Defending Comprehensive Tobacco Control Policy Implementation in Nepal From Tobacco Industry Interference (2011-2018).

INTRODUCTION: Nepal passed a comprehensive tobacco control law in 2011. Tobacco control advocates successfully countered tobacco industry (TI) interference to force implementation of law. AIMS AND METHODS: Policy documents, news stories, and key informant interviews were triangulated and interpreted using the Policy Dystopia Model (PDM). RESULTS: The TI tried to block and weaken the law after Parliament passed it. Tobacco control advocates used litigation to force implementation of the law while the TI used litigation in an effort to block implementation. The TI argued that tobacco was socially and economically important, and used front groups to weaken the law. Tobacco control advocates mobilized the media, launched public awareness campaigns, educated the legislature, utilized lawsuits, and monitored TI activities to successfully counter TI opposition. CONCLUSIONS: Both tobacco control advocates and the industry used the discursive and instrumental strategies described in the PDM. The model was helpful for understanding TI activities in Nepal and could be applied to other low- and middle-income countries. Civil society, with the help of international health groups, should continue to track TI interference and learn the lessons from other countries to proactively to counter it. IMPLICATIONS: The PDM provides an effective framework to understand battles over implementation of a strong tobacco control law in Nepal, a low- and middle-income country. The TI applied discursive and instrumental strategies in Nepal in its efforts to weaken and delay the implementation of the law at every stage of implementation. It is important to continuously monitor TI activities and learn lessons from other countries, as the industry often employ the same strategies globally. Tobacco control advocates utilized domestic litigation, media advocacy, and engaged with legislators, politicians, and other stakeholders to implement a strong tobacco control law. Other low- and middle-income countries can adapt these lessons from Nepal to achieve effective implementation of their laws.

Implementing and Evaluating a Mentor Training to Improve Support for Early-Career Scholars in Tobacco Regulatory Science.

INTRODUCTION: To implement and evaluate a blended online and in-person training to help mentors of early-career researchers appreciate the complexities of Tobacco Regulatory Science (TRS), refine TRS mentoring skills, and become acquainted with resources for providing effective guidance to TRS mentees. METHODS: TRS mentors engaged in a two-part pilot test of the training program. Authors evaluated both the online and in-person training using retrospective pre-post evaluations, which measure learning at the conclusion of a training program, and post-program focus groups. Twenty learners completed the online training, and 16 learners attended the in-person training module. Nine participants completed evaluations for the online module, and 12 participants completed evaluations for the in-person module. RESULTS: Program assessments revealed that participants found that the training achieved its overall goals. The majority of respondents (87.5%) rated the online portion of the training as valuable. For the in-person training, participants reported statistically significant improvements regarding confidence in: helping mentees to identify skills and training to effectively pursue TRS, assisting mentees in weighing career trajectories, and guiding mentees in conducting research responsive to TRS regulatory priorities. CONCLUSIONS: The novel mentoring program was well received by faculty seeking to strengthen skills for mentoring early-career TRS researchers to navigate the complex landscape of TRS, explore diverse funding opportunities, and discern potential career trajectories. It provided unique content to address issues outside the traditional tobacco research training curriculum and offered specific information on regulatory policies, priorities, and opportunities. IMPLICATIONS: This research documents the deployment and evaluation of a blended online and in-person training program for investigators mentoring early-career researchers working in TRS. Our assessment discovered that participants found the training to be valuable to their overall mentoring objectives. The training comprises a novel curriculum for investigators engaged in mentoring early-career researchers in a unique field, thus filling a deficit in the published literature by presenting a curriculum that has been customized to the unique needs of TRS mentors.

Policies for Tobacco and E-Cigarette Use: A Survey of All Higher Education Institutions and NHS Trusts in England.

