Hosting the Tobacco Industry Supply Chain and Political Interference.

INTRODUCTION: We found no comprehensive studies on the location of transnational tobacco and leaf company (TTLC) subsidiaries (business entities they control) or the consequences of their presence on health policy. AIMS AND METHODS: Here we assess (1) the global reach of TTLCs by mapping their tobacco growing and manufacturing subsidiaries and (2) the relationship between in-country presence of the tobacco industry and their power and interference. Data on subsidiaries were collated through systematic searching for countries' supply chain activities in documents and web pages. Cross-sectional multiple regression analysis was used to assess the association between the number of agricultural and manufacturing TTLCs and the Tobacco Industry Interference score, and the degree to which these were mediated by tobacco control, good governance, and economic importance of tobacco. RESULTS: TTLC supply chain activity had global reach. As the number of TTLCs with tobacco growing and manufacturing activities rose, interference increased significantly. Interference was associated with poorer tobacco control. The association with more TTLCs undertaking final product manufacturing was related to higher-value tobacco exports but was not related to tobacco making a bigger contribution to the economy. CONCLUSIONS: TTLCs continue to control the global tobacco supply chain through their globe-spanning subsidiaries. The presence of TTLCs in a country is associated with political interference. Countries should consider their participation in the tobacco supply chain alongside the understanding that they are likely to cede political power to TTLCs, potentially undermining the health of their populations. IMPLICATIONS: Tobacco control research has traditionally concentrated on the demand side of tobacco. Our results lend support to calls for more research on the supply of tobacco. Governments should require tobacco companies to provide detailed, up-to-date information in an easily accessible format on in-country supply chain activities. Policymakers should take the likelihood of political interference in health and environmental policy into account when making decisions about foreign direct investment offered by the tobacco industry.

Menthol and flavored tobacco products in LMICs: A growing menace.

INTRODUCTION: High income jurisdictions are banning menthol/flavored cigarettes and other tobacco products because they attract young people and create dependence. This study explores the importance of menthol and other flavored tobacco products for tobacco markets in low- and middle-income countries (LMICs), identifies countries where the menthol/flavor share is particularly high or rapidly growing, and identifies strategies tobacco companies are using to develop menthol/flavor markets. METHODS: Research involved analysis of menthol/flavor market data from 2005 to 2019, a systematic review of academic literature, and a scoping exercise with our advocate contacts in LMICs. RESULTS: The median menthol/capsule market share of the cigarette market grew significantly (p<0.05) between 2005 and 2019, both in lower and upper middle-income countries [lower: 2.5% (IQR: 0.5-4.0) to 6.5% (IQR: 3.6-15.9); and upper: 4.0% (IQR: 0.8-9.8) to 12.3% (IQR: 3.5-24.3)]. Countries with both high market share and high market share growth were Russia, Guatemala, Peru and Nigeria. No market data were available on low-income countries, but the academic literature suggested high prevalence of menthol use in Zambia. Tobacco industry strategies underpinning growth of menthol/flavored tobacco use in LMICs included in-store marketing and display, colorful packs and non-conventional flavor names. CONCLUSIONS: Menthol/flavor tobacco products are a growing problem in LMICs. In addition to menthol/flavor bans, we recommend marketing bans, point of sale display bans and standardized packaging.

The value of studying supply chains for tobacco control.

INTRODUCTION: Tobacco control research and advocacy has yet to capitalize on understanding the tobacco industry supply chain. The objective of this narrative review is to expose the processes, actors and supporting industries involved in tobacco production, laying the groundwork to expand the scope of tobacco control beyond the transnational tobacco companies (TTCs). METHODS: We reviewed 69 academic articles (2013 to 2019) and five tobacco industry journal issues. RESULTS: We identify six major processes in tobacco production: farming, primary processing of the leaf, secondary processing into products such as cigarettes, packaged product, usage by smokers, and decay. Supply chain actors include seed and plant retailers, farmers, leaf processors, wholesalers, brokers and middlemen, manufacturers, retailers, smokers and refuse collectors with considerable variation in intermediate actors by location. Supporting industries supply additives, machinery, packaging, logistics, marketing, and research and development (R&D). CONCLUSIONS: This expanded understanding of the supply chain can enable wider appreciation of the various incentives and risks of being involved in the industry, all of which is important information to feed into tobacco control policies. Researchers and campaigners, seeking to design effective policy preventing the expansion of this industry and the health harms it produces, need to look beyond the TTCs to identify under-exploited leverage points along the entire tobacco supply chain.

