Awareness of tobacco industry tactics among tobacco control communities in Thailand and its association with attitudes towards tobacco industry and perceptions of e-cigarettes.

BACKGROUND: Tobacco industry denormalisation is a key strategy recommended by the WHO Framework Convention on Tobacco Control as it is associated with reducing smoking behaviours and positively influencing public and policymakers' opinion towards tobacco control. However, studies of awareness of tobacco industry tactics among public health players and policymakers in low-income and middle-income countries are limited. METHODS: We conducted an online survey of individuals who had been involved in tobacco control in Thailand. Multivariate ordinal logistic regression analysis was used to determine the association between awareness of tobacco industry tactics and different attitudes towards tobacco industry and perceptions towards e-cigarettes, controlling for role in tobacco control and demographics among 441 respondents. RESULTS: Of the respondents, 11.3% had never heard of any tobacco industry tactics, whereas 11.1% had heard of all tactics asked in the survey. Tobacco industry tactics which were less known by participants were intimidation (30.6%) and illicit trade (37.4%). Participants who were more aware of tobacco industry tactics were more likely to have negative attitudes towards the tobacco industry and e-cigarettes. Compared with active experts of the Provincial Tobacco Products Control Committee and provincial public health officials who work in tobacco control programmes, advocates who worked for civil society organisations in tobacco control were more aware of tobacco industry tactics and had less favourable perceptions of e-cigarettes. CONCLUSION: This study emphasises the importance of educating public health professionals and policymakers about tobacco industry behaviour, especially in the era of e-cigarettes.

Association of Cannabis Use With Cardiovascular Outcomes Among US Adults.

BACKGROUND: We examined the association between cannabis use and cardiovascular outcomes among the general population, among never-tobacco smokers, and among younger individuals. METHODS AND RESULTS: This is a population-based, cross-sectional study of 2016 to 2020 data from the Behavioral Risk Factor Surveillance Survey from 27 American states and 2 territories. We assessed the association of cannabis use (number of days of cannabis use in the past 30 days) with self-reported cardiovascular outcomes (coronary heart disease, myocardial infarction, stroke, and a composite measure of all 3) in multivariable regression models, adjusting for tobacco use and other characteristics in adults 18 to 74 years old. We repeated this analysis among nontobacco smokers, and among men <55 years old and women <65 years old who are at risk of premature cardiovascular disease. Among the 434 104 respondents, the prevalence of daily and nondaily cannabis use was 4% and 7.1%, respectively. The adjusted odds ratio (aOR) for the association of daily cannabis use and coronary heart disease, myocardial infarction, stroke, and the composite outcome (coronary heart disease, myocardial infarction, and stroke) was 1.16 (95% CI, 0.98-1.38), 1.25 (95% CI, 1.07-1.46), 1.42 (95% CI, 1.20-1.68), and 1.28 (95% CI, 1.13-1.44), respectively, with proportionally lower log odds for days of use between 0 and 30 days per month. Among never-tobacco smokers, daily cannabis use was also associated with myocardial infarction (aOR, 1.49 [95% CI, 1.03-2.15]), stroke (aOR, 2.16 [95% CI, 1.43-3.25]), and the composite of coronary heart disease, myocardial infarction, and stroke (aOR, 1.77 [95% CI, 1.31-2.40]). Relationships between cannabis use and cardiovascular outcomes were similar for men <55 years old and women <65 years old. CONCLUSIONS: Cannabis use is associated with adverse cardiovascular outcomes, with heavier use (more days per month) associated with higher odds of adverse outcomes.

Population-Based Disease Odds for E-Cigarettes and Dual Use versus Cigarettes.

Disease Odds for E-Cigarettes and Dual Use versus CigarettesE-cigarettes have been promoted as less harmful than cigarettes. In this meta-analysis, Glantz et al. show that for some diseases, e-cigarette disease risks were similar to cigarettes, and for others e-cigarettes were nearly as risky as cigarettes. The risks associated with dual use were higher than those for smoking alone.

Vuse Solo e-cigarettes do not provide net benefits to public health: a scientific analysis of FDA's marketing authorisation.

