Boosting self-efficacy and improving practices for smoking prevention and cessation among South American cancer care providers with a web-based algorithm.

BACKGROUND: Digital technologies have positively impacted the availability and usability of clinical algorithms through the advancement in mobile health. Therefore, this study aimed to determine if a web-based algorithm designed to support the decision-making process of cancer care providers (CCPs) differentially impacted their self-reported self-efficacy and practices for providing smoking prevention and cessation services in Peru and Colombia. METHODS: A simple decision-making tree algorithm was built in REDCap using information from an extensive review of the currently available smoking prevention and cessation resources. We employed a pre-post study design with a mixed-methods approach among 53 CCPs in Peru and Colombia for pilot-testing the web-based algorithm during a 3-month period. Wilcoxon signed-rank test was used to compare the CCPs' self-efficacy and practices before and after using the web-based algorithm. The usability of the web-based algorithm was quantitatively measured with the system usability scale (SUS), as well as qualitatively through the analysis of four focus groups conducted among the participating CCPs. RESULTS: The pre-post assessments indicated that the CCPs significantly improved their self-efficacy and practices toward smoking prevention and cessation services after using the web-based algorithm. The overall average SUS score obtained among study participants was 82.9 (± 9.33) [Peru 81.5; Colombia 84.1]. After completing the qualitative analysis of the focus groups transcripts, four themes emerged: limited resources currently available for smoking prevention and cessation in oncology settings, merits of the web-based algorithm, challenges with the web-based algorithm, and suggestions for improving this web-based decision-making tool. CONCLUSION: The web-based algorithm showed high usability and was well-received by the CCPs in Colombia and Peru, promoting a preliminary improvement in their smoking prevention and cessation self-efficacy and practices.

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.

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.

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.

Graphic health warnings and plain packaging in the Philippines: results of online and household surveys.

In line with Article 11 of the WHO Framework Convention on Tobacco Control, the Philippines has implemented graphic health warnings on cigarette packs. To date, there has been no published literature evaluating the perceived effectiveness of GHWs in the Philippines. This study aims to contribute to the evidence on the perceived effects of graphic health warnings (GHWs) in cigarette packaging and the potential impact of plain packaging in the Philippines. The study involved an online convenience survey and a nationwide household survey. Mock-up sets of cigarette packs based on the Philippines' law on GHWs, and Thailand's and Singapore's plain packaging were shown to respondents to rate their attractiveness, quality, taste, cost, social appeal, appeal to youth, noticeability, appeal to non-smokers, attempt to quit, ease of quitting, discouraging smoking, and perceived harm to health on a five-point Lickert scale. The online and household surveys recruited 2,701 respondents in total. Online and household survey respondents considered plain packaging with larger graphic health warnings and visible quitlines from Thailand and Singapore to be more effective in discouraging them from smoking. Both sets of survey respondents also found mock-ups from Thailand and Singapore more motivating for them to attempt quitting than cigarette pack mock-ups from the Philippines. The study concludes that current graphic health warnings in the Philippines are ineffective in instilling health consciousness among Filipinos. Policymakers should consider larger graphic health warnings and plain packaging of cigarettes to motivate smokers to quit and discourage Filipinos from smoking.

Health and economic impacts of introducing specific excise tax to waterpipe tobacco in Egypt: a simulation model of simple and mixed tax policy approaches.

INTRODUCTION: Waterpipe tobacco is taxed at half the rate of cigarettes in Egypt and, unlike cigarettes, does not have a specific excise component. We aimed to simulate the introduction of a specific excise tax on waterpipe tobacco consumption, premature deaths and government waterpipe tobacco revenue in Egypt. METHODS: We took model inputs from the latest available data on consumption, market shares and market share prices, price elasticities of demand, tax structure and from discussions with government officials. We modelled increases to specific excise to produce a 45%, 55%, 65% and 75% tax burden and compared a simple (specific only) structure with a mixed (specific and ad valorem) structure. RESULTS: Under the simple approach, introducing a US$2.1 specific tax would result in a 75% tax burden with 67% fewer waterpipe tobacco units smoked, 1 004 604 averted premature deaths and a 236% increase in government revenue relative to the current tax structure. At the 75% tax burden, the simple approach resulted in 1.5% fewer waterpipe tobacco units consumed, 9000 more averted premature deaths and 12.7% more government revenue compared with the mixed approach. Results for other tax burdens are presented and remained robust to sensitivity analyses. CONCLUSIONS: Introducing a specific excise tax on waterpipe tobacco in Egypt can yield considerable government revenue and public health gains. We recommend the simple approach, in line with the WHO recommendations, which produces greater economic and public health gains than the mixed approach and is easier to administer for the Egyptian government.

