Effective Tobacco Control Policies Research Articles

Importance of Various E-Cigarette Device and E-Liquid Characteristics by Smoking Status among Young Adults Who Vape

Background E-cigarette product characteristics are known to influence appeal among young adults. Understanding which characteristics appeal to individuals with (vs. without) a history of combusted tobacco use is essential for developing effective tobacco control policies. Methods Anonymous, self-report data were collected from young adults (18-30 years) who had used e-cigarettes in the past 30 days (n = 295) online via Prolific from September-October 2019. Using a visual analogue scale (range: 0-100), participants rated the importance of ten e-cigarette device and nine e-liquid characteristics. Adjusted linear regression models were used to evaluate the association of combusted tobacco use status (never, former, current) with mean rating scores for each of the nineteen characteristics. Results The most important e-cigarette device characteristics were price (Mean = 81.1; [SD = 17.9]), size (Mean = 75.5 [SD = 20.9]), and hit strength (Mean = 73.8 [SD = 20.4]) while the most important e-liquid characteristics were flavor (M = 85.1 [SD = 16.3]), price (M = 80.9 [SD = 18.4]), and nicotine level (M = 77.8 [18.9]). Differences by combusted tobacco use status were observed for device brand, temperature/voltage, customizability, color, and popularity, with the highest ratings generally observed among those concurrently using combustible tobacco products. For e-liquids, differences by use status were observed for flavor, price, and bottle type. Notably, those concurrently using combusted products rated flavor as less important than those with no history of combustible tobacco use (B=-5.01[95%CI=-9.97, −0.05]). Conclusions The self-rated importance of e-cigarette device and e-liquid attributes varies by combustible tobacco use status among young adults which may be used to inform regulatory decisions regarding e-cigarette product characteristics.

Suicide mortality following the implementation of tobacco packaging and pricing policies in Korea: an interrupted time-series analysis

BackgroundTo prevent tobacco use in Korea, the national quitline number was added to tobacco packages in December 2012, tobacco prices were raised by 80% in January 2015, and graphic health warning labels were placed on tobacco packages in December 2016. This study evaluated the association of these tobacco packaging and pricing policies with suicide mortality in Korea.MethodsMonthly mortality from suicide was obtained from Cause-of-Death Statistics in Korea from December 2007 to December 2019. Interrupted time-series analysis was performed using segmented Poisson regression models. Relative risks (RRs) and 95% confidence intervals (CIs) were calculated adjusted for suicide prevention strategies.ResultsSuicide mortality was 20 per 1,000,000 in December 2007 and showed a downward trend over the study period. After the implementation of tobacco packaging and pricing policies, suicide mortality immediately declined by − 0.09 percent points (95% CI = − 0.19 to 0.01; P > 0.05) for the national quitline number, − 0.22 percent points (95% CI = − 0.35 to − 0.09; P < 0.01) for tobacco prices, and − 0.30 percent points (95% CI = − 0.49 to − 0.11; P < 0.01) for graphic health warning labels. The corresponding RRs for these post-implementation changes compared with the pre-implementation level were 0.91 (95% CI = 0.83 to 1.00), 0.80 (95% CI = 0.70 to 0.91), and 0.74 (95% CI = 0.61 to 0.90), respectively. Significant associations between tobacco control policies and suicide mortality were observed even when stratified by sex and region.ConclusionsThe findings of this study provide new evidence for an association between tobacco control policies and deaths by suicide. An array of effective tobacco control policies should be considered for prevention programs targeting suicide.

Survey from 61,748 schools in four States of India on sale of tobacco products near schools.

