Overview of systematic reviews on the health-related effects of government tobacco control policies

Understanding the mechanisms of change in social norms around tobacco use: A systematic review and meta-analysis of interventions

BACKGROUND AND AIMS

Tobacco use spreads through social networks influencing social norms around tobacco use. However, the social norms scholarship is extremely diverse and occasionally conflicting, complicating efforts to understand how best to leverage social norms to reduce tobacco use. This study systematically reviewed and meta-analyzed this vast terrain by focusing on social norms measurement and mechanism, and intervention effectiveness and modality aimed at changing social norms around tobacco use and actual tobacco use.

METHODS

We searched Scopus, PubMed, PsycInfo, Clinicaltrials.gov, ProQuest Dissertations, the Cochrane Trial Registry, as well as the websites of the Society for Research on Nicotine and Tobacco, the Open Science Framework, medrXiv and the Truth Initiative for experimental and quasi-experimental evaluation studies of interventions designed to shift tobacco use. We included studies written in English from inception to 30 May 2024. We only included studies which noted social norms or social influence as part of the intervention design or set of measured variables. We excluded studies with only one time point, without an intervention being evaluated and those not published in English. Study screening followed the PRISMA 2020 guidelines, and was conducted by at least two independent reviewers who resolved discrepancies through discussion and consensus. All included studies were analyzed in a narrative synthesis, and those providing sufficient statistics for tobacco and social norms outcomes were included in meta-analyses, which were performed separately for tobacco outcomes and social norms outcomes. Study outcomes were transformed into a standardized mean difference (Hedges' g) and several meta-regressions were fit to explore sources of heterogeneity using a robust variance estimation specification to handle effect size dependency.

RESULTS

A total of 95 studies met inclusion criteria for the narrative synthesis, 200 effect sizes from 86 studies were included in the tobacco outcomes meta-analysis, and 66 effect sizes from 29 studies were included in the social norms outcomes meta-analysis. Nearly 90% of included studies were conducted in high-income settings, with the remainder conducted in middle-income settings. No studies were conducted in Latin America or on the African continent. Social norms change interventions had a statistically significant effect on reducing tobacco use and pro-tobacco social normative perceptions [g = 0.233, 95% confidence interval (CI) = 0.166, 0.301, P < 0.001 and g = 0.292, 95% CI = 0.090, 0.494, P = 0.007, respectively]. Interventions were commonly conducted among schoolchildren in classrooms through multicomponent education sessions, often coupled with regular 'booster' sessions over time. Among adult populations, motivational interviewing and other counselling approaches were used in some cases, and few interventions leveraged digital technologies to change social norms.

CONCLUSIONS

Social norms change interventions appear to be effective for reducing tobacco use and pro-tobacco social normative perceptions. In particular, leveraging role models appears to be the most effective social norms change mechanisms for tobacco control.

A systematic review and network meta-analysis of population-level interventions to tackle smoking behaviour

This preregistered systematic review and meta-analysis (PROSPERO: CRD 42022311392) aimed to synthesize the effectiveness of all available population-level tobacco policies on smoking behaviour. Our search across 5 databases and leading organizational websites resulted in 9,925 records, with 476 studies meeting our inclusion criteria. In our narrative summary and both pairwise and network meta-analyses, we identified anti-smoking campaigns, health warnings and tax increases as the most effective tobacco policies for promoting smoking cessation. Flavour bans and free/discounted nicotine replacement therapy also showed statistically significant positive effects on quit rates. The network meta-analysis results further indicated that smoking bans, anti-tobacco campaigns and tax increases effectively reduced smoking prevalence. In addition, flavour bans significantly reduced e-cigarette consumption. Both the narrative summary and the meta-analyses revealed that smoking bans, tax increases and anti-tobacco campaigns were associated with reductions in tobacco consumption and sales. On the basis of the available evidence, anti-tobacco campaigns, smoking bans, health warnings and tax increases are probably the most effective policies for curbing smoking behaviour.

European Society of Cardiology: the 2023 Atlas of Cardiovascular Disease Statistics

This report from the European Society of Cardiology (ESC) Atlas Project updates and expands upon the 2021 report in presenting cardiovascular disease (CVD) statistics for the ESC member countries. This paper examines inequalities in cardiovascular healthcare and outcomes in ESC member countries utilizing mortality and risk factor data from the World Health Organization and the Global Burden of Disease study with additional economic data from the World Bank. Cardiovascular healthcare data were collected by questionnaire circulated to the national cardiac societies of ESC member countries. Statistics pertaining to 2022, or latest available year, are presented. New material in this report includes contemporary estimates of the economic burden of CVD and mortality statistics for a range of CVD phenotypes. CVD accounts for 11% of the EU's total healthcare expenditure. It remains the most common cause of death in ESC member countries with over 3 million deaths per year. Proportionately more deaths from CVD occur in middle-income compared with high-income countries in both females (53% vs. 34%) and males (46% vs. 30%). Between 1990 and 2021, median age-standardized mortality rates (ASMRs) for CVD decreased by median >50% in high-income ESC member countries but in middle-income countries the median decrease was <12%. These inequalities between middle- and high-income ESC member countries likely reflect heterogeneous exposures to a range of environmental, socioeconomic, and clinical risk factors. The 2023 survey suggests that treatment factors may also contribute with middle-income countries reporting lower rates per million of percutaneous coronary intervention (1355 vs. 2330), transcatheter aortic valve implantation (4.0 vs. 153.4) and pacemaker implantation (147.0 vs. 831.9) compared with high-income countries. The ESC Atlas 2023 report shows continuing inequalities in the epidemiology and management of CVD between middle-income and high-income ESC member countries. These inequalities are exemplified by the changes in CVD ASMRs during the last 30 years. In the high-income ESC member countries, ASMRs have been in steep decline during this period but in the middle-income countries declines have been very small. There is now an important need for targeted action to reduce the burden of CVD, particularly in those countries where the burden is greatest.

Nicotine replacement therapy and oral health: a network meta-analysis of adverse effects in randomized trials

BACKGROUND

Nicotine replacement therapies (NRTs) are the primary pharmacological option for smokers looking to quit. However, they can lead to oral health issues, including aphthous ulcers, gastric irritation resulting in tooth wear, mouth irritation, soreness, and dryness, which may decrease patient adherence. Dentists should be integrated into the tobacco cessation team to prevent, detect, and manage these oral side effects associated with NRT use. Therefore, the objective of this network meta-analysis is to examine the relationship between different forms of NRTs and their oral side effects.

METHODOLOGY

Databases were screened for literature and full text articles were obtained for eligible studies. Relevant data was extracted. NMA Studio was used to perform random-effects network meta-analysis to generate mixed treatment comparison pooled estimates from odds ratios (OR) and 95% confidence intervals (CI). The forest plot was generated, and the network diagram was drawn for key comparisons. The OR and 95% CI were estimated from the data on the number of patients that reported the oral side effects in the included studies.

RESULTS

A total of 21 articles were included. The Risk of Bias assessment revealed a moderate to low risk across all domains for the included studies. The mixed treatment comparison pooled estimates indicated that nicotine gum was significantly associated with the occurrence of aphthous ulcers [2.25 (1.03, 4.90)] and gastric reflux/vomiting [4.40 (1.51, 12.80)]. Additionally, the results showed that nasal spray significantly caused mouth/throat irritation [5.37 (1.03, 27.92)] and taste disturbance [4.87 (2.83, 8.37)] in comparison to tested NRT interventions.

CONCLUSION

Significant oral side effects are associated with NRT use, as demonstrated in this study. Dentists should implement tobacco cessation methods in their practices, including pharmacotherapy, to effectively monitor these patients. Continuous education and certification programs should be mandatory for dentists who want to practice tobacco cessation. This should also be included in the undergraduate dental curriculum to help dentists gain confidence in prescribing NRT. Standard evidence-based guidelines should be published to outline possible methods for encouraging tobacco cessation in dental settings.

New Zealand's world-first smokefree legislation 'goes up in smoke': A setback in ending the tobacco epidemic

For several decades, Aotearoa New Zealand has maintained a relatively strict regulatory approach towards tobacco. In response to the significant impact of tobacco-related illnesses, many countries worldwide have worked to enhance tobacco control measures. These efforts include introducing plain tobacco packaging with graphic health warnings, improving access to smoking cessation services and offering supportive treatments for tobacco dependence. In December 2022, New Zealand enacted world-leading tobacco control legislation aimed at leading the nation towards a 'smokefree' future by 2025, a future where the smoking prevalence falls below 5 percent across all population groups. To achieve this goal, revolutionary measures were needed. These measures included denicotinising cigarettes, reducing the number of tobacco retail outlets, and implementing a generational ban on smoked products. Despite receiving support from academics, clinicians, leaders of local indigenous communities, and the general public, the sixth National-led coalition government remained resolute in repealing the law and did so through parliamentary urgency on 27 February 2024. The reversal of this health policy is anticipated to result in thousands of lives lost and widen life expectancy gaps between indigenous and non-indigenous populations. This decision, driven by political agenda objectives and interference from the tobacco industry, has not only impeded New Zealand's progress but also weakened global efforts in tobacco control.

