Tobacco Control in Denmark: How the Ugly Duckling Turned into a Swan.

INTRODUCTION: The implementation of tobacco control policies has been a neglected topic in tobacco research. A comprehensive Tobacco Action Plan including plain packaging, a point-of-sale display ban, a ban on characterizing flavors (in products other than cigarettes), a strengthening of the promotion and marketing ban, a ban on the sale of novel nicotine products to minors, smoke-and nicotine-free-school hours in all-schools with minors, and a significant increase in tobacco tax, was adopted in Denmark in 2019. AIMS AND METHODS: Eleven people involved or very close to the advocacy process were invited, two did not respond and nine attended our research center. We used the nominal group technique, a consensus method, to identify the most important driving factors for passing the Tobacco Action Plan. RESULTS: The round-robin identified 39 driving factors merged into 13 in the clarification phase. In the ranking phase, participants agreed on seven factors that they perceived have strongly influenced the political will to strengthen national tobacco control comprehensively. The most important factors were national data and evidence, a nationwide alliance with broad partnerships, a strict focus on young people, continuous media coverage, intensive lobbying by many different advocates, making it a community agenda-not a political one, and effective professional campaigns. CONCLUSIONS: Our findings agree with experiences from other countries that significantly improved tobacco control. The Danish strategy, including a nationwide alliance with broad partnerships, had a high influence on the political agenda. IMPLICATIONS: In this study, there was a consensus that seven factors strongly influenced the political will to comprehensively strengthen the national tobacco control in Denmark in a short time: national data and evidence; a nationwide alliance with broad partnerships; a strict focus on children and young people; continuous media coverage; intensive lobbying by many different advocates; making it a community agenda-not a political one, and effective professional campaigns. This is consistent with findings from other countries.

Tobacco Packaging and Labeling Policies in the WHO African Region: Progress 15 Years After Adoption of the WHO Framework Convention on Tobacco Control Article 11 Implementation Guidelines.

INTRODUCTION: Article 11 of the World Health Organization's Framework Convention on Tobacco Control (WHO FCTC) requires Parties to adopt and implement effective tobacco packaging and labeling policies to communicate health risks and reduce tobacco consumption. AIMS AND METHODS: The goal of this study was to assess adoption of these policies in the WHO African Region (AFRO). We reviewed tobacco packaging and labeling policies adopted in AFRO from the Campaign for Tobacco-Free Kids' Tobacco Control Laws database (www.tobaccocontrollaws.org). We assessed these policies based on WHO FCTC Article 11 and its Implementation Guidelines examining three subpolicy areas (health warning labels [HWLs], descriptive constituents and emissions information, and misleading packaging and labeling). We developed a scoring system to rank AFRO countries individually and by the World Bank's income-level groups, and documented the progress during 1985-2023. RESULTS: Forty (of 47) AFRO countries adopted national laws, of which a majority adopted large rotating pictorial HWLs and banned misleading descriptors; only Cote d'Ivoire and Mauritius adopted standardized packaging. The higher a country is in the World Bank's income-level group, the stronger their packaging and labeling policies. This observation was not present in the HWLs subpolicy area. Prior to approving the WHO FCTC Article 11 Implementation Guidelines, only 23 countries adopted text-only HWLs, whereas 26 countries adopted pictorial HWLs after the approval. CONCLUSIONS: Several AFRO countries have adopted tobacco packaging and labeling policies that align with the WHO FCTC Article 11 Implementation Guidelines. More efforts could be directed toward the low-income group and disseminating standardized packaging throughout AFRO. IMPLICATIONS: In the AFRO, the number of tobacco users is increasing, highlighting the need for tobacco packaging and labeling policies aligned with WHO FCTC Article 11 and its Implementation Guidelines as these are proven tobacco control strategies. This study provides a country- and income-level group ranking of tobacco packaging and labeling policies, and documents the evolution of HWLs adopted in AFRO. It also identifies regional and income-level group successes and gaps in tobacco product packaging and labeling policies and provides recommendations to further align with WHO FCTC Article 11 and its Implementation Guidelines.

