What is the relationship between raising the minimum legal sales age of tobacco above 20 and cigarette smoking? A systematic review.

INTRODUCTION: There is considerable interest in raising the age of sale of tobacco above the conventional age of 18. We systematically reviewed whether raising the minimum legal sales age of tobacco (MLSA) to 20 or above is associated with reduced prevalence of smoking compared to an MLSA set at 18 or below. METHODS: Following a pre-registered protocol on PROSPERO (ref: CRD42022347604), six databases of peer-reviewed journals were searched from January 2015 to April 2024. Backwards and forwards reference searching was conducted. Included studies assessed the association between MLSAs ≥20 with cigarette smoking or cigarette sales for those aged 11-20. Assessments on e-cigarettes were excluded. Pairs of reviewers independently extracted study data. We used ROBINS-I to assess risk of bias and GRADE to assess quality of evidence. Findings were also synthesised narratively. RESULTS: 23 studies were reviewed and 34 estimates of association were extracted. All extracted studies related to Tobacco 21 laws in the United States. Moderate quality evidence was found for reduced cigarette sales, moderate quality evidence was found for reduced current smoking for 18 - 20 year olds, and low quality evidence was found for reduced current smoking for 11 - 17 year olds. The positive association was stronger for those with lower education. Study bias was variable. CONCLUSIONS: There is moderate quality evidence that Tobacco 21 can reduce overall cigarette sales and current cigarette smoking amongst those aged 18- 20. It has potential to reduce health inequalities. Research in settings other than the United States is required. IMPLICATIONS: This systematic review on raising the minimum legal sale age of tobacco to 20 or above demonstrates there is moderate quality evidence that such laws reduce cigarette sales, and moderate quality evidence they reduce smoking prevalence amongst those aged 18-20 compared to a minimum legal sale age of 18 or below. The research highlights potential benefits in reducing health inequalities, especially individuals from lower educational backgrounds. Studies are limited to the United States, highlighting a need for more global research to assess the impact of these policies in other settings.

A qualitative study of barriers and motivators to prevent second-hand smoke exposure among pregnant women and children in Egypt: Identifying appropriate approaches for change.

BACKGROUND: The prevalence of daily second-hand smoke (SHS) exposure among pregnant non-smoking women and children in Egypt is estimated to be about 50% and 55%, respectively. This study aimed to explore barriers to preventing SHS exposure among pregnant women/children and smoking in the home in Egypt. METHODS: Six focus group discussions with pregnant women/mothers of children residing in urban/rural areas (n=61) were conducted. Data were managed and analyzed using the Framework Method. RESULTS: Sixty one participants aged 18-49 were recruited. They reported being never smokers and SHS exposure for themselves and their children was mainly at home. Pregnant women/mothers had some general knowledge of the dangers of SHS, but their knowledge appeared incomplete. The most commonly reported barriers to preventing SHS exposure/adopting a smoke-free home or workplace were social acceptance of smoking and SHS exposure, masculinity and gender norms of accepting smoking among men as a normative behavior, fear among women of damaging a relationship with family or even divorce, women resigning themselves to SHS exposure, and doctors not being supportive of smoking cessation. The majority of interviewees' families were reported to allow smoking anywhere in the home. Others implemented some measures to prevent SHS; however, these tended to be inconsistently implemented. CONCLUSION: Changing the norm of accepting smoking among men as a normative behavior within Egyptian society and better enforcement of smoke-free policies, will help to protect pregnant women and children from SHS. IMPLICATIONS: This study suggests promising approaches to support the promotion of smoke-free homes (SFH) and prevention of SHS exposure among pregnant women and children in public places in Egypt. Better enforcement of smoke-free policies is needed. Health care professionals (HCPs) should support smoking cessation services in primary health centers (PHCs). SHS policy, practice and research should focus on husbands/fathers as they are the main source of SHS. There is a need for denormalization of SHS exposure in Egyptian society.

Attitudes And Exposure To Illicit Tobacco In England, 2022.

