The environmental profile of a community's health: a cross-sectional study on tobacco marketing in 16 countries

Sex-related inequalities in current cigarette smoking among adolescents in Africa

INTRODUCTION

Risky behaviours, including tobacco use, are highly prevalent among adolescents worldwide. Although these behaviours are largely influenced by various sociodemographic factors, including sex, there is a paucity of regionally representative literature on the sex-related inequalities in cigarette smoking among adolescents in Africa. This study examined the sex-based disparities in current cigarette smoking among adolescents aged 13-15 years in Africa.

METHODS

The present study employed a secondary analysis of nationally representative data on 45 African countries obtained from the Global Youth Tobacco Survey, accessible through the World Health Organization (WHO) Global Health Observatory. We used the online version of the WHO Health Equity Assessment Toolkit (HEAT) to generate the results.

RESULTS

The prevalence of current cigarette smoking among the adolescents surveyed ranged from 1.6% in Eritrea to 10.4% in Mali among the low-income countries, from 1.3% in Tanzania to 13.1% in Mauritania among the lower-middle-income countries, from 5.2% in Gabon to 15.3% in Mauritius among the upper-middle-income countries, and 14.7% in Seychelles, the only high-income country in the study. The absolute summary measure (D) showed diverse sex-related disparities in the burden of current cigarette smoking among adolescents across the sub-regions. In all countries surveyed, the prevalence of cigarette smoking was higher among male adolescents compared to females, except in Liberia and Mozambique, where female adolescents bore a more significant burden than their male counterparts. Furthermore, male adolescents were more burdened with high cigarette smoking prevalence than females in low-income countries such as Mali, Madagascar, Guinea, Burkina Faso, and The Gambia, where such disparities were most pronounced. Meanwhile, we found less disparity in the burden of cigarette smoking between male and female adolescents in most of the lower and upper-middle-income countries surveyed.

CONCLUSION

This study sheds light on the sex-based inequalities in the prevalence of current cigarette smoking among adolescents in Africa. In contrast to female adolescents, male adolescents bear a greater burden of current cigarette smoking. The burden of cigarette smoking is most pronounced in low-income countries such as Mali, Madagascar, Guinea, Burkina Faso, and The Gambia. Conversely, in most of the lower and upper-middle-income countries surveyed, the burdens of current cigarette smoking among male and female adolescents were found to be less disparate. Consequently, cigarette smoking prevention programmes and strategies must be implemented in all African nations. There is also the need to intensify interventions aimed at altering the smoking behaviour of male adolescents. Policymakers can develop and implement evidence-based interventions to address the burden of cigarette smoking among the adolescents. Finally, existing policies and programmes addressing adolescents' cigarette smoking should be re-assessed and strengthened to achieve their objectives.

Factors associated with support for social enforcement of smoke-free policies in Georgia and Armenia

INTRODUCTION

Armenia's and Georgia's high rates of smoking and secondhand smoke and recent implementation of smoke-free laws provide a timely opportunity to examine factors that increase compliance, like social enforcement and support for governmental enforcement.

METHODS

Using 2022 data from 1468 Armenian and Georgian adults (mean age=42.92 years, 48.6% male, 31.6% past-month smoking), multilevel linear regression examined tobacco-related media exposures, social exposures, and perceptions/attitudes in relation to: 1) likelihood of asking someone to extinguish cigarettes where a) prohibited and b) allowed; and 2) support of fines for smoke-free violations (1=not at all to 4=very).

RESULTS

There was low average likelihood of asking someone to extinguish cigarettes where allowed (mean=1.01, SD=1.12) or prohibited (mean=1.57, SD=1.21) and 'little' agreement with fines for smoke-free violations (mean=2.13, SD=1.06). Having fewer friends who smoked, greater support for indoor smoke-free laws, and no past-month cigarette use were positively associated with all 3 outcomes. Greater exposure to media and community-based action supporting smoke-free policies, and witnessing more requests to stop smoking where prohibited, were associated with higher likelihood of asking someone to extinguish cigarettes where allowed or prohibited. Less exposure to news stories opposing smoke-free policies and cigarette ads and higher perceived harm of cigarettes were also related to higher likelihood of asking someone to stop smoking where prohibited. Higher perceived harm of cigarettes was also associated with greater agreement with fines for smoke-free violations.

CONCLUSIONS

Comprehensive strategies targeting social norms, media exposure, and risk perceptions are needed to effectively facilitate strategies to enhance smoke-free law enforcement.

Dynamics of combatting market-driven epidemics: Insights from U.S. reduction of cigarette, sugar, and prescription opioid consumption

Misuse and overconsumption of certain consumer products have become major global risk factors for premature deaths, with their total costs in trillions of dollars. Progress in reducing such deaths has been slow and difficult. To address this challenge, this review introduces the definition of market-driven epidemics (MDEs), which arise when companies aggressively market products with proven harms, deny these harms, and resist mitigation efforts. MDEs are a specific within the broader landscape of commercial determinants of health. We selected three illustrative MDE products reflecting different consumer experiences: cigarettes (nicotine delivery product), sugar (food product), and prescription opioids (medical product). Each met the MDE case definition with proven adverse health impacts, well-documented histories, longitudinal product consumption and health impact data, and sustained reduction in product consumption. Based on these epidemics, we describe five MDE phases: market expansion, evidence of harm, corporate resistance, mitigation, and market adaptation. From the peak of consumption to the most recent data, U.S. cigarette sales fell by 82%, sugar consumption by 15%, and prescription opioid prescriptions by 62%. For each, the consumption tipping point occurred when compelling evidence of harm, professional alarm, and an authoritative public health voice and/or public mobilization overcame corporate marketing and resistance efforts. The gap between suspicion of harm and the consumption tipping point ranged from one to five decades-much of which was attributable to the time required to generate sufficient evidence of harm. Market adaptation to the reduced consumption of target products had both negative and positive impacts. To our knowledge, this is the first comparative analysis of three successful efforts to change the product consumption patterns and the associated adverse health impacts of these products. The MDE epidemiological approach of shortening the latent time to effective mitigation provides a new method to reduce the impacts of harmful products.

