Tobacco Control Policies Research Articles

Patterns, clusters, and transitions in U.S. state ENDS policy implementation: 2010-2020.

Electronic nicotine delivery systems (ENDS), such as e-cigarettes, have become increasingly used across the world. To respond to global public health challenges associated with vaping, governments have implemented numerous ENDS policies. This research highlights the patterns, clustering, and transitions in U.S. state ENDS policy implementation from 2010 to 2020. Policy data for tobacco and ENDS policies primarily from the Americans for Nonsmokers' Rights Foundation (ANRF) were analyzed for the years 2010 to 2020 for all fifty states and Washington, D.C. Patterns and clusters of policies were assessed. Latent trajectories were modeled for ENDS policies across states over time. ENDS policies commonly have analogous tobacco control policies in place prior to their implementation. ENDS policies in states were commonly implemented in "bundles." The temporal trajectories of ENDS policy implementation occurred in 3 latent forms. A majority of states were "catch-up implementers," indicating their slow initial implementation but stronger position by the end of the period of observation in 2020. These trajectories of ENDS policies were not associated with any individual tobacco control policy in place at the start of the trajectory in 2010. The development of ENDS policies in U.S. states has been temporally and geographically uneven. Many states that had initially been slow to implement ENDS policies caught up by 2020. The implementation of policy "bundles" was common. The clustering of policies in bundles has important methodological implications for analyses, which should be considered in ENDS policy evaluations.

Non-Smoke Tobacco Consumption in India: A Cost-Benefit Analysis

This study evaluates the economic and social impacts of non-smoke tobacco consumption in India and compares them with the tax revenue generated by the government from this industry. Non-smoke tobacco products, such as chewing tobacco and pan masala, are associated with various health and environmental problems, such as oral cancer and littering. The study uses the concept of externalities to analyse the costs and benefits of non-smoke tobacco consumption for the society and the government. Based on available data and assumptions, the study estimates the expenditure on oral cancer treatment and cleanliness, and the revenue from direct and indirect taxes on non-smoke tobacco products. The study finds that the government collects more revenue than it spends on mitigating the negative externalities of non-smoke tobacco consumption, but the social costs are still significant. The study suggests that the government should implement more effective tobacco taxation and control policies to reduce the consumption and harm of non-smoke tobacco products.

Breaking the habit: The impact of tobacco taxation on smoking behavior

Objective: This study investigates the influence of tobacco prices on consumption habits among 200 smokers in Lisbon, Portugal, focusing on generational preferences and perceptions of tobacco taxes. Methods: A cross-sectional survey was conducted using a quantitative approach. Participants were categorized by generational cohort, and data on tobacco consumption types, awareness of tobacco taxes, and opinions on tax increases were collected. Statistical analyses were used to explore relationships and predictors. Results: Findings reveal that 46.5% of participants favored heated tobacco, 37.0% smoked cigarettes, and 16.5% consumed other types like roll-your-own tobacco and electronic cigarettes. Significant generational differences were observed, with older cohorts predominantly smoking cigarettes (51.5%), while Generation Z showed a preference for heated tobacco (55.2%). Most smokers (79.5%) were aware of tobacco taxes, with diverse opinions on their purpose: revenue generation (44.0%), consumption reduction (44.5%), and indifference (11.5%). Despite this awareness, 60.5% reported no change in consumption habits due to tax increases. Conclusion: The study underscores the complexity of tobacco consumption behaviors influenced by price and generational factors. While heated tobacco gains popularity among younger smokers, traditional cigarettes remain prevalent among older cohorts. The findings highlight challenges in tobacco control policies, suggesting a need for comprehensive strategies integrating price measures with targeted educational and cessation interventions to effectively reduce tobacco use across different generations.

Examining the e-cigarette scenario based on distribution, availability, marketing, and banning: A GIS-Based qualitative study in Bangladesh.

