Physician-brief advice for promoting smoking cessation among cancer patients on treatment in low and middle-income countries: a scoping review.

INTRODUCTION: Physician-brief advice has been utilized in high-income countries to promote smoking cessation among cancer patients. Empirical evidence on its effectiveness among cancer patients in low and middle-income countries (LMICs) is lacking. The gap could be due to inadequate training, and competing healthcare priorities, leading to insufficient implementation of targeted smoking cessation interventions in oncology settings. We undertook this scoping review to determine if physician-brief advice is effective in promoting smoking cessation among cancer patients in LMICs. METHODS: We conducted a literature search of all relevant articles across five databases: Cochrane Central Register of Controlled Trials, Cochrane Library (Tobacco Addiction Group trials), World Conference on Lung Cancer proceedings, PubMed, and Google Scholar up to November 2023, using pre-defined inclusion criteria and keywords. The study population was cancer survivors in LMICs, the intervention was smoking cessation advice by a physician in a clinic or oncology center during a consultation, and the outcome was the effect of smoking cessation programs in discontinuing smoking among cancer survivors in LMICs. RESULTS: Overall, out of every 10 cancer patients in LMICs, about seven were smokers, and one-half had received physician-brief advice for smoking cessation. Physician-brief advice was more likely to be delivered to patients with smoking-related cancer (Cohen's d = 0.396). This means that there is a noticeable difference between patients with smoking-related cancer compared to those with cancer unrelated to smoking. Smoking cessation failure was due to the inability to cope with the symptoms of withdrawal, missed smoking cessation clinic visits, mental health disorders, limited time and resources, and minimal patient-physician contact. CONCLUSION: There is very little literature on the frequency of use or the efficacy of physician-brief advice on smoking cessation in LMICs. The literature suggests that cancer patients in LMICs have low self-efficacy to quit smoking, and smoking cessation is rarely part of cancer care in LMICs. Physicians in LMICs should be trained to use motivational messages and good counseling techniques to improve smoking cessation among cancer patients. Policymakers should allocate the resources to implement physician-brief advice and design training programs for physicians focusing on physician-brief advice tailored to cancer patients.

Combining Inserts With Warning Labels on Cigarette Packs to Promote Smoking Cessation: A 2-Week Randomized Trial.

BACKGROUND: Cigarette pack inserts with messages on cessation benefits and advice are a promising labeling policy that may help promote smoking cessation. PURPOSE: To assess insert effects, with and without accompanying pictorial health warning labels(HWLs), on hypothesized psychosocial and behavioral outcomes. METHODS: We conducted a 2 × 2 between-subject randomized trial (inserts with efficacy messages vs. no inserts; large pictorial HWLs vs. small text HWLs), with 367 adults who smoked at least 10 cigarettes a day. Participants received a 14-day supply of their preferred cigarettes with packs modified to reflect their experimental condition. Over 2 weeks, we surveyed participants approximately 4-5 times a day during their smoking sessions, querying feelings about smoking, level of worry about harms from smoking, self-efficacy to cut down on cigarettes, self-efficacy to quit, hopefulness about quitting, and motivation to quit. Each evening, participants reported their perceived susceptibility to smoking harms and, for the last 24 hr, their frequency of thinking about smoking harms and cessation benefits, conversations about smoking cessation or harms, and foregoing or stubbing out cigarettes before they finished smoking. Mixed-effects ordinal and logistic models were estimated to evaluate differences between groups. RESULTS: Participants whose packs included inserts were more likely than those whose packs did not include inserts to report foregoing or stubbing out of cigarettes (OR = 2.39, 95% CI = 1.36, 4.20). Otherwise, no statistically significant associations were found between labeling conditions and outcomes. CONCLUSIONS: This study provides some evidence, albeit limited, that pack inserts with efficacy messages can promote behaviors that predict smoking cessation attempts.