Children form the most vulnerable strata of the society and the tobacco industry is known to target them. Article 16 of the Framework Convention of Tobacco Control (FCTC) calls for prohibition of tobacco sales to and by minors. Although interventions to stop such sales are based on sound science, it is widely acknowledged that many countries find implementation, full of challenges. In India, sales near educational institutions are banned by law, Section 6b of the Cigarettes & Other Tobacco Products Act (COTPA). We conducted a survey of violations in four states [Andhra Pradesh (AP), Karnataka (KA), Meghalaya (ML), Uttar Pradesh (UP)] of India to report the number of violations and to assess if there was an association between the schools with violations and variables such as gender, size, category, location of schools. Schools in these States were asked to report the number of shops selling tobacco within 100 yards on an App circulated to all schools (289,392 in number). Chi-square tests, univariate and multivariate logistic regression performed to find association between schools with violations by Category of School, Size of School, Gender of students and location (Urban/Rural). Responses were received from 61,748 (21.3%) schools of which 16,193 (26.2%) reported violations. It was observed that the percentages of the schools with violations were similar to the prevalence of tobacco usage in the state. Four states AP, KA, ML, UP reported violations 22.2%, 17.5%, 42.9% and 31.4% respectively. On chi-square tests, there was a significant association for the states of KA and ML with regards to variables like size, category, location of schools (p-value <0.001). For AP, all variables were significantly different (p-value <0.001) while for UP variables like size and gender were significant. On logistic regression, there was significant association between the variables like size (>100), category (Upper Primary) and location (urban) for tobacco shops violations in both KA and ML except for the school category that was secondary in ML. While for AP and UP, only size (>100), location (urban) of schools have a significant association with the violations of tobacco shops. Logistic regression of pooled data of four states school size (>100) and school category (primary) and location (urban) had significantly higher association of violation of tobacco shops. This is the first large survey with responses from almost all parts of the four states in India. This study shows significant association with the size, category and location of schools. We anticipate that the lists of schools which have such violations can be used by enforcement agencies to take focused action. Such models will help develop effective tobacco control policies in developing countries with large populations where implementation remains a big challenge.

Influence of Knowledge and Attitudes on Youth Smoking in Rural Areas of the Mymensigh Districts of Bangladesh: A Cross-Sectional Study

The development of a country is strongly influenced by a higher smoking rate among the young population. Understanding knowledge and attitudes regarding smoking among young people lies at the heart of effective tobacco control policies. Bangladesh is a large, low-income country in South Asia with a high rate of youth smoking. As yet, however, little attention has been paid to knowledge and attitudes among rural youth. Face-to-face interviews were conducted with 385 youth males from the rural Mymensingh district of Bangladesh aged 15 to 24 were interviewed face-to-face. Univariate distribution (i.e., frequency analysis), bivariate analysis (i.e., Chi-square tests), and multivariate analysis (i.e., binary logistic regression model) were performed to determine the influence of knowledge and attitudes on youth male smoking. The percentage of youth smoking is 40.3 with knowledge and attitudes revealed as the more influential factors of smoking. For example, the chance of being a smoker with a satisfactory knowledge score is significantly lower than their counterparts (Odds ratio [OR]: 0.47 [0.30, 0.70]). Similarly, respondents with satisfactory attitudes scores have a significantly lower chance (OR: 0.40 [0.26, 0.61]) to be a smoker than those having an unsatisfactory score. This study exposes the influences of knowledge and attitudes among the youth toward smoking in rural parts of the Mymensingh district of Bangladesh. The findings and recommendations of this study will be more helpful to the authorities in revising the existing smoking policies accordingly to reduce and prevent youth smoking for the betterment of the country.

Awareness of lung cancer risk factors and symptoms in Syria: an online cross-sectional study

Background Globally, lung cancer is the leading cause of cancer fatalities and the second most frequent cancer. Population knowledge of the features of lung cancer is a crucial strategy for early diagnosis and decreasing the mortality rate of lung cancer patients. In this study, we aim to assess the Syrian population’s knowledge of lung cancer and its risk factors and to measure awareness of symptoms related to lung cancer. Methods This national cross-sectional study was conducted between October 12 to November 21, 2022, in Syria. We included Syrian people above 18 years from all Syrian governorates. The questionnaire consisted of three categories of questions: sociodemographic information, awareness of lung cancer symptoms, and awareness of lung cancer risk factors. Results Overall, 2251 participants were involved in this research; almost half of them (47.3%) were aged between 21-30 years, and 30.9% indicated they are smoking cigarettes. The overall mean score of knowledge regarding closed questions about risk factors of lung cancer was 4.29; however, the mean score of knowledge regarding open questions about symptoms of lung cancer was 1.52. About half of the study sample (51.3%) indicated that unexplained weight loss is a possible symptom of lung cancer. Our findings showed that cigarette smokers have a lower probability of having adequate knowledge toward lung cancer risk factors than a non-smoker (AOR=0.73, COR=0.68, P-value&lt;0.05). We also defined that females have higher statistically significant odds (AOR=1.3, COR=1.38, P-value&lt;0.05) for being knowledgeable about the symptoms of lung cancer compared to the male sample study. Conclusion According to our findings, there is inadequate knowledge toward lung cancer risk factors and moderate knowledge of lung cancer symptoms. Along with educational programs to raise public knowledge of the dangers of smoking and other LC risk factors, effective tobacco control policy execution is crucial.

