Regulation of Electronic Cigarette Use in Public and Private Areas in 48 Countries Within the WHO European Region: A Survey to In-country Informants.

BACKGROUND: The objective of this study is to describe the legislation regulating the use of electronic cigarettes (e-cigarettes) in various places in European countries. METHODS: A survey among experts from all countries of the World Health Organization (WHO) European Region was conducted in 2018. We collected and described data on legislation regulating e-cigarette use indoors and outdoors in public and private places, the level of difficulties in adopting the legislation, and the public support and compliance. Factors associated with the legislation adoption were identified with Poisson and linear regression analyses. RESULTS: Out of 48 countries, 58.3% had legislation on e-cigarette use at the national level. Education facilities were the most regulated place (58.3% of countries), while private areas (eg, homes, cars) were the least regulated ones (39.6%). A third of countries regulated e-cigarette use indoors. Difficulty and support in adopting the national legislation and its compliance were all at a moderate level. Countries' smoking prevalence and income levels were linked to legislation adoption. CONCLUSIONS: Although most WHO European Region countries had introduced e-cigarette use legislation at the national level, only a few of the legislation protect bystanders in indoor settings.

Electronic cigarette use among adolescents in 17 European study sites: findings from the Global Youth Tobacco Survey.

BACKGROUND: As new findings on public health implications of electronic cigarette (e-cigarette) use emerge, its surveillance remains of utmost importance. This study examined the latest state of e-cigarette use in youth in 17 European study sites (i.e. 16 countries and the Federation of Bosnia and Herzegovina) using the Global Youth Tobacco Survey (GYTS). METHODS: This was an observational study. Cross-sectional data on students aged 11-17 years from the latest available GYTS round completed in 17 study sites were used to estimate crude and adjusted prevalence of e-cigarette use by sex and pocket money. Panel GYTS data from five countries were used for the trend analyses. All analyses were weighted to account for the survey design and non-response. RESULTS: Compared to 2014, the age-adjusted prevalence of e-cigarette use more than doubled in Georgia and Italy, and nearly doubled in Latvia. Significantly more male than female students aged 11-17 years reported use of e-cigarettes, with little to no confounding by age, grade and pocket money across countries. Youth with medium or higher amount of pocket money was 20-200% more likely to use e-cigarettes than those with fewer to no pocket money in 14 study sites. DISCUSSION: As e-cigarette use is becoming widespread throughout the world, there is variation in use among and between countries. Expanded and consistent surveillance of e-cigarette use by all World Health Organization member states is essential to generate data on the extent and correlates of youth e-cigarette use for evidence-based planning and evaluation of the electronic nicotine delivery systems and electronic non-nicotine delivery systems national and global control programmes.

A comparison of self-reported to cotinine-detected smoking status among adults in Georgia.

BACKGROUND: Self-reported measures of tobacco use may have limited validity, particularly among some populations. This study aims to validate self-reported smoking measures among Georgian adults participating in the 2016 STEPS survey using cotinine biomarker measurements, and to explore potential differences according to sociodemographic characteristics. Additionally, this paper examines how the estimated prevalence of smoking in the population varies according to measurement type. METHODS: Using the WHO standardized STEPS methodology, adults self-reported their smoking status. In a later stage of the survey, a subset of participants provided a urine sample, which was tested for cotinine. Using each participant's objective cotinine measurement and their self-reported smoking status, we calculated the sensitivity, specificity and positive predictive value of self-reported smoking. Next, we calculated the estimated prevalence of smokers according to the type of measurement. RESULTS: Results indicated high sensitivity (83.37%, 95% CI: 76.79-88.37%) among males and relatively low sensitivity (38.60% CI: 29.23-48.90%) among females. According to self-report, the prevalence of smokers was 26.44% (23.61-29.48%), while according to cotinine detection, the prevalence of smokers was 32.27% (29.16-35.55%). Among all subgroups, the self-reported prevalence of smoking was significantly lower than the cotinine-detected prevalence. CONCLUSIONS: To the best of our knowledge, this is the first time that the validity of the STEPS self-reported tobacco indicator has been tested. Self-reported measures of smoking status may lead to an under-estimation of smoking prevalence among Georgian adults, especially women. These findings suggest that integration of biochemical measures of smoking into tobacco use studies may be an important investment.

