Evidence of the Effectiveness of Pictorial Health Warnings on Cigarette Packaging in Nepal.

BACKGROUND: Tobacco Control Act of 2010 mandates government to implement at least 75% pictorial health warnings (PHWs) on tobacco packaging that was enforced in 2013. The purpose of the study was to assess the effectiveness of PHWs and its impact to the policy change. METHODS: A cross-sectional study was conducted in 9 cities between September 2014 and March 2015. Direct interviews were made among 2250 randomly selected individuals. The effectiveness of PHWs were measured as perceived: i) scariness; ii) quit motivation iii) convincing youth not to start smoking; iv) encouraging ex-smokers to remain as quitters; v) building public awareness. Logistic regression analysis was used to determine the factors associated with the effectiveness of PHWs. RESULTS: Of the 2250 participants, 29.8% (670) were current smokers, 8.6% (193) were ex-smokers and 97.6% believed that smoking was addictive. PHWs made 83% of the participants scared. Participants believed that PHWs would be effective in motivating smokers to quit (80.2%), in convincing youth not to start smoking (86.8%), in encouraging ex-smokers to remain as quitters (89.1%) and in building public awareness on the dangers of smoking (94%). PHWs made 58% of the current smokers intended to quit smoking and reduced their daily intake of cigarettes from 11 to 5 on average.  Current smokers preferred to purchase loose cigarettes rather than a pack. The covariates significantly associated with the effectiveness of PHWs were current smokers, ex-smokers and addiction. CONCLUSION: PHWs were found important to motivate smokers to quit smoking, to reduce consumption of cigarettes and to prevent relapse in ex-smokers. Evidence from the study had triggered policy changes which included enlargement of the size of PHW to 90% and the release of a notification to ban selling of loose cigarettes. Thus, the warning messages with pictures are required to be improved and rotated.

Beyond Nutrient Deficiency-Opportunities to Improve Nutritional Status and Promote Health Modernizing DRIs and Supplementation Recommendations.

The US Dietary Guidelines for Americans (DGA) provide dietary recommendations to meet nutrient needs, promote health, and prevent disease. Despite 40 years of DGA, the prevalence of under-consumed nutrients continues in the US and globally, although dietary supplement use can help to fill shortfalls. Nutrient recommendations are based on Dietary Reference Intakes (DRIs) to meet the nutrient requirements for nearly all (97 to 98 percent) healthy individuals in a particular life stage and gender group and many need to be updated using current evidence. There is an opportunity to modernize vitamin and mineral intake recommendations based on biomarker or surrogate endpoint levels needed to 'prevent deficiency' with DRIs based on ranges of biomarker or surrogate endpoints levels that support normal cell/organ/tissue function in healthy individuals, and to establish DRIs for bioactive compounds. We recommend vitamin K and Mg DRIs be updated and DRIs be established for lutein and eicosapentaenoic and docosahexaenoic acid (EPA + DHA). With increasing interest in personalized (or precision) nutrition, we propose greater research investment in validating biomarkers and metabolic health measures and the development and use of inexpensive diagnostic devices. Data generated from such approaches will help elucidate optimal nutrient status, provide objective evaluations of an individual's nutritional status, and serve to provide personalized nutrition guidance.

Towards unified and impactful policies to reduce ultra-processed food consumption and promote healthier eating.

The global surges in obesity and nutrition-related non-communicable diseases (NCDs) have created a need for decisive new food policy initiatives. A major concern has been the impact of ultra-processed foods (UPFs) and ultra-processed drinks on weight gain and on the risk of several NCDs. These foods, generally high in calories, added sugar, sodium, and unhealthy fats, and poor in fibre, protein, and micronutrients, have extensive negative effects on human health and on the environment (due to their associated carbon emission and water use). There is a growing tendency worldwide, and especially in South America, for food companies to add micronutrients to UPFs to make health claims regarding these products, to which food-regulating authorities refer to fake foods. Although more than 45 countries and smaller subregional or urban entities have created taxes on ultra-processed drinks, such as sugar-sweetened beverages, only a few have adopted taxes on snacks and other UPFs, and none have added major subsidies for truly healthy, fresh or minimally processed food for people from lower socioeconomic backgrounds. Another major focus has been on developing effective package labelling. A smaller number of countries have selected the most impactful warning labels and linked them with other measures to create a mutually reinforcing set of policies; a few other countries have developed effective school food policies. We herein present in-depth results from key countries involved in all these actions and in comprehensive marketing controls, and conclude with our recommendations for the future. This field is quite new; progress to date is substantial, but much more is left to learn.

