The Diversity in Tobacco Use Among Women of Reproductive Age (15-49 Years) in Pakistan: A Secondary Analysis of a Multiple Indicator Cluster Survey 2016-2018.

INTRODUCTION: Tobacco use in women of reproductive age group (15-9 years) may contribute to poor maternal and child health outcomes. We estimated the prevalence of smokeless tobacco (ST), cigarette, and waterpipe use among these women in Pakistan and explored associations with socio-economic differences and birth weights after recent childbirths (past 2 years). AIMS AND METHODS: We used the Multiple Indicator Cluster Surveys datasets from three provinces in Pakistan. Prevalence was generated for current use of tobacco among women with recent childbirth (WWRC) and without recent childbirth (WWoRC). We further compared socio-economic status and birth weights between tobacco users and non-users. RESULTS: The prevalence of current ST use was 1.4% and 2.5%, and waterpipe smoking was 1.2% and 1.8%, in WWRC and WWoRC, respectively. ST use varied across Pakistan's provinces by 13 percentage points in WWRC and WWoRC while waterpipe smoking by 10 and 15 percentage points, respectively. The odds of using any form of tobacco were significantly lower with higher levels of education or wealth index. Compared to children born to mothers who did not use tobacco, the birth weight of children born to mothers who smoked waterpipe was on average 0.83 kg (95% CI -1.6 to -0.1) lower whereas it was 0.33 kg (95% CI -0.9 to 0.3) higher for ST users. CONCLUSIONS: Tobacco use among women of reproductive age in Pakistan varied significantly based on province and tobacco type. Waterpipe smoking was associated with a reduction in birth weight. Raising awareness of the harms of tobacco use among women of reproductive age and targeting interventions in high-burden regions of Pakistan should be prioritized. IMPLICATIONS: The prevalence of current smokeless tobacco use and waterpipe smoking varied significantly in Pakistan (~13 and ~15 percentage points, respectively) among women of reproductive age, and there seems to be little change in tobacco use behavior around pregnancy and early motherhood. The study highlights a need to better understand the prevalence of tobacco use in Pakistan, and further contextual research is warranted to understand the reasons for such high tobacco use in certain areas. This information highlights the need for improving current tobacco control interventions and policies, including measures that could help reduce its use and prevent its uptake. Furthermore, compared to children born to mothers who did not use any form of tobacco, we found a statistically significant difference (830 g) in birth weight for babies born to mothers who at the time of the interview smoked waterpipe and a non-statistically significant difference of about 330 g for children born to mothers who at the time of the interview used smokeless tobacco. In addition to our findings, some literature suggests the association of waterpipe smoking with low birth weight. A possible explanation could be the exposure to smoke that contains toxicants from the tobacco product itself in addition to the burning of charcoal, which is required when using waterpipe. Waterpipe smoking also results in high exposures to carbon monoxide and polycyclic aromatic hydrocarbons, which are known to be carcinogenic and teratogenic. In terms of smokeless tobacco use, further research is warranted to understand its impact on birth outcomes through longitudinal studies accounting for diverse products, its constituents and the amount of consumption.

The Effect of Adult Smoking Behavior on Children's Exposure to Secondhand Smoke. An Analysis Based on Salivary Cotinine Levels Among Children in Dhaka and Karachi.

INTRODUCTION: Exposure to secondhand smoke (SHS) risks children's health. However, biomarkers are rarely used to study SHS exposure among children in low- and middle-income countries. AIMS AND METHODS: We analyzed cross-sectional data collected between March and November 2022 for a cluster-randomized controlled trial investigating a Smoke-Free Intervention in 2769 children aged 9-15 in 74 schools (34 in Dhaka, Bangladesh, and 40 in Karachi, Pakistan). Children's saliva was tested for the concentration of cotinine-a highly sensitive and specific biomarker for SHS exposure. Based on their reports, children's homes were categorized as Nonsmoking Homes (NSH) when residents were nonsmokers; Smoke-free Homes (SFH) when residents and visitors smoked outdoors only; and Smoke-permitted Homes (SPH) when either residents or visitors smoked indoors. We compared cotinine concentrations across these home types and the two cities using a proportional odds model. RESULTS: Overall, 95.7% of children (92% in Dhaka; and 99.4% in Karachi) had cotinine levels between 0.1 and 12 ng/mL, indicating SHS exposure. Median cotinine levels were higher in Karachi (0.58 ng/mL, IQR 0.37 to 0.93) than in Dhaka (0.27 ng/mL, IQR 0.16 to 0.49). Median cotinine concentration was also higher among children living in SPH than those in either NSH or SFH; with absolute differences of approximately 0.1-0.3 and 0.05 ng/mL, respectively. CONCLUSIONS: The level of SHS exposure in Dhaka and Karachi indicates widespread and unrestricted smoking. Smoking restrictions in households and enforcement of smoking bans are urgently needed. IMPLICATIONS: The high levels of SHS exposure in children living in SFH suggest parental behavior to hide their smoking and/or exposure in private vehicles or public spaces. It is important to advocate for SFH and cars to protect children from SHS exposure. However, these initiatives alone may not be enough. There is a need to enforce smoking bans in enclosed public places and transportation, as well as extend these bans to playgrounds, parks, fairgrounds, and other public spaces that children frequently visit. It is essential to complement smoking restrictions with tobacco cessation advice and support in these settings.

