Strategies and barriers to achieving the goal of Finland's tobacco endgame

Vision for tobacco endgame in Korea: suggestions for countries with endgame aspirations

Tobacco endgame is a focal point of discussion at both national and international levels. We aimed to describe efforts related to achieving the tobacco endgame in the Republic of Korea, an exemplar of a country with endgame aspirations, and compare them with the efforts of other nations. We reviewed the tobacco endgame efforts of three nations considered tobacco control leaders: New Zealand (NZ), Australia and Finland. The efforts/attempts of each country were described using an endgame strategy category. The tobacco control leaders had explicit goals to achieve a smoking prevalence of <5% before a target date and had legislation and research centres for tobacco control and/or endgame. NZ is implementing a mixture of conventional and innovative endgame interventions; the others use incremental conventional approaches. In Korea, there has been an attempt to ban the sale and manufacture of combustible cigarettes. The attempt led to the filing of a petition, and a survey of adults showed 70% supported the legislation banning tobacco. The Korean government mentioned a tobacco endgame in a 2019 plan, yet a target and an end date were absent. The 2019 plan in Korea included incremental FCTC strategies. Practices in the leading countries show that legislation and research are key to ending the tobacco epidemic. The MPOWER measures must be strengthened, endgame objectives must be set and bold strategies must be adopted. Key endgame policies include those with evidence of effectiveness, such as retailer reductions.

[Use of tobacco cigarettes, e-cigarettes, and shishas among children and adolescents: Results of the "Präventionsradar" from 2016 to 2023]

AIM

To measure trends in the use of various smoking products among children and adolescents from 2016 to 2023.

METHOD

The data is based on seven waves of the "Präventionsradar", a school-based epidemiological study in grades 5 to 10. The primary endpoints of the study were the lifetime and monthly prevalence of the use of tobacco cigarettes, e-cigarettes, shisha and the use of at least two of these smoking products (combined use). Prevalence estimates are based on logistic regression models.

RESULTS

The analysis was based on 94,127 questionnaires. The sex ratio was balanced (49% female), mean age was 13 years (SD=1.8). In 2022/2023, the lifetime prevalence of smoking tobacco cigarettes was 18.8% (95% CI 18.1-19.5), of e-cigarettes 23.5% (95% CI 22.8-24.3), of shisha 14.0% (95% CI 13.4-14.7) and combined use 19.0% (95% CI 18.3-19.7). The monthly prevalence of smoking tobacco cigarettes was 5.9% (95% CI 5.5-6.4), of e-cigarettes 7.0% (95% CI 6.5-7.4), of shisha 3.2% (95% CI 2.8-3.5) and combined use 4.8% (95% CI 4.4-5.2). The following trends in lifetime prevalence have emerged since 2016: tobacco cigarettes (-3.0 percentage points), e-cigarettes (+1.8 percentage points), shisha (-9.2 percentage points), combined use (-2.7 percentage points). In the years of the COVID-19 pandemic, youth smoking decreased and rose again post-COVID with the exception of shisha.

DISCUSSION

The use of smoking products in adolescence occurs frequently. Over the observational period, a trend reversal towards e-cigarettes as the most popular product among children and young people is most likely. In addition, the combined use of several smoking products has become a common pattern of consumption. Consistent preventive measures are required in order to achieve the goal of a smoke-free society in 2040.

A Bivariate Twin Study of Lifetime cannabis Initiation and Lifetime Regular Tobacco Smoking Across Three Different Countries

Regular cigarette smoking and cannabis consumption are strongly positively related to each other, yet few studies explore their underlying variation and covariation. We evaluated the genetic and environmental decomposition of variance and covariance of these two traits in twin data from three countries with different social norms and legislation. Data from the Netherlands Twin Register, FinnTwin12/16, and the Minnesota Center for Twin Family Research (total N = 21,617) were analyzed in bivariate threshold models of lifetime regular smoking initiation (RSI) and lifetime cannabis initiation (CI). We ran unstratified models and models stratified by sex and country. Prevalence of RSI was lowest in the Netherlands and prevalence of CI was highest in Minnesota. In the unstratified model, genetic (A) and common environmental factors (C) contributed substantially to the liabilities of RSI (A = 0.47, C = 0.34) and CI (A = 0.28, C = 0.51). The two liabilities were significantly phenotypically (rP = 0.56), genetically (rA = 0.74), and environmentally correlated in the unstratified model (rC = 0.47and rE = 0.48, representing correlations between common and unique environmental factors). The magnitude of phenotypic correlation between liabilities varied by country but not sex (Minnesota rP ~ 0.70, Netherlands rP ~ 0.59, Finland rP ~ 0.45). Comparisons of decomposed correlations could not be reliably tested in the stratified models. The prevalence and association of RSI and CI vary by sex and country. These two behaviors are correlated because there is genetic and environmental overlap between their underlying latent liabilities. There is heterogeneity in the genetic architecture of these traits across country.

