Tobacco control in Asia-Pacific: wins, challenges and targets.

For many decades, the international tobacco industry has set its sights on Asia, due to the large population numbers, the high prevalence of male smokers who might shift to its brands, and the extremely low number of female smokers who could possibly be induced into starting smoking. Because of US trade threats against several Asian countries in the 1980s, Asia became quickly aware that tobacco control involved politics, legislation, economics and trade. Several Asian jurisdictions pioneered tobacco control measures, and the Western Pacific is still the only WHO region where all countries have ratified the WHO Framework Convention on Tobacco Control (FCTC). Progress needs to be accelerated to reduce the still high male smoking prevalence and maintain the low female prevalence by fully implementing the WHO FCTC as part of achieving sustainable development, even while grappling with the looming epidemic of new products, holding the companies accountable, and protecting tobacco control policies against constant industry interference.

What facilitates policy audacity in tobacco control? An analysis of approaches and supportive factors for innovation in seven countries.

BACKGROUND: Tobacco control policy audacity can make radical ideas seem possible, and set in motion a 'domino' effect, where precedents in one jurisdiction are followed by others. This review examines tobacco control policy audacity from seven countries to identify and compare factors that facilitated it. METHODS: A targeted search strategy and purposive sampling approach was used to identify information from a range of sources and analyse key supportive factors for policy audacity. Each case was summarised, then key themes identified and compared across jurisdictions to identify similarities and differences. RESULTS: Included cases were Mauritius' ban on tobacco industry corporate social responsibility, Uruguay's tobacco single brand presentation regulations, New Zealand's Smokefree Aotearoa 2025 Action Plan proposals and 2010 parliamentary Maori Affairs Select Committee Inquiry into the Tobacco Industry, Australia's plain packaging legislation, Balanga City's (Philippines) tobacco-free generation ordinance, Beverly Hills City Council's (USA) ordinance to ban tobacco sales and the Netherlands' policy plan to phase out online and supermarket tobacco sales. Each case was one strategy within a well-established comprehensive tobacco control and public health approach. Intersectoral and multijurisdiction collaboration, community engagement and public support, a strong theoretical evidence base and lessons learnt from previous tobacco control policies were important supportive factors, as was public support to ensure low political risk for policy makers. CONCLUSIONS: Tobacco control policy audacity is usually an extension of existing measures and typically appears as 'the next logical step' and therefore within the risk appetite of policy makers in settings where it occurs.

SEATCA Tobacco Industry Interference Index: a tool for measuring implementation of WHO Framework Convention on Tobacco Control Article 5.3.

OBJECTIVE: To measure the implementation of WHO Framework Convention on Tobacco Control (FCTC) Article 5.3 at country level using a new Tobacco Industry Interference Index and to report initial results using this index in seven Southeast Asian countries. METHODS: Score sheet based on WHO FCTC Article 5.3 Guidelines sent to correspondents in seven Southeast Asian countries, using a scoring system designed with the help of tobacco control experts and validated through focused group discussions. RESULTS: The seven countries ranked from the lowest level of interference to the highest are Brunei, Thailand, Lao PDR, Cambodia, Philippines, Malaysia and Indonesia. Countries that face high levels of unnecessary interaction with the tobacco industry also face high levels of tobacco industry influence in policy development. Most governments do not allow any tobacco industry representatives on their delegation to sessions of the Conference of the Parties or its subsidiary bodies nor accept their sponsorship for delegates, but most governments still accept or endorse offers of assistance from the tobacco industry in implementing tobacco control policies. Most governments also receive tobacco industry contributions (monetary or in kind) or endorse industry corporate social responsibility activities. Governments do not have a procedure for disclosing interactions with the tobacco industry, but Lao PDR, Philippines and Thailand have instituted measures to prevent or reduce industry interference. CONCLUSIONS: This Tobacco Industry Interference Index, based on the WHO FCTC Article 5.3 Guidelines, is a useful advocacy tool for identifying both progress and gaps in national efforts at implementing WHO FCTC Article 5.3.

