Potential Risk Factors of Smokeless Tobacco Consumption Among Adolescents in South India.

INTRODUCTION: Although most of the disease burden internationally is due to tobacco smoking, smokeless tobacco (SLT) use contributed to an estimated 76 000 deaths in 2017. We have studied the potential risk factors for SLT use among adolescents in South India. METHODS: A cross-sectional questionnaire survey of all students in grades 6-8 in schools in the Udupi district of Karnataka State ascertained SLT use status and potential determinants of SLT uptake. Ever SLT use was defined as any reported consumption of any SLT products, currently or at any time in the past. Independent effects on ever SLT use status were estimated using multiple logistic regression. RESULTS: Of 46 706 students from 914 participating schools, 39 282 (84.1%) provided questionnaire responses sufficiently complete for analysis. Ever SLT use was reported by 775 (2.0%) participants and in a mutually adjusted model was significantly related to age, male sex, family use, or friend's use of SLT, low socioeconomic status, high rebelliousness, and low self-esteem. After controlling for these effects, the odds of ever-SLT use were significantly higher among students who had least awareness of the harmful effects of tobacco use (odds ratio 3.7, 95% confidence interval [2.9, 4.7]) and significantly lower among those not exposed to tobacco advertising (odds ratio 0.7, 95% confidence interval [0.5, 0.8]). CONCLUSIONS: The prevalence of SLT use among children in Karnataka is relatively low when compared with other studies in India. The significant potential risk factors of SLT use include low awareness of the harmful effects of tobacco and tobacco control policies and exposure to tobacco advertising. IMPLICATIONS: The prevalence of SLT use among school going adolescents in South India is relatively low. The potential risk factors for SLT use among adolescents in southern India are similar to those for smoked tobacco. It includes age, male gender, family or friend's use of SLT, low socioeconomic status, high rebelliousness, low self-esteem, exposure to tobacco advertisement and least awareness about the harmful effects of tobacco and of tobacco control policies. The present study lays emphasis regarding creating awareness about tobacco harms and control policies for further reducing tobacco use among adolescents.

Exposure to tobacco imagery in popular films and the risk of ever smoking among children in southern India.

BACKGROUND: Exposure to smoking in films is a recognised cause of smoking uptake among children. In India, in an attempt to protect children, films containing smoking are required to include tobacco control messaging including audiovisual disclaimers, on-screen health warnings when tobacco imagery is displayed and antitobacco 'health spots' before and during the film. We report a study of the association between ever smoking and exposure to tobacco imagery in locally popular films among children in Udupi district of Karnataka state in southern India. METHODS: A cross-sectional questionnaire survey of all students in grades 6-8 in schools in the Udupi district ascertained smoking status and potential confounders of smoking uptake, and whether children had seen any of 27 locally popular films we had coded and found to contain imagery of actual or implied tobacco use. Ever-smoking status was defined as any reported smoking of cigarettes, beedis or other tobacco products currently or at any time in the past. Independent effects on ever-smoking status were estimated using multiple logistic regression. RESULTS: Of 46 706 students enrolled in grades 6-8 in 914 participating schools, 39 282 (84.1%) provided questionnaire responses sufficiently complete for analysis. Ever smoking was reported by 914 (2.3%) participants and in a mutually adjusted model was significantly related to age, male sex, living in a home where smoking is allowed, having parents or siblings who smoke, low paternal education, low levels of family wealth, low self-esteem, rebelliousness and poor school performance. After allowing for these effects, the odds of ever smoking were not increased among students who had seen any of the listed films containing tobacco imagery when included in the analysis as a binary exposure (OR 0.9, 95% CI 0.4 to 2.0), and decreased in relation to level of exposure graded into tertiles of tobacco intervals seen. CONCLUSIONS: In this cross-sectional study, children in southern India who had seen films containing tobacco imagery are no more likely to smoke than those who had not, indicating that the tobacco control messaging mandated by Indian law may be attenuating the effect of tobacco imagery in films on smoking uptake.

Tobacco and tobacco branding in films most popular in the UK from 2009 to 2017.

