Hosting the Tobacco Industry Supply Chain and Political Interference.

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

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

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

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

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

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

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

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

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

Availability and Use of Cheap Tobacco in the United Kingdom 2002-2014: Findings From the International Tobacco Control Project.

Introduction: Raising tobacco prices is the most effective population-level intervention for reducing smoking, but this is undermined by the availability of cheap tobacco. This study monitors trends in cheap tobacco use among adult smokers in the United Kingdom between 2002 and 2014 via changes in product type, purchase source, and prices paid. Methods: Weighted data from 10 waves of the International Tobacco Control policy evaluation study were used. This is a longitudinal cohort study of adult smokers with replenishment; 6169 participants provided 15812 responses. Analyses contrasted (1) product type: roll-your-own (RYO) tobacco, factory-made packs (FM-P), and factory-made cartons (FM-C); (2) purchase source: UK store-based sources (e.g., supermarkets and convenience stores) with non-UK/nonstore sources representing tax avoidance/evasion (e.g., outside the UK, duty free, and informal sellers); and (3) prices paid (inflation-adjusted to 2014 values). Generalized estimating equations tested linear changes over time. Results: (1) RYO use increased significantly over time as FM decreased. (2) UK store-based sources constituted approximately 80% of purchases over time, with no significant increases in tax avoidance/evasion. (3) Median RYO prices were less than half that of FM, with FM-C cheaper than FM-P. Non-UK/nonstore sources were cheapest. Price increases of all three product types from UK store-based sources from 2002 to 2014 were statistically significant but not substantial. Wide (and increasing for FM-P) price ranges meant each product type could be purchased in 2014 at prices below their 2002 medians from UK store-based sources. Conclusions: Options exist driving UK smokers to minimize their tobacco expenditure; smokers do so largely by purchasing cheap tobacco products from UK stores. Implications: The effectiveness of price increases as a deterrent to smoking is being undermined by the availability of cheap tobacco such as roll-your-own tobacco and cartons of packs of factory-made cigarettes. Wide price ranges allowed smokers in 2014 to easily obtain cigarettes at prices comparable to 12 years prior, without resorting to tax avoidance or evasion. UK store-based sources accounted for 80% or more of all tobacco purchases between 2002 and 2014, suggesting little change in tax avoidance or evasion over time. There was a widening price range between the cheapest and most expensive factory-made cigarettes.

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

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

Prevalence and Impact of Long-term Use of Nicotine Replacement Therapy in UK Stop-Smoking Services: Findings From the ELONS Study.

BACKGROUND: Nicotine replacement therapy (NRT) was licensed for harm reduction in the United Kingdom in 2005, and guidance to UK Stop-Smoking Services (SSS) to include long-term partial or complete substitution of cigarettes with NRT was issued in 2013. Yet, NRT prevalence data and data on changes in biomarkers associated with long-term NRT use among SSS clients are scarce. METHODS: SSS clients abstinent 4 weeks postquit date were followed up at 12 months. At baseline standard sociodemographic, smoking and SSS use characteristics were collected and of those eligible, 60.6% (1047/1728) provided data on smoking status and NRT use at follow-up. A subsample also provided saliva samples at baseline and of those eligible, 36.2% (258/712) provided follow-up samples. Saliva was analyzed for cotinine (a metabolite of nicotine) and alpha-amylase (a stress biomarker). RESULTS: Among those who had used NRT during their initial quit attempt (61.5%, 95% CI 58.4%-64.6%), 6.0% (95% CI 4.3%-8.3%) were still using NRT at 1 year, significantly more ex-smokers than relapsed smokers (9.5% vs. 3.7%; p = .005). In adjusted analysis, NRT use interacted with smoking status to determine change in cotinine, but not alpha-amylase, levels (Wald χ2 (1) = 13.0, p < .001): cotinine levels remained unchanged in relapsed smokers and ex-smokers with long-term NRT use but decreased in ex-smokers without long-term NRT use. CONCLUSIONS: Long-term NRT use is uncommon in SSS clients, particularly among relapsed smokers. Its use is associated with continued high intake of nicotine among ex-smokers but does not increase nicotine intake in smokers. It does not appear to affect stress response. IMPLICATIONS: Little is known about the long-term effects of NRT. Given an increasing shift towards harm reduction in tobacco control, reducing the harm from combustible products by partial or complete substitution with noncombustible products, more data on long-term use are needed. This study shows that in the context of SSS, clients rarely use products for up to a year and that NRT use does not affect users' stress response. Ex-smokers using NRT long-term can completely replace nicotine from cigarettes with nicotine from NRT; long-term NRT use by continuing smokers does not increase nicotine intake. Long-term NRT appears to be a safe and effective way to reduce exposure to combustible nicotine.

Tobacco industry strategies undermine government tax policy: evidence from commercial data.

