Showing papers in "Tobacco Control in 2004"

Tobacco smoking using a waterpipe: a re-emerging strain in a global epidemic

Abstract: Objective: To conduct a comprehensive review regarding global waterpipe use, in order to identify current knowledge, guide scientific research, and promote public policy. Data sources: A Medline search using as keywords "waterpipe", "narghile", "arghile", "shisha", "hookah", "goza", "hubble bubble" and variant spellings (for example, "hooka"; "hukka") was conducted. Resources compiled recently by members of GLOBALink were used. Study selection: Every identified published study related to waterpipe use was included. Data synthesis: Research regarding waterpipe epidemiology and health effects is limited; no published studies address treatment efforts. Waterpipe use is increasing globally, particularly in the Eastern Mediterranean Region, where perceptions regarding health effects and traditional values may facilitate use among women and children. Waterpipe smoke contains harmful constituents and there is preliminary evidence linking waterpipe smoking to a variety of life threatening conditions, including pulmonary disease, coronary heart disease, and pregnancy related complications. Conclusions: More scientific documentation and careful analysis is required before the spread of waterpipe use and its health effects can be understood, and empirically guided treatment and public policy strategies can be implemented.

Households contaminated by environmental tobacco smoke: sources of infant exposures

Abstract: Objectives: To examine (1) whether dust and surfaces in households of smokers are contaminated with environmental tobacco smoke (ETS); (2) whether smoking parents can protect their infants by smoking outside and away from the infant; and (3) whether contaminated dust, surfaces, and air contribute to ETS exposure in infants. Design: Quasi-experiment comparing three types of households with infants: (1) non-smokers who believe they have protected their children from ETS; (2) smokers who believe they have protected their children from ETS; (3) smokers who expose their children to ETS. Setting: Homes of smokers and non-smokers. Participants: Smoking and non-smoking mothers and their infants ⩽ 1 year. Main outcome measures: ETS contamination as measured by nicotine in household dust, indoor air, and household surfaces. ETS exposure as measured by cotinine levels in infant urine. Results: ETS contamination and ETS exposure were 5–7 times higher in households of smokers trying to protect their infants by smoking outdoors than in households of non-smokers. ETS contamination and exposure were 3–8 times higher in households of smokers who exposed their infants to ETS by smoking indoors than in households of smokers trying to protect their children by smoking outdoors. Conclusions: Dust and surfaces in homes of smokers are contaminated with ETS. Infants of smokers are at risk of ETS exposure in their homes through dust, surfaces, and air. Smoking outside the home and away from the infant reduces but does not completely protect a smoker’s home from ETS contamination and a smoker’s infant from ETS exposure.

Regional, disease specific patterns of smoking-attributable mortality in 2000

Abstract: Background: Smoking has been causally associated with increased mortality from several diseases, and has increased considerably in many developing countries in the past few decades Mortality attributable to smoking in the year 2000 was estimated for adult males and females, including estimates by age and for specific diseases in 14 epidemiological subregions of the world Methods: Lung cancer mortality was used as an indirect marker of the accumulated hazard of smoking Never-smoker lung cancer mortality was estimated based on the household use of coal with poor ventilation Estimates of mortality caused by smoking were made for lung cancer, upper aerodigestive cancer, all other cancers, chronic obstructive pulmonary disease (COPD), other respiratory diseases, cardiovascular diseases, and selected other medical causes Estimates were limited to ages 30 years and above Results: In 2000, an estimated 483 million premature deaths in the world were attributable to smoking, 241 million in developing countries and 243 million in industrialised countries There were 384 million male deaths and 100 million female deaths attributable to smoking 269 million smoking attributable deaths were between the ages of 30–69 years, and 214 million were 70 years of age and above The leading causes of death from smoking in industrialised regions were cardiovascular diseases (102 million deaths), lung cancer (052 million deaths), and COPD (031 million deaths), and in the developing world cardiovascular diseases (067 million deaths), COPD (065 million deaths), and lung cancer (033 million deaths) The share of male and female deaths and younger and older adult deaths, and of various diseases in total smoking attributable deaths exhibited large inter-regional heterogeneity, especially in the developing world Conclusions: Smoking was an important cause of global mortality in 2000, affecting a large number of diseases Age, sex, and disease patterns of smoking-caused mortality varied greatly across regions, due to both historical and current smoking patterns, and the presence of other risk factors that affect background mortality from specific diseases

