The impact of tobacco control policies in Albania

Tobacco tax evasion in Western Balkan countries: tax evasion prevalence and evasion determinants

BACKGROUND AND OBJECTIVE

Tobacco tax evasion undermines the goal of tobacco taxes as a tobacco control measure to make tobacco products less affordable, increases the health risks for those who smoke and decreases the government revenue. This paper analyses the tobacco tax evasion in six Western Balkan (WB) countries: Albania, Bosnia and Herzegovina, Kosovo, Montenegro, North Macedonia and Serbia. The aim of this research is to estimate the size of the illicit market and identify the main determinants of tax evasion activities in the Southeastern European region.

DATA AND METHODS

Data from 2019 Survey on Tobacco Consumption in Southeastern Europe (STC-SEE) are used. STC-SEE provides uniquely comparable nationally representative data on smoking behaviour for adult (18-85 years old) population for each country. Tax evasion is defined on the basis of available information on tax stamps, health warnings, price and the place of purchase, in accordance with the previous research on tax evasion. In order to estimate the determinants of illicit purchases we use binary choice model of tax evasion.

RESULTS

The study finds that 20.4% of all current smokers in WB countries evade taxes on tobacco products, with evasion being much more frequent for hand-rolled (HR) tobacco (86.7%) than for the manufactured cigarettes (MC) (8.6%). While HR is predominantly illicit in all six countries, MC evasion varies significantly, with evasion being significantly higher in Montenegro and Bosnia and Herzegovina. Results further suggest that tax evasion is higher in the statistical regions where institutional capacities to tackle illicit trade are lower, in municipalities bordering countries with high MC evasion, as well as among smokers with low income, women and elderly. We also provide evidence that higher tobacco taxes and prices do not increase illicit consumption.

CONCLUSION

The findings from the research suggest that in order to decrease tax evasion, governments should put additional effort to strengthen institutional capacities to tackle illicit tobacco markets. Furthermore, improving regional coordination in development and implementation of tobacco control policies, including the prevention of illicit market, is essential in lowering evasion in all WB countries. Finally, WB countries should regulate and enforce excise tax stamp requirements on the HR tobacco market to a much higher degree.

Analysis of Tobacco Price Elasticity in Albania Using Household Level Data

This paper analyzes the determinant factors of tobacco consumption in Albania, which is one of the countries with the highest smoking prevalence in Europe. To empirically estimate the elasticity of cigarettes demand in Albania, the paper uses the Living Standard Measurement Survey (LSMS) applying Deaton's (1988) demand model. This paper estimates an Almost Ideal Demand System (AIDS), which allows disentangling quality choice from exogenous price variations using unit values from cigarette consumption. Following Deaton's model, the results suggest that the demand for tobacco is inelastic, with a price elasticity of -0.57. The price elasticity appears to be within the range of elasticity estimates frequently reported for low- and middle-income countries. The results suggest that total expenditure, household size, male-to-female ratio, and adult ratio are important determinants of tobacco demand in Albania. The increase in the tobacco price, which has been mainly driven by increased excises, has demonstrated a significant impact on reducing tobacco consumption. Consequently, the Albanian government may engage in gradual increases in excise taxes given the inelastic tobacco demand.

WHO FCTC Article 14 enforcement in Albania: An urgent issue to tackle

Tobacco use is a major preventable risk factor for non-communicable diseases such as cardiovascular disease, cancer etc. Smoking prevalence in Albania is high. The country ratified the World Health Organization Framework Convention on Tobacco Control (WHO FCTC) in 2006 and has passed different bills and adopted strict tobacco control laws during the years. Despite this, there is a huge gap in primary healthcare (PHC) personnel education in this field. Additionally, tobacco treatment support facilities, such as free of charge telephone quit lines, tobacco treatment clinics in hospitals or in the community, are lacking or not well established. Training of healthcare professionals in evidence-based practices as well as the development of national guidelines on tobacco treatment, capacity building for tobacco treatment delivery, pharmacotherapy availability, public opinion awareness and promotion of smoking cessation practices are some of the measures Albanian policy makers should undertake.

Correlates of compliance with national comprehensive smoke-free laws

OBJECTIVE

To explore correlates of high compliance with smoking bans in a cross-sectional data set from the 41 countries with national comprehensive smoke-free laws in 2014 and complete data on compliance and enforcement.

