Shaping the future: Proposed bills to regulate new and emerging tobacco and nicotine products in Latin America and the Caribbean amidst public health concerns and industry interests.

INTRODUCTION: To examine legislative efforts to regulate new and emerging tobacco and nicotine products (NETNPs) in Latin America and the Caribbean (LAC) between 2017 and 2022. METHODS: Analysis of on-line national legislation databases to track NETNP bills using standard snowball search methods. RESULTS: Bills were identified in 15 out of the 33 LAC countries, accounting for a total of 91 bills targeting NETNPs (Table 1). Mexico had the highest number (n=38) of bills, followed by Brazil (n=16), Argentina (n=10), Colombia (n=8) and Chile (n=5). The remaining countries introduced two or fewer NETNP bills. Among the identified 91 bills, the majority (n=60) addressed both electronic cigarettes and HTPs, almost one third of bills (n=29) applied only to electronic cigarettes, and only two focused solely on HTPs. Six of the 15 countries with identified bills, enacted one NETNP law including Barbados, Bolivia, Costa Rica, Guyana, Mexico, and Panama. Since 2019, there has been a steady increase in the amount of NETNP bills introduced in LAC. In 2017 and 2018, 10 NETNP bills were introduced each year followed by 23 NETNP bills introduced in each 2019 and 2020, 19 in 2021, and 16 by August 2022. CONCLUSION: The substantial increase in the number of NETNP bills introduced since 2019 indicates the growing importance of regulating NETNPs in LAC. As NETNPs continue to evolve and grow it is important to continue monitoring and evaluating tobacco and nicotine regulatory initiatives while also staying ahead of the evolving market of NETNPs. IMPLICATIONS: Previous studies have analyzed the regulatory environment of new and emerging tobacco and nicotine products (NETNPs) but it is less known about legislative and regulatory efforts and attempts. This is the first known study to analyze legislative bills to regulate NETNPs in Latin America and the Caribbean (LAC). The substantial increase in the number of NETNP bills introduced in LAC since 2019 indicates the growing importance of regulating NETNPs in LAC. As NETNPs continue to evolve and grow it is important to continue monitoring and evaluating tobacco and nicotine regulatory initiatives while also staying ahead of the evolving market of NETNPs.

Measuring air quality in smoking and nonsmoking areas of Nevada casinos (Reno/Sparks): Potential exposure of minors to secondhand smoke.

To understand the potential exposure to tobacco smoke in Washoe County (Reno/Sparks), Nevada casinos by measuring air quality in smoking areas relative to non-smoking/non-gaming areas in which minors may be present. To act as a pilot study in community-based health research and policy campaigns by evaluating low-cost air monitors to measure personal secondhand smoke (SHS) exposure. We used customized mobile apps, AtmoTube PRO Air Monitors, and hand clickers to measure the timing and minute-by-minute levels of PM2.5 (a tobacco smoke marker). The app was used to record the number of smokers, minors, and total patrons associated with ~10-minute sequential time periods in standardized casino locations, including outdoor areas, slots, tables, restaurants, bars/lounges, arcades, among others. Between April and May 2022, we successfully visited 14 casinos and 18 distinct types of indoor casino locations. We found high PM2.5 peaks in casino locations even with zero, or a low percentage of, observed active smokers, including in both gaming/non-gaming areas. Indoor areas, regardless of smoking/non-smoking areas, consistently had higher PM2.5 levels than outdoor background levels. Indoor locations had median PM2.5 levels up to 18 times higher than the lowest outdoor background levels. Minors were present throughout all casino locations, and thus were likely exposed to elevated PM2.5 levels. Potential PM2.5 exposures due to smoking can be high regardless of ventilation systems. Small proportions of smokers in a location can lead to high levels of exposure. Establishing comprehensive smoke-free casinos is the only way to protect against SHS harms.

The Perfect Storm: Applying the Multiple Streams Framework to Understand the Adoption of a WHO Framework Convention on Tobacco Control-Based Policy in Mexico.