The effect of alcohol tax changes on retail prices: how do on-trade alcohol retailers pass through tax changes to consumers?

The effectiveness of alcohol duty increases relies on alcohol retailers passing the tax increase on to consumers. This study uses sales data from a market research company to investigate tax pass-through over 11 years for on-premise retailers in England and whether this varies across the price distribution, for different beverage categories and outlet types. Panel data quantile regression analysis is used to estimate the impact of 12 excise duty changes and 3 sales tax changes between 2007 and 2017 on prices. We use product-level quarterly panel data from for 777 alcoholic products. We undertake the regression at all outlets level separating products are analysed in seven broad beverage categories (Beer, Cider, RTDs, Spirits, Wine, Sparkling Wine, and Fortified Wine). We further test sensitivity by disaggregating outlets into seven outlet types. For all seven broad beverage categories, we find that there exists significant differences in tax pass-through across the price distribution. Retailers appear to "undershift" cheaper beverages (prices rise by less than the tax increase) and subsidise this loss in revenue with an "overshift" in the relatively more expensive products. Future modelling of tax change impacts on population subgroups could incorporate this evidence, and this is important because different socio-economic and drinker groups purchase alcohol at different points on the price distribution and hence are affected differently by tax changes. Governments could also potentially incorporate this evidence into future impact assessments.

Quantile regression of tobacco tax pass-through in the UK 2013-2019. How have manufacturers passed through tax changes for different tobacco products?

BACKGROUND: The effectiveness of tax increases relies heavily on the tobacco industry passing on such increases to smokers (also referred to as 'pass-through'). Previous research has found heterogeneous levels of tax pass-through across the market segments of tobacco products available to smokers. This study uses retail sales data to assess the extent to which recent tax changes have been passed on to smokers and whether this varies across the price distribution. METHODS: We use panel data quantile regression analysis on Nielsen commercial data of tobacco price and sales in the UK from January 2013 to March 2019 combined with official UK tax rates and inflation to calculate the rate of tax pass-through for factory made (FM) cigarettes and roll your own (RYO) tobacco. RESULTS: Following increases in the specific tax payable on tobacco, we find evidence of overshifting across the price distribution for both FM and RYO. The rate of the overshift in tax increased the more expensive the products were. This was consistent for FM and RYO. Additionally, our findings suggest that the introduction of standardised packaging was not followed by changes in how the tobacco industry responded to tax increases. CONCLUSIONS: Following the repeated introduction of increases in specific tobacco tax as well as standardised packaging, we show that the tobacco industry applies techniques to keep the cheapest tobacco cheaper relative to the more expensive products when passing on tax increases to smokers.

Longitudinal evaluation of the impact of standardised packaging and minimum excise tax on tobacco sales and industry revenue in the UK.

BACKGROUND: Standardised packaging for factory-made cigarettes (FM) and roll-your-own tobacco (RYO), and a minimum excise tax (MET) were fully implemented in the UK in May 2017 following a 12-month transition period. This paper is the first to examine effects on tobacco sales volumes and company revenues. METHODS: Analysis of UK commercial supermarket and convenience store electronic point of sale data on tobacco sales. FM and RYO products' data (May 2015-April 2018) yielded 107 572 monthly observations. Expected values from additive mixed modelling were used to calculate trends in: (1) volumes of tobacco sold overall, by cigarette type (FM and RYO) and by seven market segments; and (2) company net revenues. A 10-month period (June 2015-March 2016) before the transition to standardised packs was compared with a 10-month period after the introduction of the MET and full implementation of standardised packs (June 2017-March 2018). RESULTS: Postimplementation, the average monthly decline in stick sales was 6.4 million (95% CI 0.1 million to 12.7 million) sticks faster than prelegislation, almost doubling the speed of decline. Sales of cheap FM brands, previously increasing, plateaued after implementation. Company monthly net revenues declined from a stable £231 million (95% CI £228 million to £234 million), prelegislation, to £198 million (95% CI £191 million to £206 million) in April 2018. CONCLUSIONS: The concurrent introduction of standardised packaging and MET in the UK was associated with significant decline in sales and in tobacco industry revenues, and the end of the previous growth in cheap cigarette brands that appeal to young and price conscious smokers.

