Trend of Smuggled Cigarette Consumption in Tehran in the Last Two Decades.

BACKGROUND: Illicit tobacco trade is focused on Iran as a main target in the WHO's eastern Mediterranean region. Serial studies of Cigarette Packs Survey with same method were conducted in Tehran between 2003 and 2015 to evaluate consumed smuggled cigarettes. This study as the fourth Cigarette Packs Survey is designed to indicate the trends of illicit cigarette trade in Tehran in the last two decades. METHODS: A cross-sectional household study was carried out in early 2021 in Tehran on 3042 persons who smoked at least one daily cigarette for a year. The sampling method was like the sampling method used in three previous studies. Participants aged≥15 years were asked to reveal their current cigarette pack, which was either legal cigarettes (having governmental label); or illegal cigarettes (without governmental label). RESULTS: The subjects included 2536 males (83.4%) and the mean age was 39.9±12.1 years; 1854 subjects (60.9%) showed foreign cigarettes and 1188 (39.1%) showed domestic cigarettes; 2705 (88.9%) consumed legal cigarettes and 337 (11.1%) consumed illegal cigarettes. Consumption of illegal cigarettes by gender showed greater use of smuggled cigarettes in males (11.7%vs 8.1%). No significant differences were seen based on the marital and educational status in terms of illegal cigarettes prevalence. CONCLUSION: Compare with previous studies, the trend of consumption of illicit cigarettes was decreasing in past two decades. This could be due to new regulation on monitoring cigarette distribution and changing illegal brands to legal as joint production.

Tool to monitor tobacco control policy implementation: the Tobacco Control Scale in Latin America. Adaptation process and pilot study.

BACKGROUND: Monitoring tobacco control policy implementation is one of the keys for tobacco consumption reduction in Latin America (LA). This study reports on the adaptation of the Tobacco Control Scale (TCS) for use in LA countries and the level of tobacco control policy implementation in this region according to the scale. METHODS: Ecological cross-sectional survey. The questionnaire to measure tobacco control policies was a translated (into Spanish and Portuguese) and adapted version of the last TCS as used in Europe. The resulting TCS-LA maintains the same structure as the original TCS, with eight policy domains and 100 points (pts) as maximum score; however, four policy domains were adapted because the exact same rationale could not be applied. At least two non-governmental tobacco control experts were contacted per country to answer the TCS-LA. RESULTS: Informants from 17 out of 18 countries completed the questionnaire. Using the TCS-LA, Panama (70 pts), Uruguay (68 pts) and Ecuador (61 pts) exhibited the strongest tobacco control policies, while Guatemala (32 pts), Bolivia (30 pts) and Dominican Republic (29 pts) have implemented a lower number of tobacco control policies. Eight countries reached 50% of the TCS-LA total possible score, indicating a relatively good implementation level of tobacco control policies. CONCLUSIONS: Panama, Uruguay and Ecuador are the tobacco control policy leaders in LA; however, tobacco control in the region has room for improvement since nine countries have a total score under 50 pts. The TCS is a feasible and adaptable tool to monitor tobacco control in other WHO regions beyond Europe.

The association between tobacco control policy implementation and country-level socioeconomic factors in 31 European countries.

European countries have made significant progress in implementing tobacco control policies to reduce tobacco use; however, whether socioeconomic status (SES) of a country may influence the implementation of such policies is unknown. The aim of this study is to assess the association between country-level SES and the implementation level of tobacco control policies in 31 European countries. An ecological study using data from Eurostat, Human Development Reports on several SES indicators and the Tobacco Control Scale (TCS) of 2016 was conducted to measure country-level tobacco control policies. We analysed the relationship between SES indicators and the TCS by means of scatter-plots and Spearman's rank correlation coefficients (rsp) and multivariable linear regression analysis. In Europe, no statistically significant association was found between SES factors and the level of implementation of tobacco control policies. Only public spending on tobacco control was associated with all SES factors, except for Gini Index (an income inequality index). The strongest associations of TCS scores for this policy domain were found with the Human Development Index (rsp = 0.586; p < 0.001) and the Gross Domestic Product per capita (in Euros) (rsp = 0.562; p = 0.001). The adjusted linear regression model showed an association of tobacco control policy implementation with countries' geographical location (Western Europe, ß = - 15.7; p = 0.009, compared to Northern Europe). In conclusion, no association was found between SES factors and the level of implementation of tobacco control policies in 31 European countries; policymakers should be aware that tobacco control policies could be successfully implemented despite socioeconomic constraints, especially when these policies are of low cost and cost-effective (i.e., smoke-free bans and taxation).

