Maternal smoking prevalence in Brazil in 2013 and 2019: not what we expected when they were expecting!

INTRODUCTION: Monitoring tobacco use during pregnancy is critical for achieving the United Nations Sustainable Development Goals. We examined changes between 2013 and 2019 in the relative differences in smoking prevalence rates between pregnant and non-pregnant women aged 18-49 years. METHODS: We used data from a nationally representative health survey conducted in Brazil in 2013 and 2019. A generalized linear model with binomial family and logarithmic link function was used to estimate, for each year of analysis, the crude and adjusted (by age-group, educational attainment, place of residence, and status of protection from passive smoking at home) relative differences. RESULTS: In 2013,the proportion point estimate of tobacco use among pregnant women was lower than that observed among non-pregnant women (4.7% vs. 9.6%). However, in 2019 proportion point estimates were virtually the same (8.5% vs. 8.4%). After adjustment for selected variables, in 2013, smoking prevalence among pregnant women was 42% (p-value≤0.05) lower than that observed among non-pregnant women. On the other hand, in 2019, maternal smoking prevalence was 13% (p-value>0.05) higher than that found among non-pregnant women. CONCLUSIONS: Ongoing tobacco industry interference and the marketing of tobacco products to vulnerable populations pose serious threats to public health and likely contributed to increasing maternal smoking prevalence. The fact that women smoke in such an important phase of their and their unborn children's lives reinforces the need to strengthen the implementation of concurrent tobacco control actions, including tobacco excise tax policy and pre-natal tobacco prevention and cessation interventions as part of health professionals' routine consultation. IMPLICATIONS: The decline in smoking prevalence among non-pregnant women between 2013 and 2019 was accompanied by an increase in maternal smoking prevalence. Monitoring tobacco use during pregnancy is critical for achieving the United Nations Sustainable Development Goals. Ongoing tobacco industry interference and the marketing of tobacco products to vulnerable populations in Brazil pose serious threats to public health. The fact that women smoke in such an important phase of their and their unborn children's lives reinforces the need to strengthen the implementation of concurrent tobacco control actions, including tobacco excise tax policy and primary healthcare professionals´ tobacco-related assistance during interaction with their patients.

Flavours and design features on tobacco product packaging near schools before and after plain packaging implementation in Montevideo, Uruguay.

INTRODUCTION: Monitoring tobacco industry marketing strategies in countries that have introduced plain packaging helps with documenting variations in the market during the transition period. Uruguay implemented plain packaging in February 2020. We describe changes in the characteristics of tobacco packaging, content and sticks before and after plain packaging implementation. METHODS: Data were collected across 15 neighbourhoods in different socioeconomic areas in Montevideo, Uruguay, before and after implementation (2019 and 2021). A high school or college was selected in each neighbourhood as the walking protocol starting point. Two stores were visited per neighbourhood. Cigarettes and roll-your-own tobacco (RYO) were purchased and coded for the presence of taste or sensation lexical and imagery features. RESULTS: The number of unique products increased between 2019 (n=23) and 2021 (n=40). Prior to implementation, all packs presented design features. After its implementation, 95.7% of cigarette packs complied with regulations. Overall, 34.7% of cigarettes and RYO were flavoured in 2019 versus 50.0% in 2021 (p=0.01). In 2019, all flavoured cigarette packs conveyed taste through language and/or imagery, while cigarettes had designs on the filter suggesting the potential for altering the flavour. In 2021, 44.0% of cigarette packs indicated flavour through lexicon; and 81.0% of cigarette sticks still included a flavour capsule. CONCLUSIONS: After implementation, we noticed an increase in the availability of unique flavoured cigarettes and RYO among surveyed retailers. However, this increase was less pronounced compared with what is reported in the Latin American region. Non-compliance was identified. Greater efforts should be made enforcing current policy.

Tobacco product litter as a form of postconsumption marketing: an observational study in India.

