Reducing the burden of smoking world-wide: effectiveness of interventions and their coverage

Impact of New York City Cigarette Floor Price Policy on Reducing Smoking Disparities

INTRODUCTION

In 2017, New York City (NYC) passed a minimum floor price law (MFPL) to raise the minimum price of a pack of cigarettes to $13.00. Evaluation of the MFPL in NYC is limited and has yet to examine its potential as a proequity policy.

AIMS AND METHODS

Data (n = 20 241; prepolicy n = 15 037, postpolicy n = 5204) were obtained from the New York State Adult Tobacco Survey, a quarterly repeated cross-sectional survey. Using the Difference-in-Differences approach, we compared changes in reported cigarette prices, cigarette consumption, and smoking status among NYC residents before and after policy implementation to changes in the same outcomes among residents in the rest of the state (ROS) over the same period.

RESULTS

For some smokers, cigarette price increased in NYC for the postpolicy period; moreover, prices increased more in NYC than in ROS. NYC smokers who reported higher income, more education, or White or "Other" race, reported a bigger price increase than their ROS counterparts. Cigarette consumption decreased more in the postpolicy period for people in the ROS, in general and among certain groups. Everyday smoking status decreased similarly in both NYC and ROS, whereas someday smoking status decreased primarily in the ROS during the analysis period.

CONCLUSIONS

Cigarette prices in NYC increased after the 2017 MFPL; these increases were greater than those occurring elsewhere in the state, suggesting the policy might be a factor in the change. However, the increases were concentrated among relatively higher-priced purchases, and groups with lower smoking prevalence. Changes in smoking status and cigarette consumption did not correspond to study hypotheses.

IMPLICATIONS

This study provides an empirical analysis of a real-world policy in tobacco control. It examines the potential of the MFPL in NYC as a proequity policy. Findings extend the current MFPL literature and suggest that they may be able to raise cigarette prices for some purchases, but also may have a limited impact on smoking behaviors.

Preventable Deaths Attributable to Second-Hand Smoke in Southeast Asia-Analysis of the Global Burden of Disease Study 2019

Objectives

In addition to harms caused to individuals who smoke, second-hand smoke (SHS or passive smoke) is an important public health issue. We aim to estimate the extent of preventable deaths due to tobacco and SHS exposure in Southeast Asia.

Methods

Data were from the Global Burden of Disease Study 2019. We analysed data from Southeast Asia, including Cambodia, Indonesia, Laos, Malaysia, Maldives, Mauritius, Myanmar, Philippines, Seychelles, Sri Lanka, Thailand, Timor-Leste, and Vietnam.

Results

In 2019, there were 728,500 deaths attributable to tobacco in Southeast Asia, with 128,200 deaths attributed to SHS exposure. The leading causes of preventable deaths were ischemic heart disease, stroke, diabetes mellitus, lower respiratory infections, chronic obstructive pulmonary disease, tracheal, bronchus, and lung cancer. Among deaths attributable to tobacco, females had higher proportions of deaths attributable to SHS exposure than males in Southeast Asia.

Conclusion

The burden of preventable deaths in a year due to SHS exposure in Southeast Asia is substantial. The implementation and enforcement of smoke-free policies should be prioritized to reduce the disease burden attributed to passive smoking in Southeast Asia.

Reductions in smoking due to ratification of the Framework Convention for Tobacco Control in 171 countries

Smoking globally kills over half of long-term smokers and causes about 7 million annual deaths. The World Health Organization Framework Convention for Tobacco Control (FCTC) is the main global policy strategy to combat smoking, but its effectiveness is uncertain. Our interrupted time series analyses compared before- and after-FCTC trends in the numbers and prevalence of smokers below the age of 25 years (when smoking initiation occurs and during which response to interventions is greatest) and on cessation at 45-59 years (when quitting probably occurs) in 170 countries, excluding China. Contrasting the 10 years after FCTC ratification with the income-specific before-FCTC trends, we observed cumulative decreases of 15.5% (95% confidence interval = -33.2 to -0.7) for the numbers of current smokers and decreases of -7.5% (95% CI = -10.6 to -4.5) for the prevalence of smoking below age 25 years. The quit ratio (comparing the numbers of former and ever smokers) at 45-59 years increased by 1.8% (1.2 to 2.3) 10 years after FCTC ratification. Countries raising taxes by at least 10 percentage points concurrent with ratification observed steeper decreases in all three outcomes than countries that did not. Over a decade across 170 countries, the FCTC was associated with 24 million fewer young smokers and 2 million more quitters.

Nicotine consumption rate through wastewater-based epidemiology: a systematic review, meta-analysis and probabilistic risk assessment

Wastewater-based epidemiology (WBE), as a rapid tool, is used to measure and monitor illicit drug consumption in the population. This method is also used to bridge biomarkers of exposure, contaminants, and human health. Smoking cigarettes and tobacco use are everyday habits in nowadays community. This systematic review and meta-analysis aimed to calculate nicotine consumption globally. The related studies were retrieved within international databases including Scopus, Google Scholar, and Web of Science, up to February 2021. It included twenty-one articles containing 87 measurements covering 275.3 million people with total wastewater samples of 2250. Results showed that the highest and lowest nicotine consumption rate (mg/1000 inh./day) was in Portugal (5860) and Vietnam (1201), respectively. The global pooled nicotine consumption rate was 2476 mg/1000 inh./day (95% CI (2289-2663). Based on WBE results, the average daily cigarette smoked per smoker is 14 (95% CI: 10-18 cigarettes/inh./day), close to the value of 14.2 reported by the survey and interview studies. Risk assessment of the nicotine consumption rate through WBE was calculated by the margin of exposure (MOE) approach. In total, 82% of nicotine consumption measurements were located in the "risk" level (MOE < 100), and 18% of the MOE values were between 100-1000. The results reveal that nicotine consumption risks need immediate global and local action strategies. Finally, these findings are helpful for healthcare agencies and policy-makers to take action against tobacco use prevalence.

Monitoring and Combating Waterpipe Tobacco Smoking Through Surveillance and Taxation

Waterpipe tobacco smoking (WTS) is a traditional tobacco use method that originated in the Eastern Mediterranean Region (EMR) and has resurged in recent decades. WTS rates in the EMR are the highest worldwide, especially among youth, exceeding cigarette-smoking rates in select jurisdictions. Despite its documented harm, the growing prevalence of WTS has been met with a poor regulatory response globally. At the epicenter of the WTS epidemic, countries in the EMR are in urgent need of effective tobacco control strategies that consider the particularities of WTS. A roundtable session, titled "Monitoring and Combating WTS Through Taxation and the Global Tobacco Surveillance System (GTSS)," was held as part of the 7th Eastern Mediterranean Public Health Network's regional conference. The session provided an overview of evidence to date about WTS policy control, the taxation of WTS, volumetric choice experiments for tobacco control research, and monitoring WTS patterns and control policies among adults and youth through the GTSS. The session highlighted the need to update the regulation of WTS in the current global tobacco control policy frameworks and the need for developing tailored, evidence-based, and WTS-specific regulations to complement current tobacco control policy frameworks. Raising taxes to increase the price of tobacco products is the single most effective tobacco control measure, and these taxes can fund expanded government health programs. The effectiveness of taxation can be measured via volumetric choice experiments, which allow for the estimation of a complete set of own-price and cross-price elasticities that are instrumental for fiscal policy simulations. Finally, the surveillance of WTS (for example, through the GTSS) is critical to informing policy and decision makers. The Global Youth Tobacco Survey (GYTS) and Global Adult Tobacco Survey (GATS) are 2 GTSS products that provide nationally representative data among students aged 13-15 years and persons ≥15 years, respectively.