INTRODUCTION: The UK has achieved reductions in illicit tobacco (IT) market size and share. However, there remains a 17.7% tobacco duty gap, contributing to health inequalities. In January 2024, the UK government announced a new strategy to control IT, along with provision of new funding. METHODS: A representative cross-sectional survey of adults in England ran in April 2022 to evaluate attitudes and exposure to IT. Tobacco smokers were asked questions about encounters with IT, while all participants answered questions on knowledge and perspectives on IT. RESULTS: Of 262 tobacco smokers, 18.3% (95% CI 13.8% - 23.6%) had come across IT in the past year. Men had four times the odds of encountering IT recently than women. Among 1,767 adults responding to questions on IT, two-thirds agreed IT harmed children, and more than half agreed IT was linked to organised crime. Younger adults, smokers and those in lower socio-economic groups were less likely to agree IT was harmful. CONCLUSIONS: Exposure to IT, especially among younger males, remains a concern. While most of the public acknowledge its harm, this is not universal, and some population groups are less likely to do so. IMPLICATIONS: The study highlights persistent exposure to illicit tobacco in England, especially among younger males, and varying perceptions of illicit tobacco harm across socio-economic groups. Tackling illicit tobacco requires collaboration between health and enforcement agencies, independent of the tobacco industry's influence. Strategies should include components that shift demand for illicit tobacco and denormalise its presence in communities, particularly in lower socio-economic areas with higher smoking prevalence.

Association between the implementation of standardised tobacco packaging legislation and illicit tobacco and cross-border purchasing in England: a time-series analysis between 2012 and 2020.

BACKGROUND: In May 2016, the UK announced standardising packaging legislation for tobacco products. There was a 12-month transition period with both branded and standardised packs on the market until May 2017. The aim of this study was to investigate whether the implementation of standardised packaging in England was associated with changes in illicit tobacco and cross-border purchasing. METHODS: We used Smoking Toolkit Study data covering the time period from 2012 to 2020. We ran time-series analysis using Autoregressive Integrated Moving Average with Exogenous Variable models to investigate the monthly changes in illicit tobacco and cross-border purchasing in England. The model was adjusted for other tobacco control policies implemented during the relevant time period and tobacco pricing. We used May 2017 as an implementation point and run sensitivity analysis using July 2016 and February 2017 as alternative implementation points given phased introduction of the policy. RESULTS: The average prevalence of illicit tobacco and cross-border purchasing in the past 6 months was 14.4%. The implementation of standardised tobacco packaging legislation was associated with a monthly decline in illicit tobacco and cross-border purchases after May 2017 by 0.16% per month (beta=-0.158, 95% CI -0.270 to -0.046). The results were robust to considering different implementation points for the policy (July 2016: beta=-0.109, 95% CI -0.213 to -0.005; February 2017: beta=-0.141, 95% CI -0.245 to -0.036). CONCLUSIONS: In contrast to the tobacco industry's argument that the legislation would lead to an increase in the illicit tobacco and cross-border market, this study demonstrates that the implementation of the policy is associated with a decline in illicit tobacco and cross-border purchases in England.

Profile of menthol cigarette smokers in the months following the removal of these products from the market: a cross-sectional population survey in England.

INTRODUCTION: In May 2020, the EU Tobacco Products Directive ban on the sale of menthol cigarettes was implemented in England. This study examined the prevalence of menthol cigarette smoking after the ban, according to sociodemographic and smoking characteristics. METHODS: Cross-sectional data came from a representative survey of current smokers (18+) in England (unweighted n=2681) between July 2020 and June 2021. The weighted prevalence of menthol cigarette smoking as a proportion of total cigarette smoking was calculated, log-binomial regression explored trends over time, and χ2 statistics assessed the relationship between menthol smoking, sociodemographic and smoking characteristics. Sources of purchase of menthol cigarettes were explored. RESULTS: Between July 2020 and June 2021, 15.7% (95% CI 14.5 to 17.1) of smokers reported smoking menthol cigarettes. The fitted non-linear trend supported no initial change followed by a possible reduction across April-June 2021 and fit the data better than linear and null (no change) models (χ2(2)=2519.7, p=0.06; χ2(3)=2519.7, p=0.006). Menthol cigarette smoking was more common among younger groups (16-24=25.2%; 25-34=19.9%) and women (19.4%). Menthol cigarette smokers showed lower cigarette dependence compared with other smokers. Past-6-month purchases of menthol cigarettes from any illicit or cross-border source declined from 30.1% in the last 6 months of 2020 to 17.5% in the first 6 months of 2021. CONCLUSIONS: A substantial minority of current smokers in England reported menthol cigarette smoking between July 2020 and June 2021, despite the ban, possibly reflecting mitigation of restrictions by a variety of licit means, such as legal menthol accessories. The reduction in menthol smoking across April-June 2021 warrants further monitoring.