In October 2021, the US Food and Drug Administration (FDA) authorised marketing of RJ Reynolds Vapor Company's (RJR) Vuse Solo e-cigarette through FDA's Premarket Tobacco Product Application (PMTA) pathway. FDA concluded that RJR demonstrated Vuse products met the statutory standard of providing a net benefit to public health. A review of FDA's scientific justification reveals deficiencies: (1) not adequately considering Vuse's popularity with youth and evidence that e-cigarettes expanded the nicotine market and stimulate cigarette smoking; (2) trading youth addiction for unproven adult benefit without quantifying these risks and benefits; (3) not considering design factors that appeal to youth; (4) not addressing evidence that e-cigarettes used as consumer products do not help smokers quit and promote relapse in former smokers; (5) not discussing evidence that dual use is more dangerous than smoking; (6) narrowly focusing on the fact that e-cigarettes deliver lower levels of some toxicants without addressing direct evidence on adverse health effects; (7) downplaying significant evidence of other substantial harms; (8) not acting on FDA's own study showing no all-cause mortality benefit of reducing (but not stopping) cigarette use; and (9) improperly considering e-cigarettes' high abuse liability and potential for high youth addiction and undermining tobacco cessation. Because marketing these products is not appropriate for the protection of the public health, FDA should reconsider its Vuse marketing order as statutorily required and not use it as a template for other e-cigarette PMTAs. Policymakers outside the USA should anticipate that tobacco companies will use FDA's decision to try to weaken tobacco control regulation of e-cigarettes and promote their products.

Smoking in Popular Streaming Shows and Youth Protection in Germany.

Aim was to investigate the amount of smoking in popular streaming series in Germany with a focus on the comparison between series recommended for adults versus youth. The sample was drawn from the 35 highest user-rated streaming series, that released 1794 new episodes between January 1, 2017 and December 31, 2020. One-third of the episodes (N = 598) were randomly selected and analyzed for smoking content. The age ratings of these episodes ranged from 6 to 18 years, with categories of "6", "12", "16" and "18" years. Ten of the 35 shows (28.6%) were completely smoke-free, 25 shows (71.4%) had at least one episode with smoking. Of all analyzed episodes, 25.1% contained smoking (range = 1 to 36 smoking scenes; median = 4). There was a statistically significant association between episode age rating and the presence of smoking (χ2[3] = 9.1; p = 0.028; Spearman's rho = 0.11): The proportion of episodes with smoking was 0% for episodes with age ratings below 12 years, 20.4% for age ratings "12", 28.3% for age ratings "16", and 32.4% for age ratings "18". This association differed between streaming services, but all services had smoking in episodes rated for youth. Smoking is common in popular streaming series. None of the streaming services meet the recommendations of the WHO Framework Convention on Tobacco Control to reliably restrict young people's access to media content that depicts smoking.

Smoking and healthcare expenditure reductions associated with the California Tobacco Control Program, 1989 to 2019: A predictive validation.

BACKGROUND: Previous research used data through 2008 to estimate a model for the effect of the California Tobacco Control Program (CTCP) that used cumulative real per capita tobacco control expenditure to predict smoking behavior (current adult smoking prevalence and mean cigarette consumption per current smoker). Predicted changes in smoking behavior due to the CTCP were used to predict its effect on health care expenditure. This research updates the model using the most recently available data and estimates CTCP program effect through 2019. METHODS: The data used in the previous research were updated, and the original model specification and a related predictive forecast model were re-estimated. The updated regression estimates were compared to those previously published and used to update estimates of CTCP program effect in 2019 dollars. RESULTS: There was no evidence of structural change in the previously estimated model. The estimated effect of the CTCP program expenditures on adult current smoking prevalence and mean consumption per adult current smoker has remained stable over time. Over the life of the program, one additional dollar per capita of program expenditure was associated with a reduction of current adult smoking prevalence by about 0.05 percentage point and mean annual consumption per adult current smoker by about 2 packs. Using updated estimates, the program prevented 9.45 (SE 1.04) million person-years of smoking and cumulative consumption of 15.7 (SE 3.04) billion packs of cigarettes from 1989 to 2019. The program produced cumulative savings in real healthcare expenditure of $544 (SE $82) billion using the National Income and Product Accounts (NIPA), and $816 (SE $121) billion using the Center for Medicare and Medicaid Services (CMS) measure of medical costs. During this time, the CTCP expenditure was $3.5 billion. CONCLUSION: A simple predictive model of the effectiveness of the CTCP program remained stable and retains its predictive performance out-of-sample. The updated estimates of program effect suggest that CTCP program has retained its effectiveness over its 31-year life and produced a return on investment of 231 to 1 in direct CMS medical expenditure.