Political economy analysis of health taxes (tobacco, alcohol drink and sugar-sweteened beverage): qualitative study of three provinces in Indonesia

OBJECTIVE

Efforts to implement health tax policies to control the consumption of harmful commodities and enhance public health outcomes have garnered substantial recognition globally. However, their successful adoption remains a complex endeavour. This investigates the challenges and opportunities surrounding health tax implementation, with a particular focus on subnational government in Indonesia, where the decentralisation context of health tax remains understudied.

DESIGN

Employing a qualitative methodology using a problem-driven political economy analysis approach.

SETTING

We are collecting data from a total of 12 focus group discussions (FGDs) conducted between July and September 2022 in three provinces-Lampung, Special Region of/Daerah Istimewa Yogyakarta and Bali, each chosen to represent a specific commodity: tobacco, sugar-sweetened beverages (SSBs) and alcoholic beverages-we explore the multifaceted dynamics of health tax policies.

PARTICIPANT

These FGDs involved a mean of 10 participants in each FGD, representing governmental institutions, non-governmental organisations and consumers.

RESULTS

Our findings reveal that health tax policies have the potential to contribute significantly to public health. Consumers understand tobacco's health risks, and cultural factors influence both tobacco and alcohol consumption. For SSBs, the consumers lack awareness of long-term health risks is concerning. Finally, bureaucratic complexiting and decentralised government hinder implementation for all three commodities.

CONCLUSION

Furthermore, this study underscores the importance of effective policy communication. It highlights the importance of earmarking health tax revenues for public health initiatives. It also reinforces the need to see health taxes as one intervention as part of a comprehensive public health approach including complementary non-fiscal measures like advertising restrictions and standardised packaging. Addressing these challenges is critical for realising the full potential of health tax policies.

Advancements in Cardiovascular Disease Research Affected by Smoking

The harmful substances in tobacco are widely recognized to exert a significant detrimental impact on human health, constituting one of the most substantial global public health threats to date. Tobacco usage also ranks among the principal contributors to cardiovascular ailments, with tobacco being attributed to up to 30% of cardiovascular disease-related deaths in various countries. Cardiovascular disease is influenced by many kinds of pathogenic factors, among them, tobacco usage has led to an increased year by year incidence of cardiovascular disease. Exploring the influencing factors of harmful substances in tobacco and achieving early prevention are important means to reduce the incidence of cardiovascular diseases and maintain health. This article provides a comprehensive review of the effects of smoking on health and cardiovascular diseases.

Regional insights on tobacco-related tweets: unveiling user opinions and usage patterns

Introduction

Tobacco consumption and its impact on health remain high worldwide. Additionally, it is a contentious issue generating significant controversy. Twitter has proven to be a useful platform for evaluating public health topics related to population health behaviors, and tobacco consumption.

Objective

The objective of this study is to analyze the content of tweets related to tobacco. Moreover, geolocation data will be considered to understand regional differences.

Methods

Tweets published between 2018 and 2022, in both English and Spanish, containing the keyword "tobacco," were analyzed. A total of 56,926 tweets were obtained. The tweets were classified into different categories. 550 tweets were manually analyzed, and an automated and computerized classification was performed for the remaining and largest subset of tweets.

Results

The analysis yielded 30,812 classifiable tweets. Healthcare professionals were the most frequent contributors to the topic (50.2%), with the most common theme being general information about the toxic effects of tobacco. 57.9% of the tweets discussed the harmful effects of tobacco on health, with fear being the predominant emotion. The largest number of tweets were located in America.

Conclusions

Our study revealed a substantial number of tweets highlighting the health risks and negative perceptions of tobacco consumption. Africa showed the lowest percentage of tweets discussing the health risks associated with tobacco, coinciding with the continent having the least developed anti-tobacco policies. Healthcare professionals emerged as the most prominent users discussing the topic, which is encouraging as they play a crucial role in disseminating accurate and scientific health information.

Tobacco control policies and respiratory conditions among children presenting in primary care

Tobacco control policies can protect child health. We hypothesised that the parallel introduction in 2008 of smoke-free restaurants and bars in the Netherlands, a tobacco tax increase and mass media campaign, would be associated with decreases in childhood wheezing/asthma, respiratory tract infections (RTIs), and otitis media with effusion (OME) presenting in primary care. We conducted an interrupted time series study using electronic medical records from the Dutch Integrated Primary Care Information database (2000-2016). We estimated step and slope changes in the incidence of each outcome with negative binomial regression analyses, adjusting for underlying time-trends, seasonality, age, sex, electronic medical record system, urbanisation, and social deprivation. Analysing 1,295,124 person-years among children aged 0-12 years, we found positive step changes immediately after the policies (incidence rate ratio (IRR): 1.07, 95% CI: 1.01-1.14 for wheezing/asthma; IRR: 1.16, 95% CI: 1.13-1.19 for RTIs; and IRR: 1.24, 95% CI: 1.14-1.36 for OME). These were followed by slope decreases for wheezing/asthma (IRR: 0.95/year, 95% CI: 0.93-0.97) and RTIs (IRR: 0.97/year, 95% CI: 0.96-0.98), but a slope increase in OME (IRR: 1.05/year, 95% CI: 1.01-1.09). We found no clear evidence of benefit of changes in tobacco control policies in the Netherlands for the outcomes of interest. Our findings need to be interpreted with caution due to substantial uncertainty in the pre-legislation outcome trends.

Expanding on cross-price elasticity: Understanding tobacco product demand and substitution from the cross-price purchase task

We examine whether cigarettes serve as substitutes for electronic nicotine delivery systems (ENDS) among ENDS users and demonstrate methodological extensions of data from a cross-price purchase task to inform policies and interventions. During a clinical laboratory study, n = 19 exclusive ENDS users and n = 17 dual cigarette/ENDS users completed a cross-price purchase task with cigarettes available at a fixed price while prices of own-brand ENDS increased. We estimated cross-price elasticity using linear models to examine substitutability. We defined five additional outcomes: nonzero cross-price intensity (purchasing cigarettes if ENDS were free), constant null demand (not purchasing cigarettes at any ENDS price), cross-product crossover point (first price where participants purchased more cigarettes than ENDS), dual-demand score (percentage of prices where both products were purchased), and dual-use break point (minimum relative price to force complete substitution). The cross-price elasticity results indicated that cigarettes could serve as substitutes for ENDS among ENDS users on average, but this average effect masked substantial heterogeneity in profiles of demand (here, a measure of the drug's reinforcement potential). Policies and regulations that increase ENDS prices appear unlikely to steer most exclusive ENDS users toward cigarette use, as most would not purchase cigarettes at any ENDS price, but they could prompt some dual users to substitute cigarettes completely while others remain dual users. This heterogeneity in consumer responses suggests additional indices of cross-product demand are useful to characterize the anticipated and unanticipated effects of tobacco price policies more fully.

Personality traits and high cigarette dependence among university students: Insights from Lebanon

PURPOSE

The use of tobacco and cigarette products remains widespread globally, with varying patterns across countries. Understanding the factors influencing cigarette dependence among young adults is crucial for effective smoking prevention and control programs. Personality traits are one of the factors that influence smoking behaviour, yet the evidence on their role in high cigarette dependence among young adults remains inconclusive. This study aims to provide insights and initial evidence on the potential association between personality dimensions, sociodemographic factors, lifestyle habits, and high cigarette dependence among Lebanese university students.

METHODS

A convenient sample of 212 student smokers from one private and one public university in Lebanon participated in an online survey. The survey included measures of personality traits using the Big-Five framework, sociodemographic factors, lifestyle habits, and the Fagerström Test for Cigarette Dependence (FTCD). Logistic regression models and mediation analysis were used to analyze the data.

RESULTS

The results revealed significant associations between personality dimensions and high cigarette dependence among Lebanese university students. Smokers with higher levels of Openness to Experience were more likely to have high cigarette dependence (β = 0.408, p < = 0.015). Conversely, smokers with higher levels of Conscientiousness (β = -0.500, p < 0.001) and Agreeableness (β = -0.491, p < 0.01) were less likely to have high cigarette dependence. Additionally, attending a public university (β = 1.198, p = 0.018), having more close friends who smoke (β = 0.525, p < 0.01), and switching to a cheaper cigarette brand (β = 0.928, p < 0.05) were associated with a higher cigarette dependence.

CONCLUSION

These findings highlight the importance of considering personality dimensions, sociodemographic factors, and lifestyle habits in understanding high cigarette dependence among Lebanese university students. The results can inform the development of targeted interventions to address high cigarette dependence in this population.

Controlling smoking: A smoking epidemic model with different smoking degrees in deterministic and stochastic environments

Engaging in smoking not only leads to substantial health risks but also imposes considerable financial burdens. To deepen our understanding of the mechanisms behind smoking transmission and to address the tobacco epidemic, we examined a five-dimensional smoking epidemic model that accounts for different degrees of smoking under both deterministic and stochastic conditions. In the deterministic case, we determine the basic reproduction number, analyze the stability of equilibria with and without smoking, and investigate the existence of saddle-node bifurcation. Our analysis reveals that the basic reproduction number cannot completely determine the existence of smoking, and the model possesses bistability, indicating its dynamic is susceptible to interference from environmental noises. In the stochastic case, we establish sufficient conditions for the ergodic stationary distribution and the elimination of smokers by constructing appropriate Lyapunov functions. Numerical simulations suggest that the effects of inevitable random fluctuations in the natural environment on controlling the smoking epidemic may be beneficial, harmful, or negligible, which are closely related to the noise intensities, initial smoking population sizes, and the effective exposure rate of smoking transmission (β). Given the uncontrollable nature of environmental random effects, effective smoking control strategies can be achieved by: (1) accurate monitoring of initial smoking population sizes, and (2) implementing effective measures to reduce β. Therefore, it is both effective and feasible to implement a complete set of strong MPOWER measures to control smoking prevalence.