Older men and loneliness: a cross-sectional study of sex differences in the English Longitudinal Study of Ageing.

BACKGROUND: Research into men and masculinities suggests men may be more reluctant than women to state they are lonely, more reliant on partners/spouses and/or alcohol to tackle it, and that this may be a result of poorer social relationships. Ageing is often associated with loneliness, and research has indicated gendered results in older people, but existing evidence lacks generalisability and cultural context. This study tests hypotheses on sex differences in loneliness in older England-based men and women. METHODS: We conducted a cross-sectional study using a sample of 6936 respondents aged 50 + from the English Longitudinal Study of Ageing (wave 8). Multiple imputation with chained equations was conducted to handle missing data. Multivariate regression was used to investigate the impact of sex on a direct question on loneliness whilst controlling for the University of California loneliness (UCLA) scale. Multivariate regression with interaction terms were used to examine sex differences in loneliness and alcohol consumption, partner status, and social relationships. RESULTS: Older men were less likely than older women to state they are lonely even when controlling for UCLA score. Older men showed a greater association between loneliness and alcohol consumption, but only when measuring the number of units consumed in the last week, and not using a less precise measure of the past year. Older men who cohabited with a partner were less lonely than cohabiting older women, whereas previously married but not cohabiting older men were lonelier than their female counterparts. However, never married older men were less lonely than never married older women. Evidence was found to suggests older men's worse friendships mediated this association, but social isolation and number of close relationships did not. Severe isolation predicted greater loneliness in older women, but not older men. CONCLUSIONS: Cultural ideals of masculinity and older men's poorer quality friendships may explain their reluctance to directly state loneliness, greater dependency on partners/spouses, and use of alcohol. Severely isolated older men may under-report loneliness on the UCLA scale as well as a direct question.

What Factors are Associated With Waterpipe Smoking Cessation? A Secondary Data Analysis.

INTRODUCTION: Waterpipe smoking is gaining popularity and becoming a major global public health concern. An understanding of factors that predict waterpipe smoking cessation is necessary for targeting tobacco control efforts. METHODS: This is a secondary data analysis of a randomized controlled trial comparing the efficacy of varenicline against placebo in helping waterpipe smokers to quit. A total of 510 adult daily waterpipe smokers were recruited to the trial in 2016. Logistic regression models were applied to assess factors (i.e., demographic, environmental, behavioral, and physiological) associated with primary outcome (waterpipe smoking cessation) and secondary outcomes (waterpipe cessation alongside abstinence from cigarette and short-term and long-term waterpipe smoking cessation). Cessation was defined as 7-day point prevalence abstinence from smoking reported at 5,12, and/or 25 weeks follow-ups. RESULTS: Over a period of six months, 189 (39.2%) participants abstained from waterpipe smoking for at least one week. Being male (adjusted odds ratio (aOR):2.99 (95%CI:1.47-6.08)), dual smoker (waterpipe and cigarettes) (aOR:2.98 (95%CI:1.87-4.74)), more withdrawal symptoms measured by the Mood and Physical Symptoms Scale (aOR:1.08 (95%CI:1.02-1.13)), less nicotine dependency measured by Lebanon Waterpipe Dependency Scale (aOR:0.90 (95%CI:0.85-0.96)), having a history of quit attempt (aOR:2.14 (95%CI:1.16-3.96)), smoking restriction in the house (aOR:2.69 (95%CI:1.01-7.14)), and not sharing waterpipe with others (aOR:2.72 (95%CI:1.31-5.66)) predicted waterpipe smoking cessation. CONCLUSIONS: In addition to nicotine dependency, social factors such as home restrictions on smoking, and not sharing waterpipe were identified as predictors of waterpipe smoking cessation. To help waterpipe smokers quit, social environment may be just as or even more important than well-known physical and psychological factors. IMPLICATIONS: A range of factors, predominantly social factors play a significant role in facilitating or deterring waterpipe smokers from quitting smoking. Our findings suggest that interventions that focus on social as well as physical/psychological factors may encourage waterpipe smokers in achieving abstinence.

Attitudes of smokers towards tobacco control policies: findings from the Studying Tobacco users of Pakistan (STOP) survey.