A mixed-method study of perceptions of cigarette pack inserts among adult smokers from New York and South Carolina exposed as part of a randomized controlled trial.

While many countries require prominent pictorial health warning labels (PHWLs) on the outside of cigarette packs to communicate the harms of smoking, there is evidence that cigarette pack inserts that contain efficacy messages may enhance the effectiveness of PHWLs. The US Food and Drug Administration (FDA) has regulatory authority to communicate with smokers through inserts. While current labeling regulations do not require inclusion of inserts, the FDA could implement them in the future. This study assesses US smokers' perceptions of cigarette package inserts at the conclusion of a two-week randomized trial on cigarette labeling where half of participants were exposed to insert messages (two response-efficacy messages and two self-efficacy messages) in their packs. Participants (n = 359) completed a 30- to 60-min interview with both quantitative and qualitative assessments, including measures of recall and perceived message effectiveness (PME) for specific inserts. Correlates of recall and PME were estimated using mixed-effects regression models. Qualitative responses to PME items were analyzed using thematic analysis. Response-efficacy messages had higher PME and recall than self-efficacy messages. People had diverse responses to the inserts, including that they were positive, thought-provoking, and helpful. Reactions to and perceptions of the inserts indicate potential benefits of integrating efficacy messages into labeling policies.

Coordinating smoking cessation treatment with menstrual cycle phase to improve quit outcomes (MC-NRT): study protocol for a randomized controlled trial.

BACKGROUND: Women experience greater difficulty achieving smoking abstinence compared to men. Recent evidence suggests that hormonal fluctuations during different phases of the menstrual cycle can contribute to lower smoking abstinence rates following a quit attempt among women. However, these findings are limited by small sample sizes and variability among targeted smoking quit dates. This clinical trial aims to clarify whether targeting the quit date to the follicular or luteal phase of the menstrual cycle can improve smoking abstinence. METHODS: Participants will enroll in an online smoking cessation program providing nicotine replacement therapy (NRT) and behavioral support. We will randomize 1200 eligible individuals to set a target quit date: (1) during the mid-luteal phase, (2) during the mid-follicular phase, or (3) 15-30 days after enrollment with no regard to the menstrual cycle phase (usual practice). Participants will receive a 6-week supply of combination NRT consisting of a nicotine patch plus their choice of nicotine gum or lozenge. Participants will be instructed to start using NRT on their target quit date. Optional behavioral support will consist of a free downloadable app and brief videos focusing on building a quit plan, coping with cravings, and relapse prevention, delivered via e-mail. Smoking status will be assessed via dried blood spot analysis of cotinine concentration at 7 days, 6 weeks, and 6 months post-target quit date. DISCUSSION: We aim to overcome the limitations of previous studies by recruiting a large sample of participants and assigning target quit dates to the middle of both the follicular and luteal phases. The results of the trial can further elucidate the effects of the menstrual cycle on smoking cessation outcomes and whether it is beneficial to combine menstrual cycle phase timing strategies with accessible and low-cost NRT. TRIAL REGISTRATION: ClinicalTrials.gov NCT05515354. Registered on August 23, 2022.

Perceptions of plain packaging and health warnings among university students in Turkey: a survey-based experiment.

BACKGROUND: Cigarette pack design plays a crucial role in attracting customers, especially when other marketing methods are limited by policy. University students who engage in casual smoking take the risk of developing an addiction. The objective of this study was to assess the effects of plain packaging (PP) and graphic health warnings (GHWs) on cigarette packages on three outcome variables (negative affect, avoidant responses, and intentions to quit) among ever-smoker university students in Ankara, Turkey, where youth smoking prevalence is high. METHODS: An online survey-based experiment was used to collect data. The respondents were randomly assigned to one of the five conditions that contained images of cigarette packs with specific design elements. Regression analyses (n = 623) were used to compare across conditions and to estimate the effects of combined warnings (versus text-only warnings), stronger GHWs (versus old GHWs), and PP (versus branded packages) on the outcome variables, accounting for potential confounders. RESULTS: Stronger GHWs generated more negative affect (0.31 points out of 5, p = 0.010) and avoidant responses (0.42 points out of 5, p = 0.002) than old warnings (when brand logos were visible). Plain packages generated more negative affect (0.48 points out of 5, p < 0.001) and avoidant responses (0.46 points out of 5, p = 0.001) than branded packages (with old warnings). Disentangling the effects of PP and new GHWs revealed that neither had individual differential effect on intentions to quit within 6 months. CONCLUSIONS: Although no differential effect of PP or harsher GHWs was found on intentions to quit when respondents were exposed to images on screen, both design elements were found to be effective in generating negative affect and avoidant responses. More work is needed to design effective tobacco control measures among youth during critical years of tertiary education.