Analyzing arguments on tobacco tax increases. Focus on French parliamentary questions and responses, 2000-2020

INTRODUCTION

Tax increases are the most effective but still the least-used tobacco control measure. The tobacco industry (TI) employs lobbying strategies to oppose the implementation of tax policies on its products. Over the past two decades, French tobacco tax policies have been characterized by a relative inconsistency. This research aims to understand why, by analyzing the arguments of French policymakers (MPs and government) between 2000 and 2020 in favor or against tax increases.

METHODS

To capture parliamentary debates, we performed an advanced term search on the French National Assembly website, using the keyword 'tobacco'. The search returned 5126 available documents out of which 1106 (12.6%, 645 questions, 461 responses) covered price and taxation and were included. They were analyzed using descriptive statistics and thematic content analysis (NVivo) and were compared, when relevant, to arguments raised in the international literature on TI lobbying against taxation increases.

RESULTS

We found 3176 arguments on tobacco taxation: 77.2% were against tobacco tax increases and 22.7% were in favor of tax policies. Arguments varied depending on the source: 92.4% of MPs' arguments were against tax increases, while 52.1% of arguments from government responses were in favor. The anti-tax arguments were similar to those identified in the international literature that singled out negative economic and social consequences (illicit trade, penalizing tobacconists). Other arguments that were more specific to the French context, highlighted the key economic and social role played by tobacconists in France. Pro-tax arguments highlighted the health, economic and social benefits of tax policies.

CONCLUSIONS

This is the first French tobacco research on parliamentary documents, although Parliament is a place of direct TI lobbying. It will enable public health actors to better understand the arguments used by the TI in order to counter them in front of MPs, and to better monitor debates in Parliament.

The global, regional, and national disease burden of breast cancer attributable to tobacco from 1990 to 2019: a global burden of disease study

OBJECTIVE

Tobacco has been identified as a significant contributory element to the development of breast cancer. Our objective was to evaluate the spatiotemporal trends of tobacco-related breast cancer at the global, regional, and national scales during 1990-2019.

METHODS

We extracted data on mortality, disability adjusted of life years (DALYs), age-standardized mortality rate (ASMR), and age-standardized DALYs rate (ASDR) from the Global Burden of Disease (GBD) study 2019. Estimated annual percentage change (EAPC) was computed to assess the temporal change in ASDR and ASMR.

RESULTS

In 2019, the deaths and DALYs attributed to tobacco-related breast cancer were estimated to be 35,439 (95% UI: 22,179-48,119) and 1,060,590 (95% UI: 622,550-1,462,580), respectively. These figures accounted for 5.1% and 5.2% of the total burden of breast cancer. ASMR and ASDR increased in low SDI regions, remained stable in low-middle and middle SDI regions and declined in high and high-middle SDI regions. The burden of breast cancer attributable to tobacco varied notably among regions and nations. Oceania, Southern Latin America, and Central Europe were the GBD regions with the highest number of ASMR and DALYs. There was a positive relationship between age-standardized rate and SDI value in 2019 across 204 nations or territories. A negative association was observed between the EAPC in ASMR or ASDR and the human development index (HDI) in 2019 (R = -0.55, p < 0.01 for ASMR; R = -0.56, p < 0.01 for ASDR).

CONCLUSION

Tobacco is one important and modifiable risk factor for breast cancer. The heterogeneity in both the spatial and temporal distribution can be attributed to factors such as aging, population growth, and SDI. These findings substantiate the necessity of expediting the enforcement of tobacco-free legislation in order to safeguard populations from the detrimental effects of tobacco.

The stigma of smoking among women: A systematic review

BACKGROUND

Smoking stigma has been well documented, but little is known regarding its specific features and effects on women. Notably, women face unique social, cultural, and economic challenges that may interact with smoking stigma and impact health outcomes. This review investigates the extent to which smoking women encounter and internalise stigma, while examining the various coping mechanisms they employ to manage these negative experiences.

METHODS

In November 2022, major databases were systematically searched with no time restrictions. After applying inclusion and exclusion criteria, 23 studies (three quantitative and 20 qualitative) met our criteria. We conducted a quality assessment and summarised the findings pertaining to public stigma, self-stigma, and coping strategies.

RESULTS

The stigma about smoking emerges from a variety of sources, such as family, healthcare providers, or internet forums. Women smokers are universally aware of the negative image they have in society. Yet, their experiences and management of the stigma of smoking are shaped by other variables such as cultural background, social class, or motherhood status. Smoking stigma produces ambivalent effects, such as concealment, reduced usage of support services, and to a lesser extent, smoking cessation motivation.

CONCLUSIONS

These results indicate that smoking stigma is an important social justice and public health issue and that further research is needed to better prevent its effects on women's well-being and health behaviours.

How has the brain disease model of addiction contributed to tobacco control?

Our paper evaluates the extent to which the brain disease model of addiction (BDMA) has contributed to reducing the prevalence of tobacco smoking and  tobacco-related harm over the past 20 years. We discuss the ways in which genetic and neuroscience research on nicotine addiction have contributed to our understanding of tobacco smoking. We then examine the extent to which the BDMA has produced more effective treatments to assist smoking cessation. We also assess the degree to which the BDMA has contributed to the tobacco control policies that have produced substantial reductions in tobacco-related morbidity and mortality in the two decades since the model was first proposed by Alan Leshner. We also assess whether the BDMA has reduced the stigmatisation of people who smoke tobacco.

Evidence from a Smoking Management Service in a University Teaching Hospital in Dublin, Ireland monitored by repeat surveys, 1997-2022

St Vincent's University Hospital (SVUH) has a comprehensive smoking management programme and since 1997 has conducted periodic surveys of inpatients, outpatients, staff and visitors to establish prevalence of smoking and associated attitudes towards the hospital's smoke-free campus policy pioneered in 2009. We report trends and describe also the online community stop smoking course (SSC) developed more recently in response to COVID-19. A questionnaire examining attitudes and smoking status was administered by census surveys of inpatients, quota or random sub-sample surveys of staff, and quota surveys with outpatients and visitors in the time period of 1997-2018. Chi square test for trend was used. Smoking rates declined in all groups but significantly so in outpatients (19.5% vs. 10%; p < 0.01), visitors (27.4% vs. 9.5%; p < 0.0001) and staff (30.0% vs. 10.8%; p < 0.0001). Use of E-Cigarettes was low in all cohorts. Rates of smoking were borderline higher in inpatients eligible by income for state-funded General Medical Services (33.2% vs 26.8%, p = 0.099). Support for and awareness of the ban increased over time. Demographic and quit data was compared between participants of in-person or online SSC. The online courses were successful with a maintenance of quit rates (End of Course: 54.7% vs. 55.0%, 1 Month: 50.4% vs. 54.0%, 3 Month: 19.8% vs. 22.5%). While the hospital community's smoking prevalence has decreased over time and attitudes to the smoking ban have been increasingly positive, the campus is not without difficulties in keeping it smoke-free. We continue to advocate for hospital staff support in enacting this flagship initiative.

Long-Term Follow-up Study of Hospitalizations for Acute Coronary Syndrome in Kobe-City and Other Districts Under the Hyogo Smoking Ban Legislation - A Nationwide Database Study

BACKGROUND

Hyogo Prefecture has managed smoking ban legislation with partial restrictions in public places (Hyogo-L) since 2013. Previous studies have reported a significant decrease in admissions for acute coronary syndrome (ACS) in Kobe-city, but not in other districts of Hyogo Prefecture in the 2 years after Hyogo-L. The aim of the present study was to define the long-term effect of Hyogo-L.

METHODS AND RESULTS

The JROAD-DPC dataset was used to collect information on the number of hospitalizations for ACS in Hyogo Prefecture, and in Osaka-city without smoking ban legislation, from April 2013 to March 2020. Poisson regression analysis was performed to calculate incident rate ratios (IRRs) and 95% confidence intervals (CIs). ACS records of 3,101 in Kobe-city, 11,375 in areas of Hyogo Prefecture other than Kobe-city and 11,079 in Osaka-city were collected for admissions. The incidence of ACS reduced significantly over time in Kobe-city [IRR (95% CI); 0.96 (0.94-0.97)], but did not reduce in the others. The decrease in Kobe-city was observed in ACS patients without smoking, hypertension, and hyperlipidemia, but not in those with such risk factors.

CONCLUSIONS

The long-term ACS reduction or non-reduction under Hyogo-L was determined at the initial period and the same scenario continued, supporting the importance of legislation and compliance with the smoking ban. The lowering effect was remarkable in ACS patients without risk factors such as non-smoking.

Beyond MPOWER: a systematic review of population-level factors that affect European tobacco smoking rates

BACKGROUND

Population-level factors within and beyond the scope of the World Health Organization's (WHO) MPOWER policy package have significant impacts on smoking rates. However, no synthesis of the existing evidence exists. This systematic review identifies population-level factors that influence cigarette smoking rates in European countries.

