Tobacco control policies in the 21st century: achievements and open challenges.

Noncommunicable diseases (NCDs), including cancer, are responsible for almost 70% of all deaths worldwide. Tobacco use is a risk factor common to most NCDs. This article discusses tobacco control policies and highlights major achievements and open challenges to reduce smoking prevalence and attributable morbidity and mortality in the 21st century. The introduction of the WHO Framework Convention on Tobacco Control in 2005 has been a key achievement in the field and has already facilitated a drop in both smoking prevalence and exposure to secondhand smoke. Indicatively, the size of the worldwide population benefiting from at least one cost-effective tobacco control policy has quadrupled since 2007. In addition, plain cigarette packaging has been successfully introduced as a tobacco control policy, surmounting efforts of the tobacco industry to challenge this based on trade and investment law. Nevertheless, tobacco control still faces major challenges. Smoking prevalence needs to be further reduced in a rather expedited manner. Smoke-free environments should be extended, and the use of plain tobacco packaging with large pictorial health warnings for all tobacco products should be further promoted in some parts of the world. Some of these measures will require prompt determination and diligence. For example, bold political decisions are needed to significantly increase real prices of tobacco products through excise taxes, ban added ingredients that are currently used to increase the attractiveness of tobacco products and ban the tobacco industry's corporate social responsibility initiatives. Finally, the debate on harm reduction strategies for tobacco control still needs to be resolved.

Heritable hazards of smoking: Applying the "clean sheet" framework to further science and policy.

All the cells in our bodies are derived from the germ cells of our parents, just as our own germ cells become the bodies of our children. The integrity of the genetic information inherited from these germ cells is of paramount importance in establishing the health of each generation and perpetuating our species into the future. There is a large and growing body of evidence strongly suggesting the existence of substances that may threaten this integrity by acting as human germ cell mutagens. However, there generally are no absolute regulatory requirements to test agents for germ cell effects. In addition, the current regulatory testing paradigms do not evaluate the impacts of epigenetically mediated intergenerational effects, and there is no regulatory framework to apply new and emerging tests in regulatory decision making. At the 50th annual meeting of the Environmental Mutagenesis and Genomics Society held in Washington, DC, in September 2019, a workshop took place that examined the heritable effects of hazardous exposures to germ cells, using tobacco smoke as the example hazard. This synopsis provides a summary of areas of concern regarding heritable hazards from tobacco smoke exposures identified at the workshop and the value of the Clean Sheet framework in organizing information to address knowledge and testing gaps.

Menthol additives to tobacco products. Reasons for withdrawing mentholated cigarettes in European Union on 20th may 2020 according to tobacco products directive (2014/40/EU).

Menthol, which is a natural cyclic monoterpene alcohol with a minty smell, is one of the main constituents of essential oils that naturally occur in some aromatic plants, such as Mentha × piperita L. This natural compound shows many biological properties, such as anesthetic, analgesic, antibacterial and antifungal, immunomodulating, and skin penetration-enhancing. It is added to a variety of goods, such as food, oral-care products, OTC products, cosmetics, and tobacco products. Menthol is not just a simple flavoring agent, especially when it comes to tobacco products. Its ability to 'mask' the negative effects of nicotine and its additional positive sensory effects makes it the most common additive in such products. For the customers, mentholated tobacco products may be mistakenly perceived as less harmful for health, which may increase their consumption. However, as the evidence shows, menthol cigarettes are no safer than conventional cigarettes and may lead to more frequent disease exacerbation during prolonged exposure to smoke from such products. In addition, because of its complex interactions with nicotine, menthol may affect smoking behavior and may increase addiction to nicotine. For those reasons, the European Union banned flavored cigarettes (whose sale size reached more than 3% of the total tobacco product market) by implementing the Tobacco Products Directive (2014/40/EU) on 20th May 2020. While the menthol ban was based on health concerns, the ultimate effect on consumers, regarding potential quitting, is yet to be determined.

Problematic substance use or problematic substance use policies? / Consommation problématique de substances ou politiques problématiques en la matière?

