Awareness and Attitude Towards Tobacco Products and Tobacco Industry and Perception about Government's Role in Tobacco Control among the Adult Rural Population: A Cross-sectional Study in the Indian State of Bihar.

Background: Attitudes and impressions toward the tobacco industry and tobacco products among the general public are important determinants for curbing the menace of the tobacco epidemic. Accordingly, this study aimed to assess the knowledge and perceptions about the tobacco industry and tobacco products and analyze attitudes towards social denormalization (SD) of tobacco use and tobacco industry denormalization (TID) among the rural population of Bihar, India. Methods: This community-based cross-sectional survey was conducted on 421 adults aged 18 to 65 years who were selected using multistage systematic random sampling in a rural area of Bihar State in India from January to March 2022. Results were presented as proportions and the factors associated with support for TID and SD were identified using the chi-square test and binary logistic regression. Findings: Out of 421 participants, 342 (81.2%) did not consider smokeless tobacco to be very dangerous. Nearly half (192, 45.6%) of the individuals believed that tobacco companies never tell the truth about the ill effects of tobacco use on health. Maximum, 345 (89.5%) also believed that the tobacco industry is responsible for adverse health effects of tobacco use and that the government should sue them. The prevalence of favorable attitudes toward TID and SD was found to be 55.1% [95% CI: 50.3% - 59.8%] and 38.2% [95% CI: 33.7% - 42.9%], respectively. Conclusion: One out of every two and one out of every three individuals showed favorable attitudes toward TID and SD, respectively. There is a need to inform and educate the public on the ill effects of tobacco and the deceptive strategies used by the tobacco industry to help them choose health over tobacco.

Global policy scan of commercial combustible tobacco product retailing regulations by WHO region.

BACKGROUND/AIMS: Regulatory schemes for tobacco retailing help restrict the supply and availability of smoked tobacco products. Tobacco retailer density and the proximity of tobacco outlets to youth spaces, such as schools, are greater in more disadvantaged areas. Exposure to tobacco retailing normalises smoking and increases ease of access, thus increasing smoking uptake and undermining quitting. To inform future policy, we conducted a global scan of combustible tobacco retail regulatory schemes (We use the term schemes to refer to any kind of relevant initiative, policy, regulations or legislation that we found). METHODS: All types of English language records concerning the regulation of commercial tobacco product availability were considered, including peer-reviewed journal articles, key reports and policy documents. The key features of regulatory schemes were documented. In addition, we contacted key informants in different countries and regions for advice on additional sources and undertook targeted searching in regions where we initially found little data. RESULTS/FINDINGS: Although many countries have well-established and comprehensive tobacco control programmes, tobacco retail policy that actively addresses the availability of tobacco is underutilised. Many jurisdictions have implemented a minimum purchase age and restricted point-of-sale advertising and marketing. Other tobacco retailing regulations also included licensing systems with licence fees, caps on licences and restrictions on store location, type and retailer density/proximity. A very small number of jurisdictions have ended tobacco retailing altogether. CONCLUSIONS: At a minimum, policy-makers should implement licensing schemes, licence caps and proximity limits and invest in robust monitoring systems and compliance enforcement. Tobacco products' ubiquity is incompatible with its status as a dangerous addictive substance and does not align with tobacco endgame goals.

Universal smoking machine adaptor for tobacco product testing.

SIGNIFICANCE: Historically, tobacco product emissions testing using smoking machines has largely focused on combustible products, such as cigarettes and cigars. However, the popularity of newer products, such as electronic cigarettes (e-cigarettes), has complicated emissions testing because the products' mouth-end geometries do not readily seal with existing smoking and vaping machines. The demand for emissions data on popularly used products has led to inefficient and non-standardised solutions, such as laboratories making their geometry-specific custom adaptors and/or employing flexible tubing, for each unique mouth-end geometry tested. A user-friendly, validated, universal smoking machine adaptor (USMA) is needed for testing the variety of tobacco products reflecting consumer use, including e-cigarettes, heated tobacco products, cigarettes, plastic-tipped cigarillos and cigars. METHODS: A prototype USMA that is compatible with existing smoking/vaping machines was designed and fabricated. The quality of the seal between the USMA and different tobacco products, including e-cigarettes, cigars and cigarillos, was evaluated by examining the leak rate. RESULTS: Unlike commercial, product-specific adaptors, the USMA seals well with a wide range of tobacco product mouth-end geometries and masses. This includes e-cigarettes with non-cylindrical mouth ends and cigarillos with cuboid-like plastic tips. USMA leak rates were lower than or equivalent to commercial, product-specific adaptors. CONCLUSION: This report provides initial evidence that the USMA seals reliably with a variety of tobacco product mouth-end geometries and can be used with existing linear smoking/vaping machines to potentially improve the precision, repeatability and reproducibility of machine smoke yield data. Accurate and reproducible emissions testing is critical for regulating tobacco products.