Own-price and cross-price elasticities of demand for cigarettes and waterpipe tobacco in three Eastern Mediterranean countries: a volumetric choice experiment

BACKGROUND

Waterpipe tobacco smoking rates in the Eastern Mediterranean region are among the highest worldwide, yet little evidence exists on its economics. Estimates of demand elasticities for tobacco products are largely limited to cigarettes. This study aimed to estimate own-price and cross-price elasticities of demand for cigarettes and waterpipe tobacco products in Lebanon, Jordan and Palestine.

METHODS

A volumetric choice experiment was conducted using nationally representative household surveys. The choice experiment elicited respondents' stated purchases of eight cigarette and waterpipe tobacco product varieties by hypothetically varying prices. Data were analysed using zero-inflated Poisson models that yielded demand elasticity estimates of cigarette and waterpipe tobacco consumption.

RESULTS

The study included 1680 participants in Lebanon (50% female), 1925 in Jordan (44.6% female) and 1679 in Palestine (50% female). We found the demand for premium cigarettes to be price elastic (range, -1.0 to -1.2) across all three countries, whereas the demand for discount cigarettes was less elastic than premium cigarettes in Lebanon (-0.6) and Jordan (-0.7) and more elastic in Palestine (-1.2). The demand for premium waterpipe tobacco was highly elastic in Lebanon (-1.9), moderately elastic in Jordan (-0.6) and inelastic in Palestine (0.2). The cross-price elasticity between cigarettes and waterpipe tobacco was near zero, suggesting that the two products are not considered to be close substitutes by consumers.

CONCLUSIONS

These results serve as a strong evidence base for developing and implementing fiscal policies for tobacco control in the Eastern Mediterranean region that address cigarettes and waterpipe tobacco products.

A narrative systematic review of tobacco cessation interventions in Sub-Saharan Africa

AIM

In the face of increasing tobacco consumption in Sub-Saharan Africa, it is crucial to not only curb the uptake of tobacco, but to ensure that tobacco users quit. Considering the minimal attention that tobacco cessation interventions receive in Sub-Saharan Africa, this review aims to describe studies that evaluated tobacco cessation interventions in the region.

METHODS

A search of studies published till December 2019 that evaluated tobacco cessation interventions in Sub-Saharan Africa and examined tobacco quit rates was conducted in PubMed-Medline, Web of Science and Scopus. Study designs were not limited to randomised control trials but needed to include a control group.

RESULTS

Of the 454 titles and abstracts reviewed, eight studies, all conducted in South Africa, were included. The earliest publication was from 1988 and the most recent from 2019. Five studies were randomised control trials, two were quasi-experimental and one was a case-control study. Populations studied included community-based smokers (four studies) and university students, while the relevant clinic-based studies were conducted in pregnant women, tuberculosis patients and HIV-infected patients. Sample sizes were 23 in the case-control study, 87-561 in randomised control trials, and 979 (pregnant women) and 4090 (three rural communities) in the quasi-experimental studies. Four studies included nicotine replacement therapy in the interventions while four utilised only psychotherapy without adjunct pharmacotherapy. Quit rates were evaluated by exhaled carbon monoxide levels (five studies), blood carbon monoxide, urinary cotinine levels and self-reported quit rates. Four studies (two each with and without pharmacotherapy) reported significantly better outcomes in the intervention versus the control groups while one study findings (without pharmacotherapy) were significant in women but not men.

CONCLUSION

This review highlights that scant attention has been paid to tobacco cessation intervention in Sub-Saharan Africa. The heterogeneity of these studies precluded comparisons across interventions or populations. There is a need for evidence-based low-cost tobacco cessation intervention that target high-risk population in Sub-Saharan Africa.

Determinants of Tobacco Use among Children of a Rural Village in India: An Exploratory Qualitative Study

BACKGROUND

Tobacco is one of the leading causes of preventable deaths. It is both a major social and health problem. According to National Sample Survey Organization of Government of India about 20 million children of ages 10-14 are estimated to be tobacco-addicted. There are grave consequences of tobacco both socially and also on health thus it is of utmost importance to understand the factors leading to its use and to plan strategies to reduce its intake. However, the health implications of this social issue in a rural context have not been explored.

AIMS AND OBJECTIVE

this study makes an attempt to explore the health and social implications of tobacco usage by the children below the age of 14 years in hamlet.

MATERIALS AND METHODS

  The present study employed a qualitative study design. Data was collected using focus group discussion and in-depth interview of key informants. Thematic analysis for exploring the explicit and implicit meanings within the data was done. The themes which emerged were knowledge about tobacco and the various products available, children and parents' tobacco use and habits, the health and social implication of tobacco use, reasons for tobacco use by the children.

RESULTS

It was found tobacco use by the children was very common in the community. Parent, peer pressure, sibling pressure were found to be playing important role in the initiation of tobacco habit by the child. Further illiteracy and lack of awareness was also lead to tobacco use among children.

CONCLUSION

The study identifies education and awareness of parents about the ill-effects of tobacco play an important role as parents act as role model for their children, thus equal stress should be laid in improving the parental habits. Even raising the prices of tobacco products can help in controlling this habit.
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Comparing and contrasting responses to tobacco control and obesity policies: a qualitative study

OBJECTIVE

To explore people's perceptions of, and responses to, obesity and tobacco policies with a particular focus on motivation; and to compare and contrast responses to explore the potential for translating learning across domains.

DESIGN

A theoretically informed comparative qualitative study involving semi-structured interviews with two groups of participants (smokers and ex-smokers; those who have previously or are currently attempting to lose weight). Data were analysed inductively using thematic analysis and interpreted through the lens of Self-Determination Theory.

SETTING

Community-based.

PARTICIPANTS

Interviews were conducted with five smokers and four ex-smokers around tobacco policy, and seventeen people acting to control their weight around obesity policy.

RESULTS

Three primary themes were identified. (i) Participants believed social norms to be crucial to supporting health behaviour change and responses to policy; not smoking was perceived as socially normal, whereas being physically active and eating healthily were perceived to go against social norms. (ii) Policies influencing the physical environment were perceived to support stopping smoking (e.g. smoke-free laws, advertising bans), but to undermine attempts to lose or control weight (e.g. high visibility, availability and low cost of energy-dense foods). (iii) While policies for both domains were considered necessary and legitimate, both groups found policy interventions neither motivating nor undermining of their sense of autonomy.

CONCLUSIONS

The results suggest those trying to lose weight respond similarly to obesity-related policy as smokers do to tobacco policy. Environmental interventions are perceived to be more helpful than appealing to people's motivation to change for their own sake.

Controlling corporate influence in health policy making? An assessment of the implementation of article 5.3 of the World Health Organization framework convention on tobacco control

BACKGROUND

The World Health Organization (WHO) Framework Convention on Tobacco Control (FCTC) stands to significantly reduce tobacco-related mortality by accelerating the introduction of evidence-based tobacco control measures. However, the extent to which States Parties have implemented the Convention varies considerably. Article 5.3 of the FCTC, is intended to insulate policy-making from the tobacco industry's political influence, and aims to address barriers to strong implementation of the Convention associated with tobacco industry political activity. This paper quantitatively assesses implementation of Article 5.3's Guidelines for Implementation, evaluates the strength of Parties' efforts to implement specific recommendations, and explores how different approaches to implementation expose the policy process to continuing industry influence.