Exploring gender disparities in the disease and economic tobacco-attributable burden in Latin America.

Tobacco use has significant health consequences in Latin America, and while studies have examined the overall impact, the gender-specific effects have not been thoroughly researched. Understanding these differences is crucial for effective tobacco control policies. The objective of this study was to explore the differences in tobacco-attributable disease and economic burden between men and women in Argentina, Brazil, Chile, Colombia, Costa Rica, Ecuador, Mexico, and Peru. We used a previously validated economic model to quantify the impact of tobacco-related illnesses, including morbidity, mortality, healthcare costs, productivity losses, informal care expenses, and DALYs, by gender and age. We utilized data from national surveys, records, studies, and expert opinions to populate the model. In 2020, there were 351,000 smoking-attributable deaths. Men accounted for 69% and women 31%. Ecuador and Mexico had the highest male-to-female death ratio, while Peru and Chile had the smallest disparities. 2.3 million tobacco-related disease events occurred, with 65% in men and 35% in women. Ecuador and Mexico had higher disease rates among men, while Peru had a more balanced ratio. Regarding DALYs, men lost 6.3 million due to tobacco, while women lost 3.3 million, primarily from COPD, cardiovascular disease, and cancer. Brazil and Mexico had the highest DALY losses for both genders. Costa Rica had a lower male-to-female tobacco use prevalence ratio but ranked second in deaths, disease events, and DALYs attributed to tobacco. Colombia had a unique pattern with a male-to-female death ratio of 2.08 but a higher ratio for disease events. The health systems spent $22.8 billion to treat tobacco-attributable diseases, with a male-to-female cost ratio 2.15. Ecuador showed the greatest gender cost difference, while Peru had the lowest. Productivity loss due to tobacco was $16.2 billion, with Ecuador and Mexico exhibiting the highest gender disparities and Peru the lowest. Informal care costs amounted to $10.8 billion, with men incurring higher costs in Ecuador, Costa Rica, and Mexico. Tobacco causes significant health and economic burdens in Latin America, with gender-based differences. There is a need for gender-disaggregated data to improve tobacco control policies.

Smoking-Related Disease Impact in the Eastern Mediterranean Region: A Comprehensive Assessment Using Global Burden of Disease Data.

Smoking remains a significant risk factor for numerous health issues, including lung cancer, chronic obstructive pulmonary disease, ischemic heart disease, stroke, and respiratory infections. This study investigates the burden of tobacco-related diseases in the Middle East and North Africa (MENA) region. Utilizing the GBD data, we examined the risk of smoking and second-hand smoke exposure and their related causes of death and disability in the 22 MENA countries. Smoking prevalence and disease burden data were analyzed with estimates reported as age-standardized rates. Tobacco abuse accounted for 14.5% of all deaths and 23.2% of deaths tied to known risk factors, with an age-standardized death rate of 110.8 per 100,000. Cardiovascular diseases were the primary cause of smoking-related deaths and DALYs, representing 53.4% of all deaths and 50.3% of all DALYs. This was followed by neoplasms (24.6% of all deaths and 20.3% of all DALYs), chronic respiratory diseases(12.4% of all deaths and 11.9% of all DALYs), and respiratory infections and tuberculosis(4% of all deaths and 3.4% of all DALYs). Second-hand smoking caused 20.5% of tobacco-related deaths and 21.5% of tobacco-related DALYs, disproportionately affecting younger individuals. An increasing disease burden was observed in Lebanon, Turkey, Syria, Tunisia, UAE, and Libya, and declining rates were most evident in Oman and Qatar. Our study emphasizes the impact of smoking on cardiovascular disease, the primary cause of smoking-related mortality and morbidity in the MENA region. Our findings highlight the urgent need for effective tobacco control policies and interventions.