The Tobacco Control Scale as a research tool to measure country-level tobacco control policy implementation.

INTRODUCTION: The Tobacco Control Scale (TCS) was designed for advocacy purposes but has also been used as a research tool. In the present study, we characterized TCS use, its limitations and strengths, and critically assessed its use as a research instrument. METHODS: We conducted an extensive search of the biomedical databases PubMed and Web of Science for the keyword 'tobacco control scale' in all fields. The search was limited to studies published in the period March 2006 to December 2019. Out of 69 hits, 32 studies met the inclusion criteria. Two reviewers independently extracted information from each publication regarding their general characteristics, publication and research aspects, and the characteristics of the use of the TCS. RESULTS: We found that researchers have used the TCS as a tool to monitor tobacco control policies mainly in cross-sectional observational studies with ecological and multilevel designs directed to advocacy and the promotion of further research. Different outcomes, such as smoking prevalence and quit ratios, have been associated with tobacco control policy scores. The main reported limitations of the TCS were a low variance across countries and a failure to express enforcement and to incorporate the most recent legislation. CONCLUSIONS: The TCS has been commonly used to assess differences in outcomes according to tobacco control policies. However, there are still areas for improvement in its use in research regarding the lack of comparability of TCS scores across time. The lessons that have been learned should be used to adapt and expand the TCS overseas.

Potential impact of reduced tobacco use on life and health expectancies in Belgium.

OBJECTIVES: We investigated the potential impact of reduced tobacco use scenarios on total life expectancy and health expectancies, i.e., healthy life years and unhealthy life years. METHODS: Data from the Belgian Health Interview Survey 2013 were used to estimate smoking and disability prevalence. Disability was based on the Global Activity Limitation Indicator. We used DYNAMO-HIA to quantify the impacts of risk factor changes and to compare the "business-as-usual" with alternative scenarios. RESULTS: The "business-as-usual" scenario estimated that in 2028 the 15-year-old men/women would live additional 50/52 years without disability and 14/17 years with disability. The "smoking-free population" scenario added 3.4/2.8 healthy life years and reduced unhealthy life years by 0.79/1.9. Scenarios combining the prevention of smoking initiation with smoking cessation programs are the most effective, yielding the largest increase in healthy life years (1.9/1.7) and the largest decrease in unhealthy life years (- 0.80/- 1.47). CONCLUSIONS: Health impact assessment tools provide different scenarios for evidence-informed public health actions. New anti-smoking strategies or stricter enforcement of existing policies potentially gain more healthy life years and reduce unhealthy life years in Belgium.

Impact of tobacco control policies on smoking prevalence and quit ratios in 27 European Union countries from 2006 to 2014.