METHODS

We cross-referenced a broad range of documentary data (including FCTC Party reports and World Bank data on the governance of conflicts of interest in public administration) against Article 5.3 implementation guidelines (n = 24) for 155 Parties, and performed an in-depth thematic analysis to examine the strength of implementation for specific recommendations.

RESULTS

Across all Parties, 16% of guideline recommendations reviewed have been implemented. Eighty-three percent of Parties that have taken some action under Article 5.3 have introduced less than a third of the guidelines. Most compliance with the guidelines is achieved through pre-existing policy instruments introduced independently of the FCTC, which rarely cover all relevant policy actors and fall short of the guideline recommendations. Measures introduced in response to the FCTC are typically restricted to health ministries and not explicit about third parties acting on behalf of the industry. Parties systematically overlook recommendations that facilitate industry monitoring.

CONCLUSION

Highly selective and incomplete implementation of specific guideline recommendations facilitates extensive ongoing opportunities for industry policy influence. Stronger commitment to implementation is required to ensure consistently strong compliance with the FCTC internationally.

Bulky DNA Adducts, Tobacco Smoking, Genetic Susceptibility, and Lung Cancer Risk

The generation of bulky DNA adducts consists of conjugates formed between large reactive electrophiles and DNA-binding sites. The term "bulky DNA adducts" comes from early experiments that employed a ³²P-DNA postlabeling approach. This technique has long been used to elucidate the association between adducts and carcinogen exposure in tobacco smoke studies and assess the predictive value of adducts in cancer risk. Molecular data showed increased DNA adducts in respiratory tracts of smokers vs nonsmokers. Experimental studies and meta-analysis demonstrated that the relationship between adducts and carcinogens was linear at low doses, but reached steady state at high exposure, possibly due to metabolic and DNA repair pathway saturation and increased apoptosis. Polymorphisms of metabolic and DNA repair genes can increase the effects of environmental factors and confer greater likelihood of adduct formation. Nevertheless, the central question remains as to whether bulky adducts cause human cancer. If so, lowering them would reduce cancer incidence. Pooled and meta-analysis has shown that smokers with increased adducts have increased risk of lung cancer. Adduct excess in smokers, especially in prospective longitudinal studies, supports their use as biomarkers predictive of lung cancer.

Effects of Global Payment and Accountable Care on Tobacco Cessation Service Use: An Observational Study

BACKGROUND

Tobacco use is the leading cause of preventable death and disability. New payment and delivery system models including global payment and accountable care have the potential to increase use of cost-effective tobacco cessation services.

OBJECTIVE

To examine how the Alternative Quality Contract (AQC) established in 2009 by Blue Cross Blue Shield of Massachusetts (BCBSMA) has affected tobacco cessation service use.

DESIGN

We used 2006-2011 BCBSMA claims and enrollment data to compare adults 18-64 years in AQC provider organizations to adults in non-AQC provider organizations. We examined the AQC's effects on all enrollees; a subset at high risk of tobacco-related complications due to certain medical conditions; and behavioral health service users.

MAIN MEASURES

We examined use of: (1) any cessation treatment (pharmacotherapy or counseling); (2) varenicline or bupropion; (3) nicotine replacement therapies (NRTs); (4) cessation counseling; and (4) combination therapy (pharmacotherapy plus counseling). We also examined duration of pharmacotherapy use and number of counseling visits among users.

KEY RESULTS

Rates of tobacco cessation treatment use were higher following implementation of the AQC relative to the comparison group overall (2.02 vs. 1.87 %, p < 0.0001), among enrollees at risk for tobacco-related complications (4.97 vs. 4.66 %, p < 0.0001), and among behavioral health service users (3.67 vs. 3.25 %, p < 0.0001). Statistically significant increases were found for use of varenicline or bupropion alone, counseling alone, and combination therapy, but not for NRT use, pharmacotherapy duration, or number of counseling visits among users.

CONCLUSIONS

In its initial three years, the AQC was associated with increases in use of tobacco cessation services.

Believing that certain foods are addictive is associated with support for obesity-related public policies

INTRODUCTION

There is a growing body of evidence suggesting that certain foods may be addictive. Although evidence that nicotine is addictive generated support for anti-tobacco policies, little research has examined whether beliefs about the addictiveness of food are associated with support for policies to address overconsumption of nutritionally poor foods.

METHODS

U.S. adults (n=999) recruited from an online marketplace in February 2015 completed a survey. Using logistic regression, we examined the relationship between beliefs about the addictiveness of certain foods and support for twelve obesity-related policies while controlling for demographics, health status, political affiliation and ideology, beliefs about obesity, and attitudes towards food companies. We examined whether the association between beliefs about addictiveness and support for policies was consistent across other products and behaviors viewed as addictive (i.e., tobacco, alcohol, drugs, compulsive behaviors).

RESULTS

In multivariable models, there was a significant association (OR; 95% CI) between beliefs about addictiveness and support for policies for compulsive behaviors (1.48; 1.26-1.74), certain foods (1.32; 1.14-1.53), drugs (1.23; 1.05-1.45), and alcohol (1.21; 1.08-1.36) but not for tobacco (1.11; 0.90-1.37). For foods, the association between beliefs about addictiveness and obesity-related policy support was the strongest between such beliefs and support for labels warning that certain foods may be addictive, industry reductions in salt and sugar, energy drink bans, and sugary drink portion size limits.

CONCLUSIONS

Overall, believing that products/behaviors are addictive was associated with support for policies intended to curb their use. If certain foods are found to be addictive, framing them as such may increase obesity-related policy support.

Knee MRI patterns of bone marrow reconversion and relationship to anemia

BACKGROUND

Bone marrow changes are commonly encountered on knee magnetic resonance imaging (MRI). The clinical relevance of these changes, especially as they relate to anemia, has not been studied in a large patient series.

PURPOSE

To determine if the extent of bone marrow reconversion (BMR) can assist the radiologist in making recommendations for further evaluation for underlying anemia.

MATERIAL AND METHODS

This study included 457 patients who had knee MRI over a 2-year period. Bone marrow patterns in the distal femur, proximal tibia, and fibula were graded as follows: 1, homogeneous fatty marrow; 2, patchy red marrow in the distal femur; 3, patchy red marrow in the distal femur and tibia and/or fibula; and 4, complete BMR in the femoral, tibial, and/or fibular metaphyses.

RESULTS

There was a statistically significant difference (P < 0.001) between the hemoglobin concentration and BMR grades. In women, anemia (Hb ≤12.0 g/dL) was found in 31 of 127 (24%) patients with grade 1, 31 of 83 (37%) with grade 2, 24 of 64 (37%) with grade 3, and 12 of 24 (50%) with grade 4. In men, anemia (Hb ≤13.0 g/dL) was found in 33 of 125 (26%) patients with grade 1, 12 of 19 (63%) with grade 2, five of 14 (36%) with grade 3, but not in the one patient with grade 4.

CONCLUSION

Women demonstrating marrow changes of a grade 4 BMR pattern should get a laboratory assessment for anemia.

