Suicide mortality following the implementation of tobacco packaging and pricing policies in Korea: an interrupted time-series analysis.

BACKGROUND: To prevent tobacco use in Korea, the national quitline number was added to tobacco packages in December 2012, tobacco prices were raised by 80% in January 2015, and graphic health warning labels were placed on tobacco packages in December 2016. This study evaluated the association of these tobacco packaging and pricing policies with suicide mortality in Korea. METHODS: Monthly mortality from suicide was obtained from Cause-of-Death Statistics in Korea from December 2007 to December 2019. Interrupted time-series analysis was performed using segmented Poisson regression models. Relative risks (RRs) and 95% confidence intervals (CIs) were calculated adjusted for suicide prevention strategies. RESULTS: Suicide mortality was 20 per 1,000,000 in December 2007 and showed a downward trend over the study period. After the implementation of tobacco packaging and pricing policies, suicide mortality immediately declined by - 0.09 percent points (95% CI = - 0.19 to 0.01; P > 0.05) for the national quitline number, - 0.22 percent points (95% CI = - 0.35 to - 0.09; P < 0.01) for tobacco prices, and - 0.30 percent points (95% CI = - 0.49 to - 0.11; P < 0.01) for graphic health warning labels. The corresponding RRs for these post-implementation changes compared with the pre-implementation level were 0.91 (95% CI = 0.83 to 1.00), 0.80 (95% CI = 0.70 to 0.91), and 0.74 (95% CI = 0.61 to 0.90), respectively. Significant associations between tobacco control policies and suicide mortality were observed even when stratified by sex and region. CONCLUSIONS: The findings of this study provide new evidence for an association between tobacco control policies and deaths by suicide. An array of effective tobacco control policies should be considered for prevention programs targeting suicide.

Minimising carbon and financial costs of steam sterilisation and packaging of reusable surgical instruments.

BACKGROUND: The aim of this study was to estimate the carbon footprint and financial cost of decontaminating (steam sterilization) and packaging reusable surgical instruments, indicating how that burden might be reduced, enabling surgeons to drive action towards net-zero-carbon surgery. METHODS: Carbon footprints were estimated using activity data and prospective machine-loading audit data at a typical UK in-hospital sterilization unit, with instruments wrapped individually in flexible pouches, or prepared as sets housed in single-use tray wraps or reusable rigid containers. Modelling was used to determine the impact of alternative machine loading, opening instruments during the operation, streamlining sets, use of alternative energy sources for decontamination, and alternative waste streams. RESULTS: The carbon footprint of decontaminating and packaging instruments was lowest when instruments were part of sets (66-77 g CO2e per instrument), with a two- to three-fold increase when instruments were wrapped individually (189 g CO2e per instrument). Where 10 or fewer instruments were required for the operation, obtaining individually wrapped items was preferable to opening another set. The carbon footprint was determined significantly by machine loading and the number of instruments per machine slot. Carbon and financial costs increased with streamlining sets. High-temperature incineration of waste increased the carbon footprint of single-use packaging by 33-55 per cent, whereas recycling reduced this by 6-10 per cent. The absolute carbon footprint was dependent on the energy source used, but this did not alter the optimal processes to minimize that footprint. CONCLUSION: Carbon and financial savings can be made by preparing instruments as part of sets, integrating individually wrapped instruments into sets rather than streamlining them, efficient machine loading, and using low-carbon energy sources alongside recycling.

Health and Economic Impact of Health Warnings and Plain Tobacco Packaging in Seven Latin American Countries: Results of a Simulation Model.