Support for banning sale of smoked tobacco products among adults who smoke: findings from the International Tobacco Control Four Country Smoking and Vaping Surveys (2018-2022)

BACKGROUND

Many people continue to smoke despite strong policies to deter use, thus stronger regulatory measures may be required. In four high-income countries, we examined whether people who smoke would support a total ban on smoked tobacco products under two differing policy scenarios.

METHODS

Data were from 14 363 adults (≥18) who smoked cigarettes (≥monthly) and participated in at least one of the 2018, 2020 or 2022 International Tobacco Control Four Country Smoking and Vaping Surveys in Australia, Canada, England and the USA. In 2018, respondents were asked whether they would support a law that totally bans smoked tobacco if the government provides smoking cessation assistance (Cessation Assistance scenario). In 2020 and 2022, respondents were asked a slightly different question as to whether they would support a law that totally bans smoked tobacco if the government encourages people who smoke to use alternative nicotine products like vaping products and nicotine replacement products instead (substitution scenario). Responses (support vs oppose/don't know) were estimated on weighted data.

RESULTS

Support was greater for the cessation assistance scenario (2018, 36.6%) than the nicotine substitution scenario (2020, 26.9%; 2022, 26.3%, both p<0.0001). In the longitudinal analysis, there was a significant scenario by country interaction effect with lower support in Canada, the USA and Australia under the substitution scenario than in the cessation scenario, but equivalent levels in England under both scenarios. The strongest correlates of support under both scenarios were planning to quit smoking within 6 months, wanting to quit smoking 'a lot' and recent use of nicotine replacement therapy.

CONCLUSIONS

Opposition to banning smoked tobacco predominates among people who smoke, but less with a cessation assistance scenario than one encouraging nicotine substitution. Wanting to quit a lot was the strongest indicator of support.

How do New Zealand youth perceive the smoke-free generation policy? A qualitative analysis

INTRODUCTION

Aotearoa New Zealand (NZ) plans to introduce a smoke-free generation (SFG) policy, alongside denicotinisation and reducing the availability of tobacco products. The SFG has a clear rationale, yet we know little about how young people, those the policy targets, perceive it. To inform policy design, communication and implementation, we explored how NZ youth perceived the SFG.

METHODS

We undertook in-depth interviews with a sample of 20 youth aged 17 or 18 and explored their knowledge of the SFG, and how they perceived its individual and societal implications. We interpreted the data using a reflexive thematic analysis approach.

RESULTS

We identified two overarching themes. The first theme, 'societal good and protection from harm', reflected benefits participants associated with the SFG, which outweighed perceptions of lost freedoms. The second theme, 'privileging personal choice', corresponded to two small groups within the sample. The first preferred measures they considered less restrictive, such as increasing the purchase age, and some came to support the SFG as they rationalised their views. The second subgroup expressed more entrenched opposition and felt the SFG deprived them of a choice.

CONCLUSIONS

Young people's deep reflection on the SFG led most to view it as liberating rather than restrictive. Communications that avoid prompting heuristic-based responses could encourage youth to reflect on the policy and elicit strong support from the group the SFG aims to benefit.