INTRODUCTION: There is an absence of evidence regarding the impact of treating tobacco smoking and vaping equivalently in workplace policies. We aimed to describe and compare smoking and vaping policies in acute nonspecialist NHS Trusts (n = 131) and Higher Education Institutions (HEIs) (n = 131) in England. METHODS: We conducted a census of smoking and vaping policies through organizational websites searches and direct requests for information. We recorded whether and where smoking and vaping were permitted. RESULTS: Smoking was prohibited indoors in all organizations. No NHS Trust permitted smoking freely outdoors, in contrast with 60% of HEIs. In 27% of NHS Trusts and 33% of HEIs smoking was permitted in designated areas, while in 73% of NHS Trusts and 8% of HEIs smoking was prohibited anywhere on site. Vaping was prohibited indoors in all NHS Trusts and all but one HEI, but permitted freely outdoors in 18% of NHS Trusts and 75% of HEIs. Vaping was permitted in designated outdoor spaces in 23% of NHS Trusts: 21% had areas shared with smokers; 2% had separate vaping areas. Vaping was permitted in designated outdoor areas in 18% of HEIs, all of which were shared with smokers. Vaping was prohibited anywhere on site in 54% of NHS Trusts and 6% of HEIs. CONCLUSIONS: Policies vary considerably in whether vaping and smoking are treated equivalently. Smoking policies in most HEIs should be reviewed to include more effective tobacco control approaches. Evidence is needed on the impact of imposing shared or separate spaces on vapers and smokers. IMPLICATIONS: This report provides a comprehensive review of smoking and vaping policies in two types of organization across England. It highlights key discrepancies between current public health recommendations for vaping and existing workplace policies, which often lead to smokers and vapers sharing spaces. The report identifies the need for evidence on the impact of imposing shared spaces on smokers and vapers to inform workplace policies that maximize public health benefit.

Youth Access to Cigarettes Across Seven European Countries: A Mixed-Methods Study.

BACKGROUND: Despite widespread age-of-sale restrictions on tobacco, adolescents continue to obtain cigarettes and experiment with smoking. This mixed-methods study aimed to understand how European adolescents access cigarettes and how the policy context may influence this process, using a realist evaluation approach. This is the first study to assess access to cigarettes across various European contexts. METHODS: A survey of 4104 students was combined with qualitative data from focus groups among 319 adolescents aged 14-19 across seven European countries. Data were synthesized to explore mechanisms via which young people obtain cigarettes despite age-of-sale restrictions. RESULTS: While purchasing cigarettes from supermarkets was widely regarded as difficult, many participants purchased cigarettes from noncompliant retailers (often in smaller shops or cafes). Other contra-mechanisms included circumventing age checks, proxy purchases, and/or social sources. Dominant forms of access differed across the seven contexts, with direct purchases more common where perceived enforcement was low (eg, Belgium) and proxy purchases more important where perceived enforcement of age-of-sale laws was high (eg, Finland). The effectiveness of age-of-sale restrictions in reducing youth access appears to be influenced by a range of contextual factors including retailer compliance, the availability of vending machines, and the specific minimum age-of-sale. CONCLUSIONS: Our findings illustrate the relevance of programme theory in understanding the contra-mechanisms that undermine the effectiveness of age-of-sale laws in discouraging youth smoking. Young people's access to cigarettes could be further limited by addressing these contra-mechanisms, including an increase in the legal sales age (particularly in Belgium), banning vending machines, and strengthening enforcement. IMPLICATIONS: Despite widespread implementation of age-of-sale laws, a substantial proportion of minors continue to access cigarettes. Young people use a number of contra-mechanisms to circumvent age-of-sale restrictions. These include accessing cigarettes via social sources, proxy sales or by circumventing age checks. Our findings show that in contexts where perceived enforcement of age-of-sale restrictions is high, young people are more reliant on irregular forms of access such as proxy sales. Young people's access to cigarettes may be further reduced by policy interventions that address these contra-mechanisms-for example, banning vending machines, strengthening enforcement of age-of-sale laws, and increasing the minimum age-of-sale.

Economic Evaluation of Five Tobacco Control Policies Across Seven European Countries.

