Do cigarette health warning labels comply with requirements: A 14-country study.

The Framework Convention on Tobacco Control, a global health treaty ratified by over 175 countries, calls on countries to ensure that tobacco packages carry health warning labels (HWLs) describing the harmful effects of tobacco use. We assessed the extent of compliance with 14 countries' HWL requirements. Unique cigarette packs were purchased in 2013 using a systematic protocol in 12 distinct neighborhoods within three of the ten most populous cities in the 14 low- and middle-income countries with the greatest number (count) of smokers. HWL compliance codebooks were developed for each country based on the details of country-specific HWL requirements, with up to four common compliance indicators assessed for each country (location, size, label elements, text size). Packs (n=1859) were double coded for compliance. Compliance was examined by country and pack characteristics, including parent company and brand family. Overall, 72% of coded cigarette packs were compliant with all relevant compliance indicators, ranging from 17% in the Philippines to 94% in Mexico. Compliance was highest for location of the warning (ranging from 75%-100%) and lowest for warning size (ranging from 46%-99%). Compliance was higher for packs bought in high SES neighborhoods, and varied by parent company and brand family. This multi-country study found at least one pack in every country - and many packs in some countries - that were not compliant with key requirements for health warning labels in the country of purchase. Non-compliance may be exacerbating health disparities. Tobacco companies should be held accountable for complying with country HWL requirements.

Cigarette stick as valuable communicative real estate: a content analysis of cigarettes from 14 low-income and middle-income countries.

BACKGROUND: The current cigarette market is heavily focused on low-income and middle-income countries. Branding of tobacco products is key to establishing and maintaining a customer base. Greater restrictions on marketing and advertising of tobacco products create an incentive for companies to focus more on branding via the product itself. We consider how tobacco sticks are used for communicative purposes in 14 low-income and middle-income countries with extensive tobacco markets. METHODS: In 2013, we collected and coded 3232 cigarette and kretek packs that were purchased from vendors in diverse neighbourhoods in 44 cities across the 14 low-income and middle-income countries with the greatest number of smokers. A single stick from each pack was assessed for branding, decorative and communicative elements using a common coding framework. Stick communication variables included brand name, brand image/logo, brand descriptor, colour and design carried through from pack, 'capsule cigarette' symbol, and embellishment of filter end. RESULTS: Communication and branding on the stick is essentially ubiquitous (99.75%); 97% of sticks include explicit branding (brand name or logo present). Colour is commonly carried through from the pack (95%), and some sticks (13%) include decorative elements matching the pack. Decorative elements can be found anywhere on the stick, including the filter tip (8%), and 'convertible' cigarettes include a symbol to show where to push. CONCLUSIONS: Cigarette sticks are clearly valuable 'real estate' that tobacco companies are using for communicative purposes. Across all countries and brands, the stick communicates branding via text, colour and imagery.

How does social integration influence breast cancer control among urban African-American women? Results from a cross-sectional survey.

BACKGROUND: Although social integration is a well-established influence on health, less is known about how the specific types of social connection (social roles, social networks, and social support) influence knowledge, attitudes, and practices for specific prevention goals, and how to utilize these influences in interventions with priority populations. This research examined the prevalence of social roles, networks and support among 576 urban African-American women age 45-93 in East Baltimore, Maryland, and the association of these social factors with breast cancer related knowledge, attitudes, and practices. METHODS: Using data from 1997-1998 in-home interviews, we developed indices of six possible social roles, social networks of family, neighborhood and church, and instrumental and emotional social support. In multivariate models adjusting for age, education, and medical care, we examined the association of each social influence on breast cancer knowledge, attitudes, screening recency and intention, and treatment preferences. RESULTS: We found substantial variation in social integration among these women, with social integration positively associated with overall health and well-being. Social roles and networks were positively associated with screening knowledge, and emotional support and church networks were positively associated with attitudes conducive to early detection and treatment. In regard to screening behaviors, family networks were associated with both screening recency and intention. Women with greater church networks and emotional support held more conservative attitudes towards lumpectomy, reconstruction, and clinical trials. CONCLUSION: Overall, social integration is a positive influence on breast cancer control and should be utilized where possible in interventions, including identifying surrogate mechanisms for support for subgroups without existing social resources.

The cannabinoid receptor agonists, anandamide and WIN 55,212-2, do not directly affect mu opioid receptors expressed in Xenopus oocytes.

A functional link between the cannabinoid and opioid receptor pathways has been proposed based on data showing that cannabinoid effects can be blocked by opioid receptor antagonists and that cannabinoids can bind to opioid receptors. To explore this link in more detail at the receptor level, we tested the hypothesis that cannabinoids directly activate or modulate mu opioid receptor function. The G-protein coupled mu opioid receptor, MOR-1, and its effector, the G-protein activated potassium channel, GIRK2 (Kir3.2), were expressed together in Xenopus oocytes and potassium currents measured using the two-electrode voltage clamp technique. The specific mu receptor agonist DAMGO activated potassium currents in oocytes expressing the mu receptor that were fully inhibited by the mu receptor antagonist, naloxone. The endogenous cannabinoid, anandamide, and the synthetic cannabinoid, WIN 55,212-2, had no direct effects on potassium currents in the oocytes expressing the mu receptor. The cannabinoids also had no effect on the magnitude of the potassium currents activated by DAMGO or on the desensitization kinetics of MOR-1 in the continued presence of DAMGO. Both WIN 55,212-2 and anandamide activated cannabinoid CB1 receptors when co-expressed with GIRK2 in the oocytes. We conclude that neither anandamide nor WIN 55,212-2 directly activate or modulate mu opioid receptor function in oocytes and that interactions of cannabinoids with mu opioid receptors are likely to be indirect.

