Switching people who smoke to unfiltered cigarettes: Effects on smoking topography

Introduction

Smoking topography (ST) describes smoking behavior and patterns. Removal of the cigarette filter and subsequent impact on ST has not been investigated. This is the first clinical trial comparing ST for filtered and unfiltered cigarettes in a naturalistic experiment.

Methods

We conducted a crossover clinical trial following established people who smoke cigarettes (n = 32) for two weeks under filtered and unfiltered smoking experimental conditions. Participants (50 % female, mean age 38.3 yr.) smoked in each experimental condition followed by a 3-week post-washout period. ST (puff count, volume, duration, peak and average flow) was measured at six time-points. Statistical analysis included a linear repeated mixed-effects model of smoking experimental conditions by visit number and sex.

Results

Average flow (ml/sec) was significantly less for filtered smoking (-6.92 lower (95 % CI: -13.44 to -0.39), p < 0.05), thus demonstrating more resistance on inhalation. No significant differences were found between filtered or unfiltered experimental conditions for other ST variables. However, average volume and average peak flow were somewhat higher in unfiltered smoking, and lower mean puff counts/cigarette were observed for unfiltered compared to filtered smoking.

Conclusion

Lower average flow rates were associated with filtered cigarette smoking. No significant differences were found for other ST variables between smoking experimental conditions. ST measurements comparing cigarette smoking conditions may determine if product regulatory changes, such as removing the cigarette filter could impact smoking behavioral patterns among people who smoke. This proof-of-principle study measuring ST may be replicated in larger trials to determine potential behavioral changes in smoking unfiltered cigarettes.

Leached Compounds from Smoked Cigarettes and Their Potential for Bioaccumulation in Rainbow Trout (Oncorhynchus mykiss)

Cigarette butts are one of the most prevalent forms of litter worldwide and may leach toxic compounds when deposited in aquatic environments. Previous studies demonstrated that smoked cigarette leachate is toxic toward aquatic organisms. However, the specific bioavailable chemicals from the leachate and the potential for human and wildlife exposure through the food chain were unknown. Using a nontargeted analytical approach based on GC×GC/TOF-MS, 43 compounds were confirmed to leach from smoked cigarettes when exposed to a water source. Additionally, the bioaccumulation potential of organic contaminants in an edible fish, rainbow trout (Oncorhynchus mykiss), was assessed through direct exposure to the leachate of smoked cigarettes at 0.5 CB/L for 28 days. There was a significant reduction in fish mass among the exposed rainbow trout vs the control group (χ2 (1) = 5.3, p = 0.021). Both nontargeted and targeted chemical analysis of representative fish tissue identified four tobacco alkaloids, nicotine, nicotyrine, myosmine, and 2,2'-bipyridine. Their average tissue concentrations were 466, 55.4, 94.1, and 70.8 ng/g, respectively. This study identifies leached compounds from smoked cigarettes and demonstrates the uptake of specific chemicals in rainbow trout, thus suggesting a potential for accumulation in food webs, resulting in human and wildlife exposure.

First report on BTEX leaching from waterpipe tobacco wastes (WTWs) into aquatic environment

Waterpipe tobacco wastes (WTWs) may contain considerable levels of hazardous contaminants such as BTEX (benzene, toluene, ethylbenzene, o-xylene, and m/p-xylene). However, no research has been carried out on BTEX levels in WTWs and the release of these pollutants into the water environment. This research examined the levels of BTEX in WTWs of flavored/local tobacco and also the release rate of these toxins into three kinds of water, including seawater (SW), tap water (TW), and distilled water (DW) with different leaching times (15, 30 min, 1.2, 4, 8 h, and 1, 2, and 4 days). The mean contents of BTEX in WTW samples of Al-Mahmoud, Al-Fakher, Mazaya, Al-Ayan brands, and local tobacco samples were 17.0 ± 4.14, 19.1 ± 4.65, 19.6 ± 4.19, 18.8 ± 4.14, and 3.16 ± 0.63 μg/kg, respectively. The mean BTEX levels in flavored tobacco samples were considerably greater than that of local tobacco (p < 0.05). The WTWs leaching experiments showed that the levels of BTEX ranged from 5.26 to 6.12, 5.02-5.60, and 3.83-5.46 μg/L in DW, TW, and SW, respectively. All target compounds were found for all exposure times in DW, TW, and SW samples. After adding sodium azide as an antibacterial agent to water samples (simulating biodegradation processes), higher levels of BTEX compounds were detected in SW. Further research is needed to address the potential environmental hazards due to WTWs leaching into aquatic environments.

