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.

The effectiveness of plain packaging in discouraging tobacco consumption in Australia.

The removal of all branding and promotions from tobacco products, known as 'plain packaging', is intended to decrease tobacco consumption. Here we examine the effectiveness of Australia's plain packaging law, which coincided with a change in graphic and text health warnings, by using nationally indicative data 5 years post implementation. We measured the effect of the law on smoking prevalence, tobacco expenditure, expenditure intensity and quantity of tobacco consumed, using New Zealand as a control country in a difference-in-differences research design. We uncover a substitution effect that is robust to different specifications and control countries. In response to the policy, smokers switched from more expensive to cheaper cigarettes and reduced their overall tobacco expenditure and expenditure intensity. However, as smoking became less costly, smokers consumed more cigarettes. To discourage such substitution and to help the policy achieve its intended outcomes, policymakers should consider implementing auxiliary measures, such as taxes or price floors.

Compliance of Oral Snuff (Naswar) Packaging and Sales Practices with National Tobacco Control Laws and the Relevant Articles of Framework Convention on Tobacco Control in Khyber Pakhtunkhwa Pakistan.

INTRODUCTION: Smokeless tobacco (SLT) is a significant contributor to tobacco-related harm in Pakistan but its control has lags behind that of combustible tobacco. We assessed the compliance of Naswar's (a widely used SLT product in the Southeast Asia) packaging and sales practices with the national legislations and relevant articles of the WHO framework convention on tobacco control (FCTC). AIMS AND METHODS: A cross-sectional observational audit was conducted in three districts of Pakistan. We recruited 286 general point of sale (GPOS) and exclusive Naswar sellers (ENS) through a multistage cluster sampling strategy. Data were gathered on packaging and labeling practices of Naswar and advertisement and promotion practices inside and outside the shops. Statistical tests for association between the dependent variable-advertisement practices, and independent variables-area and vendor types were conducted. RESULTS: We analyzed 133 and 49 unique Naswar products sold in 229 GPOS and by 57 ENS, respectively. None of the local products had any written or pictorial health warning. More than half of retailers used one or two methods of advertising Naswar inside the shops while only 9% advertised outside the shops. ENS were more likely to be noncompliant with tobacco advertisement and promotion compared with GPOS. CONCLUSIONS: The study presents first insights on the compliance of Naswar packaging and sale practices with local regulations and WHO FCTC provisions in Pakistan. Almost all products were on display in the shops and none of the local products had any health warning or contents disclosure on the packages. IMPLICATIONS: Naswar is a form of SLT used extensively in Pakistan, Central Asia, and Pashtun populations across the globe. This study provides an important insight into the Naswar retail environment in a geographical setting where the use of Naswar is endemic. The study brings to fore previously unreported issues like an urban-rural disparity, and differences between exclusive and nonENS, with regards to Naswar advertisement and promotion. These findings have potential implication on the implementation of tobacco control retail policies. The lack of health warnings and free display of Naswar brands call for alignment of tobacco control efforts with the FCTC.

Reactions to Standardized Cigarette Packs With Varying Structural Designs, and the Association With Smoking Susceptibility: A Postimplementation Cross-Sectional Survey With Never-Smoking Adolescents in Scotland.