Regional socioeconomic deprivation in Germany and nicotine use among children and adolescents

To assess the association of regional socioeconomic deprivation and nicotine use, survey data from 17,877 pupils aged 9-17 years were analysed. Lifetime use of combustible, e-cigarettes, and both products were the outcome variables. The German Index of Socioeconomic Deprivation was the exposure variable. Logistic regression models controlling for age, gender, school type, and sensation seeking were used to examine associations between regional socioeconomic deprivation and nicotine use. Ever use of combustible cigarettes was 17.8%, of e-cigarettes 19.6%, and of both products 13.4%. Compared to the most affluent area, the adjusted odds ratio of combustible cigarette use in the most deprived area was 2.24 (95% CI: 1.67-3.00), of e-cigarette use 1.56 (95% CI: 1.20-2.03), and of poly use 1.91 (95% CI: 1.36-2.69). Nicotine use among young people across ages and especially in socioeconomic-deprived areas was widespread. Nicotine control measures are urgently needed to reduce smoking and vaping in German adolescents.

[Use of tobacco cigarettes, e-cigarettes, and shishas among children and adolescents: Results of the 'Präventionsradar' from 2016 to 2023]

AIM

To measure trends in the use of various smoking products among children and adolescents from 2016 to 2023.

METHOD

The data is based on seven waves of the "Präventionsradar", a school-based epidemiological study in grades 5 to 10. The primary endpoints of the study were the lifetime and monthly prevalence of the use of tobacco cigarettes, e-cigarettes, shisha and the use of at least two of these smoking products (combined use). Prevalence estimates are based on logistic regression models.

RESULTS

The analysis was based on 94,127 questionnaires. The sex ratio was balanced (49% female), mean age was 13 years (SD=1.8). In 2022/2023, the lifetime prevalence of smoking tobacco cigarettes was 18.8% (95% CI 18.1-19.5), of e-cigarettes 23.5% (95% CI 22.8-24.3), of shisha 14.0% (95% CI 13.4-14.7) and combined use 19.0% (95% CI 18.3-19.7). The monthly prevalence of smoking tobacco cigarettes was 5.9% (95% CI 5.5-6.4), of e-cigarettes 7.0% (95% CI 6.5-7.4), of shisha 3.2% (95% CI 2.8-3.5) and combined use 4.8% (95% CI 4.4-5.2). The following trends in lifetime prevalence have emerged since 2016: tobacco cigarettes (-3.0 percentage points), e-cigarettes (+1.8 percentage points), shisha (-9.2 percentage points), combined use (-2.7 percentage points). In the years of the COVID-19 pandemic, youth smoking decreased and rose again post-COVID with the exception of shisha.

DISCUSSION

The use of smoking products in adolescence occurs frequently. Over the observational period, a trend reversal towards e-cigarettes as the most popular product among children and young people is most likely. In addition, the combined use of several smoking products has become a common pattern of consumption. Consistent preventive measures are required in order to achieve the goal of a smoke-free society in 2040.

Tobacco and Alcohol Retailer Availability and Neighborhood Racialized, Economic, and Racialized Economic Segregation in North Carolina

BACKGROUND

Despite evidence of racialized and socioeconomic inequities in tobacco and alcohol outlet availability, few studies have investigated spatial inequities in areas experiencing both concentrated residential racialized segregation and socioeconomic disadvantage. This study examined whether segregation-racialized, economic or both-was associated with alcohol and tobacco retailer counts in North Carolina (NC).

METHODS

The NC Alcoholic Beverage Control Commission provided lists of 2021 off-premise alcohol retailers. We created a list of 2018 probable tobacco retailers using ReferenceUSA. We calculated three census tract-level measures of the Index of Concentrations at the Extremes (ICE), indicating racialized segregation between non-Hispanic White and Black residents and economic segregation based on household income. We used negative binomial regression to test associations between quintiles of each ICE measure and tobacco and, separately, alcohol retailer counts.

RESULTS

Tracts with the greatest racialized disadvantage had 38% (IRR, 1.38; 95% CI, 1.15-1.66) and 65% (IRR, 1.65; 95% CI, 1.34-2.04) more tobacco and alcohol outlets, respectively, as tracts with the lowest. Tracts with the highest racialized economic disadvantage had a predicted count of 1.51 tobacco outlets per 1000 people while those in the lowest had nearly one fewer predicted outlet. Similar inequities existed in the predicted count of alcohol outlets.

DISCUSSION

Tobacco and alcohol outlet availability are higher in NC places experiencing concentrated racialized and economic segregation. A centralized agency overseeing tobacco and alcohol outlet permits and strategies to reduce the retail availability of these harmful products (e.g., capping the number of permits) are needed to intervene upon these inequities.