Associations Between Pro/Anti-Tobacco Media and Messaging Exposure and Knowledge and Support of Smoke-Free Policy Among Adults in Armenia and Georgia

CONTEXT

Despite high smoking rates, Armenia and Georgia recently adopted smoke-free policies (2022 and 2018).

OBJECTIVE

We examined associations between exposure to pro-tobacco media (news opposing smoke-free policies; cigarette, e-cigarette, heated tobacco product [HTP] advertisements) and anti-tobacco media (media, community-based action) and (1) knowledge that the policies applied to alternative tobacco products (ATPs), and (2) support for the policies applying to ATPs and various settings.

DESIGN

We analyzed 2022 survey data.

SETTING

Data were from 28 communities in Armenia and Georgia.

PARTICIPANTS

The sample comprised 1468 adults (31.6% past-month smokers).

METHODS

We conducted multivariable regressions, controlling for country and sociodemographics.

RESULTS

Participants were knowledgeable that the policy applied to ATPs (79.2%) and supportive of them applying to ATPs and various settings (means = 3.43 and 3.00; 1-4 = strongly support). Greater exposure to anti-tobacco media/community-based action correlated with more likely knowing that the policies applied to ATPs and greater support of the policies applying to various settings; HTP advertisement exposure correlated with less support of the policies applying to various settings. Less exposure to news opposing smoke-free policies and greater exposure to media supporting such policies correlated with greater support of the policies applying to ATPs.

CONCLUSIONS

Media and community-based action may promote smoke-free policy knowledge and support. HTP advertisements may uniquely undermine smoke-free policies.

As countries improve their cigarette tax policy, cigarette consumption declines

BACKGROUND

This study examines the association between the Tobacconomics cigarette tax scores and cigarette consumption in 97 countries during the period of 2014-2020.

METHODS

Data on countries' retail cigarette sales and overall cigarette tax scores from 2014 to 2020 are drawn from the proprietary Euromonitor International database and the Tobacconomics Cigarette Tax Scorecard (second edition). Information on countries' tobacco control environments and demographic characteristics is from the relevant years' WHO Report on the Global Tobacco Epidemic, and the World Bank's World Development Indicators database. Ordinary least squares regressions are employed to examine the link between countries' overall cigarette tax scores and cigarette consumption. All regressions control for countries' tobacco control environments, countries' demographic characteristics, year indicators and country fixed effects.

RESULTS

Each unit increase in the overall cigarette tax scores is significantly associated with a reduction of 9% in countries' per-capita cigarette consumption during 2014-2020. The reduction is more pronounced in low and middle-income countries (9%) than in high-income countries (6%). The modest improvement in scores from 2014 to 2020 is associated with a reduction of 3.27% in consumption, while consumption could have been reduced by 20.74% had countries implemented optimal tax policies that would earn the highest score of 5.

CONCLUSIONS

Our results provide evidence on the association between higher cigarette tax scores and lower cigarette consumption. To reduce tobacco consumption, governments must strive to implement all four components in the Cigarette Tax Scorecard at the highest level.

Population-Level Interventions Targeting Risk Factors for Hypertension and Diabetes in Rwanda: A Situational Analysis

Background

Eighty percent (80%) of global Non-Communicable Diseases attributed deaths occur in low- and middle-income countries (LMIC) with hypertension and diabetes being key contributors. The overall prevalence of hypertension was 15.3% the national prevalence of diabetes in rural and urban was 7.5 and 9.7%, respectively among 15–64 years. Hypertension represents a leading cause of death (43%) among hospitalized patients at the University teaching hospital of Kigali. This study aimed to identify ongoing population-level interventions targeting risk factors for diabetes and hypertension and to explore perceived barriers and facilitators for their implementation in Rwanda.

Methods

This situational analysis comprised a desk review, key informant interviews, and stakeholders' consultation. Ongoing population-level interventions were identified through searches of government websites, complemented by one-on-one consultations with 60 individuals nominated by their respective organizations involved with prevention efforts. Semi-structured interviews with purposively selected key informants sought to identify perceived barriers and facilitators for the implementation of population-level interventions. A consultative workshop with stakeholders was organized to validate and consolidate the findings.

Results

We identified a range of policies in the areas of food and nutrition, physical activity promotion, and tobacco control. Supporting program and environment interventions were mainly awareness campaigns to improve knowledge, attitudes, and practices toward healthy eating, physical activity, and alcohol and tobacco use reduction, healthy food production, physical activity infrastructure, smoke-free areas, limits on tobacco production and bans on non-standardized alcohol production. Perceived barriers included limited stakeholder involvement, misbeliefs about ongoing interventions, insufficient funding, inconsistency in intervention implementation, weak policy enforcement, and conflicts between commercial and public health interests. Perceived facilitators were strengthened multi-sectoral collaboration and involvement in ongoing interventions, enhanced community awareness of ongoing interventions, special attention paid to the elderly, and increased funds for population-level interventions and policy enforcement.

Conclusion

There are many ongoing population-level interventions in Rwanda targeting risk factors for diabetes and hypertension. Identified gaps, perceived barriers, and facilitators provide a useful starting point for strengthening efforts to address the significant burden of disease attributable to diabetes and hypertension.