Improving tobacco social contagion models using agent-based simulations on networks

Tobacco use is the leading cause of preventable deaths in developed countries. Many interventions and policies have been implemented to reduce the levels of smoking but these policies rarely rely on models that capture the full complexity of the phenomenon. For instance, one feature usually neglected is the long-term effect of social contagion, although empirical research shows that this is a key driver of both tobacco initiation and cessation. One reason why social contagion is often dismissed is that existing models of smoking dynamics tend to be based on ordinary differential equation (ODE), which are not fit to study the impact of network effects on smoking dynamics. These models are also not flexible enough to consider all the interactions between individuals that may lead to initiation or cessation. To address this issue, we develop an agent-based model (ABM) that captures the complexity of social contagion in smoking dynamics. We validate our model with real-world data on historical prevalence of tobacco use in the US and UK. Importantly, our ABM follows empirical evidence and allows for both initiation and cessation to be either spontaneous or a consequence of social contagion. Additionally, we explore in detail the effect of the underlying network topology on smoking dynamics. We achieve this by testing our ABM on six different networks, both synthetic and real-world, including a fully-connected network to mimic ODE models. Our results suggest that a fully-connected network is not well-suited to replicate real data, highlighting the need for network models of smoking dynamics. Moreover, we show that when a real network is not available, good alternatives are networks generated by the Lancichinetti–Fortunato–Radicchi and Erdős–Rényi algorithms. Finally, we argue that, in light of these results, our ABM can be used to better study the long-term effects of tobacco control policies.

Preemption in State Tobacco Minimum Legal Sales Age Laws in the US, 2022: A Policy Analysis of State Statutes and Case Laws.

Preemptive statutory language within tobacco minimum legal sales age (MLSA) laws has prohibited localities from enacting stricter laws than state statutes. With the recent uptake of state Tobacco 21 laws in the US, the current landscape of preempted MLSA laws is unknown. This study sought to update the status of preemption in MLSA laws enacted in US states between 2015-2022. A public health attorney reviewed state tobacco MLSA laws (n = 50) and state tobacco control codes, searching for language regarding preemption. When statutes were unclear, case law was reviewed by examining local ordinances that were invalidated by state court decisions. Overall, 40 states enacted Tobacco 21 laws, seven of which expanded or introduced preemption when they increased the MLSA; a total of 26 states (52%) included preemption. Six states (12%) retained 'savings clauses' included in the MLSA prior to Tobacco 21, and 18 states (36%) did not mention preemption. Based on the precedent set by state courts, eight of these 18 states may preempt localities from raising their MLSA. Historically, preemption has slowed the diffusion of best practices in tobacco control, and once implemented, the laws are difficult to repeal. The recent expansion of preemption could inhibit the evolution, development, and implementation of effective tobacco control policies.

An ecological study on MPOWER and smoking prevalence rate by Tobacco control law

Objectives: The Framework Convention on Tobacco Control (FCTC) is the first international convention in the public health field. This study examines whether countries have maximized the effectiveness of tobacco regulation by appropriately utilizing measures to reduce tobacco consumption and smoking rates. It studies the effectiveness of Tobacco control law policies in various countries. Methods: Using ecological and descriptive correlation, this study attempted to verify the correlation between the Tobacco control law, the measures that help countries reduce the demand for tobacco (MPOWER) and the smoking rate. Results: It was found that the Tobacco control law was related to lower smoking rates and higher levels of implementation of the MPOWER policy. The results showed that the performance of related MPOWER policies increased according to the category of the Tobacco control law. Conclusion: FCTC measures to reduce tobacco use are effective. Enacting and strengthening comprehensive Tobacco control laws is necessary for implementing more effective tobacco control policies.

Increase of unmotivated and hardened smokers in Hong Kong: a repeated cross-sectional trend analysis

ObjectivesTo examine the trends in the prevalence of hardening indicators and hardened smokers in Hong Kong, where the low smoking prevalence has plateaued in the recent decade.MethodsThis is an analysis...

