Cigarette Packs Research Articles

Left ventricular late diastolic strain rate predicts cardiovascular mortality in patients with heart failure with reduced ejection fraction

Abstract Background Left ventricular (LV) strain rate measures provide detailed information regarding LV contraction and filling pressures. These include global systolic strain rate (GSRs), early and late diastolic strain rates (GSRe and GSRa), and ratio of transmitral early filling velocity to GSRe (E/GSRe). Purpose To investigate the prognostic value of strain rate measures with regard to cardiovascular mortality in patients with heart failure with reduced ejection fraction (HFrEF). Methods The study population was retrospectively included from a HF clinic and consisted of patients with LV ejection fraction (LVEF) ≤45%. Echocardiography was obtained within 1 year of referral. The study endpoint was cardiovascular mortality, which was analysed using univariable and adjusted Cox proportional hazards models. Incremental prognostic information was assessed using Harrell’s C-index and continuous net reclassification improvement (NRI). Cubic spline analysis was used to dichotomise variables at a hazard ratio (HR) of 1 for better interpretability. Results The final study population consisted of 1160 patients with HFrEF (mean age 68±11.8 years, 72.7% male, LV ejection fraction (LVEF) 28.6±9.9%). During follow-up (median 10.1 years, IQR: 4.7-13.0), 333 (28.7%) met the outcome. Subjects who met the outcome generally had higher age and prevalence of male sex, a higher burden of comorbidities, and more severely impaired conventional echocardiographic parameters. All four strain rate measures were significantly associated with cardiovascular mortality (GSRs: HR 16.88 95% CI [8.42, 33.84] per 1 s-1 increase, GSRe: HR 0.29 [0.18, 0.47] per 1 s-1 increase, E/GSRe ratio: HR 1.31 [1.22, 1.41] per 1 unit increase, GSRa: HR 0.15 95% CI [0.23, 0.65] per 1 s-1 increase, p<0.0001 for all). However, only GSRa remained an independent predictor in multivariable Cox regression after adjustment for clinical risk factors including sex, age, mean arterial pressure, heart rate, body mass index, cigarette pack years, diabetes mellitus, total cholesterol, ischemic heart disease, and echocardiographic factors including LVEF, global longitudinal strain, tricuspid annular plane systolic excursion, LV mass index, LV internal diameter index, E/e’ ratio and left atrial volume index (HR 0.39 [0.23,0.65], p=0.0003). Furthermore, GSRa provided incremental prognostic information to a model containing all aforementioned parameters (Harrell’s C-index 0.789 vs. 0.792 and continuous NRI 0.158). GSRa was dichotomised at 0.5 s-1, and a Kaplan-Meier curve stratified according to this was plotted (log rank p<0.0001)(Figure 2). Conclusion GSRa is an independent predictor of cardiovascular mortality in patients with HFrEF after multivariable adjustment. GSRa provides incremental prognostic value over conventional echocardiographic measures in risk stratification of HFrEF patients. Our results suggest an increased risk of cardiovascular mortality associated with a GSRa below 0.5 s-1.Figure 1:Spline of HR according to GSRaFigure 2:Kaplan-Meier curve

The impact of specific health warning messages on Chinese young people's perception of smoking risks and quitting intentions.

Although a substantial body of research has analyzed the effectiveness of cigarette package warning labels in tobacco control, the very general health warnings messages (HWMs) on cigarette packaging in China have shown limited effectiveness in deterring youth from smoking. Therefore, this study investigates the impact of specific and more detailed warning text messages on Chinese young people's risk perception of smoking and their intention to quit. We employed a randomized survey experiment to examine the impact of specific text-based warning labels on Chinese young people's risk perception of smoking and intention to quit. The total effective sample size was 1064 participants. The subjects were divided into three groups: the first group served as the control group, which was shown the existing cigarette package warning labels; the second group was shown cigarette package warning labels related to cardiovascular, digestive, and respiratory diseases; and the third group was shown cigarette package warning labels related to sexual dysfunction. The respiratory disease-related warnings significantly increased young people's awareness of smoking-related respiratory risks (p<0.01). The impact of warning labels for the three common diseases on enhancing young people's overall risk perception of smoking (p<0.05) and their intention to quit exhibited only weak statistical significance (p<0.05). In contrast, warning labels related to sexual dysfunction significantly increased young people's risk perception of smoking (p<0.001) and their intention to quit (p<0.001), with a much higher level of statistical significance compared to those related to the other three common diseases. Detailed descriptions of the risks associated with all four diseases were positively correlated with awareness of smoking-related harm and the intention to quit. However, warnings related to sexual dysfunction had a greater level of statistical significance compared to those related to the other three common diseases. This stronger significance may be attributed to young people's heightened concern about sexual dysfunction.