METHODS

Outcome variable: compliance with a national comprehensive smoke-free law in each country was obtained for 2014 from the WHO global report on the global tobacco epidemic. Explanatory variables: legal enforcement requirements, penalties, infrastructure and strategy were obtained through a separate survey of governments. Also, country socioeconomic and demographic characteristics including the level of corruption control were included.

ANALYSIS

an initial bivariate analysis determined the significance of each potentially relevant explanatory variable of high compliance. Differences in compliance were tested using the exact logistic regression.

RESULTS

High compliance with the national comprehensive smoke-free law was associated with the involvement of the local jurisdictions in providing training and/or guidance for inspections (OR=10.3, 95% CI 1.7 to 117.7) and a perception of high corruption control efforts in the country (OR=7.2, 95% CI 1.1 to 85.8).

DISCUSSION

The results show the importance of the depth of the enforcement infrastructure and effort represented by the degree to which the local government is involved in enforcement. They also show the significance of fighting corruption in the enforcement process, including the attempts of the tobacco industry to undermine the process, to achieve high levels of compliance with the law. The results point out to the need to invest minimal but essential enforcement resources given that national comprehensive smoke-free laws are self-enforcing in many but not all countries and sectors.

Smoking behaviors before and after implementation of a smoke-free legislation in Guangzhou, China

Background

According to the partial smoke-free legislation implemented on 1 September 2010 in Guangzhou, China, smoke-free did not cover all indoor areas. Some places have a full smoking ban (100 % smoke-free), other places have a partial smoking ban, and homes have no ban. This study aimed to compare the smoking behaviors before and after implementation of a smoke-free legislation.

Method

A repeated cross-sectional survey was conducted on smoking-related behaviors with a total of 4,900 respondents before, and 5,135 respondents after the legislation was instituted. For each wave of the survey, a three-stage stratified sampling process was used to obtain a representative sample. Pearson’s Chi-square test was used to determine differences of smoking prevalence and quit ratio between the two samples. Logistic regression models were used to examine the associations of a smoke-free legislation with smoking behaviors.

Results

The overall daily smoking rate declined significantly from 20.8 % to 18.2 % (p < 0.05), especially among those aged 15–24 years. The quit ratios increased significantly (from 14.5 % to 17.9 %), but remained low among 15–44 year olds. The overall self-reported smoking behaviors in locations with a full smoking ban decreased significantly from 36.4 % to 24.3 % with the greater drops occurring in cultural venues, public transport vehicles, and government offices. Smoking in places with partial smoking bans remained high (89.6 % vs. 90.4 %), although a slight decrease was observed in some of these areas. The implementation of a smoke-free legislation did not lead to more smoking in homes (91.0 % vs 89.4 %), but smoking in homes remained high.

Conclusions

These findings highlight the urgent need for a comprehensive smoke-free legislation covering all public places in Guangzhou, simultaneously educational interventions and campaigns promoting voluntary changes in home smoking need to occur.

An international smoking ban-how many lives will be saved?

Multicomponent tobacco control strategies are crucial to combat the ongoing global smoking challenge. In the twenty-first century, many countries have signed up to the World Health Organization Framework Convention on Tobacco Control, and in recent years a mounting number of countries and regions have implemented partial or complete smoking bans to protect the general public from passive smoke exposure. There is substantial evidence that workers, particularly in the hospitality sector, benefit from reduced exposure. More recently, several reports have appeared from different countries showing a temporal relationship between the introduction of a smoking ban and reduced hospital admissions for cardiovascular, respiratory and maternity outcomes. This will have a measurable benefit for public health, saving many lives. Multicomponent strategies could also reduce active smoking significantly if successfully implemented worldwide.

Reported maternal styles and substance use: a cross-sectional study among educated Albanian young adults

The study explored a predictive model of substance use including perceived maternal parenting style, age and gender. Participants were 347 Albanian young adults (144 males and 203 females) aged 18 to 28 years. They completed the Parental Authority Questionnaire and the Adolescent Alcohol and Drug Involvement Scale. Gender, perceived authoritative maternal style, and age predicted a proportion of substance use involvement. Gender and perceived authoritative maternal style also predicted the proportion of young people at risk for substance use or abuse. Implications of the findings and limitations of the study are discussed.

Second-hand smoke exposure in different types of venues: before and after the implementation of smoke-free legislation in Guangzhou, China

OBJECTIVES

Smoke-free legislation was implemented in Guangzhou on 1 September 2010. However, the smoke-free policy did not cover all indoor areas and smoking rooms can be set in some public places. This study aimed to assess changes in self-reported second-hand smoke (SHS) exposure in different types of venues and in homes, in order to evaluate the effectiveness of smoke-free legislation.