Standardised packaging, minimum excise tax, and RYO focussed tax rise implications for UK tobacco pricing.

BACKGROUND: Standardised packaging for factory made (FM) and roll your own (RYO) tobacco was fully implemented in the UK in May 2017. Around the same time, several changes to the tax system were applied (a Minimum Excise Tax (MET) for FM products and tax increases weighted towards RYO products). The tobacco industry claims that standardised packaging will lower prices (a disincentive for quitting) by commoditising the product, yet had itself taken advantage of the previous tax regime to achieve large profits from premium brands while also keeping some products' prices relatively low. Here we evaluate the impact of standardised packaging, the MET and the RYO focussed tax changes on price and industry profitability. METHODS AND FINDINGS: Nielsen electronic point of sale (EPOS) data (May 2015 to April 2018) were used to calculate real (inflation adjusted) monthly price per stick overall, by cigarette type (FM and RYO) and by seven market segments. Trend estimation, using additive mixed models, assessed weighted average price (weighted by volume of sales) and tobacco industry net revenue changes. The beginning and end of the data series were compared in terms of: (a) average monthly price growth, (b) average monthly net revenue growth, and (c) undershifting and overshifting patterns after tax changes. FM and RYO real prices changed little over the 3-year period-overall prices rose by about 1p per stick. There was no evidence of commoditisation with prices of all FM segments (but not RYO) rising faster after the implementation of standardised packaging than immediately beforehand. The prices of the cheapest FM brands rose with the implementation of the MET. RYO price increases did not close the gap to FM pricing levels despite RYO focussed tax increases. Tax changes following the implementation of standardised packaging and the MET were more widely and quickly passed on to smokers in the form of higher prices than the tax change pre-implementation. The main limitations are first that because we do not know the exact mechanism by which Nielsen scales up sample data to provide UK estimates, we could only use data for a set three year period during which the same adjustments are made. Second, the tax and standardised packaging events were sometimes too close in time to separate their consequences statistically. Third, tobacco prices may also be affected by external factors such as changes in smokers' disposable income or availability of electronic nicotine delivery systems. CONCLUSIONS: There was no long-term lowering of tobacco prices after the implementation of standardised packaging as predicted by the industry. The introduction of the MET was successful in increasing the price of the cheapest FM cigarettes and narrowing the price gap between FM brands. The RYO tax increases were, however, insufficient to narrow the price gap between RYO and FM. Overall, undershifting became less extensive indicating that tobacco industry manipulation of the tax system which had previously kept cheap products available had declined. This suggests that standardised packaging and a MET will likely contribute to further declines in UK tobacco use.

Individual-level behavioural smoking cessation interventions tailored for disadvantaged socioeconomic position: a systematic review and meta-regression.