INTRODUCTION: Economic evaluations of tobacco control policies targeting adolescents are scarce. Few take into account real-world, large-scale implementation costs; few compare cost-effectiveness of different policies across different countries. We assessed the cost-effectiveness of five tobacco control policies (nonschool bans, including bans on sales to minors, bans on smoking in public places, bans on advertising at points-of-sale, school smoke-free bans, and school education programs), implemented in 2016 in Finland, Ireland, the Netherlands, Belgium, Germany, Italy, and Portugal. METHODS: Cost-effectiveness estimates were calculated per country and per policy, from the State perspective. Costs were collected by combining quantitative questionnaires with semi-structured interviews on how policies were implemented in each setting, in real practice. Short-term effectiveness was based on the literature, and long-term effectiveness was modeled using the DYNAMO-HIA tool. Discount rates of 3.5% were used for costs and effectiveness. Sensitivity analyses considered 1%-50% short-term effectiveness estimates, highest cost estimates, and undiscounted effectiveness. FINDINGS: Nonschool bans cost up to €253.23 per healthy life year, school smoking bans up to €91.87 per healthy life year, and school education programs up to €481.35 per healthy life year. Cost-effectiveness depended on the costs of implementation, short-term effectiveness, initial smoking rates, dimension of the target population, and weight of smoking in overall mortality and morbidity. CONCLUSIONS: All five policies were highly cost-effective in all countries according to the World Health Organization thresholds for public health interventions. Cost-effectiveness was preserved even when using the highest costs and most conservative effectiveness estimates. IMPLICATIONS: Economic evaluations using real-world data on tobacco control policies implemented at a large scale are scarce, especially considering nonschool bans targeting adolescents. We assessed the cost-effectiveness of five tobacco control policies implemented in 2016 in Finland, Ireland, the Netherlands, Belgium, Germany, Italy, and Portugal. This study shows that all five policies were highly cost-effective considering the World Health Organization threshold, even when considering the highest costs and most conservative effectiveness estimates.

Differences in smokers' awareness of the health risks of smoking before and after introducing pictorial tobacco health warnings: findings from the 2012-2017 international tobacco control (ITC) Netherlands surveys.

BACKGROUND: As of May 2016, pictorial health warnings (PHWs) showing the harms of smoking were implemented in the European Union. After one year they had to be fully implemented. We studied changes in awareness of the health risks of smoking after implementation of PHWs among smokers from the Netherlands, whether the trend before the implementation changed after the implementation, and whether there were differences between subgroups. METHODS: We used survey data from six yearly waves of the International Tobacco Control (ITC) Netherlands Survey from 2012 to 2017. The number of participating smokers ranged between 1236 and 1604 per wave. Data were analyzed using Generalized Estimating Equations (GEE) analyses. RESULTS: Indicators of awareness of the health risks of smoking that did not change between 2015 and 2017 were perceived susceptibility (ß = 0.043, p = 0.059) and perceived severity (ß = - 0.006, p = 0.679) regarding lung problems. Perceived susceptibility, however, was more pronounced between 2015 and 2017 than between 2012 and 2015(p value of interaction: p = 0.044). Noticing information about the dangers of smoking (ß = 0.119, p < 0.001) and knowledge about the health risks of smoking (ß = 0.184, p < 0.001) increased between 2015 and 2017. These increases were both more pronounced when compared to 2012-2015 (p values of interactions: p = 0.002 and p < 0.001 respectively). Compared to high educated smokers, low educated smokers (ß = - 1.137, p < 0.001) and moderate educated smokers (ß = - 0.894, p < 0.001) were less knowledgeable about the health risks of smoking in 2016 and 2017. CONCLUSIONS: Introducing PHWs coincided with an increase in smokers' knowledge about the health risks of smoking. Dutch tobacco control policy and campaigns should focus on improving Dutch smokers' awareness of the health risks of smoking even more, especially among low educated smokers.

Menthol additives to tobacco products. Reasons for withdrawing mentholated cigarettes in European Union on 20th may 2020 according to tobacco products directive (2014/40/EU).

Menthol, which is a natural cyclic monoterpene alcohol with a minty smell, is one of the main constituents of essential oils that naturally occur in some aromatic plants, such as Mentha × piperita L. This natural compound shows many biological properties, such as anesthetic, analgesic, antibacterial and antifungal, immunomodulating, and skin penetration-enhancing. It is added to a variety of goods, such as food, oral-care products, OTC products, cosmetics, and tobacco products. Menthol is not just a simple flavoring agent, especially when it comes to tobacco products. Its ability to 'mask' the negative effects of nicotine and its additional positive sensory effects makes it the most common additive in such products. For the customers, mentholated tobacco products may be mistakenly perceived as less harmful for health, which may increase their consumption. However, as the evidence shows, menthol cigarettes are no safer than conventional cigarettes and may lead to more frequent disease exacerbation during prolonged exposure to smoke from such products. In addition, because of its complex interactions with nicotine, menthol may affect smoking behavior and may increase addiction to nicotine. For those reasons, the European Union banned flavored cigarettes (whose sale size reached more than 3% of the total tobacco product market) by implementing the Tobacco Products Directive (2014/40/EU) on 20th May 2020. While the menthol ban was based on health concerns, the ultimate effect on consumers, regarding potential quitting, is yet to be determined.