Cigarette pack inserts (small leaflets inside packs) with messages about quitting benefits and tips to quit may promote smoking cessation. We randomly assigned 367 adult smokers to one of four groups: control group with small health warning labels (HWLs) on the side of packs; inserts with cessation messages and small HWLs; large picture HWLs showing health effects from smoking; inserts and large picture HWLs. Participants received a 14-day supply of their preferred cigarettes in packs that reflected their assigned group. Over 2 weeks, we surveyed participants 4­5 times a day during times when they smoked, asking their feelings about smoking and smoking-related harms, confidence to reduce cigarettes and quit, hopefulness about quitting, and motivation to quit. Each evening, participants reported on the prior 24 hr: how often they thought about smoking harms and cessation benefits; conversations about smoking cessation or harms; and foregoing or stubbing out cigarettes before they finished smoking. People whose packs had inserts (with or without picture HWLs) were more likely than those whose packs did not include inserts (control group or picture HWLs only) to report foregoing or stubbing out of cigarettes. This study provides some evidence that inserts with cessation messages may promote smoking cessation.

Evaluating The Real Cost Digital and Social Media Campaign: Longitudinal Effects of Campaign Exposure on E-cigarette Beliefs.

INTRODUCTION: Over the past decade, youth e-cigarette use has risen exponentially. At the same time, digital media use increased markedly while the use of traditional broadcast TV declined. In response, the U.S. Food and Drug Administration's The Real Cost public education campaign shifted to communicating the harms of e-cigarette via primarily digital and social platforms. This study evaluated longitudinal associations between exposure to campaign advertisements and changes in campaign-specific beliefs among US youth. METHODS: A nationally representative longitudinal cohort of youth (aged 11-16 years at baseline) was surveyed five times. Building on earlier work, we analyzed data from the last three waves (April-July 2020; January-April 2021; and August-October 2021; N = 2625). We assessed self-reported exposure to six ads and agreement with 11 beliefs that were each targeted by one or more ads. Eleven weighted panel regression models assessed whether ad exposure predicted changes in campaign-specific beliefs over time. RESULTS: We observed significant associations between ad exposure and increases in at least one campaign-specific belief for five of the six ads. Across the 11 beliefs, we observed associations between increased exposure and increases in 6 beliefs related to e-cigarettes and toxic metals, lung damage, dangerous ingredients, anxiety, cigarette use, and disappointing important people. CONCLUSIONS: We found evidence that self-reported exposure to this digital and social media campaign was successful at influencing youth, providing support for the effectiveness of the campaign's adaption to address youth's changes in tobacco and media use habits. IMPLICATIONS: The Food and Drug Administration's The Real Cost public education campaign educates youth about the dangers of e-cigarette use. This study evaluates longitudinal associations between exposure to The Real Cost's advertisements and changes in campaign-specific beliefs among youth. Considering evolving trends in youth media consumption, the campaign adapted its media approach to increase delivery across digital and social media platforms. Our findings indicate that the campaign reached its intended audience and increased youth beliefs around the harm of e-cigarettes and the consequences of e-cigarette use, offering evidence for the effectiveness of digital and social media youth prevention efforts within a fragmented digital environment.

A Critical Review of E-Cigarette Regulation in China: Challenges and Prospects for Youth Prevention and Tobacco Control.

INTRODUCTION: The increasing popularity of electronic cigarettes (e-cigarettes) has led to the emergence of public health concerns, particularly among the youth. As a major producer and exporter of e-cigarettes, China has faced public health challenges in regulating the unregulated e-cigarette industry. AIMS AND METHODS: This study aims to evaluate the regulatory development of e-cigarettes in China. We searched and obtained national policy documents related to e-cigarettes and subnational smoke-free laws from LexisNexis on August 2, 2023, which were enacted between January 1, 2023 and July 31, 2023. We used 99 policy documents for the final analysis, specifically 68 national policy documents on e-cigarettes and 31 subnational smoke-free laws. We chronologically reviewed these policy documents in full text and summarized them on the basis of their content and the requirements of the World Health Organization Framework Convention on Tobacco Control (WHO FCTC). RESULTS: Chinese policymakers established the current regulatory framework for e-cigarettes by amending, enacting, and enforcing laws and regulations. E-cigarettes are categorized as tobacco products, and the State Tobacco Monopoly Administration regulates the e-cigarette industry. The Chinese authorities prioritize youth prevention in strengthening the regulation on e-cigarettes. China adopts various tobacco control measures for e-cigarettes and cigarettes. CONCLUSIONS: China gained certain degrees of progress on tobacco control by regulating e-cigarettes and adopting measures required by the WHO FCTC. However, tobacco monopoly hinders the full realization of tobacco control goals, which necessitates the National Health Commission to assume its responsibility for the complete implementation of the WHO FCTC. IMPLICATIONS: This study presents a critical review of the development of e-cigarette regulation in China by reviewing relevant policy documents and analyzing tobacco control measures. It recognizes the degrees of progress of tobacco control measures and highlights tobacco monopoly as a significant hindrance of the full implementation of the WHO FCTC. Furthermore, empirical studies are required on the enforcement of tobacco control measures in China.