METHODS

We searched the ProQuest database collection for original, peer-reviewed quantitative evaluations that investigated the effects of population-level exposures on smoking rates in European countries. Of the 3122 studies screened, 62 were ultimately included in the review. A standardized data extraction form was used to identify key characteristics of each study including publication year, years evaluated, countries studied, population characteristics, study design, data sources, analytic methods, exposure studied, relevant covariates and effects on tobacco smoking outcomes.

RESULTS

One hundred and fifty-five population-level exposures were extracted from the 62 studies included in the review, 99 of which were related to WHO MPOWER measures. An additional 56 exposures fell into eight policy realms: economic crises, education policy, macro-economic factors, non-MPOWER tobacco regulations, population welfare, public policy, sales to minors and unemployment rates. About one-half of the MPOWER exposures affected smoking rates (55/99) and did so in an overwhelmingly positive way (55/55). Over three-quarters of the non-MPOWER exposures were associated with statistically significant changes in smoking outcomes (43/56), with about two-thirds of these exposures leading to a decrease in smoking (29/43).

CONCLUSIONS

Population-level factors that fall outside of the WHO's MPOWER measures are an understudied research area. The impacts of these factors on tobacco control should be considered by policymakers.

Real-world, anti-tobacco environmental impact upon price-induced smoking reduction among urban Chinese men: Evidence from China's 2015 cigarette tax increase

INTRODUCTION

Raising the price of cigarettes via taxation has been promoted by the World Health Organization as an important tobacco control strategy. Price elasticity of cigarettes is not uniform and is dependent upon individual and environmental determinants. Many studies have examined the determinants of price-induced smoking, taking into account sociodemographic characteristics and consumption patterns. Little research has been conducted on the association between anti-smoking environments and price-induced smoking behavior. This study addresses the deficit within the Chinese context.

METHODS

Participants were 2852 male smokers identified through a multi-stage survey sampling process encompassing 6 cities in China between July and December 2016. A standardized questionnaire tapped price-induced smoking reduction and related information. Both unadjusted and adjusted logistic regression methods were applied in the analyses.

RESULTS

In all, 25.5% (95% CI: 22.5-27.9) of smokers in this study decreased their smoking expenditures following the 2015 excise tax increase. The adjusted logistic regression analysis showed that increased exposures to an anti-smoking information environment (AOR=1.39; 95% CI: 1.10-1.79), restricted smoking in their home (AOR=1.67; 95% CI: 1.32-2.08) and workplace (AOR=1.43; 95% CI: 1.09-1.85) were more likely to report diminished cigarette smoking following the tax increases.

CONCLUSIONS

This study adds to understanding price-induced smoking behavior among urban male Chinese smokers. Strengthening of excise tax policies needs to intensify environmental smoking restrictions and public education campaigns to increase the sensitivity of cigarette price changes among smokers.

Scanned information exposure and support for tobacco regulations among US youth and young adult tobacco product users and non-users

The influences of information exposure on youth and young adults' (YYA) support for smoking/vaping regulations have been understudied. This study examines (i) the relationships between routine exposure to (i.e. scanning) anti-smoking/pro-vaping information and YYA support for anti-smoking/vaping regulations and (ii) whether these relationships differ across YYA users and non-users of tobacco products. We analyzed the data from a nationally representative two-wave rolling cross-sectional survey of YYA in the United States, collected from 2014 to 2017 (baseline n = 10 642; follow-up n = 4001). Less than 5% of the participants ever scanned pro-smoking and anti-vaping information. Scanning anti-smoking information had significant positive relationships with support for all anti-smoking policies cross-sectionally, and this pattern was longitudinally significant in two anti-smoking policy contexts. Scanning pro-vaping information had significant negative associations with support for anti-vaping policies cross-sectionally, but not longitudinally. The lagged positive relationships between scanning anti-smoking information and support for anti-smoking regulations were stronger among YYA smokers than among YYA non-smokers, whereas evidence from adult data suggested the opposite pattern. The findings suggest that scanning information can affect YYA support for tobacco regulations. Future efforts are required to investigate mechanisms underlying the influences of scanned information on YYA support for tobacco regulations.

The Myth of Zero-Sum Responsibility: Towards Scaffolded Responsibility for Health

Some people argue that the distribution of medical resources should be sensitive to agents' responsibility for their ill-health. In contrast, others point to the social determinants of health to argue that the collective agents that control the conditions in which agents act should bear responsibility. To a large degree, this is a debate in which those who hold individuals responsible currently have the upper hand: warranted appeals to individual responsibility effectively block allocation of any significant degree of responsibility to collective agents. We suggest that a different understanding of individual responsibility might lead to a fairer allocation of blame. Scaffolded agency is individual agency exercised in a context in which opportunities and affordances are structured by others. Appeals to scaffolded agency at once recognize the role of the individual and of the collective agents who have put the scaffolds in place.

Trends in smoking-related diseases by socioeconomic position following a national smoking ban in 2007: a nationwide study in the Danish population

BACKGROUND

National comprehensive smoke-free legislation has been found to decrease the incidence of several smoking-related diseases. In 2007, Denmark introduced a national smoking ban, which banned smoking indoor in workplaces and public places, although only partial restrictions were applied in certain settings. We examined the impact of the smoking ban on smoking-related diseases and whether this differed across socioeconomic groups.

METHODS

Interrupted time series analyses of nationwide register data were performed using Poisson regression models to examine the differential impact of the smoking ban on monthly incidence rates of acute myocardial infarction, chronic obstructive pulmonary disease, and smoking-related cancers from 2002 to 2015. Immediate changes in incidence rates after the smoking ban and long-term changes in disease trends were estimated by comparing data from the pre- and post-ban period. Models were stratified by socioeconomic position.

RESULTS

Overall, we found neither immediate changes in rates of acute myocardial infarction, chronic obstructive pulmonary disease, and smoking-related cancers following the smoking ban nor long-term post-ban changes in disease trends as compared to before the ban. Results did not differ across socioeconomic groups. A pronounced socioeconomic gradient in incidence rates was observed for all outcomes both before and after the smoking ban.

CONCLUSION

The national smoking ban was not associated with a lower incidence of smoking-related diseases in the post-ban period compared to pre-ban levels and no differences between socioeconomic groups were observed. Future tobacco control in Denmark should consider which measures most effectively target the low socioeconomic groups to decrease the current strong socioeconomic inequality in health.

Benchmarking Social Isolation, Loneliness, and Smoking: Challenges and Opportunities for Public Health

Over the past decade, the health implications of social isolation and loneliness garnered global attention due in part to a widely cited meta-analysis that benchmarked associations between cigarette smoking and mortality with associations between several social-relationship measures and mortality. Leaders in health systems, research, government, and popular media have since claimed that the harms of social isolation and loneliness are comparable to that of cigarette smoking. Our commentary examines the basis of this comparison. We suggest that comparisons between social isolation, loneliness, and smoking have been helpful for raising awareness of robust evidence linking social relationships and health. However, the analogy often oversimplifies the evidence and may overemphasize treating social isolation or loneliness at the individual level without sufficient attention on population-level prevention. As communities, governments, and health and social sector practitioners navigate opportunities for change, we believe now is time to focus greater attention on the structures and environments that promote and constrain healthy relationships.

Evaluation of Population-Level Tobacco Control Interventions and Health Outcomes: A Systematic Review and Meta-Analysis

Importance

Smoking causes considerable noncommunicable diseases, perinatal morbidity, and mortality.

Objective

To investigate the associations of population-level tobacco-control policies with health outcomes.

Data Sources

PubMed, EMBASE, Web of Science, Cumulated Index to Nursing and Allied Health Literature, and EconLit were searched from inception to March 2021 (updated on 1 March 2022). References were manually searched.

Study Selection

Studies reporting on associations of population-level tobacco control policies with health-related outcomes were included. Data were analyzed from May to July 2022.

Data Extraction and Synthesis

Data were extracted by 1 investigator and cross-checked by a second investigator. Analyses were conducted using the Preferred Reporting Items for Systematic Reviews and Meta-analyses reporting guideline.

Main Outcomes and Measures

The primary outcomes were respiratory system disease (RSD), cardiovascular disease (CVD), cancer, mortality, hospitalization, and health care utilization. The secondary outcomes were adverse birth outcomes, such as low birth weight and preterm birth. Random-effects meta-analysis was used to estimate pooled odds ratios (ORs) and 95% CIs.

Results

Of 4952 records identified, 144 population-level studies were included in the final analysis; 126 studies (87.5%) were of high or moderate quality. The most frequently reported policies were smoke-free legislation (126 studies), followed by tax or price increases (14 studies), multicomponent tobacco control programs (12 studies), and a minimum cigarette purchase age law (1 study). Smoke-free legislation was associated with decreased risk of all CVD events (OR, 0.90; 95% CI, 0.86-0.94), RSD events (OR, 0.83; 95% CI, 0.72-0.96), hospitalization due to CVD or RSD (OR, 0.91; 95% CI, 0.87-0.95), and adverse birth outcomes (OR, 0.94; 95% CI, 0.92-0.96). These associations persisted in all sensitivity and subgroup analyses, except for the country income category, for which a significant reduction was only observed in high-income countries. In meta-analysis, there was no clear association of tax or price increases with adverse health outcomes. However, for the narrative synthesis, all 8 studies reported statistically significant associations between tax increases and decreases in adverse health events.