BACKGROUND: Tobacco product litter may be a form of postconsumption marketing if the littered items are branded. We conducted an observational study in India to assess the presence of tobacco product litter and determine the proportion that included branding. METHODS: During November-December 2022, we identified tobacco product litter (cigarette/bidi butts and packaging; smokeless tobacco packaging) in nine Indian cities: Bengaluru, Bhubaneswar, Chennai, Delhi, Guwahati, Hyderabad, Lucknow, Mumbai and Patna. In each city, we conducted observations along 15 different routes, each approximately 250 m in distance, for a total of 135 observational routes. Data collectors classified each piece of tobacco litter (product/packaging) and recorded if the litter had visible branding, such as brand names and/or logos. RESULTS: The study identified 17 261 pieces of tobacco product litter; SLT packaging comprised the largest proportion of the sample (62%), followed by cigarette butts (26%), bidi butts (8%), cigarette packaging (3%) and bidi packaging (1%). Across the sample, 81% (n=13 924) of the litter was branded. A brand was visible on most packaging for cigarettes (98%), bidis (97%) and SLT (86%), and present on 82% of cigarette butts and 26% of bidi butts. CONCLUSION: This study found that the majority of tobacco product litter in India is branded, which could function as a form of postconsumption marketing. Plain and standardised packaging and banning branding features on filters would reduce tobacco litter branding.

The Use of Packaging Descriptors in a Rapidly Growing Market for Capsule Cigarettes: Evidence From Mexico.

INTRODUCTION: The global market for capsule cigarettes has grown rapidly, especially in Latin America. This research examined the sales trends and patterns as well as packaging characteristics of capsule cigarette in Mexico in recent years. METHODS: National data on cigarette sales in Mexico between October 2018 and September 2021 licensed from NielsenIQ were supplemented with cigarette pack pictures and Internet searches to determine whether characterizing flavor, concept flavor, and action descriptors were used. Market share in sales value and volume was calculated by capsule and flavor status, descriptors, price tier, manufacturer, pack size, and cigarette length for the whole time period and for each month. Number of unique brand variants was also examined. RESULTS: Capsule cigarette sales totaled US$4.29 billion or 30.99 billion sticks during the assessed period, comprising 37.7% of the cigarette market share in sales value or 35.5% in sales volume. Over half of capsule cigarettes sold during this time period had concept flavor descriptors, 17.8% contained characterizing flavor descriptors, and 15.1% contained action descriptors that were suggestive of the interactive aspects of capsules. The monthly market share of capsule cigarette sales volume among all cigarette sales in Mexico increased steadily from 33.3% in October 2018 to 37.3% in September 2021. CONCLUSIONS: The expanding capsule cigarette market in Mexico is concerning, given the product's associated misconceptions of reduced harm and greater appeal among youth. Findings underline the need for enhanced regulations to address the public health threat posed by capsule cigarettes. IMPLICATIONS: Capsule cigarettes have a substantial market share in Mexico, with increasing popularity. Descriptors and other product characteristics such as cigarette length might be used to increase the appeal and target particular populations. Policy makers should consider banning capsules and flavors in cigarettes including descriptors or other indication in product presentation that could be perceived as denoting a taste, aroma, or sensation, and making the appearance and design of tobacco products more commensurate with the harm they cause by adopting plain and standardized packaging.

Shared perceptions of flavored cigarette pack design among young adults who smoke in Mexico and the Philippines.

INTRODUCTION: Tobacco industry documents reveal companies' knowledge of a similar young adult market across countries in terms of attitudes and lifestyle aspirations. Some tobacco companies, therefore, use similar marketing approaches across different jurisdictions. We examined young adults' perceptions of flavored cigarette packs, including those containing flavor capsules, in Mexico and the Philippines. METHODS: We conducted a secondary analysis of five focus groups held in Mexico and four in the Philippines with young adults who smoke (aged 18-24 years), separated by gender, in which participants interacted with cigarette packs purchased locally. Transcribed and translated data were thematically analyzed and compared between countries. RESULTS: Three major themes were identified: 1) Flavor capsules cigarettes are recognizable via pack design through imagery on the pack that is understood to signify capsules; 2) Colors signal flavor and make the pack attractive; and 3) Young adults who smoke identify the target audience for these products as young people and those who are beginning to smoke. CONCLUSIONS: Young adults who smoke in Mexico and the Philippines interpreted flavored cigarette pack design similarly and thought that young people are the main audience for these products. This suggests a successful marketing approach creating shared perceptions of flavored cigarette packs in different world regions. It is likely that similar tactics are used in other countries around the world. Therefore, jurisdictions might use evidence from other jurisdictions to support the implementation of evidence-based tobacco control policies. These findings also support the implementation of plain and standardized packaging and flavor bans that would also limit product innovation such as capsules.