Indexation of Tobacco Excise and Customs Duty and Smoking Prevalence Among Australian Adults, 2001-2010: A Serial Cross-sectional Study.

INTRODUCTION: Australia's excise and customs duty on tobacco has been automatically increased biannually since 1984. Increases in duty on par with inflation ensured that tobacco stayed at least as costly as other goods. This would be expected to maintain, rather than drive down, smoking prevalence. We examined the association between smoking prevalence and duty over a 10-year period. METHODS: Using monthly data from five Australian capital cities, collected from March 2001 to March 2010 among Australians aged at least 18 years, multiple linear regression modeled associations between smoking prevalence and the two components (duty and non-duty) of the recommended retail price of an average packet of cigarettes, adjusting for policy covariates. RESULTS: Prevalence declined from 23.6% in March 2001 to 17.0% in March 2010 [absolute difference 6.6%; 95% confidence interval (CI) = 6.5 to 6.8]. Duty increased from $0.2026 to $0.2622 per cigarette over the same period. In the adjusted model, a 1-cent increase in the duty component of price was not associated with changes in prevalence (0.019; 95% CI = -0.035 to 0.028). Increased non-duty component of price was associated with a decline in prevalence (-0.027; 95% CI = -0.052 to -0.002). This effect was stronger when changes in income were controlled for. CONCLUSIONS: In line with expectations, inflation-adjusted duty was not associated with changes in smoking prevalence, but it may have prevented upward pressure on prevalence that increasing affordability could have exerted. Frequent increases in duty greater than the growth in both wages and goods would more effectively reduce smoking than regular indexation. IMPLICATIONS: Few countries inflation-adjusted excise duty to ensure that tobacco products do not become more affordable; however, Australia experienced a decade of inflation adjustment alone, enabling the impact of this policy to be studied. This study shows that inflation-adjusted duty likely did prevent tobacco becoming more affordable and that indexation was associated with declines in smoking when tobacco companies over-shifted the duty rises (ie, increased price over and above duty rises).The study also suggests that frequent increases in taxation that exceed both wage growth and increases in costliness of other goods are needed to prompt increased rates of quitting.

Policies that limit youth access and exposure to tobacco: a scientific neglect of the first stages of the policy process.

BACKGROUND: Policymakers can adopt and implement various supply-side policies to limit youth access and exposure to tobacco, such as increasing the minimum age of sale, limiting the number or type of tobacco outlets, or banning the display of tobacco products. Many studies have assessed the impact of these policies, while less is known about the preceding policy process. The aim of our review was to assess the available evidence on the preceding process of agenda setting, policy formulation, and policy legitimation. METHODS: A systematic literature search was conducted using the PubMed and the Social Sciences Citation Index databases. After selection, 200 international peer-reviewed articles were identified and analyzed. Through a process of close reading, evidence based on scientific enquiry and anecdotal evidence on agenda setting, policy formulation and policy legitimation was abstracted from each article. RESULTS: Scientific evidence on the policy process is scarce for these policies, as most of the evidence found was anecdotal. Only one study provided evidence based on a scientific analysis of data on the agenda setting and legitimation phases of policy processes that led to the adoption of display bans in two Australian jurisdictions. CONCLUSION: The processes influencing the adoption of youth access and exposure policies have been grossly understudied. A better understanding of the policy process is essential to understand country variations in tobacco control policy.

Smoking in bars in eight European countries in 2010 and 2016: an observational comparative study.