INTRODUCTION: From May 20, 2017, cigarettes in the United Kingdom must be sold in standardized (plain) packaging. We explore postimplementation reactions to standardized cigarette packaging among never-smokers in Scotland, whether reactions vary in relation to permitted variations in pack structure, and whether reactions are associated with susceptibility. AIMS AND METHODS: A cross-sectional survey with 12-17-year-old never-smokers (n = 507) in Scotland, conducted November 2017-November 2018. Participants were shown one "regular" standardized cigarette pack (flip-top lid and straight-edged pack, similar to designs in Australia) and three standardized packs with varied pack structures (beveled-edges, slim pack, and shoulder box), which are permitted postimplementation in the United Kingdom. Participants rated each pack on eight five-point reaction measures (eg, attractiveness). Participants also indicated which pack, if any, they would choose. Smoking susceptibility was the outcome. RESULTS: The mean reaction scores for all four packs were mostly negative, however the shoulder box was consistently rated less negatively than the regular, slim, or beveled-edge packs. Most participants (87%) said they would not select any of the four packs, although susceptible participants were more likely to select one than nonsusceptible participants (25% vs. 7%; χ 2 = 29.70; p < .001). For all four packs, not finding them off-putting was associated with susceptibility (Adjusted Odds Ratio range: 2.73-3.69), albeit only a minority of adolescents did not find each pack off-putting. CONCLUSIONS: Adolescents have negative reactions to the standardized cigarette packs implemented in the United Kingdom, albeit permitted variations in structure can reduce the extent of negativity. Most reactions to standardized packaging had no association with susceptibility. IMPLICATIONS: We provide the first empirical evidence that adolescents find the standardized cigarette packs implemented in the United Kingdom unappealing and that most pack reactions have no association with susceptibility among never-smokers, with the exception of the minority who did not think that they would put them off smoking. This suggests that the legislation is achieving one of its primary aims, to reduce the appeal of packaging. That permitted variations in pack structure (eg, shoulder boxes) somewhat reduce negative reactions suggests that the United Kingdom, and other countries introducing similar legislation, should ensure that all aspects of pack design are fully standardized.

Effect of UK plain tobacco packaging and minimum pack size legislation on tobacco and nicotine product switching behaviour.

BACKGROUND AND AIMS: The introduction of plain tobacco packaging and minimum pack size legislation in the United Kingdom between May 2016 and May 2017 was accompanied by substantial changes in tobacco product diversity and pricing. This study investigates the extent to which these changes were associated with consumer switching between tobacco product types and price segments, and from tobacco to non-tobacco nicotine products. DESIGN: Longitudinal study (changing trends in product and price choices) and survey (reasons for consumer choices). SETTING: Great Britain PARTICIPANTS: We used 11 695 British households from Kantar Worldpanel who purchased tobacco and non-tobacco nicotine products from March 2011 to December 2017. MEASUREMENTS: Product choice was defined using household's monthly purchases of tobacco (cigarettes, roll-your-own (RYO) tobacco, cigar/cigarillo and pipe tobacco) and non-tobacco nicotine products (e-cigarettes and nicotine replacement therapy), while price was defined using price paid by pack size and by price quartiles. Our switching analysis considered three switching alternatives: switching to a different tobacco product or to a combination of tobacco products, switching to any non-nicotine tobacco product, and switching out of our dataset. We explored changes in price quartile purchasing behaviour using binary variables for whether a household purchased or not from each price quartile monthly. Finally, self-declared consumer's choice was assessed through survey responses. FINDINGS: The introduction of plain packaging and minimum pack sizes coincided with major switching to purchasing of pack sizes of 20 cigarettes or 30 g or larger RYO tobacco (>99% of purchases in December 2017) and a migration towards lower-price cigarettes, as for cigarettes, around 80% of purchases were in the lowest price quartiles at the end of the study period compared to about 50% at the start of the study period. During the first 6 months of implementation there was also a marked increase in the likelihood that cigarette smokers would switch to non-tobacco nicotine (OR 1.74, 95% CI: 1.18 to 2.57), predominantly e-cigarettes, compared with the period before May 2016. Survey results suggest that price was the main driver of changes in purchasing behaviour. CONCLUSIONS: Implementation of plain packaging and minimum pack size legislation in the UK appears to have been associated with tobacco users switching to lower price tobacco products and to e-cigarettes.

Identification of Policy Priorities to Address the Burden of Smokeless Tobacco in Pakistan: A Multimethod Analysis.