Advancing progress on tobacco control in low-income and middle-income countries through economic analysis.

BACKGROUND: More than 80% of the world's 1.3 billion tobacco users live in low-income and middle-income countries (LMICs), where progress to address tobacco and its harms has been slow. The perception that tobacco control detracts from economic priorities has impeded progress. The Secretariat of the WHO Framework Convention on Tobacco Control (FCTC) is leading the FCTC 2030 project, which includes technical assistance to LMICs to analyse the economic costs of tobacco use and the benefits of tobacco control. METHODS: The Secretariat of the WHO FCTC, United Nations Development Programme and WHO supported 21 LMICs between 2017 and 2022 to complete national investment cases to guide country implementation of the WHO FCTC, with analytical support provided by RTI International. These country-level cases combine customised estimates of tobacco's economic impact with qualitative analysis of socio-political factors influencing tobacco control. This paper overviews the approach, observed tobacco control advancements and learnings from 21 countries: Armenia, Cabo Verde, Cambodia, Chad, Colombia, Costa Rica, El Salvador, Eswatini, Georgia, Ghana, Jordan, Laos, Madagascar, Myanmar, Nepal, Samoa, Sierra Leone, Sri Lanka, Suriname, Tunisia and Zambia. RESULTS: Tobacco control advancements in line with investment case findings and recommendations have been observed in 17 of the 21 countries, and many have improved collaboration and policy coherence between health and economic stakeholders. CONCLUSIONS: Tobacco control must be seen as more than a health concern. Tobacco control leads to economic benefits and contributes to sustainable development. National investment cases can support country ownership and leadership to advance tobacco control.

Interpreting results, impacts and implications from WHO FCTC tobacco control investment cases in 21 low-income and middle-income countries.

BACKGROUND: Tobacco control investment cases analyse the health and socioeconomic costs of tobacco use and the benefits that can be achieved from implementing measures outlined in the WHO Framework Convention on Tobacco Control (WHO FCTC). They are intended to provide policy-makers and other stakeholders with country-level evidence that is relevant, useful and responsive to national priorities and policy context. METHODS: This paper synthesises findings from investment cases conducted in Armenia, Cabo Verde, Cambodia, Chad, Colombia, Costa Rica, El Salvador, Eswatini, Georgia, Ghana, Jordan, Laos, Madagascar, Myanmar, Nepal, Samoa, Sierra Leone, Sri Lanka, Suriname, Tunisia and Zambia. We examine annual socioeconomic costs associated with tobacco use, focusing on smoking-related healthcare expenditures, the value of lives lost due to tobacco-related mortality and workplace productivity losses due to smoking. We explore potential benefits associated with WHO FCTC tobacco demand-reduction measures. RESULTS: Tobacco use results in average annual socioeconomic losses of US$95 million, US$610 million and US$1.6 billion among the low-income (n=3), lower-middle-income (n=12) and upper-middle-income countries (n=6) included in this analysis, respectively. These losses are equal to 1.1%, 1.8% and 2.9% of average annual national gross domestic product, respectively. Implementation and enforcement of WHO FCTC tobacco demand-reduction measures would lead to reduced tobacco use, fewer tobacco-related deaths and reduced socioeconomic losses. CONCLUSIONS: WHO FCTC tobacco control measures would provide a positive return on investment in every country analysed.

Global smoking-related deaths averted due to MPOWER policies implemented at the highest level between 2007 and 2020.