Tobacco attributable deaths in South Africa

Abstract: Background: In mid 1998, a question "Was the deceased a smoker five years ago?" was introduced on the newly revised South African death notification form. Design: A total of 16 230 new death notification forms from 1998 have been coded, and comparison of the prevalence of smoking among those who died of different causes was used to estimate, by case–control comparisons, tobacco attributed mortality in South Africa. Cases comprised deaths from causes known (from other studies) to be causally associated with smoking, and controls comprised deaths from medical conditions expected to be unrelated to smoking. Those who died from external causes, and from diseases strongly related to alcohol consumption, were excluded. Subjects: Reports were available from 5340 deceased adults (age 25+), whose smoking status was given by a family member. Results: Significantly increased risks were found for deaths from tuberculosis (odds ratio (OR) 1.61, 95% confidence interval (CI) 1.23 to 2.11), chronic obstructive pulmonary disease (COPD) (OR 2.5, 95% CI 1.9 to 3.4), lung cancer (OR 4.8, 95% CI 2.9 to 8.0), other upper aerodigestive cancer (OR 3.0, 95% CI 1.9 to 4.9) and ischaemic heart disease (OR 1.7, 95% CI 1.2 to 2.3). Conclusion: If smokers had the same death rate as non-smokers, 58% of lung cancer deaths, 37% of COPD deaths, 20% of tuberculosis deaths, and 23% of vascular deaths would have been avoided. About 8% of all adult deaths in South Africa (more than 20 000 deaths a year) were caused by smoking.

Smoking, social class, and gender: what can public health learn from the tobacco industry about disparities in smoking?

Abstract: Objective: To discover how the tobacco industry considers social class and gender in its efforts to market cigarettes in the USA, particularly to socially disadvantaged young women. Methods: A systematic on-line search of tobacco industry documents using selected keywords was conducted, and epidemiological data on smoking rates reviewed. Results: The two largest cigarette manufacturers in the USA consider “working class” young adults to be a critical market segment to promote growth of key brands. Through their own market research, these companies discovered that socially disadvantaged young women do not necessarily desire a “feminine” cigarette brand. Conclusions: Considering the tobacco industry’s efforts, alongside the persistent and growing disparities in cigarette smoking by social class, and the narrowing of differences in smoking by gender, it is concluded that additional tobacco control resources ought to be directed toward working class women.

Genetically decreased CYP2A6 and the risk of tobacco dependence: a prospective study of novice smokers

Abstract: Objective: Case control studies in adults suggest that defective alleles in the gene that codes for the hepatic cytochrome P450 2A6 (CYP2A6) protect against nicotine dependence (ND) and higher levels of cigarette consumption. These two hypotheses were tested in young adolescents. Design: Self reports of tobacco use and ND symptoms were collected every 3–4 months in a prospective study of 1293 grade 7 students from a convenience sample of 10 schools. Subjects: 281 smokers with genetic data were analysed; those who were not already tobacco dependent and who had inhaled (n = 228) were followed 29.9 months on average, until they became dependent or were censored. Main outcome measures: The association between metabolic activity, represented by CYP2A6 genotype, and conversion to dependence was analysed using Cox's proportional hazards model. Results: During follow up 67 subjects (29.4%) became dependent. Relative to CYP2A6*1/*1, having 1–2 copies of the inactive CYP2A6*2 or *4 variant was a strong risk factor for developing dependence (hazard ratio 2.8, 95% confidence 1.3 to 6.3). Subjects with 1–2 partially inactive CYP2A6*9 or *12 variants were not at increased risk. Mean past-week cigarette consumption at the end of follow up (controlling for age, sex, and number of months since first inhalation) among dependent subjects was 29.1 among normal inactivators, compared to 17.2, and 12.7 among slower (1–2 copies of *9 or *12), and slowest (1–2 copies of *2 or *4) inactivators, respectively (p = 0.09). Conclusion: Adolescents with 1–2 copies of CYP2A6*2 or *4 are at substantially increased risk of becoming dependent but smoke less once dependent. Genetic risk for ND may need to be considered in the conceptualisation of tobacco control programmes for adolescents.

Financial implications of cigarette smoking among individuals with schizophrenia

Abstract: Individuals with schizophrenia are more likely to smoke than those with other Axis I disorders1 and are 10 times more likely to have ever smoked daily than individuals in the general population.2 In addition to more frequent medical consequences of smoking3 as compared to smokers in the general population, smokers with schizophrenia experience negative consequences unique to their mental illness. One often overlooked example includes the substantial financial implications from tobacco use among smokers with schizophrenia—many of whom are dependent on a limited, fixed income.4,5 Quality of life issues relating to the ability to pay for occasional entertainment desires, or more seriously, adequate …

Corporate social responsibility and the tobacco industry: hope or hype?

Abstract: Corporate social responsibility (CSR) emerged from a realisation among transnational corporations of the need to account for and redress their adverse impact on society: specifically, on human rights, labour practices, and the environment. Two transnational tobacco companies have recently adopted CSR: Philip Morris, and British American Tobacco. This report explains the origins and theory behind CSR; examines internal company documents from Philip Morris showing the company's deliberations on the matter, and the company's perspective on its own behaviour; and reflects on whether marketing tobacco is antithetical to social responsibility.