BACKGROUND: Socioeconomic inequalities in smoking cessation have led to development of interventions that are specifically tailored for smokers from disadvantaged groups. We aimed to assess whether the effectiveness of interventions for disadvantaged groups is moderated by tailoring for socioeconomic position. METHODS: For this systematic review and meta-regression, we searched MEDLINE, PsycINFO, Embase, Cochrane Central Register, and Tobacco Addiction Register of Clinical Trials and the IC-SMOKE database from their inception until Aug 18, 2019, for randomised controlled trials of socioeconomic-position-tailored or non-socioeconomic-position-tailored individual-level behavioural interventions for smoking cessation at 6 months or longer of follow-up in disadvantaged groups. Studies measured socioeconomic position via income, eligibility for government financial assistance, occupation, and housing. Studies were excluded if they were delivered at the community or population level, did not report differential effects by socioeconomic position, did not report smoking cessation outcomes from 6 months or longer after the start of the intervention, were delivered at a group level, or provided pharmacotherapy with standard behavioural support compared with behavioural support alone. Individual patient-level data were extracted from published reports and from contacting study authors. Random-effects meta-analyses and mixed-effects meta-regression analyses were done to assess associations between tailoring of the intervention and effectiveness. Meta-analysis outcomes were summarised as risk ratios (RR). Certainty of evidence was assessed within each study using the Cochrane risk-of-bias tool version 2 and the grading of recommendations assessment, development, and evaluation approach. The study is registered with PROSPERO, CRD42018103008. FINDINGS: Of 2376 studies identified by our literature search, 348 full-text articles were retrieved and screened for eligibility. Of these, 42 studies (26 168 participants) were included in the systematic review. 30 (71%) of 42 studies were done in the USA, three (7%) were done in the UK, two (5%) each in the Netherlands and Australia, and one (2%) each in Switzerland, Sweden, Turkey, India, and China. 26 (62%) of 42 studies were trials of socioeconomic-position-tailored interventions and 16 (38%) were non-socioeconomic-position-tailored interventions. 17 (65%) of 26 socioeconomic-position-tailored interventions were in-person or telephone-delivered behavioural interventions, four (15%) were digital interventions, three (12%) involved financial incentives, and two (8%) were brief interventions. Individuals who participated in an intervention, irrespective of tailoring, were significantly more likely to quit smoking than were control participants (RR 1·56, 95% CI 1·39-1·75; I2=54·5%). Socioeconomic-position-tailored interventions did not yield better outcomes compared with non-socioeconomic-position-tailored interventions for disadvantaged groups (adjusted RR 1·01, 95% CI 0·81-1·27; ß=0·011, SE=0·11; p=0·93). We observed similar effect sizes in separate meta-analyses of non-socioeconomic-position-tailored interventions using trial data from participants with high socioeconomic position (RR 2·00, 95% CI 1·36-2·93; I2=82·7%) and participants with low socioeconomic position (1·94, 1·31-2·86; I2=76·6%), although certainty of evidence from these studies was graded as low. INTERPRETATION: We found evidence that individual-level interventions can assist disadvantaged smokers with quitting, but there were no large moderating effects of tailoring for disadvantaged smokers. Improvements in tailored intervention development might be necessary to achieve equity-positive smoking cessation outcomes. FUNDING: Cancer Research UK.

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.

UK tobacco price increases: driven by industry or public health?

BACKGROUND: Tobacco companies claim that higher taxes will force smokers into buying illicit tobacco, but if they were truly concerned about increasing illicit sales with higher prices they would only increase retail prices in line with changes in taxation. In this paper, we explore UK pricing of both factory-made cigarettes (FM) and roll-your-own tobacco (RYO) to explore the extent to which price increases were due to government tax rises or industry strategies to increase profit per pack. METHOD: Nielsen commercial data on UK tobacco sales data (2010-2015) were combined with official UK data on inflation and tax rates, to identify the source of real price increases. RESULTS: Between 2010 and 2012, when there were unexpected large tax increases, industry driven price changes were small (16% of the price rise in FM and 20% in RYO), and changes were similar between market segments. Between 2013 and 2015, when tax increases were smaller and expected, industry behaviour generally accounted for a larger share of price rises (33% FM, 48% RYO), but changes varied considerably by segment. CONCLUSION: The industry has increased its prices beyond that required by tax changes, even when tax rises were larger and unexpected, although were notably smaller in such conditions. This suggests (1) that the industry is not actually concerned by the threat of illicit, especially since RYO had the highest levels of industry driven price increases despite higher levels of illicit, and (2) there remains scope for further tax increases, which should be relatively large and unexpected.

Corrigendum to "City scale climate change policies: Do they matter for wellbeing?" [Prev. Med. Rep. 6 (2017) 265-270].

[This corrects the article DOI: 10.1016/j.pmedr.2017.03.019.].

Stop Smoking Practitioners' understanding of e-cigarettes' use and efficacy with particular reference to vapers' socioeconomic status.