Evaluation of different smoking habits during music festivals through wastewater analysis

Wastewater analysis is a powerful method that can provide useful information about the abuse of legal and illicit drugs. The aim of our study was to determine nicotine consumption during four different music festivals and to find a connection between smoking and preferences for specific music styles using wastewater analysis. The amount of the nicotine metabolite cotinine was monitored in wastewater at the influent of three waste water treatment plants WWTPs in the Czech Republic and Slovakia, where the festivals took place. Urinary bio-markers of nicotine utilization were analyzed by LC-HRMS. More than 80,000 festival participants were monitored during our study from June to September 2014. A significant increase of nicotine consumption was observed in wastewaters during music festivals. The nicotine ingestion level was back-calculated and expressed as mass of pure drug consumed per day and per 1000 inhabitants for selected cities of both countries. The highest differences between typical levels of cotinine in wastewaters and the levels during music festivals were detected in Piešťany: 4 g/L/1000 inhabitants during non-festival days compared to 8 g/L/1000 inhabitants during the Topfest pop-rock festival and 6g/L/1000 inhabitants during the Grape dance festival. No significant increase of the amounts of cotinine in wastewater was recorded for the Country and Folk festivals.

A política antitabagismo e a variação dos gastos das famílias brasileiras com cigarro: resultados das Pesquisas de Orçamentos Familiares, 2002/2003 e 2008/2009

O estudo teve como objetivo descrever a evolução dos gastos com cigarro das famílias brasileiras e seu peso sobre a renda dessas no período de 2002-2009. Foram utilizados dados da Pesquisa de Orçamentos Familiares (POF) de 2002/2003 e 2008/2009. Foi realizada correção dos valores mediante o Índice de Preços ao Consumidor Amplo (IPCA). A proporção de famílias que tiveram gastos com cigarro reduziu de 23,5% para 18,2%, no período estudado, mas o valor do gasto aumentou de R$ 55,36 para R$ 59,45. O gasto foi maior à medida que aumentavam a renda e a escolaridade do chefe das famílias. As famílias com maior renda concentram a maior parte desses gastos, apesar da redução de sua contribuição no gasto total com cigarro. O comprometimento da renda na aquisição de cigarros foi de 5,2% no primeiro e de 1,2% no último quinto de renda. A política antitabagismo logrou êxitos na redução da prevalência do tabagismo no Brasil. Porém, medidas econômicas ainda são importantes no contexto nacional, tendo em vista que a parcela da renda e da despesa das famílias comprometida com cigarro apresentou redução.

National monitoring of nicotine use in Czech and Slovak Republic based on wastewater analysis

The aim of this study was to compare estimation of nicotine use in Slovakia (SR) and the Czech Republic (CR) based on cotinine analysis in wastewater from seven selected wastewater treatment plants (WWTPs) with conventional estimation based on tobacco product sales. Urinary bio-markers of nicotine use were analyzed by liquid chromatography coupled with tandem mass spectrometry (LC-MS/MS). The study was performed concurrently at all the WWTPs (from 11 to 18 March 2014). Representative 24 h composite samples were analyzed with on line SPE/LC-MS/MS method. Based on the average residence time of wastewater in the sewers and the average time in the sampling device, specific correction coefficients were designed to improve estimation of nicotine consumption. Nicotine ingestion level was back-calculated and expressed as mass of pure drug consumed per day and per 1000 inhabitants for selected cities of both countries (mean, 2.2 g for Piešťany and 8.0 g for Nitra, respectively). Consequently, the cigarette consumption results were recalculated for each country separately and compared with the data of both national statistical offices (2362 cigarettes/year/person--SR and 2088 cigarettes/year/person--CR). Our results highly correspond to the data of national statistical offices (up to 99.9% in SR and to 96% in CR). The average amount of money invested in cigarette sales was estimated in the capitals of both countries. It is about 1 million EUR/day for Prague and about 0.3 million EUR/day for Bratislava. The calculation of nicotine consumption, utilizing a specific correction coefficient, is the correct way to obtain more accurate data in drug studies of this kind, thus allowing a better drug abuse assessment.

Current perspective of the impact of smoking on the progression and treatment of periodontitis

This literature review provides an overview of the current scenario regarding the impact of smoking on the progression and treatment of periodontitis; clinical, microbiological and immunological data from studies from our and other groups are presented. In general, preclinical and clinical data are unanimous in demonstrating that smokers present increased susceptibility, greater severity and faster progression of periodontal disease compared with nonsmokers. The evidence further demonstrates that smokers lose more teeth and have a less favorable response to therapy than do nonsmokers. Although it is well established that smoking significantly impacts on the onset, progression and outcome of periodontal disease, the mechanisms involved remain unclear. More importantly, some of the reported deleterious effects of smoking on periodontal tissues have been reported to be reversible upon participation in smoking-cessation programs. Therefore, clinicians should strongly advise smokers to enroll in cessation strategies, even temporarily, in order to improve the overall outcome.

The association between family affluence and smoking among 15-year-old adolescents in 33 European countries, Israel and Canada: the role of national wealth

AIMS

To examine the role of national wealth in the association between family affluence and adolescent weekly smoking, early smoking behaviour and weekly smoking among former experimenters.

DESIGN AND PARTICIPANTS

Data were used from the Health Behaviour in School-aged Children (HBSC) study conducted in 2005/2006 in 35 countries from Europe and North America that comprises 60 490 students aged 15 years. Multi-level logistic regression was conducted using Markov chain Monte Carlo methods (MCMC) to explore whether associations between family affluence and smoking outcomes were dependent upon national wealth.

MEASUREMENT

Family Affluence Scale (FAS) as an indicator for the socio-economic position of students. Current weekly smoking behaviour is defined as at least weekly smoking (dichotomous). Early smoking behaviour is measured by smoking more than a first puff before age 13 years (dichotomous). Weekly smoking among former experimenters is restricted to those who had tried a first puff in the past.

FINDINGS

The logistic multi-level models indicated an association of family affluence with current weekly smoking [odds ratio (OR) = 1.088; 95% credible interval (CrI) = 1.055-1.121, P < 0.001], early smoking behaviour (OR = 1.066; CrI = 1.028-1.104, P < 0.001) and smoking among former experimenters (OR = 1.100; CrI = 1.071-1.130; P < 0.001). Gross domestic product (GDP) per capita was associated positively and significantly with the relationship between family affluence and current weekly smoking (OR = 1.005; CrI = 1.003-1.007; P < 0.001), early smoking behaviour (OR = 1.003; CrI = 1.000-1.005; P = 0.012) and smoking among former experimenters (OR = 1.004; CrI = 1.002-1.006; P < 0.001). The association of family affluence and smoking outcomes was significantly stronger for girls.

CONCLUSIONS

The difference in smoking prevalence between rich and poor is greater in more affluent countries.

Risk perceptions and smoking decisions of adult Chinese men

This study analyzes effects of changes in risk perceptions of smoking's health harms on actual and attempted quits and quitting intentions of male smokers in China. Our survey of 5000+ male smokers was conducted two years after their neighbor's lung cancer diagnosis. We use proximity to a lung cancer neighbor as an exogenous determinant of individual's smoking risk perception. We show that learning of a neighbor's lung cancer diagnosis substantially affects smokers' subjective beliefs about smoking's harms, which in turn affects decisions about continued smoking and intentions to quit. Our study findings offer important public policy implications in indicating the importance of designing health-warning messages that fit smokers' personal circumstances as opposed to warnings solely based on edicts from scientific experts and/or epidemiological evidence.