How smokers perceive pictorial and non-pictorial health warnings on cigarette packages: An online survey

Objectives This study aimed to evaluate Japanese smokers' perceptions of health warnings on tobacco packaging by comparing text-only and pictorial warnings.Methods Data were sourced from the Japan Society and New Tobacco Internet Survey (JASTIS), an online, self-reported study conducted in February and March 2020. Participants included current smokers aged 15-74 years in Japan (n＝2,372). Perceptions regarding five packaging samples were assessed: the old package (text-only warning covering 30% of the pack's front and back before April 2020), the current package (text-only warning covering 50% of the pack's front and back), and three packages with pictorial warnings covering 50% of the front and back. Respondents were asked four questions on a 5-point Likert scale regarding the effectiveness of these warnings in terms of discouraging young people from starting to smoke, encouraging them to quit, communicating the dangers of smoking, and comfort level with the warnings. A t-test was conducted to compare each pair of packages.Results There were no significant differences observed between the "text only 30%" and "text only 50%" packages in terms of preventing young individuals from starting to smoke, encouraging quitting, or communicating the dangers of smoking (P＝0.740-0.987). Conversely, packages with pictorial warnings were perceived as more effective than text-only packages (P＜0.01) in all aspects. A significant difference was observed in the respondents' perceptions of comfort levels with the packages, with the pictorial ones deemed more uncomfortable (P＜0.01).Conclusion The findings indicated that pictorial health warnings are significantly associated with increased awareness of smoking risks, motivation to quit smoking, and prevention of smoking initiation among young people. Accordingly, Japan should consider adopting pictorial health warnings in accordance with the Framework Convention on Tobacco Control.

Harm to myself or others? A qualitative study of the preferences of people who smoke for messages to be included in cigarette pack inserts.

Tobacco package inserts [TPIs] are a novel channel to transmit smoking cessation messages. Research has shown associations between inserts, intentions to quit and increased self-efficacy. In Israel, TPIs have been legislated, but not yet implemented. This study aimed to learn what kind of messages would appeal to people who smoke, for the purpose of developing effective TPIs. Semi-structured interviews with 25 people who smoke or formerly smoked, aged 18-67. An inductive and deductive thematic analysis was conducted to enable a dynamic process coding and identifying themes and categories across interviews. Two main themes identified were: harms of smoking and motivators for quitting. Many participants were averse to information about the harms of smoking but interested in specific information about the harm of smoking to others, particularly children, on comparative risks of different tobacco/nicotine products, and about how to address the challenge of addiction. There was a preference for motivational messages encouraging quitting, including how the body recovers, personal quit stories, practical quit tips, and information on cessation services. Adult who smoke were receptive to the idea of TPI, but considered some types of information superfluous. It is important to emphasize harm to others, provide information on quit services, and deliver information that is reliable, specific, and evidence-based regarding quitting, so that it can be encouraging, useful, and practical. The merits of providing information to people who smoke on relative risks of different nicotine and tobacco products should also be considered. The findings provide a basis for developing TPI content. A large proportion of adults who smoke are interested in quitting. Pack inserts with positive motivating messages, quitline details, and novel information about risks to people who smoke and particularly to others, should be developed and tested, and subsequently distributed nationally to reach all those who open a cigarette package.

Delayed effects of cigarette graphic warning labels on smoking behavior.