e-Cigarettes Used by Adolescents to Try to Quit Smoking Are Associated With Less Quitting: A Cross-Sectional Analysis of the National Youth Tobacco Survey.

PURPOSE: This paper determines the association between youth e-cigarette use "to try to quit using other tobacco products, such as cigarettes" and having stopped smoking cigarettes (defined as an ever cigarette smoker who did not smoke in the past 30 days). METHODS: This study uses data from the NYTS from 2015 through 2021, focusing on youth who started smoking cigarettes before they started using e-cigarettes. Associations between using e-cigarettes to quit and having stopped smoking were computed using logistic regression accounting for the complex survey design and adjusting for level of nicotine dependence, year, age, gender, and race/ethnicity. Sensitivity analyses allowed for having started cigarettes and e-cigarettes in the same year and without regard for starting sequence. RESULTS: The primary analytic subsample included 6435 United States middle and high school students (mean age 15.9 years, 55.4% male). Using e-cigarettes to quit was associated with significantly lower odds of having stopped smoking cigarettes (odds ratio, 0.62; 95% confidence interval, 0.45-0.85), controlling for nicotine dependence and demographics. Youth with higher levels of nicotine dependence also had lower odds of having stopped smoking. The results were stable over time. Sensitivity analyses produced similar results. DISCUSSION: Ever-smoking youth who used e-cigarettes "to try to quit using other tobacco products, such as cigarettes" had lower odds of having stopped smoking cigarettes than those who did not use e-cigarettes as to try to quit. Physicians, regulators, and educators should discourage youth from attempting to use e-cigarettes as a way to stop smoking cigarettes.

Changes in tobacco depictions after implementation of tobacco-free film and TV rules in Bollywood films in India: a trend analysis.

BACKGROUND: India's tobacco-free film and TV rules were implemented from 2012. To assess the effect of the rules, we studied tobacco depictions in top-grossing Bollywood films released between 2006 and 2017 and rule compliance after 2012. METHODS: Tobacco incidents and brand appearances were coded in 240 top-grossing Bollywood films (2006-2017) using the Breathe California method. Trends in number of tobacco incidents per film per year were studied before and after implementation of the rules using Poisson regression analysis. Compliance with rules over the years was studied using Pearson product-moment correlations. RESULTS: Forty-five films were U-rated (all ages), 162 were UA-rated (below age 12 years must be adult-accompanied), and 33 were A-rated (age 18+ years only). Before implementation of the rules, the number of tobacco incidents per film was increasing by a factor of 1.1/year (95% CI 1.0 to 1.2, p=0.002). However, beginning year 2013, the number of incidents per film started falling significantly by a factor of 0.7/year (95% CI 0.6 to 0.9; p=0.012) compared with the previous increasing trend. The percentage of youth-rated (U and UA) films with any tobacco incidents also declined from a peak of 76% in 2012 to 35% in 2017. The percentage of films complying with the rules (audio-visual disclaimers, health spots, static warnings) did not change significantly from 2012 to 2017. CONCLUSION: India's 2012 rules were followed by a reduction in tobacco depictions in Bollywood films. Enhanced monitoring of compliance is needed to ensure the continued effectiveness of the rules.

Active Smokers Are at Higher Risk of COVID-19 Death: A Systematic Review and Meta-analysis.

