Showing papers in "Tobacco Control in 2011"
TL;DR: The evidence indicates that the impact of health warnings depends upon their size and design: whereas obscure text-only warnings appear to have little impact, prominent health warnings on the face of packages serve as a prominent source of health information for smokers and non-smokers, can increase health knowledge and perceptions of risk and can promote smoking cessation.
Abstract: Objective To review evidence on the impact of health warning messages on tobacco packages. Data sources Articles were identified through electronic databases of published articles, as well as relevant ‘grey’ literature using the following keywords: health warning, health message, health communication, label and labelling in conjunction with at least one of the following terms: smoking, tobacco, cigarette, product, package and pack. Study selection and data extraction: Relevant articles available prior to January 2011 were screened for six methodological criteria. A total of 94 original original articles met inclusion criteria, including 72 quantitative studies, 16 qualitative studies, 5 studies with both qualitative and qualitative components, and 1 review paper: Canada (n¼35), USA (n¼29) Australia (n¼16), UK (n¼13), The Netherlands (n¼3), France (n¼3), New Zealand (n¼3), Mexico (n¼3), Brazil (n¼2), Belgium (n¼1), other European countries (n¼10), Norway (n¼1), Malaysia (n¼1) and China (n¼1). Results The evidence indicates that the impact of health warnings depends upon their size and design: whereas obscure text-only warnings appear to have little impact, prominent health warnings on the face of packages serve as a prominent source of health information for smokers and non-smokers, can increase health knowledge and perceptions of risk and can promote smoking cessation. The evidence also indicates that comprehensive warnings are effective among youth and may help to prevent smoking initiation. Pictorial health warnings that elicit strongemotionalreactionsaresignificantlymoreeffective. Conclusions Health warnings on packages are among the most direct and prominent means of communicating with smokers. Larger warnings with pictures are significantly more effective than smaller, text-only messages.
925 citations
TL;DR: There was sufficient evidence of effectiveness of increased tobacco excise taxes and prices in reducing overall tobacco consumption and prevalence of tobacco use and improvement of public health, including by preventing initiation and uptake among young people, promoting cessation among current users and lowering consumption among those who continue to use.
Abstract: Objective Over 20 experts on economics, epidemiology, public policy and tobacco control were asked by the International Agency for Research on Cancer (IARC) to evaluate the strength of the available evidence on the effects of tax and price policies to prevent and reduce tobacco use. Methods Draft papers presenting and assessing the evidence on the following topics were developed by the experts in an 8-month period prior to the meeting: tobacco industry pricing strategies and tax related lobbying; tax, price and aggregate demand for tobacco; tax, price and adult tobacco use, use among young people and use among the poor; tax avoidance and tax evasion; and the economic and health impact of tobacco taxation. Subsequently, papers were peer reviewed, revised and resubmitted for final discussion at a 6-day meeting at IARC in Lyon, France, where a consensus evaluation of 18 concluding statements using the pre-established criteria of the IARC Cancer Prevention Handbooks took place. Studies published (or accepted for publication) in the openly available scientific literature were the main source of evidence for the review and evaluation; other types of publications were included when appropriate. Results In support of 12 of the 18 conclusions, the experts agreed that there was sufficient evidence of effectiveness of increased tobacco excise taxes and prices in reducing overall tobacco consumption and prevalence of tobacco use and improvement of public health, including by preventing initiation and uptake among young people, promoting cessation among current users and lowering consumption among those who continue to use. For the remaining six concluding statements the evidence was strong (four statements) or limited (two statements). Conclusions The evidence presented and assessed in IARC Handbook volume 14 documents the effectiveness of tax and price policies in the control of tobacco use and improvement of public health.
568 citations
TL;DR: This study represents the first in the literature to investigate and affirm the toxicity of cigarette butts to fish, and will assist in assessing the potential ecological risks of cigaretteButt leachate to the aquatic environment.
Abstract: Background Cigarette butts are the most common form of litter, as an estimated 4.5 trillion cigarette butts are thrown away every year worldwide. Many chemical products are used during the course of growing tobacco and manufacturing cigarettes, the residues of which may be found in cigarettes prepared for consumption. Additionally, over 4000 chemicals may also be introduced to the environment via cigarette particulate matter (tar) and mainstream smoke. Methods Using US Environmental Protection Agency standard acute fish bioassays, cigarette butt-derived leachate was analysed for aquatic toxicity. Survival was the single endpoint and data were analysed using Comprehensive Environmental Toxicity Information System to identify the LC50 of cigarette butt leachate to fish. Results The LC50 for leachate from smoked cigarette butts (smoked filter + tobacco) was approximately one cigarette butt/l for both the marine topsmelt (Atherinops affinis) and the freshwater fathead minnow (Pimephales promelas). Leachate from smoked cigarette filters (no tobacco), was less toxic, with LC50 values of 1.8 and 4.3 cigarette butts/l, respectively for both fish species. Unsmoked cigarette filters (no tobacco) were also found to be toxic, with LC50 values of 5.1 and 13.5 cigarette butts/l, respectively, for both fish species. Conclusion Toxicity of cigarette butt leachate was found to increase from unsmoked cigarette filters (no tobacco) to smoked cigarette filters (no tobacco) to smoked cigarette butts (smoked filter + tobacco). This study represents the first in the literature to investigate and affirm the toxicity of cigarette butts to fish, and will assist in assessing the potential ecological risks of cigarette butts to the aquatic environment.