Conclusions and Relevance

In this systematic review and meta-analysis, smoke-free legislation was associated with significant reductions in morbidity and mortality related to CVD, RSD, and perinatal outcomes. These findings support the need to accelerate the implementation of smoke-free laws to protect populations against smoking-related harm.

Gambling problems predict suicidality in recently transitioned military veterans

OBJECTIVE

This study investigated associations between gambling problems and suicidality in Australian veterans.

METHODS

Data drawn from n = 3,511 Australian Defence Force veterans who had recently transitioned to civilian life. Gambling problems were assessed using the Problem Gambling Severity Index (PGSI) and suicidal ideation and behaviour were assessed using items adapted from the National Survey of Mental Health and Wellbeing.

RESULTS

At-risk gambling and problem gambling were associated with increased odds of suicidal ideation [at-risk gambling: odds ratio (OR), 1.93; 95% confidence interval (CI), 1.47‒2.53; problem gambling: OR, 2.75; 95% CI 1.86‒4.06] and suicide planning or attempts (at-risk gambling: OR, 2.07; 95% CI, 1.39‒3.06; problem gambling: OR 4.22, 95% CI, 2.61‒6.81). The association with total scores on the PGSI and any suicidality was substantially reduced and became non-significant when controlling for the effects of depressive symptoms, but not financial hardship or social support.

CONCLUSIONS

Gambling problems and harms are important risk factors for suicide in veterans, and should be recognised in veteran-specific suicide prevention policies and programs, along with co-occurring mental health problems.

IMPLICATIONS FOR PUBLIC HEALTH

A comprehensive public health approach to reducing gambling harm should feature in suicide prevention efforts in veteran and military populations.

The Diffusion of Smoking: Association Between School Tobacco Policies and the Diffusion of Adolescent Smoking in 38 Schools in 6 Countries

Social network research has evidenced the role of peer effects in the adoption of behaviours. Little is known, however, about whether policies affect how behaviours are shared in a network. To contribute to this literature, we apply the concept of diffusion centrality to school tobacco policies and adolescent smoking. Diffusion centrality is a measure of centrality which refers to a person's ability to diffuse a given property-in our case, smoking-related behaviours. We hypothesized that stronger school tobacco policies are associated with less diffusion centrality of smoking on school premises and of smoking in general. A whole network study was carried out in 2013 and 2016 among adolescents (n = 18,805) in 38 schools located in six European cities. Overall, diffusion centrality of smoking in general and of smoking on school premises significantly decreased over time. Diffusion centrality of smoking significantly decreased both in schools where the policy strengthened or softened over time, but for diffusion of smoking on school premises, this decrease was only significant in schools where it strengthened. Finally, stronger school tobacco policies were associated with lower diffusion centrality of smoking on school premises and of smoking in general, though to a lesser extent. With such policies, smoking may, therefore, become less prevalent, less popular, and less clustered, thereby lowering the risk of it spreading within networks in, and even outside the school.

Scoping Review of Existing Evaluations of Smokeless Tobacco Control Policies: What Is Known About Countries Covered, Level of Jurisdictions, Target Groups Studied, and Instruments Evaluated?

OBJECTIVE

The implementation of smokeless tobacco control policies lags behind those for smoking. This scoping review summarizes the studies that evaluated public policies on smokeless tobacco regulation (SLT) and provides an overview of the jurisdictional level, target groups, and policy instruments.

METHODS

Seven databases were systematically searched for studies reporting on public policies regulating SLT. Two reviewers independently screened all studies. Data extraction was performed using a predefined extraction form. Extraction was replicated for 10% of the identified studies for quality assurance. A narrative synthesis of the included studies was used to analyze and interpret the data. The protocol was published beforehand with the Open Science Foundation (OSF).

RESULTS

Fourty articles comprising 41 studies were included. Most of the studies reported in the articles were conducted in the United States (n = 17) or India (n = 14). Most studies reported outcomes for students (n = 8), retailers/sellers (n = 8), and users/former users (n = 5). The impact of public policies on smokeless tobacco use, in general, was most frequently assessed (n = 9), followed by the impact of taxes (n = 7), product bans (n = 6), sales/advertising bans near educational institutions (n = 4), and health warnings (n = 3) on consumer behavior.

CONCLUSIONS

There are significant gaps in the evaluation of smokeless tobacco regulation studies that need to be filled by further research to understand the observed outcomes. WHO reporting on Framework Convention on Tobacco Control (FCTC) implementation should be linked to studies evaluating smokeless tobacco control measures at all levels of jurisdictions and in countries not members of the WHO FCTC or do not provide data.

IMPLICATION

Large gaps in the evaluation of SLT control policies exist. For some countries, WHO FCTC evaluations are available for different levels of jurisdictions. In countries with a strong federal structure, there is a lack of data beyond the national level to provide a more detailed look at compliance, indirect effects, or implementation gaps. More research is needed at all levels of jurisdictions, which add to the work of the WHO to understand what works for which target group, how the different levels of jurisdiction interact, how the real-world context can be incorporated, and what indirect effects may occur.

Prevalence of Cigarette Smoking among Professionally Active Adult Population in Poland and Its Strong Relationship with Cardiovascular Co-Morbidities-POL-O-CARIA 2021 Study

Smoking is a leading cause of preventable mortality. It affects both the health and economic situation within societies. The aim of the study is to perform an epidemiological analysis of smoking among professionally active adults in Poland in the years 2016–2020 and its Strong Relationship with Cardiovascular Co-morbidities. The article retrospectively analyzed the records of 1,450,455 who underwent occupational medicine examinations between 2016 and 2020. Statistical analyses performed using IBM SPSS Statistics 25 software were performed. In general, irrespective of the year of measurement, 11.6% of women and 17.1% of men declared smoking. After sorting by year of measurement, we found that the percentage of female smokers was decreasing, while that of males remained relatively consistent. In the case of BMI, it was found that among tobacco smokers the percentage of people with normal body weight decreases with successive years of measurement, while the percentage of overweight and level I obesity increases. Moreover, we analyzed in detail the occurrence of particular comorbidities in the group of people who declared smoking. The most common diseases in this group were: arterial hypertension (39%), lipid disorders (26.7%), and hypertension and lipid disorders (16.5%). Active preventive measures are necessary to reduce the number of smokers and the negative impact of smoking on the occurrence of comorbid diseases.

Testing Club Convergence in Female Smoking Prevalence

In this paper, we applied the concept of convergence to examine the evolution of smoking prevalence among women in 191 countries worldwide from 1990 to 2019. First, the non-linear time-varying factor model proposed by Phillips and Sul was adopted to identify potential clusters (clubs), wherein groups of countries converge to similar female smoking rates. Second, an ordered logit regression model was used to assess the impact of cigarette affordability on the probability of falling within a given cluster. The hypothesis of global convergence was rejected. However, the clustering algorithm successfully identified five and nine clubs, within countries with increasing and decreasing smoking prevalence, respectively. A higher relative income-price ratio (i.e., lower cigarette affordability) increased the likelihood of belonging to a club of countries with a low prevalence of female tobacco smoking.

Tobacco and nicotine use

Tobacco smoking is a major determinant of preventable morbidity and mortality worldwide. More than a billion people smoke, and without major increases in cessation, at least half will die prematurely from tobacco-related complications. In addition, people who smoke have a significant reduction in their quality of life. Neurobiological findings have identified the mechanisms by which nicotine in tobacco affects the brain reward system and causes addiction. These brain changes contribute to the maintenance of nicotine or tobacco use despite knowledge of its negative consequences, a hallmark of addiction. Effective approaches to screen, prevent and treat tobacco use can be widely implemented to limit tobacco's effect on individuals and society. The effectiveness of psychosocial and pharmacological interventions in helping people quit smoking has been demonstrated. As the majority of people who smoke ultimately relapse, it is important to enhance the reach of available interventions and to continue to develop novel interventions. These efforts associated with innovative policy regulations (aimed at reducing nicotine content or eliminating tobacco products) have the potential to reduce the prevalence of tobacco and nicotine use and their enormous adverse impact on population health.

Measuring public opinion and acceptability of prevention policies: an integrative review and narrative synthesis of methods

Acceptability of and public support for prevention are an important part of facilitating policy implementation. This review aims to identify, summarize and synthesize the methods and study designs used to measure and understand public opinion, community attitudes and acceptability of strategies to prevent chronic noncommunicable disease (NCDs) in order to allow for examination of imbalances in methodological approaches and gaps in content areas. We searched four scientific databases (CINAHL, Embase, Ovid/MEDLINE and Scopus) for peer-reviewed, English-language studies published between January 2011 and March 2020 in high-income, democratic countries across North America, Europe and the Asia–Pacific region. Studies were included if they focused on opinions, attitudes and acceptability of primary prevention strategies and interventions addressing the key NCD risk factors of alcohol use, unhealthy diet, overweight/obesity, tobacco use and smoking, and physical inactivity. A total of 293 studies were included. Two thirds of studies (n = 194, 66%) used quantitative methods such as cross-sectional studies involving surveys of representative (n = 129, 44%) or convenience (n = 42, 14%) samples. A smaller number of studies used qualitative methods (n = 60, 20%) such as focus groups (n = 21, 7%) and interviews (n = 21, 7%). Thirty-nine studies (13%) used mixed methods such as content analysis of news media (n = 17, 6%). Tobacco control remains the dominant topic of public opinion literature about prevention (n = 124, 42%). Few studies looked solely at physical inactivity (n = 17, 6%). The results of this review suggest that public opinion and acceptability of prevention in the peer-reviewed literature is investigated primarily through cross-sectional surveys. Qualitative and mixed methods may provide more nuanced insights which can be used to facilitate policy implementation of more upstream strategies and policies to prevent NCDs.