Area-level sociodemographic differences in tobacco availability examined with nationwide tobacco product retail licence data in Finland

BACKGROUND

Differences in tobacco retailer density between areas by sociodemographic composition have been observed. However, little research comes from European jurisdictions and from countries with a tobacco retail licensing system. In Finland, the system consists of criteria for retailers and supervision fees.

METHODS

The tobacco product retail licence data and sociodemographic data were retrieved from corresponding Finnish authorities. Area-level tobacco availability was measured as the presence of a retailer and as the number of retailers per 1000 inhabitants by postcode area. Sociodemographic indicators included median income, percentage of inhabitants in the lowest income tertile, percentage of adults with higher education and unemployment rate. Analyses were based on logistic regression and Ordinary Least Squares regression with log-transformed density.

RESULTS

Lower area-level sociodemographic composition was mainly associated with higher tobacco availability. Income was the strongest correlate of the tobacco retailer availability: areas with higher median income had lower odds of having a tobacco retailer (OR 0.54, 95% CI 0.48 to 0.61 per €1000) and lower retailer density (-4.4% per €1000, Cohen's f=0.51). Areas with a greater proportion of people in the lowest income category had higher densities of tobacco retailers (+2.8% per percentage point, Cohen's f=0.07). Other sociodemographic indicators showed inconsistent associations with retailer presence and density.

CONCLUSION

Tobacco availability can be higher in areas with lower sociodemographic composition also in a country with a comprehensive tobacco retail licensing system and small income inequalities. Retailing policies should be further developed to reduce tobacco availability and narrow inequalities in tobacco use.

Perspective on Cancer Control: Whither the Tobacco Endgame for Canada?

Aims: In 2014, in response to evidence that Canada’s tobacco use would lead, inexorably, to substantial morbidity and mortality for the foreseeable future, a group of experts convened to consider the development of a “Tobacco Endgame” for Canada. The “Tobacco Endgame” defines a time frame in which to eliminate structural, political, and social dynamics that sustain tobacco use, leading to improved population health. Strategies: A series of Background Papers describing possible measures that could contribute to the creation of a comprehensive endgame strategy for Canada was prepared in advance of the National Tobacco Endgame Summit hosted at Queen’s University in 2016. At the summit, agreement was reached to work together to achieve <5% tobacco use by 2035 (<5 by ’35). A report of the proceedings was shared widely. Achievements: Progress since 2016 has been mixed. The Summit report was followed by a national forum convened by Health Canada in March 2017, and in 2018, the Canadian Government adopted “<5 × ’35” tobacco use target in a renewed Canadian tobacco reduction strategy. Tobacco use has declined in the last 5 years, but at a rate slower than that which will be needed to achieve the <5 by ’35 goal. There remain > 5 million smokers in Canada, signaling that smoking-related diseases will continue to be an enormous health burden. Furthermore, the landscape of new products (e-cigarettes and cannabis) has created additional risks and opportunities. Future directions: A bold, reinvigorated tobacco control strategy is needed that significantly advances ongoing policy developments, including full implementation of the key demand-reduction policies of the WHO Framework Convention on Tobacco Control. Formidable, new disruptive policies and regulations will be needed to achieve Canada’s Endgame goal.

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

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

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

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

Associations of tobacco retailer availability with chronic obstructive pulmonary disease related hospital outcomes, United States, 2014

There are associations between tobacco retailer density and smoking behaviors, but little is known about whether places with more tobacco retailers have more smoking-related health problems. Using cross-sectional data from 2014, we investigated the relationships between tobacco retailer density and chronic obstructive pulmonary disease (COPD) related outcomes in a sample of 1510 counties across the United States. Higher retailer density was associated with a 19% (IRR, 1.19; 95% CI, 1.12-1.27) higher COPD-related hospital discharge rate and 30% (IRR, 1.30; 95% CI 1.21-1.39) higher total COPD-related hospital costs per population. The tobacco retailer environment may be an important target for reducing smoking-related health burdens and costs.