INTRODUCTION: We assessed the magnitude of smokeless tobacco (ST) use in Pakistan and identified policy gaps to help ascertain short-, medium-, and long-term priorities. We then elicited stakeholders' views as to which of these identified priorities are most important. METHODS: In a multimethod study, we: analyzed Global Tobacco Surveillance System data sets to estimate ST consumption and disease burden; conducted a documentary review to identify gaps in policies to control ST in comparison with smoking; elicited stakeholders' views in an interactive workshop to identify a set of policy options available to address ST burden in Pakistan; and ranked policy priorities using a postevent survey. RESULTS: Among all tobacco users in Pakistan (n = 24 million), one-third of men and two-thirds of women consume ST. In 2017, its use led to an estimated 18 711 deaths due to cancer and ischemic heart disease. Compared to smoking, policies to control ST lag behind significantly. Priority areas for ST policies included: banning ST sale to and by minors, advocacy campaigns, introduction of licensing, levying taxes on ST, and standardizing ST packaging. A clear commitment to close cooperation between state actors and stakeholder groups is needed to create a climate of support and information for effective policy making. CONCLUSIONS: Smokeless tobacco control in Pakistan should focus on four key policy instruments: legislation, education, fiscal policies, and quit support. More research into the effectiveness of such policies is also needed. IMPLICATIONS: A number of opportunities to improve ST regulation in Pakistan were identified. Among these, immediate priorities include banning ST sale to and by minors, mobilizing advocacy campaign, introduction of licensing through the 1958 Tobacco Vendors Act, levying taxes on ST, and standardizing ST packaging.

Categorising characteristics of counterfeit Marlboro cigarettes: a systematic review of tobacco industry documents.

BACKGROUND: There is scant research on methods used to identify counterfeit Marlboro cigarettes. METHODS: Systematic analysis of internal tobacco industry documents characteristics of counterfeit Marlboro cigarettes. RESULTS: In the industry documents we identified as relevant, there were 42 characteristics of counterfeit Marlboro cigarettes. Overall, physical characteristics (88.1%) were the most commonly identified features across all locations, with the pack blank, cardboard shell of the cigarette pack, as the dominant site (30.9%). Some of the physical characteristics included offset lithography printing, incorrect font and colour. Overall, light microscopy was identified as the main method of forensic analysis for detecting counterfeits. CONCLUSION: Independent researchers employing litter pack and pack swap surveys are encouraged to use the characteristics identified in the study to gauge the prevalence of counterfeit Marlboro cigarettes and compare against industry estimates.

Flavor Capsule Variants' Performance in a "Dark Market": Implications for Standardized Packaging.

BACKGROUND: By increasing excise taxes, eliminating tobacco marketing, and requiring standardized (plain) packaging of tobacco products, governments internationally have reduced smoking's allure. Yet product innovations, such as flavor capsule variants (FCVs), remain unregulated and may appeal to non-smokers. We examined the growth of FCVs in a country with a progressive policy environment. METHODS: Each year, New Zealand tobacco companies must provide details of the number of cigarette sticks released for each brand and variant to the Ministry of Health. We used this information to analyze FCVs' performance for British American Tobacco (BAT) and Philip Morris International (PMI), which account for a large proportion of New Zealand tobacco sales. We report the quantity released of each variant and share of parent brand portfolio, and examine growth patterns within the premium, everyday, and value market subsections. RESULTS: BAT introduced FCVs in 2012 and by 2014 offered FCVs in all market subsections; PMI introduced a Marlboro FCV in 2014. FCVs grew rapidly relative to unflavored variants and, by 2017, represented nearly 10% of BAT's product portfolio and more than 3% of PMI's product portfolio. By 2017, FCVs accounted for more than a third of the Dunhill sticks released, 14% of Holiday, and 17% of Pall Mall. CONCLUSIONS: FCVs' rapid growth may have reduced declines in the numbers of sticks released. Policy makers should disallow FCV innovations, which offer no health benefits to smokers and may instead attract non-smokers to smoking. Where timely, these regulations could be incorporated into standardized packaging policies. IMPLICATIONS: FCVs have grown quickly in countries with comprehensive tobacco marketing restrictions, which suggests tobacco companies are now focusing on novel product designs to attract new smokers. Standardized packaging regulations could address both external packaging and stick design innovations, such as FCVs; alternatively, specific regulations prohibiting FCVs may be required.

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

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

Changes in roll-your-own tobacco and cigarette sales volume and prices before, during and after plain packaging legislation in the UK.