INTRODUCTION: Current evidence indicates that smoking worsens COVID-19 outcomes. However, when studies restricted their analyses to current smokers, the risks for COVID-19 severity and death are inconsistent. AIMS AND METHODS: This meta-analysis explored the association between current smoking and the risk for mortality based on the studies that reported all three categories of smoking (current, former, and never smokers) to overcome the limitation of the previous meta-analyses which former smokers might have been classified as nonsmokers. We searched PubMed and Embase up to January 1, 2021. We included studies reporting all three categories of smoking behaviors of COVID-19 patients and mortality outcomes. A random-effects meta-analysis and meta-regression were used to examine relationships in the data. RESULTS: A total of 34 articles with 35 193 COVID-19 patients was included. The meta-analysis confirmed the association between current smoking (odds ratio [OR] 1.26, 95% confidence interval [CI]: 1.01-1.58) and former smoking (OR 1.76, 95% CI: 1.53-2.03) with COVID-19 mortality. We also found that the risk for COVID-19 death in current smokers does not vary by age, but significantly drops by age in former smokers. Moreover, current smokers in non-high-income countries have higher risks of COVID-19 death compared with high-income countries (OR 3.11, 95% CI: 2.04-4.72 vs. OR 1.14, 95% CI: 0.91-1.43; p = .015). CONCLUSIONS: Current and former smokers are at higher risk of dying from COVID-19. Tobacco control should be strengthened to encourage current smokers to quit and prevent the initiation of smoking. Public health professionals should take the COVID-19 pandemic as an opportunity to promote smoking prevention and cession. IMPLICATIONS: This study makes an important contribution to the existing literature by distinguishing between current and former smoking and their separate effects on COVID-19 mortality. We also explore the effects by age of patients and country income level. Findings from this study provide empirical evidence against misinformation about the relationship between smoking and COVID-19 mortality.

Nicotine Addiction and Intensity of e-Cigarette Use by Adolescents in the US, 2014 to 2021.

Importance: As e-cigarettes have become more effective at delivering the addictive drug nicotine, they have become the dominant form of tobacco use by US adolescents. Objective: To measure intensity of use of e-cigarettes, cigarettes, and other tobacco products among US adolescents and their dependence level over time. Design, Setting, and Participants: This survey study analyzed the cross-sectional National Youth Tobacco Surveys from 2014 to 2021. Confirmatory analysis was conducted using Youth Behavioral Risk Factor Surveillance System from 2015 to 2019. The surveys were administered to national probability samples of US students in grades 6 to 12. Exposures: Use of e-cigarettes and other tobacco products before and after the introduction of e-cigarettes delivering high levels of nicotine. Main Outcomes and Measures: First tobacco product used, age at initiation of use, intensity of use (days per month), and nicotine addiction (measured as time after waking to first use of any tobacco product). Results: A total of 151 573 respondents were included in the analysis (51.1% male and 48.9% female; mean [SEM] age, 14.57 [0.03] years). Prevalence of e-cigarette use peaked in 2019 and then declined. Between 2014 and 2021, the age at initiation of e-cigarette use decreased, and intensity of use and addiction increased. By 2017, e-cigarettes became the most common first product used (77.0%). Age at initiation of use did not change for cigarettes or other tobacco products, and changes in intensity of use were minimal. By 2019, more e-cigarette users were using their first tobacco product within 5 minutes of waking than for cigarettes and all other products combined. Median e-cigarette use also increased from 3 to 5 d/mo in 2014 to 2018 to 6 to 9 d/mo in 2019 to 2020 and 10 to 19 d/mo in 2021. Conclusions and Relevance: The changes detected in this survey study may reflect the higher levels of nicotine delivery and addiction liability of modern e-cigarettes that use protonated nicotine to make nicotine easier to inhale. The increasing intensity of use of modern e-cigarettes highlights the clinical need to address youth addiction to these new high-nicotine products over the course of many clinical encounters. In addition, stronger regulation, including comprehensive bans on the sale of flavored tobacco products, should be implemented.

Impairment of Endothelial Function by Cigarette Smoke Is Not Caused by a Specific Smoke Constituent, but by Vagal Input From the Airway.