Youth susceptibility to tobacco use in the Gulf Cooperation Council Countries, 2001–2018

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Analysis of the susceptibility to initiating tobacco use identifies youth at higher risk of initiating tobacco.

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Susceptibility to initiate tobacco use in increased in the United Arab Emirates while decreased in Bahrain and Qatar.

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FCTC may have an independent impact on initiating tobacco use among youth.

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The study helps policymakers identify impactful policies and prioritize resources accordingly.

The Gulf Cooperation Council (GCC) countries – Bahrain, Kuwait, Oman, Qatar, Saudi Arabia, and the United Arab Emirates (UAE) – ratified the Framework Convention on Tobacco Control (FCTC) in 2006. Yet, GCC countries predict a slight reduction in tobacco use compared to the Eastern Mediterranean region’s significant downward trend. The purpose of this study was to examine changes in self-reported intention to initiating tobacco use (susceptibility) among youth over time in five GCC countries and the relationship between susceptibility and key FCTC provisions. Complex sample logistic regression analyses were conducted using data from the 2001 to 2018 Global Youth Tobacco Survey (n = 349,878 adolescents). Since the ratification of FCTC in GCC countries, susceptibility to initiate tobacco use significantly decreased in Bahrain and Qatar while it increased in UAE (P < 0.001). Exposure to smoking in public places increased the odds of susceptibility to tobacco use in Bahrain (AOR = 1.6, 95% CI = [1.2–2.2), Kuwait (AOR = 1.6, 95% CI = [1.2–2.0]), Qatar (AOR = 1.9, 95% CI = [1.4–2.6]), and UAE (AOR = 2.1, 95% CI = [1.6–2.7]). Susceptibility to tobacco use was significantly associated with exposure to tobacco imagery in media in the UAE (AOR = 1.7, 95% CI = [1.2–2.3]) and with tobacco industry activities like promotion in Bahrain (AOR = 2.8, 95% CI = [1.9–4.2]) and Kuwait (AOR = 2.2, 95% CI = [1.5–3.1]). In conclusion, the impact of FCTC provisions on tobacco use differs across countries. Findings suggested that the implementation of tobacco control policies may independently influence the initiation of tobacco use.

Does international trade and investment liberalization facilitate corporate power in nutrition and alcohol policymaking? Applying an integrated political economy and power analysis approach to a case study of South Africa

Background

While there is a growing body of legally-focused analyses exploring the potential restrictions on public health policy space due to international trade rules, few studies have adopted a more politically-informed approach. This paper applies an integrated political economy and power analysis approach to understand how power relations and dynamics emerging as a result of the international trade and investment regime influence nutrition and alcohol regulatory development in a case study of South Africa.

Methods

We interviewed 36 key stakeholders involved in nutrition, alcohol and/or trade/investment policymaking in South Africa. Interview transcripts and notes were imported into NVivo and analyzed using thematic analysis. We used a conceptual framework for analyzing power in health policymaking to guide the analysis.

Results

Under the neoliberal paradigm that promotes trade liberalization and market extension, corporate power in nutrition and alcohol policymaking has been entrenched in South Africa via various mechanisms. These include via close relationships between economic policymakers and industry; institutional structures that codify industry involvement in all policy development but restrict health input in economic and trade policy decisions; limited stakeholder knowledge of the broader linkages between trade/investment and food/alcohol environments; high evidentiary requirements to prove public health policy effectiveness; both deliberate use of neoliberal frames/narratives as well as processes of socialization and internalization of neoliberal ideas/values shaping perceptions and policy preferences and ultimately generating policy norms prioritizing economic/trade over health objectives.

Conclusions

Exposing power in policymaking can expand our own ideational boundaries of what is required to promote transformative policy change. This work points to a number of potential strategies for challenging corporate power in nutrition and alcohol policymaking in the context of international trade and investment liberalization in South Africa.

Tobacco product use for weight control as an eating disorder behavior: Recommendations for future clinical and public health research

Tobacco product use (TPU; e.g., smoking, e-cigarettes, other emerging products) is elevated in eating disorders (EDs), yet the phenomenology of tobacco use within EDs has not received much attention. Due to the appetite suppressant effects of tobacco products as well as the array of availability of tobacco products in hedonic flavors (e.g., gummy bear, fruit), TPU may be used for weight control, such as to suppress appetite, satisfy cravings, or for meal replacement. The purpose of this article was to outline theoretical research on TPU for weight control as a mechanism in EDs as well as key areas for future research. We discuss the conceptualization and nature of TPU for weight control and how it may be related to EDs and associated behaviors, TPU patterns and smoking for weight control in EDs, and the effectiveness of current interventions and development of novel intervention protocols for individuals with EDs who use tobacco. Overall, this article outlines novel research questions on TPU in EDs and as a weight control behavior and provides recommendations to clarify the conceptualization and role of TPU within EDs.

Beyond Educating the Masses: The Role of Public Health Communication in Addressing Socioeconomic- and Residence-based Disparities in Tobacco Risk Perception

Public health communication has long been a key component of tobacco control efforts. However, little is known whether and how such an effort could address disparities in tobacco risk perceptions among population subgroups. In this study, using data from the Global Adult Tobacco Survey of Ethiopia, we examined if tobacco risk perceptions varied across socioeconomic and urban vs. rural population subgroups, and whether and how exposure to anti-smoking message was associated with disparities in risk perceptions across socioeconomic and urban-rural subgroups. The results indicated that health risk perceptions of smoking and secondhand smoke exposure were significantly lower among rural, less educated and less affluent population subgroups. Controlling for age, gender, education, wealth, place of residence, and pro-smoking message exposure, anti-smoking message exposure was associated with greater risk perceptions of smoking. Moreover, anti-smoking message exposure moderated the associations of place of residence and education with risk perceptions of smoking and secondhand smoke exposure, respectively. The probability of risk perception of smoking associated with anti-smoking message exposure was higher among the rural populace compared to urbanites. Similarly, the probability of risk perception of secondhand smoke exposure associated with anti-smoking message exposure was the highest among individuals without formal education compared to those with primary, secondary, and college-level education. The findings suggest that efforts should be made to make sure adequate anti-smoking message exposure among less educated and rural audiences so as to reduce disparities in tobacco risk perceptions.