This special issue on substance use issues comes at a critical time for Canadian health policy makers and researchers. Most attention is currently focussed on the opioid crisis and the potential impacts of cannabis legalization. However, our most widely used and harmful substances continue to be alcohol and nicotine. Our policies to reduce harms from these substances are failing. While alcohol control policies are being gradually abandoned, opportunities to maximize the harm reduction potential of new, alternative and safer nicotine delivery devices are not being grasped. More generally, a greater focus is needed on harm reduction strategies that are informed by the experience of marginalized people with severe substance use-related problems so as to not exacerbate health inequities. In order to better inform policy responses, we recommend innovative approaches to monitoring and surveillance that maximize the use of multiple data sources, such as those used in the Canadian Substance Use Costs and Harms (CSUCH) project. Greater attention to precision in defining patterns of risky use and harms is also needed to support policies that more accurately reflect and respond to actual levels of substance use-related harm in Canadian society.

Substance use in Canada cost $46 billion in 2017, with the great majority of these costs resulting from the use of tobacco and alcohol. Substance use-related costs, harms and rates of use have been increasing in Canada over the past decades for both legal and illegal substances, including those for cannabis. Canadian policies to address our most harmful substances, i.e. alcohol, cannabis and tobacco, are largely failing, despite significant opportunities to improve policies on pricing, taxation and marketing of legal substances. Canada's monitoring and surveillance efforts can be improved by developing more discerning measures of risk and maximizing the use of multiple data sources.

Au Canada, la consommation de substances a coûté 46 milliards de dollars en 2017, la grande majorité de ces coûts découlant du tabagisme et de la consommation d'alcool. Au Canada, les taux de consommation de substances ainsi que les coûts et les méfaits connexes ont augmenté au cours des dernières décennies, que ce soit pour les substances légales ou illégales, en particulier le cannabis. Les politiques canadiennes en matière de lutte contre la consommation des substances les plus nocives, soit l'alcool, le cannabis et le tabac, sont en grande partie inefficaces, malgré d'importantes possibilités d'amélioration en matière de tarification, de taxation et de commercialisation des substances légales. Il est possible d'améliorer les efforts de contrôle et de surveillance au Canada en élaborant des mesures de risque bien pensées et en maximisant l'utilisation de multiples sources de données.

Protecting American Lungs and Reversing Youth Tobacco Epidemic Act.

Annually, the National Association of School Nurses (NASN) sets advocacy goals. The goals include legislative and policy priorities. This article sets forth current NASN legislative priorities and results of advocacy that benefit students. The NASN Board of Directors are instrumental in moving policy priorities forward. In addition, this article shares NASN advocacy during the COVID-19 pandemic.

Differences in smokers' awareness of the health risks of smoking before and after introducing pictorial tobacco health warnings: findings from the 2012-2017 international tobacco control (ITC) Netherlands surveys.

BACKGROUND: As of May 2016, pictorial health warnings (PHWs) showing the harms of smoking were implemented in the European Union. After one year they had to be fully implemented. We studied changes in awareness of the health risks of smoking after implementation of PHWs among smokers from the Netherlands, whether the trend before the implementation changed after the implementation, and whether there were differences between subgroups. METHODS: We used survey data from six yearly waves of the International Tobacco Control (ITC) Netherlands Survey from 2012 to 2017. The number of participating smokers ranged between 1236 and 1604 per wave. Data were analyzed using Generalized Estimating Equations (GEE) analyses. RESULTS: Indicators of awareness of the health risks of smoking that did not change between 2015 and 2017 were perceived susceptibility (ß = 0.043, p = 0.059) and perceived severity (ß = - 0.006, p = 0.679) regarding lung problems. Perceived susceptibility, however, was more pronounced between 2015 and 2017 than between 2012 and 2015(p value of interaction: p = 0.044). Noticing information about the dangers of smoking (ß = 0.119, p < 0.001) and knowledge about the health risks of smoking (ß = 0.184, p < 0.001) increased between 2015 and 2017. These increases were both more pronounced when compared to 2012-2015 (p values of interactions: p = 0.002 and p < 0.001 respectively). Compared to high educated smokers, low educated smokers (ß = - 1.137, p < 0.001) and moderate educated smokers (ß = - 0.894, p < 0.001) were less knowledgeable about the health risks of smoking in 2016 and 2017. CONCLUSIONS: Introducing PHWs coincided with an increase in smokers' knowledge about the health risks of smoking. Dutch tobacco control policy and campaigns should focus on improving Dutch smokers' awareness of the health risks of smoking even more, especially among low educated smokers.

Defending Comprehensive Tobacco Control Policy Implementation in Nepal From Tobacco Industry Interference (2011-2018).