BACKGROUND: Exposure to tobacco or marijuana smoke, or e-cigarette aerosols, causes vascular endothelial dysfunction in humans and rats. We aimed to determine what constituent, or class of constituents, of smoke is responsible for endothelial functional impairment. METHODS: We investigated several smoke constituents that we hypothesized to mediate this effect by exposing rats and measuring arterial flow-mediated dilation (FMD) pre- and post-exposure. We measured FMD before and after inhalation of sidestream smoke from research cigarettes containing normal and reduced nicotine level with and without menthol, as well as 2 of the main aldehyde gases found in both smoke and e-cigarette aerosol (acrolein and acetaldehyde), and inert carbon nanoparticles. RESULTS: FMD was reduced by all 4 kinds of research cigarettes, with extent of reduction ranging from 20% to 46% depending on the cigarette type. While nicotine was not required for the impairment, higher nicotine levels in smoke were associated with a greater percent reduction of FMD (41.1±4.5% reduction versus 19.2±9.5%; P=0.047). Lower menthol levels were also associated with a greater percent reduction of FMD (18.5±9.8% versus 40.5±4.8%; P=0.048). Inhalation of acrolein or acetaldehyde gases at smoke-relevant concentrations impaired FMD by roughly 50% (P=0.001). However, inhalation of inert carbon nanoparticles at smoke-relevant concentrations with no gas phase also impaired FMD by a comparable amount (P<0.001). Bilateral cervical vagotomy blocked the impairment of FMD by tobacco smoke. CONCLUSIONS: There is no single constituent or class of constituents responsible for acute impairment of endothelial function by smoke; rather, we propose that acute endothelial dysfunction by disparate inhaled products is caused by vagus nerve signaling initiated by airway irritation.

Longitudinal bidirectional association between youth electronic cigarette use and tobacco cigarette smoking initiation in Thailand.

INTRODUCTION: This study quantifies the longitudinal association between e-cigarette use and subsequent conventional cigarette initiation and vice versa among Thai youths. METHODS: Data from a longitudinal survey of 6045 Thai seventh grade students with baseline in 2019 and the 12-month follow-up in 2020 were analysed using complex survey multivariate logistic regressions to assess whether e-cigarette use was associated with subsequent cigarette smoking (ever, current and dual product users at follow-up) among baseline never smokers. RESULTS: Consistent with prior findings from other countries, among those who had never smoked cigarettes at baseline, ever e-cigarette users were more likely to try cigarette smoking (adjusted OR 4.44; 95% CI 2.23 to 8.86; p<0.001), or become dual users (adjusted OR 5.31; 95% CI 2.63 to 10.74; p<0.001) 1 year later. Baseline current e-cigarette users were more likely to become ever smokers (adjusted OR 5.37; 95% CI 1.82 to 15.90; p=0.005), current smokers (OR 3.92; 95% CI 1.69 to 9.14; p=0.003) and dual product users (adjusted OR 6.96; 95% CI 1.54 to 31.38; p=0.015) at the 12-month follow-up than non-e-cigarette users. Similarly, among never e-cigarette users at baseline, ever cigarette smoking were more likely to try e-cigarettes (adjusted OR 3.38; 95% CI 1.66 to 6.88; p=0.002), currently use e-cigarettes (adjusted OR 2.75; 95% CI 1.47 to 5.13; p=0.003) and currently use both e-cigarettes and cigarettes (adjusted OR 4.87; 95% CI 2.92 to 8.13; p<0.001) at the follow-up than never smokers. Among never e-cigarette users at baseline, current-cigarette smoking were more likely to try e-cigarettes (adjusted OR 6.21; 95% CI 2.58 to 14.95; p<0.001), currently use e-cigarettes (adjusted OR 2.80; 95% CI 1.27 to 6.14; p=0.014) and currently use both e-cigarettes and cigarettes (adjusted OR 7.70; 95% CI 3.45 to 17.19; p<0.001) at the follow-up than never smokers. CONCLUSIONS: This longitudinal study in Asian low-income and middle-income countries supports the prospective association of youth e-cigarette use with subsequent smoking initiation and youth cigarette use with subsequent e-cigarette initiation that is similar to that observed in high-income Western countries.

Content Analysis of the Corporate Social Responsibility Practices of 9 Major Cannabis Companies in Canada and the US.