Switching people who smoke to unfiltered cigarettes: perceptions, addiction and behavioural effects in a cross-over randomised controlled trial

BACKGROUND

Behavioural research is needed to inform a ban on sales of filtered cigarettes that could reduce plastic waste due to discarded filters. This study reports on differences in perceptions, nicotine dependence and behaviour among participants in a cross-over randomised trial of filtered compared with unfiltered cigarettes.

METHOD

This proof-of-concept study involved 43 people who smoke filtered cigarettes (41.9% women, mean age 36.7 years). Participants were provided 2 weeks' supply of filtered cigarettes, 2 weeks of the same brand of unfiltered cigarettes and randomly assigned to starting conditions. Measures included the Modified Cigarette Evaluation Questionnaire; single-item cigarette perception questions; Fagerström Test of Nicotine Dependence; 7-day cigarette consumption, urinary cotinine and intention to quit. Analyses included linear and ordinal repeated measures mixed-effects models and paired t-tests.

RESULTS

Filtered cigarettes were perceived as better tasting, more satisfying, more enjoyable, less aversive, less harsh, less potent and less negatively reinforcing than unfiltered cigarettes. Filtered cigarettes were smoked at a higher rate during the trial than unfiltered cigarettes (p<0.05). There was no difference in cotinine, dependence or intention to quit between filtered versus unfiltered cigarette conditions (p>0.05).

CONCLUSION

People who smoke perceived unfiltered cigarettes as having greater nicotine effects and less desirable sensory effects than filtered cigarettes, and they smoked fewer of these during the trial. Although cotinine, dependence and intention to quit were similar for smoking unfiltered and filtered cigarettes in this small trial, results suggest that banning the sale of filtered cigarettes might make smoking less attractive overall to people who smoke.

TRIAL REGISTRATION NUMBER

NCT03749876.

Post-consumption waterpipe tobacco waste as an unrecognized source of toxic metal(loid)s leachates into aquatic environments

Waterpipe is a common form of tobacco smoking, and recently, its use has been increasing globally. Therefore, concern arises regarding the large quantity of post-consumption waterpipe tobacco waste produced and released into the environment and which can contain high levels of dangerous pollutants such as toxic meta(loid)s. This study reports the concentrations of meta(loid)s in waste from fruit-flavoured and traditional tobacco smoking as well as the release rate of these pollutants from waterpipe tobacco waste into three types of water. These include distilled water, tap water, and seawater and contact times ranging from 15 min to 70 days. The mean concentration levels of Ʃmetal(loid)s in waste samples of Al-mahmoud, Al-Fakher, Mazaya, Al-Ayan brands and traditional tobacco brands were 212 ± 92.8, 198 ± 94.4, 197 ± 75.7, 214 ± 85.8 and 40.6 ± 16.1 μg/g, respectively. The concentration levels of Ʃmetal(loid)s in fruit-flavoured tobacco samples were significantly higher than for traditional tobacco samples (p < 0.05). It was found that waterpipe tobacco wastes leached toxic metal(loid)s into different water samples with similar trends. In addition distribution coefficients showed that most metal(loid)s are highly likely to enter the liquid phase. The concentration levels of these pollutants (except Ni and As) in deionized water and tap water exceeded the surface fresh water standards for sustaining aquatic life during long contact time (up to 70 days). In seawater, concentration levels of Cu and Zn exceeded the recommended standards for maintaining aquatic life in the sea. Therefore, due to the possibility of contamination by soluble metal(loid)s through disposal of waterpipe tobacco waste in wastewater, there is concern that these toxic chemicals might enter the human food chain. Appropriate regulatory measures for disposal of waterpipe tobacco waste are necessary to prevent environmental pollution due to discarded wastes into aquatic ecosystems.

Polycyclic aromatic hydrocarbon (PAH) leachates from post-consumption waterpipe tobacco waste (PWTW) into aquatic environment- a primary study