Using the Past to Understand the Future of U.S. and Global Smoking Disparities: A Birth Cohort Perspective

Using the Past to Understand the Future of U.S. and Global Smoking Disparities: A Birth Cohort Perspective

Trends in Socio-economic Inequality in Smoking Among Middle-aged and Older Adults in China: Evidence From the 2011 and 2018 China Health and Retirement Longitudinal Study.

Socio-economic inequalities in smoking and related health problems are a public health concern worldwide. To support the development of effective tobacco control policies, this study examines trends in smoking rates according to socio-economic status (SES) in China. We analyzed data from repeated cross-sectional China Health and Retirement Longitudinal Study (CHARLS) on adults aged ≥45 years for the years 2011 and 2018, which involved 16 471 participants in 2011 and 19 367 in 2018. We then estimated the SES of individuals based on four types of wealth-related variables, namely, education, occupation, household characteristics, and durable consumer goods. Principal-component analysis was conducted to measure SES, and the Erreygers normalised concentration index (ECI) was used to calculate socio-economic inequality in current smoking by gender, age, and region. The overall ECI (95% confidence interval) for women was -0.042 (-0.054 to -0.031) and -0.038 (-0.047 to -0.029) for 2011 and 2018, respectively. The ECI (95% confidence interval) for men was -0.077 (-0.101 to -0.050) and -0.019 (-0.042 to 0.005) for 2011 and 2018, respectively. The inequality in smoking by SES for adults aged < 60 years in the Northeast region increased during 2011-2018, from -0.069 (-0.144 to 0.006) to -0.119 (-0.199 to -0.038) for women and from 0.009 (-0.115 to 0.132) to -0.164 (-0.296 to -0.032) for men. smoking inequality by socio-economic among adults aged ≥45 years declined in recent years in China. However, smoking inequality by SES increased in other population groups. Our research indicated that socio-economic inequality of current smoking among residents aged 45 years and older declined in 2018 when compared with 2011 numbers, particularly for men aged ≥ 60 years. Women in the Northeast region displayed more significant smoking inequality by SES than women in other regions did. During the study period, there was an increase in inequality in smoking by SES for adults aged < 60 years in the Northeast region. Thus, tobacco control policies and interventions should be targeted at high-risk subpopulations with lower SES, particularly in Northeast China.

Trends in Hospital Admissions for Chronic Obstructive Pulmonary Diseases After Comprehensive Tobacco Control Policies in Beijing, China.

Only a few studies have examined the effectiveness of tobacco control policies on respiratory conditions, and the results were less consistent. The 2015 Beijing tobacco control policy package incorporating all six components of MPOWER has been implemented since Jun 2015. The present study aimed to evaluate the impact of a comprehensive tobacco control policy package on hospital admissions for chronic obstructive pulmonary disease (COPD) in Beijing, China. An interrupted time-series study was conducted based on the hospital admission information for about 18 million residents, who were covered by the Beijing Medical Claim Data for Employees from January 2013 to June 2017. The average percentage change of COPD hospital admission rates and reductions in hospital admission numbers were estimated by segmented Poisson regression models. There were 54 040 COPD hospital admissions with a crude rate of 67.2 per 100 000 residents during the observational period. After the implementation of the policy package, the hospital admission rates of COPD were reduced by -14.7% (95%CI: -17.8%, -11.5%) immediately. The secular trend was slowed down by -3.0% (95% CI: -5.6%, -0.4%) annually. A total of 5 581 reductions in COPD hospital admissions were estimated during the 25 months post-law period, accounting for 17.5% (95% CI: 12.5%, 22.5%) of overall COPD hospital admissions. More reductions were shown in males and those aged over 65 years old. The results indicated significant protections against hospitalization of COPD after the 2015 Beijing comprehensive tobacco control policy package. The results provide support for public health benefits for respiratory conditions from WHO-recommended tobacco control measures. Only a few studies have examined the effectiveness of tobacco control policies on respiratory conditions, and the results were less consistent. Based on medical records for about 18 million residents, this study showed an association between comprehensive tobacco control policies and significant reductions of hospital admissions for chronic obstructive pulmonary disease. The results provide support for public health benefits for respiratory conditions from WHO-recommended tobacco control measures.