INTRODUCTION: Nepal passed a comprehensive tobacco control law in 2011. Tobacco control advocates successfully countered tobacco industry (TI) interference to force implementation of law. AIMS AND METHODS: Policy documents, news stories, and key informant interviews were triangulated and interpreted using the Policy Dystopia Model (PDM). RESULTS: The TI tried to block and weaken the law after Parliament passed it. Tobacco control advocates used litigation to force implementation of the law while the TI used litigation in an effort to block implementation. The TI argued that tobacco was socially and economically important, and used front groups to weaken the law. Tobacco control advocates mobilized the media, launched public awareness campaigns, educated the legislature, utilized lawsuits, and monitored TI activities to successfully counter TI opposition. CONCLUSIONS: Both tobacco control advocates and the industry used the discursive and instrumental strategies described in the PDM. The model was helpful for understanding TI activities in Nepal and could be applied to other low- and middle-income countries. Civil society, with the help of international health groups, should continue to track TI interference and learn the lessons from other countries to proactively to counter it. IMPLICATIONS: The PDM provides an effective framework to understand battles over implementation of a strong tobacco control law in Nepal, a low- and middle-income country. The TI applied discursive and instrumental strategies in Nepal in its efforts to weaken and delay the implementation of the law at every stage of implementation. It is important to continuously monitor TI activities and learn lessons from other countries, as the industry often employ the same strategies globally. Tobacco control advocates utilized domestic litigation, media advocacy, and engaged with legislators, politicians, and other stakeholders to implement a strong tobacco control law. Other low- and middle-income countries can adapt these lessons from Nepal to achieve effective implementation of their laws.

Teeth or no teeth: exploring punitive measures for adults smoking in cars containing children in Aotearoa/New Zealand.

This viewpoint welcomes the recent announcement of the Government of Aotearoa/New Zealand to ban smoking in cars with children. However, it notes that the thorny issue of enforcement and punishment remains. Internationally there is a deficit on research on this issue. The experiences of the UK and Ireland are examined, where there was little or no enforcement of such laws, as well as a comparison with the State of Victoria in Australia, where the law was more robustly enforced. This viewpoint argues that enforcement is an important element in safeguarding the health and wellbeing of children.

Economic Evaluation of Five Tobacco Control Policies Across Seven European Countries.

INTRODUCTION: Economic evaluations of tobacco control policies targeting adolescents are scarce. Few take into account real-world, large-scale implementation costs; few compare cost-effectiveness of different policies across different countries. We assessed the cost-effectiveness of five tobacco control policies (nonschool bans, including bans on sales to minors, bans on smoking in public places, bans on advertising at points-of-sale, school smoke-free bans, and school education programs), implemented in 2016 in Finland, Ireland, the Netherlands, Belgium, Germany, Italy, and Portugal. METHODS: Cost-effectiveness estimates were calculated per country and per policy, from the State perspective. Costs were collected by combining quantitative questionnaires with semi-structured interviews on how policies were implemented in each setting, in real practice. Short-term effectiveness was based on the literature, and long-term effectiveness was modeled using the DYNAMO-HIA tool. Discount rates of 3.5% were used for costs and effectiveness. Sensitivity analyses considered 1%-50% short-term effectiveness estimates, highest cost estimates, and undiscounted effectiveness. FINDINGS: Nonschool bans cost up to €253.23 per healthy life year, school smoking bans up to €91.87 per healthy life year, and school education programs up to €481.35 per healthy life year. Cost-effectiveness depended on the costs of implementation, short-term effectiveness, initial smoking rates, dimension of the target population, and weight of smoking in overall mortality and morbidity. CONCLUSIONS: All five policies were highly cost-effective in all countries according to the World Health Organization thresholds for public health interventions. Cost-effectiveness was preserved even when using the highest costs and most conservative effectiveness estimates. IMPLICATIONS: Economic evaluations using real-world data on tobacco control policies implemented at a large scale are scarce, especially considering nonschool bans targeting adolescents. We assessed the cost-effectiveness of five tobacco control policies implemented in 2016 in Finland, Ireland, the Netherlands, Belgium, Germany, Italy, and Portugal. This study shows that all five policies were highly cost-effective considering the World Health Organization threshold, even when considering the highest costs and most conservative effectiveness estimates.

Youth Access to Cigarettes Across Seven European Countries: A Mixed-Methods Study.