Graphic warning labels (GWLs) are widely employed to communicate smoking-related health risks; however, their implementation in the US has been held back by concerns about their efficacy. Most GWLs elicit a high level of emotional reaction (ER). The extent to which ER contributes to GWLs efficacy in improving smoking outcomes is a subject of debate. Our recent study showed poorer efficacy of the high-ER GWLs versus the low-ER ones during a month-long naturalistic exposure. Whether GWL effects persist after discontinuing the exposure remains unclear. We conducted a secondary analysis to investigate the delayed effects of GWLs on smoking severity in adult smokers. The number of cigarettes smoked per day (CPD) was measured immediately as well as 4 weeks after the end of a month-long exposure to high-ER versus low-ER GWLs. Participants indicated their subjective feeling of being relieved from having to see the GWLs. We found a significant reduction in CPD from the immediate to the 4-week post-exposure timepoint. There was no difference in CPD reduction between the high-ER and low-ER groups.Subjective sense of relief from GWL exposure was associated with greater CPD reduction in the high-ER group, but not the low-ER group. Our study suggests lasting impact of GWLs on smoking behavior. The findings may be particularly important to high-arousal GWLs, which appear less effective in reducing smoking during active exposure. Whether GWLs that evoke higher ER are more effective remains inconclusive. We recently showed that high-ER GWLs are less effective than low-ER ones in reducing smoking during continuous exposure. Here, we found evidence of delayed GWL effects such that smoking decreased from immediately to four weeks after the end of GWL exposure. Feeling of relief from GWL exposure was associated greater smoking reduction in the high-ER group. We suggest that continuously exposing smokers to high-ER GWLs that have been well remembered may be unnecessary and counterproductive.

Opportunities for plain packaging of tobacco products in the Philippines: results of a nationwide online survey.

This study aimed to contribute to local research evidence to promote the implementation of plain packaging of tobacco products in the Philippines. The study aimed to assess Filipinos' perception of the effectiveness of plain packaging and their readiness by assessing the potential impact of plain packaging. We conducted a nationwide geographically representative online panel survey with a sample size of 2,000 Filipinos. The survey recruited respondents 18-65 years old and residing in the Philippines, with 500 respondents each from the National Capital Region, Luzon, Visayas, and Mindanao. We showed respondents six different mock-ups of cigarette packs in plain packaging, with two sizes of graphic health warnings (50 and 75%) and three plain packaging colors (black, white, and Pantone 448C). Using five-point Likert scales, participants rated their agreement with 18 items assessing readiness and rationales for plain packaging and 54 items related to pack design (9 items for 6 pack designs). The study showed that Filipinos recognize the value of adopting plain packaging with larger graphic health warning labels on tobacco products in the Philippines. Both non-smokers and smokers agreed that plain packaging has the potential to reduce the attractiveness and appeal of packs, prevent advertisement and promotion of tobacco products, reduce the ability of tobacco products to mislead consumers, increase the noticeability and effectiveness of the pictorial health warnings, increase recall of the pictorial health warnings, affect consumer perceptions of the attractiveness of the tobacco products and their relative safety, reduce youth experimentation with the use of tobacco products, prevent the use of tobacco brand variants as a promotional tool, prevent branding targeted toward youth, promote quitting among current users, and to more clearly inform consumers about the harmful effects of tobacco use. We recommend that policymakers pursue plain packaging as legislation or as part of a reform of the Philippines' graphic health warnings law. The law should target tobacco products sold in the Philippines.

Association Between Cigarette and Bidi Purchase Behavior (Loose vs Pack) and Health Warning Label Exposure: Findings From the Tobacco Control Policy India Survey and In-Depth Interviews With People Who Smoke.