261 citations
TL;DR: An Expert Panel was convened by four Canadian agencies to comprehensively examine the weight of evidence from epidemiological and toxicological studies and understanding of biological mechanisms regarding the relationship between tobacco smoke and breast cancer and concluded that the association between active smoking and Breast cancer is consistent with causality.
Abstract: Four authoritative reviews of active smoking and breast cancer have been published since 2000, but only one considered data after 2002 and conclusions varied. Three reviews of secondhand smoke (SHS) and breast cancer (2004–2006) each came to different conclusions. With 30 new studies since 2002, further review was deemed desirable. An Expert Panel was convened by four Canadian agencies, the Ontario Tobacco Research Unit, the Public Health Agency of Canada, Physicians for a Smoke-Free Canada and the Canadian Partnership Against Cancer to comprehensively examine the weight of evidence from epidemiological and toxicological studies and understanding of biological mechanisms regarding the relationship between tobacco smoke and breast cancer. This article summarises the panel9s full report (http://www.otru.org/pdf/special/expert_panel_tobacco_breast_cancer.pdf). There are 20 known or suspected mammary carcinogens in tobacco smoke, and recognised biological mechanisms that explain how exposure to these carcinogens could lead to breast cancer. Results from the nine cohort studies reporting exposure metrics more detailed than ever/never and ex/current smoker show that early age of smoking commencement, higher pack-years and longer duration of smoking increase breast cancer risk 15% to 40%. Three meta-analyses report 35% to 50% increases in breast cancer risk for long-term smokers with N -acetyltransferase 2 gene ( NAT2 ) slow acetylation genotypes. The active smoking evidence bolsters support for three meta-analyses that each reported about a 65% increase in premenopausal breast cancer risk among never smokers exposed to SHS. The Panel concluded that: 1) the association between active smoking and breast cancer is consistent with causality and 2) the association between SHS and breast cancer among younger, primarily premenopausal women who have never smoked is consistent with causality.
223 citations
TL;DR: The authors, who cover a broad range of scientific expertise, from basic science to public health, suggest research priorities for non-clinical, clinical and public health studies, and conclude that the first priority is to characterize the safety profile of these products, including in long-term users.
Abstract: Electronic nicotine delivery systems (ENDS, also called electronic cigarettes or e-cigarettes) are marketed to deliver nicotine and sometimes other substances by inhalation. Some tobacco smokers report that they used ENDS as a smoking cessation aid. Whether sold as tobacco products or drug delivery devices, these products need to be regulated, and thus far, across countries and states, there has been a wide range of regulatory responses ranging from no regulation to complete bans. The empirical basis for these regulatory decisions is uncertain, and more research on ENDS must be conducted in order to ensure that the decisions of regulators, health care providers and consumers are based on science. However, there is a dearth of scientific research on these products, including safety, abuse liability and efficacy for smoking cessation. The authors, who cover a broad range of scientific expertise, from basic science to public health, suggest research priorities for non-clinical, clinical and public health studies. They conclude that the first priority is to characterize the safety profile of these products, including in long-term users. If these products are demonstrated to be safe, their efficacy as smoking cessation aids should then be tested in appropriately designed trials. Until these studies are conducted, continued marketing constitutes an uncontrolled experiment and the primary outcome measure, poorly assessed, is user health. Potentially, this research effort, contributing to the safety and efficacy of new smoking cessation devices and to the withdrawal of dangerous products, could save many lives.
217 citations
TL;DR: It is indicated that THS accumulates in smokers' homes and persists when smokers move out even after homes remain vacant for 2 months and are cleaned and prepared for new residents.
Abstract: Background This study examined whether thirdhand smoke (THS) persists in smokers9 homes after they move out and non-smokers move in, and whether new non-smoking residents are exposed to THS in these homes. Methods The homes of 100 smokers and 50 non-smokers were visited before the residents moved out. Dust, surfaces, air and participants9 fingers were measured for nicotine and children9s urine samples were analysed for cotinine. The new residents who moved into these homes were recruited if they were non-smokers. Dust, surfaces, air and new residents9 fingers were examined for nicotine in 25 former smoker and 16 former non-smoker homes. A urine sample was collected from the youngest resident. Results Smoker homes9 dust, surface and air nicotine levels decreased after the change of occupancy (p Conclusions These findings indicate that THS accumulates in smokers9 homes and persists when smokers move out even after homes remain vacant for 2 months and are cleaned and prepared for new residents. When non-smokers move into homes formerly occupied by smokers, they encounter indoor environments with THS polluted surfaces and dust. Results suggest that non-smokers living in former smoker homes are exposed to THS in dust and on surfaces.
180 citations
TL;DR: Menthol cigarettes were marketed as, and are perceived by consumers to be, healthier than non-menthol cigarettes, and were marketed to specific populations and social groups, including African–Americans, young people and women.
Abstract: Objective To examine tobacco industry marketing of menthol cigarettes and to determine what the tobacco industry knew about consumer perceptions of menthol. Methods A snowball sampling design was used to systematically search the Legacy Tobacco Documents Library (LTDL) (http://legacy.library.ucsf.edu) between 28 February and 27 April 2010. Of the approximately 11 million documents available in the LTDL, the iterative searches returned tens of thousands of results from the major US tobacco companies and affiliated organisations. A collection of 953 documents from the 1930s to the first decade of the 21st century relevant to 1 or more of the research questions were qualitatively analysed, as follows: (1) are/were menthol cigarettes marketed with health reassurance messages? (2) What other messages come from menthol cigarette advertising? (3) How do smokers view menthol cigarettes? (4) Were menthol cigarettes marketed to specific populations? Results Menthol cigarettes were marketed as, and are perceived by consumers to be, healthier than non-menthol cigarettes. Menthol cigarettes are also marketed to specific social and demographic groups, including African–Americans, young people and women, and are perceived by consumers to signal social group belonging. Conclusions The tobacco industry knew consumers perceived menthol as healthier than non-menthol cigarettes, and this was the intent behind marketing. Marketing emphasising menthol attracts consumers who may not otherwise progress to regular smoking, including young, inexperienced users and those who find ‘regular’ cigarettes undesirable. Such marketing may also appeal to health-concerned smokers who might otherwise quit.