Food prices and obesity: a review

In response to rising rates of obesity in the United States due in part to excess food consumption, researchers and policy makers have argued that levying food taxes on obesity-promoting foods, perhaps combined with subsidies on healthier options, would be an effective tool to stem the obesity epidemic. The extent to which overall energy intake or weight outcomes will improve as a result of these policies is ultimately an empirical question. This review examines the link between food or beverage price changes and energy intake or weight outcomes among U.S. consumers. Current evidence indicates that, by themselves, targeted food taxes and subsidies as considered to date are unlikely to have a major effect on individual weight or obesity prevalence. While research suggests that the effects are modest, food taxes and subsidies may play an important role in a multifaceted approach to reducing obesity incidence.

Financial versus health motivation to quit smoking: a randomized field study

OBJECTIVE

Smoking is the most preventable cause of death, thus justifying efforts to effectively motivate quitting. We compared the effectiveness of financial versus health messages to motivate smoking cessation. Low-income individuals disproportionately smoke and, given their greater income constraints, we hypothesized that making financial costs of smoking more salient would encourage more smokers to try quitting. Further, we predicted that financial messages would be stronger in financial settings where pecuniary constraints are most salient.

METHODS

We conducted a field study in low-income areas of New Haven, Connecticut using brochures with separate health vs. financial messages to motivate smoking cessation. Displays were rotated among community settings-check-cashing, health clinics, and grocery stores. We randomized brochure displays with gain-framed cessation messages across locations.

RESULTS

Our predictions were confirmed. Financial messages attracted significantly more attention than health messages, especially in financial settings.

CONCLUSIONS

These findings suggest that greater emphasis on the financial gains to quitting and use of financial settings to provide cessation messages may be more effective in motivating quitting. Importantly, use of financial settings could open new, non-medical venues for encouraging cessation. Encouraging quitting could improve health, enhance spending power of low-income smokers, and reduce health disparities in both health and purchasing power.

Acceptance and practicability of a visual communication tool in smoking cessation counselling: a randomised controlled trial

BACKGROUND

Smoking cessation advice is important for reducing the worldwide burden of disease resulting from tobacco smoking. Appropriate risk communication formats improve the success of counselling interventions in primary care.

AIMS

To test the feasibility and acceptance of a smoking cessation counselling tool with different cardiovascular risk communication formats including graphs, in comparison with the International Primary Care Respiratory Group (IPCRG) 'quit smoking assistance' tool.

METHODS

GPs were randomised into an intervention group (using our communication tool in addition to the IPCRG sheet) and a control group (using the IPCRG sheet only). We asked participants for socioeconomic data, smoking patterns, understanding of information, motivation, acceptance and feasibility, and measured the duration and frequency of counselling sessions.

RESULTS

Twenty-five GPs performed 2.8 counselling sessions per month in the intervention group and 1.7 in the control group (p=0.3) with 114 patients. The median duration of a session was 10 mins (control group 11 mins, p=0.09 for difference). Median patients' motivation for smoking cessation was 7 on a 10-point visual analogue scale with no significant difference before and after the intervention (p=0.2) or between groups (p=0.73 before and p=0.15 after the intervention). Median patients' ratings of motivation, selfconfidence, understanding of information, and satisfaction with the counselling were 3-5 on a 5-point Likert scale, similar to GPs' ratings of acceptance and feasibility, with no significant difference between groups.

CONCLUSIONS

Among Swiss GPs and patients, both our innovative communication tool and the IPCRG tool were well accepted and both merit further dissemination and application in research.

Food prices and consumer demand: differences across income levels and ethnic groups

Background

Targeted food pricing policies may improve population diets. To assess their effects on inequalities, it is important to determine responsiveness to price changes across income levels and ethnic groups.

Objective

Our goal was to estimate price elasticity (PE) values for major commonly consumed food groups in New Zealand, by income and ethnicity. PE values represent percentage change in demand associated with 1% change in price of that good (own-PE) or another good (cross-PE).

Design

We used food expenditure data from national household economic surveys in 2007/08 and 2009/10 and Food Price Index data from 2007 and 2010. Adopting an Almost Ideal Demand System approach, own-PE and cross-PE estimates were derived for 24 food categories, household income quintiles, and two ethnic groups (Māori and non-Māori).

Results

Own-PE estimates (with two exceptions) ranged from −0.44 to −1.78. Cross-PE estimates were generally small; only 31% of absolute values were greater than 0.10. Excluding the outlier ‘energy drinks’, nine of 23 food groups had significantly stronger own-PEs for the lowest versus highest income quintiles (average regression-based difference across food groups −0.30 (95% CI −0.62 to 0.02)). Six own-PEs were significantly stronger among Māori; the average difference for Māori: non-Māori across food groups was −0.26 (95% CI −0.52 to 0.00).

Conclusions

Food pricing policies have potential to improve population diets. The greater sensitivity of low-income households and Māori to price changes suggests the beneficial effects of such policies on health would be greatest for these groups.

Alcohol consumption, smoking and overweight as a burden for health care services utilization: a cross-sectional study in Estonia

BACKGROUND

Alcohol consumption, smoking and weight problems are common risk factors for different health problems. We examine how these risk factors are associated with the use of health care services.

METHODS

Data for 6500 individuals in the 25-64 age group came from three cross-sectional postal surveys conducted in 2004, 2006, and 2008 in Estonia. The effect of alcohol consumption, smoking and weight problems on the use of primary and specialist care services, hospitalizations and ambulance calls was analysed separately for men and women by using binary logistic regression.

RESULTS

Overweight and/or obesity were strongly related to the use of primary care and out-patient specialist services for both genders, and to hospitalizations and ambulance calls for women. Current smoking was related to ambulance calls for both genders, whereas smoking in the past was related to the use of primary care and specialist services among men and to hospitalizations among women. Beer drinking was negatively associated with all types of health care services and similar association was found between wine drinking and hospitalizations. Wine drinking was positively related to specialist visits. The frequent drinking of strong alcohol led to an increased risk for ambulance calls. Drinking light alcoholic drinks was positively associated with all types of health care services (except ambulance calls) among men and with the use of specialist services among women.

CONCLUSIONS

Overweight and smoking had the largest impact on health care utilization in Estonia. Considering the high prevalence of these behavioural risk factors, health policies should prioritize preventive programs that promote healthy lifestyles in order to decrease the disease burden and to reduce health care costs.

Food taxes: a new holy grail?

In an effort to reduce the growing prevalence of overweight and obesity, food taxes have been introduced in several European countries, the so-called 'obesitax'. As yet little evidence is at hand, policy measures are being taken to counterweight the consumption of unhealthy food or the increasing diet-related diseases. Several questions need to be discussed, starting from a general perspective: can food taxes become an appropriate and just policy measure to reduce overweight and obesity and therefore increase consumer's health? The implementation of an effective and fair food tax is an exercise riddled with uncertainty. Not only is there a need for evidence on the health and economic impact of food taxes, we also have to think about a conceptual and ethical discussion concerning the balance between health imperatives and public health on the one hand, and social and ethical standards on the other hand.

A video feedback-based tobacco cessation counselling course for undergraduates-preliminary results

BACKGROUND

Hungary has one of the highest rates of tobacco use and decayed, missing and filled teeth in Europe, and the number of lung cancer-related deaths per annum is amongst the highest globally. As it is estimated that the rate of smokers who see their dentist or physician annually is about 70%, to involve all healthcare providers in tobacco intervention seems to be a promising strategy to reduce tobacco use in countries like Hungary. Such an intervention should obviously include the dental health team. It has already been suggested by experts on this topic that instruction in tobacco use prevention and cessation counselling for dental professionals and students of dentistry should be included in under- and postgraduate curricula.

