The tobacco endgame: The neglected role of place and environment

Which countries are ready for a tobacco endgame? A scoping review and cluster analysis

Various countries have set tobacco endgame targets to eliminate tobacco use by a certain year. Tobacco endgames are generally considered more feasible in countries with advanced tobacco control measures and a smoking prevalence of 15% or less. We conducted a scoping review of 563 articles sourced from news, academic literature, and grey literature to examine global tobacco endgame progress, and grouped 153 countries into clusters based on their tobacco policy implementation score and smoking prevalence to systematically identify countries that might be well positioned to succeed in a tobacco endgame. The EU, Pacific Islands, and 18 other individual countries have set tobacco endgame targets, with another seven countries described as well positioned for an endgame. These were mostly high-income countries with higher smoking prevalence. We identified 28 endgame-ready countries with advanced tobacco policies and a low smoking prevalence. Of these, only five were part of tobacco endgame movements; the remaining 23 were all low-income or middle-income countries in Africa, Latin America, or Asia. Therefore, the global tobacco endgame movement should focus more on low-income and middle-income countries with low smoking rates and advanced tobacco policies, particularly in Africa, Latin America, and Asia.

How do people who smoke perceive a tobacco retail outlet reduction policy in Aotearoa New Zealand? A qualitative analysis

BACKGROUND

Aotearoa New Zealand plans to greatly reduce tobacco retail outlets, which are concentrated in areas of higher deprivation and perpetuate health inequities caused by smoking and borne particularly by Māori. However, we lack in-depth analyses of how this measure could affect people who smoke.

METHODS

We undertook in-depth interviews with 24 adults from two urban areas who smoke. We used a novel interactive mapping approach to examine participants' current retail outlets and their views on a scenario where very few outlets would sell tobacco. To inform policy implementation, we probed participants' anticipated responses and explored the measure's wider implications, including unintended impacts. We used qualitative description to interpret the data.

RESULTS

Most participants anticipated accommodating the changes easily, by using alternative outlets or bulk-purchasing tobacco; however, they felt others would face access problems and increased costs, and greater stress. They thought the policy would spur quit attempts, reduce relapse among people who had quit and protect young people from smoking uptake, and expected more people to switch to alternative nicotine products. However, most foresaw unintended social outcomes, such as increased crime and reduced viability of local businesses.

CONCLUSIONS

Many participants hoped to become smoke-free and thought retail reduction measures would prompt quit attempts and reduce relapse. Adopting a holistic well-being perspective, such as those developed by Māori, could address concerns about unintended adverse outcomes and provide comprehensive support to people who smoke as they adjust to a fundamental change in tobacco availability.

Family Environment and Community Context for Longitudinal Cigarette Smoking Trajectories Among Chinese Young People

Tobacco use is the leading cause of preventable death, and China accounts for about 30% of worldwide smokers and 40% of global tobacco consumption. This study examines socioeconomic and community disparities in smoking among young Chinese people from 2010 to 2016. Data were from 953 people aged 16 to 25 in four waves of the China Family Panel Studies (CFPS). Two-level logistic regressions were fitted to account for both inter-individual and intra-individual differences over time. Weight-adjusted multilevel regression results showed a decrease in cigarette smoking among rural young people (OR = 0.71, 95% CI = [0.52, 0.98]) from 2010 to 2016. Higher family income was related to higher odds of cigarette smoking among young people (OR = 1.75, 95% CI = [1.10, 2.80]). Cigarette smoking among young people in families with higher incomes increased over time. Policies and interventions targeting the young should consider the socioeconomic disparities and multilevel context.

Economic effects for citizens and the government of a country-level tobacco endgame strategy: a modelling study

BACKGROUND

Aotearoa-New Zealand (A/NZ) was the first country to pass a comprehensive commercial tobacco endgame strategy into law. Key components include the denicotinisation of smoked tobacco products and a major reduction in tobacco retail outlets. Understanding the potential long-term economic impacts of such measures is important for government planning.