BACKGROUND: Tobacco use is still highly prevalent in Europe, despite the tobacco control efforts made by the governments. The development of tobacco control policies varies substantially across countries. The Tobacco Control Scale (TCS) was introduced to quantify the implementation of tobacco control policies across European countries OBJECTIVE: To assess the midterm association of tobacco control policies on smoking prevalence and quit ratios among 27 European Union (EU) Member States (EU27). METHODS: Ecological study. We used the TCS in EU27 in 2007 and the prevalence of tobacco and quit ratios data from the Eurobarometer survey (2006 (n=27 585) and 2014 (n=26 793)). We analysed the relationship between the TCS scores and smoking prevalence and quit ratios and their relative changes (between 2006 and 2014) by means of scatter plots and multiple linear regression models. RESULTS: In EU27, countries with higher scores in the TCS, which indicates higher tobacco control efforts, have lower prevalence of smokers, higher quit ratios and higher relative decreases in their prevalence rates of smokers over the last decade. The correlation between TCS scores and smoking prevalence (rsp=-0.444; P=0.02) and between the relative changes in smoking prevalence (rsp=-0.415; P=0.03) was negative. A positive correlation was observed between TCS scores and quit ratios (rsp=0.373; P=0.06). The percentage of smoking prevalence explained by all TCS components was 28.9%. CONCLUSION: EU27 should continue implementing comprehensive tobacco control policies as they are key for reducing the prevalence of smoking and an increase tobacco cessation rates in their population.

Assessment of the European Union's illicit trade agreements with the four major Transnational Tobacco Companies.

To address the illicit cigarette trade, the European Union (EU) has signed agreements with the four major Transnational Tobacco Companies (TTCs) that involve establishing extensive systems of cooperation. All agreements foresee two types of payments: annual payments (totalling US$ 1.9 billion over 20 years) and supplementary seizure payments, equivalent to 100% of the evaded taxes in the event of seizures of their products. While limited by the fundamental lack of transparency in this area, our analysis suggests that these agreements have served largely to secure the TTCs' interests and are threatening progress in tobacco control. The seizure payments are paltry and a wholly inadequate deterrent to TTC involvement in illicit trade. Despite the agreements, growing evidence indicates the TTCs remain involved in the illicit trade or are at best failing to secure their supply chains as required by the agreements. The intention of the seizure-based payments to deter the tobacco industry from further involvement in the illicit cigarette trade has failed because the agreements contain too many loopholes that provide TTCs with both the incentive and opportunity to classify seized cigarettes as counterfeit. In addition, the shifting nature of cigarette smuggling from larger to smaller consignments often results in seizures that are too small to qualify for the payments. Consequently, the seizure payments represent a tiny fraction of the revenue lost from cigarette smuggling, between 2004 and 2012, 0.08% of the estimated losses due to illicit cigarette trade in the EU. Our evidence suggests the EU should end these agreements.

Pricing Policies And Control of Tobacco in Europe (PPACTE) project: cross-national comparison of smoking prevalence in 18 European countries.

Limited data on smoking prevalence allowing valid between-country comparison are available in Europe. The aim of this study is to provide data on smoking prevalence and its determinants in 18 European countries. In 2010, within the Pricing Policies And Control of Tobacco in Europe (PPACTE) project, we conducted a face-to-face survey on smoking in 18 European countries (Albania, Austria, Bulgaria, Czech Republic, Croatia, England, Finland, France, Greece, Hungary, Ireland, Italy, Latvia, Poland, Portugal, Romania, Spain and Sweden) on a total of 18 056 participants, representative for each country of the population aged 15 years or older. Overall, 27.2% of the participants were current smokers (30.6% of men and 24.1% of women). Smoking prevalence was highest in Bulgaria (40.9%) and Greece (38.9%) and lowest in Italy (22.0%) and Sweden (16.3%). Smoking prevalence ranged between 15.7% (Sweden) and 44.3% (Bulgaria) for men and between 11.6% (Albania) and 38.1% (Ireland) for women. Multivariate analysis showed a significant inverse trend between smoking prevalence and the level of education in both sexes. Male-to-female smoking prevalence ratios ranged from 0.85 in Spain to 3.47 in Albania and current-to-ex prevalence ratios ranged from 0.68 in Sweden to 4.28 in Albania. There are considerable differences across Europe in smoking prevalence, and male-to-female and current-to-ex smoking prevalence ratios. Eastern European countries, lower income countries and those with less advanced tobacco control policies have less favourable smoking patterns and are at an earlier stage of the tobacco epidemic.

Illicit cigarettes and hand-rolled tobacco in 18 European countries: a cross-sectional survey.