Post-consumption waterpipe tobacco waste (PWTW) is an unrecognized type of hazardous waste that is produced and released in large quantities into the aquatic environment. It may contain high amounts of various pollutants including PAH, and to date, there has been no research on the potential for contamination by PAH from PWTW leaching into aquatic environments. In this study, the concentrations of PAH via PWTW of fruit-flavored and traditional tobacco leachate into three water types, including distilled water (DW), tap water (TW) and sea water (SW) at different contact times were evaluated. There were significantly higher concentration levels of ƩPAH in waters with leachates from fruit-flavored PWTW than traditional tobacco (P-value<0.05). The concentration levels of ƩPAH in DW, TW and SW at a total contact time of two months ranged from 0.13 to 3.51, 0.12 to 3.63 and 0.11-3.64 μg/L, respectively. Lower molecular weight PAH such as naphthalene (Naph), acenaphthylene (Acen) and fluorine (Flu) were detected in leachates immediately after a short contact time of 15 min. Higher molecular weight PAH including benzo [a]anthracene (BaA), benzo [b]fluoranthene (BbF), benzo [k]fluoranthene (BkF), chrysene (Chr), and benzo [a]pyrene (BaP) were detected after one month contact time, while indeno [1,2,3-cd] pyrene (Indp), benzo [ghi]perylene (BghiP) and dibenz [a,h]anthracene (DahA) were only observed at the contact time measurement of two months. By adding sodium azide as an antimicrobial agent and chemical preservative to SW samples, higher concentrations of PAH including IP, DahA and BghiP were observed. The concentration levels of PAH in water samples after two months contact time were higher than water quality standards provided by the World Health Organization (WHO) and other international organizations.

Policy-relevant differences between secondhand and thirdhand smoke: strengthening protections from involuntary exposure to tobacco smoke pollutants

Starting in the 1970s, individuals, businesses and the public have increasingly benefited from policies prohibiting smoking indoors, saving thousands of lives and billions of dollars in healthcare expenditures. Smokefree policies to protect against secondhand smoke exposure, however, do not fully protect the public from the persistent and toxic chemical residues from tobacco smoke (also known as thirdhand smoke) that linger in indoor environments for years after smoking stops. Nor do these policies address the economic costs that individuals, businesses and the public bear in their attempts to remediate this toxic residue. We discuss policy-relevant differences between secondhand smoke and thirdhand smoke exposure: persistent pollutant reservoirs, pollutant transport, routes of exposure, the time gap between initial cause and effect, and remediation and disposal. We examine four policy considerations to better protect the public from involuntary exposure to tobacco smoke pollutants from all sources. We call for (a) redefining smokefree as free of tobacco smoke pollutants from secondhand and thirdhand smoke; (b) eliminating exemptions to comprehensive smoking bans; (c) identifying indoor environments with significant thirdhand smoke reservoirs; and (d) remediating thirdhand smoke. We use the case of California as an example of how secondhand smoke-protective laws may be strengthened to encompass thirdhand smoke protections. The health risks and economic costs of thirdhand smoke require that smokefree policies, environmental protections, real estate and rental disclosure policies, tenant protections, and consumer protection laws be strengthened to ensure that the public is fully protected from and informed about the risks of thirdhand smoke exposure.

Cellulose acetate cigarette filter is hazardous to human health

The World No Tobacco Day 2022 theme emphasised tobacco's adverse environmental effects, including through agriculture, manufacturing, distribution, use and the disposal of tobacco product waste. A main concern regarding this toxic waste is the cigarette filter, which is attached to nearly all commercial cigarettes and is predominantly made from a plant-based plastic (cellulose acetate). Laboratory studies have demonstrated the chemical toxicity of discarded cigarette butts, and there is growing public concern regarding environmental plastic pollution resulting from single-use cellulose acetate filters. Important considerations are whether the filter has any protective role against the harms of smoking and whether it should be regulated as a plastic environmental pollutant. There is persistent misunderstanding among smokers and policy makers about the implied value of the cigarette filter. The cellulose acetate filter is simply a marketing tool that encourages smoking initiation and reduces intentions to quit smoking. This is because it makes smoking easier and implies added safety through the presumed filtration of inhaled smoke. The sale of filtered cigarettes should be prohibited to protect public health and the environment.

Toxic effect of cigarette butts leachates on blood markers of Periophthalmus waltoni species from the Persian Gulf region

Cigarette butts (CBs) are one of the most common, long-lasting, and toxic forms of marine and coastal area debris. Although the significance of CBs and the toxic contents of this waste items are well recognized, but there is still a lack of information about the effects of this waste on the aquatic organisms. Therefore in this study, the in-vivo toxic effects of various CBs leachates (smoked cigarette butts with tobacco [SCBs], smoked CBs without tobacco [SFs], and unsmoked filters [USFs]) on cellular and chemical hematologic markers in fish (Periophthalmus waltoni) were evaluated. In three acute, sub-acute, and sub-chronic exposure measurements, P. waltoni exposed to different CBs leachates showed a significant increase in white blood cells, creatine kinase, lactate dehydrogenase, alkaline phosphatase, alanine transaminase, and aspartate transaminase, as well as a decrease in hemoglobin (Hb) levels. The mean ± SD values of Hb in P. waltoni species exposed to different CBs leachates (control, SCBs, SFs and USFs) in acute (1 day) phase were 7.15 ± 0.34, 6.02 ± 0.29, 6.25 ± 0.25 and 6.89 ± 0.1 g/dl respectively. These values in subacute (28 days) phase were 6.70 ± 0.15, 5.19 ± 0.24, 5.67 ± 0.30 and 6.10 ± 0.24 g/dl and in sub chronic exposure (42 days) phase were 7.20 ± 0.40, 5.16 ± 0.30, 5.88 ± 0.34 and 6.60 ± 0.33 g/dl respectively. Our results showed that CBs leachates act as a stressor, leading to changes in some hematologic markers in P. waltoni species. Because of the continued deposition of CBs waste into global aquatic environments, policies to mitigate this waste in coastal areas are needed to prevent potentially negative effects on fish and other aquatic organisms.