Introduction: We have undertaken four online surveys of Stop Smoking Service (SSS) practitioners in England, between 2011 and 2016, in order to enhance our understanding of e-cigarettes: a fast moving new phenomenon. It is important to understand whether e-cigarettes can ameliorate or exacerbate health inequalities given that smoking is one of the most serious causes of excessive mortality and morbidity among disadvantaged groups globally. Aims: To update findings of previous surveys and examine socioeconomic status differences in e-cigarette use and efficacy. Methods: Analysis was undertaken of electronic surveys, particularly, the most recent 2016 survey (n = 514) and 2015/16 SSS client routine monitoring data. Results: SSS practitioners were becoming more positive about e-cigarettes: 42% agreed that e-cigarettes were a good thing compared with 15% in 2011. Reported use of e-cigarettes among SSS clients was low (about 3%) despite higher quit rates (63% of clients reported being quit at four week follow-up, compared with 51% overall). Where socioeconomic differences in e-cigarettes' efficacy for quitting were identified, affluent and working smokers were advantaged. Conclusions: Low use of e-cigarettes by clients and practitioner opinions suggest that further education of SSS staff is needed if they are to adopt the current service recommendations about e-cigarettes.

Individualised tobacco affordability in the UK 2002-2014: findings from the International Tobacco Control Policy Evaluation Project.

OBJECTIVE: The existing measures of tobacco affordability (smokers' purchasing power for tobacco) use national estimates of income and average cigarette prices, and exclude roll-your-own (RYO) tobacco. This study developed an individualised measure of tobacco affordability using smokers' own incomes and factory-made (FM) or RYO tobacco purchase prices, and explored how it was impacted by taxation changes, individual characteristics and purchase patterns. DESIGN: Cross-sectional survey data collated from 10 waves of a longitudinal cohort study. DATA SOURCES: Adult smokers (n=4062) from the International Tobacco Control Policy Evaluation Project United Kingdom (UK), surveyed between 2002 and 2014, providing 8943 observations over 10 surveys. ANALYSIS: Affordability was calculated as the percentage of annual income remaining with the individuals after their annual tobacco expenditure. Multilevel linear regression models were used with affordability as the outcome using time, sex, age, geographical region, ethnicity, education, nicotine dependence and tobacco purchase source as the predictor variables. RESULTS: Affordability of FM cigarettes decreased significantly from 91.5% (±95% CI: 91.0% to 91.9%) in 2002 to 87.8% (87.0% to 88.5%) in 2014; and RYO from 96.3% (95.7% to 96.9%) in 2006 to 93.7% (93.0% to 94.4%) in 2014. Affordability was significantly lower for FM than RYO. Year-on-year decreases were not statistically significant. Tobacco was more affordable for males, those with higher education, less dependent smokers and those purchasing from non-store (potentially illicit) or non-UK sources. CONCLUSIONS: An individualised measure of tobacco affordability provided useful insights on the impact of tobacco taxes, social inequalities and purchase patterns in the UK. Although tobacco became less affordable, the annual rate of decline was low, suggesting annual tax rises were not large enough.

Keeping smoking affordable in higher tax environments via smoking thinner roll-your-own cigarettes: Findings from the International Tobacco Control Four Country Survey 2006-15.

BACKGROUND: Roll-Your-Own tobacco (RYO) use is increasingly popular in many countries: it is generally cheaper than factory-made cigarettes (FM), and smokers can further reduce costs by adjusting the amount of tobacco in each cigarette. However, the level of risk of RYO compared with FM cigarettes is similar and does not meaningfully change with cigarette weight. We assessed the weight of tobacco in RYO cigarettes across jurisdictions with differing tobacco taxes/prices and over time. METHOD: Six waves of the International Tobacco Control 4 Country longitudinal study of smokers and recent ex-smokers, providing 3176 observations from exclusive RYO users covering 2006-15, are used to calculate the weight of tobacco used in RYO cigarettes in the US, Canada, Australia, and the UK. Multilevel regression analyses were used to compare weights across countries, socio-demographic factors, and over time. RESULTS: Smokers in the UK and Australia, where tobacco is relatively expensive, show higher levels of exclusive RYO use (25.8% and 13.8% respectively) and lower mean weights of tobacco per RYO cigarette (0.51 g(sd 0.32 g) and 0.53 g(0.28 g)), compared with both Canada and especially the US (6.0% and 3.5%, and 0.76 g(0.45 g) and 1.07 g(0.51 g)). Smokers in the UK and Australia also exhibited a statistically significant year-on-year decrease in the mean weight of each RYO cigarette. CONCLUSIONS: Taxation of RYO should increase considerably in the UK and Australia so that RYO and FM cigarettes are taxed equivalently to reduce RYO attractiveness and inequalities. Other measures to reduce the price differentials, including taxing RYO solely on weight, are also discussed.