The sale of loose cigarettes or bidis can undermine the purpose of requiring health warning labels (HWLs) on cigarette packs and bidi bundles by diminishing their visibility and legibility. This mixed-methods study aims to examine the association between purchase behavior (loose vs pack or bundle), HWL exposure, and responses to HWLs among Indian adults who smoke. Data were analyzed from the 2018-2019 India Tobacco Control Policy Survey and from 28 in-depth interviews conducted with Indian adults who smoked in 2022. The Tobacco Control Policy Survey sample included tobacco users who bought cigarettes (n=643) or bidis (n=730), either loose or in packs or bundles at their last purchase. Ordinal regression models were fit separately for cigarettes and bidis, whereby HWL variables (noticing HWLs, reading and looking closely at HWLs, forgoing a cigarette or bidi because of HWLs, thinking about health risks of smoking, and thinking about quitting smoking cigarettes or bidis because of HWLs) were regressed on last purchase (loose vs packs or bundles). In-depth interviews with participants from Delhi and Mumbai who purchased loose cigarettes in the last month were conducted, and thematic analysis was used to analyze the interview data. Survey findings indicated that about 74.3% (478/643) of cigarette users and 11.8% (86/730) of bidi users reported having bought loose sticks at their last purchase. Those who purchased loose cigarettes (vs packs) noticed HWLs less often (estimate -0.830, 95% CI -1.197 to -0.463, P<.001), whereas those who purchased loose bidis (vs bundles) read and looked closely at HWLs (estimate 0.646, 95% CI 0.013-1.279, P=.046), thought about the harms of bidi smoking (estimate 1.200, 95% CI 0.597-1.802, P<.001), and thought about quitting bidi smoking (estimate 0.871, 95% CI 0.282-1.461, P=.004) more often. Interview findings indicated lower exposure to HWLs among those who purchased loose cigarettes, primarily due to vendors distributing loose cigarettes without showing the original cigarette pack, storing them in separate containers, and consumers' preference for foreign-made cigarette brands, which often lack HWLs. While participants were generally aware of the contents of HWLs, many deliberately avoided them when purchasing loose cigarettes. In addition, they believed that loose cigarette purchases reduced the HWLs' potential to deliver consistent reminders about the harmful effects of cigarette smoking due to reduced exposure, an effect more common among those who purchased packs. Participants also noted that vendors, especially small ones, did not display statutory health warnings at their point of sale, further limiting exposure to warning messages. Survey and interview findings indicated that those who purchased loose cigarettes noticed HWLs less often. Loose purchases likely decrease the frequency of exposure to HWLs' reminders about the harmful effects of smoking, potentially reducing the effectiveness of HWLs.

Exploring Implicit and Explicit Affective Responses to Graphic Health Warnings on Cigarette Packages in Colombia

Graphic health warnings (GHWs) are regarded a highly cost-effective public policy to communicate the health risks involved in smoking, mainly when they trigger negative emotional reactions. GHWs promote intentions to quit among smokers and prevent smoking initiation among non-smokers. In three experiments, we study how smokers and nonsmokers differ in implicit and explicit measures of emotional reactions towards GHWs. Experiment 1 used the Self-Assessment Manikin to measure explicit emotional (arousal and valence) ratings for six warnings published in tobacco products. Experiment 2 was similar to Experiment 1 but smokers and nonsmokers rated a new set of 36 GHWs not yet published. Experiment 3 used an implicit task, the Affect Misattribution Procedure, to evaluate and compare the affective responses to GHWs provided by smokers and non-smokers. Experiments 1 and 2 showed that smokers explicitly reported weaker negative emotional reactions to both familiar and unfamiliar GHWs compared to nonsmokers. Experiment 3 showed similar levels of negative implicit emotional responses among smokers and nonsmokers. Our data suggest that the decreased affective response involves high-order cognitive elaboration and evaluations of the messages conveyed by GHW, while early negative emotions triggered by the graphic component of the warnings similarly affect smokers and non-smokers. We propose that implicit measures may serve as additional and inexpensive tools for dissociating explicit biased affective responses of smokers towards GHWs from automatic emotional responses. In particular, the affect misattribution procedure may help to design warnings that communicate the risks of smoking but prevent adverse outcomes such as cognitive dissonance.

Extent of illicit cigarette sales in Nepal: findings from a retail survey

IntroductionIncreasing the tax on cigarettes is widely considered the most effective method to reduce its consumption. However, Nepal has a low cigarette tax as policymakers in Nepal are concerned about...

Response of legal and illegal cigarette prices to a tax increase in Ethiopia

BackgroundIn 2020, Ethiopia passed a landmark tax proclamation implementing an evidence-based mixed excise system aimed at curbing tobacco use. This study evaluates the impact of the tax increase of more...