OBJECTIVES

To present a novel, video feedback-based undergraduate cessation counselling programme, which has recently been introduced to the dental curriculum at the Faculty of Dentistry, Szeged, Hungary.

METHODS

Applying a problem-based learning approach, the programme consists of three main activities: a small-group interactive training session led by a faculty member, where students learn about the basic science and clinical aspects of tobacco use, including counselling skills; student interactions with professional actors (i.e. standardised patients) simulating real-life dental situations, which are recorded for post hoc evaluation; and finally an evaluation of the recorded performance of each student, with the participation of the actor, the student and a faculty member.

RESULTS

With the help of this new approach, students had the chance to learn about and develop a deeper understanding of tobacco-related professional dental communication in realistic, case-based dental scenarios. Students have reported increased confidence in tobacco counselling after having participated in this programme. Furthermore, this method appears to be an ideal tool for the evaluation of both verbal and non-verbal tobacco counselling skills.

CONCLUSION

To our knowledge, we are the first to have applied video feedback combined with behavioural modification methods in the teaching of tobacco cessation counselling. We conclude that teaching method can help dentists better understand smokers, gain confidence in tobacco cessation counselling and become more effective promoters of a smoke-free lifestyle. In addition, this method can be easily adapted to other healthcare educational settings, including other oral health training programmes.

Moving towards a population health approach to the primary prevention of common mental disorders

There is a need for the development of effective universal preventive approaches to the common mental disorders, depression and anxiety, at a population level. Poor diet, physical inactivity and smoking have long been recognized as key contributors to the high prevalence noncommunicable diseases. However, there are now an increasing number of studies suggesting that the same modifiable lifestyle behaviors are also risk factors for common mental disorders. In this paper we point to the emerging data regarding lifestyle risk factors for common mental disorders, with a particular focus on and critique of the newest evidence regarding diet quality. On the basis of this most recent evidence, we consequently argue for the inclusion of depression and anxiety in the ranks of the high prevalence noncommunicable diseases influenced by habitual lifestyle practices. We believe that it is both feasible and timely to begin to develop effective, sustainable, population-level prevention initiatives for the common mental illnesses that build on the established and developing approaches to the noncommunicable somatic diseases.

A novel evaluation of World No Tobacco day in Latin America

BACKGROUND

World No Tobacco Day (WNTD), commemorated annually on May 31, aims to inform the public about tobacco harms. Because tobacco control surveillance is usually annualized, the effectiveness of WNTD remains unexplored into its 25th year.

OBJECTIVE

To explore the potential of digital surveillance (infoveillance) to evaluate the impacts of WNTD on population awareness of and interest in cessation.

METHODS

Health-related news stories and Internet search queries were aggregated to form a continuous and real-time data stream. We monitored daily news coverage of and Internet search queries for cessation in seven Latin American nations from 2006 to 2011.

RESULTS

Cessation news coverage peaked around WNTD, typically increasing 71% (95% confidence interval [CI] 61-81), ranging from 61% in Mexico to 83% in Venezuela. Queries indicative of cessation interest peaked on WNTD, increasing 40% (95% CI 32-48), ranging from 24% in Colombia to 84% in Venezuela. A doubling in cessation news coverage was associated with approximately a 50% increase in cessation queries. To gain a practical perspective, we compared WNTD-related activity with New Year's Day and several cigarette excise tax increases in Mexico. Cessation queries around WNTD were typically greater than New Year's Day and approximated a 2.8% (95% CI -0.8 to 6.3) increase in cigarette excise taxes.

CONCLUSIONS

This novel evaluation suggests WNTD had a significant impact on popular awareness (media trends) and individual interest (query trends) in smoking cessation. Because WNTD is constantly evolving, our work is also a model for real-time surveillance and potential improvement in WNTD and similar initiatives.

Experimental research on the relation between food price changes and food-purchasing patterns: a targeted review

One way in which to modify food purchases is to change prices through tax policy, subsidy policy, or both. We reviewed the growing body of experimental research conducted in the laboratory and in the field that investigates the following: the extent to which price changes influence purchases of targeted and nontargeted foods, total energy, or macronutrients purchased; the interaction of price changes with adjunctive interventions; and moderators of sensitivity to price changes. After a brief overview of economic principles and observational research that addresses these issues, we present a targeted review of experimental research. Experimental research suggests that price changes modify purchases of targeted foods, but research on the overall nutritional quality of purchases is mixed because of substitution effects. There is mixed support for combining price changes with adjunctive interventions, and there are no replicated findings on moderators to price sensitivity in experiments. Additional focused research is needed to better inform food policy development with the aim of improving eating behavior and preventing obesity.

Behavioral medicine and the health of our nation: accelerating our impact

PURPOSE

A key goal of this paper is to illustrate the impact of behavioral medicine on the factors that influence population health. A second goal is to consider the delicate balance between relevance and excellence as we bring our science to bear on important social and public health problems. If we are to increase the translation of our evidence and accelerate our impact, we must increase our relevance while maintaining excellence in our scientific methods.

METHODS

What are the pressing questions facing those that we would like to use our work, and how we can increase our relevance to theirs? We must work on the marriage of relevance and excellence-use rigorous methodologies, but be flexible in our approach, using study designs and methods that will get rapid yet rigorous answers to the questions that are facing practice and policy settings.

CONCLUSION

We have the tools and the knowledge to impact the health of our nation.

Birth cohort differences in cardiovascular risk factors in a Brazilian population of older elderly: the Bambuí Cohort Study of Aging (1997 and 2008)

The aim of this study was to investigate whether cohort differences exist in the prevalence of cardiovascular risk factors among older elderly from the Bambuí Cohort Study of Aging. Participants were those aged 71-81 years at two points in time a decade apart: 457 in 1997 (earlier cohort) and 553 in 2008 (recent cohort). The prevalence of hypertension (PR = 1.27; 95%CI: 1.19-1.36) and of diabetes mellitus (PR = 1.39; 95%CI: 1.06-1.83) was higher in the recent cohort compared to the earlier one, regardless of sex. The recent cohort had a lower prevalence of smoking (PR = 0.58; 95%CI: 0.42-0.80), and lower total cholesterol/HDL cholesterol ratio level (PR = 0.85; 95%CI: 0.80-0.89). There was a 136% increase in the pharmacologic treatment of diabetes and a 56% increase in pharmacologic management of hypertension in 2008 in comparison with 1997. Overall, the number of cardiovascular risk factors in the recent cohort remained similar to that of the early cohort.

Cost effectiveness of strategies to combat cardiovascular disease, diabetes, and tobacco use in sub-Saharan Africa and South East Asia: mathematical modelling study

OBJECTIVE

To determine the relative costs and health effects of interventions to combat cardiovascular disease, diabetes, and tobacco related disease in order to guide the allocation of resources in developing countries.

DESIGN

Cost effectiveness analysis of 123 single or combined prevention and treatment strategies for cardiovascular disease, diabetes, and smoking by means of a lifetime population model.

SETTING

Two World Health Organization sub-regions of the world: countries in sub-Saharan Africa with very high adult and high child mortality (AfrE) and countries in South East Asia with high adult and high child mortality (SearD).

