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.

Support for and potential impacts of key Smokefree 2025 strategies among Maori who smoke.

AIM: The recently passed Smokefree Environments and Regulated Products (Smoked Tobacco) Amendment Act has the potential to profoundly reduce smoking prevalence and related health inequities experienced among Maori. This study examined support for, and potential impacts of, key measures included within the legislation. METHOD: Data came from Wave 1 (2017-2019) of the Te Ara Auahi Kore longitudinal study, which was conducted in partnership with five primary health organisations serving Maori communities. Participants were 701 Maori who smoked. Analysis included both descriptive analysis and logistic regression. RESULTS: More Maori participants supported than did not support the Smokefree 2025 (SF2025) goal of reducing smoking prevalence to below 5%, and the key associated measures. Support was greatest for mandating very low nicotine cigarettes (VLNCs). Participants also believed VLNCs would prompt high rates of quitting. Participants who had made more quit attempts or reported less control over their life were more likely to support VLNCs. CONCLUSION: There was support for the SF2025 goal and for key measures that could achieve it. In particular, VLNCs may have significant potential to reduce smoking prevalence among Maori. As part of developing and implementing these measures it will be important to engage with Maori who smoke and their communities.

Evidence of the Effectiveness of Pictorial Health Warnings on Cigarette Packaging in Nepal.

BACKGROUND: Tobacco Control Act of 2010 mandates government to implement at least 75% pictorial health warnings (PHWs) on tobacco packaging that was enforced in 2013. The purpose of the study was to assess the effectiveness of PHWs and its impact to the policy change. METHODS: A cross-sectional study was conducted in 9 cities between September 2014 and March 2015. Direct interviews were made among 2250 randomly selected individuals. The effectiveness of PHWs were measured as perceived: i) scariness; ii) quit motivation iii) convincing youth not to start smoking; iv) encouraging ex-smokers to remain as quitters; v) building public awareness. Logistic regression analysis was used to determine the factors associated with the effectiveness of PHWs. RESULTS: Of the 2250 participants, 29.8% (670) were current smokers, 8.6% (193) were ex-smokers and 97.6% believed that smoking was addictive. PHWs made 83% of the participants scared. Participants believed that PHWs would be effective in motivating smokers to quit (80.2%), in convincing youth not to start smoking (86.8%), in encouraging ex-smokers to remain as quitters (89.1%) and in building public awareness on the dangers of smoking (94%). PHWs made 58% of the current smokers intended to quit smoking and reduced their daily intake of cigarettes from 11 to 5 on average.  Current smokers preferred to purchase loose cigarettes rather than a pack. The covariates significantly associated with the effectiveness of PHWs were current smokers, ex-smokers and addiction. CONCLUSION: PHWs were found important to motivate smokers to quit smoking, to reduce consumption of cigarettes and to prevent relapse in ex-smokers. Evidence from the study had triggered policy changes which included enlargement of the size of PHW to 90% and the release of a notification to ban selling of loose cigarettes. Thus, the warning messages with pictures are required to be improved and rotated.

Implementation of MPOWER Package in the South-East Asia Region: Evidence from the WHO Report on the Global Tobacco Epidemic (2009-2021).

The WHO MPOWER package is a set of six evidence-based and cost-effective measures which was introduced on 7 February 2008 to facilitate the implementation of the provisions of the WHO Framework Convention on Tobacco Control at the ground level. These measures are: Monitoring tobacco use and prevention policies (M); Protecting people from tobacco smoke (P); Offering help to quit tobacco use (O); Warning about the dangers of tobacco (W); Enforcing bans on tobacco advertising, promotion and sponsorship (E); and Raising taxes on tobacco (R). Since its launch, the MPOWER package has become the guiding principle for all the countries of the South-East Asia Region in their crusade against the tobacco epidemic. This review article tracks the implementation of the MPOWER measures in the 11 member countries of the Region based on the last seven WHO Report on the Global Tobacco Epidemic (GTCR), i.e., GTCR2/2009-GTCR8/2021. This is with an aim to enable the countries to review their progress in implementing the MPOWER measures and to take steps to improve their advancement towards reducing the demand for tobacco products at the country level.

Tobacco control policies and smoking cessation treatment utilization: A moderated mediation analysis.