When is Subnational, Supralocal Tobacco Control "just right"? A Qualitative Study in England.

INTRODUCTION: Subnational, supralocal (or "regional") approaches to tobacco control are often central federal nation tobacco control and can be superfluous for very small nations. However, their relevance to countries with weak intermediate tiers of governance are less clear. This study explores expert and policymaker perceptions on the function, form, footprint, and funding of regional tobacco control (RTC) in England. AIMS AND METHODS: One-to-one semistructured interviews (n = 16) and four focus groups (n = 26) exploring knowledge and perceptions of the past, present, and future of RTC in England were conducted with public health leaders, clinicians, tobacco control practitioners, civil servants, and politicians. Interviews were audio-recorded, transcribed verbatim, and analyzed thematically. RESULTS: Participants reported several key functions for RTC, including illicit tobacco control, media campaigns, advocacy, policy development, and network facilitation for local actors. A small minority of participants reported little role for RTC. Broader perceived features of effective RTC included subject expertise, strong regional ties, systems leadership, and a distinctive program of work. Views varied on whether regional programs should be developed nationally or locally, and their optimal footprint. Participants generally agreed stable funding was a prerequisite for success, although there was lesser agreement on funding sources. CONCLUSIONS: Pooling resources at the regional level in countries with weak intermediate tiers of governance may increase reach, cost-effectiveness and impact of campaigns, policy interventions, and advocacy, whilst retaining the ability to tailor approaches to regional populations. IMPLICATIONS: There are likely to be greater funding and governance challenges associated with introducing or strengthening RTC in countries with weak intermediate tiers of governance. Despite this, evidence from England shows it is possible to develop RTC approaches reported as effective by key stakeholders. Possible benefits of regional approaches in this context include cost-effective delivery of illicit tobacco control, media campaigns, advocacy, research, policy development, and coordinated support for local action on tobacco.

Potential Risk Factors of Smokeless Tobacco Consumption Among Adolescents in South India.

INTRODUCTION: Although most of the disease burden internationally is due to tobacco smoking, smokeless tobacco (SLT) use contributed to an estimated 76 000 deaths in 2017. We have studied the potential risk factors for SLT use among adolescents in South India. METHODS: A cross-sectional questionnaire survey of all students in grades 6-8 in schools in the Udupi district of Karnataka State ascertained SLT use status and potential determinants of SLT uptake. Ever SLT use was defined as any reported consumption of any SLT products, currently or at any time in the past. Independent effects on ever SLT use status were estimated using multiple logistic regression. RESULTS: Of 46 706 students from 914 participating schools, 39 282 (84.1%) provided questionnaire responses sufficiently complete for analysis. Ever SLT use was reported by 775 (2.0%) participants and in a mutually adjusted model was significantly related to age, male sex, family use, or friend's use of SLT, low socioeconomic status, high rebelliousness, and low self-esteem. After controlling for these effects, the odds of ever-SLT use were significantly higher among students who had least awareness of the harmful effects of tobacco use (odds ratio 3.7, 95% confidence interval [2.9, 4.7]) and significantly lower among those not exposed to tobacco advertising (odds ratio 0.7, 95% confidence interval [0.5, 0.8]). CONCLUSIONS: The prevalence of SLT use among children in Karnataka is relatively low when compared with other studies in India. The significant potential risk factors of SLT use include low awareness of the harmful effects of tobacco and tobacco control policies and exposure to tobacco advertising. IMPLICATIONS: The prevalence of SLT use among school going adolescents in South India is relatively low. The potential risk factors for SLT use among adolescents in southern India are similar to those for smoked tobacco. It includes age, male gender, family or friend's use of SLT, low socioeconomic status, high rebelliousness, low self-esteem, exposure to tobacco advertisement and least awareness about the harmful effects of tobacco and of tobacco control policies. The present study lays emphasis regarding creating awareness about tobacco harms and control policies for further reducing tobacco use among adolescents.