Bitter taste of the tobacco industry interference in Brazil.

OBJECTIVE: Although Brazil became the first country worldwide to ban the sale of all tobacco products with any additive that could alter their flavours and tastes in 2012, its implementation was effectively halted by tobacco industry lawsuits, including a constitutional challenge filed in the Federal Supreme Court in 2013. This study aimed at examining, for the first time in the country, the evolution over time of the new registrations of tobacco products with additives that would have been banned if not for the tobacco industry's interference ('counterfactual scenario'). METHODS: We used the newly available public database on the registration of tobacco products developed by the Health Regulatory Agency (from 2008 onwards). All types of tobacco products intended for the domestic market that contained 'banned additives in a counterfactual scenario' and were registered between January 1 and December 31 of each year were selected. RESULTS: Between 2012 and 2023, a total of 1112 new registrations of tobacco products with 'banned additives' were recorded. The spread of hookah tobacco registrations started in 2014, and by 2023, the cumulative incidence of registrations containing 'banned additives' was 641. Both manufactured cigarettes and hookah products reached their peaks in new registrations in 2020. CONCLUSIONS: After 12 years since the resolution intended to ban all additives that change the aroma and taste of tobacco products in Brazil, primarily to prevent smoking initiation, the tobacco industry's interference continues to successfully block its implementation. Countries facing similar challenges in tobacco control could consider generating comparable national data that might help expose the adverse impacts of tobacco industry interference on public health.

Tobacco and e-cigarette promotion on social media: the case of German rap music.

German rap artists advertise hookah tobacco and electronic cigarettes (e-cigarettes) on social media. Advertising tobacco products on the internet is banned under European Parliament and the German Tobacco Products Act. Despite this, 26 out of 60 famous German rap artists have their own e-cigarette or hookah tobacco editions, which are promoted on social media platforms such as Instagram, Tiktok or Youtube. The products convey the image of the artists and appeal particularly to adolescents. In the interest of preventive health protection and the well-being of children, influencers should abide by the existing laws, social media platform operators should enforce existing laws more effectively and legislators should work towards a comprehensive advertising ban for tobacco and related products and consistently prevent marketing of tobacco and e-cigarettes to youth.

Waterpipe Tobacco Brands and Flavors Sold Online in the USA.

INTRODUCTION: Flavor additives are commonly used in combustible tobacco products to mask harshness and increase appeal. However, research on the availability of flavored waterpipe tobacco (WT) is lacking, yet is important to support implementation of policies. METHODS: We completed a comprehensive online search in 2020 to identify WT brands and flavors sold online in the USA. We conducted a descriptive content analysis categorizing flavors as explicit (i.e., clear taste/flavor) or concept (i.e., no clear taste/flavor); and coded for 23 flavor descriptors (e.g., fruit, mint/menthol, tobacco). Flavor names were double-coded and discrepancies were resolved by a third coder. RESULTS: We identified 66 WT brands with 118 product lines (i.e., sub-brands). We found 2953 flavors, including 1871 unique flavors. Brands averaged 45 flavors (range: 1-183). Almost three quarters (73.5%, n = 2171) used explicit flavor names and 26.5% (n = 782) used concept flavor names. Concept flavors varied widely, and included names such as 1001 Nights and California Dream. The most common flavor descriptors were fruit (54.1%) and mint/menthol (12.5%). Tobacco was rarely (0.2%) used as a flavor descriptor. Flavor descriptors also included location (10.7%), color (11.1%), candy (6.3%), cool/ice (5.3%), and alcohol (5.5%). CONCLUSIONS: WT is available in 1871 unique flavors, likely contributing to product appeal and use. Like other tobacco products, fruit and mint/menthol are common flavors. Given the significant health consequences associated with WT smoking and the role of flavors in product use, regulatory action specifically targeting WT flavors is urgently needed.

