Tobacco Control Advocates Research Articles

Do-it-yourself flavored capsule cigarettes: Exploiting potential regulatory loopholes?

Capsule cigarettes allow users to crush liquid-filled capsules to release flavors into cigarettes' filters. New devices are emerging across the globe that allow people who smoke to circumvent tobacco flavor restrictions via injectable capsules. This study examined TikTok videos marketing flavored capsule injector devices. TikTok videos (n = 832) posted worldwide between July 6, 2021, and December 28, 2023, that used hashtags #injectorflavor, #flavourclickball, #flavorball, and #injectorballcigarette were collected using a TikTok application programing interface. A codebook was developed using a systematic iterative approach, identifying six codes: flavor capsules, promotes flavors (i.e., fruit, mint or menthol flavors, non-alcoholic drinks, alcoholic drinks), demonstrates how to use or refill large injector devices, demonstrates how to use small convenient devices, includes music (any or English-language). Two independent coders annotated all videos. Overall, 88.3% (n=735) of the videos displayed flavor capsules and had been viewed more than 72 million times. Half (51.6%) of the videos demonstrated how to use large box-shaped devices to inject capsules into the filter of a cigarette, and 15.0% of the videos showed how to do this with smaller, more convenient devices. Flavors including fruit (35.5%), menthol/mint (27.8%), non-alcoholic drinks (21.9%), and alcoholic drinks (11.6%) were used to promote these capsules. Most videos (85.6%) were uploaded by sellers on "TikTok shop." TikTok accounts are promoting injectable capsule devices that circumvent flavored tobacco sales restrictions. Policy makers, tobacco control advocates, and public health practitioners should be aware of such marketing to inform regulation and develop prevention strategies. Our findings identified an emerging product that can encourage circumvention of flavor restriction policies. Regulators, policy makers, public health practitioners, researchers, and advocates should be aware of such products to inform regulation and develop prevention strategies. Given the potential for these products to reduce the intended effects of flavored tobacco sales restrictions, policy makers must be poised to address materials that consumers use to create their own flavored tobacco products, including flavor capsules designed to be inserted into cigarettes.

Tobacco companies, corporate social responsibility and the use of third-party awards: a framing analysis

ObjectiveCorporate social responsibility activities, such as third-party awards, provide an opportunity for tobacco companies (TCs) to promote themselves as socially, economically and environmentally responsible organisations. This study aimed to determine...

Smoking at the beach: A new frontier of tobacco control advocacy

Smoking at the beach: A new frontier of tobacco control advocacy

Tobacco industry interference to undermine the development and implementation of graphic health warnings in Bangladesh

BackgroundIn Bangladesh, the 2013 Amendment of the Tobacco Control Act made graphic health warnings (GHWs) on the upper 50% of all tobacco packs obligatory. However, at the time of writing...

Key Informants' Perceptions of Health Equity and Racial Justice Impacts of the 2019 Massachusetts An Act Modernizing Tobacco Control.

The Massachusetts legislature passed An Act Modernizing Tobacco Control in November 2019 to restrict retail sales of flavored commercially manufactured tobacco products including menthol products, increase penalties for violating the law's provisions, and provide health insurance coverage for tobacco treatment. This study explores key informants' perceptions of intended and unintended impacts of implementation of the 2019 Massachusetts statewide law through a health equity and racial justice lens. We conducted in-depth interviews with 25 key informants from three key informant groups (public health officials and advocates, clinicians, and school staff) between March 2021 and April 2022. Using deductive codes on unintended impacts of the implementation of the law's policies, we conducted a focused analysis to identify impacts that were perceived and observed by informants from different key informant groups. Perceived or observed impacts of the law were identified across multiple levels by key informants and included concerns related to three broad themes: 1) intended impacts on health equity and racial justice, 2) ongoing availability of restricted products undermining the intended impact of the law, and 3) inequitable targeting by the policies and enforcement among communities of color. Future evaluation is needed to assess the intended and unintended impacts of implementation of the Massachusetts law to maximize the potential of the policies to reduce tobacco-related health disparities. We discuss implications and recommendations for achieving a national policy and equitable enforcement of flavored tobacco sales restrictions. This qualitative study among 25 key informants including public health and tobacco control advocates, clinicians, and school staff obtained perspectives of intended and unintended health equity and racial justice impacts of the 2019 Massachusetts An Act Modernizing Tobacco Control. Findings and recommendations from this study can inform monitoring efforts to assess the law's impacts in Massachusetts and the adoption of similar flavored tobacco sales restrictions and other tobacco control policies in other states to maximize the health equity benefits and minimize unintended impacts.

