Compliance to Online Retail of Electronic Nicotine Delivery Systems (ENDS) in India before and after the 2018 Ban Order of the Government of India.

Since their launch globally in 2012, electronic nicotine delivery systems (ENDS) were positioned as a harm reduction strategy and cessation device but it is yet to be proven to have clinical safety or public health benefits. Instead, recent reports suggest that the tobacco industry targeted youth and sponsored research whose evidence was used to mislead policymaking. On August 28, 2018, Ministry of Health & Family Welfare's advisory banned the sale, purchase, and trade of ENDS. A survey was done in two waves. The first survey was done between August 10 and 25 2018 all websites which sold ENDS product were mapped and documented. The survey was repeated (November 30, 2018) were after the restriction to trade on ENDS was proposed by the Department of Customs. The two waves of survey found that no website, whether comprehensive e-commerce portals or dedicated ENDS marketing platforms fully complied with government orders. National and states government enforcement agencies are currently unaware of internet-based sale of ENDS. Although some states have given specific directions to stop the sale and delivery of ENDS within the state through e-commerce, there is limited monitoring and legal compliance by seller. Public health advocates need to stay vigilant and monitor the online sale and point of sale retail of ENDS to ensure strict compliance of national and state regulations.

Banning Loose Cigarettes and Other Tobacco Products in India: A Policy Analysis.

BACKGROUND: Sale of single cigarettes (also known as singles or loosies) is a key driver for early initiation of smoking and is a leading contributor to the smoking epidemic in India. Sale of singles additionally deter implementation of tobacco control strategies of pictorial health warnings including plain packaging and defeat effective taxation and promote illicit trade. We review India's tobacco control policy responses towards banning singles and other products sold as loose tobacco and identify opportunities for future policy intervention especially in the context of the ongoing COVID-19 pandemic. METHODS: Existing national and sub-national policy documents were analyzed for their content since the inception of the tobacco control laws in the country. RESULTS: There are no effective provisions at national level to ban loose tobacco products in India. However, the implementation of multiple legislative and regulatory measures (Acts/circulars/letters/notifications/orders/court judgements) in 16 Indian states and jurisdictions provide sufficient legal framework to substantiate its complete ban pan India. While the majority of state governments have adopted state level measures, Rajasthan had issued specific directive to all the 33 districts banning loose cigarettes and other tobacco products. Himachal Pradesh introduced the most unique and comprehensive legislation, for banning the sale of cigarettes and beedis (Dated November 7, 2016). The most recent notification in the state of Maharashtra (September 24, 2020) is the first to leverage powers using a mix of national and state legislations including the legislation addressing the rapidly emerging challenge of managing COVID-19. CONCLUSION: A robust national policy which supports strong provision to deter tobacco companies, their distribution network and vendors from selling singles or loose tobacco products is urgently needed. Such policy should be backed by cautionary messaging for consumers as well. Eliminating singles and loose tobacco sale will help in blunting tobacco use prevalence besides curbing spread of infectious diseases like COVID-19 pandemic.

Tobacco price and use following California Proposition 56 tobacco tax increase.

BACKGROUND: California Proposition 56 increased cigarette excise tax by $2 per pack with equivalent increases on non-cigarette tobacco products. We estimated the changes in cigarette price, cigarette use, and non-cigarette use following the implementation of Proposition 56 in California in 2017. METHODS: Seven waves of Tobacco Use Supplements to the Current Population Survey (TUS-CPS) 2011-2019 data were used to obtain state-level aggregate self-reported outcomes, including cigarette price per pack, current and daily cigarette use, cigarette consumption per day, and current and daily use of non-cigarette tobacco products (hookah, pipe, cigar, and smokeless tobacco). A modified version of a synthetic control method was used to create a "synthetic" California that best resembled pre-policy sociodemographic characteristics and outcome trends in California while correcting time-invariant pre-policy differences. Various sensitivity analyses were also conducted. RESULTS: The implementation of Proposition 56 was associated with an increase in self-reported cigarette price per pack in California ($1.844, 95%CI: $0.153, $3.534; p = 0.032). No evidence suggested that Proposition 56 was associated with the changes in the prevalence of current or daily cigarette use, cigarette consumption per day, or the prevalence of current or daily use of non-cigarette tobacco products. CONCLUSION: Most of the cigarette tax increase following Proposition 56 in California was passed on to consumers. There is a lack of evidence that the implementation of Proposition 56 was associated with the changes in the use of cigarettes and other tobacco products such as hookah, pipe, cigar, and smokeless tobacco.

