. Studies reported data from 2009 to 2019 across eight countries, the majority of which used cross-sectional or focus group study designs. Current capsule use among smokers was highest in Chile and Mexico (40%) and was associated with younger age, and in some countries, with being female. Capsule cigarettes are perceived as tasting better, being smoother on the throat, more fun to smoke, and more attractive compared with non-capsule cigarettes, particularly among susceptible non-smokers and non-daily smokers.ConclusionFindings call for the adoption of comprehensive tobacco control policies that account for flavour capsules and similar iterations, which can increase appeal through flavours and innovative features. Continued monitoring and research of these products is critical, with particular attention to low-income and middle-income countries, which make up a disproportionately larger share of the capsule market.

Using systems science to advance health equity in tobacco control: a causal loop diagram of smoking

ObjectivesDevelop and use a causal loop diagram (CLD) of smoking among racial/ethnic minority and lower-income groups to anticipate the intended and unintended effects of tobacco control policies.MethodsWe developed a CLD to elucidate connections between individual, environmental and structural causes of racial/ethnic and socioeconomic disparities in smoking. The CLD was informed by a review of conceptual and empirical models of smoking, fundamental cause and social stress theories and 19 qualitative interviews with tobacco control stakeholders. The CLD was then used to examine the potential impacts of three tobacco control policies.ResultsThe CLD includes 24 constructs encompassing individual (eg, risk perceptions), environmental (eg, marketing) and structural (eg, systemic racism) factors associated with smoking. Evaluations of tobacco control policies using the CLD identified potential unintended consequences that may maintain smoking disparities. For example, the intent of a smoke-free policy for public housing is to reduce smoking among residents. Our CLD suggests that the policy may reduce smoking among residents by reducing smoking among family/friends, which subsequently reduces pro-smoking norms and perceptions of tobacco use as low risk. On the other hand, some residents who smoke may violate the policy. Policy violations may result in financial strain and/or housing instability, which increases stress and reduces feelings of control, thus having the unintended consequence of increasing smoking.ConclusionsThe CLD may be used to support stakeholder engagement in action planning and to identify non-traditional partners and approaches for tobacco control.

Tactics of the tobacco industry in an Arab nation: a review of tobacco documents in Oman

BackgroundFew studies have investigated tobacco industry interference in the tobacco control policies of Arab nations. This paper explores the tactics used by the industry to subvert tobacco control policies in Oman and offers lessons on how to prevent such interference in the future.MethodsWe searched the Truth Tobacco Industry Documents Archive using the word ‘Oman’, names of government institutions, policymakers and local tobacco distributors. Extracted data were noted chronologically by key elements of tobacco control measures. Gulf Cooperation Council (GCC) Health Ministers’ Council resolutions on tobacco control were also reviewed.ResultsOut of 1020 tobacco documents located, 327 were closely related to policy interference. Documents revealed that the industry met key government officials, offered in-kind services, used local diplomatic missions to influence Omani policymakers, opposed smoking bans, delayed regulations to lower tar and nicotine content of cigarettes, and to require effective health warnings, circumvented a tobacco advertising, promotion and sponsorship ban and provided voluntary codes as an alternative to effective regulations. Additionally, industry representatives lobbied individual countries in the GCC to veto tax increments and defeat consensus on agreed resolutions of the Health Ministers’ Council.ConclusionThe tobacco industry interfered in all key public health policies aimed to reduce tobacco use in Oman. There is an urgent need for the Omani government to enforce the Civil Code of Conduct and develop guidelines for all policymakers through implementing Article 5.3 of the WHO Framework Convention on Tobacco Control to curb the tobacco epidemic.