156 citations
TL;DR: Design flaws, lack of adequate labelling and concerns about quality control and health issues indicate that regulators should consider removing ENDS from the market until their safety can be adequately evaluated.
Abstract: Purpose Electronic nicotine delivery systems (ENDS) purport to deliver nicotine to the lungs of smokers. Five brands of ENDS were evaluated for design features, accuracy and clarity of labelling and quality of instruction manuals and associated print material supplied with products or on manufacturers' websites. Methods ENDS were purchased from online vendors and analysed for various parameters. Results While the basic design of ENDS was similar across brands, specific design features varied significantly. Fluid contained in cartridge reservoirs readily leaked out of most brands, and it was difficult to assemble or disassemble ENDS without touching nicotine-containing fluid. Two brands had designs that helped lessen this problem. Labelling of cartridges was very poor; labelling of some cartridge wrappers was better than labelling of cartridges. In general, packs of replacement cartridges were better labelled than the wrappers or cartridges, but most packs lacked cartridge content and warning information, and sometimes packs had confusing information. Used cartridges contained fluid, and disposal of nicotine-containing cartridges was not adequately addressed on websites or in manuals. Orders were sometimes filled incorrectly, and safety features did not always function properly. Print and internet material often contained information or made claims for which there is currently no scientific support. Conclusions Design flaws, lack of adequate labelling and concerns about quality control and health issues indicate that regulators should consider removing ENDS from the market until their safety can be adequately evaluated.
148 citations
TL;DR: Smoking continues to be the most important cause of gender differences in mortality across Europe, but its importance as an explanation for this difference is often overshadowed by presumptions about other explanations.
Abstract: Background Women now outlive men throughout the globe, a mortality advantage that is very established in developed European countries. Debate continues about the causes of the gender gap, although smoking is known to have been a major contributor to the difference in the past. Objectives To compare the magnitude of the gender gap in all-cause mortality in 30 European countries and assess the contribution of smoking-related and alcoholrelated deaths. Methods Data on all-cause mortality, smoking-related mortality and alcohol-related mortality for 30 European countries were extracted from the World Health Organization Health for All database for the year closest to 2005. Rates were standardised by the direct method using the European population standard and were for all age groups. The proportion of the gender gap in all-cause mortality attributable to smoking-related and alcoholrelated deaths was then calculated. Results There was considerable variation in the magnitude of the male ‘excess’ of all-cause mortality across Europe, ranging from 188 per 100000 per year in Iceland to 942 per 100000 per year in Ukraine. Smokingrelated deaths accounted for around 40% to 60% of the gender gap, while alcohol-related mortality typically accounted for 20% to 30% of the gender gap in Eastern Europe and 10% to 20% elsewhere in Europe. Conclusions Smoking continues to be the most important cause of gender differences in mortality across Europe, but its importance as an explanation for this difference is often overshadowed by presumptions about other explanations. Changes in smoking patterns by gender suggest that the gender gap in mortality will diminish in the coming decades.
146 citations
TL;DR: Cigarette litter was found to be a point source for metal contamination and the apparent rapid leaching of other metals may increase the risk of acute harm to local organisms.
Abstract: Background Littered cigarette butts represent potential point sources for environmental contamination. In areas with substantial amounts of cigarette litter, environmental hazards may arise as chemical components are leached from the filters and smoked tobacco. Objective The three main aims of this study were: (1) to quantify the amount of Al, Ba, Cd, Cr, Cu, Fe, Pb, Mn, Ni, Sr, Ti and Zn leached from cigarette butts, (2) to determine the relationship between the pH of the aqueous soaking solution and metal concentration leached and (3) to determine the relationship between the period of soaking in aqueous solution and metal concentration leached. Methods Smoked cigarette butts and unsmoked cigarettes were added to phials containing aqueous solutions of pH 4.00, 5.00 and 6.00 (±0.05). The metal concentration of the resultant leachates was measured via inductively coupled plasma optical emission spectroscopy (ICP-OES) 1 day, 7 days and 34 days after sample addition. Results All metals were detected in leachates 1 day after sample addition (with the exception of Cd) and were released at varying rates. No clear relationship between pH within the range typical of precipitation and metal concentration leached was observed. Conclusions Based on the gradual release of multiple metals over the full 34-day study period, cigarette litter was found to be a point source for metal contamination. The apparent rapid leaching of other metals may increase the risk of acute harm to local organisms.
141 citations
TL;DR: Knowledge of e-cigarette sales and marketing strategies is needed to fully inform responses from the tobacco control community, including consideration of product regulation.
Abstract: Electronic cigarettes (e-cigarettes) have gained considerable attention since their introduction into European and American markets in 2006 and 2007, respectively. Research to date has focused on acute exposure,1 2 nicotine delivery1–3 and consumer response,4 yet little information has so far been available on this new and rapidly developing industry. Knowledge of e-cigarette sales and marketing strategies is needed to fully inform responses from the tobacco control community, including consideration of product regulation.5
In the USA, e-cigarette promotion has coalesced around three organisations. The Electronic Cigarette Association ‘was founded to institute and promote industry-wide standards and a code of conduct, work to maintain sound professional and practices, educate the public and policy-makers on the …
TL;DR: Typical pH ranges and concentrations of total nicotine, unionised nicotine and five TSNAs in selected oral tobacco products distributed globally show that very different exposure risks may be posed through the use of these chemically diverse oral Tobacco products.