BACKGROUND: The aim of this study was to document how Mexico adopted a WHO Framework Convention on Tobacco Control (FCTC)-based national tobacco control law. METHODS: We analyzed publicly available documents and interviewed 14 key stakeholders. We applied the Multiple Streams Framework (MSF) to analyze these findings. RESULTS: Previous attempts to approve comprehensive FCTC-based initiatives failed due to a lack of political will, the tobacco industry's close connections to policymakers, and a lack of health advocacy coordination. Applying the MSF reveals increased attention towards collecting and sharing data to frame the severity of the problem (problem stream). The expansion of a coordinated health advocacy coalition and activities led to increased support for desired FCTC policy solutions (policy stream). The election of President López Obrador and legislative changes led to a deep renewed focus on tobacco control (politics stream). These three streams converged to create a policy window to secure a strong FCTC-based initiative on the political agenda that was ultimately passed. CONCLUSIONS: The Mexican experience illustrates the importance of continued health advocacy and political will in adopting FCTC-based policies. Other countries should follow Mexico's lead by collecting and sharing data through coordinating efforts in order to be prepared to seize political opportunity windows when strong political will is present.

Tobacco industry strategies to influence the regulation of new and emerging tobacco and nicotine products in Latin America and the Caribbean.

Objective: To document tobacco industry strategies to influence regulation of new and emerging tobacco and nicotine products (NETNPs) in Latin America and the Caribbean. Methods: We analyzed industry websites, advocacy reports, news media and government documents related to NETNPs, focusing on electronic cigarettes and heated tobacco products. We also conducted a survey of leading health advocates. We applied the policy dystopia model to analyze industry action and argument-based strategies on NETNP regulations. Results: Industry actors engaged in four instrumental strategies to influence NETNP regulation - coalition management, information management, direct involvement in and access to the policy process, and litigation. Their actions included: lobbying key policy-makers, academics and vaping associations; providing grants to media groups to disseminate favorable NETNP information; participating in public consultations; presenting at public hearings; inserting industry-inspired language into draft NETNP legislation; and filing lawsuits to challenge NETNP bans. The industry disseminated its so-called harm reduction argument through large/influential countries (e.g., Argentina, Brazil, and Mexico). Industry discursive strategies claimed NETNPs were less harmful, provided safer alternatives, and should be regulated as so-called harm reduction products or have fewer restrictions on their sale and use than those currently in place. Conclusion: Our analysis provides a better understanding of industry strategies to undermine tobacco and nicotine control. To help counter industry efforts, health advocates should proactively strengthen government capacities and alert policy-makers to industry attempts to create new regulatory categories (so-called reduced-risk products), provide misleading information of government authorizations of NETNPs, and co-opt so-called harm-reduction messages that serve the industry's agenda.

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.

Public-Private Partnerships in Mexico: Implications of Engaging With the Food and Beverage Industry for Public Health Nutrition.

BACKGROUND: In the last few years, Mexico adopted public health policies to tackle non-communicable diseases (NCDs), such as front of package nutrition labelling, food marketing restrictions to children, and a soda tax. In parallel, transnational food and beverage industries (F&BIs), their allies, and the government have agreed on public-private partnerships (PPPs) to implement policies or deliver programs. However, research has questioned the benefits of PPPs and exposed its limitations as a suitable mechanism to improve public health. This study analyses how four PPPs between the Mexican government, the F&BI, and allies are working to achieve their goals. We critically assessed the objectives, scope, reported impacts, governance principles and perceived risks and benefits for the public health agenda of these PPPs. METHODS: This qualitative study is based on 26 interviews with key actors, and 170 publicly available documents, including 22 obtained through freedom of information (FOI) requests related to four purposively selected PPPs aiming to improve health. RESULTS: We found that the four PPPs studied had minimal public information available on their implementation and impact. The private partners tend to dictate the design, information management, and implementation of the programs, while promoting their brands. Few independent evaluations of the PPPs exist, and none reported on their effectiveness or public health benefits. Good governance principles, such as accountability, transparency, fairness, participation, integrity, and credibility, were barely followed in each of the cases studied. Public officials did not automatically question the conflict of interest (CoI) of such arrangements. When there were COI, the potential risks these posed did not always outweigh the financial benefits of working with the F&BI and its allies. CONCLUSION: The four PPPs studied produced minimal gains for public health while boosting credibility for the participating transnational F&BIs. It shows the lack of awareness of how these PPPs might be hindering public health gains.