Reframing social media discourse following the FDA's menthol ban announcement as industry agenda setting rather than public sentiment.

BACKGROUND: The tobacco industry has spent millions of dollars promoting racialised narratives against the US Food and Drug Administration's recently announced ban on menthol as a characterising cigarette flavour. This research investigates racialised narratives in online discourse following the ban's announcement. METHODS: Tweets and users responding to the April 2022 menthol ban announcement were content analysed to examine the influence of tobacco industry affiliates and potentially organic African-American/Black (AA/B) users. Next we investigated the extent to which the menthol ban was discussed on AA/B subreddits and used Latent Dirichlet Allocation topic modelling to provide an overview of the menthol ban discussion on Reddit. RESULTS: Only 28 (13.9%) tweets by 22 users claimed that the menthol ban would lead to police violence and/or racial discrimination. Of users who tweeted about over-policing, eight (36.4%) had financial connections to the tobacco industry. There were only three tweets receiving a combined seven retweets from potentially organic AA/B users. On Reddit, only two posts with one comment discussed the menthol ban on subreddits dedicated to AA/B issues and culture. Topic modelling showed that the most common topic related to the menthol ban involved the social and political implications of the ban followed by illicit markets and protecting youth. CONCLUSION: Tweets claiming a menthol ban will lead to police violence are indicative of industry agenda-setting. The menthol ban was not a prominent topic of discussion in AA/B subreddits although users discussing news and politics expressed concern for how AA/B people would respond to a ban politically.

The Perfect Storm: Applying the Multiple Streams Framework to Understand the Adoption of a WHO Framework Convention on Tobacco Control-Based Policy in Mexico.

BACKGROUND: The aim of this study was to document how Mexico adopted a WHO Framework Convention on Tobacco Control (FCTC)-based national tobacco control law. METHODS: We analyzed publicly available documents and interviewed 14 key stakeholders. We applied the Multiple Streams Framework (MSF) to analyze these findings. RESULTS: Previous attempts to approve comprehensive FCTC-based initiatives failed due to a lack of political will, the tobacco industry's close connections to policymakers, and a lack of health advocacy coordination. Applying the MSF reveals increased attention towards collecting and sharing data to frame the severity of the problem (problem stream). The expansion of a coordinated health advocacy coalition and activities led to increased support for desired FCTC policy solutions (policy stream). The election of President López Obrador and legislative changes led to a deep renewed focus on tobacco control (politics stream). These three streams converged to create a policy window to secure a strong FCTC-based initiative on the political agenda that was ultimately passed. CONCLUSIONS: The Mexican experience illustrates the importance of continued health advocacy and political will in adopting FCTC-based policies. Other countries should follow Mexico's lead by collecting and sharing data through coordinating efforts in order to be prepared to seize political opportunity windows when strong political will is present.

Rotation of tobacco health warnings and messages: challenges and recommendations for implementation.

Health warnings and messages-or health warning labels (HWLs)-are integral to tobacco control efforts, but their sustained impact necessitates regular rotation. This paper explores challenges in HWL rotation implementation across six diverse countries: Chile, Guyana, Indonesia, Jamaica, Mexico, and Vietnam. 19 in-depth interviews were conducted with government officials and representatives from civil society organisations and academia. Interviews explored the effectiveness of HWL regulations, the processes involved in their execution, and any challenges encountered along the way. Interviews were analysed thematically, using a combination of deductive and inductive approaches. Interviews revealed critical challenges that fall into two categories: specific and overarching. Government priorities and transitions, political will, time and bureaucracy, legal loopholes, lack of images, evaluation, and economic and human resources constitute HWL-specific challenges. Broad tobacco control challenges included tobacco industry interference and enforcement difficulties. To address HWL rotation challenges, international bodies such as WHO could establish extensive image banks, pre-evaluated for effectiveness and cultural relevance. In addition, countries must institutionalise the rotation process by establishing mechanisms that avoid having to pass complex legal instruments with each new round of warnings, delegating responsibilities to stable government institutions, addressing legal loopholesand planning for multiple rounds within a single legal instrument. Further, partnerships at national and international levels, along with systematic evaluations, are crucial for successful HWL implementation. These recommendations form a comprehensive framework for global collaboration, aiming to strengthen tobacco prevention through impactful HWLs on a sustainable basis.