Depression, Anxiety, and Cigarette Smoking Among Patients with Tuberculosis

Smoking adversely affects tuberculosis (TB) outcomes and may be associated with depression and anxiety among people diagnosed with TB in Botswana. We conducted a cross-sectional study among patients newly diagnosed with TB in Gaborone, Botswana, evaluating factors associated with self-reported cigarette smoking. We performed Poisson regression analyses with robust variance to examine whether depressive and anxiety symptoms were associated with smoking. Among 180 participants with TB enrolled from primary health clinics, depressive symptoms were reported in 47 (26.1%) participants and anxiety symptoms were reported in 85 (47.2%) participants. Overall, 45 (25.0%) participants reported current smoking. Depressive symptoms were associated with a higher prevalence of smoking (adjusted prevalence ratio [aPR]: 2.04; 95% confidence interval [CI]: 1.29-3.25) in the adjusted analysis. The association between anxiety symptoms and smoking did not reach statistical significance (aPR: 1.26; 95% CI: 0.77-2.05). Future studies should further investigate these associations when addressing TB care.

Chemical contents and toxicity of cigarette butts leachates in aquatic environment: A case study from the Persian Gulf region

Cigarette butts (CBs) are one of the most commonly found types of litter contaminating the aquatic environment. However, the environmental risks posed by CBs need further investigation. In this study, the in-vivo toxic effects of various concentrations of CB leachates on juvenile (5.45 ± 1.36 gr and 7.08 ± 1.12 cm) fish (Periophthalmus waltoni) were evaluated. The LC50 values of CB leachate from smoked cigarette butts with tobacco (SCB) were 3.75, 3.0, 1.94, and 1.37 CBs/L in 24, 48, 72, and 96 h exposure times, respectively. The LC50 values for leachate of smoked CBs without tobacco (SF) were 7.58, 6.22, 4.73, and 2.9 CBs/L at 24, 48, 72, and 96 h exposure times, respectively. In the case of leachate from unsmoked filters (USF), LC50 values were 14.68, 12.44, 10.19, and 7.46 CBs/L in 24, 48, 72, and 96 h exposure time, respectively. The mean concentrations of heavy metals and polycyclic aromatic hydrocarbons in SCBs leachates were higher than in SF and USF leachates. Our findings report that even low concentrations of CBs leachates can led to lethality of P. waltoni and may pose a threat to their population density.

Support for cigarette filter waste policies among US adults

INTRODUCTION

Little is known on whether cigarette filter-related knowledge or beliefs are associated with support for policies to reduce their environmental impact.

METHODS

A cross-sectional, population-based sample of US adults aged 18-64 years (n=2979) was used to evaluate filter-related knowledge and beliefs by smoking status using data collected between 24 October 2018 and 17 December 2018. Multivariate logistic regression models explored whether these knowledge and belief items were associated with support for two policies, a US$0.75 litter fee and a ban on sales of filtered cigarettes, controlling for demographic characteristics and smoking status.

RESULTS

Regardless of smoking status, 71% did not know plastic was a cigarette filter component and 20% believed filters were biodegradable. Overall, 23% believed filters reduce health harms and 60% believed filters make it easier to smoke; 90% believed cigarette butts are harmful to the environment. Individuals believing cigarette butts harmed the environment were more likely to support a litter fee (adjusted OR (aOR)=2.33, 95% CI: 1.71 to 3.17). Individuals believing that filters are not biodegradable had higher odds of supporting a litter fee (OR=1.47, 95% CI: 1.15 to 1.88). Respondents believing that filters do not make cigarettes less harmful were more likely to support a litter fee (aOR=1.50, 95% CI: 1.20 to 1.88) and filter ban (aOR=2.03, 95% CI: 1.64 to 2.50). Belief that filters make it easier to smoke was associated with decreased support for a filter ban (aOR=0.69, 95% CI: 0.58 to 0.83).