Assessing the solutions to tobacco control's funding gap problem

Since its entry into force in February 2005, the WHO Framework Convention on Tobacco Control (FCTC) has had many significant achievements. It is one of the most widely ratified treaties within the United Nations; its Conference of the Parties has adopted many high-quality implementation guidelines, and implementation of the policy guidance in the treaty and its guidelines have decreased tobacco consumption and prevalence. Despite the effectiveness of these measures, however, FCTC implementation has been highly uneven across countries. A medium-term strategic plan was launched to clearly articulate a small number of priority areas for action in order to accelerate the pace of progress-the Global Strategy to Accelerate Tobacco Control (2019-2025)-but several barriers block its success, including the chronic lack of sustainable, long-term funding. Governments need adequate funds in order to implement FCTC policies and interventions, but many do not have the necessary resources. The global funding gap for tobacco control has been estimated at US$427.4 billion, with no signs of shrinking in the face of the ongoing pandemic. This paper is concerned with the analysis of solutions to the funding gap problem, assessing possibilities according to feasibility, opportunities, and past or potential effectiveness. Existing solutions include Official Development Assistance, FCTC extrabudgetarily funded projects like the FCTC 2030 project and domestic resource mobilisation via tobacco taxation. The paper will also consider new options including pooled funding mechanisms. Ultimately, a combination of solutions must be pursued in order to ensure Parties' national tobacco control budgets are funded in line with FCTC and Global Strategy priorities.

European Society of Cardiology: cardiovascular disease statistics 2021

AIMS

This report from the European Society of Cardiology (ESC) Atlas Project updates and expands upon the widely cited 2019 report in presenting cardiovascular disease (CVD) statistics for the 57 ESC member countries.

METHODS AND RESULTS

Statistics pertaining to 2019, or the latest available year, are presented. Data sources include the World Health Organization, the Institute for Health Metrics and Evaluation, the World Bank, and novel ESC sponsored data on human and capital infrastructure and cardiovascular healthcare delivery. New material in this report includes sociodemographic and environmental determinants of CVD, rheumatic heart disease, out-of-hospital cardiac arrest, left-sided valvular heart disease, the advocacy potential of these CVD statistics, and progress towards World Health Organization (WHO) 2025 targets for non-communicable diseases. Salient observations in this report: (i) Females born in ESC member countries in 2018 are expected to live 80.8 years and males 74.8 years. Life expectancy is longer in high income (81.6 years) compared with middle-income (74.2 years) countries. (ii) In 2018, high-income countries spent, on average, four times more on healthcare than middle-income countries. (iii) The median PM2.5 concentrations in 2019 were over twice as high in middle-income ESC member countries compared with high-income countries and exceeded the EU air quality standard in 14 countries, all middle-income. (iv) In 2016, more than one in five adults across the ESC member countries were obese with similar prevalence in high and low-income countries. The prevalence of obesity has more than doubled over the past 35 years. (v) The burden of CVD falls hardest on middle-income ESC member countries where estimated incidence rates are ∼30% higher compared with high-income countries. This is reflected in disability-adjusted life years due to CVD which are nearly four times as high in middle-income compared with high-income countries. (vi) The incidence of calcific aortic valve disease has increased seven-fold during the last 30 years, with age-standardized rates four times as high in high-income compared with middle-income countries. (vii) Although the total number of CVD deaths across all countries far exceeds the number of cancer deaths for both sexes, there are 15 ESC member countries in which cancer accounts for more deaths than CVD in males and five-member countries in which cancer accounts for more deaths than CVD in females. (viii) The under-resourced status of middle-income countries is associated with a severe procedural deficit compared with high-income countries in terms of coronary intervention, ablation procedures, device implantation, and cardiac surgical procedures.

CONCLUSION

Risk factors and unhealthy behaviours are potentially reversible, and this provides a huge opportunity to address the health inequalities across ESC member countries that are highlighted in this report. It seems clear, however, that efforts to seize this opportunity are falling short and present evidence suggests that most of the WHO NCD targets for 2025 are unlikely to be met across ESC member countries.

Social Norms Change and Tobacco Use: A Protocol for a Systematic Review and Meta-Analysis of Interventions

Tobacco use kills more than eight million individuals each year, and results in substantial economic and human capital loss across nations. While effective supply-side solutions to tobacco control exist, these approaches are less effective at promoting cessation among heavy smokers, and less feasible to implement in countries with weaker tobacco control policy environments. Thus, effective demand-side solutions are needed. Shifting social norms around tobacco use is one such promising approach. To this end, a systematic review and meta-analysis of social norms intervention studies to influence tobacco use will be conducted following PRISMA 2020 guidance. Tobacco intervention studies with at least two time points that explicitly mention social norms or social influence as part of an intervention or set of measured variables will be included. Literature sources will comprise PubMed, Scopus, PsycInfo, and the Cochrane Trial Registry, as well as several grey literature sources. Two reviewers will independently screen studies, and risk of bias will be assessed using the Cochrane Risk of Bias 2 and ROBINS-I tools. The primary outcomes will be change in tobacco use and change in social norms. A random-effects meta-analysis will be conducted for both outcomes. Sources of heterogeneity will be explored using meta-regression with key covariates. Non-reporting biases will be explored using funnel plots. PROSPERO: CRD42021251535.

Secondhand smoke exposure in European countries with different smoke-free legislation. Findings from the EUREST-PLUS ITC Europe Surveys

BACKGROUND

Exposure to secondhand smoke (SHS) poses serious and extensive health and economic-related consequences to European society and worldwide. Smoking bans are a key measure to reducing SHS exposure but have been implemented with varying levels of success. We assessed changes in the prevalence of self-reported SHS exposure and smoking behaviour in public places among smokers in six European countries and the influence of the country's type of smoking ban (partial or total ban) on such exposure and smoking behaviour.

METHODS

The EUREST-PLUS ITC Europe Surveys were conducted among adult smokers in Germany, Greece, Hungary, Poland, Romania, and Spain in 2016 (Wave 1, n=6,011) and 2018 (Wave 2, n=6,027). We used generalised estimating equations models to assess changes between Waves 1 and 2 and to test the interaction between the type of smoking ban and 1) self-reported SHS exposure, 2) self-reported smoking in public places.

RESULTS

A significant decrease in self-reported SHS exposure was observed in workplaces, from 19.1% in 2016 to 14.0% in 2018 (-5.1%; 95% CI: -8.0%;-2.2%). Self-reported smoking did not change significantly inside bars (22.7% in W2), restaurants (13.2% in W2) and discos/nightclubs (34.0% in W2). SHS exposure in public places was significantly less likely (OR=0.35; 95% CI: 0.26-0.47) in the countries with total bans as compared to those countries with partial bans.

CONCLUSION

The inverse association between smoking in public places and smoking bans indicates an opportunity for strengthening smoke-free legislation and protecting bystanders from exposure to SHS in public places.

Statewide vaping product excise tax policy and use of electronic nicotine delivery systems among US young adults, 2014-2019

OBJECTIVES

An increasing number of US states have required a tax on electronic nicotine delivery systems (ENDS) in the past few years. This study evaluated the effect of statewide vaping product excise tax policy on ENDS use among young adults.

METHODS

We used the two recent waves (2014-2019) of the Tobacco Use Supplement to the Current Population Survey. A total of 17 896 US young adults were analysed. Difference-in-differences approach along with weighted multilevel logistic regressions were used to evaluate the association of vaping product excise tax policy adoption with current ENDS use, accounting for the clustering of respondents within the same states.

RESULTS

There was an increase in current ENDS use prevalence from 2014-2015 (3.4%) to 2018-2019 (5.4%). The presence of a tax on ENDS products was significantly associated with reduced current ENDS use (adjusted OR (AOR)=0.64, 95% CI=0.43 to 0.95). Importantly, respondents living in states with the policy showed significantly lower increase in ENDS use prevalence during the study period (interaction between within-state changes and between-state differences: AOR=0.57, 95% CI=0.35 to 0.91), controlling for other state-level policies and sociodemographic characteristics.

CONCLUSIONS

Our findings suggest that adopting a vaping product excise tax policy may help reduce ENDS use and suppress the increase of ENDS use prevalence among young adults. Considering that there are still a number of US states that have not implemented vaping product excise tax policy, wider adoption of such policy across the nation would likely help mitigate ENDS use prevalence.

Implementation of tobacco control measures in the Gulf Cooperation Council countries, 2008-2020

BACKGROUND

The World Health Organization (WHO) Framework Convention on Tobacco Control (FCTC) was developed to assist nations in reducing the demand and supply of tobacco. As of 2020, 182 nations joined the FCTC, agreeing to implement the recommended tobacco control measures. The Gulf Cooperation Council (GCC) countries, including Bahrain, Kuwait, Oman, Qatar, Saudi Arabia, and United Arab Emirates (UAE) ratified the WHO FCTC by August 2006. Given the unique political, cultural, and religious context - and known tobacco industry efforts to influence tobacco use- in these nations, a careful examination of the translation of FCTC measures into policy is needed. This study aimed to assess the implementation of FCTC tobacco control measures at the national level within the six GCC countries.