The Effectiveness of Self-Help Group (SHG) Intervention on Smoking Prevention of Adolescents in Aceh, Indonesia: A Controlled Field Trail.

OBJECTIVE: This study aims to examine the effectiveness of the Self-Help Group (SHG) intervention in smoking prevention among adolescents. METHODS: This study was carried out in 2 Junior High Schools in Aceh Besar using a quasi-experimental method, which was conducted in the intervention and the control groups with a pre-post design. The number of samples was determined based on power analysis with medium effect size and power (0.08) with 40 respondents per group. After randomizing the schools, a total of 40 students who met the criteria were randomly selected for each school. The data were collected by using a self-report questionnaire, consisting of knowledge, as well as smoking attitudes, intentions, and behavior. The SHG intervention consist of 6 sessions, each of which was conducted per week with a duration of 40-60 minutes per session. The data were analyzed using descriptive and inferential statistics. RESULTS: The results of statistical tests using the Mann-Whitney and t-test showed that there was an effect of the SHG intervention on knowledge (p-value 0.043), attitude (p-value 0.001), intention (p-value 0.029), and behavior (p-value 0.003). The average score of knowledge was higher in the SHG intervention group than in the control group, while the average score of attitude, smoking intention and behavior was lower in the SHG intervention group than in the control group. CONCLUSION: Health practitioners, specifically community nurses are suggested to implement SHG interventions as one of the strategies for preventing smoking among adolescents.

A Smoking Prevention Intervention Among Young People in an Online Community Game: Results from a Pilot Randomized Controlled Trial.

Background: Innovative methods for smoking prevention interventions need to be investigated to increase attractiveness, access hard-to-reach populations, and increase effectiveness. We studied the feasibility and immediate effects of an intervention to reinforce norms and behaviors of young people related to antismoking, integrated into a popular online community game. Methods: A pilot randomized controlled trial was conducted through the HABBO online community. The intervention group was exposed to repeated discussion sessions with small groups of peer players and two facilitators once a week for 1 month (four sessions), inside the game. The control group had access to antismoking information websites. Process indicators (attractiveness, participation) and immediate outcomes (norms and intentions with regard to smoking) were assessed by questionnaire. Results: One hundred sixteen players were invited to participate in the intervention; 10 did not meet eligibility criteria, 30 were allocated to the intervention group, and 76 to the control group. Median age was 23. Twenty-four percent were not in education, employment, or training. A median of eight players attended each session and the median number of exchange chats by session was 399; 70% of chat time was occupied by the players. Twenty players attended all four sessions. Immediate norms, representations, and intentions were evaluated in 39 players and showed small differences between groups. Conclusion: Delivering and evaluating a smoking prevention intervention in an online game is feasible. In the targeted online community game, the intervention was attractive and allowed the delivery of innovative interventions to audiences with diverse social profiles. Long-term effects, sustainability, and evaluation methodology are discussed.

Effects of emotional arousal on the neural impact and behavioral efficacy of cigarette graphic warning labels.