DESIGN

A tobacco policy simulation model that evaluated the health impacts of the A/NZ Smokefree Action Plan was extended to evaluate the economic effects from both government and citizen perspectives. Estimates were presented in 2021 US$, discounted at 3% per annum.

RESULTS

The modelled endgame policy package generates considerable growth in income for the A/NZ population with a total cumulative gain of US$31 billion by 2050. From a government perspective, increased superannuation payments and reduced tobacco excise tax revenue result in a negative net financial position and a cumulative shortfall of US$11.5 billion by 2050. In a sensitivity analysis considering future labour force changes, the government's cumulative net position remained negative by 2050, but only by US$1.9 billion.

CONCLUSIONS

A policy such as the A/NZ Smokefree Action Plan is likely to produce substantial economic benefits for citizens, and modest impacts on government finances related to reduced tobacco tax and increases in aged pensions due to increased life expectancy. Such costs can be anticipated and planned for and might be largely offset by future increases in the size of the labour force and the proportion of people 65+ years old working in the formal economy.

The Tobacco Endgame—A New Paradigm for Smoking Cessation in Cancer Clinics

Smoking cessation represents an untapped resource for cancer therapy. Many people who smoke and have cancer (tobacco-related or otherwise) struggle to quit and as a result, jeopardise response to treatment, recovery after surgery and long-term survival. Many health care practitioners working in cancer medicine feel undertrained, unprepared and unsupported to provide effective smoking cessation therapy. Many institutions and healthcare systems do provide smoking cessation programs, guidelines and referral pathways for cancer patients, but these may be unevenly applied. The growing body of evidence, from both retrospective and prospective clinical studies, confirms the benefit of smoking cessation and will provide much needed evidence for the best and most effective interventions in cancer clinics. In addition to reducing demand, helping cancer patients quit and treating addiction, a firm commitment to developing smoke free societies may transform cancer medicine in the future. While the Framework Convention for Tobacco Control (FCTC) has dominated global tobacco control for the last two decades, many jurisdictions are starting to develop plans to make their communities tobacco free, to introduce the tobacco endgame. Characterised by downward pressure on tobacco supply, limited sales, limited access and denormalization of smoking, these policies may radically change the milieu in which people with cancer receive treatment, in which health care practitioners refine skills and which may ultimately foster dramatic improvements in cancer outcomes.

The Lebanese Regie state-owned tobacco monopoly: lessons to inform monopoly-focused endgame strategies

Background

Many countries have started pursuing tobacco ‘endgame’ goals of creating a ‘tobacco-free’ country by a certain date. Researchers have presented models to attain this goal, including shifting the supply of tobacco to a monopoly-oriented endgame model (MOEM), wherein a state-owned entity controls the supply and distribution of tobacco products. Although not designed to end tobacco use, the Regie in Lebanon exhibits some of the key features identified in MOEM and hence can serve as a practical example from which to draw lessons.

Methods

We comprehensively review previous literature exploring tobacco endgame proposals featuring a MOEM. We distil these propositions into core themes shared between them to guide a deductive analysis of the operations and actions of the Regie to investigate how it aligns (or does not) with the features of the MOEM.

Results

Analysing the endgame proposals featuring MOEM, we generated two main themes: the governance of the organisation; and its operational remit. In line with these themes, the investigation of the Regie led to several reflections on the endgame literature itself, including that it: (i) does not seem to fully appreciate the extent to which the MOEM could end up acting like Transnational Tobacco Companies (TTC); (ii) has only vaguely addressed the implications of political context; and (iii) does not address tobacco growing despite it being an important element of the supply chain.

Conclusion

The implementation of tobacco endgame strategies of any type is now closer than ever. Using the Regie as a practical example allows us to effectively revisit both the potential and the pitfalls of endgame strategies aiming to introduce some form of monopoly and requires a focus on: (i) establishing appropriate governance structures for the organisation; and (ii) adjusting the financial incentives to supress any motivation for the organisation to expand its tobacco market.