METHODS/DESIGN

A repeated cross-sectional survey of representative participants was conducted in Guangzhou before and after the smoke-free legislation. Logistic regression models were used to examine the effectiveness of smoke-free legislation.

MAIN OUTCOME MEASURES

Self-reported exposure to SHS,antitobacco advertisements and tobacco advertisements.

PARTICIPANTS

A total of 4900 participants before the ban and 5135 participants after the ban were selected using a multistage stratified design.

RESULTS

In full smoking ban places, overall self-reported SHS exposure has declined significantly from 58.8% to 50.3% (p<0.05) with greater drops in cultural venues, government offices and commercial venues. The smoke-free policy did not alter SHS exposure in smokers' homes (39.6% in 2009 vs 40.0% in 2011; p=0.454). Although a slight decrease in SHS exposure was observed in smoking rooms in hotels, workplaces, restaurants, cafes/bars/nightclubs and amusement parks, SHS continued to be high in those areas. The implementation of smoke-free legislation was accompanied by an increase in antitobacco advertisements.

CONCLUSIONS

SHS exposure declines more significantly in full smoking ban places than in partial smoking ban places. The smoke-free policy in public places does not lead to more SHS exposure in homes. Therefore, it is recommended that Guangzhou should implement a 100% smoke-free policy in all public places and workplaces in the future.

Tobacco Smoking Habits, Attitudes, and Beliefs among Albanian Nurse Students

Background. Available information about tobacco smoking habits, attitudes, and beliefs among Albanian nurse students shows some discrepancies and requires further investigation. Material and Methods. Cross-sectional school-based survey using a self-administered anonymous questionnaire in the Tirana Nurse University in December 2012 about tobacco smoking habits, attitudes, and beliefs. Results. Sixty hundred fifty one students (mean age 20.0 years; males 19%, females 81%) completed the questionnaire with an overall response rate of 87%. Current smokers were 19%; of this group, 37% of males and 49% of females were occasional smokers. Among current smokers, males smoked more than females (46% versus 13%; P<0.01). The knowledge about smoking was generic; only a part (24%) of students reported having received a formal specific training on smoking related issues. The percentage of current smokers who reported at least one serious attempt to quit was 64%. Most students (78%) reported recent exposure to second hand smoke at home. Most students (84%) were felt to be a model of healthy lifestyle, but only a part (42% of the total) was recognized to have a role in advising smokers to quit. Conclusions. Smoking habits of Albanian nurse students are not higher than those of other European countries and Albanian population of similar age and gender. Our students showed many positive attitudes towards tobacco. Targeted training about smoking related issues should be mandatory in nursing schools.

Implementation and research priorities for FCTC Articles 13 and 16: tobacco advertising, promotion, and sponsorship and sales to and by minors

INTRODUCTION

Article 13 of the Framework Convention on Tobacco Control (FCTC) calls for a comprehensive ban on tobacco advertising, promotion, and sponsorship (TAPS), and Article 16 calls for prohibition of tobacco sales to and by minors. Although these mandates are based on sound science, many countries have found provision implementation to be rife with challenges.

OBJECTIVE

This paper reviews the history of tobacco marketing and minor access restrictions in high-, middle-, and low-income countries, identifying past challenges and successes. We consider current challenges to FCTC implementation, how these barriers can be addressed, and what research is necessary to support such efforts. Specifically, we identify implementation and research priorities for FCTC Articles 13 and 16.

DISCUSSION

Although a solid evidence base underpins the FCTC's call for TAPS bans and minor access restrictions, we know substantially less about how best to implement these restrictions. Drawing on the regulatory experiences of high-, middle-, and low-income countries, we discern several implementation and research priorities, which are organized into 4 categories: policy enactment and enforcement, human capital expertise, the effects of FCTC marketing and youth access policies, and knowledge exchange and transfer among signatories. Future research should provide detailed case studies on implementation successes and failures, as well as insights into how knowledge of successful restrictions can be translated into tobacco control policy and practice and shared among different stakeholders.

CONCLUSION

Tobacco marketing surveillance, sales-to-minors compliance checks, enforcement and evaluation of restriction policies, and capacity building and knowledge transfer are likely to prove central to effective implementation.