BACKGROUND: Despite widespread age-of-sale restrictions on tobacco, adolescents continue to obtain cigarettes and experiment with smoking. This mixed-methods study aimed to understand how European adolescents access cigarettes and how the policy context may influence this process, using a realist evaluation approach. This is the first study to assess access to cigarettes across various European contexts. METHODS: A survey of 4104 students was combined with qualitative data from focus groups among 319 adolescents aged 14-19 across seven European countries. Data were synthesized to explore mechanisms via which young people obtain cigarettes despite age-of-sale restrictions. RESULTS: While purchasing cigarettes from supermarkets was widely regarded as difficult, many participants purchased cigarettes from noncompliant retailers (often in smaller shops or cafes). Other contra-mechanisms included circumventing age checks, proxy purchases, and/or social sources. Dominant forms of access differed across the seven contexts, with direct purchases more common where perceived enforcement was low (eg, Belgium) and proxy purchases more important where perceived enforcement of age-of-sale laws was high (eg, Finland). The effectiveness of age-of-sale restrictions in reducing youth access appears to be influenced by a range of contextual factors including retailer compliance, the availability of vending machines, and the specific minimum age-of-sale. CONCLUSIONS: Our findings illustrate the relevance of programme theory in understanding the contra-mechanisms that undermine the effectiveness of age-of-sale laws in discouraging youth smoking. Young people's access to cigarettes could be further limited by addressing these contra-mechanisms, including an increase in the legal sales age (particularly in Belgium), banning vending machines, and strengthening enforcement. IMPLICATIONS: Despite widespread implementation of age-of-sale laws, a substantial proportion of minors continue to access cigarettes. Young people use a number of contra-mechanisms to circumvent age-of-sale restrictions. These include accessing cigarettes via social sources, proxy sales or by circumventing age checks. Our findings show that in contexts where perceived enforcement of age-of-sale restrictions is high, young people are more reliant on irregular forms of access such as proxy sales. Young people's access to cigarettes may be further reduced by policy interventions that address these contra-mechanisms-for example, banning vending machines, strengthening enforcement of age-of-sale laws, and increasing the minimum age-of-sale.

Policies for Tobacco and E-Cigarette Use: A Survey of All Higher Education Institutions and NHS Trusts in England.

INTRODUCTION: There is an absence of evidence regarding the impact of treating tobacco smoking and vaping equivalently in workplace policies. We aimed to describe and compare smoking and vaping policies in acute nonspecialist NHS Trusts (n = 131) and Higher Education Institutions (HEIs) (n = 131) in England. METHODS: We conducted a census of smoking and vaping policies through organizational websites searches and direct requests for information. We recorded whether and where smoking and vaping were permitted. RESULTS: Smoking was prohibited indoors in all organizations. No NHS Trust permitted smoking freely outdoors, in contrast with 60% of HEIs. In 27% of NHS Trusts and 33% of HEIs smoking was permitted in designated areas, while in 73% of NHS Trusts and 8% of HEIs smoking was prohibited anywhere on site. Vaping was prohibited indoors in all NHS Trusts and all but one HEI, but permitted freely outdoors in 18% of NHS Trusts and 75% of HEIs. Vaping was permitted in designated outdoor spaces in 23% of NHS Trusts: 21% had areas shared with smokers; 2% had separate vaping areas. Vaping was permitted in designated outdoor areas in 18% of HEIs, all of which were shared with smokers. Vaping was prohibited anywhere on site in 54% of NHS Trusts and 6% of HEIs. CONCLUSIONS: Policies vary considerably in whether vaping and smoking are treated equivalently. Smoking policies in most HEIs should be reviewed to include more effective tobacco control approaches. Evidence is needed on the impact of imposing shared or separate spaces on vapers and smokers. IMPLICATIONS: This report provides a comprehensive review of smoking and vaping policies in two types of organization across England. It highlights key discrepancies between current public health recommendations for vaping and existing workplace policies, which often lead to smokers and vapers sharing spaces. The report identifies the need for evidence on the impact of imposing shared spaces on smokers and vapers to inform workplace policies that maximize public health benefit.

Implementing and Evaluating a Mentor Training to Improve Support for Early-Career Scholars in Tobacco Regulatory Science.