Abstract: Objective Oral tobacco products contain nicotine and carcinogenic tobacco-specific N-nitrosamines (TSNAs) that can be absorbed through the oral mucosa. The aim of this study was to determine typical pH ranges and concentrations of total nicotine, unionised nicotine (the most readily absorbed form) and five TSNAs in selected oral tobacco products distributed globally. Methods A total of 53 oral tobacco products from 5 World Health Organisation (WHO) regions were analysed for total nicotine and TSNAs, including 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol (NNAL), using gas chromatography or liquid chromatography with mass spectrometric detection. Unionised nicotine concentrations were calculated using product pH and total nicotine concentrations. Fourier transform infrared spectroscopy was used to help categorise or characterise some products. Results Total nicotine content varied from 0.16 to 34.1 mg/g product, whereas, the calculated unionised nicotinerangedfrom0.05to31.0 mg/gproduct;a620-fold range of variation. Products ranged from pH 5.2 to 10.1, which translates to 0.2% to 99.1% of nicotine being in the unionised form. Some products have very high pH and correspondingly high unionised nicotine (eg, gul powder, chimo´, toombak) and/or high TSNA (eg, toombak, zarda, khaini) concentrations. The concentrations of TSNAs spanned five orders of magnitude with concentrations of 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanone (NNK) ranging from 4.5 to 516000 ng/g product. Conclusions These data have important implications for risk assessment because they show that very different exposure risks may be posed through the use of these chemically diverse oral tobacco products. Because of the wide chemical variation, oral tobacco products should not be categorised together when considering the public health implications of their use.
TL;DR: Recall of displays dropped significantly among adults and teenagers post-legislation and there were encouraging signs that the law helped de-normalise smoking.
Abstract: Aim To evaluate the short-term impacts of removing point-of-sale tobacco displays in Ireland, implemented in July 2009. Methods Retailer compliance was assessed using audit surveys in 2007, 2008 and 2009. Using a monthly survey of 1000 adults carried out since 2002, changes in smoking prevalence were assessed; attitudes were measured using extra questions added for a 10-month period before and after the law. Youth responses were assessed using a cohort of 180 13–15 year olds, interviewed in June and August 2009. Results Immediately following implementation, compliance was 97%. Support for the law increased among adults after implementation (58% Apr-Jun vs 66% Jul-Dec, p Conclusions Compliance was very high and the law was well supported. Recall of displays dropped significantly among adults and teenagers post-legislation and there were encouraging signs that the law helped de-normalise smoking.
TL;DR: Plain packs that feature large graphic health warnings are significantly more likely to promote cessation among young adult smokers than fully or partially branded packs and use of unbranded package space to feature larger health warnings would further promote cessation.
Abstract: Background Tobacco industry documents illustrate how packaging promotes smoking experimentation and reinforces existing smokersbehaviour. Plain packaging reduces the perceived attractiveness of smoking and creates an opportunity to introduce larger pictorial warnings that could promote cessation-linked behaviours. However, little is known about the effects such a combined policy measure would have on smokers’ behaviour. Methods A 3 (warning size) *4 (branding level) plus control (completely plain pack) best-worst experiment was conducted via face-to-face interviews with 292 young adult smokers from a New Zealand provincial city. The Juster Scale was also used to estimate cessationlinked behaviours among participants. Results Of the 13 options tested, respondents were significantly less likely to choose those featuring fewer branding elements or larger health warnings. Options that featured more branding elements were still preferred even when they also featured a 50% health warning, but were significantly less likely to be chosen when they featured a 75% warning. Comparison of a control pack representing the status quo (branded with 30% front of pack warning) and a plain pack (with a 75% warning) revealed the latter would be significantly more likely to elicit cessation-related behaviours. Conclusions Plain packs that feature large graphic health warnings are significantly more likely to promote cessation among young adult smokers than fully or partially branded packs. The findings support the
TL;DR: This pilot naturalistic study suggests that plain packaging could potentially help reduce tobacco consumption among some young adult smokers, and women in particular.
Abstract: Aims To explore the impact, if any, that using plain (non-branded) cigarette packs in real-life settings has on young adult smokers. Methods Naturalistic-type research was employed, where smokers used brown ‘plain’ packs for 2 weeks and their regular packs for 2 weeks, in real-life settings. Participants were recruited in Glasgow, Scotland. Of the 140 smokers aged 18–35 years who participated in the naturalistic study, 48 correctly completed and returned all questionnaires. Over the 4-week study period, participants completed a questionnaire twice a week assessing pack perceptions and feelings, feelings about smoking, salience of health warnings and smoking-related behaviours. A subsample of 18 participated in a post-study interview, which employed a semistructured topic guide to assess perceptions and experiences of using plain packs. Results Trends in the data show that in comparison with branded packaging, plain packaging increased negative perceptions and feelings about the pack and about smoking. Plain packaging also increased avoidant behaviour (hiding the pack, covering the pack), certain smoking cessation behaviours, such as smoking less around others and forgoing cigarettes, and thinking about quitting. Almost half (n=8) of those in the post-study interview, predominantly women (n=6), reported that the use of plain packs had either increased avoidant behaviour or reduced consumption. Conclusions This pilot naturalistic study suggests that plain packaging could potentially help reduce tobacco consumption among some young adult smokers, and women in particular. Employing an innovative research methodology, the findings of this study are consistent with, and indeed support, past plain packaging research.