INTRODUCTION: The burden of disease attributable to tobacco use in Latin America is very high. Our objective was to evaluate the 10-year potential impact of current legislation related to cigarette packaging and warnings and expected effects of moving to a higher level of strategies implementing cigarette plain packaging on health and cost outcomes in Argentina, Bolivia, Brazil, Chile, Colombia, Mexico, and Peru, using a microsimulation model. AIMS AND METHODS: We used a probabilistic state-transition microsimulation model, considering natural history, costs, and quality of life losses associated with main tobacco-related diseases. We followed up individuals in hypothetical cohorts and calculated health outcomes annually to obtain aggregated long-term population health outcomes and costs. We performed a literature review to estimate effects and analyzed studies and information from ministries, relevant organizations, and national surveys. We calibrated the model comparing the predicted disease-specific mortality rates with local statistics. RESULTS: Current graphic warnings already in place in each country could avert, during 10 years, 69 369 deaths and 638 295 disease events, adding 1.2 million years of healthy life and saving USD 5.3 billion in the seven countries. If these countries implemented plain packaging strategies, additional 155 857 premature deaths and 4 133 858 events could be averted, adding 4.1 million healthy years of life and saving USD 13.6 billion in direct health care expenses of diseases attributable to smoking. CONCLUSIONS: Latin American countries should not delay the implementation of this strategy that will alleviate part of the enormous health and financial burden that tobacco poses on their economies and health care systems. IMPLICATIONS: Tobacco smoking is the single most preventable and premature mortality cause in the world. The Framework Convention on Tobacco Control, supported by the World Health Organization, introduced a package of evidence-based measures for tobacco control. This study adds evidence on the potential health effects and savings of implementing cigarette plain packaging in countries representing almost 80% of the Latin American population; findings are valuable resources for policy makers in the region.

A discarded cigar package survey in New York City: indicators of non-compliance with local flavoured tobacco restrictions.

INTRODUCTION: In 2009, New York City (NYC) restricted the sale of flavoured tobacco products. We assessed product availability as a proxy for potential non-compliance by analysing discarded cigar, cigarillo and blunt wrap packages in New York City. METHODS: A discarded cigar package survey was conducted in 2016, in a stratified random sample of 94 block groups in NYC resulting in the collection of 886 discarded cigar packages. Each package was coded for brand name, flavour description (explicit and implicit) and size. FINDINGS: Overall, 19.2% of the cigar packages were explicitly flavoured. An additional 9.4% of the packages reflected implicit flavours. Explicit flavoured cigar packages were at increased odds of being found in Staten Island (adjusted OR (AOR)=3.96, 95% CI=1.66 to 9.46), in packaging size of two or three (AOR=8.49, 95% CI=4.24 to 17.02) or four or more (AOR=4.26, 95% CI=1.95 to 9.30). CONCLUSION: Nearly one out of three cigar packages were flavoured products suggesting a problematic level of non-compliance and continued availability. Potential non-compliance is likely fueled by licensed wholesalers and retailers who continue to sell restricted flavoured products. Some retailers may be unaware that implicitly named cigars are typically flavoured and are, therefore, illegal. This lack of awareness of implicit flavoured cigars may be exacerbated by NYC's lack of education or enforcement specific to implicitly flavoured tobacco products.

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.

Presence of Counterfeit Marlboro Gold Packs in Licensed Retail Stores in New York City: Evidence From Test Purchases.

BACKGROUND: There are no independent studies measuring the availability of premium brand counterfeit cigarettes in New York City from licensed retailers. METHODS: We forensically analyzed the cigarette packaging of Marlboro Gold (n = 1021) purchased from licensed tobacco retailers in New York City, using ultraviolet irradiation and light microscopy to determine whether they were counterfeit. RESULTS: We find that while only 0.5% (n = 5) of our sample exhibits at least one characteristic synonymous with counterfeit packaging, none of our packs can be conclusively classified as counterfeit. CONCLUSIONS: We do not find any counterfeit Marlboro Gold packs purchased at full price from licensed cigarette retailers throughout New York City. Future research using test purchases should include other venues (eg, street and online) and specifically ask for discounts to ascertain the overall presence of counterfeit cigarettes. IMPLICATIONS: This is the first study to independently measure the availability of counterfeit cigarette packs purchased at full price from licensed retailers in New York City. We find that none of the Marlboro Gold packs purchased from licensed cigarette retailers are counterfeit.