Straw cigarette branding: misleading descriptors and a new Marlboro man.

BACKGROUND: Straw cigarettes are hand-rolled tobacco in a corn straw, common in Brazil and believed to be less harmful by consumers. Traditionally consumed in rural areas and by men, a recent increase in use among young people in urban areas was observed. This study assessed marketing appeals of straw cigarette packaging in Brazil. METHODS: Following a systematic protocol, unique straw cigarette packs were purchased in 2013, 2016 and 2019 from three cities: Manaus, Salvador and São Paulo. Packs were double-coded for the absence/presence of marketing appeals (ie, luxury/quality, masculinity, classic/timeless, flavours and less harm). RESULTS: The number of unique straw cigarette packs purchased as part of the overall sample increased in the most recent collection: 2.3% (n=3), 1.3% (n=2) and 15.5% (n=27) in 2013, 2016 and 2019, respectively. Across the years, all packs presented luxury/quality elements (eg, images of crests); 93.8% (n=30) included the word 'artisanal'. Masculine appeal (eg, images of men) was present on 56.3% (n=18) of packs. Almost half had classic/timeless elements, including the words 'tradition'/'original'. In 2019, 59.3% (n=16) of the packs were flavoured compared with none in previous years. Over a quarter of all packs presented a less harm appeal (eg, 'smooth'). CONCLUSION: We identified an increase in availability of unique straw cigarette packs, strong branding and use of misleading descriptors on the packs. The adoption of plain packaging and the implementation of Brazil's additive ban could help to reduce the appeal of straw cigarettes and curb the current increase in use among youth.

Colours, capsules and concept flavour names on cigarette packs appeal to youth in Mexico.

BACKGROUND: Flavoured cigarettes are popular in Mexico. We examined how cigarette packaging design features used to communicate flavour influence perceptions of appeal, harm, perceived interest and pack preference among Mexico City residents. METHODS: We conducted an experimental survey. Participants aged 13-34 years were randomly assigned to one of three conditions, viewed packs with systematically manipulated design features (colour, capsule image and flavour name) and answered questions on appeal, perceived harm, perceived interest and pack preference. Data were analysed using mixed effects and conditional logistic regression. RESULTS: 1500 adolescents and 950 adults participated. Regardless of flavour, cigarette packs with a background colour and capsule image were more appealing to adolescents (OR=13.19, 95% CI 11.53 to 15.10; OR=1.68, 95% CI 1.45 to 1.88) and adults (OR=4.18, 95% CI 3.73 to 4.69; OR=1.66, 95% CI 1.49 to 1.85) than packs without. Among adolescents, 'Tropical Burst' named packs were more appealing (OR=1.43, 95% CI 1.20 to 1.72) than packs without a flavour name and among adults, 'Arctic Air' named packs were more appealing (OR=1.20, 95% CI 1.02 to 1.14). Adolescents and adults reported a preference for trying packs that displayed a flavour name, background colour or capsule image (b=0.104, b=0.702, b=1.316, p<0.001 and b=0.126, b=0.619, b=0.775, p<0.001). CONCLUSIONS: Colours and flavour capsule images appeal to adolescents and adults in Mexico. Mexico should consider adopting plain packaging to reduce appeal and interest.

Disparities in self-reported exposure to tobacco marketing among youth and young adults from low-socioeconomic status neighbourhoods in Mexico City.