Tobacco industry efforts to present ventilation as an alternative to smoke-free environments in North America

Abstract: Objective: To describe how the tobacco industry developed a network of consultants to promote ventilation as a "solution" to secondhand smoke (SHS) in the USA. Methods: Analysis of previously secret tobacco industry documents. Results: As with its other strategies to undermine the passage of clean indoor legislation and regulations, the tobacco industry used consultants who represented themselves as independent but who were promoting the industry's ventilation "solution" strategies under close, but generally undisclosed, industry supervision. The nature of the industry's use of ventilation consultants evolved over time. In the 1980s, the industry used them in an effort to steer the concerns about indoor air quality away from secondhand smoke, saying SHS was an insignificant component of a much larger problem of indoor air quality and inadequate ventilation. By the 1990s, the industry and its consultants were maintaining that adequate ventilation could easily accommodate "moderate smoking". The consultants carried the ventilation message to businesses, particularly the hospitality business, and to local and national and international regulatory and legislative bodies. Conclusion: While the tobacco industry and its consultants have gone to considerable lengths to promote the tobacco industry's ventilation "solution", this strategy has had limited success in the USA, probably because, in the end, it is simpler, cheaper, and healthier to end smoking. Tobacco control advocates need to continue to educate policymakers about this fact, particularly in regions where this strategy has been more effective.

Moving East: how the transnational tobacco industry gained entry to the emerging markets of the former Soviet Union—part I: establishing cigarette imports

Abstract: Objectives: To identify British American Tobacco’s (BAT) reasons for targeting the former Soviet Union following its collapse in 1991 and the initial strategies BAT used to enter the region. Design: Analysis of tobacco industry documents held at the Guildford BAT archive. Results: Desire to expand to new markets was based in part on the decline in old markets. The large population, proximity to China, scope to expand sales to women and, in Central Asia, a young population with high growth rates made the former Soviet Union particularly attractive. High consumption rates and unfilled demand caused by previous shortages offered potential for rapid returns on investment. A series of steps were taken to penetrate the markets with the initial focus on establishing imports. The documents suggest that BAT encouraged the use of aid money and barter trade to fund imports and directed the smuggling of cigarettes which graduated from an opportunistic strategy to a highly organised operation. In establishing a market presence, promotion of BAT’s brands and corporate image were paramount, and used synonymously to promote both the cigarettes and the company. The tobacco industry targeted young people and women. It used the allure of western products to promote its brands and brand stretching and corporate imagery to pre-empt future marketing restrictions. Conclusions: BAT used the chaotic conditions in the immediate post-transition period in the former Soviet Union to exploit legislative loopholes and ensure illegal cigarette imports. Governments of countries targeted by the tobacco industry need to be aware of industry tactics and develop adequate tobacco control policies in order to prevent the exploitation of vulnerable populations. Marketing restrictions that focus on advertising without restricting the use of brand or company promotions will have a limited impact.

An international analysis of cigarette affordability

Abstract: Objective: To investigate how affordable cigarettes are in developed and developing countries, and to calculate by how much the affordability of cigarettes has changed between 1990 and 2001; and secondly, to investigate the relation between cigarette affordability and consumption. Design: Affordability was defined as the cost of cigarettes relative to per capita income. Trends in cigarette affordability, and affordability elasticities of demand, were estimated using regression techniques. Subjects: Seventy countries were investigated, of which 28 are categorised as high income developed countries, while 42 are categorised as developing countries. Cigarette prices were obtained for the main city/cities in the countries. Results: Despite the fact that cigarettes are more expensive in developed countries, the high levels of income make cigarettes more affordable in these countries vis-a-vis developing countries. Of the 28 developed countries, cigarettes became more affordable in 11 and less affordable in 17 countries during the 1990s. Of the 42 developing countries, cigarettes became more affordable in 24 and less affordable in 18 countries. Based on a cross sectional analysis, a 1% increase in the relative income price (the inverse of cigarette affordability) is expected to decrease cigarette consumption by between 0.49–0.57%. Conclusions: Cigarette affordability, more than just the price, determines cigarette consumption. While cigarettes have become more affordable in many developing countries, some developing countries (for example, South Africa, Poland, and Thailand) have implemented strong and effective tobacco control policies, and have been able to decrease cigarette consumption as a result.

Changes in population attitudes about where smoking should not be allowed: California versus the rest of the USA

Abstract: Background: The decade long California Tobacco Control Program is unique to the nation in its duration, emphasis, and level of funding. Programme emphasis is on changing social norms about smoking as a means to discourage smoking and thus reduce the harmful health effects of tobacco to the population. Methods: Data from the 1992–93, 1995–96, and 1998–99 Tobacco Use Supplements to the national Current Population Survey (n > 175 000 each period) were used to examine changes in norms regarding where smoking should “not be allowed at all” in both California and in the rest of the USA. Venues queried were restaurants, hospitals, work areas, bars, indoor sports venues, and indoor shopping malls. Results: There were substantial increases in the percentages of the adult population (18+ years) stating that smoking should not be allowed in the venues queried in California by 1998–99 compared to 1992–93; only modest increases were observed in the rest of the USA. In fact, for most venues, the percentages for the rest of the USA were lower in 1998–99 than in California in 1992–93. Further, the percentage increase over this period in respondents stating that smoking should not be allowed in four or more of the six venues was 30% in California and 23% in the rest of the USA. The most dramatic percentage increase in California occurred among current smokers (93%). Conclusions: A strong, comprehensive tobacco control programme such as California’s can influence population norms, including those of smokers, with respect to where smoking should not be allowed.