Background: Most European countries established laws against smoking in public places. We aimed to describe the prevalence of smoking in bars in 2010 and 2016 in eight European countries and to characterise those bars in which smoking still occurred in 2016. Methods: Smoking in bars was studied in 16 cities in 8 European countries (Austria, Belgium, Czech Republic, Denmark, England, France, Germany and the Netherlands). In 2010, 96 bars were visited. In 2016, 51 bars were revisited and 45 new bars were visited. Smoking indoors and characteristics of bars, terrace and customers were observed using a standard observation template. Associations between bar characteristics and smoking were analyzed using logistic regression. Results: Overall prevalence of in-bar smoking was 39.6% in 2010 and 34.4% in 2016. Prevalence in bars covered by smoke-free legislation decreased from 24.2 to 13.0% between 2010 and 2016 whereas prevalence in bars where smoking was legally allowed increased from 73.3 to 88.9%. In-bar smoking almost exclusively occurred in countries with partial smoke-free legislation compared with more comprehensive legislation. Smoking was more prevalent in bars for locals, with a counter for drinks, slot-machines, no outside seating and no food service. Size of the bar, comfort of the terrace and the presence of cigarette vending machines were not associated with in-bar smoking. Conclusions: Whereas comprehensive smoke-free legislation resulted in high compliance, smoking increased in bars in countries with partial or no smoke-free legislation. This study confirms that comprehensive smoke-free legislation is needed to protect customers and personnel against second-hand-smoke exposure in all bars.

Exposure to second-hand smoke in the context of tobacco policy changes in Estonia, 1996-2016.

BACKGROUND: Exposure to second-hand smoke (SHS) is a preventable cause of disease and disability that can effectively be tackled by tobacco legislation. The aim of the study was to analyse the trends of SHS exposure and its sociodemographic patterning during 1996-2016 in the context of tobacco policy changes in Estonia. METHODS: Nationally representative data from biennial health surveys in 1996-2016 (n = 14 629) were used to present prevalence ratios for SHS exposure among non-smokers in Estonia. Joinpoint regression and multivariable logistic regression were used to study the sociodemographic and socio-economic differences in SHS exposure and its changes during the period. RESULTS: Exposure to SHS among non-smoking men and women has declined 3.6 and 5 times, respectively, during 1996-2016. While the rate of change was constant among men throughout the period, the decline in SHS exposure among women became significantly faster after 2006 compared with the previous period. However, 15.6% [95% confidence interval (CI) 13.1-18.3%] of men and 8.8% (95% CI 7.1-10.6%) of women were still exposed to SHS in 2016 with higher odds found for younger age groups, non-Estonians and those with lower education and income. CONCLUSIONS: The consistently declining prevalence of SHS exposure among non-smoking population can be at least partially attributed to implementation of tobacco legislations in 2000s. However, the existing sociodemographic and socio-economic differences in SHS exposure require further attention as those in more vulnerable positions are also more exposed to SHS-related health harms.

Childcare Providers' Possession or Use of Marijuana, Tobacco, or Alcohol While Caring for Children: A Comparison of US State Regulations.

OBJECTIVES: To evaluate US state regulations regarding marijuana, tobacco, and alcohol to determine the extent to which states attempt to govern these substances in early care and education (ECE) settings. METHODS: Two independent reviewers assessed regulations enacted by December 2016 for all states and the District of Columbia. Reviewers compared regulations to national standards on the possession or use of marijuana, tobacco, and alcohol in ECE settings. RESULTS: Fewer states regulated marijuana than tobacco or alcohol in ECE settings. More states restricted the use of these 3 substances than they restricted the possession of them. CONCLUSIONS: Most states address alcohol or tobacco possession or use in their regulations but should consider updating these provisions to align with national standards. Public Health Implications. Updating and strengthening state childcare regulations regarding marijuana, tobacco, and alcohol possession and use may help protect children in ECE settings, where many children spend a substantial portion of time. As more states legalize marijuana, they may consider updating their regulations and including precise language to better protect children from unintended pediatric marijuana exposure or impaired childcare providers.

How can a ban on tobacco sales to minors be effective in changing smoking behaviour among youth? - A realist review.