BACKGROUND: Exposure to tobacco content in films is a cause of smoking uptake in young people. In an earlier study, we reported that tobacco content occurred in 70% of UK box office films popular between 1989 and 2008. We now report an analysis of tobacco content in a sample of the top grossing UK box office films between 2009 and 2017, and of population exposure resulting from audience exposure to the 2017 films. METHODS: Occurrence of tobacco intervals (actual tobacco use, implied use, appearance of smoking paraphernalia or branding) was measured by 5 min interval coding in the 15 most commercially successful films in the UK in each year from 2009 to 2017. A nationally representative survey was used to estimate population exposure to the top 15 films from 2017. RESULTS: We coded 3248 intervals from the 135 films. Tobacco content appeared in 245 intervals (8%, 95% CI 7% to 9%) across 56 (41%, 95% CI 33% to 49%) films. Tobacco content occurred in films in all BBFC age ratings, and 36 (64%, 95% CI 51% to 77%) of films containing tobacco imagery were classified as suitable for viewing by people aged under 15 years. Although less prevalent than in our earlier study, there was no evidence of a secular decline in tobacco content during this study period. The top 15 films from 2017 delivered approximately 21.6 (95% CI 21.06-22.14) million tobacco impressions to young people aged 10-18 years in the UK. CONCLUSIONS: Tobacco content continues to appear in UK Box Office films and is widely seen by young people, representing a major driver of smoking uptake.

Assessment of tobacco imagery and compliance with tobacco-free rules in popular Indian films.

BACKGROUND: Exposure to smoking in films causes smoking uptake among adolescents. Investigation of the extent to which tobacco imagery appears, or tobacco control laws are complied with in Indian films is limited, and especially so for films in regional languages. This study presents an analysis of tobacco content and compliance with tobacco control laws in popular films in several languages from the Karnataka state of India. METHODS: We used 5 min interval coding to measure actual tobacco use, implied tobacco use, tobacco paraphernalia and tobacco branding in the top 10 films identified from national box office ratings and regional distributor reports in Karnataka in 2015 and 2016. We also assessed compliance with tobacco-free film rules in India. FINDINGS: A total of 47 films, in English, Hindi, Malayalam, Tamil, Telugu and Tulu languages were coded. Any tobacco imagery was observed in 72% of films, and actual tobacco use in 50%. Tobacco imagery was equally prevalent in films classified as suitable for universal viewing (U category) or at age 12 or more (U/A category) films; and significantly more common in films made in regional than national language (Hindi). None of the films were fully compliant with legal requirements on health spots, audiovisual disclaimers and health warnings. CONCLUSIONS: Tobacco content was common in films classified as suitable for viewing by children, more among regional than national languages. Compliance with tobacco control laws was low. Stricter enforcement of tobacco-free film rules will protect children and adolescents from exposure to tobacco use on screen.

Hospital doctors' attitudes to brief educational messages that aim to modify diagnostic test requests: a qualitative study.

BACKGROUND: Avoidable use of diagnostic tests can both harm patients and increase the cost of healthcare. Nudge-type educational interventions have potential to modify clinician behaviour while respecting clinical autonomy and responsibility, but there is little evidence how this approach may be best used in a healthcare setting. This study aims to explore attitudes of hospital doctors to two nudge-type messages: one concerning potential future cancer risk after receiving a CT scan, another about the financial costs of blood tests. METHODS: We added two brief educational messages to diagnostic test results in a UK hospital for one year. One message on the associated long-term potential cancer risk from ionising radiation imaging to CT scan reports, and a second on the financial costs incurred to common blood test results. We conducted a qualitative study involving telephone interviews with doctors working at the hospital to identify themes explaining their response to the intervention. RESULTS: Twenty eight doctors were interviewed. Themes showed doctors found the intervention to be highly acceptable, as the group had a high awareness of the need to prevent harm and optimise use of finite resources, and most found the nudge-type approach to be inoffensive and harmless. However, the messages were not seen as personally relevant because doctors felt they were already relatively conservative in their use of tests. Cancer risk was important in decision-making but was not considered to represent new knowledge to doctors. Conversely, financial costs were considered to be novel information that was unimportant in decision-making. Defensive medicine was commonly cited as a barrier to individual behaviour change. The educational cancer risk message on CT scan reports increased doctors' confidence to challenge decisions and explain risks to patients and there were some modifications in clinical practice prompted by the financial cost message. CONCLUSION: The nudge-type approach to target avoidable use of tests was acceptable to hospital doctors but there were barriers to behaviour change. There was evidence doctors perceived this cheap and light-touch method can contribute to culture change and form a foundation for more comprehensive educational efforts to modify behaviour in a healthcare environment.