DATA SOURCES

Demographic and epidemiological data were taken from the WHO databases of mortality and global burden of disease. Estimates of intervention coverage, effectiveness, and resource needs were drawn from clinical trials, observational studies, and treatment guidelines. Unit costs were taken from the WHO-CHOICE (Choosing Interventions that are Cost-Effective) price database.

MAIN OUTCOME MEASURES

Cost per disability adjusted life year (DALY) averted, expressed in international dollars ($Int) for the year 2005.

RESULTS

Most of the interventions studied were considered highly cost effective, meaning they generate one healthy year of life at a cost of <$Int2000 (which is the gross domestic product per capita of the two regions considered here). Interventions that offer particularly good monetary value, and which could be considered for prioritised implementation or scale up, include demand reduction strategies of the Framework Convention for Tobacco Control (<$Int950 and <$Int200 per DALY averted in AfrE and SearD respectively); combination drug therapy for people with a >25% chance of experiencing a cardiovascular event over the next decade, either alone or together with specific multidrug regimens for the secondary prevention of post-acute ischaemic heart disease and stroke (<$Int150 and <$Int230 per DALY averted in AfrE and SearD respectively); and retinopathy screening and glycaemic control for patients with diabetes (<$Int2100 and <$Int950 per DALY averted in AfrE and SearD respectively).

CONCLUSION

This comparative economic assessment has identified a set of population-wide and individual strategies for prevention and control of cardiovascular disease that are inexpensive and cost effective in low resource settings.

Effect of self-administered auricular acupressure on smoking cessation--a pilot study

Background

Tobacco smoking is still a worldwide health risk. Current pharmacotherapies have at best, a success rate of no more than 50%. Auricular (ear) acupressure has been purported to be beneficial in achieving smoking cessation in some studies, while in others has been deemed insignificant. We hereby describe the protocol for a three-arm randomised controlled trial to examine the possible benefits of self-administered acupressure for smoking cessation.

Methods

Sixty consenting participants with confirmed habit of tobacco smoking will be recruited and randomized into three arms to receive either auricular acupressure at five true acupoints (NADA protocol), auricular acupressure at five sham points, or no auricular acupressure at all. Participants having auricular acupressure will exert firm pressure to each acupoint bilaterally via the bead in the attached plasters whenever they feel the urge to smoke. The treatment phase will last for six weeks during which all participants will be assessed weekly to review their smoking log, state of abstinence, end-exhalation carbon monoxide levels and possible adverse effects including withdrawal reactions and stress levels. At any time, a successful quit date will be defined with continuous abstinence for the following consecutive 7 days. From then on, participants will be evaluated individually for continuous abstinence rate (CAR), end-exhalation carbon monoxide levels and adverse effects of stress and withdrawal at specified intervals up to 26 weeks. Expectancy of treatment will be assessed with a four-item Borkovec and Nau self-assessment credibility scale during and after intervention.

Discussion

We incorporate validated outcome measures of smoking cessation into our randomised controlled trial design with the objectives to evaluate the feasibility and possible benefits of self-administered auricular acupressure as a non-invasive alternative to pharmacotherapy for smoking cessation.

Trial Registration

ClinicalTrials.gov: NCT01389622 (registered Jul 7 2011)

Practising what we preach: A look at healthy active living policy and practice in Canadian paediatric hospitals

BACKGROUND

In the past 30 years, the rate of obesity has risen considerably among Canadian children. Paediatric hospitals are in a unique position to model healthy environments to Canadian children.

OBJECTIVE

To obtain an overview of healthy active living (HAL) policy and practice in Canadian paediatric hospitals.

METHODS

Working in partnership with the local Canadian Paediatric Society HAL champions and the Canadian Association of Paediatric Health Centres liaisons, a nationwide survey was conducted in 2006/2007 to identify healthy eating, physical activity and smoking cessation practices in all 16 Canadian paediatric academic hospitals.

RESULTS

Policies addressing healthy eating and/or physical activity promotion were present in 50% of hospitals with a greater focus on nutrition. Wellness committees were created in 50% of the hospitals, most of which were recently established. Healthy food options were available in cafeterias, although they were often more expensive. Fast food outlets were present in 75% of hospitals. Although inpatient meals were designed by dietitians, 50% offered less nutritious replacement kids meals (ie, meal substitutions) on request. Options for play available to inpatients and outpatients were primarily sedentary, with screen-based activities and crafts predominating over active play. Physical activity promotion for staff focused on reduced membership fees to fitness centres and classes.

CONCLUSION

Canadian paediatric hospitals do not adequately promote HAL for patients and staff. The present study findings suggest further effort is required to create necessary healthy lifestyle modifications in these institutions through Canadian Paediatric Society/Canadian Association of Paediatric Health Centres-led policy development and implementation initiatives. A national-level policy framework is required to regulate interhospital variability in policies and practices.

Mindfulness training for smoking cessation: results from a randomized controlled trial

BACKGROUND

Cigarette smoking is the leading cause of preventable death in the world, and long-term abstinence rates remain modest. Mindfulness training (MT) has begun to show benefits in a number of psychiatric disorders, including depression, anxiety and more recently, in addictions. However, MT has not been evaluated for smoking cessation through randomized clinical trials.

METHODS

88 treatment-seeking, nicotine-dependent adults who were smoking an average of 20cigarettes/day were randomly assigned to receive MT or the American Lung Association's freedom from smoking (FFS) treatment. Both treatments were delivered twice weekly over 4 weeks (eight sessions total) in a group format. The primary outcomes were expired-air carbon monoxide-confirmed 7-day point prevalence abstinence and number of cigarettes/day at the end of the 4-week treatment and at a follow-up interview at week 17.

RESULTS

88% of individuals received MT and 84% of individuals received FFS completed treatment. Compared to those randomized to the FFS intervention, individuals who received MT showed a greater rate of reduction in cigarette use during treatment and maintained these gains during follow-up (F=11.11, p=.001). They also exhibited a trend toward greater point prevalence abstinence rate at the end of treatment (36% vs. 15%, p=.063), which was significant at the 17-week follow-up (31% vs. 6%, p=.012).

CONCLUSIONS

This initial trial of mindfulness training may confer benefits greater than those associated with current standard treatments for smoking cessation.

Changing the future of obesity: science, policy, and action

The global obesity epidemic has been escalating for four decades, yet sustained prevention efforts have barely begun. An emerging science that uses quantitative models has provided key insights into the dynamics of this epidemic, and enabled researchers to combine evidence and to calculate the effect of behaviours, interventions, and policies at several levels--from individual to population. Forecasts suggest that high rates of obesity will affect future population health and economics. Energy gap models have quantified the association of changes in energy intake and expenditure with weight change, and have documented the effect of higher intake on obesity prevalence. Empirical evidence that shows interventions are effective is limited but expanding. We identify several cost-effective policies that governments should prioritise for implementation. Systems science provides a framework for organising the complexity of forces driving the obesity epidemic and has important implications for policy makers. Many parties (such as governments, international organisations, the private sector, and civil society) need to contribute complementary actions in a coordinated approach. Priority actions include policies to improve the food and built environments, cross-cutting actions (such as leadership, healthy public policies, and monitoring), and much greater funding for prevention programmes. Increased investment in population obesity monitoring would improve the accuracy of forecasts and evaluations. The integration of actions within existing systems into both health and non-health sectors (trade, agriculture, transport, urban planning, and development) can greatly increase the influence and sustainability of policies. We call for a sustained worldwide effort to monitor, prevent, and control obesity.