Methods of the 2020 (Wave 1) International Tobacco Control (ITC) Korea Survey.

This article presents methods used in the 2020 International TC Korea Wave 1 (KRA1) Survey. To date, three cohorts of Korean respondents have participated in the larger ITC Korea Project (cohort 1: 2005–2014, cohort 2: 2016, and cohort 3: 2020–present). The overall objectives of the ITC KRA1 Survey were to examine the use of cigarettes, heated tobacco products (HTPs), e-cigarettes (ECs); whether HTPs might help smokers quit; and the effectiveness of tobacco control policies, such as large graphic warnings, high cigarette taxes, and smoking bans in public places. The KRA1 Survey measures were identical or functionally similar to those of the ITC Japan Survey and, to a lesser extent, those of other ITC countries. Key measures assessed sociodemographic characteristics of respondents; the use of combustible cigarettes, e-cigarettes, and heated tobacco products; and measures assessing policies of the WHO Framework Convention on Tobacco Control, including price and tax (Article 6), smoke-free laws (Article 8), health warnings (Article 11), education, communication and public awareness (Article 12), advertising, promotion, and sponsorship restrictions (Article 13), and support for cessation (Article 14). Adult tobacco and/or nicotine users aged ≥19 years in South Korea were recruited by a commercial survey firm from its online panel. Overall, 4794 respondents completed the KRA1 Survey. The cooperation rate was 97.4% and the response rate was 15.2%. The cohort design permits assessment of transitions in products used among users in South Korea and evaluations of the impact of policies on tobacco and/or nicotine products used and transitions in use.

The First State Tobacco Flavor Ban: High School Tobacco Control Needs in a Changing Landscape.

Despite recent tobacco control efforts, adolescent vaping remains an epidemic in the United States. The purpose of our study was to understand high school student vaping behaviors using the perceptions of Massachusetts school personnel during the critical window from when the Massachusetts statewide flavor ban legislation was passed in November 2019 through the first year of the COVID-19 pandemic. High school personnel throughout Massachusetts were invited to complete a cross-sectional survey. Analysis of survey responses was conducted in R. A total of 162 respondents completed the survey representing 137 schools that draw enrollments from 216 (61%) of the 352 cities and towns in Massachusetts. The most popular products that respondents believed their students were using were JUULs (95.7%), other e-cigarettes (85.3%), and disposable vapes (79.6%). Following the flavor ban, the majority (90.7%) did not report an increase in combusted tobacco product use. All participants (100%) reported wanting more access to prevention and treatment resources. Our findings suggest that a comprehensive flavor ban may be an effective tobacco control policy that does not appear to promote student switching from vaping products to combusted tobacco products. These data also indicate that schools report needing additional resources to address the vaping epidemic.

Is Tobacco Marketing Overpowering Tobacco Control in India?

The tobacco industry has made a gradual move from developed countries to developing countries to expand its market. As part of this trend, tobacco companies in India invest a substantial amount of money in marketing activities. Although the government of India has gradually been increasing restrictions on marketing and sales of tobacco products, the creative and evolving marketing practices of tobacco companies have ensured that such measures have little effect. In this perspective paper, a critical evaluation of marketing practices used by the tobacco industry in India suggests that pro-tobacco marketing is a major hurdle towards bringing effective tobacco control policies and their successful implementation. It is demonstrated that the big tobacco companies in India backed by immense resources have been capable of countering the various legislative provisions for tobacco control in India through creative and manipulative marketing practices.