Exploring associations of population characteristics and tobacco and vape retailer density and proximity in Australia: a scoping review.

OBJECTIVE: This scoping review synthesises Australian evidence on associations between tobacco and vape retailer density/proximity and various population measures and smoking behaviour to identify research gaps and inform future policy and strategies. DATA SOURCES: Following Joanna Briggs Institute methodology, relevant studies published in English since 2003 were identified via searches of eight databases in March and August 2023. STUDY SELECTION: Two reviewers independently completed screening procedures. Eligible studies were from Australia and described associations between tobacco or vape retailer density/proximity and adult or youth smoking/vaping prevalence or behaviours, neighbourhood socioeconomic status, geographic location, school locations and/or Indigenous status. DATA EXTRACTION: Results are reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews checklist. DATA SYNTHESIS: Of 794 publications screened, 12 studies from 6 Australian states were included. Six studies from five states reported statistically significant associations between neighbourhood-level socioeconomic disadvantage and tobacco retailer density, yet only two studies from two states found a significant relationship between retailer density and adult smoking prevalence. Increasing retailer density was consistently significantly associated with increasing geographical remoteness in three states. No studies explored associations with tobacco retailer proximity or vape retailer density/proximity. CONCLUSIONS: Despite a moderate number of studies overall, state-level evidence is limited, and unknown for Australian territories. Evidence from five Australian states reflects the international evidence that increasing retailer density is significantly associated with increasing socioeconomic disadvantage and remoteness, supporting the need for tobacco supply-based policies. Further research is required to understand the impact of retailer density and adult and youth smoking prevalence in Australia.

IQOS news media coverage in Israel: a comparison across three subpopulations.

BACKGROUND: Philip Morris International's (PMI) IQOS, a leading heated tobacco product globally, entered the Israeli market in 2016. IQOS and/or electronic cigarette use is higher in Israel's Arab population (2.8% vs 1.2% of Jews). However, previous research indicated possible targeting of the Ultra-orthodox Jewish population with more IQOS paid ads. This paper examined how IQOS is framed in news media articles directed at three subpopulations in Israel: Arab, Ultra-orthodox Jews and general public. METHODS: Media articles (January-October 2020) were obtained from Ifat media and were coded using abductive coding. Characteristics of articles (photo and article content) targeting each subpopulation were compared using χ2, Fisher's exact test, one-way analysis of variance and median test, as appropriate. RESULTS: Of the 63 unique articles identified, 16 targeted Arab, 24 Ultra-orthodox Jews and 23 general public. Arab and Ultra-orthodox Jewish media significantly differed from the general public's media in their positive framing of PMI (100% Arab and 75% Ultra-orthodox Jews vs 52% general public, p=0.004), and IQOS (100% Arab and 88% Ultra-orthodox Jews vs 61% general public, p=0.006). Arab media differed from others by highlighting IQOS' retail locations (81% vs 17% Ultra-orthodox Jews and 13% general public), social benefits (88% vs 8% Ultra-orthodox Jews and 17% general public) and reflecting content from PMI's press release (100% vs 46% Ultra-orthodox Jews and 35% general public; ps <0.001). CONCLUSIONS: IQOS was framed more positively in media targeting minority populations (Arab and Ultra-orthodox Jews), compared with general public. Arabic media in particular emphasised IQOS' retail accessibility and social benefits. These findings highlight the need for media surveillance and regulation, especially of minority-oriented media.

Tobacco endgame goals and measures in Europe: current status and future directions.