BACKGROUND: Plain packaging and minimum pack size legislation for tobacco products was introduced in the UK in May 2016, with a 1-year sell-off period until May 2017, during which both fully branded and plain packs of various sizes were legally available. This study investigates trends in prices of roll-your-own tobacco (RYO) before, during and after implementation of this legislation, and compares trends with those observed in the cigarette market. METHODS: We used Nielsen Scantrack data for the period from March 2013 to June 2018 to describe trends in UK inflation-adjusted prices and volumes of both RYO and cigarettes, and linear regression to estimate changes in prices associated with the introduction of plain packaging and the minimum pack sizes of 30 g RYO and 20 cigarettes. RESULTS: In contrast to a downward trend in cigarette sales volumes, RYO volumes rose throughout the study period. By the time plain packs accounted for 75% or more of sales, the average price of products sold in equivalent pack sizes had increased, relative to average prices in the year before implementation and with adjustment for tax changes, from 34.9 to 38.8 pence per gram for RYO (mean difference 4.26, 95% CI 3.99 to 4.53 pence, 12% increase), and from 38.6 to 41.13 pence for cigarettes (mean difference 2.53, 95% CI 2.24 to 2.83 pence, 7% increase) per cigarette. CONCLUSIONS: New legislation resulted in higher prices for RYO and manufactured cigarettes. However, sales volumes of RYO continued to increase throughout the study period, perhaps because RYO remains a less expensive means of smoking tobacco.

Should cigarette pack sizes be capped?

BACKGROUND: Very few countries regulate maximum cigarette pack size. Larger, non-standard sizes are increasingly being introduced by the tobacco industry. Larger portion sizes increase food consumption; larger cigarette packs may similarly increase tobacco consumption. Here we consider the evidence for legislation to cap cigarette pack size to reduce tobacco-related harm. AIMS AND ANALYSIS: We first describe the regulations regarding minimum and maximum pack sizes in the 12 countries that have adopted plain packaging legislation and describe the range of sizes available. We then discuss evidence for two key assumptions that would support capping pack size. First, regarding the causal nature of the relationship between pack size and tobacco consumption, observational evidence suggests that people smoke fewer cigarettes when using smaller packs. Secondly, regarding the causal nature of the relationship between reducing consumption and successful cessation, reductions in number of cigarettes smoked per day are associated with increased cessation attempts and subsequent abstinence. However, more experimental evidence is needed to infer the causal nature of these associations among general populations of smokers. CONCLUSION: Cigarette pack size is positively associated with consumption and consumption is negatively associated with cessation. Based on limited evidence of the causal nature of these associations, we hypothesize that government regulations to cap cigarette pack sizes would positively contribute to reducing smoking prevalence.

A health professional's guide to the intersection of public health with intellectual property rights in trade and investment: the case of tobacco plain packaging.

Intellectual property law is a crucial determinant of global public health, capable of both endangering and facilitating advances in the health of populations. This Viewpoint explains the most important aspects of the interaction between intellectual property law and public health. We use the plain packaging of tobacco products to illustrate how public health policies may be subject to scrutiny under existing trade and investment law structures. Plain packaging of tobacco products is challenging to implement due to legal complexities and uncertainties surrounding the status of mandated plain packaging for consumer products. While the tobacco industry and its proponents once relied on the denial of scientific evidence to delay legislation and influence consumers, its tactics have shifted to the use of trade threats and investment disputes, directly challenging the sovereignty of governments to enact bona fide public health measures to improve the health of their population.

Prospective longitudinal study of tobacco company adaptation to standardised packaging in the UK: identifying circumventions and closing loopholes.