OBJECTIVE: Little evidence, other than that commissioned by the tobacco industry, exists on the size of the illicit tobacco trade. This study addresses this gap by examining the level and nature of illicit cigarettes and hand-rolled tobacco in 18 European countries. DESIGN: Face-to-face cross-sectional survey on smoking. SETTING: 18 European countries. PARTICIPANTS: For each country, around 1000 subjects representative of the population aged 15 and over were enrolled. Current cigarette smokers were asked to show their latest purchased pack of cigarettes or hand-rolled tobacco. MAIN OUTCOME MEASURE: A comprehensive measure called an Identification of an Illicit Pack (IIP) was used to study the extent of illicit trade, defining a pack as illicit if it had at least one of the following tax evasion indicators: (1) it was bought from illicit sources, as reported by smokers, (2) it had an inappropriate tax stamp, (3) it had an inappropriate health warning or (4) its price was substantially below the known price in their market. RESULTS: Overall, the proportion of illicit packs was 6.5%. The highest prevalence of IIP was observed in Latvia (37.8%). Illicit packs were more frequent among less educated smokers and among those living in a country which shared a land or sea border with Ukraine, Russia, Moldova or Belarus. No significant association was found with price of cigarettes. CONCLUSIONS: This study indicates that IIP is less than 7% in Europe and suggests that the supply of illicit tobacco, rather than its price, is a key factor contributing to tax evasion.

Socioeconomic and country variations in cross-border cigarette purchasing as tobacco tax avoidance strategy. Findings from the ITC Europe Surveys.

BACKGROUND: Legal tobacco tax avoidance strategies such as cross-border cigarette purchasing may attenuate the impact of tax increases on tobacco consumption. Little is known about socioeconomic and country variations in cross-border purchasing. OBJECTIVE: To describe socioeconomic and country variations in cross-border cigarette purchasing in six European countries. METHODS: Cross-sectional data from adult smokers (n=7873) from the International Tobacco Control (ITC) Surveys in France (2006/2007), Germany (2007), Ireland (2006), The Netherlands (2008), Scotland (2006) and the rest of the UK (2007/2008) were used. Respondents were asked whether they had bought cigarettes outside their country in the last 6 months and how often. FINDINGS: In French and German provinces/states bordering countries with lower cigarette prices, 24% and 13% of smokers, respectively, reported purchasing cigarettes frequently outside their country. In non-border regions of France and Germany, and in Ireland, Scotland, the rest of the UK and The Netherlands, frequent purchasing of cigarettes outside the country was reported by 2-7% of smokers. Smokers with higher levels of education or income, younger smokers, daily smokers, heavier smokers and smokers not planning to quit smoking were more likely to purchase cigarettes outside their country. CONCLUSIONS: Cross-border cigarette purchasing is more common in European regions bordering countries with lower cigarette prices and is more often reported by smokers with higher education and income. Increasing taxes in countries with lower cigarette prices, and reducing the number of cigarettes that can be legally imported across borders could help to avoid cross-border purchasing.

Towards a greater understanding of the illicit tobacco trade in Europe: a review of the PMI funded 'Project Star' report.

BACKGROUND: Following a legal agreement with the European Union (EU), Philip Morris International (PMI) commissions a yearly report ('Project Star', PS) on the European illicit cigarette trade from KPMG, the global accountancy firm. METHODS: Review of PS 2010 report. Comparison with data from independent sources including a 2010 pan-European survey (N=18,056). FINDINGS: Within PS, data covering all 27 EU countries are entered into a model. While the model itself seems appropriate, concerns are identified with the methodologies underlying the data inputs and thus their quality: there is little transparency over methodologies; interview data underestimate legal non-domestic product partly by failing to account for legal cross-border sales; illicit cigarette estimates rely on tobacco industry empty pack surveys which may overestimate illicit; and there is an over-reliance on data supplied by PMI with inadequate external validation. Thus, PMI sales data are validated using PMI smoking prevalence estimates, yet PMI is unable to provide sales (shipment) data for the Greek islands and its prevalence estimates differ grossly from independent data. Consequently, comparisons with independent data suggest PS will tend to overestimate illicit cigarette levels particularly where cross-border shopping is frequent (Austria, Finland, France) and in Western compared with Eastern European countries. The model also provides data on the nature of the illicit cigarette market independent of seizure data suggesting that almost a quarter of the illicit cigarette market in 2010 comprised PMI's own brands compared with just 5% counterfeited PMI brands; a finding hidden in PMI's public representation of the data. CONCLUSIONS: PS overestimates illicit cigarette levels in some European countries and suggests PMI's supply chain control is inadequate. Its publication serves the interests of PMI over those of the EU and its member states. PS requires greater transparency, external scrutiny and use of independent data.