Observed retail price of Australia's market-leading cigarette brand before and up to 3 years after the implementation of plain packaging.

OBJECTIVE: Despite claims by tobacco companies that plain packaging would lead to lower cigarette prices, recommended and observed real cigarette prices in Australia rose in the 9-11 months after plain packaging was introduced. However, little is known about trends in prices longer term. In this report, we assess whether inflation (Consumer Price Index; CPI) and tax adjusted ('CPI-tax-adjusted') prices of the market-leading Australian cigarette brand changed in the 3-year period after plain packaging, and whether price changes were associated with retailer characteristics. METHOD: Cigarette prices were ascertained from a panel of tobacco retailers at three time points: (1) in November 2012 (n=857) (before full implementation of plain packaging, compulsory in retail outlets from December 2012), (2) between October 2014 and February 2015 (n=789) and (3) between November 2015 and March 2016 (n=579). Generalised estimating equations were used to estimate percentage change in mean CPI/tax-adjusted cigarette prices over time. RESULTS: CPI/tax-adjusted adjusted mean stick prices rose by 13.7% (95% CI 13.0 to 16.0) and 15.2% (95% CI 14.3 to 16.0) at 2.1 and 3.1 years after plain packaging was introduced, respectively. Increases in mean CPI/tax-adjusted stick prices varied by outlet type (p<0.001), socioeconomic status (p=0.013) and remoteness of retailer's area (p=0.028) and whether twin packs were sold (p=0.009). CONCLUSIONS: Contrary to tobacco company predictions of a fall in prices, the price of the market-leading Australian cigarette brand increased significantly in the 3 years after plain packaging was introduced, and these increases were above the combined effects of inflation and increases in excise/customs duty.

'It will harm business and increase illicit trade': an evaluation of the relevance, quality and transparency of evidence submitted by transnational tobacco companies to the UK consultation on standardised packaging 2012.

INTRODUCTION: Transnational tobacco companies (TTCs) submitted evidence to the 2012 UK Consultation on standardised packaging (SP) to argue the policy will have detrimental economic impacts and increase illicit tobacco trade. METHODS: A content analysis of the four TTC submissions to the consultation assessed the relevance and quality of evidence TTCs cited to support their arguments. Investigative research was used to determine whether the cited evidence was industry connected. Fisher's exact tests were used to compare the relevance and quality of industry-connected and independent from the industry evidence. The extent to which TTCs disclosed financial conflicts of interest (COI) when citing evidence was examined. RESULTS: We obtained 74 pieces of TTC-cited evidence. The quality of the evidence was poor. TTCs cited no independent, peer-reviewed evidence that supported their arguments. Nearly half of the evidence was industry-connected (47%, 35/74). None of this industry-connected evidence was published in peer-reviewed journals (0/35) and 66% (23/35) of it was opinion only. Industry-connected evidence was of significantly poorer quality than independent evidence (p<0.001). COIs were not disclosed by TTCs in 91% (32/35) of cases. CONCLUSIONS: In the absence of peer-reviewed research to support their arguments, TTCs relied on evidence they commissioned and the opinions of TTC-connected third-parties. Such connections were not disclosed by TTCs when citing this evidence and were time consuming to uncover. In line with Article 5.3 of the Framework Convention on Tobacco Control and broader transparency initiatives, TTCs should be required to disclose their funding of all third-parties and any COIs when citing evidence.

Availability of illicit tobacco in small retail outlets before and after the implementation of Australian plain packaging legislation.