International investment liberalization, transnational corporations and NCD prevention policy non-decisions: a realist review on the political economy of tobacco, alcohol and ultra-processed food

BACKGROUND

Public health concerns relating to international investment liberalization have centred on the potential for investor-state dispute settlement (ISDS)-related regulatory chill. However, the broader political and economic dimensions that shape the relationship between the international investment regime and non-communicable disease (NCD) policy development have been less well explored. This review aimed to synthesise the available evidence using a political economy approach, to understand why, how and under what conditions transnational corporations may use the international investment regime to promote NCD prevention policy non-decisions.

MAIN BODY

Methods: Mechanisms explaining why/how the international investment regime may be used by transnational health-harmful commodity corporations (THCCs) to encourage NCD prevention policy non-decisions, including regulatory chill, were iteratively developed. Six databases and relevant grey literature was searched, and evidence was extracted, synthesized and mapped against the various proposed explanatory mechanisms.

FINDINGS

Eighty-nine sources were included. THCCs may be incentivised to use the ISDS mechanism since the costs may be outweighed by the benefits of even just delaying regulatory adoption, particularly since the chilling effect tends to ripple out across jurisdictions. Drivers of regulatory chill may include ambiguity in treaty terms, inconsistency in arbitral rulings, potential arbitrator bias and the high cost of arbitration. Evidence indicates ISDS can delay policy adoption both within the country directly involved but also in other jurisdictions. Additionally, governments are adopting standard assessments of public health regulatory proposals for trade and ISDS risk. Various economic, political and industry-related factors likely interact to increase (or decrease) the ultimate risk of regulatory chill. Some evidence indicates that THCCs take advantage of governments' prioritization of foreign investment over NCD prevention objectives to influence the NCD prevention regulatory environment.

CONCLUSIONS

While ISDS-related regulatory chill is a real risk under certain conditions, international investment-related NCD prevention policy non-decisions driven by broader political economy dynamics may well be more widespread and impactful on NCD regulatory environments. There is therefore a clear need to expand the research agenda on investment liberalization and NCD policy beyond regulatory chill and engage with theories and approaches from international relations and political science, including political economy and power analyses.

Do international trade and investment agreements generate regulatory chill in public health policymaking? A case study of nutrition and alcohol policy in South Africa

BACKGROUND

Trade and health scholars have raised concern that international trade and particularly investment disputes may be used by transnational health harmful commodity corporations (THCCs) to effectively generate public health regulatory chill. The purpose of this study was to contribute to the limited evidence base of trade or investment dispute-related regulatory chill using a case study of nutrition and alcohol policy in South Africa.

METHODS

We conducted 35 semi-structured interviews with 36 key stakeholders involved in nutrition, alcohol and/or trade/investment policymaking in South Africa. Interview transcripts were analyzed using thematic analysis. We used Schram et al's theory on three forms of regulatory chill (anticipatory, response and precedential) to guide the analysis. We report evidence on each form of regulatory chill as well as specific contextual factors that may influence the risk of regulatory chill.

RESULTS

Trade obligations were found to generate a significantly greater anticipatory-type chilling effect on nutrition and alcohol regulation than South Africa's investment treaty obligations. Response chill was reported to have occurred in relation to South Africa's proposed tobacco plain packaging regulation while awaiting the outcome of both Australia's investor-state and WTO state-state disputes. No cases were reported of THCCs threatening an investor-state dispute over nutrition or food regulations, but there were reported cases of THCCs using arguments related to South Africa's trade obligations to oppose policy action in these areas. No evidence of nutrition or alcohol policy precedential chill were identified. Factors affecting the risk of policy chill include legitimacy and perceived bias of the dispute system, costs involved in pursuing a regulation/defending a dispute and capacity to pay, social acceptability of the industry, a product's perceived risk to health and confidence in a successful dispute outcome e.g. through cross-border policy learning.

CONCLUSIONS

Our findings indicate that currently, South Africa's trade obligations have a more prominent role in inhibiting nutrition and alcohol action than investment treaty-related concerns. However, given the potential for wider use of the ISDS mechanism by THCCs in the future, strategies to protect public health policy space in the context of both international trade and investment treaty and dispute settlement contexts remain important.