Content analysis of tobacco content in UK television.

AIMS: Exposure to audiovisual tobacco content in media is a risk factor for smoking in young people. While tobacco content in films has been extensively documented, content in mainstream television has received relatively little attention. We report an analysis of tobacco content in a sample of UK free-to-air prime-time television broadcasts in 2015, and compare this with a similar analysis from 2010. DESIGN: Content analysis of all programmes and advertisements or trailers broadcast on the five national UK free-to-air channels in the UK between 18:00 and 22:00 during three separate weeks in September, October and November 2015. SETTING: Great Britain. PARTICIPANTS: None (media analysis only). MEASUREMENTS: Occurrence of any tobacco, tobacco use, implied use, other tobacco reference/related objects and branding in every 1 min coding interval. FINDINGS: Tobacco content occurred in 33% of all programmes and 8% of all adverts or programme trailer breaks. Actual tobacco use occurred in 12% of all programmes broadcast. Tobacco-related objects, primarily no smoking signs, occurred in 2% of broadcasts; implied tobacco use and tobacco branding were also rare. The majority of tobacco content occurred after the 21:00 watershed. CONCLUSIONS: These findings are virtually unchanged from our earlier analysis of programme content from 2010. Audiovisual tobacco content remains common in UK television programmes.

A content analysis of alcohol content in UK television.

BACKGROUND: Exposure to audio-visual alcohol content in media is associated with subsequent alcohol use in young people, but the extent of exposure contained in UK free-to-air prime-time television has not been explored since 2010. We report an analysis of alcohol content in a sample of UK free-to-air prime-time television broadcasts in 2015 and compare this with a similar analysis from 2010. METHODS: Content analysis of all programmes and advertisement/trailer breaks broadcast on the five national UK free-to-air channels in the UK between 6 and 10 pm during three separate weeks in September, October and November 2015. RESULTS: Alcohol content occurred in over 50% of all programmes broadcast and almost 50% of all advert/trailer periods between programmes. The majority of alcohol content occurred before the 9 pm watershed. Branding occurred in 3% of coded intervals and involved 122 brands, though three brands (Heineken, Corona and Fosters) accounted for almost half of all brand appearances. CONCLUSION: Audio-visual alcohol content, including branding, is prevalent in UK television, and is therefore a potential driver of alcohol use in young people. These findings are virtually unchanged from our earlier analysis of programme content from 2010.

Evaluation of the impact of a brief educational message on clinicians' awareness of risks of ionising-radiation exposure in imaging investigations: a pilot pre-post intervention study.

BACKGROUND: In the context of increasing availability of computed tomography (CT) scans, judicious use of ionising radiation is a priority to minimise the risk of future health problems. Hence, education of clinicians on the risks and benefits of CT scans in the management of patients is important. METHODS: An educational message about the associated lifetime cancer risk of a CT scan was added to all CT scan reports at a busy acute teaching hospital in the UK. An online multiple choice survey was completed by doctors before and after the intervention, assessing education and knowledge of the risks involved with exposure to ionising radiation. RESULTS: Of 546 doctors contacted at baseline, 170 (31%) responded. Over a third (35%) of respondents had received no formal education on the risks of exposure to ionising radiation. Over a quarter (27%) underestimated (selected 1 in 30,000 or negligible lifetime cancer risk) the risk associated with a chest, abdomen and pelvis CT scan for a 20 year old female. Following exposure to the intervention for 1 year there was a statistically significant improvement in plausible estimates of risk from 68.3 to 82.2% of respondents (p < 0.001). There was no change in the proportion of doctors correctly identifying imaging modalities that do or do not involve ionising radiation. CONCLUSIONS: Training on the longterm risks associated with diagnostic radiation exposure is inadequate among hospital doctors. Exposure to a simple non-directional educational message for 1 year improved doctors' awareness of risks associated with CT scans. This demonstrates the potential of the approach to improve knowledge that could improve clinical practice. This approach is easily deliverable and may have applications in other areas of clinical medicine. The wider and longer term impact on radiation awareness is unknown, however, and there may be a need for regular mandatory training in the risks of radiation exposure.

