Luces y sombras para la salud pública: análisis crítico de la legislación sobre el tabaco en España / Lights and shadows for public health: a critical analysis of the tobacco legislation in Spain

El tabaquismo es una enfermedad crónica que constituye la primera causa evitable de muerte en los países desarrollados. En España, la prevalencia de consumo de tabaco ha disminuido gracias a la aplicación de políticas de control del tabaco; sin embargo, la legislación vigente no establece una regulación armonizada para todos los productos. El objetivo de este artículo es revisar la legislación actual y analizar sus limitaciones en relación con los principios de buena regulación administrativa definidos ahora en la Ley 39/2015. Las principales limitaciones pueden vertebrarse en cuatro ejes: la falta de regulación específica de estos nuevos productos, las diferencias en su regulación, la falta de información de sus efectos nocivos y de las novedades en la regulación de los espacios libres de humo, y la falta de adaptación de la regulación a la evidencia científica más reciente. Con todo, la calidad de la regulación para el control del tabaco en España, pese a los éxitos conseguidos con la Ley 28/2005, se ha visto comprometida por la relajación del Estado en el ámbito legislativo, regulatorio y administrativo, que ha comportado un estancamiento normativo opuesto a los principios de buena regulación. Esta revisión debería animar a las sociedades científicas y las asociaciones ciudadanas a reclamar igualmente la modernización de la legislación sobre tabaquismo, con políticas decididas y coordinadas de prevención y control para poder promover una España libre de tabaco. (AU)

Tobacco smoking is a chronic disease that is the leading preventable cause of death in developed countries. In Spain, the prevalence of tobacco use has decreased driven by the implementation of tobacco control policies; however, current legislation does not establish a harmonized regulation for all tobacco products. The aim of this article is to review the current legislation and critically analyze its limitations in relation to the principles of good administration now defined in the Law 39/2015. Spanish in force tobacco control policies main limitations can be divided into four areas: the lack of specific regulation for new tobacco products; the differences in their regulation; the lack of information to the general population on their harmful effects and the new developments in the regulation of smoke-free spaces; and the lack of adaptation of the regulation to the most recent scientific evidence. All in all, the quality of tobacco control regulations in Spain, despite the successes achieved with the Law 28/2005, has been compromised by the State's laxity in the legislative, regulatory, and administrative spheres, which has led to a regulatory stagnation that runs counter to the principles of good regulation. This review should encourage scientific organizations and civil society associations to call for an actualization of the tobacco legislation, with determined and coordinated prevention and control policies to promote a tobacco-free Spain. (AU)

Need for Gender Focused Policies Addressing Smokeless Tobacco Use among Women in India: A Review.

BACKGROUND: Nearly 8 million annual deaths occurring globally are attributable to tobacco use. Among more than 356 million smokeless tobacco (SLT) users in 140 countries, 82% reside in Southeast Asia with the vast majority being in India and Bangladesh. According to the Global Adult Tobacco Survey -2 data, 21.4% of adults in India consume SLT, among them 29.6% are men and 12.1% women. SLT has received less attention compared to its smoked counterparts in the public health measures to curb tobacco use. Though women are a sizable proportion of users, majority of the awareness building measures as well as governmental policies do not target them. This review aims to highlight these gaps objectively with constructive suggestions to enable a changed strategy to reduce tobacco consumption. AIM: (1) To critically review the gender sensitivity of tobacco control measures in India, (2) to conduct a comparative analysis of gender responsive strategies in India with those in smokeless tobacco high burden countries and (3) to make practical, feasible recommendations to enhance gender responsiveness of tobacco control measures in India in general and smokeless tobacco in particular. METHODOLOGY AND RESULTS: Following a comprehensive literature review to capture key information on gender responsiveness/sensitivity of strategies for tobacco control publications in English within the last 20 years, our search yielded 35 papers and reports from India describing policies relevant to SLT and women. Public health approach to tobacco control in general was found to be gender blind. CONCLUSION: It is evident that tobacco and smokeless tobacco related information and awareness activities need to focus more on women with improved messaging strategy to make it easily understandable and tailor the same to address the immediate and delayed health concerns. This much needed change would receive impetus with revisions in Governmental tobacco control policies, implementation and uptake.

Health Warning Label Compliance for Smokeless Tobacco Products and Bidis in Five Indian States.