Corporate power and the international trade regime preventing progressive policy action on non-communicable diseases: a realist review

Transnational tobacco, alcohol and ultra-processed food corporations use the international trade regime to prevent policy action on non-communicable diseases (NCDs); i.e. to promote policy 'non-decisions'. Understanding policy non-decisions can be assisted by identifying power operating in relevant decision-making spaces, but trade and health research rarely explicitly engages with theories of power. This realist review aimed to synthesize evidence of different forms and mechanisms of power active in trade and health decision-making spaces to understand better why NCD policy non-decisions persist and the implications for future transformative action. We iteratively developed power-based theories explaining how transnational health-harmful commodity corporations (THCCs) utilize the international trade regime to encourage NCD policy non-decisions. To support theory development, we also developed a conceptual framework for analysing power in public health policymaking. We searched six databases and relevant grey literature and extracted, synthesized and mapped the evidence against the proposed theories. One hundred and four studies were included. Findings were presented for three key forms of power. Evidence indicates THCCs attempt to exercise instrumental power by extensive lobbying often via privileged access to trade and health decision-making spaces. When their legitimacy declines, THCCs have attempted to shift decision-making to more favourable international trade legal venues. THCCs benefit from structural power through the institutionalization of their involvement in health and trade agenda-setting processes. In terms of discursive power, THCCs effectively frame trade and health issues in ways that echo and amplify dominant neoliberal ideas. These processes may further entrench the individualization of NCDs, restrict conceivable policy solutions and perpetuate policymaking norms that privilege economic/trade interests over health. This review identifies different forms and mechanisms of power active in trade and health policy spaces that enable THCCs to prevent progressive action on NCDs. It also points to potential strategies for challenging these power dynamics and relations.

Dyslipidemia and Cardiovascular Disease Prevention in South Asians: A Review and Discussion of Causes, Challenges and Management Strategies

BACKGROUND

South Asians are at a significantly increased risk of atherosclerotic cardiovascular disease (ASCVD). For a major portion of the South Asian population, the cardiovascular disease events occur at a relatively younger age, are associated with worse outcomes, and have potentially more severe socioeconomic implications compared to their western counterparts.

METHODS

The term "South Asian" typically constitutes individuals from India, Pakistan, Nepal, Bhutan, Bangladesh, Sri Lanka, and Maldives, including expatriates as well as their families from these countries. Based on this, South Asians form approximately 25% of the world's population, with a high ASCVD burden in this group. In this review, we discuss the pathophysiological factors underlying ASCVD in South Asians, the dyslipidemia types and management, and discuss approaches to improve the overall ASCVD prevention efforts in this large subset population of the world. Although the pathophysiological mechanisms underlying the excess risk of cardiovascular disease in South Asians are multifactorial, dyslipidemia is a primary risk factor for the incidence and prevalence of this disease. The traditional "South Asian" dyslipidemia pattern includes levels of low-density lipoprotein cholesterol (LDL-C) in the normal range with a high concentration of LDL particles, elevated triglycerides, low levels of high-density lipoprotein cholesterol (HDL-C) with dysfunctional HDL particles, and high levels of lipoprotein(a).

CONCLUSION

While combined efforts to study the expatriate South Asians in western countries have been able to identify South Asian specific dyslipidemias, causal associations and optimal management remain relatively less explored. Larger scale studies are needed to better quantify the relationship of each lipid parameter with ASCVD risk among South Asians as well as optimal lipid targets and management strategies to reduce morbidity and mortality in this high-risk group.

Smoking behavior and symptoms of depression and anxiety among young adult backpackers: Results from a short longitudinal study

Levels of smoking and smoking initiation have been found to increase during the transition to adulthood. Symptoms of depression and anxiety may both precede or follow smoking behavior, yet there is equivocal evidence regarding the direction of this relationship. The aim of the current study was to examine the direction of this relationship in a group of young adult backpackers who traveled to social environments which are permissive of smoking. The current study involved a quasi-experimental design examining 199 (52% men, mean age 24.27, SD = 1.05 years at time 1) young adults, before, during and following a backpacking experience of at least six months. Regression analyses was used to examine the association between smoking and symptoms of depression and anxiety over time. Relative to smoking levels before the journey, a significant transient increase in smoking was found during the journey. The increase in smoking during the journey predicted increases in both depressive and anxiety symptoms following the journey. The reverse direction models were not significant. Our study suggests that social contexts which are permissive of smoking, such as backpacking, increase young adult smoking behavior. Mood symptoms did not contribute to the observed increase in smoking behavior but, inversely, increases in smoking contributed to heightened mood symptoms. Additional longitudinal studies are needed to explore the role that smoking behavior plays in young adults' mental health.

'As Long as It Comes off as a Cigarette Ad, Not a Civil Rights Message': Gender, Inequality and the Commercial Determinants of Health

Scholarship on the commercial determinants of health (CDoH) has sought to understand the multiple ways corporate policies, practices and products affect population health. At the same time, gender is recognised as a key determinant of health and an important axis of health inequalities. To date, there has been limited attention paid to the ways in which the CDoH engage with and impact on gender inequalities and health. This review seeks to address this gap by examining evidence on the practices and strategies of two industries-tobacco and alcohol-and their interaction with gender, with a particular focus on women. We first describe the practices by which these industries engage with women in their marketing and corporate social responsibility activities, reinforcing problematic gender norms and stereotypes that harm women and girls. We then examine how tobacco and alcohol companies contribute to gender inequalities through a range of strategies intended to protect their market freedoms and privileged position in society. By reinforcing gender inequalities at multiple levels, CDoH undermine the health of women and girls and exacerbate global health inequalities.

Size matters: An analysis of cigarette pack sizes across 23 European Union countries using Euromonitor data, 2006 to 2017

INTRODUCTION

The tobacco industry (TI) has used small cigarette pack sizes to encourage brand-switching and consumption, and to mitigate the impacts of tobacco tax increases. Since 2016, the European Union (EU) Tobacco Products Directive (TPD) specifies a minimum pack size of 20 cigarettes. We examined cigarette pack sizes in the EU and whether pack size composition differed between cheap and expensive price segments, as well as the impact of the revised TPD.

METHODS

We conducted a longitudinal analysis of pricing data from 23 EU countries between 2006-2017. We examined pack sizes over time to assess the impact of the TPD, differences in pack size composition between cheap and expensive price segments, and compared gaps in median prices between products using actual and 'expected' prices (price if all packs contained 20 sticks).