Impact of Pictorial Health Warnings on Cigarette Packs among Current Smokers of Sub-Metropolitan City of Nepal: A Descriptive Cross-sectional Study

Introduction: Pictorial health warning on cigarette packs is one of the strategies undertaken by Nepal Government as per the directive of World Health Organization Framework Convention on Tobacco Control to control smoking. It has been more than a decade since the introduction of pictorial health warnings on cigarette packs in Nepal. The objective of this study was to assess the impact of the pictorial warnings among current smokers of Dharan, Nepal.Methods: A descriptive cross-sectional study was conducted among current smokers visiting local shops located near ward offices of Dharan after obtaining ethical approval from Institutional Review Committee (Reference number: 204/080/01 -IRC). A structured and validated Nepali questionnaire was used to interview the smokers about the impact of the pictorial warnings based on their noticeability, behavioural and cognitive responses. Statistical analysis was done using Statistical Package for Social Sciences (SPSS) version 20.0. The responses of the participants were tabulated in frequencies and percentages.Results: The pictorial warnings were noticed by 277 (98.93%) participants in past one month out of which 11 (3.93%) smokers had always read or looked closely at them. Smoking less frequently was the behaviour change reported by 70 (25%) participants and smoking less around others was reported by and 56 (20%) participants. In total, 189 (67.50%) smokers had thought about the harms of smoking and 160 (57.14%) had intention to quit smoking due to the pictorial warnings.Conclusions: The pictorial health warnings were not so effective in bringing about changes in smoking behaviour of smokers.

Contingent Effects of E-Cigarette Warning Label Messages on Cognitive Elaboration and Fear Among U.S. Youth Ages 14-17 by Vaping Experience and Peer Vaping Behavior.

The U.S. Food and Drug Administration (FDA) currently requires a warning about the addictive nature of nicotine to be placed on electronic cigarette advertisements and packaging. To consider the value of additional warning messages on public health outcomes, this study examines the additive effect of new warnings that are based on recent claims from U.S. federal authorities. We conducted a secondary analysis of recent data from 1,202 U.S. youth ages 14-17 to test the impact of exposure to additional warnings placed on advertisements for vaping products on cognitive elaboration, fear, and willingness to vape and smoke. This investigation also looked closely at effects on youth who may have increased risk of future vaping due to prior vaping experiences or having friends who vape. Exposure to the alternative warnings did not amplify cognitive elaboration compared to the current FDA warning alone, but it did increase fear. Youth elaboration on both the benefits and risks of vaping was associated with willingness to both vape and smoke, but fear was not associated with either outcome. The effects of warning label exposure and cognitive elaboration varied by prior vaping experience and having at least one friend who vapes. We conclude by discussing the implications of this contingent pattern of effect and association.

Association between current cigarette prices and cessation behaviors among male adult smokers: findings from 2018 to 2020 ITC Vietnam surveys

BackgroundThis study evaluated the impact of the tax increase in January 2019 on changes in intention to quit and the effect of cigarette prices on quit attempts and successful quitting among male cigarette smokers in Vietnam.MethodsData were derived from the ITC project in Vietnam, which included 1585 adult smokers at baseline (Wave 1, Aug-Oct 2018) followed up to waves 2 (Sep-Nov 2019) and 3 (Sep-Dec 2020). Generalized estimating equations regression was performed to estimate changes in the intention to quit. Multiple logistic regression analysis was used to evaluate the cigarette price of a cigarette pack in relation to quit attempts and successful quitting.ResultsThe increase in cigarette tax in 2019 did not significantly increase the likelihood of the intention to quit. After the tax increase, 63.6% of participants who smoked made a quit attempt, and 27.6% successfully quit smoking in the follow-up waves. However, the price of a cigarette pack was not significantly associated with quit attempts and successful quitting. The study did not observe a significant impact of cigarette prices on quit attempts and successful quitting in all subgroups of household income. Factors associated with quit attempts included the number of cigarettes smoked and the intention to quit, while those associated with successful quitting included age, dual use of cigarettes and other tobacco products, and the intention to quit.ConclusionCurrent cigarette prices were not associated with cessation behaviors even within the lowest household income group. Therefore, a sharp rise in cigarette tax is required to incentivize smokers to quit smoking.