BACKGROUND: Public attitude is a political driver in successful implementation of tobacco control policies. We assessed support for a range of tobacco control policies among smokers in Pakistan. METHODS: We conducted a household survey among adult smokers in 10 cities of Pakistan, using a two-stage random sampling strategy to select households and Kish grid method to select one smoker per household. Attitudes were measured using a five-point ordinal scale on four policy statements: a complete ban on tobacco sale within 10 years; raising the legal age to buy tobacco from 18 to 21; increasing tobacco taxes to fund healthcare and a ban on smoking in cars with minors. RESULTS: 6014 participants were interviewed between September 2019 and March 2020. Most participants demonstrated strong support for all policy statements: a ban on smoking in cars with minors (86.5%); a complete ban on tobacco sale within 10 years (82.1%); raising the legal age to buy tobacco (77.9%) and increasing tobacco taxes (68.1%). Smokers' support for tobacco control policies increased with age but decreased with higher educational attainment and heaviness of smoking. CONCLUSIONS: There is strong support among smokers in Pakistan to strengthen tobacco control. Given this, policy-makers should strongly consider strengthening existing national policies on tobacco control.

Awareness, perceptions of and compliance with tobacco control policies among naswar vendors in Khyber Pakhtunkhwa Pakistan.

INTRODUCTION: Regulatory compliance in the retail environment is integral to the success of tobacco control. We assessed compliance among naswar (smokeless tobacco product widely used in South Asia) vendors with tobacco control laws. We also assessed their awareness of tobacco-related harms and policies and perceived effect of policies on their sales. METHODS: We surveyed 286 naswar vendors in three districts of the Khyber Pakhtunkhwa province of Pakistan. We recruited general and specialty vendors from urban and rural areas through multistage cluster sampling. Compliance was measured for promotion, sale to/by minors and tax paid on naswar. We used logistic regression analyses for assessing the association between the outcome variables (awareness of tobacco harms and laws, perceptions about the effect of policies on business and compliance with laws) and their predictors. RESULTS: Most vendors (70%) were aware of tobacco-related harms of naswar. Although educated vendors were more aware of tobacco control policies, the greatest awareness was for a ban on sales to/by minors (21% overall). The majority of vendors (76%) violated this policy (measured by self-report), and violations were more common among rural than urban vendors (OR 2.27, 95% CI 1.05 to 4.96). Most vendors (71%) violated a ban on promotion of naswar. Vendors perceived tax increases and sales ban to/by minors as most detrimental for business. CONCLUSIONS: There was poor awareness and compliance among naswar vendors in Pakistan with tobacco control laws. This study finds potential areas for policy interventions that can reduce urban/rural disparities in implementation of and compliance with tobacco control laws.

Illicit cigarette trade in the cities of Pakistan: comparing findings between the consumer and waste recycle store surveys.

BACKGROUND: Concerns about the magnitude of illicit cigarette trade have prevented the Government of Pakistan from increasing tobacco taxes. We estimated the proportion of illicit cigarettes sold in Pakistani cities. Moreover, we compared two methods for collecting cigarette packs and investigated if the illicit cigarette trade equates to tax evasion. METHOD: We analysed cigarette packs collected from 10 cities of Pakistan using two methods: consumer survey based on a two-stage random sampling strategy to recruit adult smokers and photograph their cigarette packs and waste recycle store survey to purchase used cigarette packs. Cigarettes were considered illicit if any one of the following was absent from their packs: text and pictorial health warning, underage sale prohibition warning, retail price and manufacturer's name. From the consumer survey, we also estimated the proportion of smokers who purchased loose cigarettes (illegal) and packs below the minimum retail price. Taxation officers (n=4) were consulted to assess their level of confidence in judging tax evasion using the above criteria. RESULTS: Out of 2416 cigarette packs in the consumer survey, 454 (17.8%; 95% CI 15.4% to 20.2%) were illicit. Similarly, out of 6213 packs from waste recycle shops, 1046 (16.8%; 95% CI 15.9% to 17.7%) were illicit; the difference was not statistically significant (p=0.473). Among consumers, 29.5% bought loose cigarettes and 13.8% paid less than the minimum retail price. The taxation officers considered the manufacturer's name and retail price on cigarette packs as the most relevant criteria to detect tax evasion. CONCLUSIONS: One in six cigarette packs consumed in Pakistan could be illicit. These figures are far less than those propagated by the tobacco industry. Collecting packs from waste recycle stores is an efficient and valid method to estimate illicit cigarette trade.

Non-compliant packaging and illicit smokeless tobacco in Bangladesh, India and Pakistan: findings of a pack analysis.