Examining the sources of evidence in e-cigarette policy recommendations: A citation network analysis of international public health recommendations.

BACKGROUND: Public health policies and recommendations aim to be informed by the best available evidence. Evidence underpinning e-cigarettes policy recommendations has been necessarily limited due to the novelty of the technology and the lack of long-term epidemiological studies and trials. Some public health bodies have actively encouraged e-cigarette use whilst others have raised concerns over introducing new health risks and renormalising tobacco smoking. Using citation network analysis we investigated the author conflicts of interest and study funding statements within sources of evidence used by public health bodies when making recommendations about e-cigarette policy. METHODS: We conducted citation network analysis of public health recommendation documents across four purposively selected diverse jurisdictions: WHO, UK, Australia, and USA. We extracted all citations from 15 public health recommendation documents, with more detailed data collected for influential citations (used in 3+ recommendation documents). We analysed the relationships between the sources of evidence used across jurisdictions using block modelling to determine if similar groups of documents were used across different jurisdictions. We assessed the frequency and nature of conflicts of interest. RESULTS: 1700 unique citations were included across the 15 public health recommendation documents, with zero to 923 citations per document (median = 63, IQR = 7.5-132). The evidence base underpinning public health recommendations did not systematically differ across jurisdictions. Of the 1700 citations included, the majority were journal articles (n = 1179). Across 1081 journal articles published between 1998-2018, 200 declared a conflict of interest, 288 contained no mention of conflicts of interest, and 593 declared none. Conflicts of interest were reported with tobacco (3%; n = 37 journal articles of 1081), e-cigarette (7%; n = 72), and pharmaceutical companies (12%; n = 127), with such conflicts present even in the most recent years. There were 53 influential citations, the most common study type was basic science research without human subjects (e.g. examination of aerosols and e-liquids) (n = 18) followed by systematic review (n = 10); with randomised control trial being least common (n = 4). Network analysis identified clusters of highly-cited articles with a higher prevalence of conflicts of interest. CONCLUSION: Public health bodies across different jurisdictions drew upon similar sources of evidence, despite articulating different policy approaches to e-cigarettes. The evidence drawn upon, including the most influential evidence, contained substantial conflicts of interest (including relationships with e-cigarette and tobacco industries). Processes to explicitly manage conflicts of interest arising from the underlying evidence base may be required when developing public health recommendations.

An Overview of the Policy and Market Landscape of Tobacco Production and Control in Mozambique.

Background: Tobacco growing has been considered a mainstay of Mozambique's economy, but there is a dearth of analysis of the tobacco policy landscape in the country. Methods: Review of government and non-government documents and academic papers addressing Mozambique's tobacco-growing history, the changes in the political economy of tobacco, and health policies addressing tobacco use and prevention of noncommunicable diseases. Results: Despite its tobacco growing and exporting history, the contribution of tobacco to the economy has been in steady decline in the past two decades, including in the areas dedicated to growing. At the same time there has been an increase in multinational control of the tobacco economy. In parallel, Mozambique's commitment to addressing the growing burden of noncommunicable disease and accession to the Framework Convention on Tobacco Control indicate a potential for internal government tensions to balance immediate economic interests with long term health goals. Conclusions: With the decline in tobacco share of the overall economy, Mozambique may be well-positioned to explore alternative, sustainable livelihoods for farmers that grow tobacco, but it must overcome inter-sectoral barriers and advocate for a whole of government approach to address the health and economic impact of tobacco.

Trends in Manufacturer-Reported Nicotine Yields in Cigarettes Sold in the United States, 2013-2016.