Globally, over 81 million people use e-cigarettes, and the majority of them are young adults. Using e-cigarettes causes different types of adverse health effects both in adults and elderly people. Over time, using e-cigarettes has detrimental consequences on lung function, brain development and numerous other illnesses. This study employed a mixed-methods conducted between June and September 2023, comprising two phases: Geographical Information System (GIS) mapping of available e-cigarette point-of-sale (POS) locations and conducting 15 in-depth interviews (IDIs) with e-cigarette retailers, along with 5 key informant interviews (KIIs) involving tobacco control activists and policy experts. ArcGIS was employed for spatial analysis, creating distribution and type maps, and buffer and multi-buffer ring analyses were conducted to assess proximity to hospitals and academic institutions. Data analysis involved descriptive statistics for GIS mapping and qualitative analysis for interview transcripts, utilizing a priori codebook and thematic analysis. A total of 276 POS were mapped in the entire Dhaka city. About 55 POS were found within 100m distance from academic institutions in Dhaka city, which offers the easy accessibility of young generations to e-cigarettes. The younger generation is becoming the major target for e-cigarettes because of their alluring flavors, appealing looks, and variation in flavors. Sellers have been using different marketing tactics such as postering, offering discounts and using internet marketing on social media. Moreover, they try to convince the customers by saying that e-cigarettes are 'not harmful' or 'less harmful'. However, retailers were mostly taking e-cigarettes from local wholesalers or distributors. Customers buy these products both from in-store and online services. Due to the absence of laws and regulations on e-cigarettes in Bangladesh, the availability, marketing, and selling of e-cigarettes are increasing alarmingly. E-cigarette retail shops are mostly surrounded by academic institutions, and it is expanding. Besides, frequent exposure, easy accessibility, and tactful promotion encourage the younger generations to consume e-cigarettes. The government should take necessary control measures on manufacturing, storage, advertising, promotion, sponsorship, marketing, distribution, sale, import, and export in order to safeguard the health and safety of young and future generations.

Compliance to the tobacco-free educational institution policy (ToFEI study) in urban areas of selected districts of Karnataka: A situational analysis

BackgroundYouth smoking is a major concern as the average age at which people start smoking has been declining in recent years. Strengthening tobacco control policies at educational institutions (EI) will prevent the access to tobacco products for minors. The current study aims to assess teacher’s knowledge and compliance to tobacco-free-educational-institution (ToFEI) policy. MethodsFour districts of a south Indian state were chosen for the study. A face-to-face interview with approximately 50 head teachers from respective districts was carried out by a trained interviewer to assess the compliance to ToFEI guidelines. The shops within 100 yards of EI were visited to confirm the sale of tobacco using geographic information system. ResultsA total of 234 EI were surveyed, of which 79 (33.8%) institutions had ‘tobacco-free institution’ board. A display board prohibiting tobacco sale within 100 yards of school was present in 175 (74.8%) institutions. A total of 733 shops were found around 195 EI and of them, 9.7% (71/733) shops were selling tobacco products. ConclusionDespite the existence of tobacco-free school guidelines in India, there was a lacunae in compliance with provisions of guidelines among various EIs across Karnataka state. With nearly one-fifth of institutions having shops that sell tobacco within 100-yard of institutions, further laxity in implementation of tobacco control activities can be a threat and can lead to easy availability of tobacco products and attract more students to use the lethal products.

The hidden crisis: Health impacts of tobacco and nicotine products on Indian women

ABSTRACT Tobacco use among women in India is becoming a critical public health issue. Once viewed predominantly as a male habit, tobacco consumption among Indian women has seen a rising trend. This shift is driven by factors such as evolving societal norms, aggressive marketing by the tobacco industry, and increasing urbanization. Women are now using a variety of tobacco products, including smokeless tobacco and electronic nicotine delivery systems (ENDS). The health effects are particularly alarming, with elevated risks for cancers, cardiovascular diseases, respiratory conditions, and reproductive health problems. Despite these concerns, public health initiatives and policies often fail to address the specific needs of women. editorial examines the social and cultural drivers of tobacco use among Indian women, outlines the severe health risks, and calls for immediate action through gender-sensitive tobacco control policies. It provides recommendations, including robust regulation, community involvement, and specialized cessation programs to reduce the growing tobacco use among women.

Single cigarette sales contravene tobacco control policies, Brazil.

Single cigarette sales contravene tobacco control policies, Brazil.

How do industry and other actors undermine tobacco control policies post-adoption? A scoping review