METHOD

We collected and coded the FCTC measures that were implemented in the GCC countries. We examined trends and variations of the implementation between 2008 and 2020.

RESULTS

GCC countries implemented most FCTC measures targeting the demand for and supply of tobacco, with some variation among countries. Bahrain and Qatar were more comprehensively implementing FCTC measures while Kuwait and Oman implemented the least number of the FCTC measures. Implementing measures related to tobacco prices and eliminating the illicit tobacco trade has slowly progressed in GCC countries. All GCC countries entirely banned smoking in workplaces while three countries implemented a partial ban in restaurants. Only Oman has restrictions on tobacco ads shown in media. There is progress in implementing FCTC measures related to tobacco packaging, cessation, and sale to minors in most GCC countries.

CONCLUSIONS

Given the influence of the tobacco industry in the Gulf region, the findings suggest a need for ongoing surveillance to monitor the proliferation of tobacco control measures and evaluate their effectiveness. Efforts required to address tobacco use should correspond to the unique political and cultural background of the GCC countries.

Baseline risk factor prevalence among adolescents aged 15-17 years old: findings from National Non-communicable Disease Monitoring Survey (NNMS) of India

OBJECTIVE

To generate national estimates of key non-communicable disease (NCD) risk factors for adolescents (15-17 years) identified in the National NCD Monitoring Framework and, study the knowledge, attitudes and practices towards NCD risk behaviours among school-going adolescents.

DESIGN AND SETTING

A community-based, national, cross-sectional survey conducted during 2017-2018. The survey was coordinated by the Indian Council of Medical Research-National Centre for Disease Informatics and Research with 10 reputed implementing research institutes/organisations across India in urban and rural areas.

PARTICIPANTS

A multistage sampling design was adopted covering ages between 15 and 69 years-adolescents (15-17 years) and adults (18-69 years). The sample included 12 000 households drawn from 600 primary sampling units. All available adolescents (15-17 years) from the selected households were included in the survey.

MAIN OUTCOME MEASURES

Key NCD risk factors for adolescents (15-17 years)-current tobacco and alcohol use, dietary behaviours, insufficient physical activity, overweight and obesity.

RESULTS

Overall, 1402 households and 1531 adolescents completed the survey. Prevalence of current daily use of tobacco was 3.1% (95% CI: 2.0% to 4.7%), 25.2% (95% CI: 22.2% to 28.5%) adolescents showed insufficient levels of physical activity, 6.2% (95% CI: 4.9% to 7.9%) were overweight and 1.8% (95% CI: 1.0% to 2.9%) were obese. Two-thirds reported being imparted health education on NCD risk factors in their schools/colleges.

CONCLUSION

The survey provides baseline data on NCD-related key risk factors among 15-17 years in India. These national-level data fill information gaps for this age group and help assess India's progress towards NCD targets set for 2025 comprehensively. Though the prevalence of select risk factors is much lower than in many developed countries, this study offers national evidence for revisiting and framing appropriate policies, strategies for prevention and control of NCDs in younger age groups.

Changes in tobacco use patterns and motivation to quit related to the new smoke-free legislation in the Czech Republic

BACKGROUND

Smoke-free policy belongs to key public health instruments to promote health in populations. In 2017, new comprehensive smoke-free law prohibiting smoking in indoor public places was implemented. We aimed to measure changes in tobacco smoking patterns and changes in motivation to quit in adult smokers prior to and after the new smoke-free legislation came into force.

METHODS

We conducted a prospective cohort study prior to and post the implementation of Act No. 65/2017 Coll. Self-reported questionnaires were administered to 131 adult smokers by trained nurses in general practitioner offices in Prague. We analysed changes in cigarette consumption per day; ratio of cigarettes smoked in pub, street, work and home; and motivation to quit using regression modelling.

RESULTS

We found a statistically significant decrease in the daily consumption of cigarettes (an average of 1.7 cigarettes per day, P < 0.001, d = 0.34). Smoking in indoor public spaces decreased to almost zero, while tobacco consumption in outdoor public spaces (such as streets and squares) increased by nearly 20%. We observed statistically significant increase of motivation to quit smoking (P = 0.021, d = 0.21).

CONCLUSION

The study brings valuable indication of the desired public health impact related to key legislative change in the Czech Republic.

Reducing smoking in youth by a smoke-free school environment: A stratified cluster randomized controlled trial of Focus, a multicomponent program for alternative high schools

Youth smoking remains a major challenge for public health. Socioeconomic position influences the initiation and maintenance of smoking, and alternative high school students are at particularly high risk. The school environment is an important setting to promote health, however there is a lack of evidence-based school intervention programs. This article presents the Focus study, which aims to test the implementation and effectiveness of a school-based intervention integrating¹ a comprehensive school smoking policy [i.e. smoke-free school hours (SFSH)]², a course for school staff in short motivational conversations³, school class-based teaching material⁴, an edutainment session5, a class-based competition, and6 access to smoking cessation support. Together these intervention components address students' acceptability of smoking, social influences, attitudes, motivation, and opportunities for smoking. The setting is alternative high schools across Denmark, and the evaluation design is based on a stratified cluster randomized controlled trial comparing the intervention group to a control group. Outcome data is collected at baseline, midway, and at the end of the intervention period. Moreover, a detailed process evaluation, using qualitative and quantitative methods, is conducted among students, teachers, and school principals. The results from this trial will provide important knowledge on the effectiveness of a smoke-free school environment. The findings will lead to a better understanding of which policies, environments, and cognitions, contribute to preventing and reducing cigarette use among young people in a diverse and high-risk school setting, and illuminate which complementary factors are significant to achieve success when implementing SFSH.

Powering population health research: Considerations for plausible and actionable effect sizes

Evidence for Action (E4A), a signature program of the Robert Wood Johnson Foundation, funds investigator-initiated research on the impacts of social programs and policies on population health and health inequities. Across thousands of letters of intent and full proposals E4A has received since 2015, one of the most common methodological challenges faced by applicants is selecting realistic effect sizes to inform calculations of power, sample size, and minimum detectable effect (MDE). E4A prioritizes health studies that are both (1) adequately powered to detect effect sizes that may reasonably be expected for the given intervention and (2) likely to achieve intervention effects sizes that, if demonstrated, correspond to actionable evidence for population health stakeholders. However, little guidance exists to inform the selection of effect sizes for population health research proposals. We draw on examples of five rigorously evaluated population health interventions. These examples illustrate considerations for selecting realistic and actionable effect sizes as inputs to calculations of power, sample size and MDE for research proposals to study population health interventions. We show that plausible effects sizes for population health interventions may be smaller than commonly cited guidelines suggest. Effect sizes achieved with population health interventions depend on the characteristics of the intervention, the target population, and the outcomes studied. Population health impact depends on the proportion of the population receiving the intervention. When adequately powered, even studies of interventions with small effect sizes can offer valuable evidence to inform population health if such interventions can be implemented broadly. Demonstrating the effectiveness of such interventions, however, requires large sample sizes.

Estimates of future cancer mortality attributable to modifiable risk factors in Canada

OBJECTIVES

Modifiable lifestyle, environmental, and infectious risk factors associated with cancer impact both cancer incidence and mortality at the population level. Most studies estimating this burden focus on cancer incidence. However, because these risk factors are associated with cancers of disparate mortality rates, the burden associated with cancer incidence could differ from cancer mortality. Therefore, estimating the cancer mortality attributable to these risk factors provides additional insight into cancer prevention. Here, we estimated future cancer deaths and the number of avoidable deaths in Canada due to modifiable risk factors.

METHODS

The projected cancer mortality data came from OncoSim, a web-based microsimulation tool. These data were applied to the methodological framework that we previously used to estimate the population attributable risks and the potential impact fractions of modifiable risk factors on Canadian cancer incidence.

RESULTS

We estimated that most cancer deaths will be attributed to tobacco smoking with an average of 27,900 deaths annually from 2024 to 2047. If Canada's current trends in excess body weight continue, cancer deaths attributable to excess body weight would double from 2786 deaths in 2024 to 5604 deaths in 2047, becoming the second leading modifiable cause of cancer death. Applying targets to reduce these risk factors, up to 34,600 cancer deaths could be prevented from 2024 to 2047.

CONCLUSION

Our simulated results complement our previous findings on the cancer incidence burden since decreasing the overall burden of cancer will be accelerated through a combination of decreasing cancer incidence and improving survival outcomes through improved treatments.

Assessing public support for extending smoke-free policies beyond enclosed public places and workplaces: protocol for a systematic review and meta-analysis

INTRODUCTION

Smoke-free enclosed public environments are effective in reducing exposure to secondhand smoke and yield major public health benefits. Building on this, many countries are now implementing smoke-free policies regulating smoking beyond enclosed public places and workplaces. In order to successfully implement such 'novel smoke-free policies', public support is essential. We aim to provide the first comprehensive systematic review and meta-analysis assessing levels and determinants of public support for novel smoke-free policies.