RESULTS

Cigarette pack sizes changed over time, across the EU. The distribution of pack sizes varied between price segments, with small pack sizes especially frequent in the cheap segment of the cigarette market, but this varied over time and across countries. Packs of <20 cigarettes almost disappeared from the data samples after implementation of the TPD.

CONCLUSION

Implementation of the TPD appears to have virtually eliminated packs with <20 cigarettes, restricting their use by the TI. Our analysis suggests pack sizes have been used differentially across the EU. Country-level analyses on the industry's use of pack sizes, consumer responses, and evaluations of restricting certain pack sizes are needed to confirm our findings and strengthen policy.

Big Tobacco, Alcohol, and Food and NCDs in LMICs: An Inconvenient Truth and Call to Action Comment on "Addressing NCDs: Challenges From Industry Market Promotion and Interferences"

In their editorial, Tangcharoensathien et al1 describe the challenges of industry market promotion and policy interference from Big Tobacco, Alcohol, and Food in addressing non-communicable diseases (NCDs). They provide an overview of the increasing influence of corporate interest in emerging economies and government attempts to implement the World Health Organization (WHO) 'best buy' interventions. The authors largely draw on examples from Asia and a few selected countries, but provide little detail as to how aggressive marketing and policy interference plays out in a context of poor legislation and regulation in many low- and middleincome countries (LMICs), where the burden of NCDs is increasing at an alarming rate and governments face a high burden of disease with a limited budget for countering industry interference. This commentary provides some poignant examples of the influence of Big Tobacco, Alcohol, and Food on market regulation and policy interference in LMICs and argues for more policy coherence and accountability in terms of multisectoral action and civil society activism. Securing funds for health promotion and establishing health promotion foundations could help achieve that goal.

Transnational tobacco companies and the mechanism of externalization: A realist synthesis

Externalization theory assumes that risks and costs are systematically displaced from high-income countries (HICs) to low- and middle-income countries (LMICs). We review how and why transnational tobacco companies (TTCs) influence the local circumstances of LMICs that trigger externalization mechanisms, leading to tobacco-attributable risk outcomes. Our realist synthesis of scientific evidence and gray literature identifies externalization mechanisms with risk outcomes at the level of health policy, smoking trends, and tobacco production. The results reveal the mediating role of local and global third parties and intermediaries. Externalization mechanisms produce systematic tobacco-attributable inequalities between places located in HICs and those located in LMICs.

Tobacco and Alcohol Use Among Youth in Low and Middle Income Countries: A Multi-Country Analysis on the Influence of Structural and Micro-Level Factors

BACKGROUND

The transition from adolescence to adulthood is a critical life phase as it is during this period that substance use and disorders typically emerge and escalate. Globally, few studies have examined the prevalence and correlates of alcohol and tobacco use among youth (ages 15-24). This study seeks to bridge this gap by assessing the influence of structural and micro-level factors on tobacco and alcohol use among youth in Low- and Middle-income countries (LMICs).

METHODS

Data are drawn from the Multiple Indicator Cluster Surveys (MICS) conducted in 29 countries or regions in Eastern Europe, Latin America, Asia and Africa between 2010 and 2015. Analyses focus on lifetime prevalence and age of onset for tobacco and alcohol use.

RESULTS

Descriptive analyses highlight regional variations in the prevalence and age of onset of tobacco and alcohol use: tobacco use is more concentrated among youth in Eastern Europe but alcohol use is generalized across the regions. Using multi-level analyses, we find statistically significant main effects for age, gender, educational attainment, rural residence, marital status and exposure to mass media on tobacco and alcohol use outcomes as well as interaction effects for age, gender and education on tobacco and alcohol use outcomes. Conclusions/importance: These findings highlight the need for structural interventions to control tobacco social marketing, and for gender considerations in tobacco and alcohol use prevention programs and policies.

Ideal Cardiovascular Health in the southern cone of Latin America

OBJECTIVE

The American Heart Association developed the concept of 'Ideal Cardiovascular Health', which is based on the presence of ideal levels across seven health factors. The goal of this study is to assess the prevalence of Ideal Cardiovascular Health in the Southern Cone of Latin America.

STUDY DESIGN

We conducted a cross-sectional analysis as part of CESCAS I cohort.

METHODS

This report included 5458 participants aged between 35 and 75 years who were selected using stratified multistage probability sampling in Argentina, Chile and Uruguay. Interviews included demographic information, the International Physical Activity Questionnaire, and a food frequency questionnaire on dietary habits. Participants were classified as current, former or non-smokers. Weight, height and blood pressure were measured by trained personnel, and fasting cholesterol and glucose plasma levels were measured.

RESULTS

Only 0.1% (95% confidence interval [CI]: 0.0-0.2) met the seven criteria that define the Ideal Cardiovascular Health. The least prevalent healthy behaviour was having a healthy diet: 0.5% (95% CI: 0.3-0.7), while the least prevalent health factor was having blood pressure < 120/80 mmHg: 23.6% (95% CI: 22.1-25.0).

CONCLUSIONS

The prevalence of Ideal Cardiovascular Health is very low in a representative sample of population from the Southern Cone of Latin America, and the levels of healthy lifestyle behaviours are even lower than ideal biochemical parameters. These results highlight the challenge of developing strategies to improve the levels of Ideal Cardiovascular Health at primary prevention levels.