TL;DR: The ubiquity of cigarette butt waste and its potential for adverse effects on human and animal health warrants additional research and policy interventions to reduce the stream of these pollutants in the environment.
Abstract: Discarded cigarette butts may present health risks to human infants and animals because of indiscriminate eating behaviours. Nicotine found in cigarette butts may cause vomiting and neurological toxicity; leachates of cigarette butts in aquatic environments may cause exposure to additional toxic chemicals including heavy metals, ethyl phenol and pesticide residues. This report reviews published and grey literature regarding cigarette butt waste consumption by children, pets and wildlife. Although reports of human and animal exposures number in the tens of thousands, severe toxic outcomes due to butt consumption are rare. Nonetheless, the ubiquity of cigarette butt waste and its potential for adverse effects on human and animal health warrants additional research and policy interventions to reduce the stream of these pollutants in the environment.
TL;DR: Measurements of the prevalence of smoking, the biggest avoidable public health threat in the European Union, are highly discrepant within countries between national and European Commission survey estimates.
Abstract: Objectives To determine whether the European Commission Eurobarometer survey of 27 European Union (EU) member states produces reliable smoking prevalence estimates when compared to national prevalence survey data, and to identify approaches to standardising the measurement of smoking prevalence in the EU. Methods This was a direct comparison of questions, sampling methods and smoking prevalence estimates, between the 2006 Eurobarometer study and contemporaneous national surveys. All 27 EU member states were included. Participants were people surveyed in the 2006 Eurobarometer study and in various national surveys in the closest year to 2006 for which data were available. The main outcome measures were the mean and range of differences in prevalence estimates between the Eurobarometer and national surveys. Results Most national surveys used similar multistage sampling methods and involved sample sizes of 3000 or more, but the phrasing of the questions used to define smoking, the inclusion or exclusion of occasional smokers, the age ranges of participants and the frequency of national surveys varied substantially between countries. The Eurobarometer study used the same questions in all countries but in sample sizes of 1000, or in 3 countries, 500. Eurobarometer 2006 smoking prevalence estimates were on average 0.37 percentage points higher than those in national surveys, but with a 95% range from −10.49 to +11.23 percentage points. At the extremes, the equivalent national prevalence estimate for Slovakia was 13.0% higher and for the UK 10.0% lower than the Eurobarometer figure. Conclusions Measurements of the prevalence of smoking, the biggest avoidable public health threat in the European Union, are highly discrepant within countries between national and European Commission survey estimates. Monitoring national smoking prevalence on a regular basis, using standardised methods in representative population samples, is an urgent priority for the EU.
TL;DR: Tobacco control programmes that utilise cessation-focus advertising should focus relatively more on ads that adopt the ‘why to quit’ strategy with either graphic images or personal testimonials.
Abstract: Objective To examine which types of cessation-focused advertisements are associated with perceived advertisement effectiveness among smokers and to assess whether key smoker characteristics (ie, cigarette consumption, desire to quit and past quit attempts) influence perceived effectiveness of different types of cessation ads. Methods We used data from the New York Media Tracking Survey Online, a web survey of 7060 adult smokers in New York. Participants were exposed to four categories of cessation ads: (1) why to quit—graphic images, (2) why to quit—testimonial, (3) how to quit and (4) anti-industry. Perceived ad effectiveness was measured with a four-item scale assessing the degree to which participants thought the ads made them stop and think, grabbed their attention, were believable and made them want to quit smoking. We categorised smokers based on cigarette consumption, desire to quit and past quit attempts. We used multivariable analyses to examine how smoker characteristics and category of cessation ads predict perceived ad effectiveness. Results Ads using the ‘why to quit’ strategy with either graphic images or personal testimonials were perceived as more effective than the other ad categories. Smokers who had less desire to quit or had not tried quitting in the past 12 months responded significantly less favourably to all types of cessation ads tested. Greater cigarette consumption was also associated with lower perceived effectiveness, but this association was smaller in magnitude. Conclusions Tobacco control programmes that utilise cessation-focus advertising should focus relatively more on ads that adopt the ‘why to quit’ strategy with either graphic images or personal testimonials.
TL;DR: ‘Plain’ packaging—removing colours and design elements—and removing descriptors such as ‘slims’ from packs may reduce brand appeal and thereby susceptibility to smoking among young women.
Abstract: Background This study sought to examine the impact of cigarette packaging on young women, including the impact of ‘plain’ packaging. Methods Participants were randomised to view eight cigarette packs designed according to one of four experimental conditions: fully-branded female brands; the same brands without descriptors (eg, ‘slims’); the same brands without brand imagery or descriptors (ie, ‘plain’ packs); and fully branded non-female brands as a control condition. Participants rated packs on perceived appeal, taste, tar, health risks and smoker ‘traits’. Results Fully-branded female packs were rated as significantly more appealing than ‘no descriptor’ packs, ‘plain’ packs and non-female branded packs. Female branded packs were associated with a greater number of positive attributes including glamour, slimness and attractiveness, compared to brands without descriptors and ‘plain’ packs. Women who viewed plain packs were less likely to believe that smoking helps people control their appetite—an important predictor of smoking among young women—compared to women who viewed branded female packs. Conclusions ‘Plain’ packaging—removing colours and design elements—and removing descriptors such as ‘slims’ from packs may reduce brand appeal and thereby susceptibility to smoking among young women.