Greenwashed Cigarette Ad Text and Imagery Produce Inaccurate Harm, Addictiveness, and Nicotine Content Perceptions: Results from a Randomized Online Experiment.

The tobacco industry has a long history of circumventing regulations to present their products, inaccurately, as less harmful. Greenwashing (portraying a product as natural/eco-friendly) is increasingly used by tobacco companies and may mislead consumers to believe that certain cigarettes are less harmful than others. This study assesses the effect of some common greenwashing tactics on consumer product perceptions. We conducted an online experiment with 1,504 participants ages 18-29, randomized to view a cigarette ad manipulated for presence/absence of a combination of 4 different greenwashing techniques: greenwashed ad text, greenwashed ad imagery, recycled paper ad background, and image of greenwashed cigarette pack. Participants rated perceived absolute harm, relative harm to other cigarettes, absolute addictiveness, relative addictiveness, and relative nicotine content. Participants who viewed ads containing greenwashed text were more likely to have inaccurate perceptions about absolute harm (AOR=1.72), relative harm (AOR=3.92), relative addictiveness (AOR=2.93) and nicotine content (AOR=2.08). Participants who viewed ads containing greenwashed imagery were more likely to have inaccurate perceptions of relative harm (AOR=1.55), absolute addictiveness (AOR=1.72), relative addictiveness (AOR=1.60) and nicotine content (AOR=1.48). Forty-two percent of those who saw an ad with all greenwashed features believed the product was less harmful than other cigarettes vs. 2% of those who saw an ad without greenwashed features. We found greenwashed text and imagery produced inaccurate risk perceptions. More active U.S. Food & Drug Administration (FDA) enforcement against such greenwashing and new FDA rulemaking to prohibit unnecessary imagery in tobacco advertising and establish plain packaging requirements would help protect consumers and public health. These findings provide evidence that greenwashing tactics used by the tobacco industry increase inaccurate product risk perceptions. These tactics could be a way for the industry to make implicit modified risk claims, despite applicable U.S. Family Smoking Prevention and Tobacco Control Act prohibitions. Findings from this study support the need for prohibitions on these tactics, and the potential for such prohibitions to help protect public health.

Mobile Phone–Based Personalized and Interactive Augmented Reality Pictorial Health Warnings for Enhancing a Brief Advice Model for Smoking Cessation: Pilot Randomized Controlled Trial

Background Augmented reality (AR) is a novel modality for promoting smoking cessation (SC). AR-visualized adverse consequences for education and smoking prevention have only been evaluated in nonsmokers in previous studies. Objective To assess the feasibility and preliminary effectiveness for SC of AR pictorial health warnings (PHWs) on cigarette packs. Methods We conducted a pilot randomized controlled trial in adult daily smokers in communities in Hong Kong. All participants received AWARD (ask, warn, advise, referral, do-it-again) model–guided SC advice, a warning leaflet, and referral to SC services at baseline. Interactive, chat-based SC support comprising regular messages and real-time support was provided to all participants via instant messaging apps (eg, WhatsApp) for 3 months after randomization. Participants in the intervention group additionally received 6 links to the AR PHWs showing the worsening health status of various organs caused by smoking. The level of the AR PHWs was adjustable to smoking behaviors (ie, smoking duration or daily cigarette consumption) to increase interaction. Participants could swipe, drag, or rotate the 3D PHWs to reinforce their impression of the health consequences of smoking. The primary outcome was self-reported past 7-day point-prevalence abstinence (PPA) at 3 months. The acceptability of the AR intervention was assessed by the proportion of participants who had viewed AR PHWs during the intervention. Participants who viewed AR PHWs further evaluated the perceived effect of the AR PHWs on a scale of 0 (not helpful at all) to 10 (very helpful). Intention to treat was used, and the risk ratio (RR) of the intervention effect was estimated by Poisson regression. Results From April to November 2021, 80 participants were recruited and randomly assigned to intervention (n=40) and control (n=40) groups. Most participants were male (66/80, 83%) and planned to quit beyond 30 days or were undecided (65/80, 81%). The intervention group had a higher but nonsignificant 7-day PPA (7/40, 18% vs 5/40, 13%; RR 1.40, 95% CI 0.48-4.07) and quit attempts (15/40, 38% vs 11/40, 28%; RR 1.36, 95% CI 0.71-2.60) at 3 months than the control group. In the intervention group, 17 of 40 (43%) participants viewed the AR PHWs. The AR PHWs had modest effects on knowledge of the adverse consequences of smoking on personal health (mean score 3.94, SD 3.52), reducing the frequency of buying cigarettes (mean score 3.29, SD 3.08), increasing the perceived importance of quitting (mean score 3.88, SD 3.50), and making the PHWs more disgusting (mean score 3.41, SD 3.08) and horrible (mean score 3.38, SD 3.05). The 3-month self-reported 7-day PPA was higher in those who ever (vs never) viewed the AR PHWs (5/17, 29% vs 2/23, 9%). Conclusions The mobile-based interactive AR PHWs were feasible, and the effectiveness on smoking abstinence warrants further testing. Trial Registration ClinicalTrials.gov NCT04830072; https://clinicaltrials.gov/study/NCT04830072