BACKGROUND AND AIMS: Graphic warning labels (GWLs) on cigarette packs have been adopted by many jurisdictions world-wide. In the United States, the introduction of GWLs has been delayed by claims that their high level of negative emotional arousal unnecessarily infringed upon the tobacco manufacturers' free speech. This study aimed to provide experimental data on the contribution of emotional arousal to GWL efficacy. DESIGN: Observational study using long-term naturalistic exposure and functional magnetic resonance imaging. SETTING: Research university in Philadelphia, PA, USA. PARTICIPANTS: A total of 168 adult smokers. MEASUREMENTS: For 4 weeks, participants received cigarettes in packs that carried either high-arousal or low-arousal GWLs (n = 84 versus 84). Smoking behavior, quitting-related cognitions and GWL-induced brain response were measured before and after the 4-week exposure. The amygdala and medial prefrontal cortex served as regions of interest. FINDINGS: Compared with the high-arousal group, the low-arousal group smoked fewer cigarettes [log10 -transformed, 1.076 versus 1.019; difference = 0.056, 95% confidence interval (CI) = 0.027, 0.085, χ2 (1)  = 14.21, P < 0.001] and showed stronger intention to quit (2.527 versus 2.810; difference = -0.283, 95% CI = -0.468, -0.098, χ2 (1) = 8.921, P = 0.007) and endorsement of the GWLs' textual component (4.805 versus 5.503; difference = -0.698, 95% CI = -1.016, -0.380, χ2 (1) = 18.47, P < 0.001). High-arousal GWLs induced greater amygdala response than low-arousal GWLs (0.157 versus 0.052; difference = 0.105, 95% CI = 0.049, 0.161, χ2 (1) = 23.52, P < 0.001), although the response to high-arousal GWLs declined over time (slope = -0.087 versus 0.016; difference = -0.103, 95% CI = -0.198, -0.009, χ2 (1) = 6.370, P = 0.046). Greater baseline amygdala response was associated with more smoking at 4 weeks in the high-arousal group, but less smoking in the low-arousal group (slope = 0.179 versus -0.122; difference = 0.287, 95% CI = 0.076, 0.498, χ2 (1) = 7.086, P = 0.008). Medial prefrontal response did not differ significantly between groups. CONCLUSIONS: High-arousal cigarette graphic warning labels (GWLs) appear to be less efficacious than low-arousal GWLs. The high emotional reaction that high-arousal GWLs elicit wanes over time. Baseline amygdala response negatively predicts efficacy of high-arousal GWLs and positively predicts efficacy of low-arousal GWLs. High emotional arousal may not be required for sustained GWL efficacy.

Analyse macroéconomique de l'efficacité de la politique fiscale antitabac en Algérie.

INTRODUCTION: WHO advocates that financial and fiscal measures, aimed at making tobacco acquisition less affordable, are most effective, particularly in low- and middle-income countries. PURPOSE OF RESEARCH: The objective is to analyze the application and effectiveness of the tobacco fiscal policy in Algeria in accordance with the provisions of the WHO Convention-Framework for Tobacco Control. METHOD: Using macroeconomic data covering the period 1970-2018, we verified whether the levels, structure and evolution of tobacco taxes are oriented towards the implementation of a tobacco control tax policy. Then, we analyzed the conditions for the effectiveness of this policy and its viability through an econometric study of the price elasticity of cigarette demand, the income elasticity of cigarette demand, and the elasticity of affordable tobacco demand. RESULTS: We have shown that in Algeria, the tobacco control fiscal Policy is not applied, it is not effective in the long term, and the conditions for its viability are not met. CONCLUSIONS: The results of this study have led to question Article 6 of the WHO FCTC.

The Differential Impact of the 2000 Canadian Graphic Warning Label Policy on Smoking Prevalence by Sex and Education: A Difference-in-Difference-in-Difference Model.

INTRODUCTION: Using a quasiexperimental design, we compared the impact of the 2000 Canadian introduction of graphic warning labels (GWLs) on differences in smoking prevalence by sex and education, to the United States, where no GWLs were introduced. METHODS: We pooled 1999-2004 data from the Canadian Tobacco Use Monitoring Survey and the U.S. Behavioral Risk Factor Surveillance System. We used a difference-in-difference (DD) model to assess the impact of Canadian policy introduction on smoking prevalence, and a difference-in-difference-in-difference (DDD) model to examine differences in the policy impact by sex and education, comparing Canada (the treatment group) with the United States (the control group). RESULTS: From 1999 to 2004, smoking prevalence decreased from 23.7% to 18.6% in Canada, and from 21.7% to 20.0% in the United States. Results from the DD regression models showed that Canadian respondents reported lower odds of being a current smoker compared to the U.S. respondents following the 2000 introduction of GWLs (OR = 0.84, 95% CI = 0.74-0.94). The DDD model showed that the impact of the Canadian GWLs versus the United States did not differ by sex or education. CONCLUSIONS: The 2000 Canadian GWL policy reduced smoking prevalence overall, with similar reductions for males and females and across education levels. The impact of the Canadian GWLs in reducing smoking prevalence did not reduce differences by sex or education. Although beneficial for all smokers, GWLs may not serve to decrease existing disparities, especially those by socioeconomic status. IMPLICATIONS: Existing evidence shows that GWL implementation is associated with reductions in smoking prevalence. But there is limited evidence from past evaluation studies on whether the impact of GWLs on smoking prevalence differs by sociodemographic subgroup. Our findings confirm existing studies that the 2000 implementation of GWLs in Canada was significantly associated with an overall reduction in smoking prevalence in Canada compared to the United States. However, our study improves existing evidence by showing that the impact of the Canadian GWLs on smoking prevalence did not differ by sex or education, and thus did not reduce existing smoking disparities by educational levels.