Should tobacco sales be restricted to state-run alcohol outlets? Perspectives from 10 US alcohol control states.

The ubiquity of tobacco retailers helps to sustain the tobacco epidemic. A tobacco retail reduction approach that has not been tried is transitioning tobacco sales to state-controlled alcohol stores (TTS), which are limited in number and operate under some restrictions, e.g. regarding opening hours or marketing materials. This study summarizes policy experts' and advocates' views of TTS, including (1) advantages and disadvantages; (2) feasibility; and (3) potential implementation obstacles. This study was a qualitative content analysis of semi-structured interviews. Ten US states with alcoholic beverage control systems wereincluded. The participants comprised a total of 103 tobacco control advocates and professionals, public health officials, alcohol policy experts and alcohol control system representatives, including two tribal community representatives. Interviewees' perspectives on their state's alcoholic beverage control agency (ABC, the agency that oversees or operates a state alcohol monopoly) and on TTS were assessed. Interviewees thought TTS offered potential advantages, including reduced access to tobacco products, less exposure to tobacco advertising and a greater likelihood of successful smoking cessation. Some saw potential long-term health benefits for communities of color, due to the smaller number of state alcohol stores in those communities. Interviewees also raised concerns regarding TTS, including ABCs' limited focus on public health and emphasis on revenue generation, which could conflict with tobacco use reduction efforts. Some interviewees thought TTS could enhance the power of the tobacco and alcohol industries, increase calls for alcohol system privatization or create difficulties for those in recovery. In the United States, transitioning tobacco sales to state-controlled alcohol stores (TTS) could have a positive public health impact by reducing tobacco availability, marketing exposure and, ultimately, tobacco use. However, tensions exist between alcohol control system goals of providing revenue to the state and protecting public health. Should a state decide to pursue TTS, several guardrails should be established, including building into the legislation an explicit goal of reducing tobacco consumption.

“They try to suppress us, but we should be louder”: a qualitative exploration of intimidation in tobacco control

BackgroundTobacco control advocates and researchers face powerful opponents who go to great lengths to protect their interests. While threats and attacks are documented in the grey literature, research into intimidation remains scarce. Building on previous exploratory research, this study seeks to offer in-depth insights into experiences of intimidation in the global tobacco control community.MethodsUsing qualitative description, we conducted a focus group and semi-structured interviews with tobacco control advocates and researchers to explore their experiences, including forms of, and responses to, intimidation, and ways forward. Data were analysed using qualitative content analysis.ResultsTwenty-nine individuals from across the globe participated in the study. They reported several forms of intimidation including attacks in the media; online harassment; legal threats; non-legal threats, including death threats; Freedom of Information requests; perceived or actual surveillance; as well as burglary and theft. Responses included non-action (i.e. ignoring attacks); withdrawal (i.e. abandoning a project, area or field); defensive adaptation, for example through self-censorship; and offensive measures, including exposing attacks or filing complaints. Responses were shaped by several factors, including type and level of support from within internal and external networks; as well as an individual’s mindset, skills and experiences; and state-civil society relations. Participants suggested several measures that could help address intimidation: 1) report and monitor intimidation; 2) (better) prepare individuals through awareness raising and training (e.g. IT security, legal); 3) support those in need through legal advice, a peer-support network and involvement in response; and 4) look beyond tobacco control to learn and build connections.ConclusionIntimidation is a significant challenge to tobacco control that needs urgent attention. This study suggests measures to address intimidation that require commitment from, and collaboration amongst, multiple actors including governments, international organisations, funders, researchers and civil society. Moreover, collective action beyond tobacco control is needed to not only manage but move beyond intimidation.