Abstract Background Over recent decades, many countries have strengthened their tobacco control policies. To be effective, full implementation is needed. Tobacco industry interference is widely recognised as a key barrier to tobacco control progress and evidence-based models like the policy dystopia model (PDM) list industry strategies, focusing on those avoiding and undermining policy adoption. While prior research highlighted industry activities post-adoption, these have not been captured systematically. This review aimed to map the efforts of industry, front groups and other actors to undermine the implementation of policies, including marketing, packaging, smokefree and flavour measures. Methods We searched six literature databases, relevant bibliographies and grey literature, and consulted experts. We included articles describing one or more attempts to undermine adopted policies, including marketing, packaging, smokefree and flavour. The PDM served as starting point for coding; additional strategies were identified inductively. Strategies were charted against aims and policies. Results Several aims and strategies were identified which were similar across policies. Following policy adoption efforts to 1) overturn and 2) weaken measures, and 3) delay implementation continued. Legal strategies were utilised and there were attempts to influence stakeholders. In addition, tobacco industry and other actors sought to 4) undermine policy effectiveness by creating confusion, circumventing policies, and noncompliance, and 5) use implementation as an opportunity to enhance industry reputation. Conclusions Interference from tobacco industry and other actors threatens effective tobacco control policy implementation. The public health community must continue to monitor, expose and counter industry conduct after policy adoption. More research is needed to enhance our understanding of how industry interferes in policy implementation, and how this can be pre-empted and countered. Key messages • The interference from tobacco industry and other actors following policy adoption threatens effective tobacco control, and needs to be monitored, exposed and countered by the public health community. • Policymakers and civil servants need to be wary of efforts to undermine tobacco control policies and act to ensure effective policy implementation.

DYNAMO-HIA: A health impact assessment tool fit for quantifying tobacco control policy

Abstract DYNAMO-HIA is a generic, publicly-available and easy to use software tool for health impact assessments of changes in health risk-factors such as obesity, air pollution, processed meat consumption, physical activity, alcohol taxation, or smoking. The tool uses a graphic use interface, does not require programming skills, and has comparatively modest data requirements. Health outcomes that can be investigated are mortality, life expectancy, healthy-life expectancy, disability and prevalence of various chronic disease such as chronic obstructive pulmonary disease (COPD), cancer, or coronary heart diseases. DYNAMO-HIA can in principle be used for any tobacco control policy or ordinance-e.g. price increases or pictorial health warning labels-that target changes in smoking prevalence or smoking initiation/quitting rates. Past applications of DYNAMO-HIA for tobacco control policy included country studies for Belgium, Mongolia, or Korea and several comparative country studies. In this presentation we will give a general overview into the use of DYNAMO-HIA and show-case a recently published study. This study quantified the reduction in COPD burden that would occur in Italy, England and Sweden over 40 years if tobacco prices were increased by 5%, 10% and 20% over current local prices.

Calculating potential impact fractions to assess the impact of tobacco control policies

Abstract This presentation will provide a straightforward and accessible method for evaluating the effectiveness of various tobacco control policies in reducing the smoking-associated disease burden. To estimate numbers and proportions of potentially avoidable disease cases under different policy intervention scenarios (such as cigarette tax/price increases, comprehensive marketing ban, and plain packaging), this approach entails the calculation of age- and sex-specific potential impact fractions, representing the percentage change in disease risk following changes in exposure to smoking. The approach can account for lag and latency periods between reductions in smoking prevalence and declines in disease excess risks. The future disease burden is estimated by combining data on the incidence or mortality of the disease of interest, published effect sizes of tobacco control policies, and national smoking prevalence data. Intervention scenarios are compared against a status quo scenario that assumes the continuation of recent smoking trends. The presentation will outline the approach, using the example of smoking-associated cancer, and discuss model assumptions, required data, and sensitivity analyses. This straightforward modelling framework enables the comparison of different health policy measures’ impacts, providing valuable insights for policymakers and public health officials regarding the potential public health impact of tobacco control policy measures.

An Overview of Tobacco Control Policies in China

The tobacco epidemic is a global public health concern as the toxic substances in tobacco pose a severe threat to human health. In response to this issue, countries around the world have adopted various strategies to control tobacco use. The Chinese government began to pay attention to the health hazards of smoking in the 1970s and joined the international community in tobacco control endeavors by becoming a signatory of the World Health Organization Framework Convention on Tobacco Control in the early 21st century. It has further intensified its tobacco control measures in recent years with its “Healthy China” strategy. This article gives an overview of tobacco control policies released by the Chinese government over the years, with a separate analysis of the provisions on smoking control stipulated in the Health China Action Plan (2019-2030). Also discussed are the outcomes of those policies and the challenges China faces in tobacco control, as well as the lessons China can learn from international experiences in this regard.