Official Positions for FRAX® clinical regarding smoking from Joint Official Positions Development Conference of the International Society for Clinical Densitometry and International Osteoporosis Foundation on FRAX®

The worldwide prevalence of smoking has been estimated at about 50% in men, and 10% in women, with larger variations among different populations studied. Smoking has been shown to affect many organ systems resulting in severe morbidity and increased mortality. In addition, smoking has been identified as a predictor of ten-year fracture risk in men and women, largely independent of an individual's bone mineral density. This finding has eventually lead to incorporation of this risk factor into FRAX®, an algorithm that has been developed to calculate an individual's ten-year fracture risk. However, only little, or conflicting data is available on a possible association between smoking dose, duration, length of time after cessation, type of tobacco and fracture risk, limiting this risk factor's applicability in the context of FRAX®.

Estimating the potential of taxes on sugar-sweetened beverages to reduce consumption and generate revenue

OBJECTIVE

Beverage taxes came into light with increasing concerns about obesity, particularly among youth. Sugar-sweetened beverages have become a target of anti-obesity initiatives with increasing evidence of their link to obesity. Our paper offers a method for estimating revenues from an excise tax on sugar-sweetened beverages that governments of various levels could direct towards obesity prevention.

MODEL

We construct a model projecting beverage consumption and tax revenues based on best available data on regional beverage consumption, historic trends and recent estimates of the price elasticity of sugar-sweetened beverage demand.

RESULTS

The public health impact of beverage taxes could be substantial. An estimated 24% reduction in sugar-sweetened beverage consumption from a penny-per-ounce sugar-sweetened beverage tax could reduce daily per capita caloric intake from sugar-sweetened beverages from the current 190-200 cal to 145-150 cal, if there is no substitution to other caloric beverages or food. A national penny-per-ounce tax on sugar-sweetened beverages could generate new tax revenue of $79 billion over 2010-2015.

CONCLUSION

A modest tax on sugar-sweetened beverages could both raise significant revenues and improve public health by reducing obesity. To the extent that at least some of the tax revenues get invested in obesity prevention programs, the public health benefits could be even more pronounced.

Global oral health inequalities in incidence and outcomes for oral cancer: causes and solutions

The mouth and oropharynx are among the ten most common sites affected by cancer worldwide, but global incidence varies widely. Five-year survival rates exceed 50% in only the best treatment centers. Causes are predominantly lifestyle-related: Tobacco, areca nut, alcohol, poor diet, viral infections, and pollution are all important etiological factors. Oral cancer is a disease of the poor and dispossessed, and reducing social inequalities requires national policies co-ordinated with wider health and social initiatives - the common risk factor approach: control of the environment; safe water; adequate food; public and professional education about early signs and symptoms; early diagnosis and intervention; evidence-based treatments appropriate to available resources; and thoughtful rehabilitation and palliative care. Reductions in inequalities, both within and between countries, are more likely to accrue from the application of existing knowledge in a whole-of-society approach. Basic research aimed at determining individual predisposition and acquired genetic determinants of carcinogenesis and tumor progression, thus allowing for targeted therapies, should be pursued opportunistically.

A cost-effectiveness analysis of India's 2008 prohibition of smoking in public places in Gujarat

Tobacco smoking and exposure to secondhand tobacco smoke are associated with disability and premature mortality in low and middle-income countries. The aim of this study was to assess the cost-effectiveness of implementing India's Prohibition of Smoking in Public Places Rules in the state of Gujarat, compared to implementation of a complete smoking ban. Using standard cost-effectiveness analysis methods, the cost of implementing the alternatives was evaluated against the years of life saved and cases of acute myocardial infarction averted by reductions in smoking prevalence and secondhand smoke exposure. After one year, it is estimated that a complete smoking ban in Gujarat would avert 17,000 additional heart attacks and gain 438,000 life years (LY). A complete ban is highly cost-effective when key variables including legislation effectiveness were varied in the sensitivity analyses. Without including medical treatment costs averted, the cost-effectiveness ratio ranges from $2 to $112 per LY gained and $37 to $386 per acute myocardial infarction averted. Implementing a complete smoking ban would be a cost saving alternative to the current partial legislation in terms of reducing tobacco-attributable disease in Gujarat.

Tobacco: a product like any other?

Legislation in most countries regulates trade in poisons and highly addictive products, such as narcotics. The statements that (1) tobacco harms health and (2) causes addiction are established as facts in international and national law. Yet in Russia, and in many other countries, there is a contradiction between the open sale of this addictive poison and basic laws, such as those on product safety. Provisions in both the Russian constitution and the criminal code can be interpreted as making the sale of tobacco illegal, setting out severe penalties for those involved. Yet, remarkably, tobacco is treated quite differently from other products. In this paper, we describe the experience so far in seeking to enforce this legislation in Russia. Attempts to persuade the police to enforce the legislation have been unsuccessful, although they accept that there is a prima facie case for action but, in private, express fear of taking it. The case for action is currently being argued before the Russian Supreme Court but this could take many years to reach a conclusion. In the mean time, new legislation on the regulation of tobacco production has been passed by the State Duma, with the support of the tobacco industry, which implicitly assumes that tobacco is a lawful product, thereby creating legal confusion. We argue that the only way to redress this situation is to recognize that tobacco production and sales must be regulated in the same way as any other harmful and addictive substance.

Economic benefits of achieving realistic smoking cessation targets in Australia

OBJECTIVES

We estimated the economic impact of reductions in the prevalence of tobacco smoking on health, production, and leisure in the 2008 Australian population.

METHODS

We selected a prevalence target of 15%. Cohort lifetime health benefits were modeled as fewer incident cases of tobacco-related diseases, deaths, and disability-adjusted life-years. We estimated production gains by comparing surveyed participation and absenteeism rates of adult smokers and ex-smokers valued according to the human capital and friction cost approaches. We estimated household production and leisure gains from time use surveys and valued these gains with the appropriate proxy.

RESULTS

In the 2008 Australian population, an absolute reduction in smoking prevalence of 8% would result in 158,000 fewer incident cases of disease, 5000 fewer deaths, 2.2 million fewer lost working days, and 3000 fewer early retirements and would reduce health sector costs by AUD 491 million. The gain in workforce production was AUD 415 million (friction cost) or AUD 863 million (human capital), along with gains of 373,000 days of household production and 23,000 days of leisure time.

CONCLUSIONS

Lowering smoking prevalence rates can lead to substantial economic savings and health benefits.

High prevalence of smoking among patients with suspected tuberculosis in South Africa

There is growing evidence that tobacco smoking is an important risk factor for tuberculosis (TB). There are no data validating the accuracy of self-reported smoking in TB patients and limited data about the prevalence of smoking in TB patients from high-burden settings. We performed a cross-sectional analysis of 500 patients with suspected TB in Cape Town, South Africa. All underwent comprehensive diagnostic testing. The accuracy of their self-reported smoking status was determined against serum cotinine levels. Of the 424 patients included in the study, 56 and 60% of those with active and latent TB infection (LTBI), respectively, were current smokers. Using plasma cotinine as a reference standard, the sensitivity of self-reported smoking was 89%. No statistically significant association could be found between smoking and active TB or LTBI. In Cape Town, the prevalence of smoking among patients with suspected and confirmed TB was much higher than in the general South African population. Self-reporting is an accurate measure of smoking status. These results suggest the need to actively incorporate tobacco cessation programmes into TB services in South Africa.