A Systematic Review of Qualitative Studies on Factors Associated With Smoking Cessation Among Adolescents and Young Adults.

OBJECTIVE: To summarize findings from qualitative studies on factors associated with smoking cessation among adolescents and young adults. DATA SOURCES: We searched Pubmed, Psychinfo, CINAHL, Embase, Web of Science, and SCOPUS databases, as well as reference lists, for peer-reviewed articles published in English or French between January 1, 2000, and November 18, 2020. We used keywords such as adolescents, determinants, cessation, smoking, and qualitative methods. STUDY SELECTION: Of 1724 records identified, we included 39 articles that used qualitative or mixed methods, targeted adolescents and young adults aged 10-24, and aimed to identify factors associated with smoking cessation or smoking reduction. DATA EXTRACTION: Two authors independently extracted the data using a standardized form. We assessed study quality using the National Institute for Health and Care Excellence checklist for qualitative studies. DATA SYNTHESIS: We used an aggregative meta-synthesis approach and identified 39 conceptually distinct factors associated with smoking cessation. We grouped them into two categories: (1) environmental factors [tobacco control policies, pro-smoking norms, smoking cessation services and interventions, influence of friends and family], and (2) individual attributes (psychological characteristics, attitudes, pre-quitting smoking behavior, nicotine dependence symptoms, and other substances use). We developed a synthetic framework that captured the factors identified, the links that connect them, and their associations with smoking cessation. CONCLUSIONS: This qualitative synthesis offers new insights on factors related to smoking cessation services, interventions, and attitudes about cessation (embarrassment when using cessation services) not reported in quantitative reviews, supplementing limited evidence for developing cessation programs for young persons who smoke. IMPLICATIONS: Using an aggregative meta-synthesis approach, this study identified 39 conceptually distinct factors grouped into two categories: Environmental factors and individual attributes. These findings highlight the importance of considering both environmental and individual factors when developing smoking cessation programs for young persons who smoke. The study also sheds light on self-conscious emotions towards cessation, such as embarrassment when using cessation services, which are often overlooked in quantitative reviews. Overall, this study has important implications for developing effective smoking cessation interventions and policies that address the complex factors influencing smoking behavior among young persons.

The Challenges of Tobacco Fiscal Policy Implementation in Mexico From the Perspective of Key Actors.

INTRODUCTION: Raising tobacco taxes is considered the most effective strategy to avoid smoking initiation and discourage its use, especially among vulnerable groups. However, few low- and middle-income countries have adopted high tobacco taxes. Raising taxes is, therefore, an opportunity to strengthen and accelerate tobacco control. The objective of this study is to analyze the barriers and facilitators to the tobacco tax increase in Mexico. AIMS AND METHODS: Based on the Governance Analytical Framework, data were generated through 17 in-depth interviews with key intersectoral actors for fiscal policy. The interviews were transcribed and coded according to Hufty's theory of governance. RESULTS: Robust scientific evidence, intersectoral coordination, and the presence of "champions" boosted progress in tobacco control (facilitators). The main barriers were the incomplete implementation of the World Health Organization-Framework Convention on Tobacco Control (WHO-FCTC) and MPOWER package and lack of commitment ("political will") by government decision makers and legislators, misinformation about the effects of tobacco taxes, and strong tobacco industry interference. CONCLUSIONS: Robust evidence is necessary but not sufficient to advance the implementation of the MPOWER (WHO-FCTC) actions. To achieve tobacco tax increases and public policies that protect people from unhealthy products in general, the implementation of policies or legal frameworks against industry interference in the development of public policies is imperative. IMPLICATIONS: By analyzing the barriers and facilitators to increasing the tobacco tax in Mexico, this study identifies two key messages: (1) The need to sensitize legislators and the general population to the problem of smoking not only through epidemiological data but also through testimonies that highlight the life experiences and adversities faced by people who smoke. (2) The need for a regulatory framework to prevent industry interference in public affairs and conflicts of interest. The same framework could be very useful for public health policies to control the consumption of ultra-processed food products or alcohol.