Evaluation of research on interventions aligned to WHO 'Best Buys' for NCDs in low-income and lower-middle-income countries: a systematic review from 1990 to 2015

Background

Non-communicable diseases (NCDs) are the leading cause of death and disability worldwide, with low-income and middle-income countries experiencing a disproportionately high burden. Since 2010 WHO has promoted 24 highly cost-effective interventions for NCDs, dubbed ‘best buys’. It is unclear whether these interventions have been evaluated in low-income and lower-middle-income countries (LLMICs).

Aim

To systematically review research on interventions aligned to WHO ‘best buys’ for NCDs in LLMICs.

Methods

We searched 13 major databases and included papers conducted in the 83 World Bank-defined LLMICs, published between 1 January 1990 and 5 February 2015. Two reviewers independently screened papers and assessed risk of bias. We adopted a narrative approach to data synthesis. The primary outcomes were NCD-related mortality and morbidity, and risk factor prevalence.

Results

We identified 2672 records, of which 36 were included (608 940 participants). No studies on ‘best buys’ were found in 89% of LLMICs. Nineteen of the 36 studies reported on the effectiveness of tobacco-related ‘best buys’, presenting good evidence for group interventions in reducing tobacco use but weaker evidence for interventions targeting individuals. There were fewer studies on smoking bans, warning labels and mass media campaigns, and no studies on taxes or marketing restrictions. There was supportive evidence that cervical screening and hepatitis B immunisation prevent cancer in LLMICs. A single randomised controlled trial supported polypharmacy for cardiovascular disease. Fourteen of the ‘best buy’ interventions did not have any good evidence for effectiveness in LLMICs.

Conclusions

We found studies on only 11 of the 24 interventions aligned with the WHO ‘best buys’ from LLMIC settings. Most LLMICs have not conducted research on these interventions in their populations. LLMICs should take action to implement and evaluate ‘best buys’ in their national context, based on national priorities, and starting with interventions with the strongest evidence base.

Standardized Tobacco Assessment for Retail Settings (STARS): dissemination and implementation research

Objective

The Standardized Tobacco Assessment for Retail Settings (STARS) was designed to characterise the availability, placement, promotion and price of tobacco products, with items chosen for relevance to regulating the retail tobacco environment. This study describes the process to develop the STARS instrument and protocol employed by a collaboration of US government agencies, US state tobacco control programmes (TCPs), advocacy organisations, public health attorneys and researchers from the National Cancer Institute's State and Community Tobacco Control (SCTC) Research Initiative.

Methods

To evaluate dissemination and early implementation experiences, we conducted telephone surveys with state TCP leaders (n=50, response rate=100%), and with individuals recruited via a STARS download registry on the SCTC website. Website registrants were surveyed within 6 months of the STARS release (n=105, response rate=66%) and again after ∼5 months (retention rate=62%).

Results

Among the state TCPs, 42 reported conducting any retail marketing surveillance, with actual or planned STARS use in 34 of these states and in 12 of the 17 states where marketing surveillance was not previously reported. Within 6 months of the STARS release, 21% of surveyed registrants reported using STARS and 35% were likely/very likely to use it in the next 6 months. To investigate implementation fidelity, we compared data collected by self-trained volunteers and by trained professionals, the latter method being more typically in retail marketing surveillance studies. Results suggest high or moderate reliability for most STARS measures.

Conclusion

The study concludes with examples of states that used STARS to inform policy change.

Smoking prevalence and attributable disease burden in 195 countries and territories, 1990-2015: a systematic analysis from the Global Burden of Disease Study 2015

BACKGROUND

The scale-up of tobacco control, especially after the adoption of the Framework Convention for Tobacco Control, is a major public health success story. Nonetheless, smoking remains a leading risk for early death and disability worldwide, and therefore continues to require sustained political commitment. The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) offers a robust platform through which global, regional, and national progress toward achieving smoking-related targets can be assessed.

METHODS

We synthesised 2818 data sources with spatiotemporal Gaussian process regression and produced estimates of daily smoking prevalence by sex, age group, and year for 195 countries and territories from 1990 to 2015. We analysed 38 risk-outcome pairs to generate estimates of smoking-attributable mortality and disease burden, as measured by disability-adjusted life-years (DALYs). We then performed a cohort analysis of smoking prevalence by birth-year cohort to better understand temporal age patterns in smoking. We also did a decomposition analysis, in which we parsed out changes in all-cause smoking-attributable DALYs due to changes in population growth, population ageing, smoking prevalence, and risk-deleted DALY rates. Finally, we explored results by level of development using the Socio-demographic Index (SDI).

FINDINGS

Worldwide, the age-standardised prevalence of daily smoking was 25·0% (95% uncertainty interval [UI] 24·2-25·7) for men and 5·4% (5·1-5·7) for women, representing 28·4% (25·8-31·1) and 34·4% (29·4-38·6) reductions, respectively, since 1990. A greater percentage of countries and territories achieved significant annualised rates of decline in smoking prevalence from 1990 to 2005 than in between 2005 and 2015; however, only four countries had significant annualised increases in smoking prevalence between 2005 and 2015 (Congo [Brazzaville] and Azerbaijan for men and Kuwait and Timor-Leste for women). In 2015, 11·5% of global deaths (6·4 million [95% UI 5·7-7·0 million]) were attributable to smoking worldwide, of which 52·2% took place in four countries (China, India, the USA, and Russia). Smoking was ranked among the five leading risk factors by DALYs in 109 countries and territories in 2015, rising from 88 geographies in 1990. In terms of birth cohorts, male smoking prevalence followed similar age patterns across levels of SDI, whereas much more heterogeneity was found in age patterns for female smokers by level of development. While smoking prevalence and risk-deleted DALY rates mostly decreased by sex and SDI quintile, population growth, population ageing, or a combination of both, drove rises in overall smoking-attributable DALYs in low-SDI to middle-SDI geographies between 2005 and 2015.