INTRODUCTION: A gradual reduction of cigarette nicotine content to nonaddictive levels has been proposed as an endgame strategy to accelerate declines in combustible tobacco smoking. We assessed manufacturer-reported nicotine yield in cigarettes sold in the United States from 2013 to 2016. METHODS: We merged machine-measured nicotine yield in cigarette smoke and pack characteristics obtained from reports filed by tobacco manufacturers with the Federal Trade Commission for 2013-2016 with monthly Nielsen data on US cigarette sales. Manufacturer-reported, sales-weighted, average annual nicotine yield was assessed, as were nicotine yield sales trends by quartile: markedly low (0.10-0.60 mg/stick), low (0.61-0.80 mg/stick), moderate (0.81-0.90 mg/stick), and high (0.91-3.00 mg/stick). Trends in overall, menthol, and nonmenthol pack sales, by nicotine yield quartiles over the study period and by year, were determined by using Joinpoint regression. RESULTS: During 2013-2016, average annual sales-weighted nicotine yield for all cigarettes increased from 0.903 mg/stick (95% CI, 0.882-0.925) in 2013 to 0.938 mg/stick (95% CI, 0.915-0.962) in 2016 (P < .05). For menthol cigarettes, yield increased from 0.943 mg/stick in 2013 (95% CI, 0.909-0.977) to 1.037 mg/stick in 2016 (95% CI, 0.993-1.081), increasing 0.2% each month (P < .05). Most pack sales occurred among high (41.5%) and low (30.7%) nicotine yield quartiles. Cigarette sales for the markedly low quartile decreased by an average of 0.4% each month during 2013-2016 (P < .05). CONCLUSION: During 2013-2016, manufacturer-reported, sales-weighted nicotine yield in cigarettes increased, most notably for menthol cigarettes. Continued monitoring of nicotine yield and content in cigarettes can inform tobacco control strategies.

Area-level differences in the prices of tobacco and electronic nicotine delivery systems - A systematic review.

OBJECTIVE: To examine associations between area-level characteristics (socioeconomic status, racial or ethnic characteristics, age, and any other characteristics that may be associated with vulnerability) and the prices of tobacco products and electronic nicotine delivery systems (ENDS). DATA SOURCES: We searched MEDLINE, EconLit and Scopus, unpublished and grey literature, hand-searched four specialty journals, examined references of relevant studies, and contacted key informants. STUDY SELECTION: We considered all studies that quantitatively examined area-level variations in the prices of tobacco products and ENDS. We included all studies that examined any area-level measures regardless of the geographic location, language or time of publication. At least two reviewers independently screened the articles. We identified 20 studies. DATA EXTRACTION: At least two reviewers independently extracted the characteristics, methods, and main results and assessed the quality of each included study. DATA SYNTHESIS: Overall, cigarette prices were found to be lower in lower socioeconomic status neighbourhoods, and in neighbourhoods with a higher percentage of youth, and Blacks or African Americans. We identified too few studies that examined price differences for cigarillos, chewing tobacco, roll-your-own, and ENDS to reach any conclusions. CONCLUSIONS: Our findings are in keeping with tobacco industry documents that detailed how manufacturers used race, class, and geography to target vulnerable populations and suggest that regulations that can limit industry price manipulation such as minimum, maximum, and uniform prices, and high specific excise taxes should be considered. More frequent and systematic monitoring of tobacco prices and ENDS is warranted.

Raising Tobacco Taxes: The Philippine Experience.

The 2012 Philippine Sin Tax Reform Law or Republic Act No. 10351 (RA10351) offers important lessons on tobacco taxation and tobacco control. In a span of five years, it increased the excise tax rate on cigarettes to as high as 1000% for low-priced brands. It is recognized by the international community not only because of the magnitude of the tobacco tax increase that it stipulated but also because of the challenging context within which it was achieved. This article presents the Philippine experience as a case study in pursuing bold reforms in tobacco taxation and tobacco control amidst strong opposition by the tobacco industry. It considers: 1) the key events and factors that led to successful reform of the Philippine tobacco tax system; 2) the impact of higher tobacco taxes on health and the economy; and 3) the emerging challenges in tobacco taxation in the Philippines.
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Comparison of tobacco import and tobacco control in five countries: lessons learned for Indonesia.