The neighborhood environment and its association with the spatio-temporal footprint of tobacco consumption and changes in smoking-related behaviors in a Swiss urban area

This study aimed to evaluate the association of the neighborhood environment with the spatio-temporal dependence of tobacco consumption and changes in smoking-related behaviors in a Swiss urban area. Data were obtained from the CoLaus cohort (2003-2006, 2009-2012, and 2014-2017) in Lausanne, Switzerland. Local Moran's I was performed to assess the spatial dependence of tobacco consumption. Prospective changes in tobacco consumption and the location of residence of participants were assessed through Cox regressions. Analyses were adjusted by individual and neighborhood data. The neighborhood environment was spatially associated with tobacco consumption and changes in smoking-related behaviors independently of individual factors.

Retail endgame strategies: reduce tobacco availability and visibility and promote health equity

An increasing number of countries have set tobacco endgame goals that target dramatic reductions in smoking prevalence. To achieve those targets and promote health equity, policies are needed to reduce the retail supply and visibility of tobacco products. Focusing on retailer reduction strategies and tobacco display bans, this special communication reviews solution-oriented research about the retail environment. It highlights examples of policy implementation and identifies data needs and research gaps for designing and evaluating retail policies to promote population health equitably.

From silos to policy coherence: tobacco control, unhealthy commodity industries and the commercial determinants of health

Tobacco control has achieved remarkable successes, underpinned by the distinctive norms codified in Article 5.3 of the WHO Framework Convention on Tobacco Control. Tobacco control's experience in managing conflicts of interest is increasingly recognised as relevant for addressing other non-communicable disease epidemics. At the same time, the wider environmental and social harms of tobacco-and other unhealthy commodity industries-underline the potential for enhanced strategic collaboration across health, development and environmental agendas. Such collaboration is increasingly necessary to address key challenges shared across tobacco control and related policy spheres, including the extent to which the harms of tobacco (and other unhealthy commodities) are underpinned by economic and social inequities. Here we demonstrate the relevance of a commercial determinants of health perspective, both for advancing tobacco control and for linking it with health and development more broadly. This perspective is already evident in many areas of research, policy and advocacy, where innovative approaches support the development of closer links with actors in related fields. We draw on the concepts of policy coordination, coherence and integration to show how tobacco control can advance key strategic goals via information sharing, complementary approaches to common problems and collective action with other related movements. Embrace of a commercial determinants perspective will help in building on tobacco control's successes and reorienting strategies in other sectors to more effectively manage health risks and promote sustainable development.

Smoking-related behaviour changes among Korean men after the 2015 tobacco price increase: assessing the implications for the tobacco endgame using a reconstructed retrospective cohort study

OBJECTIVES

To examine the effect of Korea's 2015 tax policy, discuss its effectiveness and limitations and present future directions for tax policy in the context of the tobacco endgame.

DESIGN

A retrospectively reconstructed cohort study.

SETTING

Korea, August 2014-October 2015.

PARTICIPANTS

The study examined 41,605 male smokers aged 19 years and older who participated in the 2015 Korea Community Health Survey.

MEASURES AND ANALYSIS

Binary and multinomial logistic regression was used to assess the impact of the tax policy on smoking-related behaviour. We adjusted for demographic and health-related variables.

RESULTS

Among 41,605 men who were smokers in 2014, 15,499 (35.85%, weighted) reported being affected by the price increase. Of all smokers, 1,772 (3.96%, weighted) reported quitting smoking because of the tobacco price increase. Others reduced their smoking amount (n=9,714, 22.48%, weighted) or made other changes such as switching brands (n=4,013, 9.41%, weighted). An additional 2,401 smokers (5.72%, weighted) quit smoking for reasons other than the tobacco price increase. Compared with those in the highest quintile of household income, the odds that those in the lowest quintile quit smoking due to the price increase were almost twice as high (OR=1.98, 95% CI 1.54 to 2.54).