Reaching youth at the point of sale: cigarette marketing is more prevalent in stores where adolescents shop frequently

Abstract: Objective: Although numerous studies describe the quantity and nature of tobacco marketing in stores, fewer studies examine the industry's attempts to reach youth at the point of sale This study examines whether cigarette marketing is more prevalent in stores where adolescents shop frequently Design, setting, and participants: Trained coders counted cigarette ads, products, and other marketing materials in a census of stores that sell tobacco in Tracy, California (n = 50) A combination of data from focus groups and in-class surveys of middle school students (n = 2125) determined which of the stores adolescents visited most frequently Main outcome measures: Amount of marketing materials and shelf space measured separately for the three cigarette brands most popular with adolescent smokers and for other brands combined Results: Compared to other stores in the same community, stores where adolescents shopped frequently contained almost three times more marketing materials for Marlboro, Camel, and Newport, and significantly more shelf space devoted to these brands Conclusions: Regardless of whether tobacco companies intentionally target youth at the point of sale, these findings underscore the importance of strategies to reduce the quantity and impact of cigarette marketing materials in this venue

Complicity in contraband: British American Tobacco and cigarette smuggling in Asia

Abstract: Objectives: To examine the complicity of British American Tobacco (BAT) in cigarette smuggling in Asia, and to assess the centrality of illicit trade to regional corporate strategy. Methods: Analysis of previously confidential documents from BAT's Guildford depository. An iterative strategy combined searches based on geography, organisational structure, and key personnel, while corporate euphemisms for contraband were identified by triangulation. Results: BAT documents demonstrate the strategic importance of smuggling across global, regional, national, and local levels. Particularly important in Asia, contraband enabled access to closed markets, created pressure for market opening, and was highly profitable. Documents demonstrate BAT's detailed oversight of illicit trade, seeking to reconcile the conflicting demands of control and deniability. Conclusions: BAT documents demonstrate that smuggling has been driven by corporate objectives, indicate national measures by which the problem can be addressed, and highlight the importance of a coordinated global response via WHO's Framework Convention on Tobacco Control.

Tobacco and transition: an overview of industry investments, impact and influence in the former Soviet Union

Abstract: Objectives: To quantify the contribution the tobacco industry has made to foreign direct investment (FDI) in the former Soviet Union (FSU) as an indicator of its political and economic leverage; to explore the impact this has had on production capacity and tobacco control in the region. Design: Data on industry investment and its impact on cigarette production capacity were collated from industry journals, reports, and websites. Data on total FDI were obtained from the European Bank of Reconstruction and Development. Results: By the end of 2000, transnational tobacco companies (TTCs) had invested over US$2.7 billion in 10 countries of the FSU. Tobacco money as a proportion of FDI varies from 1% to over 30% in Uzbekistan. Cigarette production capacity in the factories receiving investments tripled from 146 to 416 billion cigarettes per annum and the TTCs' market share has increased from nothing to between 50–100% in the markets in which they invested. Findings suggest that the effectiveness of national tobacco control measures corresponds broadly to the nature of the political and economic transition in each country and the size of industry investment, which is determined in part by the political context. Thus more effective measures tend to be seen in democratic states with smaller or no industry investments while the least effective measures are seen in highly centralised, one party states with high levels of industry investment or those with limited governmental capacity. Conclusions: The entry of the TTCs at a time of major political and economic change left the FSU particularly vulnerable to industry influence. This influence was enhanced by the industry's significant contribution to FDI, their ability to take over existing state monopolies in all but the largest countries, and the lack of democratic opposition.

A prospective study of household smoking bans and subsequent cessation related behaviour: the role of stage of change.

Abstract: Objective: To assess the degree to which smokers living with a full household ban on smoking change their cessation related behaviour. Design, setting, and participants: Prospective cohort study; follow up of a population based cohort of 1133 smokers, identified from a 1997 telephone survey of adult Oregonians. After a median of 21 months, 565 were located and reinterviewed. Main outcome measures: Quit attempts, time until relapse, and smoking cessation, defined as seven day and 90 day sustained abstinence at follow up. Results: A full ban at baseline was associated with a doubling of the odds of a subsequent quit attempt (odds ratio (OR) = 2.0, 95% confidence interval (CI), 1.0 to 3.9). Among respondents in the preparation stage at baseline (intention to quit in the next month with a quit attempt in the previous year), a full ban was associated with a lower relapse rate (hazard ratio = 0.5 (95% CI, 0.2 to 0.9)), while for those in precontemplation/contemplation (no intention to quit or intention to quit within the next six months, respectively), there was no significant association between full ban and relapse rate. For respondents in preparation, those with a full ban had over four times the odds of being in cessation for seven or more days before the follow up call (OR = 4.4 (1.1 to 18.7)), but for those in precontemplation/contemplation, full bans were unrelated to cessation. Conclusions: Full household bans may facilitate cessation among smokers who are preparing to quit by increasing quit attempts. They may also prolong time to relapse among those smokers.