INTRODUCTION: Illicit smokeless tobacco (ST) trade has seldom been documented despite ST use in at least 127 countries across the world. Based on non-compliance with packaging regulations, we report the proportion of illicit ST products from samples on sale in Bangladesh, India and Pakistan where 85% of global ST users reside. METHODS: We purchased unique ST products from tobacco sellers in two purposively selected administrative areas (division/district) in each of the three countries. The criteria to determine illicit ST products were based on country-specific legal requirements for ST packaging and labelling. These requirements included: 'market retail price disclosure', 'sale statement disclosure', 'pictorial health warning (PHW) pertinence', 'appropriate textual health warning' and 'using misleading descriptors (MDs)'. Non-compliance with even one of the legal requirements was considered to render the ST product illicit. RESULTS: Almost all ST products bought in Bangladesh and India were non-compliant with the local packaging requirements and hence potentially illicit, all products in Pakistan lacked desirable features. The most common feature missing was health warnings: 84% packs in Bangladesh, 93% in India, and 100% in Pakistan either did not have PHW or their sizes were too small. In Bangladesh, 61% packs carried MDs. In India and Pakistan, the proportions of such packs were 32% and 42%, respectively. CONCLUSIONS: Weak and poorly enforced ST control policies may be slowing the progress of tobacco control in South Asia. Standardised regulations are required for packaging and labelling ST. Improving compliance and reducing sale of cheap illicit products may require business licensing and market surveillance.

Eliciting uncertainty for complex parameters in model-based economic evaluations: quantifying a temporal change in the treatment effect.

BACKGROUND: In model-based economic evaluations, the effectiveness parameter is often informed by studies with a limited duration of follow-up, requiring extrapolation of the treatment effect over a longer time horizon. Extrapolation from short-term data alone may not adequately capture uncertainty in that extrapolation. This study aimed to use structured expert elicitation to quantify uncertainty associated with extrapolation of the treatment effect observed in a clinical trial. METHODS: A structured expert elicitation exercise was conducted for an applied study of a podiatry intervention designed to reduce the rate of falls and fractures in the elderly. A bespoke web application was used to elicit experts' beliefs about two outcomes (rate of falls and odds of fracture) as probability distributions (priors), for two treatment options (intervention and treatment as usual) at multiple time points. These priors were used to derive the temporal change in the treatment effect of the intervention, to extrapolate outcomes observed in a trial. The results were compared with extrapolation without experts' priors. RESULTS: The study recruited thirty-eight experts (geriatricians, general practitioners, physiotherapists, nurses, and academics) from England and Wales. The majority of experts (32/38) believed that the treatment effect would depreciate over time and expressed greater uncertainty than that extrapolated from a trial-based outcome alone. The between-expert variation in predicted outcomes was relatively small. CONCLUSIONS: This study suggests that uncertainty in extrapolation can be informed using structured expert elicitation methods. Using structured elicitation to attach values to complex parameters requires key assumptions and simplifications to be considered.

Tobacco Use Among 1 310 716 Women of Reproductive age (15-49 Years) in 42 Low- and Middle-Income Countries: Secondary Data Analysis From the 2010-2016 Demographic and Health Surveys.

INTRODUCTION: Tobacco use among women, especially during pregnancy is a public health concern. There is a need to understand the diverse nature of their tobacco consumption across the globe. METHODS: We used Demographic and Health Surveys (DHS) data collected between 2010 and 2016 from 42 low- and middle-income countries (LMICs) to estimate the prevalence of smoking, smokeless tobacco, and dual use among pregnant and non-pregnant women of reproductive age (15-49 y). We compared tobacco use between both groups adjusted for age, type of residence, education and combined wealth index, and a subgroup analysis for the South-East Asia Region (SEAR) as the tobacco use in SEAR among women is far more diverse than in other regions primarily due to the popularity of smokeless tobacco use in this region. RESULTS: Based on the data of 1 310 716 women in 42 LMICs, the prevalence of smoking was 0.69%(95%CI: 0.51-0.90) among pregnant women and 1.09%(95%CI: 0.81-1.42) among non-pregnant women. The prevalence of smokeless tobacco use was 0.56%(95%CI: 0.33-0.84) among pregnant women and 0.78%(95%CI: 0.35-1.37) among non-pregnant women. The relative risk ratios(RRR) for smoking (0.85; 95%CI: 0.67-1.09) and smokeless tobacco use (0.81; 95%CI:0.67-1.00) were not-significantly lower among pregnant women than non-pregnant women and education and wealth index had an inverse relationship with both forms of tobacco. In SEAR, among pregnant women, the prevalence of smoking and smokeless tobacco use was 1.81% and 0.45%, respectively. However, pregnant women were 7%(RRR 1.07; 95%CI:1.02-1.12) more likely to use smokeless tobacco than non-pregnant women. CONCLUSION: Despite the added risk of foetal harm during pregnancy, there is no evidence that the tobacco consumption between pregnant and non-pregnant women differ in 42 LMICs. A significantly higher use of smokeless tobacco among pregnant women in SEAR is of particular concern and warrants further investigation. IMPLICATIONS: Tobacco use among women in low- and middle-income countries (LMICs) is lower than high-income countries (HICs), but this may be because LMICs are earlier in the epidemiological transition of tobacco use. If ignored as a public health issue and the tobacco industry continues to market its products to women, the level of tobacco use may rise as it did in HICs. Also, despite low prevalence rates and with no evidence that these differ among pregnant and non-pregnant women, is concerning as tobacco consumption in any form during pregnancy is associated with poor birth outcomes. This suggests a need for raising awareness about the harms of tobacco use among women in LMICs, especially during pregnancy. There is a need to develop preventive and cessation interventions to decrease tobacco use (smoking and smokeless) among women who are from low socio-economic status and less educated, as they bear the greatest burden of tobacco use.