Developing a novel e-cigarette regulatory and policy control scale: results from the European Union.

Background: E-cigarette regulations vary considerably between countries though a standard approach for comparing regulatory frameworks does not exist. Additionally, there is no evidence on whether regulatory variations are associated with differences in e-cigarette use and smoking cessation. This study aims to develop a regulatory scale to measure and compare e-cigarette regulations between European Union countries and investigate whether scores are associated with e-cigarette use and smoking cessation. Methods: Data from a range of sources, such as ECigIntelligence, were used to develop a scale and score countries in the respective areas of e-cigarette scale. We used correlation analysis to investigate association between scale scores and e-cigarettes market, e-cigarette prevalence and use of e-cigarettes for smoking cessation. Results: An e-cigarette scale consisting of 10 domains was developed. Our analysis suggests that higher e-cigarette scale scores were associated with significantly greater use of e-cigarettes within countries, and greater increases in the prevalence of former smoking smokers between 2014 and 2017. Conclusions: Whilst further work is needed to develop the scale in line with rapidly changing regulatory landscape and product development, the current findings suggest that countries that have implemented e-cigarette regulations might be more successful in obtaining public health gains such as increase in the proportion of former smokers compared to countries where e-cigarette market and sales is not regulated.

Was the implementation of standardised tobacco packaging legislation in England associated with changes in smoking prevalence? A segmented regression analysis between 2006 and 2019.

BACKGROUND AND AIM: In 2016, England initiated the implementation of standardised tobacco packaging, introduced in conjunction with minimum pack sizes and other measures included in the 2014 European Tobacco Products Directive, over the course of a 1-year sell-off period ending in May 2017. These measures have been shown to have been associated with increases in tobacco prices and product diversity. We now investigate the association between implementation of the new legislation and smoking status in England. DESIGN: Segmented regression analysis of repeated cross-sectional surveys using a generalised linear model with individual-level data to test for a change in trend and immediate step change. SETTING: England. PARTICIPANTS: Participants in the Smoking Toolkit Study, which involves repeated, cross-sectional household surveys of individuals aged 16 years and older in England. The sample included 278 219 individual observations collected between November 2006 and December 2019. INTERVENTION: Implementation of standardised packaging legislation (May 2016 and May 2017). MEASUREMENTS: Individual-level current smoking status adjusted for implementation of tobacco control policies, cigarette price, seasonality and autocorrelation. FINDINGS: The implementation of standardised packaging was associated with a significant step reduction in the odds of being a smoker after May 2017 (OR: 0.93; 95% CI 0.87 to 0.99). The magnitude of the association was similar when modelling the step change in May 2016 at the start of the 1-year policy implementation period (OR: 0.90; 95% CI: 0.83 to 0.97). CONCLUSIONS: This is the first independent study demonstrating that implementation of standardised packaging was associated with a reduction in smoking in England which occurred in anticipation of, rather than after, full policy implementation. It appears that the odds of being a smoker were affected by the prospect of the move to standardised packs and accompanying legislation.

Exposure to tobacco imagery in popular films and the risk of ever smoking among children in southern India.