Adopting a WHO Framework Convention on Tobacco Control-Based Tobacco Control Law in Ethiopia: Sustained Transnational Health Advocacy and Multi-Sectoral Institutionalized Support.

OBJECTIVE: The objective of this study was to document how Ethiopia adopted a WHO Framework Convention on Tobacco Control (FCTC)-based tobacco control law. METHODS: We analyzed publicly available documents, including news media articles, advocacy reports, and government documents. We triangulated these findings by interviewing nine key stakeholders. Data were analyzed to construct a historical and thematic narrative and analyzed through a retrospective policy analysis. RESULTS: Local and international health advocacy efforts helped introduce and support WHO FCTC-based legislation by (1) educating policymakers about the WHO FCTC, (2) providing legal assistance in drafting legislation, (3) generating local data to counter industry claims, and (4) producing media advocacy to expose industry activity. Health advocates worked closely with government officials to create a multi-sectoral tobacco committee to institutionalize efforts and insulate tobacco companies from the policymaking process. Japan Tobacco International bought majority shares of the government-owned tobacco company and attempted to participate in the process, using standard industry tactics to undermine legislative efforts. However, with health advocacy assistance, government officials were able to reject these attempts and adopt a WHO FCTC-based law in 2019 that included 100% smoke-free indoor places, a comprehensive ban on tobacco advertising, and large pictorial health warning labels, among other provisions. CONCLUSION: Sustained local health advocacy efforts supported by international technical and financial assistance can help establish WHO FCTC-based tobacco control laws. Applying a standardized multi-sectoral approach can establish coordinating mechanisms to further institutionalize the WHO FCTC as a legal tool to build support with other government sectors and insulate the tobacco industry from the policymaking process.

Tobacco industry strategies to influence the regulation of new and emerging tobacco and nicotine products in Latin America and the Caribbean / Estrategias de la industria tabacalera para influir en la regulación de los productos de tabaco y nicotina novedosos y emergentes en América Latina y el Caribe / Estratégias da indústria do tabaco para influenciar a regulamentação de produtos novos e emergentes de tabaco e nicotina na América Latina e no Caribe

ABSTRACT Objective. To document tobacco industry strategies to influence regulation of new and emerging tobacco and nicotine products (NETNPs) in Latin America and the Caribbean. Methods. We analyzed industry websites, advocacy reports, news media and government documents related to NETNPs, focusing on electronic cigarettes and heated tobacco products. We also conducted a survey of leading health advocates. We applied the policy dystopia model to analyze industry action and argument-based strategies on NETNP regulations. Results. Industry actors engaged in four instrumental strategies to influence NETNP regulation - coalition management, information management, direct involvement in and access to the policy process, and litigation. Their actions included: lobbying key policy-makers, academics and vaping associations; providing grants to media groups to disseminate favorable NETNP information; participating in public consultations; presenting at public hearings; inserting industry-inspired language into draft NETNP legislation; and filing lawsuits to challenge NETNP bans. The industry disseminated its so-called harm reduction argument through large/influential countries (e.g., Argentina, Brazil, and Mexico). Industry discursive strategies claimed NETNPs were less harmful, provided safer alternatives, and should be regulated as so-called harm reduction products or have fewer restrictions on their sale and use than those currently in place. Conclusion. Our analysis provides a better understanding of industry strategies to undermine tobacco and nicotine control. To help counter industry efforts, health advocates should proactively strengthen government capacities and alert policy-makers to industry attempts to create new regulatory categories (so-called reduced-risk products), provide misleading information of government authorizations of NETNPs, and co-opt so-called harm-reduction messages that serve the industry's agenda.