Determination of tar, nicotine, and carbon monoxide yields in the mainstream smoke of selected international cigarettes.

Abstract: Objective: Survey of nicotine, tar, and carbon monoxide (CO) smoke deliveries from 77 cigarette brands purchased in 35 countries was conducted using a standardised machine smoking method. The goal of this study was to determine regional variations and differences in the tar, nicotine, and CO smoke yields of a cigarette brand manufactured by a leading transnational corporation and of non-US locally popular cigarette brands. Design: The majority of the cigarettes were purchased in each of the participating countries by delegate members of the World Health Organization and forwarded to the Centers for Disease Control and Prevention for analysis. Smoke deliveries were determined using a standardised smoking machine method and subsequent gravimetric and gas chromatography analysis. Results: The smoke deliveries varied widely. Mainstream smoke deliveries varied from 6.8 to 21.6 mg tar/cigarette, 0.5 to 1.6 mg nicotine/cigarette, and 5.9 to 17.4 mg CO/cigarette. In addition to the smoke deliveries, the cigarettes were examined to determine physical parameters such as filter composition, length, and ventilation levels. Conclusion: Analysis of the smoke deliveries suggested that cigarettes from the Eastern Mediterranean, Southeast Asia, and Western Pacific WHO regions tended to have higher tar, nicotine, and CO smoke deliveries than did brands from the European, American, or African WHO regions surveyed.

Short term patterns of early smoking acquisition

Abstract: Objective: To describe short term patterns of smoking acquisition exhibited by adolescent smokers. Design: Interview records from the prospective development and assessment of nicotine dependence in youth study were examined retrospectively. Interviews were conducted three times per year over 30 months. Subjects: 164 students in grades 7–9 (ages 12–15 years, 86 girls, 78 boys) who had used cigarettes at least twice. Main outcome measures: A continuous timeline of smoking activity, beginning with the subject's first use of tobacco and continuing through follow up, was translated into six patterns—abstinent, sporadic, occasional, daily, escalating, and intermittent. Outcome measures were the proportion of subjects starting/ending in each pattern, and the number of transitions per subject between patterns. Results: There was a general but discontinuous progression from infrequent to more frequent use, with many interspersed periods of not smoking. Escalation to daily smoking was common after the development of dependence symptoms, but was rare among those who did not have symptoms. After the appearance of symptoms, both transitions to heavier daily smoking and attempts at cessation increased. Conclusions: Movement to heavier, more frequent smoking is generally unidirectional, although many youths attempt to quit one or more times. The appearance of any symptom of dependence altered the subsequent pattern of smoking behaviour. Future investigators might consider using more frequent data points and a continuous timeline to track smoking behaviour.

The effectiveness of workplace smoking cessation programmes: a meta-analysis of recent studies.

Abstract: Objective: Using meta-analytic procedures, we compare the effectiveness of recent controlled trials of worksite smoking cessation during the 1990s with a previous meta-analysis of programmes conducted in the 1980s. Data sources: ABI/Inform, BRS, CHID, Dissertation Abstracts International, ERIC, Medline, Occupational Health and Safety Database, PsycInfo, Smoking and Health Database, SSCI, and Sociological Abstracts. Study selection: Controlled smoking cessation interventions at the workplace with at least six months follow up published from 1989 to 2001 and reporting quit rates (QRs). Data extraction: Two reviewers independently scanned titles/abstracts of relevant reports, and we reached consensus regarding inclusion/exclusion of the full text reports by negotiation. A third reviewer resolved disagreements. Two reviewers extracted data according to a coding manual. Consensus was again reached through negotiation and the use of a third reviewer. Data synthesis: 19 journal articles were found reporting studies conforming to the study's inclusion criteria. Interventions included self help manuals, physician advice, health education, cessation groups, incentives, and competitions. A total of 4960 control subjects were compared with 4618 intervention subjects. The adjusted random effects odds ratio was 2.03 (95% confidence interval 1.42 to 2.90) at six months follow up, 1.56 (95% CI 1.17 to 2.07) at 12 months, and 1.33 (95% CI 0.95 to 1.87) at more than 12 months follow up. Funnel plots were consistent with strong publication bias at the first two follow ups but not the third. In Fisher et al's 1990 study, the corresponding ORs were 1.18, 1.66, and 1.18. Conclusions: Smoking cessation interventions at the worksite showed initial effectiveness, but the effect seemed to decrease over time and was not present beyond 12 months. Compared to the Fisher (1990) analysis, the effectiveness was higher for the six month follow up. Disappointingly, we found methodological inadequacies and insufficient reporting of key variables that were similar to those found in the earlier meta-analysis. This prevented us from determining much about the most effective components of interventions. It is advisable for researchers conducting studies in the future to report data on attrition and retention rates of participants who quit, because these variables can affect QRs.

Carcinogen derived biomarkers: applications in studies of human exposure to secondhand tobacco smoke.