INTRODUCTION: To implement and evaluate a blended online and in-person training to help mentors of early-career researchers appreciate the complexities of Tobacco Regulatory Science (TRS), refine TRS mentoring skills, and become acquainted with resources for providing effective guidance to TRS mentees. METHODS: TRS mentors engaged in a two-part pilot test of the training program. Authors evaluated both the online and in-person training using retrospective pre-post evaluations, which measure learning at the conclusion of a training program, and post-program focus groups. Twenty learners completed the online training, and 16 learners attended the in-person training module. Nine participants completed evaluations for the online module, and 12 participants completed evaluations for the in-person module. RESULTS: Program assessments revealed that participants found that the training achieved its overall goals. The majority of respondents (87.5%) rated the online portion of the training as valuable. For the in-person training, participants reported statistically significant improvements regarding confidence in: helping mentees to identify skills and training to effectively pursue TRS, assisting mentees in weighing career trajectories, and guiding mentees in conducting research responsive to TRS regulatory priorities. CONCLUSIONS: The novel mentoring program was well received by faculty seeking to strengthen skills for mentoring early-career TRS researchers to navigate the complex landscape of TRS, explore diverse funding opportunities, and discern potential career trajectories. It provided unique content to address issues outside the traditional tobacco research training curriculum and offered specific information on regulatory policies, priorities, and opportunities. IMPLICATIONS: This research documents the deployment and evaluation of a blended online and in-person training program for investigators mentoring early-career researchers working in TRS. Our assessment discovered that participants found the training to be valuable to their overall mentoring objectives. The training comprises a novel curriculum for investigators engaged in mentoring early-career researchers in a unique field, thus filling a deficit in the published literature by presenting a curriculum that has been customized to the unique needs of TRS mentors.

Patient perceptions of tobacco control after smoke-free hospital grounds legislation: Multi-center cross-sectional study.

OBJECTIVE: To examine patient perceptions of the role of health care providers in tobacco control and tobacco-related services they should provide after the introduction of national smoke-free hospital grounds legislation in Spain. DESIGN: Multi-center cross-sectional study. SETTING: Thirteen hospitals in Barcelona province in 2014-2015. PARTICIPANTS: A total of 1,047 adult hospital patients, with a stay ≥ 24 h were randomly selected. METHOD: We explored participants' perceptions of the role of health professionals and hospitals in tobacco control by asking about their agreement with several statements after the introduction of national legislation on smoke-free hospital grounds: (i) health professionals "should set an example and not smoke" and "should provide smoking cessation support"; (ii) hospitals "should provide smoking cessation treatments" and are "role model organizations in compliance with the smoke-free legislation", and (iii) "hospitalization is a perfect moment to quit smoking". Responses were described overall and according to participant and hospital characteristics: patient sex and age, type of hospital unit, number of beds, and smoking prevalence among hospital staff. RESULTS: The majority of participants considered that health professionals should be role models in tobacco cessation (75.3%), should provide smoking cessation support to patients (83.0%), and that hospitalization is a good opportunity for initiating an attempt to quit (71.5%). Inpatients admitted to general hospitals where smoking cessation was not given as part of their portfolio, with a low level of implementation in tobacco control, and who stayed in surgical units had higher expectations of receiving smoking cessation interventions. CONCLUSIONS: Inpatients strongly support the role of hospitals and health professionals in tobacco control and expect to receive smoking cessation interventions during their hospital stay. Systematically providing smoking cessation services in hospitals may have a relevant impact on health outcomes among smokers and on health care system expenditures.

Policies that limit youth access and exposure to tobacco: a scientific neglect of the first stages of the policy process.

BACKGROUND: Policymakers can adopt and implement various supply-side policies to limit youth access and exposure to tobacco, such as increasing the minimum age of sale, limiting the number or type of tobacco outlets, or banning the display of tobacco products. Many studies have assessed the impact of these policies, while less is known about the preceding policy process. The aim of our review was to assess the available evidence on the preceding process of agenda setting, policy formulation, and policy legitimation. METHODS: A systematic literature search was conducted using the PubMed and the Social Sciences Citation Index databases. After selection, 200 international peer-reviewed articles were identified and analyzed. Through a process of close reading, evidence based on scientific enquiry and anecdotal evidence on agenda setting, policy formulation and policy legitimation was abstracted from each article. RESULTS: Scientific evidence on the policy process is scarce for these policies, as most of the evidence found was anecdotal. Only one study provided evidence based on a scientific analysis of data on the agenda setting and legitimation phases of policy processes that led to the adoption of display bans in two Australian jurisdictions. CONCLUSION: The processes influencing the adoption of youth access and exposure policies have been grossly understudied. A better understanding of the policy process is essential to understand country variations in tobacco control policy.