BACKGROUND: Tobacco policies, including clean indoor air laws and cigarette taxes, increase smoking cessation in part by stimulating the use of cessation treatments. We explored whether the associations between tobacco policies and treatment use varies across sociodemographic groups. METHODS: We used data from 62,165 U.S. adult participants in the 2003 and 2010/11 Tobacco Use Supplement to the Current Population Survey (TUS-CPS) who reported smoking cigarettes during the past-year. We built on prior structural equation models used to quantify the degree to which smoking cessation treatment use (prescription medications, nicotine replacement therapy, counseling/support groups, quitlines, and internet resources) mediated the association between clean indoor air laws, cigarette excise taxes, and recent smoking cessation. In the current study, we added selected moderators to each model to investigate whether associations between tobacco polices and smoking cessation treatment use varied by sex, race/ethnicity, education, income, and health insurance status. RESULTS: Associations between clean indoor air laws and the use of prescription medication and nicotine replacement therapies varied significantly between racial/ethnic, age, and education groups in 2003. However, none of these moderation effects remained significant in 2010/11. Higher cigarette excise taxes in 2010/2011 were associated with higher odds of using counseling among older adults and higher odds of using prescription medications among younger adults. No other moderator reached statistical significance. Smoking cessation treatments did not mediate the effect of taxes on smoking cessation in 2003 and were not included in these analyses. CONCLUSIONS: Sociodemographic differences in associations between clean indoor air laws and smoking cessation treatment use have decreased from 2003 to 2010/11. In most cases, policies appear to stimulate smoking cessation treatment use similarly across varied sociodemographic groups.

Performance Obligations to Improve Delivery of Hospital-Initiated Smoking Cessation Interventions: A Before-and-After Evaluation.

INTRODUCTION: This study evaluated whether introducing performance obligations (a policy intervention) to service agreements between hospitals (n = 15) and their local health authority: (1) improved provision of an evidence-based tobacco cessation intervention (the "Ottawa Model" for Smoking Cessation) and (2) changed the quality of the cessation intervention being delivered. METHODS: Interrupted time series analysis was used to evaluate the change in the proportion of smoker patients provided the Ottawa Model 3 years before and 3 years after introducing the performance obligations. Changes in secondary outcomes related to program quality were described using mean differences, risk differences, and risk ratios, as appropriate. RESULTS: The proportion and number of patients provided the Ottawa Model doubled in the 3-year period following introduction of the new policy-from 3453 patients (33.7%) in the year before to 6840 patients (62.8%) in the final assessment year. This resulted in a signification slope change (+9.2%; 95% confidence interval [CI] 4.5%, 13.9%; p = .01) between the pre- and post-obligation assessment periods, signifying the policy had a positive impact on performance. Quality and effectiveness of the in-hospital intervention remained steady. CONCLUSIONS: Implementation of performance obligations by a healthcare funder increased delivery of an evidence-based smoking cessation intervention across multiple hospitals. Given the known health and economic impacts of smoking cessation interventions, health authorities and hospitals should consider pairing adoption of systematic interventions, like the Ottawa Model, with policy to enhance reach and impact. IMPLICATIONS: • The hospital-based Ottawa Model for Smoking Cessation (OMSC) intervention has been shown to increase smoking abstinence, while reducing mortality and healthcare utilization.• The uptake of systematic, evidence-based interventions, like the OMSC, by hospitals has been relatively low despite the known positive impacts.• The introduction of smoking cessation performance obligations by a healthcare funder resulted in more patients receiving an OMSC intervention while in hospital, with no corresponding change in intervention quality or effectiveness.• Healthcare funders and hospitals should consider pairing the adoption of effective, systematic interventions, like the OMSC, with policy to enhance reach and impact.

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.

The Ethics of Tobacco Harm Reduction: An Analysis of E-Cigarette Availability From the Perspectives of Utilitarianism, Bioethics, and Public Health Ethics.