OBJECTIVES: UK standardised packaging legislation was introduced alongside pack size and product descriptor restrictions of the European Union Tobacco Products Directive to end tobacco marketing and misinformation via the pack. This paper aims to assess compliance with the restrictions and identify attempts to continue to market tobacco products and perpetuate misperceptions of harm post legislation. DESIGN, SETTING AND INTERVENTION: A prospective study of the introduction of standardised packaging of tobacco products to the UK. PARTICIPANTS AND OUTCOMES: We analysed commercial sales data to assess whether the legally required changes in pack branding, size and name were implemented. To explore any adaptations to products and packaging we analysed sales data, monthly pack purchases of factory-made (FM) cigarettes and roll-your-own (RYO) tobacco, tobacco advertisements from retail trade magazines and articles on tobacco from commercial literature (retail trade, market analyst and tobacco company publications). RESULTS: One month after full implementation of the UK and European Union policies, 97% FM and 98% RYO was sold in compliant packaging. Nevertheless, tobacco companies made adaptations to tobacco products which enabled continued brand differentiation after the legislation came into force. For example, flavour names previously associated with low tar were systematically changed to colour names arguably facilitating continued misperceptions about the relative harms of products. Tobacco companies used the 1-year sell-through to their advantage by communicating brand name changes and providing financial incentives for retailers to buy large volumes of branded packs. In addition, tobacco companies continued to market their products to retailers and customers by innovating exemptions to the legislation, namely, filters, packaging edges, seals, multipack outers, RYO accessories, cigars and pipe tobacco. CONCLUSIONS: Tobacco companies adapted to packaging restrictions by innovating their tobacco products and marketing activities. These findings should enable policy makers globally to close loopholes and increase the potential efficacy of standardised packaging policies.

Emerging Public Health Law and Policy Issues Concerning State Medical Cannabis Programs.

Thirty-four states, the District of Columbia, and Puerto Rico have legalized medical cannabis. While no two state medical cannabis programs are alike, public health concerns related to advertising, packaging and labeling, pesticide use, scientific research, and the role of medical cannabis in the opioid crisis are emerging across the country. This article examines these issues, the policy approaches states are adopting to protect patients and the public, and an assessment of the underlying federal legal landscape.

Removing the last billboard for the tobacco industry: Tobacco standardized packaging in Ireland.

The World Health Organization's Framework Convention on Tobacco Control (FCTC) implementation guidelines recommend that governments adopt plain packaging (also known as standardized packaging (SP)) along with pictorial health warning labels covering 50% or more of the tobacco package. The 2014 revised European Union Tobacco Product Directive also supports EU member states to introduce SP. Following these developments and recommendations, in 2013 the Department of Health launched a "Tobacco Free Ireland" policy which aimed to reduce the smoking prevalence rate to less than 5% by 2025. Tobacco Free Ireland set out 60 recommendations and measures to reach the 2025 target, including introducing SP. Tobacco companies and trademark and intellectual property organizations opposed the SP proposal claiming it would; 1) not work to reduce smoking levels, 2) increase illicit tobacco trade, 3) create unnecessary problems for retailers, and 4) violate domestic and international laws governing trademarks. However leading health groups in Ireland presented evidence on how SP would communicate the harms of tobacco to smokers and discourage young people from beginning to smoke. These efforts combined with strong political will helped Ireland to become the second country in the world to enact standardized packaging for all tobacco products.

Lower smoking rates and increased perceived harm of cigarettes among French adults one year after comprehensive tobacco control measures.

CONTEXT: France has high smoking rates, and recently intensified tobacco control policies spearheaded by the introduction of plain tobacco packaging (PP), and an increase in graphic health warnings (GHW). We examine smoking and e-cigarettes use rates, as well as smoking-related perceptions before (2016) and one year after (2017) comprehensive tobacco control measures. METHODS: DePICT is a two waves cross-sectional national telephone survey of French adults aged 18-64 years (2016: 4456 - 2017: 4114). Data were weighted to be representative of the French adult population. Adjusted prevalence ratios (PR, 95% CI) estimating changes between the two study waves were calculated using multivariate Log-Binomial regression models. MAIN FINDINGS: In 2017, as compared with 2016, smoking rates (PR = 0.93 (0.88-0.99) and current e-cigarette use (PR = 0.76 (0.61-0.96)) decreased in France. Further, French adults were more likely to report fear of the consequences of smoking (PR = 1.10 (1.06-1.14)) and that smoking is dangerous (PR = 1.08 (1.06-1.11)). Smokers were also more likely to report that health messages on tobacco products are efficient (PR = 1.18 (1.05-1.32)). CONCLUSIONS: Our study provides early and encouraging results on potential effects of the comprehensive tobacco control strategies in France introduced in 2017, including PP and larger GHW. Our findings also suggest that e-cigarettes did not replace traditional smoking.