Predictors of Cigarette Smoking, Smokeless Tobacco Consumption, and Use of both forms in Adolescents in South Asia: A Secondary Analysis of the Global Youth Tobacco Surveys.

INTRODUCTION: Tobacco uptake in adolescents is associated with a range of predictors. We examined the predictors of cigarette smoking, smokeless tobacco (ST) consumption, and use of both ST and cigarettes among adolescents in four South Asian countries. METHODS: We analyzed the Global Youth Tobacco Surveys (GYTS) data for Bangladesh (2013), India (2009), Pakistan (2013), and Sri Lanka (2015), using multinomial regression to examine associations between several predictors and tobacco use. RESULTS: Data from 23 681 adolescents were analyzed. Overall, 82.8% of the study population were between 13 and 15 years and 52.7% were girls, 2% were cigarette smokers, 6.5% were ST users, and 1.1% used both ST and cigarettes, in the past 30 days. Exposure to smoking in public places was associated with past 30-day smoking (relative risk ratio [RRR] 5.59, 95% confidence intervals [CI] 4.28-7.28), ST use (RRR 2.07, 95% CI 1.84-2.32), and use of both ST and cigarettes (RRR 11.42, 95% CI 7.44-17.54). Exposure to tobacco use in electronic media and being offered free tobacco products were associated with all forms of tobacco use. Shopkeepers' refusal to sell cigarettes protected adolescents from smoking (RRR 0.47, 95% CI 0.36-0.63) and ST use (RRR 0.65, 95% CI 0.45-0.95). However, exposure to antitobacco mass media messages was not protective for any form of tobacco use. Adolescents taught at school about harmful effects of tobacco were less likely to use ST; no evidence of this association was observed for smoking. CONCLUSION: The associations between tobacco use and protobacco factors were strong, but the associations with antitobacco factors lacked strength and consistency in this study population. IMPLICATIONS: The predictors of adolescents using different tobacco products, crucial to inform and evaluate tobacco control efforts, are poorly understood. We investigated the associations between several environmental-level factors and cigarette smoking, ST consumption, and use of both forms among adolescents, whereas most of the previous studies focused on individual-level factors. Our study found strong associations between tobacco use and protobacco factors and lack of strength and consistency in associations between antitobacco factors and tobacco use in the study population. Our results indicate that the current tobacco control policies need strengthening to curb the tobacco epidemic in these countries.

The Impact of COVID-19 on Smoking Patterns in Pakistan: Findings From a Longitudinal Survey of Smokers.

INTRODUCTION: We investigated the influence of COVID-19 on smoking patterns in Pakistan. METHODS: In a longitudinal survey, we asked cigarette smokers in Pakistan about their smoking behaviors before and since COVID-19. Smokers were recruited before COVID-19 using two-stage random probability sampling. Since COVID-19, three subsequent waves were conducted over the telephone, asking additional questions on social determinants, mental health, and well-being. Based on the first two waves, we estimated the proportion of smokers who stopped, decreased, maintained, or increased smoking. We also explored any factors associated with the change in smoking patterns. In those who stopped smoking soon after COVID-19, we estimated the proportion relapsed in subsequent waves. We estimated all proportions based on complete-case analysis. RESULTS: We recruited 6014 smokers between September 2019 and February 2020; of these, 2087 (2062 reported smoking outcomes) were followed up in May 2020 after COVID-19. Since COVID-19, 14% (290/2062) smokers reported quitting. Among those who continued smoking: 68% (1210/1772) reduced, 14% (239/1772) maintained, and 18% (323/1772) increased cigarette consumption; 37% (351/938) reported at least one quit attempt; 41% (669/1619) were more motivated; while 21% (333/1619) were less motivated to quit. Changes in smoking patterns varied with nicotine dependence, motivation to quit, and financial stability since COVID-19. Among those reporting quitting soon after COVID-19, 39% (81/206) relapsed in the subsequent months (June-July 2020). CONCLUSIONS: There have been significant bidirectional changes in smoking patterns since COVID-19 in Pakistan. Although many people stopped, reduced, or tried quitting smoking, some increased smoking and some relapsed after quitting. IMPLICATIONS: We observed significant and complex changes in people's smoking patterns, which are likely to be attributable to the COVID-19 pandemic and replicated in similar events in the future. Assessing these changes is essential for most low- and middle-income countries like Pakistan, where the vast majority of tobacco users live, but cessation support is still rudimentary. If provided routinely, smoking cessation interventions can potentially support millions of highly motivated individuals in quitting successfully both in general and in global events like COVID-19, in particular.