TL;DR: Television advertisements and pictorial health warnings on cigarette packets may operate in a complementary manner to positively influence awareness of the health consequences of smoking and motivation to quit.
Abstract: Background In Australia, introduction of pictorial health warnings on cigarette packets was supported by a televised media campaign highlighting illnesses featured in two of the warning labels—gangrene and mouth cancer. Methods Two studies examined whether the warnings and the television advertisements complemented one another. Population telephone surveys of two cross-sections of adult smokers measured changes in top-of-mind awareness of smoking-related health effects from before (2005; n=587) to after the pack warnings were introduced (2006; n=583). A second study assessed cognitive and emotional responses and intentions to quit after smokers watched one of the campaign advertisements, comparing outcomes of those with and without prior pack warning exposure. Results Between 2005 and 2006, the proportion of smokers aware that gangrene is caused by smoking increased by 11.2 percentage points (OR=23.47, p=0.000), and awareness of the link between smoking and mouth cancer increased by 6.6 percentage points (OR=2.00, p=0.006). In contrast, awareness of throat cancer decreased by 4.3 percentage points, and this illness was mentioned in the pack warnings but not the advertisements. In multivariate analyses, smokers who had prior exposure to the warnings were significantly more likely to report positive responses to the advertisements and stronger post-exposure quitting intentions. Conclusions Television advertisements and pictorial health warnings on cigarette packets may operate in a complementary manner to positively influence awareness of the health consequences of smoking and motivation to quit. Jurisdictions implementing pictorial warnings should consider the benefits of supportive mass media campaigns to increase the depth, meaning and personal relevance of the warnings.
TL;DR: There is a significant gap between the current state of affairs in China and the requirements of the FCTC, and the Chinese tobacco monopoly under which commercial and other vested interests of the tobacco industry are jeopardising tobacco control efforts is thought to be the most crucial obstacle.
Abstract: As per China's ratification of the WHO Framework Convention on Tobacco Control (FCTC), it should have implemented effective packaging and labelling measures prior to 9 January 2009 and enacted a comprehensive ban on all tobacco advertising, promotion and sponsorship prior to 9 January 2011. In addition, universal protection against secondhand tobacco smoke should have been implemented before 9 January 2011 by ensuring that all indoor workplaces, all indoor public places, all public transportation and possibly other (outdoor or quasi-outdoor) public places are free of secondhand smoke. The authors conducted a review of various sources of information to determine the current status of FCTC implementation in mainland China. Even though China has made considerable efforts to implement the FCTC, there is still a significant gap between the current state of affairs in China and the requirements of the FCTC. The Chinese tobacco monopoly under which commercial and other vested interests of the tobacco industry are jeopardizing tobacco control efforts is thought to be the most crucial obstacle to the effective implementation of the FCTC across the country.
TL;DR: What the tobacco industry knew about menthol cigarettes and the initiation of smoking was determined using a snowball sampling strategy and showed that menthol is a prominent design feature used by cigarette manufacturers to attract and retain new, younger smokers.
Abstract: Objectives To determine what the tobacco industry knew about menthol cigarettes and the initiation of smoking. Methods Based on Food and Drug Administration staff-supplied research questions we used a snowball sampling strategy to search the Legacy Tobacco Documents Library (http://legacy.library.ucsf.edu) between February and April 2010. Of the approximately 11 million documents available in the LTDL, the iterative searches returned tens of thousands of results. Researchers reviewed 2634 documents and 128 were deemed relevant to one or more of the research questions. Results The documents show that menthol is added to cigarettes in part because it is known to be an attractive feature to inexperienced smokers who perceive menthol cigarettes as less harsh and easier to smoke and because of their availability from friends and family. Second, the tobacco industry found that some youths smoke menthols because they perceive them to be less harmful than non-menthol cigarettes. A key product design issue concerns whether to increase brand menthol levels to appeal to the taste preferences of long-term menthol smokers or keep menthol levels lower to appeal to inexperienced smokers. Marketing studies showed that the companies carefully researched the menthol segment of the market in order to recruit younger smokers to their brands. The industry tracked menthol cigarette usage by age, gender and race to inform product development and marketing decisions. Conclusions Menthol is a prominent design feature used by cigarette manufacturers to attract and retain new, younger smokers.
TL;DR: The economic burden of cigarette smoking has increased substantially in China during the past decade and is expected to continue to increase as the national economy and the price of healthcare services grow.
Abstract: Objective To estimate the health-related economic costs attributable to smoking in China for persons aged 35 and older in 2003 and in 2008 and to compare these costs with the respective results from 2000. Methods A prevalence-based, disease-specific approach was used to estimate smoking-attributable direct and indirect economic costs. The primary data source was the 2003 and 2008 China National Health Services Survey, which contains individual participant’s smoking status, healthcare use and expenditures. Results The total economic cost of smoking in China amounted to $17.1 billion in 2003 and $28.9 billion in 2008 (both measured in 2008 constant US$). Direct smoking-attributable healthcare costs in 2003 and 2008 were $4.2 billion and $6.2 billion, respectively. Indirect economic costs in 2003 and 2008 were $12.9 billion and $22.7 billion, respectively. Compared to 2000, the direct costs of smoking rose by 72% in 2003 and 154% in 2008, while the indirect costs of smoking rose by 170% in 2003 and 376% in 2008. Conclusions The economic burden of cigarette smoking has increased substantially in China during the past decade and is expected to continue to increase as the national economy and the price of healthcare services grow. Stronger intervention measures against smoking should be taken without delay to reduce the health and financial losses caused by smoking.