Tobacco Control in Denmark: How the Ugly Duckling Turned into a Swan.

INTRODUCTION: The implementation of tobacco control policies has been a neglected topic in tobacco research. A comprehensive Tobacco Action Plan including plain packaging, a point-of-sale display ban, a ban on characterizing flavors (in products other than cigarettes), a strengthening of the promotion and marketing ban, a ban on the sale of novel nicotine products to minors, smoke-and nicotine-free-school hours in all-schools with minors, and a significant increase in tobacco tax, was adopted in Denmark in 2019. AIMS AND METHODS: Eleven people involved or very close to the advocacy process were invited, two did not respond and nine attended our research center. We used the nominal group technique, a consensus method, to identify the most important driving factors for passing the Tobacco Action Plan. RESULTS: The round-robin identified 39 driving factors merged into 13 in the clarification phase. In the ranking phase, participants agreed on seven factors that they perceived have strongly influenced the political will to strengthen national tobacco control comprehensively. The most important factors were national data and evidence, a nationwide alliance with broad partnerships, a strict focus on young people, continuous media coverage, intensive lobbying by many different advocates, making it a community agenda-not a political one, and effective professional campaigns. CONCLUSIONS: Our findings agree with experiences from other countries that significantly improved tobacco control. The Danish strategy, including a nationwide alliance with broad partnerships, had a high influence on the political agenda. IMPLICATIONS: In this study, there was a consensus that seven factors strongly influenced the political will to comprehensively strengthen the national tobacco control in Denmark in a short time: national data and evidence; a nationwide alliance with broad partnerships; a strict focus on children and young people; continuous media coverage; intensive lobbying by many different advocates; making it a community agenda-not a political one, and effective professional campaigns. This is consistent with findings from other countries.

Promising Themes for Electronic Cigarette Prevention Campaigns for Youth and Young Adults.

INTRODUCTION: Electronic cigarettes (e-cigarettes) are the most widely used tobacco product by youth and young adults in the United States. Effective prevention campaigns require the identification of appropriate content focus for message construction. AIMS AND METHODS: A sample of 2622 youth and young adults ages 15-24 were recruited through social media advertisements and completed an online survey. Respondents reported current e-cigarette use or intention to use if not currently using. They also indicated agreement or disagreement with 75 e-cigarette-related beliefs representing 16 themes. The relative promise of each theme/belief for campaign messaging was investigated by examining its association with the behavior/intention outcomes and the opportunity for positive change in its distribution (room to move). RESULTS: All themes showed significant associations with the behavior (ORs = 2.49-19.04) and intention (ORs = 2.21-6.11) outcomes. Room to move for themes ranged from 32.9% to 96.3% in behavior analysis and 15.6-93.9% in intention analysis. A normed relative promise index (M = 50, SD = 17) showed flavors (72), comparison to cigarettes (69), and relaxation and mental health (68) as the top ranked themes. Subgroup analyses by demographics revealed few differences. Results on the belief level were largely consistent with those on the theme level. CONCLUSIONS: Data from this study provide timely evidence for the relative value of various themes/beliefs as potential targets for message development in e-cigarette prevention campaigns. The final selection of target themes/beliefs requires consideration of openness to persuasion, which may be informed by additional testing. IMPLICATIONS: Electronic cigarettes (e-cigarettes) are the most widely used tobacco products among youth and young adults in the United States. This study adds new evidence on the relative promise of a wide range of e-cigarette beliefs and belief clusters (themes) as potential targets for message development in educational campaigns. This evidence is important to consider in future campaign efforts directed at the youth and young adult populations in the United States.

Tobacco Imagery in Indian Over-the-Top (OTT) Media and Its Compliance With Existing Tobacco Laws: A Content Analysis.