CONCLUSIONS

Comprehensive efforts are needed to educate the public about the impact of cigarette filters in order to build support for effective tobacco product waste policy.

Paediatric trauma education in low- and middle-income countries: A systematic literature review

Background

Trauma-specific training improves clinician comfort and reduces patient morbidity and mortality; however, curricular content, especially with regard to paediatric trauma, varies greatly by region and income status. We sought to understand how much paediatric education is included in trauma curricula taught in low- and middle-income countries (LMICs).

Methods

We conducted a systematic literature review in October 2020 and in July 2022 based on PRISMA guidelines, utilizing seven databases: MEDLINE, Scopus, Web of Science, CINAHL, Cochrane Reviews, Cochrane Trials, and Global Index Medicus. Reports were limited to those from World Bank-designated LMICs. Key information reviewed included use of a trauma curriculum, patient-related outcomes, and provider/participant outcomes.

Results

The search yielded 2008 reports, with 987 included for initial screening. Thirty-nine of these were selected for review based on inclusion criteria. Sixteen unique trauma curricula used in LMICs were identified, with only two being specific to paediatric trauma. Seven of the adult-focused trauma programmes included sections on paediatric trauma. Curricular content varied significantly in educational topics and skills assessed. Among the 39 included curricula, 33 were evaluated based on provider-based outcomes and six on patient-based outcomes. All provider-based outcome reports showed increased knowledge acquisition and comfort. Four of the five patient-based outcome reports showed reduction in trauma-related morbidity and mortality.

Conclusion

Trauma curricula in LMICs positively impact provider knowledge and may decrease trauma-related morbidity and mortality; however, there is significant variability in existing trauma curricula regarding to paediatric-specific content. Trauma education in LMICs should expand paediatric-specific education, as this population appears to be underserved by most existing curricula.

Modelling the global economic costs of tobacco product waste

Tobacco smoking continues to cause considerable premature mortality and morbidity worldwide. Most of the approximately six trillion cigarettes sold globally each year are discarded improperly as toxic environmental waste. Tobacco product waste, including cigarette butts, is the most commonly collected waste item worldwide. Of particular concern is the cellulose acetate filter, a poorly degradable plastic additive attached to most commercially manufactured cigarettes. This filter was introduced by the tobacco industry to reduce smokers' perception of harm and risk but it has no health benefit. To inform health policy and practice and improve public health outcomes, governments and society can benefit from cost estimates of preventing, properly disposing of and/or cleaning up tobacco product waste. Estimating the costs of tobacco product waste to communities and responsible authorities could encourage the development of health, environmental and fiscal policy interventions and shift accountability for the costs of tobacco product waste onto the global tobacco industry. To support health and environmental policy-making, we therefore propose an empirical approach to estimate the economic costs of tobacco product waste based on its negative environmental externalities. We first present general estimates for six representative countries and then identify data gaps that need to be addressed to develop global estimates. Interventions against tobacco product waste may be new channels to regulate tobacco products across sectors - for example, health, environment and finance - and consequently reduce overall tobacco use.

Naturalistic Topography Assessment in a Randomized Clinical Trial of Smoking Unfiltered Cigarettes: Challenges, Opportunities, and Recommendations

Smoking topography (ST) is a set of measures profiling the behavioral characteristics of smoking in various settings. The CReSS portable device can measure ST in the natural environment. No standard protocol exists for measuring ST longitudinally with the CReSS. This study examined the utilization of the CReSS to measure ST and highlights challenges and opportunities in a naturalistic setting. This study is part of a randomized cross-over clinical trial of smoking filtered or unfiltered cigarettes. Participants (n = 43) smoked in each study condition for two weeks using the CReSS device for five days in their naturalistic smoking setting. The devices were calibrated and cleaned during the washout period, and data were downloaded every visit. Five test puffs were administered to calibrate each device. Moderate compliance rates (74.1%) were found with device usage, and the issues encountered were overheating/clogging, incorrectly registered date/time-stamped data, and device repair/replacement. Routine inspection/cleaning and training in device usage were instrumental in mitigating device malfunctioning. The CReSS device proved to be a feasible tool to examine naturalistic smoking topography and the potential impact of changes in tobacco product design on smoking unfiltered cigarettes. This is the first study to examine ST variables longitudinally, measured at multiple time points, and using unfiltered cigarettes.

Perceptions About the Impact of Cigarette Filters on the Environment and Smoking-Related Behaviors

PURPOSE

Examine adolescents' and young adults' (AYAs) knowledge and perceptions about the composition and environmental harms of cigarette filters and determine how perceptions are associated with support for policy interventions.