Popular Votes on Tobacco Tax Increases, 2012–2022

Context: Researchers have examined the campaign strategies, messaging, and outcomes of popular votes on tobacco tax increases from 1998 to 2008, but no study has investigated measures that have appeared since 2008. Methods: The author uses state newspaper archives, voter pamphlets, academic reports, advocacy websites, and personal interviews to obtain information about the 11 tobacco tax increase ballot measures that appeared from 2012 to 2022. Findings: The three measures that succeeded during 2012–2022 featured sufficient financial resources, collaboration with influential stakeholders, and early public support. Two of the three successful measures offered significant concessions to the tobacco industry, and both were designed as legislatively referred statutes. Elsewhere, proponents sought unsuccessfully to enact citizen-led initiatives that would allocate revenue to progressive policy priorities. In contrast to previous eras, tobacco industry arguments often centered around antitax and antigovernment rhetoric, which was viewed as especially compelling in conservative states. The industry's success rate was higher than in the past, and it continued to outspend its opponents, sometimes by staggering margins. Conclusions: Campaign spending and early support remain critical to the success of tobacco tax ballot measures. Big Tobacco can extract significant concessions even in defeat, and direct democracy is an effective but imperfect ally to tobacco control advocates.

Smoking-attributable mortality in Portugal and its regions in 2019

Introduction and objectivesTimely regional-specific estimates of smoking-attributable mortality (SAM) are crucial for healthcare planning and tobacco control advocacy. Currently, this information is lacking in Portugal. The aim of this study was to estimate SAM by region in 2019 among the Portuguese population aged ≥35 years. MethodsSAM was estimated using an independent-prevalence method. Observed mortality was obtained from Portugal Statistics; lung cancer mortality rates in smokers and never-smokers from the Cancer Prevention Study I-II and updated relative risks from five contemporary US cohort studies. SAM was estimated for each NUTS-II region by sex, age, and cause of death. Crude SAM rates, sex and age-specific rates, and age-adjusted rates were calculated using the direct method. ResultsIn 2019, tobacco consumption caused 13,847 deaths, representing 12.3% of total mortality among the Portuguese population aged ≥35 years. Of the total SAM, 71.2% occurred in men and 22.2% in those under 65 years; 42.5% was due to cancer, 35.4% to cardiovascular and metabolic diseases, and 22.2% to respiratory diseases. SAM greatly varied among regions from 2.1% in Madeira to 36.2% in the North region. In men, cancer was the leading cause of death in all regions, while in women it was cardiovascular and metabolic diseases. ConclusionIn Portugal, tobacco-mortality burden is high and varies significantly by region, sex and age. Therefore, estimates disaggregated by sociodemographic data and region may better support decision-makers while tailoring and implementing tobacco control policies addressing health population needs. The apparent lower tobacco burden among women and in some Portuguese regions may dramatically rise in the near future. This and the high SAM in Portugal, particularly in some regions, highlights the need to accelerate tobacco control both at national and regional levels.

Achieving a tobacco-free Bangladesh by 2040: a qualitative analysis of the tobacco advertising environment and prohibitions in Bangladesh

ObjectivesThis paper explores the Bangladeshi tobacco advertising, promotion and sponsorship (TAPS) legislative environment, to highlight any potential policy loopholes and to facilitate the identification of additional provisions for inclusion. The...

Illuminating a Path Forward for Tobacco Nation: Projected Impacts of Recommended Policies on Geographic Disparities.

This study quantifies the impacts of strengthening 2 tobacco control policies in "Tobacco Nation," a region of the United States (U.S.) with persistently higher smoking rates and weaker tobacco control policies than the rest of the US, despite high levels of support for tobacco control policies. We used a microsimulation model, ModelHealthTM:Tobacco, to project smoking-attributable (SA) outcomes in Tobacco Nation states and the U.S. from 2022 to 2041 under 2 scenarios: (1) no policy change and (2) a simultaneous increase in cigarette taxes by $1.50 and in tobacco control expenditures to the CDC-recommended level for each state. The simulation uses state-specific data to simulate changes in cigarette smoking as individuals age and the health and economic consequences of current or former smoking. We simulated 500 000 individuals for each Tobacco Nation state and the U.S. overall, representative of each population. Over the next 20years, without policy changes, disparities in cigarette smoking will persist between Tobacco Nation and other U.S. states. However, compared to a scenario with no policy change, the simulated policies would lead to a 3.5% greater reduction in adult smoking prevalence, 2361 fewer SA deaths per million persons, and $334M saved in healthcare expenditures per million persons in Tobacco Nation. State-level findings demonstrate similar impacts. The simulations indicate that the simulated policies could substantially reduce cigarette smoking disparities between Tobacco Nation and other U.S. states. These findings can inform tobacco control advocacy and policy efforts to advance policies that align with evidence and Tobacco Nation residents' wishes.