OBJECTIVE: Taxation equitably reduces smoking, the leading cause of health inequalities. The tobacco industry (TI) can, however, undermine the public health gains realised from tobacco taxation through its pricing strategies. This study aims to examine contemporary TI pricing strategies in the UK and implications for tobacco tax policy. DESIGN: Review of commercial literature and longitudinal analysis of tobacco sales and price data. SETTING: A high-income country with comprehensive tobacco control policies and high tobacco taxes (UK). PARTICIPANTS: 2009 to 2015 Nielsen Scantrak electronic point of sale systems data. MAIN OUTCOME MEASURES: Tobacco segmentation; monthly prices, sales volumes of and net revenue from roll-your-own (RYO) and factory-made (FM) cigarettes by segment; use of price-marking and pack sizes. RESULTS: The literature review and sales data concurred that both RYO and FM cigarettes were segmented by price. Despite regular tax increases, average real prices for the cheapest FM and RYO segments remained steady from 2013 while volumes grew. Low prices were maintained through reductions in the size of packs and price-marking. Each year, at the point the budget is implemented, the TI drops its revenue by up to 18 pence per pack, absorbing the tax increases (undershifting). Undershifting is most marked for the cheapest segments. CONCLUSIONS: The TI currently uses a variety of strategies to keep tobacco cheap. The implementation of standardised packaging will prevent small pack sizes and price-marking but further changes in tax policy are needed to minimise the TI's attempts to prevent sudden price increases.

Public health impacts of city policies to reduce climate change: findings from the URGENCHE EU-China project.

BACKGROUND: Climate change is a global threat to health and wellbeing. Here we provide findings of an international research project investigating the health and wellbeing impacts of policies to reduce greenhouse gas emissions in urban environments. METHODS: Five European and two Chinese city authorities and partner academic organisations formed the project consortium. The methodology involved modelling the impact of adopted urban climate-change mitigation transport, buildings and energy policy scenarios, usually for the year 2020 and comparing them with business as usual (BAU) scenarios (where policies had not been adopted). Carbon dioxide emissions, health impacting exposures (air pollution, noise and physical activity), health (cardiovascular, respiratory, cancer and leukaemia) and wellbeing (including noise related wellbeing, overall wellbeing, economic wellbeing and inequalities) were modelled. The scenarios were developed from corresponding known levels in 2010 and pre-existing exposure response functions. Additionally there were literature reviews, three longitudinal observational studies and two cross sectional surveys. RESULTS: There are four key findings. Firstly introduction of electric cars may confer some small health benefits but it would be unwise for a city to invest in electric vehicles unless their power generation fuel mix generates fewer emissions than petrol and diesel. Second, adopting policies to reduce private car use may have benefits for carbon dioxide reduction and positive health impacts through reduced noise and increased physical activity. Third, the benefits of carbon dioxide reduction from increasing housing efficiency are likely to be minor and co-benefits for health and wellbeing are dependent on good air exchange. Fourthly, although heating dwellings by in-home biomass burning may reduce carbon dioxide emissions, consequences for health and wellbeing were negative with the technology in use in the cities studied. CONCLUSIONS: The climate-change reduction policies reduced CO2 emissions (the most common greenhouse gas) from cities but impact on global emissions of CO2 would be more limited due to some displacement of emissions. The health and wellbeing impacts varied and were often limited reflecting existing relatively high quality of life and environmental standards in most of the participating cities; the greatest potential for future health benefit occurs in less developed or developing countries.

Smoking patterns in Great Britain: the rise of cheap cigarette brands and roll your own (RYO) tobacco.

BACKGROUND: In Britain, the tobacco industry segments cigarettes into four price categories-premium, mid-price, economy and ultra-low-price (ULP). Our previous work shows that tobacco companies have kept ULP prices stable in real terms. Roll your own (RYO) tobacco remains cheaper still. METHODS: Analysis of 2001-08 General Household Survey data to examine trends in use of these cheap products and, using logistic regression, the profile of users of these products. RESULTS: Among smokers, the proportion using cheap products (economy, ULP and RYO combined) increased significantly in almost all age groups and geographic areas. Increases were most marked in under 24 year olds, 76% of whom smoked cheap cigarettes by 2008. All cheap products were more commonly used in lower socio-economic groups. Men and younger smokers were more likely to smoke RYO while women smoked economy brands. Smokers outside London and the South East of England were more likely to smoke some form of cheap tobacco even once socio-economic differences were accounted for. CONCLUSIONS: This paper demonstrates that cheap tobacco use is increasing among young and disadvantaged smokers compromising declines in population smoking prevalence. Thus, tobacco industry pricing appears to play a key role in explaining smoking patterns and inequalities in smoking.

Do general medical practice characteristics influence the effectiveness of smoking cessation programs? A multilevel analysis.