BACKGROUND: Exposure to smoking in films is a recognised cause of smoking uptake among children. In India, in an attempt to protect children, films containing smoking are required to include tobacco control messaging including audiovisual disclaimers, on-screen health warnings when tobacco imagery is displayed and antitobacco 'health spots' before and during the film. We report a study of the association between ever smoking and exposure to tobacco imagery in locally popular films among children in Udupi district of Karnataka state in southern India. METHODS: A cross-sectional questionnaire survey of all students in grades 6-8 in schools in the Udupi district ascertained smoking status and potential confounders of smoking uptake, and whether children had seen any of 27 locally popular films we had coded and found to contain imagery of actual or implied tobacco use. Ever-smoking status was defined as any reported smoking of cigarettes, beedis or other tobacco products currently or at any time in the past. Independent effects on ever-smoking status were estimated using multiple logistic regression. RESULTS: Of 46 706 students enrolled in grades 6-8 in 914 participating schools, 39 282 (84.1%) provided questionnaire responses sufficiently complete for analysis. Ever smoking was reported by 914 (2.3%) participants and in a mutually adjusted model was significantly related to age, male sex, living in a home where smoking is allowed, having parents or siblings who smoke, low paternal education, low levels of family wealth, low self-esteem, rebelliousness and poor school performance. After allowing for these effects, the odds of ever smoking were not increased among students who had seen any of the listed films containing tobacco imagery when included in the analysis as a binary exposure (OR 0.9, 95% CI 0.4 to 2.0), and decreased in relation to level of exposure graded into tertiles of tobacco intervals seen. CONCLUSIONS: In this cross-sectional study, children in southern India who had seen films containing tobacco imagery are no more likely to smoke than those who had not, indicating that the tobacco control messaging mandated by Indian law may be attenuating the effect of tobacco imagery in films on smoking uptake.

Changes in roll-your-own tobacco and cigarette sales volume and prices before, during and after plain packaging legislation in the UK.

BACKGROUND: Plain packaging and minimum pack size legislation for tobacco products was introduced in the UK in May 2016, with a 1-year sell-off period until May 2017, during which both fully branded and plain packs of various sizes were legally available. This study investigates trends in prices of roll-your-own tobacco (RYO) before, during and after implementation of this legislation, and compares trends with those observed in the cigarette market. METHODS: We used Nielsen Scantrack data for the period from March 2013 to June 2018 to describe trends in UK inflation-adjusted prices and volumes of both RYO and cigarettes, and linear regression to estimate changes in prices associated with the introduction of plain packaging and the minimum pack sizes of 30 g RYO and 20 cigarettes. RESULTS: In contrast to a downward trend in cigarette sales volumes, RYO volumes rose throughout the study period. By the time plain packs accounted for 75% or more of sales, the average price of products sold in equivalent pack sizes had increased, relative to average prices in the year before implementation and with adjustment for tax changes, from 34.9 to 38.8 pence per gram for RYO (mean difference 4.26, 95% CI 3.99 to 4.53 pence, 12% increase), and from 38.6 to 41.13 pence for cigarettes (mean difference 2.53, 95% CI 2.24 to 2.83 pence, 7% increase) per cigarette. CONCLUSIONS: New legislation resulted in higher prices for RYO and manufactured cigarettes. However, sales volumes of RYO continued to increase throughout the study period, perhaps because RYO remains a less expensive means of smoking tobacco.

Tobacco control efforts in Europe.

Smoking is prevalent across Europe, but the severity and stage of the smoking epidemic, and policy responses to it, vary substantially between countries. Much progress is now being made in prohibition of paid-for advertising and in promotion of smoke-free policies, but mass media campaigns are widely underused, provision of services for smokers trying to quit is generally poor, and price policies are undermined by licit and illicit cheap supplies. Monitoring of prevalence is inadequate in many countries, as is investment in research and capacity to address this largest avoidable cause of death and disability across Europe. However, grounds for optimism are provided by progress in implementation of the WHO Framework Convention on Tobacco Control, and in the development of a new generation of nicotine-containing devices that could enable more widespread adoption of harm-reduction strategies. The effect of commercial vested interests has been and remains a major barrier to progress.

Smoking in cars in England: a study of school students in an English city.

BACKGROUND: Exposure to secondhand smoke is associated with an increased risk of adverse health effects among children. Although smoking in the home is an established major source of exposure, less is known about rules on smoking in cars. METHODS: In a survey including a sample of secondary school students in Nottingham (UK) in 2012, participants were asked whether smoking was allowed in the family car, and how often the respondent travelled in a car in which smoking was allowed. Rules on smoking in cars were investigated in relation to socio-demographic variables and whether children had ever smoked themselves using logistic regression. RESULTS: Of 4,190 students aged 11-16 who provided data, approximately 12% reported that smoking was allowed in their family car and 35% that they travelled in a car where smoking was allowed at least sometimes. Absence of smoke free rules in the family car was more likely to be reported by children from more disadvantaged families, if parents and friends were smokers and if smoking was allowed in the main home. These factors, and having a sibling who smokes, were also independently associated with an increased risk of travelling in a car in which smoking was allowed at least sometimes. Respondents who were not protected from secondhand smoke in the car were also more likely to have ever smoked (adjusted odds ratio 1.59, 95% CI 1.18-2.14). CONCLUSIONS: Absence of smoke free rules in a family car and travelling in a car where smoking was allowed was relatively common among secondary school students, was strongly related to social disadvantage and a higher risk of smoking experimentation. Measures to prevent such exposure are therefore indicated.