Importance: The cannabis industry has sought to normalize itself and expand its markets in the 21st century. One strategy used by companies to generate positive public relations is corporate social responsibility (CSR). It is critical to understand these efforts to influence the public and politicians given the risks of increased cannabis use. Objectives: To analyze cannabis industry CSR behaviors, determine their characteristics, and compare their practices with those of the tobacco industry. Design, Setting, and Participants: This qualitative study of CSR activities conducted between January 1, 2012, and December 31, 2021, evaluated 9 of the 10 largest publicly traded cannabis companies in the US and Canada. Data were collected from August 1 to December 31, 2021. The 10th company was excluded because it engaged in cannabis-based pharmaceutical sales but not CSR. A systematic review of corporate websites and Nexis Uni was performed, resulting in collection of 153 news articles, press releases, and Web pages. Charitable and philanthropic actions were included. Themes were identified and interpreted using modified grounded theory. Main Outcomes and Measures: CSR activities and spending. Results: Nine major cannabis companies in the US and Canada engaged in CSR activities that encouraged increased consumption and targeted marginalized communities. Companies claimed these activities would mitigate the harms of cannabis prohibition, promote diversity, expand access to medical cannabis, and support charitable causes. They developed educational programs, sustainability initiatives, and voluntary marketing codes and used strategies similar to those used by tobacco companies to recruit public interest organizations as allies. Conclusions and Relevance: These findings suggest that cannabis companies developed CSR strategies comparable to those used by the tobacco industry to influence regulation, suggesting that cannabis companies should be included when addressing commercial determinants of health.

Securing Smokefree Laws Covering Casinos and Bars in Louisiana via Messaging, Continuous Campaigning and Health Coalitions.

In this paper, we examine efforts by health organizations seeking comprehensive smokefree ordinances over Louisiana casinos and bars between 2010 and 2020 to determine best practices for increasing coverage. Bars and casinos remain less protected from secondhand smoke compared to other workplaces in the United States. Casino behavior is compared to the Policy Dystopia Model (PDM), a tobacco industry strategy framework. We performed a historical case study using snowball searches for news on the Access World News Database and the internet. We performed web searches using the names of key actors, organizations, and locations and interviewed nine participants. Starting in 2010, the Louisiana Campaign for Tobacco-Free Living ran ordinance campaigns supplemented by an ongoing statewide smokefree media initiative. Utilizing consistent strategies, including promoting performers as cultural emblems deserving protection, health organizations coalesced in New Orleans during 2014 and Baton Rouge in 2016 and 2017 to pursue ordinances. The coalitions secured ordinances in Louisiana's population and tourism centers despite business resistance. Organizations obtained 30 smokefree laws across Louisiana by 2021. Casinos used PDM strategies to resist ordinances, indicating the framework may predict strategies by non-tobacco entities resisting tobacco control. Louisiana shows that ongoing local campaigns, social justice themes and cultural messaging with coalitions in cities can secure smokefree laws covering casinos and bars and that local ordinance campaigns are a viable method for advancing smokefree protections over those venues in states where the state legislatures are resistant to action.

Tobacco industry thwarts ad ban legislation in India in the 1990s: Lessons for meeting FCTC obligations under Articles 13 and 5.3.

Bans on tobacco advertising are important for reducing tobacco-caused disease. Previously secret internal tobacco industry documents and organizational and newspaper websites related to tobacco control efforts in India during 1990s were analyzed. The Ministry of Health and Family Welfare, World Health Organization, Indian Council of Medical Research, and civil society played important roles in pushing for tobacco control legislation beginning in the 1980s. Guided by transnational tobacco companies, especially British American Tobacco, Philip Morris International, and RJ Reynolds, Indian cigarette companies formed the Tobacco Institute of India (TII). Following the industry's global strategy, TII proposed voluntary advertising codes, used diplomatic channels and high level political and judicial lobbying, and allied with other industry, sports and trade groups to delay legislation for ten years. TII argued for the social and economic importance of tobacco and that laws were unnecessary, unconstitutional, and would hurt the economy. These early global strategies were continuing in 2022 to delay and evade legislative efforts to ban tobacco advertising. Understanding these strategies can inform public health efforts to counter industry efforts to thwart the WHO Framework Convention on Tobacco Control in 2022 not only in India, where the Ministry of Health and Family Welfare has proposed strengthening India's tobacco control law, but globally.