BACKGROUND: In response to the harm caused by tobacco use worldwide, the World Health Organization (WHO) World Health Assembly actioned the WHO Framework Convention on Tobacco Control (FCTC) in 2005. To help countries meet their FCTC obligations, the WHO introduced in 2008 the MPOWER policy package and by 2020 the FCTC had been ratified by 182 parties. The package consists of six evidence-based demand reduction smoking cessation policies to assist countries to achieve best practice. We used published evaluation results and replicated the published model to estimate current policy achievement and demonstrate the impact and equity of the MPOWER policy package in reducing the global number of smokers and smoking-attributable deaths (SADs) between 2007 and 2020. METHODS: We replicated an evaluation model (the Abridged SimSmoke model) used previously for country impact assessments and validated our replicated reduction in SADs for policies between 2014 and 2016 against the published results. The replicated model was then applied to report on the country level SADs averted from achieving the highest level of implementation, that is best practice in MPOWER policies, between 2016 and 2020. The latest results were then combined with past published results to estimate the reduction in SADs since the commencement of the MPOWER policy package. Country level income status was used to investigate the equity in the uptake of MPOWER policies worldwide. RESULTS: Identical estimates for SADs in 41 out of 56 MPOWER policies implemented in 43 countries suggested good agreement in the model replication. The replicated model overestimated the reduction in SADs by 159,800 (1.5%) out of a total of 10.5 million SADs with three countries contributing to the majority of this replication discrepancy. Updated analysis estimated a reduction of 8.57 million smokers and 3.37 million SADs between 2016 and 2020. Between 2007 and 2020, 136 countries had adopted and maintained at least one MPOWER policy at the highest level which was associated with a reduction in 81.0 million smokers and 28.3 million SADs. Seventy five percent of this reduction was in middle income countries, 20% in high income and less than 5% in low income countries. CONCLUSIONS: Considerable progress has been made by MPOWER policies to reduce the prevalence of smokers globally. However, there is inequality in the implementation and maintenance, reach and influence, and the number of SADs averted. Future research to modify the model could provide a more comprehensive evaluation of past and future progress in tobacco control policies, worldwide.

Facilitators and Barriers to Passing Local Policies That Prohibit the Sale of Flavored Tobacco Products: Qualitative Analysis of Strategies Implemented by 36 Communities in California, 2017-2021.

To reduce youth access to tobacco products, the California Tobacco Prevention Program funded local tobacco prevention programs from July 2017 through December 2021 to address its Communities of Excellence Indicator 3.2.9: "the number of jurisdictions with a policy eliminating or restricting the sale and/or distribution of any mentholated cigarettes and other flavored tobacco products, and paraphernalia." We examined the strategies by which community coalitions attempted to limit the number of stores selling flavored tobacco across California. Thirty-six final evaluation reports (FERs) were used for our analysis. We examined certain elements or factors as primary areas of interest because of their apparent link to successful outcomes in analyses of FERs in the past. Over half (19 of 36) of FERs reported successfully passing at least 1 policy to regulate the sale of flavored tobacco products. Urban communities passed more policies (16 of 18) compared with rural communities (3 of 18). Successful campaigns tended to involve youth, demonstrate illegal sales to minors and public support for a ban, and identify a champion. Barriers included the COVID-19 pandemic, California wildfires, staffing shortages, and conservative political climates. This evaluation offers insights into the successes and challenges faced by local coalitions seeking policy changes for tobacco use prevention, which can be different for urban and rural communities. The evaluation also indicates the necessity of adopting flexible tactical plans for overcoming environmental factors that affected intervention and evaluation activities.

[Tabacco harm reduction: the need for a paradigm shift in German tobacco control policy]. / Tabak Harm Reduction: Die Notwendigkeit eines Paradigmenwechsels in der deutschen Tabakkontrollpolitik.

The consumption of tobacco continues to be the greatest preventable health risk in Germany. Every year, more than 127,000 people die prematurely as a result of using tobacco - one in five new cases of cancer is a consequence of smoking. Germany's current tobacco control policy, consisting of advertising bans, the promotion of smoke-free environments, and an abstinence-only paradigm, are only able to initiate slow change. Other countries have shown how the number of smokers can be reduced and deaths prevented by integrating harm reduction as a complementary measure and providing a much more active support for people who want to quit. This article first presents the current situation and current measures in Germany. Then recommendations for changes to the current tobacco control policy in Germany are derived from a look at the United Kingdom, which is considered a pioneer throughout Europe with its tobacco control policy, as well as a summary of the current state of research.