BACKGROUND: With a 264 million population and the second highest male smoking prevalence in the world, Indonesia hosted over 60 million smokers in 2018. However, the government still has not ratified the Framework Convention on Tobacco Control. In the meantime, tobacco import increases rapidly in Indonesia. These create a double, public health and economic burden for Indonesia's welfare. OBJECTIVE: Our study analyzed the trend of tobacco import in five countries: Indonesia, Pakistan, Bangladesh, Zimbabwe, and Mozambique. Also, we analyze the tobacco control policies implemented in these countries and determine some lessons learn for Indonesia. METHODS: We conducted quantitative analyses on tobacco production, consumption, export, and import during 1990-2016 in the five countries. Data were analyzed using simple ordinary least square regressions, correcting for time series autocorrelation. We also conducted a desk review on the tobacco control policies implemented in the five countries. RESULTS: While local production decreased by almost 20% during 1990-2016, the proportion of tobacco imports out of domestic production quadrupled from 17 to 65%. Similarly, the ratio of tobacco imports to exports reversed from 0.7 (i.e., exports were higher) to 2.9 (i.e., import were 2.9 times higher than export) in 1990 and 2016, respectively. This condition is quite different from the other four respective countries in the observation where their tobacco export is higher than the import. From the tobacco control point of view, the four other countries have ratified the Framework Convention on Tobacco Control (FCTC). CONCLUSION: The situation is unlikely for Indonesia to either reduce tobacco consumption or improve the local tobacco farmer's welfare, considering that the number of imports continued to increase. Emulating from the four countries, Indonesia must ratify the FCTC and implement stricter tobacco control policies to decrease tobacco consumption and import.

Tobacco industry and public health responses to state and local efforts to end tobacco sales from 1969-2020.

BACKGROUND: In June 2019, Beverly Hills, California, became the first American city in the 21st century to pass an ordinance ending the sale of most tobacco products, including cigarettes, and it is unlikely to be the last. Knowledge of previous efforts to ban tobacco sales in the US, both successful and unsuccessful, may help inform tobacco control advocates' approach to future efforts. METHODS: We retrieved and analyzed archival tobacco industry documents. We confirmed and supplemented information from the documents with news media coverage and publicly available state and local government materials, such as meeting minutes and staff reports, related to proposed bans. RESULTS: We found 22 proposals to end the sale of cigarettes or tobacco products from 1969-2020 in the US. Proposals came from five states, twelve cities or towns, and one county. Most came from elected officials or boards of health, and were justified on public health grounds. In opposing tobacco sales bans, the tobacco industry employed no tactics or arguments that it did not also employ in campaigns against other tobacco control measures. Public health groups typically opposed sales ban proposals on the grounds that they were not evidence-based. This changed with Beverly Hills' 2019 proposal, with public health organizations supporting this and other California city proposals because of their likely positive health impacts. This support did not always translate into passage of local ordinances, as some city council members expressed reservations about the impact on small businesses. CONCLUSION: Tobacco control advocates are likely to encounter familiar tobacco industry tactics and arguments against tobacco sales ban proposals, and can rely on past experience and the results of a growing body of retail-related research to counter them. Considering how to overcome concerns about harming retailers will likely be vital if other jurisdictions are to succeed in ending tobacco sales.

Cigarette Pack Prices and Sales Following Policy Changes in California, 2011-2018.

Objectives. To estimate the combined effect of California's Tobacco 21 law (enacted June 2016) and $2-per-pack cigarette excise tax increase (enacted April 2017) on cigarette prices and sales, compared with matched comparator states.Methods. We used synthetic control methods to compare cigarette prices and sales after the policies were enacted, relative to what we would have expected without the policy reforms. To estimate the counterfactual, we matched pre-reform covariate and outcome trends between California and control states to construct a "synthetic" California.Results. Compared with the synthetic control in 2018, cigarette prices in California were $1.89 higher ($7.86 vs $5.97; P < .001), and cigarette sales were 16.6% lower (19.9 vs 16.6 packs per capita; P < .001). This reduction in sales equates to 153.9 million fewer packs being sold between 2017 and 2018.Conclusions. California's new cigarette tax was largely passed on to consumers. The new cigarette tax, combined with the Tobacco 21 law, have contributed to a rapid and substantial reduction in cigarette consumption in California.

How Should Physicians in Low- and Middle-Income Countries Regard Electronic Nicotine Delivery Systems to Facilitate Smoking Cessation?

Electronic nicotine delivery systems (ENDS) have been widely referred to as "safer," "healthier," and more "effective" smoking cessation aids, but little evidence supports such claims. New concerns about pulmonary injuries associated with ENDS suggest reasons for concern about these products' health risks and potential for nicotine addiction. Nevertheless, multinational tobacco companies heavily market ENDS to retain customers with nicotine addiction, and global progress against tobacco use might slow as a result. The tobacco industry has managed to divide the tobacco control community by offering hope of harm reduction without actual evidence of ENDS' effectiveness or long-term safety. Low- and middle-income countries need this evidence to assess ENDS' value in mitigating tobacco use.