BACKGROUND: The burden of tobacco use In India is very high. To inform users of harm, India has a strong health warning label law that applies to all tobacco products. This study examines the extent of compliance of health warning labels on smokeless tobacco (SLT) and bidi products with the Indian law. METHODS: In 2017, a systematic protocol was used to collect unique SLT and bidi packages from five Indian states. To assess compliance, we used three indicators: location, label elements, and warning size. RESULTS: Only 1% of the 133 SLT products and none of the 32 bidi packs were compliant with all three compliance indicators. Other compliance-related issues included non-standardized packaging, incomplete health warning labels, poor printing quality, and old warning labels. CONCLUSION: There is very poor compliance with the health warning label law on bidi and SLT products. India needs to regularly monitor and address implementation to ensure that warning labels are effective.

Raising the Age of Purchase and Use of Tobacco Product in Bangladesh: Benefits and Challenges in Protecting Youth from the Tobacco Epidemic.

BACKGROUND: Tobacco use among young and adolescents is the biggest threat to public health globally. In Bangladesh, every one in 14 youth (13-15 years) uses tobacco in some form. While this problem is growing in the country, we estimate the underage initiation of tobacco use and present evidence that policy measures like increasing the age of purchase and use from the current 18 years to 21 years in the country backed with current tobacco control efforts and adopting vendor licensing will significantly reduce future tobacco burden. METHOD: We analysed the two rounds of nationally representative Global Adult Tobacco Survey (GATS) data: GATS-1 (2009-10) and GATS-2 (2016-17) and segregated the data for two categories of tobacco consumption (smokers and smokeless tobacco users) based on the age of initiation (<18, 18-21 and >21 years). Consumption patterns were also analyaed by using the GATS-2 data. Projections from sub-national level analysis for youth initiating tobacco use before 21 years and change in the prevalence of overall underage tobacco users were calculated based on weighted value. RESULT: According to GATS-2, around 89% of current tobacco users initiated tobacco use into daily use before the age of 18 years in Bangladesh. Whereas, striking differences were observed (statistically significant) for the average age of initiation of smoking among smokers aged 20-34 increased from 17.4 in 2009 to 19.3 years; and 20.1 to 22 years for SLT.  Moreover, more than 24% of them initiated into regular smoking before the age of 15 years. CONCLUSION: There is an increasing trends of tobacco initiation among the underage youth of Bangladesh. By increasing the age of access, sale, purchase, and use of tobacco from current 18 years to 21 years will significantly reduce youth initiation and taper down the overall adult tobacco use prevalence over the long run in Bangladesh.

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

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

Prevalence of Smoke-Free Zone Compliance among Schools in Indonesia: A Nationwide Representative Survey.

BACKGROUND: With the increasing prevalence of teenage or school-age smokers, schools have become the main focus of the Indonesian government in tobacco control, including through the smoke-free zone (SFZ) policy. This study aims to obtain information related to the implementation of SFZ policies in schools. METHODS: A nationally representative survey was employed in 900 elementary, junior high, and senior high schools that were located in 60 regions or 24 provinces of Indonesia. Each school's compliance with SFZ parameters was measured using a closed-ended questionnaire. The dataset was analyzed using frequency distribution, while the chi-square was performed to analyze the measurement effect of each parameter for SFZ compliance. RESULTS: Java Island is the region with the largest proportion of school units (10%) studied in this study, and the largest group of the schools are high schools (36.1%). In terms of SFZ compliance, 413 (45.9%) of schools had perfect compliance scores of 8, followed by 183 schools (20.3%) with a score of 7 and 107 (11.9%) with a score of 6. It was found that parameter 5, namely cigarette butts found in the school environment, had the largest proportion when a school did not apply SFZ. Cigarette butts were found in 261 (29.0%) schools. Cigarette butts found in schools contributed 7.8 times to not applying SFZ compared to schools where no cigarette cutters were found. CONCLUSION: Although the SFZ compliance rate in Indonesian schools is 66.2% at least on 7 of 8 existed parameters, this means most of schools still aren't fully complying with the regulations for SFZs. This recent evidence will help decisionmakers to enforce tobacco control, particularly among youth, which form the pillar of national development.
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Retrospective Policy Analysis of Tobacco Prevention and Control in Ethiopia.