Chemical Components in Smokeless Tobacco Products and Impact on Health

Smokeless Tobacco [SLT], a non-combustible form of tobacco, is consumed by 350 million people in 133 countries across the globe. Worldwide, Smokeless Tobacco products vary greatly in their formulations and chemical composition. Understanding of toxic and carcinogenic constituent variations in such products can provide valuable insights for the development of effective tobacco control policies. Though the assessment of SLT products has been done earlier, the information is not available in an inclusive and handy format as entire profiling. Hence, there is a vital need to develop a one-stop information source providing comprehensive information on SLT products. PubMed and Google scholar databases were systematically searched from 1995 till April 2020 for observational studies on Smokeless Tobacco products and their chemical components. The included studies were evaluated and data were extracted and reviewed.A wide variation was noted in the association of various diseases and specific Smokeless Tobacco product constituents based on their nature and inherent toxicity. The majority of chewing tobacco products displayed a higher risk for users.This review emphasizes the significant positive association of Smokeless Tobacco product components with health hazards. Pathways estimates for smokeless tobacco-associated disease need further analysis. The profiling of Smokeless Tobacco products also requires multi-centric well-designed studies. Further, the information would be a guide for researchers interested in the components of SLT products.

Cost of premature mortality attributable to smoking in the Middle East and North Africa.

Tobacco smoking is a leading cause of premature mortality, incurring substantial economic costs. To estimate the rate and cost of premature mortality attributable to smoking in the 24 Middle East and North Africa (MENA) countries in 2015. Smoking attributable fractions were estimated. Twenty-four smoking-related diseases were included in the analysis. For each country, the total number of deaths by disease, age, and gender among individuals aged ≥ 15 years were derived from a World Health Organization database. Human capital approach was used in calculating cost of premature mortality. Smoking was responsible for 465 285 deaths in MENA countries, resulting in 7 122 706 years of potential life lost, or an average of 15.23 years lost per smoking-related death. Of the total 465 285 smoking-related deaths, 412 415 (88.6%) occurred in men, accounting for 37% of all deaths from the diseases considered in this analysis among men. The total mortality cost attributable to smoking was estimated at US$ 29.7 billion in 2015 (0.76% of MENA's gross domestic product). Turkey was the country most affected by the tobacco epidemic, representing 41% of smoking-related mortality cost in the whole region, followed by Saudi Arabia (8.76%) and Egypt (7.88%). Smoking is an important preventable cause of premature mortality in MENA countries. Substantial decline in smoking-attributable deaths and significant economic cost saving can be achieved in this region through more effective tobacco control policies.

Kretek Cigarettes and Particulate Matter Emissions—An Aerosol Spectrometric Study on Typical Indonesian Brands Flavored With Cloves

Abstract Introduction In Indonesia, smoking is widespread. The same applies to second-hand smoke (SHS) exposure. More than 90% of Indonesian smokers smoke clove cigarettes, so-called Kreteks. They often contain more tar and nicotine than conventional cigarettes, but little is known about particulate matter (PM) emissions. In smokers’ homes, SHS is the main source of PM that is hazardous to health. This study presents data of PM emissions from Kreteks. Methods SHS was generated in a closed 2.88 m³ measuring chamber. PM fractions (PM10, PM2.5, PM1) of three popular Kretek brands (two king-sized and one slim-sized) in comparison to conventional cigarettes and a reference cigarette were measured by laser aerosol spectroscopy in real-time. Results The king-sized Kreteks reached PM10 and PM2.5 mean concentrations of up to about 3000 µg/m³, and PM1 mean concentrations of up to about 2700 µg/m³. Consequently, these Kreteks emitted up to about 100% more PM10 and PM2.5, respectively 84% more PM1 than the reference cigarette, and up to about 260% more PM10 and PM2.5, respectively 234% more PM1 than the other investigated cigarettes. Conclusions PM emissions from Kreteks can be very high. The Indonesian public should be informed and warned about it, considering the high prevalence of smoking and SHS exposure, in particular. The Indonesian tobacco control regulation is limited, and it is overdue to start with a serious and effective tobacco control policy. PM declaration to government authorities could be useful in smoking prevention and tobacco control. Implications Research data are limited for Kretek cigarettes, including data on particulate matter (PM). The clove buds in Kretek cigarettes are for flavoring the smoke and shall soften the smoke feeling. That makes them very popular in Indonesia, in particular. The declaration of PM data of Kreteks and other tobacco products can play a key role in a more effective tobacco policy to reduce consumption of tobacco products, not only in Indonesia. To provide data on PM emissions, this study ascertained PM amounts in passive smoke from Indonesian Kreteks.