INTRODUCTION: Over-the-top (OTT) media are internet-based content delivery systems offering media services to the viewers bypassing the traditional broadcasting platforms. The OTT media, with limited regulatory oversight, can serve as a source of exposure to tobacco-promoting content. AIMS AND METHODS: This study analyzed the depiction of tobacco imagery in Indian OTT programs and assessed their compliance with existing Indian tobacco control policies. We conducted a content analysis of 28 purposively sampled OTT exclusive programs (14 movies and 14 web series) in India. Breathe California method was used to code the OTT content for tobacco imagery. We assessed the prevalence of tobacco imagery, its duration per episode or program, product placements, and brand appearances. We also evaluated OTT programs adherence to existing tobacco control policies in India. RESULTS: Tobacco imagery was identified in all of the web series and most OTT-exclusive movies. On average the web series depicted seven incidents of tobacco imagery per episode, whereas there were close to 19 incidents of tobacco imagery per movie. Ten minutes of OTT programming (including movies and web series) had on average 8.40 s of tobacco imagery. None of the OTT programs studied fully complied with Indian tobacco control policies. CONCLUSIONS: Depiction of tobacco imagery in OTT exclusive programs is common in India. Streaming platforms need to comply with existing tobacco control policies. Furthermore, there is a need to strengthen these policies and strictly enforce them to ensure tobacco-free mass media. IMPLICATIONS: India has more than 267 million tobacco users and accounts for the largest share of smokeless tobacco use globally. OTT platforms are largely unregulated and are considered drivers for global tobacco use. This is one of the few studies examining tobacco imagery in Indian OTT content, reporting the gaps in tobacco control policies in India. This study documents the product placement of smokeless tobacco, duration of exposure to tobacco imagery, and empirically report the compliance of OTT platforms with Indian tobacco control policies. The study findings can aid in strengthening tobacco control policies in India.

Commercial Tobacco Endgame Goals: Early Experiences From Six Countries.

INTRODUCTION: Tobacco use is a major threat to health globally. A number of countries have adopted "endgame goals" to minimize smoking prevalence. The INSPIRED project aims to describe and compare the experiences of the first six countries to adopt an endgame goal. AIMS AND METHODS: Data were collected on the initial experiences of endgame goals in Canada, Finland, Ireland, New Zealand (Aotearoa), Scotland, and Sweden up to 2018. Information was collated on the nature of the endgame goals, associated interventions and strategies, potential enablers and barriers, and perceived advantages and disadvantages. RESULTS: The INSPIRED countries had relatively low smoking prevalences and moderate-to-strong smoke-free policies. Their endgame goals aimed for smoking prevalences of 5% or less. Target dates ranged from 2025 to 2035. Except for New Zealand (Aotearoa), all countries had an action plan to support their goal by 2018. However, none of the plans incorporated specific endgame measures. Lack of progress in reducing inequities was a key concern, despite the consideration of equity in all of the country's goals and/or action plans. Experience with endgame goals was generally positive; however, participants thought additional interventions would be required to equitably meet their endgame goal. CONCLUSIONS: There was variation in the nature and approach to endgame goals. This suggests that countries should consider adopting endgame goals and strategies to suit their social, cultural, and political contexts. The experiences of the INSPIRED countries suggest that further and more significant interventions will be required for the timely and equitable achievement of endgame goals. IMPLICATIONS: By 2018, six countries (Canada, Finland, Ireland, New Zealand (Aotearoa), Scotland, and Sweden) had introduced government-endorsed "endgame goals," to rapidly reduce smoking prevalence to very low levels by a specified date. The nature and implementation of endgame goals were variable. Early experiences with the goals were generally positive, but progress in reducing smoking prevalence was insufficient, particularly for priority groups. This finding suggests more significant interventions ("endgame interventions") and measures to reduce inequities need to be implemented to achieve endgame goals. Variation in the nature and experience of endgame goals demonstrates the importance of designing endgame strategies that suit distinct social, cultural, and political contexts.

Tobacco Packaging and Labeling Policies in the WHO African Region: Progress 15 Years After Adoption of the WHO Framework Convention on Tobacco Control Article 11 Implementation Guidelines.