Population exposure to smoking and tobacco branding in the UK reality show 'Love Island'.

BACKGROUND: Reality television shows are popular with children and young adults; inclusion of tobacco imagery in these programmes is likely to cause smoking in these groups. Series 3 of the UK reality show Love Island, broadcast in 2017, attracted widespread media criticism for high levels of smoking depicted. We have quantified this tobacco content and estimated the UK population exposure to generic and branded tobacco imagery generated by the show. METHODS: We used 1-min interval coding to quantify actual or implied tobacco use, tobacco paraphernalia or branding, in alternate episodes of series 3 of Love Island, and Census data and viewing figures from Kantar Media to estimate gross and per capita tobacco impressions. RESULTS: We coded 21 episodes comprising 1001 min of content. Tobacco imagery occurred in 204 (20%) intervals; the frequency of appearances fell significantly after media criticism. An identifiable cigarette brand, Lucky Strike Double Click, appeared in 16 intervals. The 21 episodes delivered an estimated 559 million gross tobacco impressions to the UK population, predominantly to women, including 47 million to children aged <16 and 44 million gross impressions of Lucky Strike branding, including 4 million to children <16. CONCLUSION: Despite advertising legislation and broadcasting regulations intended to protect children from smoking imagery in UK television, series 3 of Love Island delivered millions of general and branded tobacco impressions both to children and adults in the UK. More stringent controls on tobacco content in television programmes are urgently needed.

Alcohol Content in the 'Hyper-Reality' MTV Show 'Geordie Shore'.

AIM: To quantify the occurrence of alcohol content, including alcohol branding, in the popular primetime television UK Reality TV show 'Geordie Shore' Series 11. METHODS: A 1-min interval coding content analysis of alcohol content in the entire DVD Series 11 of 'Geordie Shore' (10 episodes). Occurrence of alcohol use, implied use, other alcohol reference/paraphernalia or branding was recorded. RESULTS: All categories of alcohol were present in all episodes. 'Any alcohol' content occurred in 78%, 'actual alcohol use' in 30%, 'inferred alcohol use' in 72%, and all 'other' alcohol references occurred in 59% of all coding intervals (ACIs), respectively. Brand appearances occurred in 23% of ACIs. The most frequently observed alcohol brand was Smirnoff which appeared in 43% of all brand appearances. Episodes categorized as suitable for viewing by adolescents below the legal drinking age of 18 years comprised of 61% of all brand appearances. CONCLUSIONS: Alcohol content, including branding, is highly prevalent in the UK Reality TV show 'Geordie Shore' Series 11. Two-thirds of all alcohol branding occurred in episodes age-rated by the British Board of Film Classification (BBFC) as suitable for viewers aged 15 years. The organizations OfCom, Advertising Standards Authority (ASA) and the Portman Group should implement more effective policies to reduce adolescent exposure to on-screen drinking. The drinks industry should consider demanding the withdrawal of their brands from the show. SHORT SUMMARY: Alcohol content, including branding, is highly prevalent in the MTV reality TV show 'Geordie Shore' Series 11. Current alcohol regulation is failing to protect young viewers from exposure to such content.

Carlsberg alibi marketing in the UEFA euro 2016 football finals: implications of Probably inappropriate alcohol advertising.