Computational modeling and multilevel cancer control interventions

This chapter presents an overview of computational modeling as a tool for multilevel cancer care and intervention research. Model-based analyses have been conducted at various "beneath the skin" or biological scales as well as at various "above the skin" or socioecological levels of cancer care delivery. We review the basic elements of computational modeling and illustrate its applications in four cancer control intervention areas: tobacco use, colorectal cancer screening, cervical cancer screening, and racial disparities in access to breast cancer care. Most of these models have examined cancer processes and outcomes at only one or two levels. We suggest ways these models can be expanded to consider interactions involving three or more levels. Looking forward, a number of methodological, structural, and communication barriers must be overcome to create useful computational models of multilevel cancer interventions and population health.

Second hand smoke and cardiovascular disease in Low and Middle Income Countries: a case for action

Second hand tobacco smoke (SHS) is an environmental toxin and an established cause of cardiovascular disease in nonsmokers. Smoke free laws reduce SHS and its downstream cardiovascular disease, but until recently evidence to support smoke free law implementation in low and middle income country settings was limited. In 14 low and middle income nations surveyed by the Global Adult Tobacco Survey active smoking prevalence in adults (≥15 years old) was universally higher in males (range 21.6-60.2%) compared with females (0.5-24.4%), and the highest burden of SHS exposure was in women (strong positive association between male/female active smoking ratio and female SHS exposure prevalence). A systematic review was conducted of MEDLINE-indexed studies of self-reported SHS exposure and cardiovascular harms in low or middle income nations. Eight papers reported the association of SHS with ischemic heart disease and four reported the association of SHS with stroke. For all the studies, and almost all sources of SHS surveyed, a strong positive association between SHS and ischemic heart disease (main relative odds ratio range 1.17-2.36) and SHS and stroke (odds ratio or hazard ratio 1.41-1.49). Prevalence of SHS exposure is high in low and middle income nations, especially among women. Epidemiologic evidence supports the conclusion that SHS harms are the same across low, middle and high income nations. Governments have an obligation to protect citizens from SHS exposure, enforcing smoke-free legislation and providing public education about SHS harms.

Comprehensive tobacco marketing restrictions: promotion, packaging, price and place

Evidence of the causal role of marketing in the tobacco epidemic and the advent of the WHO Framework Convention on Tobacco Control have inspired more than half the countries in the world to ban some forms of tobacco marketing. This paper briefly describes the ways in which cigarette marketing is restricted and the tobacco industry's efforts to subvert restrictions. It reviews what is known about the impact of marketing regulations on smoking by adults and adolescents. It also addresses what little is known about the impact of marketing bans in relation to concurrent population-level interventions, such as price controls, anti-tobacco media campaigns and smoke-free laws. Point of sale is the least regulated channel and research is needed to address the immediate and long-term consequences of policies to ban retail advertising and pack displays. Comprehensive marketing restrictions require a global ban on all forms of promotion, elimination of packaging and price as marketing tools, and limitations on the quantity, type and location of tobacco retailers.

Three-year follow-up of attitudes and smoking behaviour among hospital nurses following enactment of France's national smoke-free workplace law

OBJECTIVE

This study evaluated among hospital nurses the smoking status, knowledge and attitudes regarding smoking cessation services, and smoking behaviour 3years after the implementation of smoke-free workplace law (decree no. 2006-1386).

METHODS

A descriptive study was undertaken in a public referral hospital in the South of France. Between February and April 2010, a questionnaire was distributed to the nurses. Data on demographic information, smoking status, behaviour and attitudes regarding smoking addiction, and knowledge regarding smoking cessation services were collected. Changes in nurses' smoking habits were studied through a former study conducted in this hospital a year after the law had come into effect.

RESULTS

Three years after the enactment of the smoking ban, 30% (30% in 2008) reported themselves as current smokers, 26% (25% in 2008) as ex-smokers and 44% (45% in 2008) as non-smokers. Among smokers, 72% (68% in 2008) declared they had decreased tobacco consumption during working hours and 50% (29% in 2008) daily cigarette consumption. The majority of nurses (88%) supported the smoke-free law. A higher percentage of smokers than non smokers have knowledge of smoking cessation services. The smoking prevalence among hospital nurses seemed to have remained constant between 2008 and 2010 despite a better compliance with the law.

CONCLUSIONS

France's national smoke-free workplace law is associated with a reduction in tobacco consumption and exposure to second-hand smoke in nurses but not smoking prevalence. The other measures of the MPOWER package have to be reinforced.