OBJECTIVE: We aimed to assess change in the availability of illicit tobacco in small mixed business retail outlets following the December 2012 introduction of plain packaging in Australia. METHODS: 303 small retail outlets were visited in June and September 2012 (baseline months), and in December 2012 and February, April and July 2013. Fieldworkers requested a particular low-cost brand of cigarettes and then pressed the retailer for an 'even cheaper' brand. The cheapest pack of cigarettes offered was purchased and later examined to assess any divergence from prescribed Australian packaging regulations. The price paid was compared with tax liability and recommended retail price for the particular brand and pack size. In a sub-set of 179 stores, fieldworkers then asked the retailer about availability of unbranded (chop-chop) tobacco. RESULTS: Thirteen (2.2%) of 598 packs purchased pre-plain packaging were either non-compliant with Australian health warnings and/or suspiciously priced. Four packs (1.3%) of 297 met either or both criteria in the December implementation month, and five (0.6%) of 878 did so in the three collection months following implementation. Chop-chop was offered upon enquiry on 0.6% (n=2) of 338 occasions prior to implementation, 0.6% (n=1) of 170 occasions in the December 2012 implementation month, and 0.6% (n=3) of 514 occasions postimplementation. The likelihood of a 'positive' response (either an offer to sell or information about where unbranded tobacco may be purchased) did not differ across preimplementation, during-implementation and postimplementation waves. CONCLUSIONS: Overall, packs judged likely to be illicit were sold in response to requests for cheapest available packs on fewer than one percent of occasions. Offers to sell unbranded tobacco were rare. No change in availability of illicit tobacco was observed following implementation of plain packaging.

The importance of cigarette packaging in a 'dark' market: the 'Silk Cut' experience.

In a growing number of countries tobacco companies are severely restricted in how they can legally market their products. In these 'dark' markets the role of packaging as a promotional and communications tool becomes more pronounced. How packaging is used for the most expensive cigarette brands in dark markets has received limited attention however, even though these 'premium' cigarette brands significantly impact upon the profitability of tobacco companies. We outline, using retail trade press journals, how packaging was used for premium brand 'Silk Cut' in the UK from 2004 to 2011, following a comprehensive ban on tobacco advertising, promotions and sponsorship. From 2004 to 2008 packaging was used to help launch two new variants and during this period Silk Cut market share of the premium sector grew by 1.1%. Overall share of the cigarette market for the Silk Cut house (brand family) fell however due to the continuing decline of the premium sector. From 2008 to 2011 changes to the packaging were much more frequent, including the repeated use of limited-edition designs, and modifications to pack shape, texture, style of opening, cellophane, foil and inner frame. Silk Cut's share of the premium sector grew a further 2.9% from 2008 to 2011, and overall cigarette market share increased. That a premium brand can report any level of growth within such a hostile market, where most advertising, promotion and sponsorship is banned, taxation is among the highest in the world, and in the midst of a recession, is testament to the value of packaging.

Product retrieval time in small tobacco retail outlets before and after the Australian plain packaging policy: real-world study.

OBJECTIVE: We aimed to assess change in cigarette pack retrieval time in small retail outlets following the introduction of plain packaging in Australia in 1 December 2012. METHODS: A sample of 303 milk bars, convenience stores, petrol stations and newsagents was selected in four capital cities, stratified by area socioeconomic status. In June and September (baseline months), the first 2 weeks of December 2012, and February 2013, stores were visited by trained fieldworkers who requested a cigarette pack of a pre-determined brand, variant and pack size, unobtrusively recording the time from the end of the request to when the pack was scanned or placed on the counter. RESULTS: In multivariate analysis, December retrieval time (12.43 s) did not differ from June (10.91 s; p=0.410) or February (10.37 s; p=0.382), but was slower than September (9.84 s; p=0.024). In December, retrieval time declined as days after plain packaging implementation increased (ß=-0.21, p=0.011), returning to the baseline range by the second week of implementation. This pattern was not observed in baseline months or in February. Sensitivity analyses showed that results were robust to the variability in purchasing circumstances in tobacco retail outlets. CONCLUSIONS: Retailers quickly gained experience with the new plain packaging legislation, evidenced by retrieval time having returned to the baseline range by the second week of implementation and remaining so several months later. The long retrieval times predicted by tobacco industry-funded retailer groups and the consequent costs they predicted would fall upon small retailers from plain packaging are unlikely to eventuate.