Cost-effectiveness analysis of public health interventions with impacts on health and criminal justice: An applied cross-sectoral analysis of an alcohol misuse intervention.

Cost-effectiveness analyses of health care programs often focus on maximizing health and ignore nonhealth impacts. Assessing the cost-effectiveness of public health interventions from a narrow health care perspective would likely underestimate their full impact, and potentially lead to inefficient decisions about funding. The aim of this study is to provide a practical application of a recently proposed framework for the economic evaluation of public health interventions, evaluating an intervention to reduce alcohol misuse in criminal offenders. This cross-sectoral analysis distinguishes benefits and opportunity costs for different sectors, makes explicit the value judgments required to consider alternative perspectives, and can inform heterogeneous decision makers with different objectives in a transparent manner. Three interventions of increasing intensity are compared: client information leaflet, brief advice, and brief lifestyle counseling. Health outcomes are measured in quality-adjusted life-years and criminal justice outcomes in reconvictions. Costs considered include intervention costs, costs to the NHS and costs to the criminal justice system. The results are presented for four different perspectives: "narrow" health care perspective; criminal justice system perspective; "full" health care perspective; and joint "full" health and criminal justice perspective. Conclusions and recommendations differ according to the normative judgment on the appropriate perspective for the evaluation.

Smokeless tobacco products, supply chain and retailers' practices in England: a multimethods study to inform policy.

BACKGROUND: In England, many people of South Asian origin consume smokeless tobacco (ST). ST use can lead to oral cancer, which is disproportionately high in South Asians. Our aims were to assess the compliance of ST product retailers with statutory regulations and to explore the supply chain of ST. METHODS: We undertook a multimethods study between August 2017 and July 2019 in five English boroughs with a high proportion of ethnic South Asians. We purchased ST products and conducted field surveys with ST retailers at point of sale. Qualitative interviews were conducted with ST retailers and suppliers. ST packs were assessed for regulatory compliance, while quantitative and qualitative data triangulated information on retailers' practices and the ST supply chain. RESULTS: We collected 41 unique ST products, which included dry snuff, naswar, gutka, chewing tobacco and zarda. ST products were not registered, and demonstrated low compliance with health warning (14.6%) and packaging (56.1%) requirements. ST availability in surveyed boroughs was high (38.2%-69.7%); dry snuff, naswar and zarda were most commonly available. ST retailers demonstrated limited knowledge of regulations, and one-third were found to advertise ST at point of sale. Qualitative insights revealed illicit supply and distribution networks, as well as ST production in discreet locations. CONCLUSION: ST products are widely available in England, yet non-compliant with statutory regulations. In order to safeguard consumers, in particular ethnic South Asians, stronger efforts are needed to regulate the supply chain of ST at both national and international levels.

"Did I just do that?"-Six-month-olds learn the contingency between their vocalizations and a visual reward in 5 minutes.

It has been shown that infants can increase or modify a motorically available behavior such as sucking, kicking, arm waving, etc., in response to a positive visual reinforcement (e.g., DeCasper & Fifer, 1980; Millar, 1990; Rochat & Striano, 1999; Rovee-Collier, 1997; Watson & Ramey, 1972). We tested infants to determine if they would also change their vocal behavior in response to contingent feedback, which lacks the social, emotional, and auditory modeling typical of parent-child interaction. Here, we show that in a single five-minute session infants increase the rate of their vocalizations in order to control the appearance of colorful shapes on an iPad screen. This is the first experimental study to demonstrate that infants can rapidly learn to increase their vocalizations, when given positive reinforcement with no social element. This work sets the foundations for future studies into the causal relationship between the number of early vocalizations and the onset of words. In addition, there are potential clinical applications for reinforcing vocal practice in infant populations who are at risk for poor language skills.

Secondhand Smoke Exposure in Primary School Children: A Survey in Dhaka, Bangladesh.