A Latin American view of the human rights approach to tobacco control.

Human rights law is a powerful legal tool to protect health, including tobacco control. The International Covenant on Economic, Social and Cultural Rights (IESCR) obliges States to produce results and is enforceable. Although a human rights approach would have many advantages for Latin American tobacco control, it has not been appropriately used for advocacy purposes yet. Human rights law is a powerful legal tool to protect health, including tobacco control and smoking cessation. Therefore, I appreciate this article by Meier et al. [1]. I will briefly comment on some additional aspects, both generally and as they relate to the current situation in Latin America. Are human rights enforceable? In theory, yes. Human rights are inherent to human beings and empower individuals (rights holders) to demand that States (duty holders) comply with the obligations of those rights. However, an “artificial” contrast has been raised about differences in enforceability between civil and political rights (e.g. the right to life, liberty, property, etc.) and economic, social and cultural rights (ESCR), related to living conditions and access to material and cultural goods (including the right to health). Civil and political rights confer an obligation of results and no one disputes they are enforceable. ESCR confer obligations of means or behaviour and can be viewed as enforceable only to the extent that the State has sufficient resources; they are, therefore, often regarded as “expectations” [2]. For most Latin American law, the fact that ESCR must be fulfilled according to the available resources does not imply they are not enforceable. The obligation to use “the maximum” of the “available resources,” together with the obligation of progressive satisfaction and the need to the results to the appropriate technical or political standards, would make ESCR enforceable. In addition, international law imposes a fundamental rule: pacta sunt servanda, which means that “contracts are to be fulfilled.” Traditionally, the human rights State obligations were classified into positive obligations (to carry out certain activities leading to compliance; in the case of civilians and politicians) and negative obligations (to refrain from actions that violated them; in the case of ESCR). Currently, the Van Hoof classification describes three types of human rights State obligations: to respect (refrain from interfering directly or indirectly), to protect (take measures to prevent third parties from interfering), and to comply (adopt all legislative, administrative, budgetary and other measures appropriate for its realization) [2]. Although ESCR are considered enforceable rights, they are threatened by the doctrine, linked to economic liberalism, which aims to make the State cheaper, often at the cost of social policies. Additionally, although a human rights approach would have many advantages for Latin American tobacco control, this approach has traditionally not been used by tobacco control advocates, but by rather by the tobacco industry (e.g. arguing freedom of expression violation) to attack tobacco control policies [3]. A human rights approach currently has limited relevance for tobacco control policies in Latin America. As Meier et al. point out, human rights law has a prominent role in political and regulatory discourses, and some countries have already established a connection between tobacco control and the fundamental right to health. Because most Latin American countries belong to the civil law tradition, controlling private actors through civil liability litigation is underdeveloped. However, Latin America also has a strong tradition of controlling State action through fundamental rights litigation. Likewise, the Inter-American Human Rights System provides a way to demand human rights State responsibility. Although the current relevance of a human rights approach in Latin America may be limited, it seems a promising approach that ought to be explored [2]. None. None.

Advancement of Tobacco Control in Ghana: Barriers & Opportunities – A Brief Situation Report

Adequate tobacco control in the wake of the ongoing COVID-19 pandemic cannot be overemphasized. As a Lower Middle-Income Country (LMIC) with peculiar needs, Ghana can strengthen her tobacco control regime by advancing country-specific and resilient programmes. The Food and Drugs Authority (FDA) in partnership with WHO embarked on a national project to sensitize law enforcement officers on the existing tobacco control provisions whilst identifying control barriers peculiar to the various regional groupings. The main outcome of this meeting was the development of a tobacco control enforcement plan which defined the framework for regional participation in tobacco control. The next phase of this project is the sustainability of the regional tobacco control units and the exploration of the inclusion of traditional leadership in tobacco control policy implementation. FDA recognizes that there is an important role of Traditional Authorities, Law enforcement agencies and other state agencies as tobacco control advocates. Keywords: Ghana, Tobacco, enforcement, control