METHODS

Cross-sectional, convenience sample from 10 California schools. AYAs (N = 429; 70% < 21 years) were surveyed about tobacco use, perceptions of cigarette filters, their impact on the environment, and cigarette sales bans.

RESULTS

Most agreed that filters are harmful to the environment and not biodegradable (89%, n = 383 respectively); fewer knew filters are made of plastic (43%, n = 185). AYAs who agreed that filters are harmful to the environment were more supportive of cigarette sales bans (OR = 2.78 [95% CI: 1.18, 6.58]).

CONCLUSIONS

Knowledge of the environmental harms of cigarettes among AYAs may strengthen support for tobacco control. More research is needed to further understand the knowledge and attitudes about the environmental impact of tobacco and to clarify how this might add support for tobacco-related policies.

Remediating Thirdhand Smoke Pollution in Multiunit Housing: Temporary Reductions and the Challenges of Persistent Reservoirs

INTRODUCTION

Toxic tobacco smoke residue, also known as thirdhand smoke (THS), can persist in indoor environments long after tobacco has been smoked. This study examined the effects of different cleaning methods on nicotine in dust and on surfaces.

AIMS AND METHODS

Participants had strict indoor home smoking bans and were randomly assigned to: dry/damp cleaning followed by wet cleaning 1 month later (N = 10), wet cleaning followed by dry/damp cleaning (N = 10) 1 month later, and dry/damp and wet cleaning applied the same day (N = 28). Nicotine on surfaces and in dust served as markers of THS and were measured before, immediately after, and 3 months after the cleaning, using liquid chromatography with triple quadrupole mass spectrometry (LC-MS/MS).

RESULTS

Over a 4-month period prior to cleaning, surface nicotine levels remained unchanged (GeoMean change: -11% to +8%; repeated measures r = .94; p < .001). Used separately, dry/damp and wet cleaning methods showed limited benefits. When applied in combination, however, we observed significantly reduced nicotine on surfaces and in dust. Compared with baseline, GeoMean surface nicotine was 43% lower immediately after (z = -3.73, p < .001) and 53% lower 3 months later (z = -3.96, p < .001). GeoMean dust nicotine loading declined by 60% immediately after (z = -3.55, p < .001) and then increased 3 months later to precleaning levels (z = -1.18, p = .237).

CONCLUSIONS

Cleaning interventions reduced but did not permanently remove nicotine in dust and on surfaces. Cleaning efforts for THS need to address persistent pollutant reservoirs and replenishment of reservoirs from new tobacco smoke intrusion. THS contamination in low-income homes may contribute to health disparities, particularly in children.

IMPLICATIONS

Administered sequentially or simultaneously, the tested cleaning protocols reduced nicotine on surfaces by ~50% immediately after and 3 months after the cleaning. Nicotine dust loading was reduced by ~60% immediately after cleaning, but it then rebounded to precleaning levels 3 months later. Cleaning protocols were unable to completely remove THS, and pollutants in dust were replenished from remaining pollutant reservoirs or new secondhand smoke intrusion. To achieve better outcomes, cleaning protocols should be systematically repeated to remove newly accumulated pollutants. New secondhand smoke intrusions need to be prevented, and remaining THS reservoirs should be identified, cleaned, or removed to prevent pollutants from these reservoirs to accumulate in dust and on surfaces.

Effects of Unfiltered Cigarettes on Smoking Behavior and Toxicant Exposure: Protocol for a Randomized Crossover Clinical Trial

Background

Plastic filters on cigarette butts are a widespread source of nonbiodegradable, toxic environmental waste. State and local legislation to ban the sale of single-use cigarettes may be considered to prevent this waste, but scientific evidence on the impact of switching smokers to unfiltered cigarettes on smoking behavior and toxicant exposures is needed to inform this policy. We have designed an open-label, randomized, 9-week, crossover clinical trial of adult filtered-cigarette smokers who switch to unfiltered cigarettes.

Objective

Our objective is to understand the impact of switching smokers of filtered cigarettes to unfiltered cigarettes on smoking behavior and toxic exposures.

Methods

This trial involves a 1-week baseline period; a 2-week period of smoking filtered or unfiltered cigarettes, where groups are randomly assigned; a 3-week washout period; another 1-week baseline period; and a 2-week crossover period of smoking the opposite condition (ie, filtered or unfiltered cigarettes) for a sufficient sample size of 40 participants. We will determine changes in (1) observed topography (ie, puff count, interpuff interval, and puff volume) and cigarettes smoked per day, via butt counts and self-report, (2) expired carbon monoxide and excretion of urinary cotinine, 4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol, and volatile organic compounds, and (3) participants’ knowledge and attitudes toward unfiltered cigarettes, satisfaction with smoking, and intention to quit if they were not able to smoke filtered cigarettes.