The economic impact of individually packaged screws.

BACKGROUND: Trends in orthopaedic surgery have seen a migration towards using individually packaged screws (IPS). The manufacturers claim IPS improves sterility, traceability, and avoids the effects of repeated sterilisation. In recent times there has been increasing pressure on the NHS to be more cost-efficient. Challenging decisions must be made to make cost-efficient choices without comprising the quality of care provided. AIM: This study investigates the cost-benefit of IPS compared to the conventional screw rack stored screws (SRSS). METHODS: A single-centred observational study was carried out in a district general hospital between February and March 2013. One-hundred and forty-seven screws were requested intra-operatively and the screw acquisition time was measured with a digital handheld timer. Screw acquisition time was defined as the time taken from the initial verbal request to when the screw was mounted ready for use. The screws were categorised into two groups: SRSS and IPS. RESULTS: The mean screw acquisition time for the SRSS group (n = 94) was 6.6 s (S.D ± 2.5). The mean screw acquisition time for the IPS group (n = 53) was 102.1 s (S.D ± 25.7). The mean difference between SRSS and IPS was 96 s (95%CI 90.3-100.8; p < 0.001). CONCLUSION: Our study suggests that the use of IPS significantly (p < 0.001) increases the operation duration and costs compared to SRSS. Based on ankle ORIF procedures alone, the use of IPS could potentially increase department spending by approximately £76,680 per year.

Modelling growth of Escherichia coli O157:H7 in fresh-cut lettuce submitted to commercial process conditions: chlorine washing and modified atmosphere packaging.

Fresh-cut iceberg lettuce inoculated with Escherichia coli O157:H7 was submitted to chlorine washing (150 mg/mL) and modified atmosphere packaging on laboratory scale. Populations of E. coli O157:H7 were assessed in fresh-cut lettuce stored at 4, 8, 13 and 16 °C using 6-8 replicates in each analysis point in order to capture experimental variability. The pathogen was able to grow at temperatures ≥8 °C, although at low temperatures, growth data presented a high variability between replicates. Indeed, at 8 °C after 15 days, some replicates did not show growth while other replicates did present an increase. A growth primary model was fitted to the raw growth data to estimate lag time and maximum growth rate. The prediction and confidence bands for the fitted growth models were estimated based on Monte-Carlo method. The estimated maximum growth rates (log cfu/day) corresponded to 0.14 (95% CI: 0.06-0.31), 0.55 (95% CI: 0.17-1.20) and 1.43 (95% CI: 0.82-2.15) for 8, 13 and 16 °C, respectively. A square-root secondary model was satisfactorily derived from the estimated growth rates (R(2) > 0.80; Bf = 0.97; Af = 1.46). Predictive models and data obtained in this study are intended to improve quantitative risk assessment studies for E. coli O157:H7 in leafy green products.

Young adult smokers' perceptions of illicit tobacco and the possible impact of plain packaging on purchase behaviour.

Plain (unbranded) packaging for cigarettes is at the top of the tobacco control agenda in both Australia and Europe. The evidence suggests that it will benefit public health by decreasing the appeal of tobacco products and increasing the power of the health warning. The tobacco industry instead argues that plain packaging would make it easier to counterfeit cigarettes, which would both confuse consumers and reduce price; thereby increasing consumption. Using focus group research we examined young adult smokers (N = 54) perceptions of, and ability to recognize, illicit tobacco and the possible impact of plain packaging on illicit tobacco purchasing behaviour. We found that the pack has no impact on the decision to buy illicit tobacco. Smokers were easily able to identify counterfeit cigarettes, not least by the pack, and buy it knowingly and in the full expectation that it will be inferior in quality. Illicit tobacco purchase, including that for counterfeit tobacco, was instead driven by availability and price. Given the extremely low manufacturing cost, per pack, of certain types of illicit cigarettes, it is difficult to envisage how plain packaging would alter the price of illicit tobacco in any meaningful way. The findings therefore suggest that a move to plain packaging would have no impact on young adult smokers' purchase behaviour.