Abstract: Objective: To review the literature on carcinogen derived biomarkers of exposure to secondhand tobacco smoke (SHS). These biomarkers are specifically related to known carcinogens in tobacco smoke and include urinary metabolites, DNA adducts, and blood protein adducts. Method: Published reviews and the current literature were searched for relevant articles. Results: The most consistently elevated biomarker in people exposed to SHS was 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol (NNAL) and its glucuronides (NNAL-Gluc), urinary metabolites of the tobacco specific lung carcinogen 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone (NNK). The tobacco specificity of this biomarker as well as its clear relation to an established lung carcinogen are particularly appropriate for its application in studies of SHS exposure. Conclusion: The results of the available carcinogen derived biomarker studies provide biochemical data which support the conclusion, based on epidemiologic investigations, that SHS causes lung cancer in non-smokers.

The impact of anti-tobacco industry prevention messages in tobacco producing regions: evidence from the US truth® campaign

Abstract: Background: Adolescents who live in tobacco producing regions may not respond favourably to anti-industry ads. Objective: To examine whether state level involvement in tobacco production appears to limit the effectiveness of anti-industry ads to prevent tobacco use among adolescents in the USA. Design: Time trend analyses were done using repeated cross sectional data from six waves of the Legacy Media Tracking Survey, which were collected between 1999 and 2003. Setting and participants: 28 307 adolescents, ages 12–17 years, were classified as living in: tobacco producing states (TPS) (n = 1929); non-tobacco producing states (non-TPS) with low tobacco control funding comparable to TPS (n = 5323); non-TPS with relatively high funding (n = 15 076); and non-TPS with established anti-industry ad campaigns (n = 5979). Main outcome measures: Reactions to anti-industry ads; strength of anti-industry attitudes/beliefs; changes in anti-industry attitudes/beliefs over time. Results: Ad reactions did not differ by state type. Multivariate adjusted time trend analyses indicated significant, comparable increases in anti-industry attitudes/beliefs since the onset of the truth® campaign, in both TPS and non-TPS. Mediation analyses indicated that these increases were due, in part, to campaign exposure. Conclusions: Adolescents who live in tobacco producing regions appear to be as responsive to anti-industry ads as their counterparts in non-tobacco producing regions. This study provides further evidence for the effectiveness of such ads.

Relation between local restaurant smoking regulations and attitudes towards the prevalence and social acceptability of smoking: a study of youths and adults who eat out predominantly at restaurants in their town

Abstract: Objective: To examine the relation between strength of local restaurant smoking regulations and smoking related social norms among youths and adults. Design: We used generalised estimating equations logistic regression analysis to examine the relation between regulation strength and youths’ and adults’ perceptions of adult smoking prevalence and the social acceptability of smoking in their town, while controlling for baseline anti-smoking sentiment in the town. Setting: Each of the 351 Massachusetts towns were classified as having strong (complete smoking ban), medium (restriction of smoking to enclosed, separately ventilated areas), or weak (all others) restaurant smoking regulations. Subjects: 1147 Massachusetts youths ages 12–17 years and 2116 adults who reported that they often or always eat out in their own town, drawn from a random digit dial survey. Main outcome measures: Perceived adult smoking prevalence and perceived social acceptability of smoking in restaurants, in bars, or in general. Results: Compared to youths from towns with weak regulations, youths from towns with strong regulations were more likely to perceive lower adult smoking prevalence (odds ratio (OR) 1.71; 95% confidence interval (CI) 1.02 to 2.84) and social unacceptability of adult smoking (OR 2.00, 95% CI 1.29 to 3.08) in their town. Adults from towns with strong regulations were not more likely to perceive lower adult smoking prevalence, but had more than twice the odds of perceiving that smoking was unacceptable in restaurants (OR 2.19, 95% CI 1.58 to 3.02) or bars (OR 2.51, 95% CI 1.90 to 3.31). Conclusions: Strong local restaurant smoking regulations are associated with favourable smoking related social norms among youths and adults.

Particulate matter from tobacco versus diesel car exhaust: an educational perspective

Abstract: Background: Air pollution is a common alibi used by adolescents taking up smoking and by smokers uncertain about quitting. However, environmental tobacco smoke (ETS) causes fine particulate matter (PM) indoor pollution exceeding outdoor limits, while new engines and fuels have reduced particulate emissions by cars. Data comparing PM emission from ETS and a recently released diesel car are presented. Methods: A 60 m 3 garage was chosen to assess PM emission from three smouldering cigarettes (lit sequentially for 30 minutes) and from a TDCi 2000cc, idling for 30 minutes. Results: Particulate was measured with a portable analyser with readings every two minutes. Background PM 10 , PM 2.5 , and PM 1 levels (mean (SD)) were 15 (1), 13 (0.7), and 7 (0.6) μg/m 3 in the car experiment and 36 (2), 28 (1), and 14 (0.8) μg/m 3 in the ETS experiment, respectively. Mean (SD) PM recorded in the first hour after starting the engine were 44 (9), 31 (5), and 13 (1) μg/m 3 , while mean PM in the first hour after lighting cigarettes were 343 (192), 319 (178), and 168 (92) μg/m 3 for PM 10 , PM 2.5 , and PM 1 , respectively (p Conclusions: ETS is a major source of PM pollution, contributing to indoor PM concentrations up to 10-fold those emitted from an idling ecodiesel engine. Besides its educational usefulness, this knowledge should also be considered from an ecological perspective.