RESUMEN Objetivo. Documentar las estrategias de la industria tabacalera para influir en la regulación de los productos de tabaco y nicotina novedosos y emergentes (PTNNE) en América Latina y el Caribe. Métodos. Se analizaron los sitios web de la industria, los informes de defensa de la salud, los medios de información y los documentos gubernamentales relacionados con los PTNNE, prestando especial atención a los cigarrillos electrónicos y los productos de tabaco calentado. También se realizó una encuesta a líderes de la promoción de la salud. Aplicamos el modelo de distopía política para analizar las estrategias de acción y argumentación de la industria en relación con la regulación de los PTNNE. Resultados. Las partes interesadas de la industria recurrieron a cuatro estrategias instrumentales para influir en la regulación de los PTNNE: gestión de coaliciones, gestión de la información, participación directa y acceso al proceso de formulación de políticas, y litigios. Sus acciones incluyeron: trabajar con los principales responsables de la formulación de políticas, académicos y asociaciones de vapeo; conceder subvenciones a grupos de medios de comunicación para que difundan información favorable a los PTNNE; participar en consultas públicas; realizar presentaciones en audiencias públicas; introducir un lenguaje inspirado por la industria en la legislación sobre los PTNNE; y presentar demandas judiciales para dificultar las prohibiciones de los PTNNE. La industria difundió su argumentación, denominada de reducción de daños, en países grandes e influyentes como, por ejemplo, Argentina, Brasil y México. Las estrategias discursivas de la industria afirmaban que los PTNNE eran menos nocivos, proporcionaban alternativas más seguras y debían regularse del mismo modo que los denominados productos de reducción de daños o tener menos restricciones que las vigentes en la actualidad para su venta y consumo. Conclusión. Este análisis permite comprender mejor las estrategias de la industria para socavar el control del tabaco y la nicotina. Para contribuir a contrarrestar los esfuerzos de la industria, los defensores de la salud deberían fortalecer activamente las capacidades gubernamentales y alertar a los responsables políticos de los intentos de la industria de crear nuevas categorías reglamentarias (los denominados productos de riesgo reducido), proporcionar información engañosa sobre las autorizaciones gubernamentales de los PTNNE y apropiarse de los denominados mensajes de reducción de daños que responden a la agenda de la industria.

RESUMO Objetivo. Documentar as estratégias usadas pela indústria do tabaco para influenciar a regulamentação de produtos novos e emergentes de tabaco e nicotina (NETNPs, sigla em inglês) na América Latina e no Caribe. Métodos. Foram analisados sites do setor, relatórios de ativistas, notícias em meios de comunicação e documentos governamentais relacionados aos NETNPs, com foco em cigarros eletrônicos e produtos de tabaco aquecido. Também foi realizada uma pesquisa com ativistas importantes na área da saúde. O modelo de distopia política foi utilizado para analisar as ações e as estratégias baseadas em argumentos do setor para a regulamentação de NETNPs. Resultados. Os agentes do setor utilizaram quatro estratégias instrumentais para influenciar a regulamentação de NETNPs: gestão de coalizões; gestão de informações; envolvimento direto e acesso ao processo de formulação de políticas; e ações legais. As ações dos agentes incluíram: trabalhar com os principais formuladores de políticas, acadêmicos e associações de cigarros eletrônicos; conceder subsídios a grupos de comunicação para disseminar informações favoráveis aos NETNPs; participar de consultas públicas; fazer apresentações em audiências públicas; inserir linguagem gerada pela indústria na legislação de NETNPs; e entrar com ações judiciais para contestar proibições de NETNPs. O setor disseminou seu argumento de "redução de danos" em países grandes e influentes (por exemplo, Argentina, Brasil e México). As estratégias discursivas do setor afirmavam que os NETNPs eram menos prejudiciais, ofereciam alternativas mais seguras e deveriam ser regulamentados como "produtos de redução de danos" ou ter menos restrições à venda e ao uso do que as atualmente em vigor. Conclusão. Nossa análise oferece uma melhor compreensão das estratégias usadas pelo setor para enfraquecer o controle do tabaco e da nicotina. Para ajudar a combater os esforços do setor, os ativistas em saúde devem fortalecer de forma proativa a capacidade dos governos e alertar os formuladores de políticas sobre as tentativas da indústria de criar novas categorias regulatórias (os chamados "produtos de risco reduzido"), fornecer informações enganosas sobre as autorizações governamentais de comercialização dos NETNPs e cooptar mensagens de "redução de danos" para atender aos interesses do setor.