Association of state tobacco control policies with active smoking at the time of intervention for intermittent claudication.

OBJECTIVE: Active smoking among patients undergoing interventions for intermittent claudication (IC) is associated with poor outcomes. Notwithstanding, current levels of active smoking in these patients are high. State-level tobacco control policies have been shown to reduce smoking in the general US population. We evaluated whether state cigarette taxes and 100% smoke-free workplace legislation are associated with active smoking among patients undergoing interventions for IC. METHODS: We queried the Vascular Quality Initiative database for peripheral endovascular interventions, infrainguinal bypasses, and suprainguinal bypasses for IC. Active smoking at the time of intervention was defined as smoking within one month of intervention. We implemented difference-in-differences analysis to isolate changes in active smoking owing to cigarette taxes (adjusted for inflation) and implementation of smoke-free workplace legislation. The difference-in-differences models estimated the causal effects of tobacco policies by adjusting for concurrent temporal trends in active smoking unrelated to cigarette taxes or smoke-free workplace legislation. The models controlled for age, sex, race/ethnicity, insurance type, diabetes, chronic obstructive pulmonary disease, state, and year. We tested interactions of taxes with age and insurance. RESULTS: Data were available for 59,847 patients undergoing interventions for IC in 25 states from 2011 to 2019. Across the study period, active smoking at the time of intervention decreased from 48% to 40%. Every $1.00 cigarette tax increase was associated with a 6-percentage point decrease in active smoking (95% confidence interval, -10 to -1 percentage points; P = .02), representing an 11% decrease relative to the baseline proportion of patients actively smoking. The effect of cigarettes taxes was greater in older patients and those on Medicare. Among patients aged 60 to 69 and 70 to 79 years, every $1.00 tax increase resulted in 14% and 21% reductions in active smoking relative to baseline subgroup prevalences of 53% and 29%, respectively (P < .05 for both); however, younger age groups were not affected by tax increases. Among insurance groups, only patients on Medicare exhibited a significant change in active smoking with every $1.00 tax increase (an 18% decrease relative to a 33% baseline prevalence; P = .01). The number of states implementing smoke-free workplace legislation increased from 9 to 14 by 2019; however, this policy was not significantly associated with active smoking prevalence. At follow-up (median, 12.9 months), $1.00 tax increases were still associated with decreased smoking prevalence (a 25% decrease relative to a 33% baseline prevalence; P < .001). CONCLUSIONS: Cigarette tax increases seem to be an effective strategy to decrease active smoking among patients undergoing interventions for IC. Older patients and Medicare recipients are the most responsive to tax increases.

Impact of banning smoking in cars with children on exposure to second-hand smoke: a natural experiment in England and Scotland.

England banned smoking in cars carrying children in 2015 and Scotland in 2016. We used survey data from 3 years for both countries (NEngland=3483-6920, NScotland=232-319) to assess effects of the English ban using logistic regression within a difference-in-differences framework. Among children aged 13-15 years, self-reported levels of regular exposure to smoke in cars for Scotland were 3.4% in 2012, 2.2% in 2014 and 1.3% in 2016 and for England 6.3%, 5.9% and 1.6%. The ban in England was associated with a -4.1% (95% CI -4.9% to -3.3%) absolute reduction (72% relative reduction) in exposure to tobacco smoke among children.

Preemption in Tobacco Control: A Framework for Other Areas of Public Health.