The European Union (EU) aims for a tobacco use prevalence of less than 5% by 2040 with its Tobacco-Free Generation goal, aligning with the tobacco endgame approach. In the Joint Action on Tobacco Control 2 (JATC-2) -project, we examined adopted and planned endgame goals and measures as well as preparedness to counter tobacco industry interference in the process. We surveyed key informants in 24 out of 50 countries in the WHO European Region (19 of the 27 EU Member States, MS). Altogether, eight countries (7 EU MS) had official governmental endgame goals, and an additional six EU MS had similar proposals from government, civil society or research entities. Movement towards tobacco endgame was most evident in retail-oriented and consumer-oriented policies. These include restricting the sales of tobacco and related products and raising the age limit above 18 years. Product standards were used especially to regulate flavours but no measures to substantially reduce addictiveness were reported. Market-oriented measures that tap into industry profits were predominantly missing, and countries often lacked concrete tools to prevent industry interference. Respondents' concerns around tobacco endgame were related to high smoking prevalence in some population groups, non-combustible and new nicotine products, cross-border marketing, political will, challenges with the existing regulations and industry interference. Results indicate both momentum and challenges in adopting and disseminating measures that facilitate achieving tobacco endgame goals. The EU goal can be used to advocate for national endgame goals and measures, and for the strengthened implementation of the WHO Framework Convention on Tobacco Control.

Cigarette unit sales volume for brands using 'natural', 'organic' and 'tobacco and water' pack terms in the USA, 2018-2022.

BACKGROUND: Terms such as 'natural', 'organic' and 'tobacco and water' on cigarette packs may communicate misleading reduced harm messages to consumers. This study describes sales volume and price for brands that used these misleading descriptors in the USA by year, brand and state. METHODS: The data come from Information Resources Incorporated sales data collected in 44 US states from January 2018 to January 2023. Trained coders used Universal Product Codes, purchased packs and internet searches to identify cigarettes sold with 'natural', 'organic' and 'tobacco and water' on packs. We report cigarette pack unit sales counts (sales volume) and average price per pack by year, as well as per cent year-over-year change in sales volume and price and annual market share by descriptor terms. RESULTS: Overall, pack sales volume decreased year-over-year from 2019 to 2022. Sales volume for packs with 'natural', 'tobacco and water' and 'organic' decreased less than overall; in some cases, they increased. In 2022, packs with 'natural' accounted for the greatest share of cigarette unit sales (5.42% or 33 605 036 packs), followed by 'tobacco and water' (2.25% or 12 959 905 packs) and 'organic' (0.53% or 4 614 592 packs). Natural American Spirit (NAS) and Winston accounted for most sales with 'natural' and 'tobacco and water'; NAS accounted for nearly all sales with 'organic'. Packs with 'natural', 'tobacco and water' or 'organic' made up the largest portion of sales in western (Oregon, Idaho, California, Colorado and Washington) and northeastern (Vermont, Massachusetts and New Hampshire) US states. CONCLUSION: Brands using 'natural', 'tobacco and water' and 'organic' on packs increased their market share between 2019 and 2022; in some states, market share was over 10% in 2022. Our findings emphasise the importance of regulating these terms and continually monitoring their population impact.

Birthdate-based commercial tobacco sales restrictions: will 'tobacco-free generation' policies advance or delay the endgame?

Endgame thinking means transitioning from merely trying to 'control' the tobacco epidemic to developing plans and measures to bring it to an end within a specific time, by changing the underlying dynamics that have created and perpetuated it for more than a century. Among the innovative policies characterised as 'endgame' policies are so-called 'tobacco-free generation' or 'smoke-free generation' policies, which prohibit sales of some or all tobacco products to individuals born on or after a particular date. Such birthdate-based sales restrictions (BSR) have intuitive appeal, largely because they do not appreciably disrupt the status quo of retail sales, which continue unchanged for all those born before the designated cut-off date. They also hold the potential for further denormalising tobacco use and sales by anticipating the long-term end of tobacco sales. In this Special Communication, we analyse BSR policies through an endgame lens and propose questions that should be discussed in jurisdictions considering them. We suggest that this policy has potential underexamined pitfalls, particularly related to equity, and that if enacted, it should include policy guardrails and be part of a package of endgame measures.

Tobacco industry strategies to influence the regulation of new and emerging tobacco and nicotine products in Latin America and the Caribbean.