Cigarette price level and variation in five Southeast Asian countries.

OBJECTIVES: To monitor and analyse impacts of the interaction between tobacco excise tax policy and industry price strategy, on the price level and variation of cigarettes sold in five Southeast Asian countries (Indonesia, Cambodia, Lao PDR, the Philippines and Vietnam). METHODS: Prices of cigarette sold by sticks and packs were collected through an in-person survey of retailers during 2011. Mean cigarette prices and price variation were calculated in each study country for single cigarettes, whole packs and brand groups. RESULTS: Price variation of whole packs was greater in countries with ad-valorem excise tax structures (Cambodia, Lao PDR and Vietnam) than in countries with multitiered specific excise taxes (Indonesia and the Philippines). The price variation for single sticks appeared to be driven by local currency denomination. Cigarettes sold individually cost more per stick than cigarettes sold in whole packs in every brand group except for Indonesia's domestic brands. CONCLUSIONS: Tobacco industry strategy and excise tax structure drove the price level and variation of cigarettes sold in packs, while currency denominations influence the selling price of single sticks. To maximise the effectiveness of tobacco tax policies, countries should adopt specific excise tax structures to decrease cigarette price variation, which would minimise opportunities for smokers to 'trade down' to a cheaper brand to avoid a tax-driven price increase.

Nicotine and Cardiovascular Health: When Poison is Addictive - a WHF Policy Brief.

Nicotine is universally recognized as the primary addictive substance fuelling the continued use of tobacco products, which are responsible for over 8 million deaths annually. In recent years, the popularity of newer recreational nicotine products has surged drastically in many countries, raising health and safety concerns. For decades, the tobacco industry has promoted the myth that nicotine is as harmless as caffeine. Nonetheless, evidence shows that nicotine is far from innocuous, even on its own. In fact, numerous studies have demonstrated that nicotine can harm multiple organs, including the respiratory and cardiovascular systems. Tobacco and recreational nicotine products are commercialized in various types and forms, delivering varying levels of nicotine along with other toxic compounds. These products deliver nicotine in profiles that can initiate and perpetuate addiction, especially in young populations. Notably, some electronic nicotine delivery systems (ENDS) and heated tobacco products (HTP) can deliver concentrations of nicotine that are comparable to those of traditional cigarettes. Despite being regularly advertised as such, ENDS and HTP have demonstrated limited effectiveness as tobacco cessation aids in real-world settings. Furthermore, ENDS have also been associated with an increased risk of cardiovascular disease. In contrast, nicotine replacement therapies (NRT) are proven to be safe and effective medications for tobacco cessation. NRTs are designed to release nicotine in a slow and controlled manner, thereby minimizing the potential for abuse. Moreover, the long-term safety of NRTs has been extensively studied and documented. The vast majority of tobacco and nicotine products available in the market currently contain nicotine derived from tobacco leaves. However, advancements in the chemical synthesis of nicotine have introduced an economically viable alternative source. The tobacco industry has been exploiting synthetic nicotine to circumvent existing tobacco control laws and regulations. The emergence of newer tobacco and recreational nicotine products, along with synthetic nicotine, pose a tangible threat to established tobacco control policies. Nicotine regulations need to be responsive to address these evolving challenges. As such, governments should regulate all tobacco and non-medical nicotine products through a global, comprehensive, and consistent approach in order to safeguard tobacco control progress in past decades.

Decrease in Secondhand Smoke Exposure in Work and Public Places among Adults in the Philippines: An Analysis of the Global Adult Tobacco Survey, 2009 and 2015.