Potential impact of strong tobacco-control policies in 11 newly independent states.

OBJECTIVE: While some countries of the WHO European Region are global leaders in tobacco control, the Newly Independent States (NIS) have the highest tobacco-smoking prevalence globally and a relatively low overall level of the WHO Framework Convention on Tobacco Control (WHO FCTC) implementation. An abridged version of the SimSmoke tobacco control policy simulation model has been developed to project the health impact of implementing tobacco-control policies in line with the WHO FCTC. METHODS: Data on population size, smoking prevalence, policy-specific effect sizes and formulas were applied in 11 NIS - Armenia, Azerbaijan, Belarus, Georgia, Kazakhstan, Kyrgyzstan, the Russian Federation, Tajikistan, Turkmenistan, Ukraine, and Uzbekistan. The aim was to project the relative reduction in smoking prevalence, number of smokers and number of smoking-attributable deaths resulting from implementing six individual and/or combined WHO FCTC measures. RESULTS: An increase in excise cigarette taxes to 75% of price yields the largest relative reduction in smoking prevalence (range 12.1-44%) for all countries. The projections show that when all six tobacco control measures are fully implemented in line with the WHO FCTC, smoking prevalence in each of the NIS countries can be reduced by at least 39% by the year 2033 (baseline 2015). CONCLUSION: The projections show that the NIS countries can expect a large number of smoking-attributable deaths just among those smokers alive today, but large reductions in smoking prevalence and smoking-attributable deaths can be achieved if the WHO FCTC demand reduction policies are implemented. The results can be used as an advocacy tool for accelerating enforcement of tobacco control laws in NIS.

The perspectives of politicians on tobacco control in Turkey.

Background: Tobacco use is a leading but preventable cause of non-communicable diseases and premature death. The legislature has a key role in setting tobacco control policies. Smoking trends are decreasing thanks to the introduction of effective tobacco control policies in Turkey and these policies may have been shaped by how politicians' interpreted social problems that were prominent during the development and implementation of tobacco regulations. Aim: This paper explores the long-term national relationship between tobacco consumption, tobacco control policies and the associated political discourse in Turkey, considering the varying influences through national leadership on this important public health agenda. This relationship is studied by comparing a time series analysis of tobacco consumption trends with a policy analysis of the minutes of deliberations at the Grand National Assembly of Turkey (GNAT). Methods: This study uses Bayesian time series analysis in order investigate whether the tobacco control policies and related activities influenced the annual per adult cigarette consumption in Turkey. We used a novel method to identify change points in tobacco trends and whether they correspond with key policy changes intended to alter usage after adjusting for the effect of other non-policy related covariates, such as the purchasing power. The policy analysis included an examination of the minutes of deliberations at the GNAT-which is the Turkish parliament and unicameral Turkish legislature-1 year before and 1 year after the break years associated with an increase or decrease in tobacco consumption. Results and recommendations: Tobacco consumption increased with the encouragement of tobacco production and the entrance of multinational companies in the country in 1976 and 1993, respectively. The National Tobacco Law of 1996 and comprehensive amendments in 2008, including smoke-free public places and tax increases, appear to have helped reduce tobacco consumption in Turkey. The focus of Parliamentary discussions throughout this period changed, becoming less supportive of tobacco over time. However, throughout the period there remained discussions focussing on concerns around the implications for the economy and the privatization agenda, national agriculture and the welfare of farmers. Effective control appears to require certain political ingredients to be implemented: politicians who are well informed on tobacco control measures and understand the range of issues surrounding the policies (not only those directly health-related); and supportive public health information in the community. Evidence-based public health policy should be introduced to the politicians.

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

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

Effects of tobacco control policy on cardiovascular morbidity and mortality in Russia.