Barriers to Overcoming Child Hunger and Malnutrition: Applying a Human Rights Approach to Improve Policy and Action.

Objective: Analyze key barriers to achieving children's right to food under Colombia's food and nutrition security policies and programs. Methods: A literature review was conducted along with 17 semi-structured expert interviews. The law framework on the right to food was applied to analyze findings. Results: Four key barriers were found. First, a reductionist approach prevails in the political narrative. This focuses on ensuring personal food access overlooking societal and environmental impacts. Second, the implementation of policies and programs is passed on to third parties, preventing civic participation and accountability. Third, there are insufficient national data sources and indicators to monitor the impact of interventions and funding. Fourth, program implementation is unequal and inadequate, which inadvertently supports illicit economies that thrive on conditions of hunger and poverty. Conclusion: Children's food and nutrition are reliant on organizations that focus on personal food supply without strengthening civic participation. Strengthening participation requires a human rights approach. International organizations can help the government to engage communities in policy and program improvement and oversight.

Implementing front-of-pack nutrition warning labels in Mexico: important lessons for low- and middle-income countries.

OBJECTIVE: To analyse the implementation of front-of-pack nutrition labelling (FOPNL) in Mexico. DESIGN: Review of publicly accessible documents, including legislative websites, news sources, and government, intergovernmental, and advocacy reports. Usage of the policy cycle model to analyse the implementation and evaluation stages of Mexico's General Health Law, amended with FOPNL (2019-2022). RESULTS: In October 2019, the government published a draft modification of the Norma Oficial Mexicana (Official Mexican Standard) to regulate and enforce a new FOPNL warning label system. A 60-d public consultation period followed (October-December 2019), and the regulation was published in March 2020 and implementation began in October 2020. An analysis of nine key provisions of the Standard revealed that the food and beverage industry and its allies weakened some original provisions including health claims, warnings for added sweeteners and display areas. On the other hand, local and international public health groups maintained key regulations including the ban on cartoon character advertisements, standardised portions and nutrient criteria following international best practices. Early implementation appears to have high compliance and helped contribute to reformulating unhealthy products. Continued barriers to implementation include industry efforts to create double fronts and market their cartoon characters on social media and through digitalised marketing. CONCLUSION: Early success in implementing the new FOPNL system in Mexico was the result of an inclusive and participatory regulatory process dedicated to maintaining public health advances, local and international health advocacy support, and continued monitoring. Other countries proposing and enacting FOPNL should learn from the Mexican experience to maintain scientifically proven best practices, counter industry barriers and minimise delays in implementation.

Preemption in State Tobacco Minimum Legal Sales Age Laws in the US, 2022: A Policy Analysis of State Statutes and Case Laws.

Preemptive statutory language within tobacco minimum legal sales age (MLSA) laws has prohibited localities from enacting stricter laws than state statutes. With the recent uptake of state Tobacco 21 laws in the US, the current landscape of preempted MLSA laws is unknown. This study sought to update the status of preemption in MLSA laws enacted in US states between 2015-2022. A public health attorney reviewed state tobacco MLSA laws (n = 50) and state tobacco control codes, searching for language regarding preemption. When statutes were unclear, case law was reviewed by examining local ordinances that were invalidated by state court decisions. Overall, 40 states enacted Tobacco 21 laws, seven of which expanded or introduced preemption when they increased the MLSA; a total of 26 states (52%) included preemption. Six states (12%) retained 'savings clauses' included in the MLSA prior to Tobacco 21, and 18 states (36%) did not mention preemption. Based on the precedent set by state courts, eight of these 18 states may preempt localities from raising their MLSA. Historically, preemption has slowed the diffusion of best practices in tobacco control, and once implemented, the laws are difficult to repeal. The recent expansion of preemption could inhibit the evolution, development, and implementation of effective tobacco control policies.

A policy study on front-of-pack nutrition labeling in the Americas: emerging developments and outcomes.