The implementation of several tobacco control policies in the Philippines may have contributed to a decrease in secondhand smoke (SHS) exposure. We examined changes in SHS exposure at work and in public places between 2009 and 2015 among adults aged ≥15 years and interpreted these results within the tobacco policy landscape in the Philippines. We analyzed the Philippines Global Adult Tobacco Survey 2009 and 2015 data. We examined marginal effects in logistic regression to get the adjusted prevalence of SHS exposure at five work and public places, controlling for selected characteristics. We calculated adjusted prevalence ratios and adjusted prevalence differences between 2009 and 2015. Adjusted prevalence of SHS exposure decreased from 2009 to 2015 by 19% (5.7 percentage points) at work, 45% (11.2 percentage points) in government buildings, 48% (3.2 percentage points) in healthcare facilities, 29% (8.2 percentage points) in restaurants, and 33% (19.9 percentage points) on public transportation. Although the prevalence of SHS exposure at work and in public places decreased significantly between 2009 and 2015, a substantial proportion of adults remain exposed to SHS. This study highlights the importance of continued implementation, enforcement, monitoring, and evaluation of tobacco control and prevention measures in the Philippines.

E-Cigarettes: A New Threat to Cardiovascular Health - A World Heart Federation Policy Brief.

Tobacco is widely recognized as a leading cause of cardiovascular morbidity and mortality, accounting for approximately seventeen percent of all cardiovascular disease deaths globally. Electronic nicotine delivery systems such as e-cigarettes have been developed and advertised as safer alternatives to traditional tobacco cigarettes. Aggressive marketing strategies, as well as misleading claims by manufacturers, have largely contributed to the belief that e-cigarettes are harmless. In reality, e-cigarettes are far from innocuous. E-cigarette solutions and aerosols generally contain harmful substances that are commonly found in tobacco cigarette emissions. A growing body of literature suggests that e-cigarettes are associated with an increased risk of cardiovascular morbidity and mortality. In addition, the effectiveness of e-cigarettes as smoking cessation tools has yet to be determined. Concerningly, most smokers do not give up on tobacco cigarettes and eventually become dual users. Unregulated, e-cigarettes constitute a serious threat to established tobacco control policies. Fortunately, many countries have demonstrated that strong regulations were effective in protecting their populations from the dangers of e-cigarettes. The World Heart Federation recommends applying the precautionary principle and a set of measures to protect vulnerable populations, prevent exposure to second-hand smoking, and address misleading claims. In this regard, we recommend that governments, policymakers, and other relevant stakeholders enact or support the following measures, among others: Prohibit the sale and distribution of e-cigarettes to minors, as well as the use of flavouring agents.Prohibit the use of e-cigarettes anywhere tobacco cigarettes have been banned.Prohibit marketing, advertising, and misleading claims regarding e-cigarettes.Apply excise taxes on e-cigarettes.Conduct more research regarding the long-term effects of e-cigarettes on cardiovascular health. Lastly, countries that have banned the commercialization of e-cigarettes should maintain these measures.

Tobacco Industry Fingerprints on Delaying Implementation of Pictorial Health Warnings in the Western Pacific.

OBJECTIVE: This case series describes tobacco industry tactics and strategies used to interfere, derail, delay, and weaken the development of effective health warning regulations in Malaysia, Cambodia, the Philippines, and Hong Kong. METHODS: A historical review of official reports, news articles, and gray literature was undertaken to identify tobacco industry tactics and strategies to hamper government efforts in implementing stronger pictorial health warning regulations in four Asian jurisdictions (Cambodia, Hong Kong, Malaysia, and the Philippines). RESULTS: Nineteen countries/jurisdictions in the WHO Western Pacific region currently require pictorial health warnings on cigarette packs, including some of the world's largest, in line with the WHO Framework Convention on Tobacco Control Article 11 Guidelines. In the four jurisdictions examined, tobacco industry interference consisted of lobbying and misinformation of high-level government officers and policy-makers, distributing industry-friendly legislative drafts, taking government to court, challenging government timelines for law implementation, and mobilizing third parties. Strong political leadership and strategic advocacy enabled governments to successfully overcome this industry interference. CONCLUSION: The tobacco industry uses similar tactics in different jurisdictions to derail, delay, and weaken the implementation of effective health warning policies. Identifying and learning from international experiences can help anticipate and defeat such challenges.

Compressive optic neuropathy after use of oxidized regenerated cellulose in orbital surgery: review of complications, prophylaxis, and treatment.