Opportunities to Promote Healthy Weight Through Child Care Licensing Regulations: Trends in the United States, 2016-2020.

BACKGROUND: Policies that support healthy nutrition and physical activity environments in early care and education (ECE) settings can help promote healthy weight in children. State child care licensing regulations are a critical mechanism for setting such policies. OBJECTIVES: To develop a research instrument to evaluate the promotion of healthy child weight in state child care licensing regulations and assess the strength of the regulations over time. DESIGN: For measure development, systematic reviews of evidence on the impact of healthy weight strategies relevant to the ECE environment were combined with expert stakeholder input to identify 15 healthy weight promotion policy standards and a coding tool to measure the strength and comprehensiveness of regulatory language matching these standards. For assessing the strength of regulations, the coding tool was applied to child care regulations nationwide in 2016 and again in 2020. SUBJECTS/SETTING: Child care licensing regulations in 2016 and 2020 for all 50 US states plus Washington DC. OUTCOME MEASURES: Strength and comprehensiveness scores for state licensing regulations. STATISTICAL ANALYSES: Intraclass correlation coefficients were calculated to estimate interrater reliability of the coding tool. Paired t tests were used to compare scores within states from 2016 to 2020. RESULTS: Interrater reliability for the coding tool had intraclass correlation coefficients of 0.81 for strength and 0.87 for comprehensiveness scores. Strength and comprehensiveness of states' healthy weight promotion policies increased significantly over time (P < .001). However, most states still lack important healthy weight policies in their licensing regulations, such as prohibiting serving sugary drinks. CONCLUSIONS: This study presents a reliable research instrument for measuring the strength and comprehensiveness of healthy weight promotion standards in child care licensing regulations. States have increased their incorporation of strategies for healthy weight into state policy.

The Political Determinants of China'S New Health Constitution.

The Basic Healthcare and Health Promotion Law 2019 became the new constitution of China's health system in June 2020, giving legal effect to ambitious health reform programmes like Healthy China 2030. The concurrent outbreak of coronavirus disease 2019 must not distract us from appreciating the fact that this Law will comprehensively overhaul the health regulatory framework of the world's most populous country during the coming decade, if not beyond. This article offers an original evaluation of the Law in its political context. The Law commendably promises to safeguard the right to health, assist citizens to live a 'complete cycle of life', and promote health using the resources of the public health system. However, it is also deeply politicised, guaranteeing extensive and penetrative political control in health campaigns, digitalised health data, the governance of health institutions, and the resolution of medical disputes. This can be explained by the consequential roles played by epidemics in China's historical dynastic cycles, but even more so by powerful tendencies of centralisation on the part of the Leninist Party-state. The Law's potential is thus subject to the overriding caveat that the Party-state's existence and influence over law and public health must be secured.

Eliminating Religious and Philosophical Exemptions: The Next Step in Ontario's Campaign against Vaccine Hesitancy.

Ontario families are required to provide up-to-date vaccination records as children begin schooling. Exemptions are allowed on both medical and nonmedical (religious or philosophical) grounds. In a recent report, Toronto Public Health (2019) called for an end to nonmedical exemptions - a proposal some allege infringes the Canadian Charter of Rights and Freedoms right to freedom of religion and conscience. This paper explores whether and to what extent vaccine refusal is protected under the Charter and argues that the elimination of nonmedical exemptions can be justified under Section 1 of the Charter. The issue of mandatory vaccination may take on special urgency in the coming months and years, if and when a vaccine is found for COVID-19.

Secondhand Smoke from a Veranda Spreading to Neighboring Households.

Secondhand smoke (SHS) caused by smoking on apartment verandas is a severe social problem in Japan. If someone smokes on a veranda, SHS drifts into other residents' rooms through their windows. Most non-smoking residents are annoyed by this, but they do not confront the person responsible. To study this situation, we burned cigarettes and measured the spread of SHS in terms of fine particle (PM2.5) concentrations. Cigarette smoke generated on a lower veranda spread to upper and horizontal neighboring verandas and into rooms through windows, reaching a maximum concentration of 139 µg/m3. The Health Promotion Act that was revised in 2018 and enacted in 2019-2020 requires all smokers to avoid producing SHS, even outdoors and at home. It is expected that combining the measurement of SHS from verandas to other verandas and rooms with the revised Health Promotion Act could create a national consensus on "no smoking on apartment verandas."

Program Evaluation of Environmental and Policy Approaches to Physical Activity Promotion in a Lower Income Latinx School District in Southeast Los Angeles.