TL;DR: The price elasticity of cigarette demand among youth in low- and middle-income countries (LMIC) is estimated, implying that an increase in price of 10% would reduce youth cigarette consumption by 21.1% at the mean.
Abstract: Objective To estimate the price elasticity of cigarette demand among youth in low- and middle-income countries (LMIC). Data The Global Youth Tobacco Survey was used to obtain data on the smoking behaviour of 315353 adolescents from 17 LMIC. Design Two-part model of cigarette demand with country fixed effects. The first part estimates the impact of prices on smoking participation while the second part estimates the impact of prices on the number of cigarettes smoked among current smokers. Besides controlling for individual characteristics such as Age, Gender, Parental Smoking and availability of Pocket Money, the authors control for confounding environmental factors such as anti-smoking sentiment, the prevalence of cigarette advertising and anti-tobacco media messAges, and ease of purchasing cigarettes. All countries in this study are represented with at least two observations over time, which allows us to control for unobserved country characteristics and/or policies that may influence smoking patterns within countries. Results Cigarette price is an important determinant of smoking. The estimated price elasticity of smoking participation is � 0.74, and the estimated price elasticity of conditional cigarette demand is approximately � 1.37. The total price elasticity of cigarette demand is � 2.11, implying that an increase in price of 10% would reduce youth cigarette consumption by 21.1% at the mean.
TL;DR: Electronic nicotine delivery systems (ENDS) have started to appear in popular entertainment through movies, television shows and on-air advocacy by Hollywood celebrities.
Abstract: Electronic nicotine delivery systems (ENDS) (colloquially called electronic cigarettes or e-cigarettes) have been advertised increasingly aggressively in the USA and other countries in the past 4–5 years.1 These cigarette-shaped battery-powered devices heat a liquid solution containing various concentrations of nicotine, creating a vapour for inhalation. In recent months, ENDS have started to appear in popular entertainment through movies, television shows and on-air advocacy by Hollywood celebrities. On 7 January 2011, the Los Angeles Times noted that ENDS were used by movie star Johnny Depp in the recently released film The Tourist .2 On 27 September 2010, star Katherine Heigl appeared on ‘The Late Show with David Lettermen’, where …
TL;DR: The prevalent use of smokeless tobacco in places with smoking restrictions and lack of planning to quit by ‘dual users’ suggest the need to promote cessation among these users.
Abstract: Background Marketing and advertising of smokeless tobacco products towards cigarette smokers has increased recently. Because the use of multiple tobacco products is a growing public health concern, the present work assesses the use of smokeless tobacco among cigarette smokers, a behaviour termed as ‘dual use’, as well as attitudes and beliefs on their ‘dual use’ of tobacco. Methods Data were used from the 2008 ConsumerStyles survey, a nationally representative, mail-in survey of consumers in the USA (n=10 108). Results ‘Dual use’ was more common among cigarette smokers who were young, white men living in the Midwest or South. The majority of ‘dual users’ reported using smokeless tobacco in places where they could not smoke (67.7%) and did not believe smokeless tobacco would help in quitting smoking (75.1%). ‘Dual users’ reported planning to quit within the next 6 months less often than adults who smoke cigarettes exclusively and close to half (42.3%) never plan to quit smoking. Conclusions Tobacco use is attributed to a number of diseases and deaths worldwide, and cessation of tobacco use can reduce these health risks. The prevalent use of smokeless tobacco in places with smoking restrictions and lack of planning to quit by ‘dual users’ suggest the need to promote cessation among these users.
TL;DR: Information from industry documents with results from large population-based surveys of tobacco use and other independent sources consistently demonstrates that menthol increases population harm from smoking by increasing initiation and reducing cessation in some groups.
Abstract: Objective To integrate information on cigarette companies9 understanding and use of menthol as summarised in published research based on previously internal tobacco industry documents with results from large population-based surveys of tobacco use and other independent sources. Data sources Papers published in this supplement of Tobacco Control , together with papers identified using PubMed searches. Results Tobacco companies shaped consumer perceptions of menthol cigarettes. Menthol is not just a flavouring agent. Cigarette companies use menthol9s ability to mask irritation and provide sensory effects to make menthol cigarettes appeal to youth and health-concerned smokers, in part because menthol makes low-tar cigarettes more palatable. Consistent with targeted marketing, youths, women and African Americans disproportionately smoke menthols. There appear to be complex interactions with addictive effects of nicotine. The ubiquitous addition of menthol by tobacco companies to over 90% of all tobacco products, whether labelled ‘menthol’ or not, demonstrates that menthol is not simply a flavour or brand. Menthol imparts sensory characteristics to cigarettes and has a complex interaction with nicotine that affects smoking behaviour whether it is perceived or not, or whether cigarettes containing menthol are marketed as ‘menthol’ or not. Adding menthol increases fine particles in cigarette smoke, which have immediate adverse effects on the risk of heart attack. Conclusion Information from industry documents, confirmed by independent scientific literature, consistently demonstrates that menthol increases population harm from smoking by increasing initiation and reducing cessation in some groups. Menthol facilitates and increases smoking, which causes disease and death.
TL;DR: This study indicates that cigarette designers at Philip Morris, British-American Tobacco, Lorillard and other companies believed for a time that they might be able to reduce some of the most dangerous substances in mainstream smoke through advanced engineering of filter tips.