The aim of the study was to understand, from the perspective of youth, how and under which circumstances a ban on tobacco sales to minors can be effective in influencing youth smoking behaviour. We searched Medline, Embase, and PsychINFO in February 2016. A systematic search for studies about a ban on sales to minors and smoking behaviour was performed. Only studies that addressed potential mechanisms were included, resulting in thirty-three studies. We extracted evidence from 26 quantitative, 5 qualitative, and 2 mixed-methods studies, explaining how the ban may be effective in reducing smoking behaviour, and contextual factors that may influence these mechanisms. We identified two mechanisms and three contra-mechanisms. First, when direct access to commercial sources is limited, cigarette consumption may be reduced because minors have restricted access to commercial cigarettes. Minors' access to social sources and the various ways in which they continue to buy cigarettes by circumventing the ban, are two contra-mechanisms that undermine this effect. Second, when the ban is strongly enforced, an anti-smoking norm may be created and adolescents may smoke less as a result. One contra-mechanism may possibly undermine this effect: the 'forbidden fruit' effect. Whether these (contra-)mechanisms occur depends on contextual and individual factors such as level of enforcement, the minors' social network, and their dependence on smoking. The ban can be effective if well enforced. However, minors' access to social sources and their ways to circumvent the ban should be addressed to achieve its full potential.

Geographical Inequality in Tobacco Control in China: Multilevel Evidence From 98†058 Participants.

Background: We investigated the spatial patterning and correlates of tobacco smoking, exposure to secondhand smoke, smoking in public places, workplace smoking prohibition, pro- and counter-tobacco advertisements in mainland China. Methods: Choropleth maps and multilevel models were used to assess geographical variation and correlates of the aforementioned outcome variables for 98 058 participants across 31 provinces of China in 2010. Results: Current tobacco smoking prevalence was higher in the central provinces for men and in the north eastern provinces and Tibet for women. Secondhand smoke was higher for both genders in Qinghai and Hunan provinces. Workplace tobacco restrictions was higher in the north and east, whereas smoking in public places was more common in the west, central, and far northeast. Protobacco advertising was observed in public places more often by men (18.5%) than women (13.1%). Men (35.5%) were also more likely to sight counter-tobacco advertising in public places than women (30.1%). Awareness of workplace tobacco restrictions was more common in affluent urban areas. Lower awareness of workplace tobacco restrictions was in less affluent urban and rural areas. Sightings of tobacco smoking in public places was highest in restaurants (80.4% for men, 75.0% for women) and also commonly reported in less affluent urban and rural areas. Exposure to secondhand smoke was lower among women (but not men) where workplace tobacco restrictions was more common and higher regardless of gender in areas where smoking in public places was more commonly observed. Conclusions: Geographical and gender-sensitive targeting of tobacco prevention and control initiatives are warranted. Implications: This study demonstrates spatial patterning of China's 300 million smokers across the country that are different for men and women. Many of the factors that influence tobacco use, such as pro- and counter-advertising, also vary geographically. Workplace smoking restrictions are more commonly reported among individuals with higher educational attainment, but this not does appear to translate into reduced exposure to secondhand smoke. There is a need to intervene in other contexts, especially in restaurants and on public transport. Geographically targeted and gender-sensitive policy is required to advance effective tobacco control and prevention of noncommunicable diseases across all of China.

UK news media representations of smoking, smoking policies and tobacco bans in prisons.

BACKGROUND: Prisoner smoking rates remain high, resulting in secondhand smoke exposures for prison staff and non-smoker prisoners. Several jurisdictions have introduced prison smoking bans with little evidence of resulting disorder. Successful implementation of such bans requires staff support. As news media representations of health and other issues shape public views and as prison smoking bans are being introduced in the UK, we conducted content analysis of UK news media to explore representations of smoking in prisons and smoke-free prisons. METHODS: We searched 64 national and local newspapers and 5 broadcast media published over 17 months during 2015-2016, and conducted thematic analysis of relevant coverage in 106 articles/broadcasts. RESULTS: Coverage was relatively infrequent and lacked in-depth engagement with the issues. It tended to reinforce a negative view of prisoners, avoid explicit concern for prisoner or prison staff health and largely ignore the health gains of smoke-free policies. Most coverage failed to discuss appropriate responses or support for cessation in the prison context, or factors associated with high prisoner smoking rates. Half the articles/broadcasts included coverage suggesting smoke-free prisons might lead to unrest or instability. CONCLUSIONS: Negative news media representations of prisoners and prison smoking bans may impact key stakeholders' views (eg, prison staff, policy-makers) on the introduction of smoke-free prison policies. Policy-makers' communications when engaging in discussion around smoke-free prison policies should draw on the generally smooth transitions to smoke-free prisons to date, and on evidence on health benefits of smoke-free environments and smoking cessation.