INTRODUCTION: General practice is a recommended setting for the delivery of smoking cessation programs. Little is known about the types of practice that achieve higher cessation rates. To address this gap in knowledge, we assessed the impact of general practice characteristics on the outcomes of a large scale smoking cessation intervention delivered in general practice settings. METHOD: A cross-sectional study was undertaken of 7,778 participants enrolled on a structured cessation program comprising repeated brief interventions in one-to-one sessions and nicotine replacement therapy in Christchurch New Zealand, 2001-2007. We employed a logistic multilevel analysis of respondents nested in general practices with cessation at 6 months as the outcome measure. RESULTS: After taking into account relevant individual-level predictors (age, sex, smoking intensity) and area-level surrogates for individual predictors (socioeconomic status and access to tobacco retail outlets), there remained significant variation in quit rates between practices. This variation reduced when practice characteristics were included. Practices with a majority of male doctors and practices with fewer male patients were associated with better quit rates. Practices with large numbers of doctors were less effective in achieving cessation with heavy smokers. CONCLUSIONS: The effectiveness of smoking cessation programs can be influenced significantly by practice characteristics. To increase quit rates, more attention should be paid to the institutional setting of smoking cessation programs. Assessments of the effectiveness of cessation programs should give appropriate recognition to the fact that some practices may find higher quit rates more difficult to achieve.

Smoking and socioeconomic status in England: the rise of the never smoker and the disadvantaged smoker.

BACKGROUND: Since 2000 various tobacco control measures have been implemented in the UK. Changes in the smoking status of low and high socioeconomic status (SES) groups in England during this period (2001-08) are explored. METHODS: Secondary analysis of the Health Survey for England general population samples was undertaken. Over 88 000 adults, age 16 or over, living in England were included. Smoking status (current, ex or never) was reported. SES was assessed through a count of seven possible indicators of disadvantage: National Statistics Socio-Economic Classification (NSSEC), neighbourhood index of multiple deprivation, lone parenting, car availability, housing tenure, income and unemployment. RESULTS: Smoking rates were four times higher among the most disadvantaged [60.7% (95% CI: 58.2-63.3)] than the most affluent [15.3% (95% CI: 14.8-15.8)]. Smoking prevalence declined between 2001 and 2008 except among the multiply disadvantaged. This trend appeared to be due to an increase in never smoking rather than an increase in quitting. Disadvantage declined among non-smokers but not smokers. CONCLUSIONS: In general never smoking and affluence increased in England over this period. The disadvantaged, however, did not experience the decline in smoking and smokers missed out from the increase in affluence. Smoking and disadvantage may increasingly coexist.

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

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

One-year outcomes and a cost-effectiveness analysis for smokers accessing group-based and pharmacy-led cessation services.

INTRODUCTION: An observational study examining 1-year follow-up of clients of two National Health Service smoking cessation services in Glasgow was used to inform a cost-effectiveness analysis. One service involved 7 weeks of group-based support (n = 411) and the other consisted of up to 12 weeks of one-to-one counseling with pharmacists (n = 1,374). Pharmacological aids to quitting (e.g., nicotine replacement therapy) were available to all clients. METHODS: Quit rates were calculated for each service at 52 weeks after the quit date, and these were used for an economic evaluation of both the annual and the lifetime cost-effectiveness of the pharmacy- and group-based interventions in comparison with a baseline "self-quit" scenario. The annual cost-effectiveness model established the incremental cost per 52-week quitter, while a Markov model was developed for the lifetime analysis to estimate the potential lifetime outcomes in terms of cost per quality-adjusted life years (QALY) gained, to account for the benefits quitters will receive in terms of extended life years and improvements in quality of life from smoking cessation. RESULTS: The proportion of carbon monoxide-validated quitters from both services combined fell from 22.5% at 4-week follow-up to 3.6% at 52 weeks. The group service achieved a higher quit rate (6.3%) than the pharmacy service (2.8%) but was more intensive and required greater overhead costs. The lifetime analysis resulted in an incremental cost per QALY of £4,800 for the group support and £2,600 for pharmacy one-to-one counseling. CONCLUSIONS: Despite disappointing 1-year quit rates, both services were considered to be highly cost-effective.

Social inequalities in quitting smoking: what factors mediate the relationship between socioeconomic position and smoking cessation?

BACKGROUND: Smokers from lower socio-economic groups are less likely to be successful in a quit attempt than more affluent smokers, even when they access smoking cessation services. METHODS: Data were collected from smoking cessation service users from three contrasting areas of Great Britain-Glasgow, North Cumbria and Nottingham. Routine monitoring data were supplemented with CO-validated smoking status at 52-week follow-up and survey data on socio-economic circumstances and smoking-related behaviour. Analysis was restricted to the 2397 clients aged between 25 and 59. RESULTS: At 52-week follow-up, 14.3% of the most affluent smokers remained quit compared with only 5.3% of the most disadvantaged. After adjustment for demographic factors, the most advantaged clients at the English sites and the Glasgow one-to-one programme were significantly more likely to have remained abstinent than those who were most disadvantaged [odds ratio: 2.5, confidence interval (CI): 1.4-4.7 and 7.5 CI: 1.4-40.3, respectively). Mechanisms producing the inequalities appeared to include treatment compliance, household smokers and referral source. CONCLUSIONS: Rather than quitting smoking, disadvantaged smokers quit treatment. More should be done to encourage them to persevere through the first few weeks. Other causes of inequalities in quitting varied with the service provided.

The value of studying supply chains for tobacco control.

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