INTRODUCTION: We report on second-hand smoke (SHS) exposure based on saliva cotinine levels among children in Bangladesh-a country with laws against smoking in public places. METHODS: A survey of primary school children from two areas of the Dhaka district was conducted in 2015. Participants completed a questionnaire and provided saliva samples for cotinine measurement to assess SHS exposure with a cut-off range of ≥0.1ng/mL. RESULTS: Four hundred and eighty-one children studying in year-5 were recruited from 12 primary schools. Of these, 479 saliva samples were found sufficient for cotinine testing, of which 95% (453/479) were positive for recent SHS exposure. Geometric mean cotinine was 0.36 (95% CI = 0.32 to 0.40); 43% (208/479) of children lived with at least one smoker in the household. Only 21% (100/479) reported complete smoking restrictions for residents and visitors; 87% (419/479) also reported being recently exposed to SHS in public spaces. Living with a smoker and number of tobacco selling shops in the neighborhood had positive associations with recent SHS exposure. CONCLUSIONS: Despite having a ban on smoking in public places, recent SHS exposure among children in Bangladesh remains very high. There is an urgent need to reduce exposure to SHS in Bangladeshi children. IMPLICATIONS: Children bear the biggest burden of disease due to SHS exposure than any other age group. However, children living in many high-income countries have had a sharp decline in their exposure to SHS in recent years. What remains unknown is if children living in low-income countries are still exposed to SHS. Our study suggests that despite having a ban on smoking in public places, most primary school children in Dhaka, Bangladesh are still likely to be exposed to SHS.

Children Learning About Secondhand Smoke (CLASS II): A Pilot Cluster Randomized Controlled Trial.

INTRODUCTION: Children exposed to secondhand smoke (SHS) are at increased risk of respiratory illnesses. We piloted a Smoke Free Intervention (SFI) and trial methods before investigating its effectiveness and cost-effectiveness in primary school children. METHODS: In a pilot cluster randomized controlled trial in Bangladesh, primary schools were allocated to usual education (control) or SFI, using minimization. Year-5 children were recruited. Masking treatment allocation was not possible. Delivered by schoolteachers, SFI consisted of two 45-min and four 15-min educational sessions. Our primary outcome was SHS exposure at two months post randomization, verified by children's salivary cotinine. The trial is registered at ISRCTN.com; ISRCTN68690577. RESULTS: Between April 1, 2015 and June 30, 2015, we recruited 12 schools. Of the 484 children present in Year-5, 481 consented. Six schools were allocated to both SFI (n = 245) and to usual education only (n = 236). Of them, 450 children (SFI = 229; control = 221) who had cotinine levels indicative of SHS exposure were followed-up. All schools were retained, 91% children (208/229) in SFI and 88% (194/221) in the control arm completed primary outcome assessment. Their mean cotinine at the cluster level was 0.53 ng/ml (SD 0.36) in SFI and 1.84 ng/ml (SD 1.49) in the control arm-a mean difference of -1.31 ng/ml (95% CI = -2.86 to 0.24). CONCLUSION: It was feasible to recruit, randomize, and retain primary schools and children in our trial. Our study, though not powered to detect differences in mean cotinine between the two arms, provides estimates to inform the likely effect size for future trials. IMPLICATIONS: In countries with high smoking prevalence, children remain at risk of many conditions due to secondhand smoke exposure. There is little empirical evidence on the effectiveness and cost-effectiveness of interventions that can reduce their exposure to secondhand smoke at homes. CLASS II trial found that a school-based intervention (SFI) has the potential to reduce children's exposure to SHS-an approach that has been rarely used, but has considerable merit in school-based contexts. CLASS II trial provides key information to conduct a future definitive trial in this area of public health, which despite its importance has so far received little attention.

Which Behavior Change Techniques May Help Waterpipe Smokers to Quit? An Expert Consensus Using a Modified Delphi Technique.

Introduction: Waterpipe smoking is addictive and harmful. The determinants of waterpipe smoking may differ from those of cigarette smoking; therefore, behavioral approaches to support quitting may also differ between these two tobacco products. While some evidence exists on effective behavioral change techniques (BCTs) to facilitate cigarette smoking cessation, there is little research on waterpipe smoking cessation. Methods: Twenty-four experts were selected from the author lists of peer-reviewed, randomized controlled trials on waterpipe smoking cessation. They were invited to two rounds of a consensus development exercise using modified Delphi technique. Experts ranked 55 BCTs categorized further into those that promote; "awareness of harms of waterpipe smoking and advantages of quitting" (14), "preparation and planning to quit" (29), and "relapse prevention and sustaining an ex-smoker identity" (12) on their potential effectiveness. Kendall's W statistics was used to assess agreement. Results: Fifteen experts responded in round 1 and 14 completed both rounds. A strong consensus was achieved for BCTs that help in "relapse prevention and sustaining ex-smoker identity" (w = 0.7; p < .001) and a moderate for those that promote "awareness of harms of waterpipe smoking and advantages of quitting" (w = 0.6; p < .001) and "preparation and planning to quit" (w = 0.6; p < .001). Providing information on the consequences of waterpipe smoking and its cessation, assessing readiness and ability to quit, and making people aware of the withdrawal symptoms, were the three highest-ranking BCTs. Conclusion: Based on expert consensus, an inventory of BCTs ordered for their potential effectiveness can be useful for health professionals offering cessation support to waterpipe smokers. Implications: Waterpipe smoking is addictive, harmful, and gaining global popularity, particularly among youth. An expert consensus on behavior change techniques, likely to be effective in supporting waterpipe smokers to quit, has practice and research implications. Smoking cessation advisors can use these techniques to counsel waterpipe smokers who wish to quit. Behavioral and public health scientists can also use these to develop and evaluate behavioral support interventions for this client group.