7.P. Skills building seminar: Using health impact assessment for assessing tobacco control policies

Abstract Tobacco use is the largest contributor to premature death and preventable disease in Europe. Despite decreasing tobacco use in recent years, the European Commission estimates that the number of smokers in Europe is 26% in the population, and 29% among 15-24 year olds. This persistent public health risk is amenable to policy, but targeted and effective strategies are needed. Health impact assessment (HIA) methods can aid decision-makers in exploring the consequences of policy actions on select outcomes, providing a platform for informed, evidence-based policy design. Routine data collection on risk factors including smoking and tobacco use behaviour is common and available in Europe. Analysing and valorising these data can provide a better picture of vulnerable and target groups for which tobacco use is a persistent problem, or where the attributable disease burden is particularly high. These data can form the basis for robust projections and the application of HIA methods. In addition, a number of policy strategies exist for tobacco control including changes in packaging, taxation, labelling, ingredients, creation of smoke-free environments, and restrictions on advertising. These policies have a common goal in improving tobacco control, but may lead to differential effects across age groups, populations, and different measures of tobacco use. It is thus necessary to use robust tools to understand these effects and better coordinate and plan policy. HIA methods, each with their own strengths and limitations, have been applied successfully to estimate the impact of different tobacco control measures. Novel methodologies that make use of available data, computational power, and provide a low-cost way to explore policy interventions can be an essential tool to policy planning and in particular to tackle the intractable areas of tobacco control. This skills building workshop will present two key approaches, each with their own strengths and weaknesses, that have been applied in HIA studies on tobacco control - i.e., a static approach based on the calculation of potential impact fraction, and a dynamic approach based on microsimulation models. Furthermore, the workshop will demonstrate, using two real-life examples, how policy measures can be translated into effect size estimates - which is one of the most crucial steps in any HIA. By providing a step-by-step presentation of how HIA has been applied in practice, attendees will gain unique insights in the different ways by which HIA can be used to gain insights into the relative impact of policy strategies for tobacco control. Key messages • Tobacco use remains the largest contributor to preventable disease burden in Europe; a key area for analysing policies using health impact assessment. • Attendees will gain unique insights in the different ways by which HIA can be used to gain insights into the relative impact of policy strategies for tobacco control.

The impact of the tobacco law on tobacco-related hospitalizations in Portugal - a natural experiment

Abstract Introduction Tobacco is responsible for approximately 8 million deaths annually worldwide, with 1.2 million resulting from passive exposure to smoke, as reported by the WHO. Comprehensive tobacco control policies have been enacted across Europe, yet their impacts are seldom assessed. This study evaluates the effects of the anti-tobacco legislation enacted in Portugal in 2007 on tobacco-related hospitalizations between 2002 and 2018. Methods Data from all in-patient admissions in public hospitals throughout the 2002-2018 period were utilized. A quasi-experimental interrupted time series design was employed, treating 2008 as an exogenous shock. The dependent variables include the municipality-based incidence of hospitalizations by year for tobacco-related diseases, namely, Acute Myocardial Infarction, stroke, lower respiratory tract infections, chronic obstructive pulmonary disease, and asthma. The analysis was adjusted for the percentage of women, the percentage of individuals aged over 65, and purchasing power in the municipality. Time trend graphs for each variable were generated, followed by an adjustment using the Poisson regression model to forecast their trends. A comparison was conducted between observed post-law implementation data and projected values from the regression model to ascertain the percentage difference between the two. Expected Results The 2007 tobacco law led to significant reductions in tobacco-related disease incidence, with the most notable effects immediately post-implementation. The impact varies across age groups, with younger individuals (30-49 years) showing a sharper decrease. The effect diminished over time, as indicated by negative coefficients in time:law interactions, such as -0.03. Conclusions The anti-tobacco laws implemented in Portugal have effectively decreased hospitalizations related to tobacco use, suggesting potential increases in life expectancy and reduction in health system burden. Key messages • Public health policies are crucial for the long-term improvement of people’s health. • Non-exposure to tobacco can bring health gains on several levels.

Tobacco control policies discussed on social media: a scoping review

ObjectiveTo describe the scope of published literature about tobacco-related policy discussions from social media data and discuss implications for tobacco control policy and future research.Data sourcesPubMed, Medline, CINAHL and Web...