Impacts of Canada's minimum age for tobacco sales (MATS) laws on youth smoking behaviour, 2000-2014.

BACKGROUND: Recently, the US Institute of Medicine has proposed that raising the minimum age for tobacco purchasing/sales to 21 years would likely lead to reductions in smoking behavior among young people. Surprisingly few studies, however, have assessed the potential impacts of minimum-age tobacco restrictions on youth smoking. OBJECTIVE: To estimate the impacts of Canadian minimum age for tobacco sales (MATS) laws on youth smoking behaviour. DESIGN: A regression-discontinuity design, using seven merged cycles of the Canadian Community Health Survey, 2000-2014. PARTICIPANTS: Survey respondents aged 14-22 years (n=98 320). EXPOSURE: Current Canadian MATS laws are 18 years in Alberta, Saskatchewan, Manitoba, Quebec, the Yukon and Northwest Territories, and 19 years of age in the rest of the country. MAIN OUTCOMES: Current, occasional and daily smoking status; smoking frequency and intensity; and average monthly cigarette consumption. RESULTS: In comparison to age groups slightly younger than the MATS, those just older had significant and abrupt increases immediately after the MATS in the prevalence of current smokers (absolute increase: 2.71%; 95% CI 0.70% to 4.80%; P=0.009) and daily smokers (absolute increase: 2.43%; 95% CI 0.74% to 4.12%; P=0.005). Average past-month cigarette consumption within age groups increased immediately following the MATS by 18% (95% CI 3% to 39%; P=0.02). There was no evidence of significant increases in smoking intensity for daily or occasional smokers after release from MATS restrictions. CONCLUSION: The study provides relevant evidence supporting the effectiveness of Canadian MATS laws for limiting smoking among tobacco-restricted youth.

Variation across Romania in the health impact of increasing tobacco taxation.

Background: Tobacco is the leading preventable cause of death globally and tobacco taxation is a cost-effective method of reducing tobacco use in countries and increasing revenue. However, without adequate enforcement some argue the risk of increasing illicit trade in cheap tobacco makes taxation ineffective. We explore this by testing sub-national variations in the impact of tobacco tax increases from 2009 to 2011, on seven smoking-related diseases in adults in Romania, to see if regions that are prone to cigarette smuggling due to bordering other countries see less benefit. Method: We use a pragmatic natural experiment study approach to analyse the study period 2009-15. Findings from hospital episodes data relating to smoking-attributable diseases are analysed for six regional subgroups which are compared according to border characteristics with other countries. Results: At a national level smoking-attributable diseases reduced over the study period especially around the tax increase years, with asthma showing the most significant decline. Sub-nationally there was no statistically significant correlation in variations between central regions and those bordering other countries. Conclusion: There is a reassuring decline in hospitalizations for smoking-related diseases associated with the tax increases, and no sub-national association with smuggling risk measured by variation in the size of this effect and regions that border other countries. More comprehensive and progressive tobacco control in Romania should be implemented in line with the WHO Framework Convention for Tobacco Control.

A Multi-Year Study of Tobacco Control in Newspaper Editorials Using Community Characteristic Data and Content Analysis Findings.

We content analyzed 1,473 newspaper editorials for topic, tone, and slant, and connected the results to community characteristic data: clean indoor air ordinance status for cities, and official smoking rates for counties. The analysis occurred during a multi-year project aimed at prompting communities to adopt clean indoor air policies. The results showed that most editorials were about tobacco restrictions or ordinances, were neutral in tone, and provided factual information about tobacco control. More editorials were negatively slanted vs. positively slanted toward tobacco control. Most editorials with positive tones were published in newspapers in towns that already had clean indoor air policies. We concluded that editorials might hold increased weight in spurring change, as the percentage of smokers in a city is unrelated to the town enacting a clean indoor air ordinance.