BACKGROUND: Alcohol advertising is a key driver of alcohol consumption, and is prohibited in France by the Loi Evin. In 2016 the Danish brewer Carlsberg sponsored the UEFA Euro 2016 finals, held in France, and used the alibis 'Probably' and '…the best in the world' in place of Carlsberg in pitch-side advertising. We have quantified the advertising exposure achieved during the final seven games in the UEFA Euro 2016 championship. METHODS: Appearances of the Carlsberg alibis 'Probably' and 'the best in the world' were counted and timed to the nearest second during all active play in live coverage of quarter final, semi-final and final matches broadcast in the UK. We used census data and viewing figures from Kantar Media to estimate gross and per capita impressions of these advertisements in the UK population. RESULTS: In 796 min, 29 s of active play there were 746 alibi appearances, totalling 68 min 35 s duration and representing 8.6% of active playing time. Appearances were particularly frequent at the end of normal time, extra time and penalties. The seven matches delivered up to 7.43 billion Carlsberg alibi impressions to UK adults and 163.3 million to children. In the only match involving a second country with laws prohibiting alcohol advertising (France versus Iceland), exposure occurred for only 1.8% of playing time. CONCLUSIONS: Alibi marketing achieved significant advertising coverage during the final seven EURO 2016 championship games, particularly to children. Since 'Probably' is registered by Carlsberg as a wordmark this advertising appears to contravene the Loi Evin, though Carlsberg have defended their marketing actions.

Portrayal of tobacco smoking in popular women's magazines: a content analysis.

Background: Whilst many countries have introduced legislation prohibiting tobacco advertising and sponsorship, references to tobacco continue to appear in the media. This study quantified and characterized tobacco smoking content in popular women's magazines. Methods: The 10 top weekly and 5 monthly women's magazines most popular among 15-34 year olds in Britain published over a 3-month period were included. A content analysis was conducted for both written and visual content. Results: In 146 magazines, there were 310 instances of tobacco content, the majority of which were positive towards smoking. Instances of celebrities smoking were most common (171, 55%), often in holiday or party settings that could be perceived to be luxurious, glamorous or fun. In all, 55 (18%) tobacco references related to fashion, which generally created an impression of smoking as a norm within the industry; and 34 (11%) text and image references to tobacco in TV and film. There were 50 (16%) reader-initiated mentions of smoking, typically in real-life stories or readers writing in to seek advice about smoking. Anti-smoking references including the hazards of smoking were infrequent (49; 16%). Conclusions: Although tobacco advertising is prohibited in Britain, women's magazines still appear to be promoting positive messages about tobacco and smoking.

"F*ck It! Let's Get to Drinking-Poison our Livers!": a Thematic Analysis of Alcohol Content in Contemporary YouTube MusicVideos.

PURPOSE: The purpose of the present study is to describe the portrayal of alcohol content in popular YouTube music videos. METHOD: We used inductive thematic analysis to explore the lyrics and visual imagery in 49 UK Top 40 songs and music videos previously found to contain alcohol content and watched by many British adolescents aged between 11 and 18 years and to examine if branded content contravened alcohol industry advertising codes of practice. RESULTS: The analysis generated three themes. First, alcohol content was associated with sexualised imagery or lyrics and the objectification of women. Second, alcohol was associated with image, lifestyle and sociability. Finally, some videos showed alcohol overtly encouraging excessive drinking and drunkenness, including those containing branding, with no negative consequences to the drinker. CONCLUSION: Our results suggest that YouTube music videos promote positive associations with alcohol use. Further, several alcohol companies adopt marketing strategies in the video medium that are entirely inconsistent with their own or others agreed advertising codes of practice. We conclude that, as a harm reduction measure, policies should change to prevent adolescent exposure to the positive promotion of alcohol and alcohol branding in music videos.

Larger and More Prominent Graphic Health Warnings on Plain-Packaged Tobacco Products and Avoidant Responses in Current Smokers: a Qualitative Study.