Preemption-when a higher level of government limits the authority of a lower level to enact new policies-has been devastating to tobacco control. We developed a preemption framework based on this experience for anticipating and responding to the possibility of preemption in other public health areas. We analyzed peer-reviewed literature, reports, and government documents pertaining to tobacco control preemption. We triangulated data and thematically analyzed them.Since the 1980s, tobacco companies have attempted to secure state preemption through front groups, lobbying key policymakers, inserting preemption into other legislation, and issuing legal threats and challenges. The tobacco control community responded by creating awareness of preemption through media advocacy, educating policymakers, mobilizing national collaborations, and expanding networks with the legal community. Ten of the 25 state smoke-free preemption laws have been fully repealed. Repeal, however, took an average of 11 years.State preemption has been detrimental to tobacco control by dividing the health community, weakening local authority, chilling public education and debate, and slowing local policy diffusion. Health scholars, advocates, and policymakers should use the framework to anticipate and prevent industry use of preemption in other public health areas.

Exceeding WHO Framework Convention on Tobacco Control (FCTC) Obligations: Nepal Overcoming Tobacco Industry Interference to Enact a Comprehensive Tobacco Control Policy.

BACKGROUND: The tobacco industry works to block, delay, and weaken national tobacco control legislation to implement the WHO Framework Convention on Tobacco Control (FCTC). This article reviews how Nepal overcame industry opposition and to a comprehensive tobacco control law implementing the FCTC. METHODS: We triangulated newspaper articles and policy documents with key informant interviews. RESULTS: With the support of international health groups, local tobacco control advocates worked with policymakers in Nepal to pass a comprehensive tobacco control law that exceeded FCTC obligations. The tobacco industry exploited a time of political transition to block consideration by Parliament, arranged and sponsored foreign tours for legislators, made death threats to tobacco control advocates and their families, and argued for the economic importance of tobacco farms. Despite strong interference from Health, and Law and Justice ministers, a 2009 Supreme Court ruling helped tobacco control advocates secure a comprehensive tobacco control law in 2011 that included rotating pictorial health warning labels covering 75% of both sides of cigarette packages, 100% smoke free public places and workplaces, private homes and vehicles, and a tobacco advertising, promotion, and sponsorship ban. CONCLUSIONS: Advocates in developing countries should utilize Nepal's experience to reject tobacco industry offers of compromise and continue educating politicians and legislators to generate political support to pass a comprehensive tobacco control law. Technical and financial support from international agencies, and effective collaboration and coordination of civil societies, and utilization of domestic litigation are helpful in LMICs where governance is weak (the abstract in Nepali is available as a Supplementary Material). IMPLICATIONS: The tobacco industry exploited a time of political transition in Nepal in its effort to block comprehensive tobacco control policy in Parliament by sponsoring foreign tours of legislatures, making death threats to tobacco control advocates and their families, and arguing for the economic importance of tobacco farms. Tobacco control advocates used litigation to raise awareness and educate legislators and promote strong legislation with the involvement of international health groups. Technical and financial support from international agencies, and effective collaboration and coordination of civil societies, and utilization of domestic litigation are helpful in LMICs where governance is weak.

Impact of nations meeting the MPOWER targets between 2014 and 2016: an update.

OBJECTIVE: Since the WHO released the Monitoring tobacco use and tobacco control policies; Protecting from the dangers of tobacco smoke; Offering help to quit tobacco; Warning the public about the dangers; Enforcing bans on advertising, promotion and sponsorship; and Raising tobacco taxes (MPOWER) policy package to assist nations with implementing the Framework Convention on Tobacco Control (FCTC), 88 countries have adopted at least one MPOWER policy at the highest level as of 2014. Building on previous evaluations, we estimated the reduction in smoking-attributable deaths (SADs) from all policies newly adopted at the highest level between 2014 and 2016. METHODS: For each nation that implemented highest level policies, the difference in policy effect sizes from previously validated SimSmoke models for the policies in effect in 2014 and 2016 were multiplied by the number of smokers in that nation to derive the reduction in the number of smokers. Based on research that half of all smokers die from smoking, we derived SADs averted. FINDINGS: In total, 43 nations adopted at least one highest-level MPOWER policy between 2014 and 2016, resulting in 14.6 million fewer SADs. The largest number of SADs averted were due to stronger health warnings (13.3 million), followed by raising taxes (0.6 million), increased marketing bans (0.4 million), smoke-free air laws (0.3 million) and cessation interventions (2500). CONCLUSION: These findings demonstrate the continuing public health impact of tobacco control policies adopted globally since the FCTC, and highlight the importance of more countries adopting MPOWER policies at the highest level to reduce the global burden of tobacco use.