Prospective study of exposure to smoking imagery in films and changes in susceptibility to smoking in a cohort of school students in Southern India.

INTRODUCTION: India has unique tobacco-free film and TV rules designed to prevent tobacco uptake. In this study, we examined the potential influence of exposure to smoking imagery in regionally famous films, on susceptibility to smoke in teenagers enrolled in schools in a district in Southern India. METHODS: A longitudinal survey of students, in grades 6 to 8 at baseline in 2017 and grades 7 to 9 one year later in 2018, ascertained prospective incident susceptibility to smoking during the study period in relation to baseline exposure to 27 locally popular films with actual or implied smoking imagery. RESULTS: We analyzed linked data from 33676 participants, and 3973 (11.8%) of the adolescents reported incident susceptibility. There was a significant increase in susceptibility to smoking with increasing exposure at baseline to smoking imagery in films on univariable analysis, highest tertile of exposure relative to no exposure (OR=1.4; 95% CI: 1.0 -2.1, ptrend<0.001), and this trend remained significant (p=0.022) after mutual adjustment for recognized confounders, highest vs no exposure (AOR=1.3; 95% CI: 0.9-1.8). We found no statistically significant association between exposure to tobacco-free film rules and change in susceptibility. CONCLUSIONS: Prospectively, watching films featuring smoking imagery increases adolescents' vulnerability to smoking. Further research revealed no difference in susceptibility change between youth who saw partially compliant films and those who watched non-compliant films. Our findings, thus, underscore the need to incorporate comprehensive approaches to prevent the inclusion of smoking imagery in films.

Instructor and client views of a community falls prevention service and the impact of the COVID-19 pandemic: A qualitative exploration of a service in England.

Objectives: Falls are the most common cause of injury related deaths in people over 75 years. The aim of this study was to explore the experience of providers (instructors) and service users (clients) of a fall's prevention exercise programme and the impact of the COVID-19 pandemic in Derbyshire, UK. Methods: Ten one-to-one interviews with class instructors and five focus groups with clients (n=41). Transcripts were analysed using inductive thematic analysis. Results: Most clients were initially motivated to attend the programme to improve their physical health. All clients reported improvements in their physical health as a result of attending the classes; additional benefits to social cohesion were also widely discussed. Clients referred to the support provided by instructors during the pandemic (online classes and telephone calls) as a 'life-line'. Clients and instructors thought more could be done to advertise the programme, especially linking in with community and healthcare services. Conclusions: The benefits of attending exercise classes went beyond the intended purpose of improving fitness and reducing the risk of falls, extending into improved mental and social wellbeing. During the pandemic the programme also prevented feelings of isolation. Participants felt more could be done to advertise the service and increase referrals from healthcare settings.

Programme and policy perspectives towards a tobacco-free generation in India: findings from a qualitative study.

OBJECTIVE: This study explored multistakeholder perspectives on existing adolescent-specific tobacco control policies and programmes, to advance India's transition towards a tobacco-free generation. DESIGN: Qualitative semi-structured interviews. SETTING: Interviews were conducted with officials involved in tobacco control at the national (India), state (Karnataka), district (Udupi) and village level. Interviews were audio recorded, transcribed verbatim and analysed thematically. PARTICIPANTS: Thirty-eight individuals representing national (n=9), state (n=9), district (n=14) and village (n=6) levels, participated. RESULTS: The study findings highlighted the need to strengthen and amend the existing Tobacco Control Law (2003) provisions, particularly in the vicinity of schools (Sections 6a and 6b). Increasing the minimum legal age to buy tobacco from 18 to 21 years, developing an 'application' for 'compliance and monitoring indicators' in Tobacco-Free Educational Institution guidelines were proposed. Policies to address smokeless tobacco use, stricter enforcement including regular monitoring of existing programmes, and robust evaluation of policies was underscored. Engaging adolescents to co-create interventions was advocated, along with integrating national tobacco control programmes into existing school and adolescent health programmes, using both an intersectoral and whole-societal approach to prevent tobacco use, were recommended. Finally, stakeholders mentioned that when drafting and implementing a comprehensive national tobacco control policy, there is a need to adopt a vision striving toward a tobacco-free generation. CONCLUSION: Strengthening and developing tobacco control programmes and policies are warranted which are monitored and evaluated rigorously, and where adolescents should be involved, accordingly.