POP goes the power wall? Taking aim at tobacco promotional strategies utilised at retail

Abstract: Tobacco promotion at the retail level is pervasive Tobacco firms face an increasingly stringent regulatory environment. Despite having fewer viable options in the promotional mix, industry promotional spending has persisted, reaching record levels. In the USA, $11.22 billion was spent on tobacco promotion during 2001.1 Once one form of promotion is banned, tobacco firms utilise other marketing strategies to continue communicating brand imagery. Radio and television advertising was no longer acceptable for cigarettes in New Zealand, the UK, the USA, Canada, and Australia, commencing in 1963, 1965, 1971, 1972, and 1976, respectively. Consequently, the tobacco industry shifted their promotional spending largely toward the print media. Individual tobacco companies also turned to sponsoring broadcast sports events to compensate for lost broadcast advertising exposure. In Canada, with the implementation of the Tobacco Products Control Act that stipulated a ban on tobacco product advertising, expenditures on sponsorship increased considerably during the late 1980s and early 1990s.2 And once bans were placed on tobacco sponsorship in countries such as Australia, Canada, and New Zealand, the tobacco industry placed further resources toward point-of-sale strategies, package design, trademark diversification, direct marketing campaigns, and “cigarette girls” who returned to bars and nightclubs.3–9 In the USA, a ban on billboard advertising, in accordance with the 1998 Master Settlement Agreement, prompted an increase in the prevalence of both interior and exterior tobacco advertising at retail outlets (fig 1).10,11 Richard Pollay has remarked, “It’s like squeezing a balloon. You can shut down one media, but the problem just moves somewhere else”.12 Figure 1 Marlboro signage, located next to a gas (petrol) station in Baton Rouge, Louisiana, USA, serves …

Recent trends in home and work smoking bans

Abstract: Objectives: Home and work smoking bans at the national and state level in the USA, and their relation to smoking prevalence and to tobacco control policies, are examined. Data: The Current Population Survey’s 1992/93 and 1998/99 tobacco use supplement surveys are the primary data source, supplemented with information on state level tobacco control policies. Methods: The national and state rate of bans are estimated, and changes over the course of the 1990s and their relation to smoking rates and tobacco control policies are examined. Results: The prevalence of work and home bans has increased considerably between 1992/93 and 1998/99. By 1999, over 65% of the population age 15 and above work in places with smoking bans, and over 60% live in homes with bans. We found that states with lower than average ban rates in 1993 tended to have had larger increases in ban rates between 1993 and 1999. We also found that home and work bans became more prevalent in states with initially low smoking rates, and that the growth in home bans coincided with a declining prevalence of smoking. States with higher levels of bans by 1999 also tended to have higher cigarette taxes, stricter clean air laws, and media/comprehensive campaigns in place. Conclusions: The results indicate that lower smoking rates are associated with higher rates of work and home bans, although substantial progress has also been made by those states with initially low rates of bans. While further work is needed to establish the direction of causality, it would appear that reductions in smoking rates, either through stronger tobacco control policies or otherwise, may reduce exposure to tobacco smoke not only by reducing the number of smokers, but also through increasing the number of firms and homes with smoking restrictions.

Moving East: how the transnational tobacco industry gained entry to the emerging markets of the former Soviet Union—part II: an overview of priorities and tactics used to establish a manufacturing presence

Abstract: Objectives: To explore how British American Tobacco (BAT), having established cigarette imports, responded to the opportunities for investment in cigarette manufacturing in the former Soviet Union (FSU). Design: Analysis of documents held at the BAT archive in Guildford, UK. Results: Considerable priority was attached to investing in the FSU. This led BAT to undertake a major organisational change and to intense competition to acquire assets. BAT used flawed economic arguments to persuade cash starved governments that its investment would reap economic rewards. It offered excise advice that disadvantaged governments while benefiting BAT, confused issues over pricing, and avoided competitive tendering. BAT targeted agriculture ministries, using its expertise in leaf production to differentiate itself from other potential investors. It subverted the principles of corporate social responsibility to promote itself as a business partner. BAT's task was made easier by the naivety of post-Soviet governments and by the international financial organisations' support for rapid economic reform. The latter permitted tobacco transnationals to penetrate markets before effective competitive tendering processes had been established, giving them the opportunity to minimise prices and establish monopolies. Conclusions: Many of the arguments employed when penetrating post-Soviet markets were highly misleading but governments lacked expertise to realise this. There is a need to build tobacco control capacity in transition economies, within and outside government, to ensure that governments are better informed of the true economic and health impacts of tobacco. Rapid transition from socialist to market economies without establishing regulatory institutional structures may be dangerous when investing companies use business practices that fall short of international standards.