Smartphones: A Catalyst for Tobacco Control Training in India

The tobacco crisis confronting low- and middle-income countries (LMICs) requires scale-up of effective tobacco control programs, such as Tobacco Free Teachers-Tobacco Free Society (TFT-TFS). We previously demonstrated the efficacy of TFT-TFS in increasing tobacco use cessation among teachers and schools’ adoption of tobacco control policies in Bihar, India. To scale TFT-TFS, we are now pioneering a smartphone-based mobile learning strategy to train principals (or their designees) in Madhya Pradesh to implement and monitor TFT-TFS in schools. Research underscores the transformative potential of mobile learning: a flexible, scalable, and cost-effective alternative to in-person training methods. Our study is a unique opportunity to test a training approach that could have implications for wider and more efficient delivery of other public health programs. The strategic use of gamification and digital storytelling enhances the TFT-TFS mobile training app. Gamification mechanics—including points, leaderboards, and digital badging—foster a dynamic learning environment to enhance learning outcomes. This approach propels continuous participant engagement toward understanding and implementation of TFT-TFS’s six monthly themes and four program components. The TFT-TFS smartphone training program weaves in elements of Indian culture, notably the symbolic use of colors and kites. The Indian kite festival celebrates communal harmony through healthy competition. Similarly, the app employs the idea of school kites, which are divided into six blank segments corresponding to the TFT-TFS monthly themes. Participants navigate each module, engaging with animated videos, digital assessments, and interactive activities. Upon a principal’s successful completion of each monthly theme’s program components, the school’s kite receives a new color, unlocking the subsequent theme. The TFT-TFS smartphone training showcases a unique interactive mobile learning application that integrates gamification and tests how to scale up an effective tobacco control program in schools in India and other LMICs. The TFT-TFS smartphone-based training app may also have relevance to other public health-related training efforts in resource-constrained areas.

Trend and determinants of tobacco use among Indian males over a 22-year period (1998-2021) using nationally representative data.

Tobacco consumption is associated with an increased risk of morbidity and mortality. India is one of the largest consumers of tobacco worldwide. We assessed the trend of tobacco use among Indian males over a period of 20 years using data obtained from four rounds of the National Family Health Survey (NFHS). Data on tobacco usage and relevant socioeconomic variables obtained from NFHS rounds 2 to 5 over the period 1998-2021, was used for analysis. Specifically, data were available for 138,951 males from NFHS-2, 74,369 males from NFHS-3, 112,222 males from NFHS-4, and 101,839 males from NFHS-5. Significance of association between various socio-economic factors and tobacco usage was ascertained using a multicategory logistic regression model. Among all the forms of tobacco, smokeless tobacco was predominantly used by Indian males. The proportion of smokers and those using both smoke and smokeless forms peaked during NFHS-3, followed by a consistent dip; however, the use of smokeless tobacco plateaued from NFHS-4 to NFHS-5. NFHS-5 shows that 19.2% of Indian males smoked, 27.0% used smokeless tobacco, and 6.3% used both. Tobacco use has declined significantly over the last two decades. Tobacco usage is noticeably higher among the elderly, Muslims, and those from the backward classes, while it was considerably lower for individuals belonging to the educated and wealthier segment. There has been a steady decline in tobacco use in India over the past 22 years, specifically in the smoke-form category. However, smokeless tobacco use remains nearly unaffected. The outcome of this study might aid policymakers in devising targeted tobacco control policies and improving existing ones.

How do Chinese young adult women initiate smoking and progress to become regular smokers? A qualitative study

ABSTRACT Objective The increasing prevalence of smoking among young adult women in China raises concerns about the associated health risks. This study aims to investigate the trajectory of smoking and its influencing factors among Chinese young adult women in order to gain a comprehensive understanding and reduce the prevalence of smoking. Methods Using purposive sampling, one-on-one interviews were conducted with 28 young female smokers aged 20–31 years between May 2022 and September 2022. Results The findings revealed that the trajectory of smoking among Chinese young adult women is divided into three stages: smoking initiation, maintenance of smoking, and becoming addicted to smoking. Participants were initially attracted to smoking due to factors such as the taste of tobacco, peer influence, stress in interpersonal interactions, and cigarettes marketed for women. As smoking behavior progressed, participants mentioned motivations including relieving negative emotions, experiencing relaxation and pleasure, shaping their personal image, and confronting discrimination and prejudice. Eventually, when they became addicted to smoking, the physical dependence on nicotine and the smoking habit prevented them from stopping. Conclusions Understanding the influence of these factors on women’s smoking behaviors is crucial for informing tobacco control policies and reducing tobacco use among women.

An overlooked market: loose cigarettes, informal vendors and their implications for tobacco taxation

ObjectiveTo examine the features of markets for loose cigarettes in several low-income and middle-income countries and their effects on tobacco control policies, particularly taxation.DesignAn analysis of survey data targeting people...

Tobacco industry corporate social responsibility activities and other interference after ratification of a strong tobacco law in Ethiopia

BackgroundSince strict new tobacco control laws were introduced in 2019 and 2020, the National Tobacco Enterprise (NTE), the main manufacturer and distributor of cigarettes in Ethiopia, strategically engaged in corporate...

Moving hearts and minds: how the Big Tobacco, Tiny Targets campaign builds support for tobacco control policy

Moving hearts and minds: how the Big Tobacco, Tiny Targets campaign builds support for tobacco control policy