INTERPRETATION

The pace of progress in reducing smoking prevalence has been heterogeneous across geographies, development status, and sex, and as highlighted by more recent trends, maintaining past rates of decline should not be taken for granted, especially in women and in low-SDI to middle-SDI countries. Beyond the effect of the tobacco industry and societal mores, a crucial challenge facing tobacco control initiatives is that demographic forces are poised to heighten smoking's global toll, unless progress in preventing initiation and promoting cessation can be substantially accelerated. Greater success in tobacco control is possible but requires effective, comprehensive, and adequately implemented and enforced policies, which might in turn require global and national levels of political commitment beyond what has been achieved during the past 25 years.

FUNDING

Bill & Melinda Gates Foundation and Bloomberg Philanthropies.

Tobacco Control Progress in Low and Middle Income Countries in Comparison to High Income Countries

The study aimed to describe worldwide levels and trends of tobacco control policy by comparing low and middle income countries with other income categories from 2007 to 2014 and to analyze the corresponding relation to recent changes in smoking prevalence. Policy measure data representing years 2007 to 2014 were collected from all available World Health Organization (WHO) reports on the global tobacco epidemic. Corresponding policy percentage scores (PS) were calculated based on MPOWER measures. Age-standardized smoking prevalence data for years 2010 and 2015 were collected from the WHO Global Health Observatory Data Repository. Trends of PS were analysed with respect to WHO region and OECD country income category. Scatter plots and regression analysis were used to depict the relationship between tobacco control policy of 2010 and change in smoking prevalence between 2015 and 2010 by sex and income category. Combined PS for all countries increased significantly from 47% in 2007 to 61% by 2014 (p < 0.001). When grouped by income category and region, policies were strengthened in all categories, albeit with varying progression. By 2014, tobacco control policy legislation had reached 45% in the Least Developed Countries (LDCs), 59% in Low Middle Income Countries (LMICs), 66% in Upper Middle Income Countries (UMICs) and 70% in High Income Countries (HICs). Overall, there was a negative relationship between higher policy scores and change in smoking prevalence. Although policy strengthening had been conducted between 2007 and 2014, room for considerable global improvement remains, particularly in LDCs.

Resource Effective Strategies to Prevent and Treat Cardiovascular Disease

Cardiovascular disease (CVD) is the leading cause of global deaths, with the majority occurring in low- and middle-income countries. The primary and secondary prevention of CVD is suboptimal throughout the world, but the evidence-practice gaps are much more pronounced in low- and middle-income countries. Barriers at the patient, healthcare provider, and health system level prevent the implementation of optimal primary and secondary prevention. Identification of the particular barriers that exist in resource-constrained settings is necessary to inform effective strategies to reduce the identified evidence-practice gaps. Furthermore, targeting modifiable factors that contribute most significantly to the global burden of CVD, including tobacco use, hypertension, and secondary prevention for CVD, will lead to the biggest gains in mortality reduction. We review a select number of novel, resource-efficient strategies to reduce premature mortality from CVD, including (1) effective measures for tobacco control, (2) implementation of simplified screening and management algorithms for those with or at risk of CVD, (3) increasing the availability and affordability of simplified and cost-effective treatment regimens including combination CVD preventive drug therapy, and (4) simplified delivery of healthcare through task-sharing (nonphysician health workers) and optimizing self-management (treatment supporters). Developing and deploying systems of care that address barriers related to the above will lead to substantial reductions in CVD and related mortality.

Tobacco is "our industry and we must support it": Exploring the potential implications of Zimbabwe's accession to the Framework Convention on Tobacco Control

BACKGROUND

Zimbabwe is the largest tobacco producer in Africa. Despite expressing opposition in the past, Zimbabwe recently acceded to the World Health Organization's Framework Convention on Tobacco Control (FCTC). We explored why Zimbabwe acceded to the FCTC and the potential implications for tobacco control within Zimbabwe and globally.

METHODS

We conducted a qualitative archival case study based on 542 documents collected from 1) the Truth Tobacco Industry Documents; 2) media indexed in the Lexis-Nexis media database; 3) the websites for tobacco growers' associations, tobacco control groups, and international agencies; 4) FCTC reports and Framework Convention Alliance newsletters; 5) Zimbabwe's legal codes; and 6) the peer reviewed scientific literature related to tobacco growing.

RESULTS

Zimbabwe has a long history of tobacco growing. There are currently over 90,000 tobacco farmers, and tobacco growing is prioritized, despite widespread food insecurity and environmental degradation. Zimbabwean government officials have been outspoken FCTC critics; but recently joined the accord to better protect Zimbabwe's tobacco growing interests. FCTC membership obligates nations to implement a variety of tobacco control measures; Zimbabwe has implemented several measures aimed at reducing tobacco demand, but fewer aimed at reducing tobacco supply or protecting the environment. Zimbabwe joins the FCTC amid increased efforts to protect FCTC proceedings from industry interference, to adopt recommendations for alternative crops and livelihoods and reduce environmental damage.

CONCLUSION

Zimbabwe's decision to accede to the FCTC does not appear to represent a softening of its historical opposition to the treaty. Thus, its status as a Party creates opportunities for it to undermine ongoing efforts to implement and strengthen the treaty. At the same time, however, Zimbabwe's accession could provide much needed international support for Zimbabwe's civic organizations and its Ministry of Health to develop stronger tobacco control measures. How Zimbabwe's participation impacts the work of the FCTC as a whole may ultimately depend on the allegiances of its delegates, and the effectiveness of FCTC measures to limit tobacco industry interference and enforce compliance with FCTC measures.