CONCLUSIONS

Korea's 2015 tobacco price increase affected a significant number of smokers within a year, especially in the lowest income group, inducing some to quit or reduce their smoking amount. However, more smokers quit for reasons independent of the price change. Tax policy can effectively reduce smoking, but needs to be combined with other policies for optimal results.

New Zealand Smokers' Perceptions of Tobacco Endgame Measures: A Qualitative Analysis

INTRODUCTION

New Zealand's equity-focused endgame goal (Smokefree 2025) aims to reduce smoking prevalence to minimal levels (ie, <5%) in all population groups by 2025. Inadequate progress has stimulated discussion of innovative measures to reduce prevalence; because few studies have explored how marginalized groups perceive these measures, we addressed this knowledge gap.

AIMS AND METHODS

In November and December 2020, we conducted 20 in-depth interviews with people who smoked daily, were aged between 21 and 53, earned less than the median income (NZD33 900), and had marginal or inadequate income sufficiency. We explored participants' smoking history and used an elicitation exercise to probe their views on smokefree policies, including potential endgame measures. We used qualitative descriptive analysis and reflexive thematic analysis to interpret the data.

RESULTS

Participants favored increasing personal support to quit and reducing nicotine levels in cigarettes, but generally opposed tobacco excise tax increases and paying people to quit. While many privileged their right to "choose," some recognized that stronger policies could restore the loss of agency addiction caused. Participants felt smoking's powerful addictiveness remained poorly understood, and called for smoking to be recognized and treated as an addiction.

CONCLUSIONS

Several participants supported intensifying existing measures or introducing new measures. However, their use of tobacco industry rhetoric to frame smoking as a choice they had made could inadvertently reinforce the stigma they experienced. Reframing cigarettes as an addictive product engineered by a deceptive industry, may make it easier for participants to access the expanded support and compassion they sought.

IMPLICATIONS

Policy measures, such as reducing the nicotine level in cigarettes, could support endgame goals; however, greater public understanding of addiction is needed to reduce stigma, support self-efficacy, and foster smoking cessation. Industry denormalization campaigns could challenge views of smoking as a personal choice, decrease self-blame among people who smoke, and present endgame goals as likely to enhance agency.

Boosting the Tobacco Control Vaccine: recognizing the role of the retail environment in addressing tobacco use and disparities

Much of the progress in reducing cigarette smoking and tobacco-related morbidity and mortality among youth and adults is attributable to population-level strategies previously described in the context of the Tobacco Control Vaccine. The retail environment is used heavily by the tobacco industry to promote and advertise its products, and variations in exposure to and characteristics of the retail environment exist across demographic groups. It is therefore also an essential environment for further reducing smoking, as well as ameliorating racial, ethnic and socioeconomic tobacco-related disparities. This commentary provides an overview of the importance of incorporating strategies focused on the tobacco retailer environment (availability; pricing and promotion; advertising and display; age of sale; and retail licensure) as part of a comprehensive approach to tobacco prevention and control. To reach tobacco endgame targets, such innovative strategies are a complement to, but not a replacement for, long-standing evidence-based components of the Tobacco Control Vaccine.

Characteristics of proposed and enacted state tobacco control legislation in the United States, 2010-2015

This study documents all tobacco control proposals (bills) introduced in the United States into all 50 state legislatures from the start of 2010 through 2015 and assesses associations between tobacco-related strategies and tobacco product types with enactment of the bills into law. In total, members of state legislatures introduced 2801 tobacco control bills, and state legislatures enacted 17.4%. Bills most introduced addressed clean air (n = 696) and tax or price bills (n = 582), yet both had lower likelihood of enactment (each OR, 0.51; 95% CI 0.38-0.69) compared to bills on any other tobacco control strategy. Legislators introduced only 147 product manufacturing bills, but these had the highest odds of enactment (OR, 3.70, 95% CI 2.52-5.44) compared to any other intended strategy, followed by tax evasion (OR, 3.08; 95% CI 2.33-4.08) and retailer licensing or location (OR, 1.73; 95 CI 1.24-2.41). Compared to other products, bills regulating e-cigarettes had the highest enactment rate (21.2%). Despite introduction of many bills promoting traditional, evidence-based tobacco control strategies, these had less likelihood of enactment than others.