Determining the Perception Created by Health Warnings on Plain Cigarette Packs with Visual Attention: Eye-Tracking Technique

This study examines the effects of the plain packaging policy implemented in Türkiye, analyzing how different demographic groups perceive health warnings on cigarette packaging. Employing advanced eye-tracking technology, the research identifies distinct visual attention patterns between smokers and non-smokers when exposed to ‘Anxiety’ and ‘Disturbing’ visual cues. Detailed metrics, including fixation counts, durations, and saccade amplitudes, are used to measure and analyze the responses of these groups to the health warnings. The findings reveal that non-smokers significantly focus more on textual warnings, suggesting that text-based elements are more impactful for this group. Conversely, smokers tend to either avoid or become desensitized to disturbing imagery. Additionally, the study finds that female participants exhibit higher saccade amplitudes compared to males, indicating a more thorough examination of the packaging. This gender-specific difference is especially pronounced in their responses to ‘Disturbing’ images, where females show greater engagement, pointing to an increased sensitivity to such stimuli. These insights not only advance our understanding of effective health communication but also underscore the importance of designing public health interventions that cater to the unique responses of different demographic groups. This research significantly enriches the field of tobacco control, providing evidence-based strategies to enhance the effectiveness of visual warnings, thereby supporting targeted smoking cessation efforts.

Compliance with tobacco advertising and promotion laws at points-of-sale in Ethiopia: an observational study in 10 cities

BackgroundEthiopia enacted a comprehensive tobacco control law in 2019, which bans tobacco advertising and promotion activities. However, compliance with these laws at points-of-sale (PoS) has not been studied, resulting in a lack of research evidence on how the regulations are implemented. The purpose of the study was to assess compliance with tobacco advertising and promotion laws at PoS in 10 cities in Ethiopia.MethodsMulti-stage cluster sampling was used to select 1468 PoS (supermarkets, minimarkets, merchandise stores, regular shops, permanent kiosks, khat shops, street vendors, and food and drink wholesalers). Data were collected using standardized observational checklists. Tobacco advertising and promotion indicators were used to compute indoor and outdoor compliance. Poisson regression models with log link function and robust variance were used to assess factors associated with open display of cigarette packages and indoor non-compliance.ResultsThe average indoor compliance rate was 92.9% (95% CI:92.3–93.5). Supermarkets had the highest compliance (99.7%), while permanent kiosks showed the lowest compliance (89.8%). The highest average indoor compliance was observed at PoS in Addis Ababa (98.0%). About 60% of PoS were fully compliant in indoors. Indoor open display of cigarette packages was prevalent (32.5%, 95% CI:30.0-35.1). The average outdoor compliance was 99.6% (95% CI:99.5–99.7). Outdoor full compliance was 96.5%. Open display of cigarettes was significantly higher in permanent kiosks (adjusted prevalence ratio (adjPR) 6.73; 95% CI: 3.96–11.42), regular shops (adjPR 5.16; 95% CI: 3.05–8.75), and khat shops (adjPR 2.06; 95% CI: 1.11–3.83), while indoor non-compliance was significantly higher in these same types of PoS.ConclusionsWhile outdoor compliance rates were relatively high, the lower indoor compliance rates particularly due to the high prevalence of open cigarette package displays indicates a major area for improvement in enforcing anti-tobacco advertising and promotion laws.