Text mining tweets on e-cigarette risks and benefits using machine learning following a vaping related lung injury outbreak in the USA.

Electronic nicotine delivery systems (ENDS) (also known as 'e-cigarettes') can support smoking cessation, although the long-term health impacts are not yet known. In 2019, a cluster of lung injury cases in the USA emerged that were ostensibly associated with ENDS use. Subsequent investigations revealed a link with vitamin E acetate, an additive used in some ENDS liquid products containing tetrahydrocannabinol (THC). This became known as the EVALI (E-cigarette or Vaping product use Associated Lung Injury) outbreak. While few cases were reported in the UK, the EVALI outbreak intensified attention on ENDS in general worldwide. We aimed to describe and explore public commentary and discussion on Twitter immediately before, during and following the peak of the EVALI outbreak using text mining techniques. Specifically, topic modelling, operationalised using Latent Dirichlet Allocation (LDA) models, was used to discern discussion topics in 189,658 tweets about ENDS (collected April-December 2019). Individual tweets and Twitter users were assigned to their dominant topics and countries respectively to enable international comparisons. A 10-topic LDA model fit the data best. We organised the ten topics into three broad themes for the purposes of reporting: informal vaping discussion; vaping policy discussion and EVALI news; and vaping commerce. Following EVALI, there were signs that informal vaping discussion topics decreased while discussion topics about vaping policy and the relative health risks and benefits of ENDS increased, not limited to THC products. Though subsequently attributed to THC products, the EVALI outbreak disrupted online public discourses about ENDS generally, amplifying health and policy commentary. There was a relatively stronger presence of commercially oriented tweets among UK Twitter users compared to USA users.

Healthcare Professionals' Knowledge, Attitudes and Counselling Practice Regarding Prevention of Secondhand Smoke Exposure Among Pregnant Women/Children in Assiut, Egypt.

Objectives and Methods: A cross sectional study of HCPs working in public MCH clinics in Assiut city was conducted to explore their knowledge, attitudes and counselling practices regarding prevention of SHS exposure among pregnant women and children. Descriptive and regression analyses were performed. Results: 367 HCPs participated in the study, 12% of whom were smokers. The majority were nurses (45%). A considerable proportion of HCPs reported being exposed to SHS in workplace (70%) and home (52%). About half HCP reported high SHS knowledge (56%), supportive attitude towards preventing SHS exposure (53%), and having good counselling practice regarding SHS exposure (52%). Being a GP and serving urban communities were significantly associated with high knowledge. Being female, serving a rural population, receiving training on smoking cessation services, not being exposed to SHS at home, and having a supportive attitude towards prevention of SHS exposure were significantly associated with good counselling practice. Conclusion: Awareness, attitudes and counselling practice of HCPs should be improved. Training for HCPs and enforcement of smoke free polices are needed to improve awareness and facilitate changes in social norms.

Experiences and views of parents on the prevention of second-hand smoke exposure in Middle Eastern countries: a qualitative systematic review.