Objective: To document tobacco industry strategies to influence regulation of new and emerging tobacco and nicotine products (NETNPs) in Latin America and the Caribbean. Methods: We analyzed industry websites, advocacy reports, news media and government documents related to NETNPs, focusing on electronic cigarettes and heated tobacco products. We also conducted a survey of leading health advocates. We applied the policy dystopia model to analyze industry action and argument-based strategies on NETNP regulations. Results: Industry actors engaged in four instrumental strategies to influence NETNP regulation - coalition management, information management, direct involvement in and access to the policy process, and litigation. Their actions included: lobbying key policy-makers, academics and vaping associations; providing grants to media groups to disseminate favorable NETNP information; participating in public consultations; presenting at public hearings; inserting industry-inspired language into draft NETNP legislation; and filing lawsuits to challenge NETNP bans. The industry disseminated its so-called harm reduction argument through large/influential countries (e.g., Argentina, Brazil, and Mexico). Industry discursive strategies claimed NETNPs were less harmful, provided safer alternatives, and should be regulated as so-called harm reduction products or have fewer restrictions on their sale and use than those currently in place. Conclusion: Our analysis provides a better understanding of industry strategies to undermine tobacco and nicotine control. To help counter industry efforts, health advocates should proactively strengthen government capacities and alert policy-makers to industry attempts to create new regulatory categories (so-called reduced-risk products), provide misleading information of government authorizations of NETNPs, and co-opt so-called harm-reduction messages that serve the industry's agenda.

Low compliance and proliferation of IQOS purchase cues at points-of-sale: a comparative study before and after Israel's display ban.

INTRODUCTION: It is unclear how tobacco companies respond to increasing restrictions on points-of-sale (POS) (eg, advertisement ban, display ban), especially regarding newer products, such as IQOS, a heated tobacco product. This study compared POS marketing strategies for IQOS (and HEETS tobacco sticks) before and after Israel implemented a display ban and plain packaging. METHODS: Audits of stores selling IQOS (n=87) in four Israeli cities were conducted, 16-20 months post display ban and plain packaging introduction, including previously audited stores (n=60) (prior to the implementation of these measures). Descriptive analyses and matched pre-post comparisons were conducted to assess regulatory compliance and marketing strategies over time. RESULTS: Almost all stores (90.8%) were non-compliant with the display ban; but most were compliant with plain packaging (81.6%) and advertisement ban (83.5%) regulations. Following the display ban, there was a significant increase in the number of IQOS/HEETS internal advertisements (21.7% vs 41.7%, p=0.023). These were mostly compliant with the advertisement ban (ie, did not mention the brand name explicitly), and appeared in the form of generic signs or flags and/or special displays. The percentage of stores featuring the IQOS device increased (1.7% to 20.0%, p=0.003), as did the percentage carrying at least four HEETS flavours (36.7% to 63.3%, p=0.006). CONCLUSION: This sample of Israeli stores selling IQOS showed low compliance with the display ban. The increase in signs/special displays, mostly compliant with the advertisement ban, could serve as purchase cues circumventing the intent of the legislation. Regulatory efforts should consider more specific legislative language and comprehensive enforcement plans.

Impact of product-based e-cigarette marketing on the attitudes and behavioural intentions of young Australians: an experimental study.

BACKGROUND: The tobacco industry has a history of using language to downplay the harms associated with cigarettes and mislead consumers and policymakers. Emerging evidence suggests similar tactics are being used in the context of e-cigarettes; however, exploration of the impact of product name on attitudes towards e-cigarettes and susceptibility to use is lacking. This experimental study explored whether attitudes towards e-cigarettes and susceptibility to use are influenced by the names used by the industry to describe and market these products. METHOD: An accredited web panel provider recruited a sample of 383 Australians aged 12-29 years who had never smoked to participate in an online survey that featured an embedded experiment. Participants were randomly allocated to one of three conditions, each of which used a different name to describe e-cigarettes (condition 1: 'e-cigarettes', condition 2: 'vapes'; condition 3: either 'IGETS', 'Puff Bars', 'HQD Cuvies' or 'Gunnpods'). The survey assessed respondents' overall opinion of the product described; attitudes towards the product; liking of the product; and curiosity, willingness and intentions to use the product. RESULTS: Those in the 'brand name' condition scored higher than those in the 'e-cigarettes' condition on all dependent variables. Those in the 'vapes' condition scored higher than those in the 'e-cigarettes' condition on product attitude. CONCLUSION: Findings indicate that the use of brand names and terms such as 'vapes' instead of 'e-cigarettes' results in more favourable attitudes towards e-cigarettes and susceptibility to use among young Australians. Results highlight the problematic influence of promotional language use favoured by industry.