Reducing tobacco addiction through tobacco product regulation

Abstract: Tobacco product regulation has the potential to help reduce tobacco attributable disease by reducing the toxicity of these products and by reducing the prevalence of tobacco use and addiction.

The economic burden of smoking in California

Abstract: Objective: To develop estimates of the direct and indirect costs of smoking for California in 1999. Methods: A prevalence based approach was used to estimate the annual costs of smoking. Econometric models were used to estimate the smoking attributable fraction (SAF) for direct costs (hospitalisations, ambulatory care, prescription drugs, home health care, and nursing home services) and indirect costs due to lost productivity from smoking related illness. The models controlled for socioeconomic factors and other risk behaviours. Epidemiological methods were used to estimate the SAF for indirect costs due to lost productivity from premature deaths. The SAFs were applied to total health care expenditures, days lost, and deaths to obtain smoking attributable total costs. Results: In 1999, the total costs of smoking in California were $15.9 billion, $475 per resident, and $3331 per smoker. Direct costs were $8.6 billion (54% of the total), indirect costs due to lost productivity from illness were $1.5 billion (10%), and indirect costs due to premature deaths were $5.7 billion (36%). The cost of smoking was $9.4 billion for men and $6.3 billion for women. There were 43 137 deaths attributed to smoking, representing a total of 535 000 years of life lost. The value of life lost per death averaged $132 000, or 12.4 years. Conclusions: California smoking related costs are high. The cost methodology presented is useful for other states and nations interested in estimating their costs of smoking. Cost estimates can be used to evaluate the level of cigarette taxes and other policies related to smoking.

Smoker and ex-smoker reactions to cigarettes claiming reduced risk

Abstract: Context: The tobacco industry is introducing modified tobacco products claiming to reduce the risk of smoking (potential reduced exposure products, PREPs). If PREPs are perceived as safe, they may deter smokers from quitting and encourage re-initiation by smokers who have quit. Objective: To assess smokers’ and ex-smokers’ perceptions of PREPs and the impact of PREP claims on interest in quitting (among smokers) or in resuming smoking (ex-smokers). Design: A random-digit-dialled survey of US smokers and ex-smokers. We used Eclipse, a modified PREP cigarette, as an exemplar PREP. During the survey, the interviewer read risk reduction claims made for Eclipse by its manufacturer, assessing smokers’ interest in quitting before and after the exposure. Participants: 1000 current cigarette smokers and 499 ex-smokers (300 quit within the last two years), over 18 years old. Main outcome measures: Perception of risk reduction from Eclipse; interest in using Eclipse; smokers’ interest in quitting was assessed using a stage of change approach (pre- and post-exposure to claims). Results: 91% of smokers thought Eclipse was safer than regular cigarettes. 24% believed Eclipse was completely safe. 57.4% of smokers were interested in using Eclipse; interest was greatest among smokers who were contemplating quitting. Exposure to Eclipse’s claims was followed by reduced interest in quitting. Among all ex-smokers, interest in Eclipse was 6.2%, but interest was 15.2% among young adults (18–25 years) who had stopped smoking within two years. Conclusions: There is substantial risk that smokers will overinterpret reduced risk claims made for modified tobacco products. PREPs appeal to smokers who are contemplating quitting and exposure to reduced risk product claims appears to reduce smokers’ readiness to quit. PREPs also appealed to young adults who had recently stopped smoking. Thus, reduced risk tobacco product claims can undermine adult cessation and youth prevention, possibly resulting in increased harm even if the products are less toxic.

Current smoking and the risk of non-fatal myocardial infarction in the WHO MONICA Project populations.

Abstract: Background: Cohort studies have shown that smoking has a substantial influence on coronary heart disease mortality in young people. Population based data on non-fatal events have been sparse, however. Objective: To study the impact of smoking on the risk of non-fatal acute myocardial infarction (MI) in young middle age people. Methods: From 1985 to 1994 all non-fatal MI events in the age group 35–64 were registered in men and women in the WHO MONICA (multinational monitoring of trends and determinants in cardiovascular disease) project populations (18 762 events in men and 4047 in women from 32 populations from 21 countries). In the same populations and age groups 65 741 men and 66 717 women participated in the surveys of risk factors (overall response rate 72%). The relative risk of non-fatal MI for current smokers was compared with non-smokers, by sex and five year age group. Results: The prevalence of smoking in people aged 35–39 years who experienced non-fatal MI events was 81% in men and 77% in women. It declined with increasing age to 45% in men aged 60–64 years and 36% in women, respectively. In the 35–39 years age group the relative risk of non-fatal MI for smokers was 4.9 (95% confidence interval (CI) 3.9 to 6.1) in men and 5.3 (95% CI 3.2 to 8.7) in women, and the population attributable fractions were 65% and 55%, respectively. Conclusions: During the study period more than half of the non-fatal MIs occurring in young middle age people can be attributed to smoking.