Exposure to tobacco marketing is positively associated with smoking initiation and behaviours. There is limited literature examining disparities among reported exposure in low- and middle-income countries. This study sought to fill this gap with a survey among 1427 adolescents and 889 adult smokers in Mexico City in 2020. Data were analysed using chi-square and hierarchical regression models. Two-thirds of adolescents noticed cigarette pack displays in stores. Participants from low- and mid-socioeconomic status (SES) neighbourhoods were more exposed to tobacco marketing than their counterparts through several channels. After addressing the shared variance among participants from the same household nested in neighbourhood SES level and controlling for gender, adolescent non-smokers and adult smokers who noticed pack displays were more likely to be susceptible to smoking (OR = 1.8, 95% CI 1.4-2.4) and to smoke more (OR = 1.7, 95% CI 1.21-2.47); adult smokers who noticed tobacco marketing at more places were less likely to be certain about smoking risks (OR = 0.9, 95% CI 0.8-0.9). The results suggest that the tobacco industry targets youth and individuals from low-SES neighbourhoods through several channels. Greater exposure to tobacco marketing was associated with increased susceptibility to smoking and decreased risk perception. These findings support a comprehensive ban on tobacco marketing in Mexico.

"It's all About the Colors:" How do Mexico City Youth Perceive Cigarette Pack Design.

Objectives: Cigarette packs are relevant to branding strategies, designed to appeal to specific groups. There is little research on how pack features increase product appeal among key constituents such as youth in low- and middle-income countries. Methods: We conducted 10 focus group discussions (FGDs) with adolescents and 5 FGDs with young adult smokers in Mexico City, separated by age, gender, smoking, and socioeconomic status. Participants separated 23 cigarette packs into "appealing" and "unappealing" groups, and were asked to explain their decisions, describing the features that supported their views. FGDs were video-recorded, transcribed in Spanish, translated into English, and subjected to thematic analysis. Results: Pack groupings did not differ greatly across FGDs; bold, contrasting colors and elements communicating flavor and promotion increased cigarette pack appeal and desire to try. Participants perceived packs with these features to be used by and designed for youth, like themselves. Conclusion: Our findings reinforce the importance of packaging design in attracting new consumers and maintaining current ones. Mexico should consider stronger tobacco advertising policies that include packaging color and depiction of flavor to reduce product appeal.

A scoping review on disparities in exposure to advertising for e-cigarettes and heated tobacco products and implications for advancing a health equity research agenda.

BACKGROUND: Disparities in exposure to and density of tobacco advertising are well established; however, it is still unclear how e-cigarette and heated tobacco product (HTP) advertising vary by age, education, sex, gender identity, race/ethnicity, sexual orientation, socioeconomic status (SES), and/or urban/rural area. Through a scoping review, we sought to identify potential disparities in exposure to e-cigarette and HTP advertising and promotion across populations. METHODS: In January 2020, a systematic literature search was conducted in five databases: PubMed, Scopus, Embase, Web of Science, and the Cochrane Library. The search was updated in October 2020. Articles reporting on exposure to e-cigarette and/or HTP advertising and promotion across age, education, sex, gender identity, race/ethnicity, sexual orientation, SES, and/or urban/rural areas were included for full-text review (n = 25). Of those, 15 were deemed relevant for data extraction. RESULTS: The majority of the studies were from the U.S. (n = 12) and cross-sectional (n = 14). Studies were published between 2014 and 2020 and focused on determining causal relationships that underlie disparities; only one study assessed HTP advertising and promotion. Exposure to e-cigarette and HTP advertising was assessed at the individual-level (e.g., recall seeing ads on television) and at the neighborhood-level (e.g., ad density at the point-of-sale). Studies addressed differences across age (n = 6), education (n = 2), sex (n = 6), gender identity and sexual orientation (n = 3), race/ethnicity (n = 11), SES (n = 5), and urban/rural (n = 2). The following populations were more likely to be exposed to e-cigarette advertising: youth, those with more than a high school diploma, males, sexual and gender minorities, Whites, and urban residents. At the neighborhood-level, e-cigarette advertisements were more prevalent in non-White neighborhoods. CONCLUSIONS: Exposure to e-cigarette/HTP advertising varies based on sociodemographic characteristics, although the literature is limited especially regarding HTPs. Higher exposure among youth might increase tobacco-related disparities since it can lead to nicotine/tobacco use. Research should incorporate and apply a health equity lens from its inception to obtain data to inform the elimination of those disparities.

New tobacco products, old advertising strategies: point-of-sale advertising in Guatemala.