PURPOSE: We report 2 cases of compressive optic neuropathy after use of oxidized regenerated cellulose (ORC) in orbital surgery. To our knowledge, no complications have been reported previously after use of this material in orbital surgery. We also review the complications related to its retention at operative sites outside the orbit and recommend precautions to avoid them. DESIGN: Retrospective interventional case reports. PARTICIPANTS: Two patients with compressive optic neuropathy after use of ORC in orbital surgery. METHODS: Case reports from 2 different clinics and review of the English scientific literature. MAIN OUTCOME MEASURES: Best-corrected visual acuity, extraocular motility, proptosis, and chemosis. RESULTS: One patient underwent orbital exploration and biopsy of an orbital tumor, and the second had repair of an orbital floor fracture. Postoperatively, both presented with chemosis, ophthalmoplegia, and progressive loss of vision. Orbital imaging revealed a retrobulbar soft-tissue density compatible with hematoma. Repeat orbital exploration revealed the soft-tissue mass to be swollen ORC. CONCLUSIONS: Retained intraorbital ORC may cause a compartment syndrome and should be suspected in postoperative patients with orbital symptoms. When ORC is used around the optic nerve, it should be removed after hemostasis is achieved.

Her vision was tied down.

A 50-year-old female presented with progressive painless vision loss in the left eye and was subsequently diagnosed to have a pituitary macroadenoma, consistent with a prolactinoma, which was compressing the chiasm primarily on the left and involving the left cavernous sinus. She was treated with oral bromocriptine, resulting in marked shrinkage of the tumor and significant visual field recovery. Subsequently, she again began noting progressive vision loss in both eyes and was initially thought to have pituitary tumor regrowth. Repeat brain MRI, however, showed chiasmal prolapse with inferior tethering into an empty sella. Surgical fat padding to reposition the chiasm resulted in visual improvement with a different visual field pattern in the left eye. The clinical manifestations and etiopathogenesis of the empty sella syndrome are discussed.

Giant cell arteritis: diagnosing and treating inflammatory disease in older adults.

Giant cell arteritis (GCA), also known as temporal arteritis, cranial arteritis, or granulomatous arteritis, is a systemic necrotizing vasculitis seen in patients typically over age 50. If untreated, GCA can cause permanent visual loss in one or both eyes in 13% to 50% of patients. Primary care physicians routinely see elderly patients with headaches and fatigue; these may be potential symptoms of GCA. C-reactive protein (CRP) in conjunction with erythrocyte sedimentation rate (ESR) has 97% specificity in diagnosing GCA. Temporal artery biopsy confirms the diagnosis in many cases. Early recognition and treatment of this potentially blinding condition is thus essential. Systemic steroids are the standard therapy for patients with a positive diagnosis of GCA, and in a high percentage of patients the treatment may extend for more than one year.

Photopic ERGs in patients with optic neuropathies: comparison with primate ERGs after pharmacologic blockade of inner retina.