Social well-being in pregnant women: intended versus unintended pregnancies.

The relationship between pregnancy intention (unintended versus intended pregnancy) and social well-being was examined in a sample of 72 pregnant, mostly low-income women attending Women, Infants, and Children programs and prenatal clinics in a midwestern community. Feelings of happiness about giving birth and the extent to which having a baby would fill a void in one's life were also examined. Pregnancy intention was significantly associated with reduced social support. Feelings of happiness about having the baby positively correlated with all domains of social support and negatively correlated with loneliness and family relationship problems. The belief that having a baby could fill a void in a woman's life was strongly correlated with perceived loneliness. Interventions to increase social support and to address areas of stress for women whose pregnancies are unintended are recommended. Future research in larger random samples is needed to better test these associations and to make recommendations for specific practice interventions to increase social well-being.

An analysis of purchase price of legal and illicit cigarettes in urban retail environments in 14 low- and middle-income countries.

BACKGROUND/AIMS: To estimate and compare price differences between legal and illicit cigarettes in 14 low- and middle-income countries (LMIC). DESIGN: A cross-sectional census of all packs available on the market was purchased. SETTING: Cigarette packs were purchased in formal retail settings in three major cities in each of 14 LMIC: Bangladesh, Brazil, China, Egypt, India, Indonesia, Mexico, Pakistan, the Philippines, Russia, Thailand, Turkey, Ukraine and Vietnam. PARTICIPANTS: A total of 3240 packs were purchased (range = 58 packs in Egypt to 505 in Russia). Packs were categorized as 'legal' or 'illicit' based on the presence of a health warning label from the country of purchase and existence of a tax stamp; 2468 legal and 772 illicit packs were in the analysis. MEASUREMENTS: Descriptive statistics stratified by country, city and neighborhood socio-economic status were used to explore the association between price and legal status of cigarettes. FINDINGS: The number of illicit cigarettes in the sample setting was small (n < 5) in five countries (Brazil, Egypt, Indonesia, Mexico, Russia) and excluded from analysis. In the remaining nine countries, the median purchase price of legal cigarettes ranged from US$0.32 in Pakistan (n = 72) to US$3.24 in Turkey (n = 242); median purchase price of illicit cigarettes ranged from US$0.80 in Ukraine (n = 14) to US$3.08 in India (n = 41). The difference in median price between legal and illicit packs as a percentage of the price of legal packs ranged from 32% in Philippines to 455% in Bangladesh. Median purchase price of illicit cigarette packs was higher than that of legal cigarette packs in six countries (Bangladesh, India, Pakistan, Philippines, Thailand, Vietnam). Median purchase price of illicit packs was lower than that of legal packs in Turkey, Ukraine and China. CONCLUSIONS: The median purchase price of illicit cigarettes is higher than that of legal cigarette packs in Bangladesh, India, Pakistan, Philippines, Thailand, and Vietnam, Brazil, Egypt, Indonesia, Mexico, Russia appear to have few or no illicit cigarettes for purchase from formal, urban retailers.

The Tobacco Pack Surveillance System: A Protocol for Assessing Health Warning Compliance, Design Features, and Appeals of Tobacco Packs Sold in Low- and Middle-Income Countries.

BACKGROUND: Tobacco remains the world's leading preventable cause of death, with the majority of tobacco-caused deaths occurring in low- and middle-income countries. The first global health treaty, the Framework Convention on Tobacco Control (FCTC), outlines a set of policy initiatives that have been demonstrated as effective in reducing tobacco use. Article 11 of the FCTC focuses on using the tobacco package to communicate tobacco-caused harms; it also seeks to restrict the delivery of misleading information about the product on the pack. OBJECTIVE: The objective of this study was to establish a surveillance system for tobacco packs in the 14 low- and middle-income countries with the greatest number of smokers. The Tobacco Pack Surveillance System (TPackSS) monitors whether required health warnings on tobacco packages are being implemented as intended, and identifies pack designs and appeals that might violate or detract from the communication of harm-related information and undermine the impact of a country's tobacco packaging laws. The protocol outlined is intended to be applicable or adaptable for surveillance efforts in other countries. METHODS: Tobacco packs were collected in 14 countries during 2013. The intention was, to the extent possible, to construct a census of "unique" pack presentations available for purchase in each country. The TPackSS team partnered with in-country field staff to implement a standardized protocol for acquiring packs from 36 diverse neighborhoods across three cities in each country. At the time of purchase, data on price and place of acquisition of each pack was recorded. The field staff, according to a standardized protocol, then photographed packs before they were shipped to the United States for coding and archiving. RESULTS: Each pack was coded for compliance with the country-specific health warning label laws, as well as for key design features of the pack and appeals of the branding elements. The coding protocols were developed based upon prior research, expert opinion, and communication theories. Each pack was coded by two independent coders, with consistency of personnel across the project. We routinely measured intercoder reliability, and only retained variables for which a good level of reliability was achieved. Variables where reliability was too low were not included in final analyses, and any inconsistencies in coding were resolved on a daily basis. CONCLUSIONS: Across the 14 countries, the TPackSS team collected 3307 tobacco packs. We have established a publicly accessible, Internet archive of these packs that is intended for use by the tobacco control policy advocacy and research community.