Models of reablement evaluation (MoRE): a study protocol of a quasi-experimental mixed methods evaluation of reablement services in England.

BACKGROUND: Reablement is a time-limited intervention that aims to support people to regain independence and enable them to resume their daily activities after they return home from an in-patient care setting, or to maintain independence to enable them to remain at home. There is some evidence that reablement can enhance independence and has the potential to contain costs. However, reablement services are funded and provided in different ways and by different organisations, and there is limited research evidence about the effectiveness of different reablement service models. This study will evaluate the effectiveness and cost-effectiveness of different reablement service models and service users' and carers' experiences of reablement in England, UK. METHODS/DESIGN: The study will use a quasi-experimental mixed methods design that comprises three work packages (WP) extending over a period of 34 months. WP1 will conduct cluster analysis on survey data to develop a typology of current models of reablement services in order to describe the current reablement service landscape. WP2 will comprise a quantitative outcomes evaluation of the effectiveness of the different service models; a process evaluation and an economic evaluation. WP2 will be set within generic reablement services, where providers are using the most commonly employed generic reablement service types identified in WP1; the primary outcome measure is health-related quality of life measured by the EQ-5D-5L. WP3 will provide evidence about specialist reablement services and how specialist approaches and practices are organised and delivered. DISCUSSION: Managing demands on care services is, and will remain, a crucial factor for the UK National Health Service as the number of people with long-term conditions rise. There has been, and will continue to be, significant investment in reablement services. The proposed study will address several key areas where there is limited evidence regarding the organisation and delivery of reablement services in England, UK. Specifically, it will provide new evidence on different models of reablement services that will be of direct benefit to health and social care managers, commissioners and their partner organisations.

A randomised controlled trial of three or one breathing technique training sessions for breathlessness in people with malignant lung disease.

BACKGROUND: About 90 % of patients with intra-thoracic malignancy experience breathlessness. Breathing training is helpful, but it is unknown whether repeated sessions are needed. The present study aims to test whether three sessions are better than one for breathlessness in this population. METHODS: This is a multi-centre randomised controlled non-blinded parallel arm trial. Participants were allocated to three sessions or single (1:2 ratio) using central computer-generated block randomisation by an independent Trials Unit and stratified for centre. The setting was respiratory, oncology or palliative care clinics at eight UK centres. Inclusion criteria were people with intrathoracic cancer and refractory breathlessness, expected prognosis ≥3 months, and no prior experience of breathing training. The trial intervention was a complex breathlessness intervention (breathing training, anxiety management, relaxation, pacing, and prioritisation) delivered over three hour-long sessions at weekly intervals, or during a single hour-long session. The main primary outcome was worst breathlessness over the previous 24 hours ('worst'), by numerical rating scale (0 = none; 10 = worst imaginable). Our primary analysis was area under the curve (AUC) 'worst' from baseline to 4 weeks. All analyses were by intention to treat. RESULTS: Between April 2011 and October 2013, 156 consenting participants were randomised (52 three; 104 single). Overall, the 'worst' score reduced from 6.81 (SD, 1.89) to 5.84 (2.39). Primary analysis [n = 124 (79 %)], showed no between-arm difference in the AUC: three sessions 22.86 (7.12) vs single session 22.58 (7.10); P value = 0.83); mean difference 0.2, 95 % CIs (-2.31 to 2.97). Complete case analysis showed a non-significant reduction in QALYs with three sessions (mean difference -0.006, 95 % CIs -0.018 to 0.006). Sensitivity analyses found similar results. The probability of the single session being cost-effective (threshold value of £20,000 per QALY) was over 80 %. CONCLUSIONS: There was no evidence that three sessions conferred additional benefits, including cost-effectiveness, over one. A single session of breathing training seems appropriate and minimises patient burden. TRIAL REGISTRATION: Registry: ISRCTN; TRIAL REGISTRATION NUMBER: ISRCTN49387307; http://www.isrctn.com/ISRCTN49387307 ; registration date: 25/01/2011.