Poor nutrition is one of the leading causes of non-communicable diseases (NCDs), especially in the WHO Region of the Americas (AMRO). In response, international organisations recommend front-of-pack nutrition labelling (FOPNL) systems that present nutrition information clearly to help consumers make healthier choices. In AMRO, all 35 countries have discussed FOPNL, 30 countries have formally introduced FOPNL, eleven have adopted FOPNL, and seven countries (Argentina, Chile, Ecuador, Mexico, Peru, Uruguay and Venezuela) have implemented FOPNL. FOPNL has gradually spread and evolved to better protect health by increasingly adopting larger warning labels, contrasting background devices for better salience, using "excess" instead of "high in" to improve efficacy, and adopting the Pan American Health Organization's (PAHO) Nutrient Profile Model to better define nutrient thresholds. Early evidence illustrates successful compliance, decreased purchases and product reformulation. Governments still discussing and waiting to implement FOPNL should follow these best practices to help reduce poor nutrition related NCDs. Translated versions of this manuscript are available in Spanish and Portuguese in the supplementary material.

New tobacco and nicotine products in Latin America and the Caribbean: assessing the market and regulatory environment.

OBJECTIVE: To document the regulatory environment of new tobacco and nicotine products (NTNPs), including electronic nicotine delivery systems (ENDS) and heated tobacco products (HTPs), in Latin America and the Caribbean (LAC). METHODS: Review of market research reports and databases, regulatory websites, Campaign for Tobacco-Free Kids, relevant published literature and the 2021 WHO Report on the Global Tobacco Epidemic. RESULTS: ENDS entered the LAC market in the 2010s and are now available in most LAC countries. A majority of LAC countries (n=18) have either banned the commercialisation of ENDS (n=7) or regulated ENDS as tobacco products (n=7), medicinal products (n=1) or consumer products (n=3). The remaining LAC countries (n=15) do not regulate ENDS. HTPs were first introduced in 2017 and have been officially launched in five countries (Colombia, Guatemala, Dominican Republic, Mexico and Costa Rica). Few countries have banned HTP commercialisation (n=3) or regulated commercialisation and use (n=7), while the majority of countries have existing legislation that applies to HTPs (n=19). A few countries (n=4) have no tobacco control legislation and therefore do not regulate HTPs. CONCLUSION: NTNPs are emerging products in the LAC region. Governments should follow WHO guidance and the decisions of the Conference of Parties to the WHO Framework Convention on Tobacco Control and ban or regulate NTNPs as tobacco products; otherwise NTNPs could create a new generation of tobacco and nicotine users.

Moving in the right direction: tobacco packaging and labeling in the Americas.

Objectives: To assess the adoption of tobacco packaging and labeling policies based on the World Health Organization (WHO) Framework Convention on Tobacco Control (FCTC)'s Article 11 guidelines, in the WHO Region of the Americas (AMRO). Methods: We reviewed tobacco control laws in AMRO from the Campaign for Tobacco-Free Kids' Tobacco Control Laws database. We analyzed four sub-policy areas for smoked and smokeless tobacco products: 1) health warning labels (HWLs), 2) constituents and emissions (C&Es), 3) misleading tobacco packaging and labeling, and 4) standardized "plain" packaging. Results: Of 35 countries in AMRO, 31 have tobacco packaging and labeling laws. Twenty-six countries require pictorial HWLs, 24 require warnings printed on at least 50% of the front and back of the packs, and 24 rotate a single or multiple (from 2 to 16) warnings within a specified period (from 5 up to 24 months). Only 21 countries require descriptive messages on toxic C&Es information. Twenty-seven countries ban brand descriptors with references to implied harm reduction (e.g., "light"), 24 ban figures, colors, and other signs, but only 13 prohibit emission yields printed on the packs. Only Canada and Uruguay have adopted standardized tobacco packaging while Uruguay also requires a single presentation (one brand variant) per brand family. Conclusion: Many countries in AMRO have made good progress in adopting multiple, rotating, large pictorial HWLs and banning misleading brand descriptors. However, there needs to be greater attention on other tobacco packaging and labeling provisions with a focus on implementing standardized tobacco packaging.