Much evidence suggests e-cigarettes are substantially less harmful than combustible cigarettes. Assuming this is true, we analyze the ethical case for a policy of e-cigarette availability (ECA) as a tobacco harm reduction strategy. ECA involves making e-cigarettes available to allow smokers to switch to them, and informing smokers of the lower risks of e-cigarettes vis-à-vis smoking. After suggesting that utilitarian/consequentialist considerations do not provide an adequate ethical analysis, we analyze ECA using two other ethical frameworks. First, ECA is supported by a public health ethics framework. ECA is a population-level intervention consistent with respecting individual autonomy by using the least restrictive means to accomplish public health goals, and it supports equity and justice. Second, ECA is supported by four principles that form a biomedical ethics framework. By reducing smokers' health risks and not harming them, ECA fulfills principles of beneficence and non-maleficence. Because ECA allows smokers to make informed health decisions for themselves, it fulfills the principle requiring respect for persons and their autonomy. Here, we consider whether nicotine addiction and thus ECA undermine autonomy, and also discuss the ethical warrant for special protections for youth. Finally, ECA can also advance justice by providing a harm reduction alternative for disadvantaged groups that disproportionately bear the devastating consequences of smoking. Policies of differential taxation of cigarettes and e-cigarettes can facilitate adoption of less harmful alternatives by those economically disadvantaged. We conclude that public health and biomedical ethics frameworks are mutually reinforcing and supportive of ECA as a tobacco harm reduction strategy. Implications: Making e-cigarettes and information about them available is supported as ethical from multiple ethical perspectives.

The level of effectiveness of Polish legislation relating to health protection against the consequences of tobacco use.

The purpose of this work is to analyze the regulatory environment for tobacco use, with particular reference to changes made in the last 10 years. An attempt was made to answer the question of the extent to which the regulatory environment has a real impact on the achievement of the objective set out in the existing legal provisions, which is to protect the health and rights of the persons concerned. An analytical method was used in the work to assess the application of legal principles. A method of analyzing the current line of jurisprudence was also used. In the process of final evaluation of public utilities, certain functional methods were used. The assessment was subjected to Polish law, within the scope of the currently binding Act on Health Protection Against the Consequences of Using Tobacco and Tobacco Products of 1995. The study states that the provisions of this Act are only a formal guarantee of protection. The liability arising from the application of its standard is illusory because the procedure for imposing penalties is ineffective. The pursuit of any property claims related to violation of the rights of related entities, as envisaged in this Act, is complicated. This does not apply to a case which is not affected by the decision. Int J Occup Med Environ Health. 2020;33(5):599-610.

Making Strides Together against Tobacco Use.

In the Western Pacific Region, more than 3 million people die each year as a result of tobacco use - a problem for health and a threat to social and economic development. Countries around the world made a commitment by adopting the WHO Framework Convention on Tobacco Control of which implementation was then further facilitated by WHO's MPOWER package. Recognizing the importance of data as a powerful tool for tobacco control, this special supplement presents papers showcasing efforts by a number of Western Pacific countries and areas and data around these efforts to combat tobacco use and further advance progress in the battle against it. Despite the substantial progress that countries and areas have made in tobacco control, there is still much to be done in order to sustain the momentum to fight against this preventable killer and the industry which promotes it in our continued fight against the world's deadliest epidemic.

Investing in Tobacco Control: Twelve Years of MPOWER Measures and Progress in the Western Pacific Region.

Tobacco use has detrimental effects in the Western Pacific Region. The World Health Organization (WHO) Framework Convention on Tobacco Control (FCTC) came into effect in 2005 to address the global tobacco epidemic, and WHO introduced the MPOWER measures to facilitate implementation of key demand-reduction measures of the WHO FCTC at the country level. This paper provides an overview of progress made by countries within the Region since the introduction of the MPOWER measures 12 years ago, and examines challenges and threats hindering their further implementation.

Improving Information to Enable Effective Tobacco Control Intervention and Measure Progress Over Time: The Cambodia Country Experience.

Tobacco is a leading cause of noncommunicable diseases (NCDs) which kill about 41 million people each year. Of these, 15 million die prematurely between the ages of 30 and 69 years, most of which occur in low- and middle-income countries (LMICs). The adoption of the Sustainable Development Goals and their targets under the 2030 Agenda for Sustainable Development provides a new impetus for countries to accelerate tobacco control efforts as they specifically call for strengthening implementation of the World Health Organization (WHO) Framework Convention on Tobacco Control and striving to achieve a one-third reduction in premature deaths from NCDs. While NCD prevention and control is a priority in the national strategic plans and policies for health in most countries in the Western Pacific Region, few have formally adopted a national target for reducing tobacco use. Article 20 of the WHO FCTC calls on all countries to improve tobacco surveillance to enable monitoring and evaluation of tobacco control efforts. The increase in timely and standardized comparable data presents new opportunities to set scientifically valid and achievable national indicators and targets for development and implementation of strong tobacco control measures. Cambodia is yet to establish national targets and full implementation of legislative measures. However, with strong tobacco surveillance mechanism in place, it can provide the country experience for a LMIC that has developed its own capacity to conduct periodic monitoring and surveillance of tobacco use and for using national data to advocate successfully for stronger tobacco control policies.