BACKGROUND: The introduction of tobacco plain packaging legislation in Australia meant that all tobacco products were to be sold in plain dark-brown packaging with 75% front-of-pack graphic health warnings and standardised font type and size for brand name and product variant. The change in the size and prominence of the warnings has been proposed as a reason for behaviour change in smokers in terms of increased intentions to quit and quit attempts. PURPOSE: The current research examined attitudes and beliefs of cigarette smokers toward the increased size and prominence of the warnings and effects on their behaviour. METHOD: Participants (N = 160) completed open-ended responses to questions on beliefs, attitudes and responses to plain packaging. Responses were subjected to inductive thematic content analysis for key themes. RESULTS: Four themes emerged from the analysis: emotional response to packaging, scepticism of health warnings, warnings and cessation behaviour, and avoidant coping behaviours. Participants reported increased negative emotional responses to the packaging and made specific reference to the graphic health warnings. Some participants attempted to discredit the messages. Others reported increased intentions to quit or quitting attempts. There were pervasive reports of avoidant responses including covering or hiding the warnings. CONCLUSION: Consistent with theories of illness perceptions and coping, current findings indicate that the larger, prominent graphic health warnings on plain-packaged tobacco products had pervasive effects on threat perceptions and subsequent behavioural responses. While some of the reported responses were adaptive (e.g. attempts to quit), others were maladaptive (e.g. avoiding the warnings).

Prospective study of exposure to smoking imagery in films and changes in susceptibility to smoking in a cohort of school students in Southern India.

INTRODUCTION: India has unique tobacco-free film and TV rules designed to prevent tobacco uptake. In this study, we examined the potential influence of exposure to smoking imagery in regionally famous films, on susceptibility to smoke in teenagers enrolled in schools in a district in Southern India. METHODS: A longitudinal survey of students, in grades 6 to 8 at baseline in 2017 and grades 7 to 9 one year later in 2018, ascertained prospective incident susceptibility to smoking during the study period in relation to baseline exposure to 27 locally popular films with actual or implied smoking imagery. RESULTS: We analyzed linked data from 33676 participants, and 3973 (11.8%) of the adolescents reported incident susceptibility. There was a significant increase in susceptibility to smoking with increasing exposure at baseline to smoking imagery in films on univariable analysis, highest tertile of exposure relative to no exposure (OR=1.4; 95% CI: 1.0 -2.1, ptrend<0.001), and this trend remained significant (p=0.022) after mutual adjustment for recognized confounders, highest vs no exposure (AOR=1.3; 95% CI: 0.9-1.8). We found no statistically significant association between exposure to tobacco-free film rules and change in susceptibility. CONCLUSIONS: Prospectively, watching films featuring smoking imagery increases adolescents' vulnerability to smoking. Further research revealed no difference in susceptibility change between youth who saw partially compliant films and those who watched non-compliant films. Our findings, thus, underscore the need to incorporate comprehensive approaches to prevent the inclusion of smoking imagery in films.

Tobacco advertising, promotion, and sponsorship ban adoption: A pilot study of the reporting challenges faced by low- and middle-income countries.

INTRODUCTION: The WHO Framework Convention for Tobacco Control (FCTC) Secretariat has identified issues with Article 13 (Tobacco Advertising, Promotion and Sponsorship) Party policy progress reporting, whilst some researchers remain skeptical of the completeness and accuracy of the data collected as part of the required reporting questionnaire. Gaining a deeper understanding of the challenges encountered when completing these questionnaires could provide insights to improve WHO FCTC progress reporting. METHODS: Qualitative semi-structured interviews were conducted between January and June 2021, with nine national tobacco control focal point (NFP) individuals (designates who report on WHO FCTC implementation on the Party's behalf) from low- and middle-income countries. The study analysis used a thematic framework approach involving data familiarization, thematic framework construction, indexing and refining, mapping and interpretation of the results. RESULTS: The analysis generated four themes: 1) use of different resources, 2) presence of compounding complexities, 3) use of supporting mechanisms employed for tackling the challenges, and 4) recommendations for refinements within the questionnaire and for those completing it. CONCLUSIONS: The WHO FCTC reporting questionnaire needs improvements that could be piloted and discussed between the Convention Secretariat and the Parties prior to wide scale implementation.

Achieving a tobacco-free Bangladesh by 2040: a qualitative analysis of the tobacco advertising environment and prohibitions in Bangladesh.