Challenges and opportunities for tobacco control in Australia: a qualitative study

ObjectiveA greater understanding of the challenges and opportunities for tobacco control in Australia can assist with accelerating efforts in this space. This study sought to explore these challenges and identify priorities for policy and practice. MethodsInterviews were conducted with 31 individuals working in tobacco‐ and/or nicotine‐related research, policy and practice in Australia. Interviewees were tobacco control and cessation advocates, researchers, public servants and health practitioners representing a range of government and non‐government organisations. ResultsCommonly reported challenges included e‐cigarettes distracting from evidence‐based reform, lack of government investment, a misperception that tobacco control is ‘done’ and tobacco industry interference. Advocating for tobacco control to be high on political agendas, sustained investment in evidence‐based measures, improved support for cessation and addressing industry interference were considered important means of addressing these challenges. ConclusionsSeveral challenges are perceived to be hampering Australia's tobacco control efforts. The attention being devoted to e‐cigarettes at the expense of effective control measures warrants immediate addressing. Implications for public healthIncreasing awareness that smoking continues to be the leading cause of preventable death, developing an evidence‐based national cessation strategy and implementing measures that protect tobacco control efforts from vested interests are critical to reducing smoking prevalence rates.

Health effects associated with smoking: a Burden of Proof study

As a leading behavioral risk factor for numerous health outcomes, smoking is a major ongoing public health challenge. Although evidence on the health effects of smoking has been widely reported, few attempts have evaluated the dose–response relationship between smoking and a diverse range of health outcomes systematically and comprehensively. In the present study, we re-estimated the dose–response relationships between current smoking and 36 health outcomes by conducting systematic reviews up to 31 May 2022, employing a meta-analytic method that incorporates between-study heterogeneity into estimates of uncertainty. Among the 36 selected outcomes, 8 had strong-to-very-strong evidence of an association with smoking, 21 had weak-to-moderate evidence of association and 7 had no evidence of association. By overcoming many of the limitations of traditional meta-analyses, our approach provides comprehensive, up-to-date and easy-to-use estimates of the evidence on the health effects of smoking. These estimates provide important information for tobacco control advocates, policy makers, researchers, physicians, smokers and the public.

’To be honest, I’m really scared’: perceptions and experiences of intimidation in the LMIC-based tobacco control community

BackgroundIt is well-evidenced that environmental or human rights advocacy comes with risks for those involved. Much less is known about the risks of tobacco control advocacy despite the emphasis on...

Tobacco endgame has arrived: What that means for tobacco control advocates and ministries of health

Tobacco endgame has arrived: What that means for tobacco control advocates and ministries of health

Shaping tobacco control advocacy with youth approach: Planned discussion session

Shaping tobacco control advocacy with youth approach: Planned discussion session

Readability of online e-cigarette cessation information.

INTRODUCTIONGiven the growing awareness of the health risks associated with e-cigarettes, many users will access information about how to effectively quit using e-cigarettes, and the internet likely will be a popular source of information. However, little is known about the readability of online e-cigarette cessation information. Therefore, the goal of the current study was to assess the readability of webpage information about e-cigarette cessation.METHODSA search of webpages was conducted using the following search terms: vaping addiction, quit vaping, quit Juul, stop vaping, stop Juul, and vaping cessation. The 464 webpages identified were coded for target audience, message valence, and source, and then assessed for reading level with the Flesch-Kincaid Grade Level assessment.RESULTSOn average, webpage content was written at a 7th grade reading level (Flesch-Kincaid Grade Level Mean=7.34, SD=2.22) and less than 25% of webpages met readability guidelines (i.e. ≤6th grade reading level). There were no differences in readability by target audience, message valence, or webpage source.CONCLUSIONSThe results suggest that most online content related to e-cigarette cessation is not written at a level that is easily understood by general audiences. Thus, tobacco control advocates should assess the reading level of their messaging to ensure wide accessibility of information.

Tobacco Control Advocacy and Tobacco Cessation Programs

Tobacco Control Advocacy and Tobacco Cessation Programs