Secondhand Smoke Exposure among Nonsmokers in China.

BACKGROUND: China signed the World Health Organization Framework Convention on Tobacco Control and conducted a series of activities to protect people from secondhand smoke exposure. This paper explores the changes in prevalence of secondhand smoke exposure among nonsmokers between 2010 and 2015. METHODS: Data from the 2010 Global Adult Tobacco Survey and 2015 National Adult Tobacco Survey were used in this study. Due to the complex sample design for these surveys, data were weighted and analyzed using the SAS 9.3 complex survey data analysis procedure. The Chi-square test was used for comparison among different groups. RESULTS: From 2010 to 2015, secondhand smoke exposure among nonsmokers decreased in restaurants, government buildings, health-care facilities, schools, and public transportation in China (p<0.05). The relative change was most significant for schools (52.1%), followed by public transportation (49.4%) and government buildings (42.2%). The percentage of secondhand smoke exposure reported in workplaces declined from 55.2% to 45.3%. Secondhand smoke exposure at home reduced from 58.3% to 46.7%. People's awareness that secondhand smoke could cause heart disease in adults, lung illness in children, and lung cancer in adults increased from 24.6% to 36.0%. Additionally, support for smoke-free policies is high among the Chinese population. Even for restaurants, where support for smoke-free policies was lowest, 75.1% of nonsmokers and 55.3% of smokers supported smoke-free policies. CONCLUSION: Secondhand smoke exposure declined from 2010 to 2015 in China but remains a serious problem. Public awareness about the hazards of secondhand smoke is increasing and Chinese people support smoke-free laws.

Tobacco Industry Fingerprints on Delaying Implementation of Pictorial Health Warnings in the Western Pacific.

OBJECTIVE: This case series describes tobacco industry tactics and strategies used to interfere, derail, delay, and weaken the development of effective health warning regulations in Malaysia, Cambodia, the Philippines, and Hong Kong. METHODS: A historical review of official reports, news articles, and gray literature was undertaken to identify tobacco industry tactics and strategies to hamper government efforts in implementing stronger pictorial health warning regulations in four Asian jurisdictions (Cambodia, Hong Kong, Malaysia, and the Philippines). RESULTS: Nineteen countries/jurisdictions in the WHO Western Pacific region currently require pictorial health warnings on cigarette packs, including some of the world's largest, in line with the WHO Framework Convention on Tobacco Control Article 11 Guidelines. In the four jurisdictions examined, tobacco industry interference consisted of lobbying and misinformation of high-level government officers and policy-makers, distributing industry-friendly legislative drafts, taking government to court, challenging government timelines for law implementation, and mobilizing third parties. Strong political leadership and strategic advocacy enabled governments to successfully overcome this industry interference. CONCLUSION: The tobacco industry uses similar tactics in different jurisdictions to derail, delay, and weaken the implementation of effective health warning policies. Identifying and learning from international experiences can help anticipate and defeat such challenges.

Secondhand Tobacco Smoke Exposure in Indoor Workplaces in Viet Nam and Associated Factors: Findings from Two Rounds of Global Adult Tobacco Surveys (GATS) 2010 and 2015.

OBJECTIVES: This paper explores changes in the level of secondhand smoke (SHS) exposure at indoor workplaces between 2010 and 2015 in Viet Nam and the association between the exposure and various demographic factors, using data from Viet Nam's Global Adult Tobacco Surveys (GATS) 2010 and 2015. METHODS: Data was pooled from the two GATS surveys and analysed using descriptive and Poisson regression analyses. RESULTS: There was a highly statistically significant reduction in the level of SHS exposure at indoor workplaces from 55.9% to 42.6% (p.

The E-cigarette ban in India-A step in the right direction?

Electronic cigarettes (e-cigarettes) are a popular method to help quit tobacco smoking. However, there is a paucity of data in the literature on their safety and efficacy. Recently, the Indian Government has called for a ban on all e-cigarettes and taken steps to restrict access to vaping products from the market. This major decision was an attempt to safeguard the younger population from using e-cigarette and their possible longer-term addiction together with its promotions by domestic industries. In this article, we evaluate the role of e-cigarettes to help stop smoking tobacco cessation and consider the factors that have facilitated the ban on e-cigarettes in India.