OBJECTIVE: Capsule cigarettes, electronic cigarettes (e-cigarettes) and heated tobacco products (HTPs) are now readily available in Guatemala. As in most countries, the point-of-sale (POS) remains an important marketing channel for the tobacco industry. Therefore, we sought to characterise the POS marketing of these products in the two largest cities in Guatemala. METHODS: Convenience stores were randomly surveyed in mid and high socioeconomic status (SES) neighbourhoods in Guatemala City (n=60) and Quetzaltenango (n=15) in 2019. We adapted a previously implemented checklist to assess the availability of interior advertising of capsule cigarettes, e-cigarettes and HTP. Data entry was done in Kobo toolbox and analysis in STATA. RESULTS: All stores sold conventional and flavoured capsule cigarettes, 78% e-cigarettes and 68% HTP. Most cigarette advertising was for capsule cigarettes. E-cigarettes were more likely to be sold in Guatemala City (96%) than in Quetzaltenango (13%). HTPs were only found in Guatemala City (85%), with no difference between high and medium SES neighbourhoods. Median number of ads for cigarettes and capsule cigarettes was higher in the high SES neighbourhood. Most e-cigarettes (83%) and HTP (74%) were found <50 cm from candy. E-cigarettes and HTP were available in a wide range of flavours. All stores that sold HTP had flavoured HEETS (amber, bronze, turquoise, yellow, blue and purple). CONCLUSION: We found a high prevalence of advertising for capsule cigarettes, e-cigarettes and HTP at the POS. The POS, a crucial advertising channel for the tobacco industry, is now being used for new products and therefore needs to be urgently regulated.

The Intersection of Gender-Based Violence and Risky Sexual Behaviour among University Students in Ethiopia: A Qualitative Study.

Women who experience gender-based violence (GBV) are at risk for adverse sexual health outcomes, as they may be unable to fully negotiate sexual encounters. This may be especially true for females at universities in Ethiopia, where women are the minority and patriarchal norms prevail. This study explored students' experiences and faculty's perceptions of GBV and sexual risk behaviours at two Ethiopian universities. Individual interviews were conducted with male and female students, and focus group discussions were held with students and faculty/staff. Qualitative thematic analysis was used to explore the relationship between GBV and sexual risk and identify intervention points. Data revealed that female students at both universities are regularly exposed to GBV, which in combination with risky sexual behaviours may threaten their health. Participants (n = 126) reported a belief that women who violate traditional gender norms are more prone to violence. Substance use was reported to contribute to risky behaviours, particularly for women. Participants reported male students sometimes encourage female intoxication in order to achieve sexual encounters, resulting in coercive situations. Sexual health and GBV-related services are provided on campus, but participants highlighted ways they can be improved. In order for females to safely pursue higher education in Ethiopia, campus-based interventions focused on the intersection of GBV and sexual risk are greatly needed.

"We are responsible for the violence, and prevention is up to us": a qualitative study of perceived risk factors for gender-based violence among Ethiopian university students.

BACKGROUND: There is a high prevalence of gender-based violence (GBV) victimization among young Ethiopian women, including in universities, where female enrollment is low but growing. Understanding factors contributing to GBV in this context and students' perspectives on gender, relationships, and interpersonal violence is essential to creating effective interventions to prevent GBV and support female students' rights and wellbeing. METHODS: In-depth interviews (IDIs) and focus group discussions (FGDs) were held with male and female students (male IDI n = 36, female IDI n = 34, male FGD n = 18, female FGD n = 19) and faculty and staff (FGD n = 19) at two Ethiopian universities. Audio recordings were transcribed and translated into English. Transcripts were coded thematically to identify key factors contributing to GBV and provide narratives of students' experiences. RESULTS: GBV against female students was a salient issue, including narrative accounts of harassment, intimidation, and physical and sexual violence on the university campuses and the towns in which they are located. Reported risks for GBV included receiving academic support from male peers, exercising agency in relationship decision-making, having a negative self-concept, belief in stereotypical gender expectations, and engaging in transactional sex and/or substance use. While students recognized these risk factors, they also suggested GBV may be the result of females' "improper" behavior, attire, use of males for personal gain, or personal failure to prevent violence. CONCLUSIONS: GBV is a serious issue in these two Ethiopian universities, creating a tenuous learning environment for female students. Programs are needed to address areas of vulnerability and negative attitudes toward female students in order to decrease female victimization.