Abstract: Background When lung cancer fears emerged in the 1950s, cigarette companies initiated a shift in cigarette design from unfiltered to filtered cigarettes. Both the ineffectiveness of cigarette filters and the tobacco industry9s misleading marketing of the benefits of filtered cigarettes have been well documented. However, during the 1950s and 1960s, American cigarette companies spent millions of dollars to solve what the industry identified as the ‘filter problem’. These extensive filter research and development efforts suggest a phase of genuine optimism among cigarette designers that cigarette filters could be engineered to mitigate the health hazards of smoking. Objective This paper explores the early history of cigarette filter research and development in order to elucidate why and when seemingly sincere filter engineering efforts devolved into manipulations in cigarette design to sustain cigarette marketing and mitigate consumers9 concerns about the health consequences of smoking. Methods Relevant word and phrase searches were conducted in the Legacy Tobacco Documents Library online database, Google Patents, and media and medical databases including ProQuest, JSTOR, Medline and PubMed. Results 13 tobacco industry documents were identified that track prominent developments involved in what the industry referred to as the ‘filter problem’. These reveal a period of intense focus on the ‘filter problem’ that persisted from the mid-1950s to the mid-1960s, featuring collaborations between cigarette producers and large American chemical and textile companies to develop effective filters. In addition, the documents reveal how cigarette filter researchers9 growing scientific knowledge of smoke chemistry led to increasing recognition that filters were unlikely to offer significant health protection. One of the primary concerns of cigarette producers was to design cigarette filters that could be economically incorporated into the massive scale of cigarette production. The synthetic plastic cellulose acetate became the fundamental cigarette filter material. By the mid-1960s, the meaning of the phrase ‘filter problem’ changed, such that the effort to develop effective filters became a campaign to market cigarette designs that would sustain the myth of cigarette filter efficacy. Conclusions This study indicates that cigarette designers at Philip Morris, British-American Tobacco, Lorillard and other companies believed for a time that they might be able to reduce some of the most dangerous substances in mainstream smoke through advanced engineering of filter tips. In their attempts to accomplish this, they developed the now ubiquitous cellulose acetate cigarette filter. By the mid-1960s cigarette designers realised that the intractability of the ‘filter problem’ derived from a simple fact: that which is harmful in mainstream smoke and that which provides the smoker with ‘satisfaction’ are essentially one and the same. Only in the wake of this realisation did the agenda of cigarette designers appear to transition away from mitigating the health hazards of smoking and towards the perpetuation of the notion that cigarette filters are effective in reducing these hazards. Filters became a marketing tool, designed to keep and recruit smokers as consumers of these hazardous products.
TL;DR: The difference in cigarette consumption between legal sale and self-reported data has substantially increased over the last two decades in Italy, reflecting increasing under-reporting of cigarette consumption mainly due to a decreasing social acceptability of smoking.
Abstract: Objectives To monitor trends in under-reporting of smoking in Italy over the last two decades. Methods A total of 9 representative population-based surveys on smoking conducted in Italy in 1990 and annually between 2001 and 2008, covering 26 397 individuals, were studied. The number of cigarettes per day per person aged 15 years or over, obtained from these interview-based surveys, was compared with official data from legal sales. Results Over the last two decades, self-reported smoking prevalence progressively decreased from 32% in 1990 to 22% in 2008. Self-reported daily per capita consumption of cigarettes also showed a reduction between 1990 and 2008, notably so over the last few years (from 5.2 in 1990 to 4.0 in 2004 to 3.2 in 2008). According to data from legal sales, number of cigarettes per day per person decreased from 5.3 in 1990 to 5.0 in 1992, levelled off from 1992 to 1997, subsequently increased from 5.0 in 1997 to 5.8 in 2002 (likely due to control of smuggling), and decreased over the last 6 years (to 4.9 in 2008). These figures correspond to an under-reporting of approximately 1% in 1990, 25% in 2001 and up to 35% in 2008. Conclusions The difference in cigarette consumption between legal sale and self-reported data has substantially increased over the last two decades in Italy, reflecting increasing under-reporting of cigarette consumption mainly due to a decreasing social acceptability of smoking. Comparisons between interview-based and legal sale data are complicated by factors such as smuggling control and changes in the population (eg, increased proportion of immigrants); however these are able to justify only a small proportion of the gap found in Italy.
TL;DR: By using either extended producer responsibility (EPR) or the Maine model, the tobacco industry will be required to cover the cost of collecting and disposing of cigarette butt waste.
Abstract: The trillions of cigarette butts generated each year throughout the world pose a significant challenge for disposal regulations, primarily because there are millions of points of disposal, along with the necessity to segregate, collect and dispose of the butts in a safe manner, and cigarette butts are toxic, hazardous waste. There are some hazardous waste laws, such as those covering used tyres and automobile batteries, in which the retailer is responsible for the proper disposal of the waste, but most post-consumer waste disposal is the responsibility of the consumer. Concepts such as extended producer responsibility (EPR) are being used for some post-consumer waste to pass the responsibility and cost for recycling or disposal to the manufacturer of the product. In total, 32 states in the US have passed EPR laws covering auto switches, batteries, carpet, cell phones, electronics, fluorescent lighting, mercury thermostats, paint and pesticide containers, and these could be models for cigarette waste legislation. A broader concept of producer stewardship includes EPR, but adds the consumer and the retailer into the regulation. The State of Maine considered a comprehensive product stewardship law in 2010 that is a much better model than EPR. By using either EPR or the Maine model, the tobacco industry will be required to cover the cost of collecting and disposing of cigarette butt waste. Additional requirements included in the Maine model are needed for consumers and businesses to complete the network that will be necessary to maximise the segregation and collection of cigarette butts to protect the environment.