Regular Physical Activity: A Key to Healthy Living and an Indispensable Pillar of Lifestyle Medicine

Individuals who choose to be inactive accept the same increased risk of heart disease as individuals who smoke a pack of cigarettes a day! Unfortunately, between 11%-15% of the adult population still smoke a pack of cigarettes a day, whereas, 60%-80% of adults are either not adequately active or completely inactive. Thus, inactivity carries the same risk as smoking a pack of cigarettes per day and is between 4-5 times more prevalent!

The Extent of Illicit Cigarette Sales in Five Rural Districts of Pakistan: A Cross-sectional Study.

The Illicit Tobacco Trade (ITT) subverts tobacco control efforts. Cigarette packs sold without legal health warnings undermine efforts to warn the public about the dangers of tobacco. Furthermore, cigarettes sold below minimum retail prices are indicative of tax evasion leading to revenue loss and budgetary deficits in high tobacco-burden economies. The extent of the ITT in rural areas of such countries might differ from urban. We estimated the extent of illicit cigarette sales in selected rural areas of Pakistan. We analyzed cigarette packs collected from 85 villages in Pakistan as part of a cross-sectional consumer survey of 2550 rural households. We classified cigarette packs as noncompliant if these were missing: A text health warning, pictorial health warning (PHW), underage sale prohibition warning, retail price, or manufacturer details. To measure the extent of tax evasion, we estimated the proportion of packs purchased below the legal minimum retail price. Only 35% (429/1228) of rural smokers were able to show their cigarette packs. Out of these, 89% (382/429) of packs were noncompliant with the cigarette packaging and labeling laws. In rural areas, 83% (357/429) of packs did not have PHW and 33.8% (145/429) did not have printed retail prices. Among all packs, 41% (177/429) were purchased below the minimum retail price of 63 Pakistani Rupees and hence highly likely to have evaded taxes. We found a very high previously unreported proportion of noncompliant cigarette packs in selected rural areas of Pakistan indicating weaker implementation of tobacco control laws in rural areas. This paper presents previously unreported estimates of the share of illicit cigarette sales in rural areas of Pakistan. Most packs (89%) in our sample were noncompliant with the packaging and labeling regulations and a significant proportion (41%) were purchased below the minimum price. The extent of illicit tobacco was found to be far greater in rural than in urban areas of Pakistan. Taking advantage of poor law enforcement, the tobacco industry may be complicit in flooding the rural markets with illegal and cheap cigarettes. Given this disparity, law enforcement authorities must focus on rural areas.

The Relationship between Promotional Media on Cigarette Packaging and the Level of Susceptibility and Seriousness that Students Feel about Quitting Smoking in State High Schools of the Same Level in the City of Kendari

Introduction: The inclusion of advertisements warning of the dangers of smoking on cigarette packaging raises various views among teenagers, especially among students, who are easily influenced by something new, unique and interesting. Most Indonesian student smokers already have a smoking habit, with 33.9% being male and 2.5% female. This study aims to analyze the relationship between Promotional Media on Cigarette Packaging and the Level of Susceptibility and Seriousness that students feel about quitting smoking in State High Schools of the same level in Kendari City. Method: This research uses a quantitative research design with a cross-sectional research design. The population is all students who smoke in Kendari City High Schools, totaling 104 people. The number of samples using the Lameshow sample formula is 60 people and the sampling technique uses stratified random sampling. Result: This research shows that promotional media on cigarette packaging is related to the vulnerability and seriousness felt by students in quitting smoking in State High Schools of the same level in Kendari City. Conclusion: The government needs to change the promotional media on cigarette packaging, by changing the size of the image to 50% of the width of the front and back of the cigarette pack, accompanied by larger warning writing.