[Economic effects of single-pack dental hygienic materials introduced into daily clinical practice].

To improve and maintain medical safety and quality, it is necessary to construct and manage a safe and economical medical system. Almost five years have passed since single-pack dental hygienic materials were introduced into daily clinical practice in the University Hospital, Faculty of Dentistry, Tokyo Medical and Dental University. The costs of purchasing hygienic materials themselves are higher when using outsourced sterilized single packed ones, compared with when using intra-murally sterilized ones in the past. Proper usage of single-pack hygienic materials sterilized with Ethylene Oxide Gas (EOG) would reduce waste of unused materials and save labor for staff in the Section of Central Supplies. Financially, the use of hygienic materials could be reduced if single-pack dental hygienic materials by outsourcing were introduced into the hospital, because all costs for sterilizing hygienic materials in the hospital could be eliminated.

Standardised packaging, minimum excise tax, and RYO focussed tax rise implications for UK tobacco pricing.

BACKGROUND: Standardised packaging for factory made (FM) and roll your own (RYO) tobacco was fully implemented in the UK in May 2017. Around the same time, several changes to the tax system were applied (a Minimum Excise Tax (MET) for FM products and tax increases weighted towards RYO products). The tobacco industry claims that standardised packaging will lower prices (a disincentive for quitting) by commoditising the product, yet had itself taken advantage of the previous tax regime to achieve large profits from premium brands while also keeping some products' prices relatively low. Here we evaluate the impact of standardised packaging, the MET and the RYO focussed tax changes on price and industry profitability. METHODS AND FINDINGS: Nielsen electronic point of sale (EPOS) data (May 2015 to April 2018) were used to calculate real (inflation adjusted) monthly price per stick overall, by cigarette type (FM and RYO) and by seven market segments. Trend estimation, using additive mixed models, assessed weighted average price (weighted by volume of sales) and tobacco industry net revenue changes. The beginning and end of the data series were compared in terms of: (a) average monthly price growth, (b) average monthly net revenue growth, and (c) undershifting and overshifting patterns after tax changes. FM and RYO real prices changed little over the 3-year period-overall prices rose by about 1p per stick. There was no evidence of commoditisation with prices of all FM segments (but not RYO) rising faster after the implementation of standardised packaging than immediately beforehand. The prices of the cheapest FM brands rose with the implementation of the MET. RYO price increases did not close the gap to FM pricing levels despite RYO focussed tax increases. Tax changes following the implementation of standardised packaging and the MET were more widely and quickly passed on to smokers in the form of higher prices than the tax change pre-implementation. The main limitations are first that because we do not know the exact mechanism by which Nielsen scales up sample data to provide UK estimates, we could only use data for a set three year period during which the same adjustments are made. Second, the tax and standardised packaging events were sometimes too close in time to separate their consequences statistically. Third, tobacco prices may also be affected by external factors such as changes in smokers' disposable income or availability of electronic nicotine delivery systems. CONCLUSIONS: There was no long-term lowering of tobacco prices after the implementation of standardised packaging as predicted by the industry. The introduction of the MET was successful in increasing the price of the cheapest FM cigarettes and narrowing the price gap between FM brands. The RYO tax increases were, however, insufficient to narrow the price gap between RYO and FM. Overall, undershifting became less extensive indicating that tobacco industry manipulation of the tax system which had previously kept cheap products available had declined. This suggests that standardised packaging and a MET will likely contribute to further declines in UK tobacco use.