BACKGROUND: The trend of non-communicable diseases is alarmingly increasing and tobacco consumption and exposure to its smoke have been playing the leading role. Thirty-seven Ethiopians deaths per day are attributable to tobacco. Unless appropriately mitigated, this has social, economic and political impacts. Implementation of the appropriate policy is a good remedy; however, the policy process has never been straight forward and always successful. The involvement of different actors makes policy process complex hence agenda setting, policy formulation, implementation, and evaluations have been full of chaos and even may fail at any of these levels. Thus the aim of this review was retrospectively analyzing tobacco-related policies in Ethiopia that are relevant to control tobacco use and mitigate its impacts. METHODS: Systematically, we searched in pub-med, Scopus, Web of Science and Embase. Additionally, we did hand search on Google scholar and national websites. The terms "tobacco", "cigar", "cigarette", "control", "prevention", "policy" and "Ethiopia" were used. Eleven of 128 records met the inclusion criteria and then included. For data analysis, we applied the health policy analysis framework developed by Walt and Gilson. RESULT: Lately, Ethiopia enacted and started to implement tobacco control policies and programs, but its implementation is problematic and consumption rate is increasing. CONCLUSION: Despite the early involvement in tobacco control initiatives and enactment of legal frameworks, Ethiopia's journey and current stand to prevent and control the devastating consequences of tobacco is very limited and unsatisfactory. Therefore, we strongly call for further action, strong involvement of private sector and non-governmental organizations.

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

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

Assessment of Incorporation of Lessons From Tobacco Control in City and County Laws Regulating Legal Marijuana in California.

Importance: As marijuana continues to be legalized in many states, little is known about best regulatory practice, exposing the population to significant potential harm. Objective: To assess the extent to which potential best practices, including those from tobacco control, were incorporated into state and local marijuana policies in California. Design and Setting: California legalized medical marijuana in 1996 and adult recreational use in 2016, effective in January 2018. A cross-sectional study with data collection and analysis from February 1 to November 30, 2019, measured the adoption of potential demand reduction and youth protection best practices, including restrictions on sales, products, marketing, warnings, and taxation. Laws in effect by January 31, 2019, were verified and all 539 California local jurisdictions were studied. Main Outcomes and Measures: Adoption of potential best practices in marijuana laws for demand reduction and youth protection. Results: The laws of 534 of California's 539 jurisdictions (99%) were successfully identified; 263 of these 534 jurisdictions (49%) allowed any retail sale of marijuana, covering 57% of the state's population. More than one-third of jurisdictions allow sales of marijuana for adult recreational use (203 of 534 [38%]); of those, 122 allow storefront dispensaries and 81 allow sales by delivery only. A total of 257 of 534 jurisdictions (48%) allow medical sales. Of 147 jurisdictions allowing medical or adult use dispensaries, 93 (63%) limited the number of licenses, with a mean of 1 store for every 19 058 residents (range, 154-355 143). The state imposed no limits on number of dispensaries or deliverers. Forty-two jurisdictions increased the state-specified distances required between dispensaries and schools. Only 8 jurisdictions allowing retail sales imposed restrictions on products exceeding state regulations; 1 prohibited sale of flavored products, 3 prohibited sale of marijuana-infused beverages, and 5 imposed additional restrictions on edible marijuana products. No jurisdictions limited potency of products sold, although 1 established a potency-linked tax. The state did not limit or tax potency, except for establishing a standard 10-mg dose of tetrahydrocannabinol for edible marijuana products, nor did they limit manufacturing or sale of flavored products. The state required only a health warning in 6-point font on packages. Twenty-seven jurisdictions required additional health warnings in stores or on packages, 27 allowed onsite consumption of marijuana products, and 13 allowed marijuana-related events. More than half of jurisdictions legalizing any cannabis commerce (154 of 289 [53%]) did not tax marijuana locally and little revenue was captured for prevention. Much of the state excise and cultivation taxes is slated for youth substance use prevention and treatment. Conclusions and Relevance: In implementing legalization of marijuana in California, local policies varied widely. Where marijuana was legalized, many lessons from tobacco control to reduce demand, limit harm, and prevent youth use were not adopted, potentially creating greater risk of harm.

Historic tobacco legislation in Israel: a moment to celebrate.