There is alarming population wide prevalence of low adolescent physical activity as this represents a risk factor for later chronic disease development. There is evidence to suggest that schools with strong wellness policies have students that are more frequently active. We designed an intervention to enhance students' physical activity levels in five majority Latinx, underserved school districts. Evaluation consisted of assessment of written quality of school-district wellness policies; observation of student's physical activity during leisure times; and after-school program practices and policies. We examined one of these district's results more closely, the only participating district with a community coalition, and extracted lessons learned. On the physical activity section of the wellness policy, this district covered a moderate extent of recommended content areas using weak language. Compared to previous reports, we identified low vigorous activity levels for girls and boys at baseline (respectively, 12% and 18%). Finally, we identified that of four after school program sites assessed at baseline, no program reported the recommended 50% or more of program time dedicated to physical activity. Based on these evaluation findings, additional strategies are urgently needed to encourage all students and particularly more girls to be physically active throughout the school day.

World Heart Federation Policy Brief: Front-Of-Pack Labelling: Unhealthy Changes in the Global Food System.

On World Food Day, the World Heart Federation calls on governments to implement mandatory front-of-pack food labels. The World Heart Federation (WHF) has developed a new policy brief on front-of-pack labelling (FOPL) aimed at improving global standards on nutrition and creating healthy food environments. Poor diet is responsible for more deaths worldwide than any other risk factor, and is a leading cause of obesity, type 2 diabetes, and cardiovascular disease (CVD). Global estimates suggest that almost 2.3 billion children and adults are overweight. The growing availability of ultra-processed foods, which contain high levels of sugars, sodium, saturated fats and refined carbohydrates, is a key contributor to the current obesity epidemic, which is increasingly impacting low- and middle-income countries. The WHF Front-of-Pack Labelling Policy Brief highlights front-of-pack labelling as a way to create environments where consumers are able to make better informed, healthier food choices for themselves and their families. Currently, a wide variety of front-of-pack labelling systems have been implemented by governments and food manufacturers around the world, with varying levels of success. The new WHF Policy Brief provides evidence-based, practical guidance that can be adapted to local contexts. It highlights that in order the be implemented successfully, FOPL systems must take into account consumer literacy and prevailing cultural norms around food and nutrition. FOPL must be mandatory, government-led, and accompanied by broad public nutrition education initiatives. The WHF Policy Brief includes a set of policy recommendations to give governments the tools they need to select the FOPL system that will best meet the needs of their populations, including recommendations on how to develop an effective FOPL programme, how to implement it successfully, and how to monitor and evaluate outcomes.

The President's Emergency Plan for AIDS Relief and adult mortality: A replication study of HIV development assistance effects in Sub-Saharan African countries.

The US budget for global health funding, which was by far the largest of similar funding in the world, increased from US $1.3 billion in 2001 to more than US $10 billion in recent years. More than 54% of this funding was allocated to the Global Fund to Fight HIV/AIDS through the US President's Emergency Plan for AIDS Relief (PEPFAR) in Africa. However, recent studies indicate contradictory results regarding the effectiveness of PEPFAR. One by Bendavid, Holmes, Bhattacharya, and Miller shows positive effects of PEPFAR in reducing adult mortality in Africa, while another by Duber, Coates, Szekeras, Kaji, and Lewis finds that there are no significant differences in reducing adult mortality in countries that received PEPFAR funding vs countries that did not. Due to their potential impact on policy decisions regarding critical global health funding, we wanted to assess why the results are discrepant. To do this, we replicated the Bendavid study. The replication provides verification that the study replicable and that the analytic choices of the authors are robust to different assumptions or restrictions. This allows us to assess the different choices and data available to the two research groups and draw some conclusions about why the results may be different. Then, focusing on two of the prominently discrepant studies, i.e., the Bendavid study (1998-2008) and the Duber study (2000-2006), we establish why the two studies are in disagreement. We apply appropriate individual-level and country-level analytical methodology as used by Bendavid over the analytical time period used for the Duber study (2000-2006), which originally focused on nationally aggregated data and differed in some key focus countries. For our first objective, we replicated the original Bendavid study findings and our findings support their conclusion that between 1998-2008 all-cause mortality decreased significantly more (OR = 0.84, CI, 0.72-0.99) in countries that implemented PEPFAR. For our second objective (Bendavid's data and methodology applied to Duber's study period), we found reduction in all cause adult mortality to be borderline insignificant (OR = 0.87 CI, 0.75-1.01, p = 0.06), most possibly reflecting the abbreviated fewer number of events and sample size over a shorter period. Therefore, our overall analyses are consistent with the conclusion of positive impact of the PEPFAR program in reducing adult mortality. We believe that the discrepancy observed in the original studies mainly a reflection of shortcomings in the analytical approach necessitated by the Duber study's nationally aggregated dataset or "may reflect a lack of data quality" in the Duber study (Duber, et al. 2010).