PURPOSE: To determine whether anterior ischemic optic neuropathy and compressive optic neuropathy in humans alter the photopic flash ERG and to investigate the cellular origins of the waves that are affected by pharmacologic agents in primates. METHODS: Photopic flash ERGs were recorded differentially, with DTL electrodes, between the two eyes of 22 patients with diagnosed optic neuropathy (n = 17, anterior ischemic optic neuropathy [AION]; n = 5, compressive optic neuropathy) and 25 age-matched control subjects and in 17 eyes of 13 monkeys (Macaca mulatta). The stimulus consisted of brief (<5 ms) red (lambda(max) = 660 nm) Ganzfeld flashes (energy range, 0.5-2.0 log td-s) delivered on a rod-saturating blue background of 3.7 log sc td (lambda(max) = 460 nm). An eye of the patient with ischemic changes at the disc was classified as symptomatic if it showed visual field defects with a mean deviation (MD) of P < 2%. Recordings in macaque monkeys were made before and after inner retinal blockade with tetrodotoxin (TTX) (1.2-2.1 microM; n = 7), TTX+N-methyl-d-aspartate (NMDA; 1.4-6.4 mM; n = 7), and cis-2, 3 piperidine dicarboxylic acid (PDA; 3.3-3.8 mM; n = 3). RESULTS: The PhNR amplitude was significantly reduced in both symptomatic (P = 3.4 x 10(-8)) and asymptomatic (P = 0.036) eyes of patients with AION or compressive optic neuropathy (P = 0.0054) compared with control subjects. The PhNR amplitude in the symptomatic eye showed a moderate correlation with field defects (P < 0.05) similar to previous findings in open-angle glaucoma. The a-wave also was reduced significantly in the symptomatic eye (P = 0.0002) of patients with AION. The i-wave, a positive wave on the trailing edge of the b-wave peaking around 50 ms, became more prominent in eyes in which the PhNR was significantly reduced. In monkeys, the PhNR was eliminated by TTX. The a-wave at the peak and later times was reduced by TTX, further reduced by NMDA, and eliminated after PDA in response to the red stimuli. PDA also eliminated the i-wave. CONCLUSIONS: PhNR amplitude is significantly reduced in eyes with open-angle glaucoma, AION, and compressive optic neuropathy. Experiments in primates indicate that this reduction reflects loss of a spike-driven contribution to the photopic ERG. There also are small spike-driven contributions to the a-wave elicited by full-field red stimuli. The i-wave, which becomes more prominent when the PhNR is reduced, has origins in the off-pathway distal to the ganglion cells.

Evaluation and treatment of papilledema in pregnancy.

Papilledema is defined as optic disk edema that is secondary to increased intracranial pressure. During pregnancy, papilledema poses additional diagnostic and therapeutic challenges. As in the nonpregnant patient, the primary goal is to urgently determine the cause of the papilledema followed by implementing appropriate management for life-threatening conditions in a timely fashion while safeguarding the fetus. Papilledema may occur also in conditions that are not life threatening; in either case, papilledema may cause visual failure. We describe the two most common causes of papilledema during pregnancy, idiopathic intracranial hypertension and cerebral venous thrombosis. In the former, there is no threat to life, while in the latter, depending on the extent of the cerebral venous thrombosis, life-threatening medical issues may dominate the picture. In these conditions, attention to the prevention of visual failure is of major importance; however, treatment options may need to be modified to safeguard the developing fetus. In this article, we review the current diagnostic and treatment options for patients with papilledema, emphasizing special considerations for the pregnant patient, including a chart to help the clinician differentiate between the different conditions causing papilledema. A flow chart suggests an approach as to how to monitor vision function and steps to take to prevent visual loss in these conditions causing papilledema. Drugs that may be considered in the management of papilledema are reviewed, and the FDA information regarding their safety for the fetus is provided.

Medical and surgical management of idiopathic intracranial hypertension in pregnancy.

Idiopathic intracranial hypertension (IIH) is a syndrome of increased intracranial pressure without hydrocephalus or mass lesion with elevated cerebrospinal fluid (CSF) pressure but otherwise normal CSF composition. It has been found that pregnancy occurs in IIH patients at about the same rate as in the general population, that IIH can occur in any trimester of pregnancy, that patients have the same spontaneous abortion rate as the general population, and that the visual outcome is the same as for nonpregnant patients with IIH. Although it is also stated that pregnant patients with IIH should be managed and treated the same way as any other patient with IIH, the use of imaging and drug contraindications do make a difference between the two groups. The treatment has two major goals, which are to preserve vision and to improve symptoms. The medical therapy includes weight control, nonketotic diet, serial lumbar punctures, diuretics, steroids, and certain analgesics. When medical therapy fails, surgical procedures should be considered. The two main procedures are optic nerve sheath fenestration and lumboperitoneal shunt. Anesthetic considerations in the pregnant patient are an additional factor when surgeries are contemplated. It is also noted that therapeutic abortion to limit progression of disease is not indicated and that subsequent pregnancies do not increase the risk of recurrence.