Results

This study was funded in June 2018 and approved by the relevant Institutional Review Boards in July 2018. This study has enrolled 37 participants as of October 2020. Data analysis is currently underway, and trial results are expected to be published in spring 2021.

Conclusions

This pilot proof-of-principle study will inform the design of a larger, future research project that can provide robust scientific evidence on our research question. Such a large study could inform possible state or local legislation to ban the sale of single-use filtered cigarettes in order to mitigate the environmental impact of discarded single-use plastic filters.

Trial Registration

ClinicalTrials.gov NCT03749876; https://clinicaltrials.gov/ct2/show/NCT03749876

International Registered Report Identifier (IRRID)

DERR1-10.2196/19603

Online Simulation Model to Estimate the Total Costs of Tobacco Product Waste in Large U.S. Cities

Tobacco product waste (TPW) is one of the most ubiquitous forms of litter, accumulating in large amounts on streets, highways, sidewalks, beaches, parks, and other public places, and flowing into storm water drains, waste treatment plants, and solid waste collection facilities. In this paper, we evaluate the direct and indirect costs associated with TPW in the 30 largest U.S. cities. We first developed a conceptual framework for the analysis of direct and indirect costs of TPW abatement. Next, we applied a simulation model to estimate the total costs of TPW in major U.S. cities. This model includes data on city population, smoking prevalence rates, and per capita litter mitigation costs. Total annual TPW-attributable mean costs for large US cities range from US$4.7 million to US$90 million per year. Costs are generally proportional to population size, but there are exceptions in cities that have lower smoking prevalence rates. The annual mean per capita TPW cost for the 30 cities was US$6.46, and the total TPW cost for all 30 cities combined was US$264.5 million per year. These estimates for the TPW-attributable cost are an important data point in understanding the negative economic externalities created by cigarette smoking and resultant TPW cleanup costs. This model provides a useful tool for states, cities, and other jurisdictions with which to evaluate a new economic cost outcome of smoking and to develop new laws and regulations to reduce this burden.

Persistent tobacco smoke residue in multiunit housing: Legacy of permissive indoor smoking policies and challenges in the implementation of smoking bans

Secondhand smoke (SHS) is a common indoor pollutant in multiunit housing (MUH). It is also the precursor of thirdhand smoke (THS), the toxic mixture of tobacco smoke residue that accumulates in indoor environments where tobacco has been used. This study examined the levels, distribution, and factors associated with THS pollution in low-income MUH. Interviews were conducted 2016-2018 in a cross-sectional study of N = 220 MUH homes in San Diego, California. Two surface wipe samples were collected per home and analyzed for nicotine, a THS marker, using liquid chromatography-triple quadrupole mass spectrometry. Nicotine was detected in all homes of nonsmokers with indoor smoking bans (Geo Mean = 1.67 µg/m²; 95% CI = [1.23;2.30]) and smokers regardless of an indoor ban (Geo Mean = 4.80 µg/m²; 95% CI = [1.89;12.19]). Approximately 10% of nonsmokers' homes with smoking bans showed nicotine levels higher than the average level in homes of smokers without smoking bans from previous studies (≥30 µg/m²). Housing for seniors, smoking bans on balconies, indoor tobacco use, difficult to reach surfaces, and self-reported African-American race/ethnicity were independently associated with higher THS levels. Individual cases demonstrated that high levels of surface nicotine may persist in nonsmoker homes for years after tobacco use even in the presence of indoor smoking bans. To achieve MUH free of tobacco smoke pollutants, attention must be given to identifying and remediating highly polluted units and to implementing smoking policies that prevent new accumulation of THS. As THS is a form of toxic tobacco product waste, responsibility for preventing and mitigating harmful impacts should include manufacturers, suppliers, and retailers.

How Should Physicians in Low- and Middle-Income Countries Regard Electronic Nicotine Delivery Systems to Facilitate Smoking Cessation?

Electronic nicotine delivery systems (ENDS) have been widely referred to as "safer," "healthier," and more "effective" smoking cessation aids, but little evidence supports such claims. New concerns about pulmonary injuries associated with ENDS suggest reasons for concern about these products' health risks and potential for nicotine addiction. Nevertheless, multinational tobacco companies heavily market ENDS to retain customers with nicotine addiction, and global progress against tobacco use might slow as a result. The tobacco industry has managed to divide the tobacco control community by offering hope of harm reduction without actual evidence of ENDS' effectiveness or long-term safety. Low- and middle-income countries need this evidence to assess ENDS' value in mitigating tobacco use.