Compliance with the Framework Convention on Tobacco Control in Slovakia and in Finland: Two Different Worlds

The Framework Convention on Tobacco Control (FCTC) developed by the State Parties to the World Health Organization was ratified in Slovakia in 2004 and in Finland in 2005. The aim of this study was to explore and compare compliance with the FCTC in Finland and Slovakia. This is a two-country comparative study of tobacco control policy based on implementation of the FCTC in Slovakia and Finland. Compliance with the FCTC was measured similarly in Slovakia and Finland in terms of their institutional structure supporting a smoking free environment and implementation of selected articles of the FCTC. In Finland the responsibilities for anti-tobacco policy are clearly assigned. Slovakia does not have specifically responsible institutions. Finland has a clear plan for achieving the goal of a smoking-free country based on empirical evidence. Slovakia meets only the minimum standard resulting from its commitment as ratified in the FCTC and data are out of date or missing completely.

[Smoke-free Germany 2040: a discussion paper]

INTRODUCTION

A "smoke-free" society is assumed if less than 5 % of a population smoke. We predict when this goal could be reached in Germany. To reduce the proportion of smokers in the population, the World Health Organization recommends a bundle of measures (MPOWER) that should minimize both the supply of and the demand for tobacco. The current level of implementation of these recommendations in Germany is presented.

METHODS

A total of 21 representative cross-sectional surveys of the Drug Affinity Study and the Epidemiological Survey of Substance Abuse since 2000/2001 with adolescents and adults show the smoking behavior of the population until 2018. Per capita consumption of factory-built and self-made cigarettes during the same period is used as an objective data basis. Regression analyses are used to model the date at which less than 5 % of the German population smoke. A selective literature review is carried out to describe the implementation of the MPOWER program.

RESULTS

Before 2000 there was no trend in Germany towards non-smoking. After the implementation of various preventive measures such as price increases for tobacco products and the introduction of non-smoking protection laws, the spread of smoking among the population has steadily decreased since 2000. By 2018, the 5 % prevalence target among adolescents had almost been reached, as the relative proportion of adolescents who smoked fell by 20.9 percentage points to 6.6 %. The relative proportion of smoking in adult women fell by 12.1 percentage points to 18.5 %, the relative proportion of smoking in men by 14.8 percentage points to 24.2 %. Assuming a linear trend, the prevalence target of less than 5 % smoking adults can be reached by around 2043. Of the six recommended measures of the MPOWER program, Germany is currently only implementing the monitoring of tobacco consumption in society without compromises.

DISCUSSION

After various tobacco prevention measures were implemented, a trend towards non-smoking began in Germany. The continual price increase recommended by the World Health Organization, the further restriction of availability, the ban on all tobacco advertising and promotion, the support of smoking cessation as well as the education of the population appear to be necessary to reinforce this trend and to achieve the health policy goal of a smoke-free society in 2040.

Helsinki by nature: The Nature Step to Respiratory Health

Background

The Nature Step to Respiratory Health was the overarching theme of the 12th General Meeting of the Global Alliance against Chronic Respiratory Diseases (GARD) in Helsinki, August 2018. New approaches are needed to improve respiratory health and reduce premature mortality of chronic diseases by 30% till 2030 (UN Sustainable Development Goals, SDGs). Planetary health is defined as the health of human civilization and the state of the natural systems on which it depends. Planetary health and human health are interconnected, and both need to be considered by individuals and governments while addressing several SDGs.

Results

The concept of the Nature Step has evolved from innovative research indicating, how changed lifestyle in urban surroundings reduces contact with biodiverse environments, impoverishes microbiota, affects immune regulation and increases risk of NCDs. The Nature Step calls for strengthening connections to nature. Physical activity in natural environments should be promoted, use of fresh vegetables, fruits and water increased, and consumption of sugary drinks, tobacco and alcohol restricted. Nature relatedness should be part of everyday life and especially emphasized in the care of children and the elderly. Taking “nature” to modern cities in a controlled way is possible but a challenge for urban planning, nature conservation, housing, traffic arrangements, energy production, and importantly for supplying and distributing food. Actions against the well-known respiratory risk factors, air pollution and smoking, should be taken simultaneously.

Conclusions

In Finland and elsewhere in Europe, successful programmes have been implemented to reduce the burden of respiratory disorders and other NCDs. Unhealthy behaviour can be changed by well-coordinated actions involving all stakeholders. The growing public health concern caused by NCDs in urban surroundings cannot be solved by health care alone; a multidisciplinary approach is mandatory.