Twenty-five years of Health & Place: Citation classics, internationalism and interdisciplinarity

To mark 25 years of Health & Place Health & Place, we identify and appraise some key contributions to the journal over this period. We use citation data to identify 'classics' from the journal's back catalogue. We also examine trends in the international reach and disciplinary homes of our authors. We show that there has been a near 7-fold increase in the number of published papers between the early and most recent years of the journal and that the journal's citation levels are amongst the top 2% of social science journals. Amongst the most cited papers, some clear themes are evident such as physical activity, diet/food, obesity and topics relating to greenspace. The profile of the journal's authors is becoming more internationally diverse, represents a broader range of disciplines, and increasingly demonstrating cross/interdisciplinary ways of working. Although Anglophone countries have led the way, there is an increasing number of contributions from elsewhere including emerging economies such as China. We conclude with some comments on likely future directions for the journal including enduring concerns such as greenspace, obesity, diet and unhealthy commodities (alcohol, tobacco, ultra-processed food) as well as more recent directions including planetary health, longitudinal and lifecourse analyses, and the opportunities (and challenges) of big data and machine learning. Whatever the thematic concerns of the papers over next 25 years, we will continue to welcome outstanding research that is concerned with the importance place makes to health.

Smoking in apartment buildings - Spatiality, meanings and understandings

Increased higher density urban living may exacerbate exposure to environmental tobacco smoke. Using a social practices lens, this research explored the locations, experiences and governance of smoking in apartment buildings in Melbourne, Australia, through semi-structured interviews in high-rise buildings ranging from subsidised housing to luxury apartments. Tacit rules on acceptable locations, building rules and smoke alarms in public areas consigned smoking to balconies and building entrances. The perceived health threat from second hand smoke and mental stress due to invasion of olfactory and visual privacy undermined the full enjoyment of the home environment. Interventions may benefit from targeting the link between smoking and balconies.

Socioeconomic inequalities in children's exposure to tobacco retailing based on individual-level GPS data in Scotland

BACKGROUND

Identifying factors shaping knowledge of and attitudes towards tobacco products in preadolescence is a key component supporting tobacco control policies aimed at preventing smoking initiation. This study quantified exposure to tobacco retailing environments within the individual-level activity spaces of children across a socioeconomic gradient.

METHODS

One week of global positioning system (GPS) tracking data were collected at 10 s intervals from a nationally representative sample of 10-11-year olds (n=692). Proximity of GPS locations (n=~16 M) to the nearest tobacco retailer (n=9030) was measured and exposure defined when a child came within 10 m of a retailer. Duration, frequency, timing and source of exposure were compared across income deprivation quintiles, along with retail density within children's home neighbourhoods.

RESULTS

On average, children were exposed to tobacco retailing for 22.7 min (95% CI 16.8 to 28.6) per week in 42.7 (35.2-50.1) independent encounters. However, children from the most deprived areas accumulated six times the duration and seven times the frequency of exposure as children from the least deprived areas. Home neighbourhood retail densities were 2.6 times higher in deprived areas, yet the average number of businesses encountered did not differ. Most exposure came from convenience stores (35%) and newsagents (15%), with temporal peaks before and after school hours.

CONCLUSIONS

By accounting for individual mobility, we showed that children in socially disadvantaged areas accumulate higher levels of exposure to tobacco retailing than expected from disparities in home neighbourhood densities. Reducing tobacco outlet availability, particularly in areas frequently used by children, might be crucial to policies aimed at creating 'tobacco-free' generations.