INTRODUCTION: Article 11 of the World Health Organization's Framework Convention on Tobacco Control (WHO FCTC) requires Parties to adopt and implement effective tobacco packaging and labeling policies to communicate health risks and reduce tobacco consumption. AIMS AND METHODS: The goal of this study was to assess adoption of these policies in the WHO African Region (AFRO). We reviewed tobacco packaging and labeling policies adopted in AFRO from the Campaign for Tobacco-Free Kids' Tobacco Control Laws database (www.tobaccocontrollaws.org). We assessed these policies based on WHO FCTC Article 11 and its Implementation Guidelines examining three subpolicy areas (health warning labels [HWLs], descriptive constituents and emissions information, and misleading packaging and labeling). We developed a scoring system to rank AFRO countries individually and by the World Bank's income-level groups, and documented the progress during 1985-2023. RESULTS: Forty (of 47) AFRO countries adopted national laws, of which a majority adopted large rotating pictorial HWLs and banned misleading descriptors; only Cote d'Ivoire and Mauritius adopted standardized packaging. The higher a country is in the World Bank's income-level group, the stronger their packaging and labeling policies. This observation was not present in the HWLs subpolicy area. Prior to approving the WHO FCTC Article 11 Implementation Guidelines, only 23 countries adopted text-only HWLs, whereas 26 countries adopted pictorial HWLs after the approval. CONCLUSIONS: Several AFRO countries have adopted tobacco packaging and labeling policies that align with the WHO FCTC Article 11 Implementation Guidelines. More efforts could be directed toward the low-income group and disseminating standardized packaging throughout AFRO. IMPLICATIONS: In the AFRO, the number of tobacco users is increasing, highlighting the need for tobacco packaging and labeling policies aligned with WHO FCTC Article 11 and its Implementation Guidelines as these are proven tobacco control strategies. This study provides a country- and income-level group ranking of tobacco packaging and labeling policies, and documents the evolution of HWLs adopted in AFRO. It also identifies regional and income-level group successes and gaps in tobacco product packaging and labeling policies and provides recommendations to further align with WHO FCTC Article 11 and its Implementation Guidelines.

Exposure to cigarette taxes as a teenager and the persistence of smoking into adulthood.

Are teenage and adult smoking causally related? Recent anti-tobacco policy is predicated on the assumption that preventing teenagers from smoking will ensure that fewer adults smoke, but direct evidence in support of this assumption is scant. Using data from three nationally representative sources and instrumenting for teenage smoking with cigarette taxes experienced at ages 14-17, we document a strong positive relationship between teenage and adult smoking: deterring 10 teenagers from smoking through raising cigarette taxes roughly translates into 5 fewer adult smokers. We conclude that efforts to reduce teenage smoking can have long-lasting consequences on smoking participation and, presumably, health.

Advancing progress on tobacco control in low-income and middle-income countries through economic analysis.

BACKGROUND: More than 80% of the world's 1.3 billion tobacco users live in low-income and middle-income countries (LMICs), where progress to address tobacco and its harms has been slow. The perception that tobacco control detracts from economic priorities has impeded progress. The Secretariat of the WHO Framework Convention on Tobacco Control (FCTC) is leading the FCTC 2030 project, which includes technical assistance to LMICs to analyse the economic costs of tobacco use and the benefits of tobacco control. METHODS: The Secretariat of the WHO FCTC, United Nations Development Programme and WHO supported 21 LMICs between 2017 and 2022 to complete national investment cases to guide country implementation of the WHO FCTC, with analytical support provided by RTI International. These country-level cases combine customised estimates of tobacco's economic impact with qualitative analysis of socio-political factors influencing tobacco control. This paper overviews the approach, observed tobacco control advancements and learnings from 21 countries: Armenia, Cabo Verde, Cambodia, Chad, Colombia, Costa Rica, El Salvador, Eswatini, Georgia, Ghana, Jordan, Laos, Madagascar, Myanmar, Nepal, Samoa, Sierra Leone, Sri Lanka, Suriname, Tunisia and Zambia. RESULTS: Tobacco control advancements in line with investment case findings and recommendations have been observed in 17 of the 21 countries, and many have improved collaboration and policy coherence between health and economic stakeholders. CONCLUSIONS: Tobacco control must be seen as more than a health concern. Tobacco control leads to economic benefits and contributes to sustainable development. National investment cases can support country ownership and leadership to advance tobacco control.

Interpreting results, impacts and implications from WHO FCTC tobacco control investment cases in 21 low-income and middle-income countries.