Perceptions of cigarette pack inserts promoting cessation and dissuasive cigarettes among young adult smokers in the UK: a cross-sectional online survey.

OBJECTIVES: To explore young adult smokers' perceptions of cigarette pack inserts promoting cessation and cigarettes designed to be dissuasive. DESIGN: Cross-sectional online survey. SETTING: UK. PARTICIPANTS: The final sample was 1766 young adult smokers, with 50.3% male and 71.6% white British. To meet the inclusion criteria, participants had to be 16-34 years old and smoke factory-made cigarettes. PRIMARY AND SECONDARY OUTCOME MEASURES: Salience of inserts, perceptions of inserts as information provision, perceptions of inserts on quitting, support for inserts and perceived appeal, harm and trial of three cigarettes (a standard cigarette, a standard cigarette displaying the warning 'Smoking kills' and a green cigarette). RESULTS: Half the sample indicated that they would read inserts with three-fifths indicating that they are a good way to provide information about quitting (61%). Just over half indicated that inserts would make them think more about quitting (53%), help if they decided to quit (52%), are an effective way of encouraging smokers to quit (53%) and supported having them in all packs (55%). Participants who smoked factory-made cigarettes and other tobacco products (compared with exclusive factory-made cigarette smokers), had made a quit attempt within the last 6 months (compared with those that had never made a quit attempt) or were likely to make a successful quit attempt in the next 6 months (compared with those unlikely to make a quit attempt in the next 6 months) were more likely to indicate that inserts could assist with cessation. Multivariable logistic regression modelling suggested that compared with the standard cigarette, the cigarette with warning (adjusted OR=17.71; 95% CI 13.75 to 22.80) and green cigarette (adjusted OR=30.88; 95% CI 23.98 to 39.76) were much less desirable (less appealing, more harmful and less likely to be tried). CONCLUSIONS: Inserts and dissuasive cigarettes offer policy makers additional ways of using the pack to reduce smoking.

Biomarkers of exposure in environment-wide association studies - Opportunities to decode the exposome using human biomonitoring data.

BACKGROUND: The European Union's 7th Framework Programme (EU's FP7) project HEALS - Health and Environment-wide Associations based on Large Population Surveys - aims a refinement of the methodology to elucidate the human exposome. Human biomonitoring (HBM) provides a valuable tool for understanding the magnitude of human exposure from all pathways and sources. However, availability of specific biomarkers of exposure (BoE) is limited. OBJECTIVES: The objective was to summarize the availability of BoEs for a broad range of environmental stressors and exposure determinants and corresponding reference and exposure limit values and biomonitoring equivalents useful for unraveling the exposome using the framework of environment-wide association studies (EWAS). METHODS: In a face-to-face group discussion, scope, content, and structure of the HEALS deliverable "Guidelines for appropriate BoE selection for EWAS studies" were determined. An expert-driven, distributed, narrative review process involving around 30 individuals of the HEALS consortium made it possible to include extensive information targeted towards the specific characteristics of various environmental stressors and exposure determinants. From the resulting 265 page report, targeted information about BoE, corresponding reference values (e.g., 95th percentile or measures of central tendency), exposure limit values (e.g., the German HBM I and II values) and biomonitoring equivalents (BEs) were summarized and updated. RESULTS: 64 individual biological, chemical, physical, psychological and social environmental stressors or exposure determinants were included to fulfil the requirements of EWAS. The list of available BoEs is extensive with a number of 135; however, 12 of the stressors and exposure determinants considered do not leave any measurable specific substance in accessible body specimens. Opportunities to estimate the internal exposure stressors not (yet) detectable in human specimens were discussed. CONCLUSIONS: Data about internal exposures are useful to decode the exposome. The paper provides extensive information for EWAS. Information included serves as a guideline - snapshot in time without any claim to comprehensiveness - to interpret HBM data and offers opportunities to collect information about the internal exposure of stressors if no specific BoE is available.