Background: According to the Global Adult Tobacco Survey carried out in Russia in 2009, the country had one of the highest smoking prevalence rates in Europe. In response to this health and economic burden, Russia implemented a comprehensive Tobacco Control Law (TCL) in 2013, which has been associated with a 21.5% relative decline in adult smoking prevalence in 2016 compared with 2009. This study tests the impact of the TCL on cardiovascular disease (CVD) related health outcomes, including morbidity and mortality. Method: The study evaluated the TCL as an intervention in a natural experiment during the period 2003-2015. A synthetic control was created as a comparator, using data from countries that did not have a comparable comprehensive tobacco control intervention. Changes in trends in CVD outcomes - hospital discharge rates (HDRs) and standardized death rates (SDRs) - were then compared to test for an impact associated with the TCL. Results: Pre-intervention trends in CVD-related HDRs were similar between Russia and the synthetic control, but became divergent after the TCL with greater benefit observed in Russia. This implies a beneficial impact of the TCL on CVD related morbidity in the Russian population. Whilst SDRs continued to reduce in both Russia and the control, the impact of TCL is less clear. Conclusion: This study provides further evidence to support comprehensive tobacco control in line with the WHO Framework Convention for Tobacco Control (WHO FCTC). Alongside a reduction in tobacco consumption, smoking-related CVD morbidity appears to benefit quite soon after implementation, whilst smoking-related deaths might need a longer post-intervention period to be detectable.

The WHO-ERS Smoking Cessation Training Project: the first year of experience.

Strategic @ERSTalk-@WHO alliance to address tobacco use by training health professionals on brief advice resulted in establishing smoking cessation in real care settings with quit rates higher than the literature and high propensity for wider dissemination http://ow.ly/lWDF30krq5V.

Potential health impact of strong tobacco control policies in 11 South Eastern WHO European Region countries.

Background: While some WHO European Region countries are global tobacco control leaders, the South Eastern region of Europe has the highest tobacco smoking prevalence globally and a relatively low level of overall implementation of the WHO Framework Convention on Tobacco Control (WHO FCTC). An abridged version of SimSmoke has been developed to project the health impact of implementing tobacco control policies in line with the WHO FCTC. Methods: Data on population size, smoking prevalence, policy-specific effect sizes and formulas were applied in 11 South Eastern WHO European Region countries [Albania, Bosnia and Herzegovina (the Federation of Bosnia and Herzegovina and the Republika Srpska), Bulgaria, Croatia, Israel, Montenegro, Republic of Moldova, Romania, Serbia, Slovenia and the former Yugoslav Republic of Macedonia] to project the relative reduction in smoking prevalence, number of smokers and number of smoking-attributable deaths resulting from implementing individual and/or combined six WHO FCTC measures. Results: For all countries, an increase in excise cigarette taxes to 75% of price yields the largest relative reduction in smoking prevalence (range 8-28%). The projections show that within 15 years smoking prevalence can be reduced by at least 30% in all countries when all six tobacco control measures are fully implemented in line with the WHO FCTC. Conclusion: The projections show that large health effects can be achieved and the results can be used as an advocacy tool towards acceleration of the enforcement of tobacco control laws in WHO European Region countries.

Tobacco control in Europe: a policy review.

Tobacco is responsible for the death of 6 million people every year globally, of whom 700 000 are in Europe. Effective policies for tobacco control exist; however, the status of their implementation varies across the World Health Organization (WHO) European Region. In order to tackle the tobacco epidemic, action has been taken though the implementation of both legally binding and non-legally binding measures. This article aims to present the achievements and challenges of tobacco control in Europe, focussing on the available legally binding instruments such as the WHO Framework Convention on Tobacco Control and the revision of the Tobacco Products Directive at the European Union level. Tobacco still faces heavy lobbying of the tobacco industry, which has systematically contrasted policies to achieve public health objectives. The legal instruments for tobacco control in Europe presented here are not always adequately enforced in all the countries and there is certainly room for improving their implementation. Finally, the need for a strong political commitment towards the end-game of the tobacco epidemic is emphasised.