OBJECTIVE: The objective of this review was to identify, appraise, and synthesize the evidence related to experiences and views of parents, children, and professionals on the prevention of second-hand smoke exposure to women and children in Middle Eastern countries. INTRODUCTION: Second-hand smoke exposure is a major health concern. It is problematic during pregnancy because of potential adverse reproductive effects and poor fetal outcomes. Childhood second-hand smoke exposure is linked to increased morbidity and mortality. Smoking prevalence is high among men in Middle Eastern countries and, as a result, large numbers of non-smoking men, women, and children are exposed to second-hand smoke daily. INCLUSION CRITERIA: Studies were considered for inclusion if they explored experiences and views on the prevention of second-hand smoke exposure among women and children in homes, workplaces, schools, personal vehicles, and public places in 17 Middle Eastern countries. This review included studies that focused on qualitative data, including, but not limited to, designs such as phenomenology, grounded theory, ethnography, qualitative descriptive, and feminist research. METHODS: MEDLINE, Embase, CINAHL, PsycINFO, Web of Science, and Scopus databases were searched to identify published studies from inception to January 2021. The search for unpublished studies included EThOS, OpenGrey, and ProQuest Dissertations and Theses. No language restrictions were applied. The JBI guidelines for qualitative systematic reviews were followed in conducting the review. The JBI process of meta-aggregation was used to identify categories and synthesize findings. RESULTS: Of 5229 records identified, two qualitative studies (in three publications) met the eligibility criteria and were included in the review. One study was conducted in Turkey and the other study (reported in two papers) was conducted in Israel. The methodological quality of the studies was high. The participants in the included studies were parents (n = 118 participants) aged between 18 and 42 years. The methods used for data collection were interviews analyzed using thematic content analysis. A total of 50 findings were extracted and aggregated into eight categories, based on the similarity of meaning. Three synthesized finding were generated (all with moderate confidence): i) Parents were aware of second-hand smoke and that exposure to second-hand smoke is harmful, although the health dangers of second-hand smoke exposure were not commonly discussed with parents during pregnancy;ii) Smoking is a socially and culturally accepted norm, with parents reporting cultural beliefs about traditional values as a barrier to reducing second-hand smoke exposure in the home and personal psychological factors to quitting smoking; iii) Parents implemented different physical restrictions on smoking, such as having rules about where smoking can take place, with psychological motivators reported as drivers to decrease second-hand smoke exposure among children in the home, but tended to lack certainty or confidence regarding whether such protective measures were needed or would be effective. CONCLUSIONS: The findings of this study offer an insight into parents' views on second-hand smoke exposure and its prevention in Middle Eastern countries. Parents have conflicting views on second-hand smoke exposure and techniques to minimize it. Interventions are needed to increase parents' knowledge about the harms of second-hand smoke to reduce women's and children's exposure to second-hand smoke. SYSTEMATIC REVIEW REGISTRATION NUMBER: PROSPERO CRD42019137006.

Understanding long-term trends in smoking in England, 1972-2019: an age-period-cohort approach.

BACKGROUND AND AIMS: Smoking prevalence has been falling in England for more than 50 years, but remains a prevalent and major public health problem. This study used an age-period-cohort (APC) approach to measure lifecycle, historical and generational patterns of individual smoking behaviour. DESIGN: APC analysis of repeated cross-sectional smoking prevalence data obtained from three nationally representative surveys. SETTING: England (1972-2019). PARTICIPANTS: Individuals aged 18-90 years. MEASUREMENTS: We studied relative odds of current smoking in relation to age in single years from 18 to 90, 24 groups of 2-year survey periods (1972-73 to 2018-19) and 20 groups of 5-year birth cohorts (1907-11 to 1997-2001). Age and period rates were studied for two groups of birth cohorts: those aged 18-25 years and those aged over 25 years. FINDINGS: Relative to age 18, the odds of current smoking increased with age until approximately age 25 [odds ratio (OR) = 1.48, 95% confidence interval (CI) = 1.41-1.56] and then decreased progressively to age 90 (OR = 0.06, 95% CI = 0.04-0.08). They also decreased almost linearly with period relative to 1972-73 (for 2018-19: OR = 0.30, 95% CI = 0.26-0.34) and with birth cohort relative to 1902-06, with the largest decreased observed for birth cohort 1992-96 (OR = 0.44, 95% CI = 0.35-0.46) and 1997-2001 (OR = 0.35, 95% CI = 0.74-0.88). Smoking declined in the 18-25 age group by an average of 7% over successive 2-year periods and by an average of 5% in those aged over 25. CONCLUSIONS: Smoking in England appears to have declined over recent decades mainly as a result of reduced smoking uptake before age 25, and to a lesser extent to smoking cessation after age 25.