METHODS AND ANALYSIS

The primary objective of this review is to summarise the level of public support for novel smoke-free policies. Eight online databases (Embase.com, Medline ALL Ovid, Web of Science Core Collection, WHO Library Database, Latin American and Caribbean Health Sciences Literature, Scientific Online Library Online, PsychINFO and Google Scholar) will be searched from 1 January 2004 by two independent researchers with no language restrictions. The initial search was performed on 15 April 2020 and will be updated prior to finalisation of the report. Studies are eligible if assessing support for novel smoke-free policies in the general population (age ≥16 years) and have a sample size of n≥400. Studies funded by the tobacco industry or evaluating support among groups with vested interest are excluded. The primary outcome is proportion of public support for smoke-free policies, subdivided according to the spaces covered: (1) indoor private spaces (eg, cars) (2) indoor semiprivate spaces (eg, multi-unit housing) (3) outdoor (semi)private spaces (eg, courtyards) (4) non-hospitality outdoor public spaces (eg, parks, hospital grounds, playgrounds) and (5) hospitality outdoor public spaces (eg, restaurant terraces). The secondary objective is to identify determinants associated with public support on three levels: (1) within-study determinants (eg, smoking status) (2) between-study determinants (eg, survey year) and (3) context-specific determinants (eg, social norms). Risk of bias will be assessed using the Mixed Methods Appraisal Tool and a sensitivity analysis will be performed excluding studies at high risk of bias.

ETHICS AND DISSEMINATION

No formal ethical approval is required. Findings will be disseminated to academics, policymakers and the general public.

The effects of tobacco control policies on global smoking prevalence

Substantial global effort has been devoted to curtailing the tobacco epidemic over the past two decades, especially after the adoption of the Framework Convention on Tobacco Control1 by the World Health Organization in 2003. In 2015, in recognition of the burden resulting from tobacco use, strengthened tobacco control was included as a global development target in the 2030 Agenda for Sustainable Development2. Here we show that comprehensive tobacco control policies-including smoking bans, health warnings, advertising bans and tobacco taxes-are effective in reducing smoking prevalence; amplified positive effects are seen when these policies are implemented simultaneously within a given country. We find that if all 155 countries included in our counterfactual analysis had adopted smoking bans, health warnings and advertising bans at the strictest level and raised cigarette prices to at least 7.73 international dollars in 2009, there would have been about 100 million fewer smokers in the world in 2017. These findings highlight the urgent need for countries to move toward an accelerated implementation of a set of strong tobacco control practices, thus curbing the burden of smoking-attributable diseases and deaths.

Association of state tobacco control policies with active smoking at the time of intervention for intermittent claudication

OBJECTIVE

Active smoking among patients undergoing interventions for intermittent claudication (IC) is associated with poor outcomes. Notwithstanding, current levels of active smoking in these patients are high. State-level tobacco control policies have been shown to reduce smoking in the general US population. We evaluated whether state cigarette taxes and 100% smoke-free workplace legislation are associated with active smoking among patients undergoing interventions for IC.

METHODS

We queried the Vascular Quality Initiative database for peripheral endovascular interventions, infrainguinal bypasses, and suprainguinal bypasses for IC. Active smoking at the time of intervention was defined as smoking within one month of intervention. We implemented difference-in-differences analysis to isolate changes in active smoking owing to cigarette taxes (adjusted for inflation) and implementation of smoke-free workplace legislation. The difference-in-differences models estimated the causal effects of tobacco policies by adjusting for concurrent temporal trends in active smoking unrelated to cigarette taxes or smoke-free workplace legislation. The models controlled for age, sex, race/ethnicity, insurance type, diabetes, chronic obstructive pulmonary disease, state, and year. We tested interactions of taxes with age and insurance.

RESULTS

Data were available for 59,847 patients undergoing interventions for IC in 25 states from 2011 to 2019. Across the study period, active smoking at the time of intervention decreased from 48% to 40%. Every $1.00 cigarette tax increase was associated with a 6-percentage point decrease in active smoking (95% confidence interval, -10 to -1 percentage points; P = .02), representing an 11% decrease relative to the baseline proportion of patients actively smoking. The effect of cigarettes taxes was greater in older patients and those on Medicare. Among patients aged 60 to 69 and 70 to 79 years, every $1.00 tax increase resulted in 14% and 21% reductions in active smoking relative to baseline subgroup prevalences of 53% and 29%, respectively (P < .05 for both); however, younger age groups were not affected by tax increases. Among insurance groups, only patients on Medicare exhibited a significant change in active smoking with every $1.00 tax increase (an 18% decrease relative to a 33% baseline prevalence; P = .01). The number of states implementing smoke-free workplace legislation increased from 9 to 14 by 2019; however, this policy was not significantly associated with active smoking prevalence. At follow-up (median, 12.9 months), $1.00 tax increases were still associated with decreased smoking prevalence (a 25% decrease relative to a 33% baseline prevalence; P < .001).

CONCLUSIONS

Cigarette tax increases seem to be an effective strategy to decrease active smoking among patients undergoing interventions for IC. Older patients and Medicare recipients are the most responsive to tax increases.

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

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

A Scoping Review of Foci, Trends, and Gaps in Reviews of Tobacco Control Research

INTRODUCTION

The burden of disease associated with tobacco use has prompted a substantial increase in tobacco-related research, but the breadth of this literature has not been comprehensively examined. This review examines the nature of the research addressing the action areas in World Health Organization's Framework Convention on Tobacco Control (FCTC), the populations targeted and how equity-related concepts are integrated.

METHOD

A scoping review of published reviews addressing tobacco control within the primary prevention domain. We searched PubMed, Scopus, Cumulative Index to Nursing and Allied Health Literature, Cochrane Library, Educational Resources Information Centre, and PsycInfo from 2004 to 2018.

RESULTS

The scoping review of reviews offered a "birds-eye-view" of the tobacco control literature. Within the 681 reviews meeting inclusion criteria, there was a strong focus on smoking cessation targeting individuals; less attention has been given to product regulation, packaging, and labeling or sales to minors. Equity-related concepts were addressed in 167/681 (24.5%); few were focused on addressing inequity through structural and systemic root causes.

CONCLUSION

This analysis of foci, trends, and gaps in the research pursuant to the FCTC illustrated the particular action areas and populations most frequently addressed in tobacco control research. Further research is needed to address: (1) underlying social influences, (2) particular action areas and with specific populations, and (3) sustained tobacco use through the influence of novel marketing and product innovations by tobacco industry.

IMPLICATIONS

This scoping review of the breadth of tobacco control research reviews enables a better understanding of which action areas and target populations have been addressed in the research. Our findings alongside recommendations from other reviews suggest prioritizing further research to support policymaking and considering the role of the tobacco industry in circumventing tobacco control efforts. The large amount of research targeting individual cessation would suggest there is a need to move beyond a focus on individual choice and decontextualized behaviors. Also, given the majority of reviews that simply recognize or describe disparity, further research that integrates equity and targets various forms of social exclusion and discrimination is needed and may benefit from working in collaboration with communities where programs can be tailored to need and context.

Cigarette excise taxes, clean indoor air laws, and use of smoking cessation treatments: A mediation analysis

The role of smoking cessation treatments in the link between clean indoor air laws and cigarette taxes with smoking cessation is not known. This study examined whether the use of smoking cessation treatments mediates the association between clean indoor air laws and cigarette excise taxes, on the one hand, and recent smoking cessation, on the other hand. Using data on 62,165 adult participants in the 2003 and 2010-2011 Current Population Survey-Tobacco Use Supplement who reported smoking cigarettes in the past year, we employed structural equation models to quantify the degree to which smoking cessation treatments (prescription medications, nicotine replacement therapy, counseling/support groups, quitlines, and internet-based resources) mediate the association between clean indoor air laws, cigarette excise taxes and recent smoking cessation. Recent smoking cessation was associated with clean indoor air laws in 2003 and with both clean indoor air laws and excise taxes in 2010-2011. Smoking cessation treatments explained between 29% to 39% of the effect of clean indoor air laws and taxes on recent smoking cessation. While clean indoor air laws remained significantly associated with the recent smoking cessation over the first decade of the 2000s, excise taxes gained a more prominent role in later years of that decade. The influence of these policies was partly mediated through the use of smoking cessation treatments, underscoring the importance of policies that make these treatments more widely available.

Electronic cigarette

Despite significant efforts during the last decades, cigarette smoking still remains prevalent. Discouraging the use of all tobacco products, it is certainly the most effective mean to enhance public health, but complete prohibition is unlikely to succeed. The greatest challenge is the approach to chronic smokers, particularly those affected with cardiovascular conditions. To better support these patients during the difficult process leading to complete smoke cessation, it is important to characterize each patient from a clinical and psychological perspective, introducing the most reliable approaches to incentivize and support abstinence, such as varenicline and nicotine replacement therapy, thus providing a personalized recommendation. The recent introduction of electronic systems for nicotine release or tobacco heating (electronic cigarettes), offers an important challenge. These devices are reasonably considered as lower risk tools, thus providing a useful alternative which unable the patient a smoother transition toward smoking cessation, also presenting an array of choices among which a personalized selection could be made. This technology, though, should not be overemphasized, considering also its potential harmful effects, and certainly its use should be strongly discouraged in non-smokers, particularly at young age. This approach, cautious and pragmatic, aside from demonization or over-enthusiastic appraisal, could provide favourable results in the constant struggle against cigarette smoking.