Concern about passive smoking and tobacco control policies in European countries: an ecological study.

BACKGROUND: Because of the magnitude of the global tobacco epidemic, the World Health Organisation developed the Framework Convention on Tobacco Control (FCTC), an international legally binding treaty to control tobacco use. Adoption and implementation of specific tobacco control measures within FCTC is an outcome of a political process, where social norms and public opinion play important roles. The objective of our study was to examine how a country's level of tobacco control is associated with smoking prevalence, two markers of denormalisation of smoking (social disapproval of smoking and concern about passive smoking), and societal support for tobacco control. METHODS: An ecological study was conducted, using data from two sources. The first source was the Tobacco Control Scale (TCS) from 2011, which quantifies the implementation of tobacco control policies in European Union (EU) countries. Data on smoking prevalence, societal disapproval of smoking, concern about passive smoking, and societal support for policy measures were taken from the Eurobarometer survey of 2009. Data from Eurobarometer surveys were aggregated to country level. Data from the 27 European Union member states were used. RESULTS: Smoking prevalence rates in 2009 were negatively associated with a country's TCS 2011 score, although not statistically significant (r = -.25; p = .21). Experience of societal disapproval was positively associated with higher TCS scores, though not significantly (r = .14; p = .48). The same was true for societal support for tobacco control (r = .27; p = .18). The TCS score in 2011 was significantly correlated with concern about passive smoking (r = .42; p =.03). Support for tobacco control measures was also strongly correlated with concern about passive smoking (r = .52, p = .006). CONCLUSIONS: Smokers in countries with a higher TCS score were more concerned about whether their smoke harms others. Further, support for tobacco control measures is higher in countries that have more of these concerned smokers. Concerns about passive smoking seem central in the implementation of tobacco control measures, stressing the importance of continuing to educate the public about the harm from passive smoking.

From cigarette smuggling to illicit tobacco trade.

BACKGROUND: Tax policy is considered the most effective strategy to reduce tobacco consumption and prevalence. Tax avoidance and tax evasion therefore undermine the effectiveness of tax policies and result in less revenue for governments, cheaper prices for smokers and increased tobacco use. Tobacco smuggling and illicit tobacco trade have probably always existed, since tobacco's introduction as a valuable product from the New World, but the nature of the trade has changed. METHODS: This article clarifies definitions, reviews the key issues related to illicit trade, describes the different ways taxes are circumvented and looks at the size of the problem, its changing nature and its causes. The difficulties of data collection and research are discussed. Finally, we look at the policy options to combat illicit trade and the negotiations for a WHO Framework Convention on Tobacco Control (FCTC) protocol on illicit tobacco trade. RESULTS: Twenty years ago the main type of illicit trade was large-scale cigarette smuggling of well known cigarette brands. A change occurred as some major international tobacco companies in Europe and the Americas reviewed their export practices due to tax regulations, investigations and lawsuits by the authorities. Other types of illicit trade emerged such as illegal manufacturing, including counterfeiting and the emergence of new cigarette brands, produced in a rather open manner at well known locations, which are only or mainly intended for the illegal market of another country. CONCLUSIONS: The global scope and multifaceted nature of the illicit tobacco trade requires a coordinated international response, so a strong protocol to the FCTC is essential. The illicit tobacco trade is a global problem which needs a global solution.

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.