OBJECTIVES: This paper explores the Bangladeshi tobacco advertising, promotion and sponsorship (TAPS) legislative environment, to highlight any potential policy loopholes and to facilitate the identification of additional provisions for inclusion. The study also aimed to identify valuable lessons applicable to other low-income and middle-income countries (LMICs). METHODS: We conducted a qualitative health policy analysis using the health policy triangle model to frame the collection and extraction of publicly available information from academic literature search engines, news media databases and websites of national and international organisations, published up until December 2020. We coded and analysed textual data using the thematic framework approach to identify themes, relationships and connections. RESULTS: Four themes underpin the Bangladesh legislative environment on TAPS: (1) engaging international actor interest in TAPS policies, (2) the incremental approach to TAPS policy-making, (3) time-sensitive TAPS monitoring data and (4) innovative TAPS monitoring and policy enforcement system. The findings highlight the role of international actors (such as multinational organisations and donors), tobacco control advocates and the tobacco industry in the policy-making process and the competing agendas they bring. We also outline the chronology of TAPS policy-making in Bangladesh and the existing loopholes and policy changes over time. Lastly, we describe the innovative approaches to TAPS monitoring and policy enforcement in Bangladesh to combat the tobacco industry marketing strategies. CONCLUSION: This study highlights the role of tobacco control advocates as crucial in TAPS policy-making, monitoring and enforcement in LMICs, and identifies good practices for the sustainability of tobacco control programmes. However, it also points out that tobacco industry interference, coupled with increasing pressure on advocates and legislators, may block progress in tobacco endgame approaches.

From the international tobacco control arena to the local context: a qualitative study on the tobacco advertising, promotion and sponsorship legislative environment in Sudan and the challenges characterising it.

OBJECTIVES: The aim of the study was to assess the Sudanese tobacco advertising, promotion and sponsorship (TAPS) legislative environment and the challenges characterising it. We formulated three research questions: What is the TAPS policy context in Sudan? What circumstances led to the development of the current legislative text? Finally, what was the involvement of the different actors in these events? DESIGN: We conducted a qualitative analysis using the Health Policy Triangle model to frame the collection and extraction of publicly available information from academic literature search engines, news media databases or websites of national and international organisations, as published by February 2021. The thematic framework approach was employed to code and analyse the textual data and the generated themes were used to map connections across the data and to explore relationships among the generated subthemes and themes. SETTING: Sudan. DATA: Using a combination of the keywords "Sudan" and "tobacco advertising" (or "tobacco marketing" or "tobacco promotion"), we collected publicly available documents in the English language. We included 29 documents in the analysis. RESULTS: Three themes underpin the Sudanese legislative environment on TAPS: (1) limited and outdated TAPS data, (2) stakeholder involvement and tobacco industry interference and (3) TAPS legislation not aligned with the WHO Framework Convention on Tobacco Control Secretariat recommendations. CONCLUSIONS: Findings from this qualitative analysis suggest that recommendations to move forward in Sudan should include the systematic and periodic collection of TAPS surveillance data, addressing any remaining legislative content loopholes and protecting policy-making from tobacco industry interference. In addition, best practices from other low-income and middle-income countries with good TAPS monitoring systems, such as Egypt, Bangladesh and Indonesia, or with protective provisions against tobacco industry interference, such as Thailand and the Philippines, could be considered for adaptation and implementation.

Monitoring and normalising a lack of appetite and weight loss. A discursive analysis of an online support group for bariatric surgery.

A significant adjustment in eating practices is required before and after bariatric surgery, yet we know relatively little about how patients manage these changes. In this paper, we explored how members of an online bariatric support group constructed their appetite and weight loss. Two hundred and eighty four online posts were collected, covering a period of just over a year, and analysed using discursive psychology. We found that a lack of appetite post-surgery was oriented to as something that was positively evaluated yet a cause for concern. Indeed, members monitored their food intake and marked out food consumption as a necessary activity in line with notions of healthy eating. Through monitoring members also normalised periods of weight stabilisation and were inducted into a group philosophy which encouraged a more holistic approach to post-surgery 'success'. Our analysis also highlights how monitoring and policing work as social support mechanisms which help to maintain weight management. Thus we argue, in line with others, that weight management, typically depicted as an individual responsibility, is bound up with the social practices of the online support group. We suggest that clinical advice about a loss of appetite and periods of weight stabilisation post-surgery perhaps need further explanation to patients.