BACKGROUND: Tobacco control investment cases analyse the health and socioeconomic costs of tobacco use and the benefits that can be achieved from implementing measures outlined in the WHO Framework Convention on Tobacco Control (WHO FCTC). They are intended to provide policy-makers and other stakeholders with country-level evidence that is relevant, useful and responsive to national priorities and policy context. METHODS: This paper synthesises findings from investment cases conducted in Armenia, Cabo Verde, Cambodia, Chad, Colombia, Costa Rica, El Salvador, Eswatini, Georgia, Ghana, Jordan, Laos, Madagascar, Myanmar, Nepal, Samoa, Sierra Leone, Sri Lanka, Suriname, Tunisia and Zambia. We examine annual socioeconomic costs associated with tobacco use, focusing on smoking-related healthcare expenditures, the value of lives lost due to tobacco-related mortality and workplace productivity losses due to smoking. We explore potential benefits associated with WHO FCTC tobacco demand-reduction measures. RESULTS: Tobacco use results in average annual socioeconomic losses of US$95 million, US$610 million and US$1.6 billion among the low-income (n=3), lower-middle-income (n=12) and upper-middle-income countries (n=6) included in this analysis, respectively. These losses are equal to 1.1%, 1.8% and 2.9% of average annual national gross domestic product, respectively. Implementation and enforcement of WHO FCTC tobacco demand-reduction measures would lead to reduced tobacco use, fewer tobacco-related deaths and reduced socioeconomic losses. CONCLUSIONS: WHO FCTC tobacco control measures would provide a positive return on investment in every country analysed.

Evolving methodology of national tobacco control investment cases.

BACKGROUND: This article describes an investment case methodology for tobacco control that was applied in 36 countries between 2017 and 2022. METHODS: The WHO Framework Convention on Tobacco Control (FCTC) investment cases compared two scenarios: a base case that calculated the tobacco-attributable mortality, morbidity and economic costs with status quo tobacco control, and an intervention scenario that described changes in those same outcomes from fully implementing and enforcing a variety of proven, evidence-based tobacco control policies and interventions. Health consequences included the tobacco-attributable share of mortality and morbidity from 38 diseases. The healthcare expenditures and the socioeconomic costs from the prevalence of those conditions were combined to calculate the total losses due to tobacco. The monetised benefits of improvements in health resulting from tobacco control implementation were compared with costs of expanding tobacco control to assess returns on investment in each country. An institutional and context analysis assessed the political and economic dimensions of tobacco control in each context. RESULTS: We applied a rigorous yet flexible methodology in 36 countries over 5 years. The replicable model and framework may be used to inform development of tobacco control cases in countries worldwide. CONCLUSION: Investment cases constitute a tool that development partners and advocates have demanded in even greater numbers. The economic argument for tobacco control provided by this set of country-contextualised analyses can be a strong tool for policy change.

Equity implications of tobacco taxation: results from WHO FCTC investment cases.

BACKGROUND: Across time, geographies and country income levels, smoking prevalence is highest among people with lower incomes. Smoking causes further impoverishment of those on the lower end of the income spectrum through expenditure on tobacco and greater risk of ill health. METHODS: This paper summarises the results of investment case equity analyses for 19 countries, presenting the effects of increased taxation on smoking prevalence, health and expenditures. We disaggregate the number of people who smoke, smoking-attributable mortality and cigarette expenditures using smoking prevalence data by income quintile. A uniform 30% increase in price was applied across countries. We estimated the effects of the price increase on smoking prevalence, mortality and cigarette expenditures. RESULTS: In all but one country (Bhutan), a one-time 30% increase in price would reduce smoking prevalence by the largest percent among the poorest 20% of the population. All income groups in all countries would spend more on cigarettes with a 30% increase in price. However, the poorest 20% would pay an average of 12% of the additional money spent. CONCLUSIONS: Our results confirm that health benefits from increases in price through taxation are pro-poor. Even in countries where smoking prevalence is higher among wealthier groups, increasing prices can still be pro-poor due to variable responsiveness to higher prices. The costs associated with higher smoking prevalence among the poor, together with often limited access to healthcare services and displaced spending on basic needs, result in health inequality and perpetuate the cycle of poverty.