Periodic Revisions of the International Choices Criteria: Process and Results.

Unhealthy diets contribute to an increased risk of non-communicable diseases, which are the leading causes of deaths worldwide. Nutrition policies such as front-of-pack labeling have been developed and implemented globally in different countries to stimulate healthier diets. The Choices Programme, including the International Choices criteria, is an established tool to support the implementation of such policies. The Choices criteria were developed to define the healthier choices per product group, taking saturated fatty acids, trans fatty acids, sodium, sugars, energy, and fiber into account. To keep these criteria updated, they are periodically revised by an independent international scientific committee. This paper explains the most important changes resulting from revisions between 2010 and 2016 and describes the process of the latest revision, resulting in the International Choices criteria version 2019. Revisions were based on national and international nutrition and dietary recommendations, large food composition databases, and stakeholders' feedback. Other nutrient profiling systems served as benchmarks. The product group classification was adapted and new criteria were determined in order to enhance global applicability and form a credible, intuitively logical system for users. These newly developed criteria will serve as an international standard for healthier products and provide a guiding framework for food and nutrition policies.

The level of effectiveness of Polish legislation relating to health protection against the consequences of tobacco use.

The purpose of this work is to analyze the regulatory environment for tobacco use, with particular reference to changes made in the last 10 years. An attempt was made to answer the question of the extent to which the regulatory environment has a real impact on the achievement of the objective set out in the existing legal provisions, which is to protect the health and rights of the persons concerned. An analytical method was used in the work to assess the application of legal principles. A method of analyzing the current line of jurisprudence was also used. In the process of final evaluation of public utilities, certain functional methods were used. The assessment was subjected to Polish law, within the scope of the currently binding Act on Health Protection Against the Consequences of Using Tobacco and Tobacco Products of 1995. The study states that the provisions of this Act are only a formal guarantee of protection. The liability arising from the application of its standard is illusory because the procedure for imposing penalties is ineffective. The pursuit of any property claims related to violation of the rights of related entities, as envisaged in this Act, is complicated. This does not apply to a case which is not affected by the decision. Int J Occup Med Environ Health. 2020;33(5):599-610.

Lessons from the Field: The Traditional Monarch of Kitti in Pohnpei Addresses the High Rates of Non-Communicable Diseases through Local Policy.

Almost a quarter of Pohnpei's population is overweight or obese, a major factor influencing a 2010 non-communicable diseases (NCD) emergency declaration. The Racial and Ethnic Approaches to Community Health (REACH) project in Pohnpei is implementing a culturally tailored policy, systems, and environmental (PSE) intervention to reduce NCDs through healthy nutrition projects. Through collaboration with traditional leaders and using traditional protocols, REACH succeeded in soliciting formal approval from a Traditional Monarch to serve only healthy beverages during events at all traditional houses in the municipality. The Governor, in turn, also supported this initiative. This project cultivated relationships with traditional and government leaders to implement a culturally appropriate healthy nutrition PSE change intervention.

Healthy Eating Policy Improves Children's Diet Quality in Early Care and Education in South Carolina.

Policies to promote healthy foods in early care and education (ECE) in the United States exist, but few have been prospectively evaluated. In South Carolina, a statewide program serving low-income children in ECE enacted new policies promoting healthy foods. We conducted an evaluation to measure changes in dietary intake among children in ECE exposed and not exposed to the new policy. Using direct observation, we assessed dietary intake in 112 children from 34 ECE centers in South Carolina and 90 children from 30 ECE centers in North Carolina (a state with no policy). We calculated Healthy Eating Index-2015 (HEI) scores to measure diet quality consumed before and after the policy was enacted. We fit mixed-effects linear models to estimate differences in HEI scores by state from baseline to post-policy, adjusting for child race, number of children enrolled, director education, center years in operation, participation in the Child and Adult Care Food Program (CACFP), and center profit status. The policy increased HEI scores for whole fruits, total fruits, and lean proteins, but decreased scores for dairy. Thus, the policy was associated with some enhancements in dietary intake, but additional support may help improve other components of diet.