BACKGROUND: Israel was once a leader in tobacco control, but fell behind other countries, particularly during the past decade, as smoking rates stagnated. TEXT: Landmark tobacco control legislation, which banned advertising (with the exception of the print press) and limited marketing, was passed in Israel on Dec. 31rst, 2018. The changes occurred following years of attempts which culminated in successful last-minute efforts to promote the legislation just before the early disbanding of the 20th Knesset (Israeli Parliament). Regulations concerning marketing and advertising were substantially strengthened to address all tobacco, nicotine and smoking products. Digital media was included for the first time. Electronic cigarettes, which were previously largely unregulated, now fall under existing tobacco legislation. The changes overcame intense opposition from the tobacco lobby, and occurred despite the fact that the basic elements for prevention policy postulated by the Richmond model were not in place. CONCLUSIONS: This legislation represents an important and long-awaited change in Israeli tobacco control policy. Many deficiencies in existing tobacco control regulation were overcome, and some measures went beyond current international regulations. The cohesive partnership between legislators, public health organizations and professionals, advocacy groups, academia, and leading journalists was critical to this success. The progress was lauded by the World Health Organization with its highest award for tobacco control, which was presented to Smoke Free Israel. This case study provides important lessons for up-to-date tobacco control policy, in the age of rapid global changes in the tobacco, vaping and nicotine landscape.

Development of a computational modeling laboratory for examining tobacco control policies: Tobacco Town.

A key focus of recent policy efforts to curb tobacco product usage has been the role of place-specifically the density of retail and advertising and the resulting spatial pattern of access and exposure for consumers. Policies can alter the environment by reducing density or shifting distribution of tobacco retail and thus limiting access and exposure. Since little empirical evidence exists for the potential impact of these policies across potentially heterogeneous places, we develop and apply an original spatial computational model to simulate place-based retail tobacco control policies. The model is well-grounded in theory and available empirical evidence. We apply the model in four representative settings to demonstrate the utility of this approach as a policy laboratory, to develop general insights on the relationship between retailer density, retail interventions, and tobacco costs incurred by consumers, and to provide a framework to guide future modeling and empirical studies. Our results suggest that the potential impact on costs of reducing tobacco retailer density are highly dependent on context. Projected impacts are also influenced by assumptions made about agent (smoker) purchasing decision-making processes. In the absence of evidence in this area, we tested and compared three alternative decision rules; these interact with environmental properties to produce different results. Agent properties, namely income and cigarettes per day, also shape purchasing patterns before and after policy interventions. We conclude that agent-based modeling in general, and Tobacco Town specifically, hold much potential as a platform for testing and comparing the impact of various retail-based tobacco policies across different communities. Initial modeling efforts uncover important gaps in both data and theory and can provide guidance for new empirical studies in tobacco control.

The impact of anti-tobacco legislation on birth weight in Peru.

Background: Tobacco exposure remains a significant issue for public health, especially for pregnant women. It increases the risk for premature labor, low birth weight and small for gestational age (SGA), among other effects. To reduce these risks, many countries have enacted public policies to curb tobacco exposure. Peru enacted anti-tobacco laws that forbid smoking in public places, require prevention text and images in products and publicity, along with restriction of sales to adults. We evaluated the effect of the implementation of this law on newborn outcomes: birth weight, prematurity and SGA. Methods: This was a quasi-experimental study that utilized data from the Peruvian Live Birth Registry. Children born to mothers from urban areas were the intervention group, while children born to mothers from rural areas were considered the control group. Only singletons with information on birth weight and gestational age, born to mothers aged 12 to 49 years were included in the study. In addition, newborns with birth weights greater than + 4 standard deviations (SD) or less than - 4 SD from the gestational age-specific mean were excluded. To measure the effect of legislation on birth weight we performed a difference in differences analysis. Results: A total of 2,029,975 births were included in the analysis. After adjusting for characteristics of the mother and the child, and contextual variables, the anti-tobacco law in Peru reduced the incidence of prematurity by 30 cases per 10,000 live births (95% CI: 19 to 42). Conclusions: The reform had negligible effects on overall birth weights and on the incidence of SGA. This modest result suggests the need for a more aggressive fight against tobacco, prohibiting all types of advertising and promotion of tobacco products, among others measures.