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.

Puffing Away Parental Rights: A Survey and Analysis of Whether Secondhand Smoke Exposure is Child Abuse.

The steps taken thus far to protect children in public areas, custody cases, and in vehicles show the legislature's awareness of the chemical harms of secondhand smoke for children. This article will analyze those steps and discuss what they mean for both parents' and children's constitutional rights. This article proposes that the legislature take a vital fourth step by including secondhand smoke exposure in child abuse laws. Section II of this article provides the history of smoking tobacco and its transition from a trendy social status to an unpopular, harmful habit. Section II also introduces the steps that have been taken so far to protect children from secondhand smoke. Section III, Part A discusses how and why there has never been a successful constitutional argument against smoking bans. Section III, Part B looks further into the three steps that courts and legislators have already taken to protect children from secondhand smoke and how those steps are constitutionally permissible. Section III, Part C discusses whether courts and legislators can apply the same constitutional basis of existing statutes to take the next step and interpret child abuse statutes to include secondhand smoke exposure.

Exposure to second-hand smoke in the context of tobacco policy changes in Estonia, 1996-2016.

BACKGROUND: Exposure to second-hand smoke (SHS) is a preventable cause of disease and disability that can effectively be tackled by tobacco legislation. The aim of the study was to analyse the trends of SHS exposure and its sociodemographic patterning during 1996-2016 in the context of tobacco policy changes in Estonia. METHODS: Nationally representative data from biennial health surveys in 1996-2016 (n = 14 629) were used to present prevalence ratios for SHS exposure among non-smokers in Estonia. Joinpoint regression and multivariable logistic regression were used to study the sociodemographic and socio-economic differences in SHS exposure and its changes during the period. RESULTS: Exposure to SHS among non-smoking men and women has declined 3.6 and 5 times, respectively, during 1996-2016. While the rate of change was constant among men throughout the period, the decline in SHS exposure among women became significantly faster after 2006 compared with the previous period. However, 15.6% [95% confidence interval (CI) 13.1-18.3%] of men and 8.8% (95% CI 7.1-10.6%) of women were still exposed to SHS in 2016 with higher odds found for younger age groups, non-Estonians and those with lower education and income. CONCLUSIONS: The consistently declining prevalence of SHS exposure among non-smoking population can be at least partially attributed to implementation of tobacco legislations in 2000s. However, the existing sociodemographic and socio-economic differences in SHS exposure require further attention as those in more vulnerable positions are also more exposed to SHS-related health harms.

Independent or synergistic? Effects of varying size and using pictorial images in tobacco health warning labels.

INTRODUCTION: Legal challenges have blocked the implementation of large, pictorial health warning labels (HWLs) in the U.S. In light of future legal questions the U.S. Food and Drug Administration may face in proposing alternative HWLs, we examined whether less restrictive HWL versions on the front of packs-smaller HWLs and/or text-only HWLs that do not include pictorial imagery-may be sufficient to promote cognitive and affective outcomes associated with smoking cessation. METHODS: We recruited low-income smokers in two separate experiments through field-based recruitment methods (Study 1, N = 497) or Amazon Mechanical Turk (MTurk) (Study 2, N = 495). In both studies, we randomly assigned participants to a no-HWL control condition or one of four HWL conditions in a 2 (pictorial vs. text-only) × 2 (50% vs. 30% size) between-subjects design. RESULTS: Relative to text-only HWLs, pictorial HWLs increased negative affect but not risk belief acceptance, cognitive elaboration about smoking harms, or quit intentions. The 50% HWLs increased quit intentions relative to the control condition in both studies. The 50% HWLs also outperformed the 30% HWLs in promoting quit intentions in Study 2. Subsequent analyses revealed that this effect in Study 2 may have been driven by the 50% HWLs strengthening the relationship between risk-related thoughts and intentions, although there was no evidence for this pattern in Study 1. We found no evidence for interaction effects between the pictorial and size manipulations. CONCLUSIONS: Our findings suggest that 50% HWLs, whether pictorial or text-only, can encourage low-income smokers to consider quitting under some conditions.