How has the introduction of point-of-sale legislation affected the presence and visibility of tobacco retailing in Scotland? A longitudinal study.

BACKGROUND: Reducing the local availability of tobacco is identified as the 'next frontier' in tobacco control. This paper examines the roles of tobacco retail outlet density and tobacco visibility in changing exposure to tobacco retailing before and after the introduction of point-of-sale (POS) legislation in Scotland. METHODS: National tobacco retailer register data were analysed to examine time trends in tobacco retailer density (2012-2017). Results were stratified by local authority, neighbourhood deprivation and urbanity. Next, an annual retail audit using a POS tobacco visibility tool assessed changes in total product visibility in all retail outlets in four study communities between 2013 and 2017. A longitudinal survey (2013-2017) of 5527 adolescents aged 12-17 in the four study communities enabled the calculation of residential and journey-to-school measures of tobacco retailer exposure. Trends were stratified by deprivation, urbanity and socioeconomic status. RESULTS: Retail provision of tobacco declined following the introduction of the POS legislation in 2013. However, there were strong geographic differences; nationally, one-fifth of local authorities have increased provision since 2015. In the four study communities, tobacco retail provision was generally stable over the study period. Although product visibility of tobacco products reduced for adolescents there was growing socioeconomic disparity in the density of tobacco retailers and the visibility of tobacco storage. CONCLUSIONS: The POS ban reduced exposure to tobacco products in communities across Scotland. However, tobacco products remain widely available, and there is growing socioeconomic disparity in the availability and visibility of tobacco.

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.

Adolescents' perceptions of tobacco accessibility and smoking norms and attitudes in response to the tobacco point-of-sale display ban in Scotland: results from the DISPLAY Study.

BACKGROUND: Scotland implemented a ban on open display of tobacco products in supermarkets in April 2013, and small shops in April 2015. This study aimed to quantify changes in perceived tobacco accessibility, smoking norms and smoking attitudes among adolescents in Scotland, following the implementation of partial and comprehensive point-of-sale (POS) tobacco display bans. METHODS: From the Determining the Impact of Smoking Point of Sale Legislation Among Youth (DISPLAY) Study's 2013-2017 annual surveys we retrieved data comprising 6202 observations on 4836 12-17-year-old adolescents from four schools. Applying generalised estimating equations, associations between time (postban: 2016-2017 vs preban:2013) and three outcomes were estimated. Outcomes were perceived commercial access to tobacco, perceived positive smoking norm (friends think it's OK to smoke) and positive smoking attitude (you think it's OK to smoke). Analyses were adjusted for sociodemographics, smoking status, family smoking, friend smoking and e-cigarette use. RESULTS: Crude trends showed an increase over time in perceived accessibility, norms and attitudes. However, after adjustment for confounders, mainly e-cigarette use, we found significant declines in perceived access (OR = 0.72, 95% CI 0.57 to 0.90) and in positive smoking attitude (OR = 0.67, 95% CI = 0.49 to 0.91), but no change in perceived positive smoking norm (OR = 1.00, 95% CI 0.78 to 1.29). Current/past occasional or regular e-cigarette use was associated with higher odds of perceived access (OR = 3.12, 95% CI 2.32 to 4.21), positive norm (OR = 2.94, 95% CI 2.16 to 4.02) and positive attitude (OR = 3.38, 95% CI 2.35 to 4.87). CONCLUSION: Only when taking into account that the use of e-cigarettes increased in 2013-2017 did we find that the POS tobacco display ban in supermarkets and small shops in Scotland was followed by reductions in adolescents' perceived accessibility of tobacco and positive attitudes towards smoking.