Global Health Perspectives on Cigarette Butts and the Environment

Cigarette butts, whuch are also known as tobacco product waste (TPW), are the single most collected item in environmental trash cleanups worldwide. This study used an online survey tool (Qualtrics) to assess knowledge, attitudes, and perceptions regarding this issue among individuals representing the Framework Convention Alliance (FCA). The FCA has about 680 members on its listserv, including non-governmental tobacco control advocacy groups that support the implementation of the World Health Organization's (WHO) Framework Convention on Tobacco Control (FCTC). Respondents (n = 65) represented countries from all six WHO regions. The majority (82%) had heard the term TPW, and they all considered TPW as an environmental harm at some level. Additionally, 29% of respondents failed to identify that "cigarette filters make smoking easier". Most (73%) correctly identified TPW components; however, fewer (60%) correctly identified the composition of cigarette butts. The majority (57%) were unfamiliar with Extended Producer Responsibility (EPR) and Product Stewardship (PS) as possible environmental intervention strategies. Respondents expressing opinions concurred that adding a litter fee to fund TPW programs will aid in reducing tobacco use and reduce the environmental impacts of TPW (100%); that prevention, reduction, and mitigation of TPW could be an important part of international tobacco control programs (98%); and, that banning smoking in outdoor venues could reduce TPW (95%). Only 16% reported effective prevention or clean-up efforts in their countries. Weighted rankings revealed that respondents' saw the national government, the tobacco industry, and state governments as the most important in addressing TPW. The results of this research will inform continuing international discussions by the FCTC Conference of the Parties (COP) regarding environmental policies that may be addressed within FCTC obligations.

Coronary Artery Calcium Volume and Density: Potential Interactions and Overall Predictive Value: The Multi-Ethnic Study of Atherosclerosis

OBJECTIVES

This study sought to determine the possibility of interactions between coronary artery calcium (CAC) volume or CAC density with each other, and with age, sex, ethnicity, the new atherosclerotic cardiovascular disease (ASCVD) risk score, diabetes status, and renal function by estimated glomerular filtration rate, and, using differing CAC scores, to determine the improvement over the ASCVD risk score in risk prediction and reclassification.

BACKGROUND

In MESA (Multi-Ethnic Study of Atherosclerosis), CAC volume was positively and CAC density inversely associated with cardiovascular disease (CVD) events.

METHODS

A total of 3,398 MESA participants free of clinical CVD but with prevalent CAC at baseline were followed for incident CVD events.

RESULTS

During a median 11.0 years of follow-up, there were 390 CVD events, 264 of which were coronary heart disease (CHD). With each SD increase of ln CAC volume (1.62), risk of CHD increased 73% (p < 0.001) and risk of CVD increased 61% (p < 0.001). Conversely, each SD increase of CAC density (0.69) was associated with 28% lower risk of CHD (p < 0.001) and 25% lower risk of CVD (p < 0.001). CAC density was inversely associated with risk at all levels of CAC volume (i.e., no interaction was present). In multivariable Cox models, significant interactions were present for CAC volume with age and ASCVD risk score for both CHD and CVD, and CAC density with ASCVD risk score for CVD. Hazard ratios were generally stronger in the lower risk groups. Receiver-operating characteristic area under the curve and Net Reclassification Index analyses showed better prediction by CAC volume than by Agatston, and the addition of CAC density to CAC volume further significantly improved prediction.

CONCLUSIONS

The inverse association between CAC density and incident CHD and CVD events is robust across strata of other CVD risk factors. Added to the ASCVD risk score, CAC volume and density provided the strongest prediction for CHD and CVD events, and the highest correct reclassification.

Applied global health diplomacy: profile of health diplomats accredited to the UNITED STATES and foreign governments

BACKGROUND

Global health diplomacy (GHD) is a burgeoning field bridging the priorities of global health and foreign affairs. Given the increasing need to mobilize disparate global health stakeholders coupled with the need to design complex public health partnerships to tackle issues of international concern, effective and timely cooperation among state actors is critical. Health Attachés represent this coordination focal point and are key diplomatic professionals at the forefront of GHD. Despite their unique mandate, little is published about this profession and the perspectives of those who work in the field.

METHODS

Through purposive sampling, we performed in-depth qualitative interviews with seven Health Attachés: three foreign Health Attachés accredited to the United States and four U.S. Health Attachés accredited to foreign governments. Our interviews explored four key topics: the role and mission of Health Attachés, skills needed to perform GHD, examples of successes and challenges in accomplishing their respective missions, and suggestions for the future development of the diplomatic profession.

RESULTS

We identified several lessons to apply to the growing field of GHD. First, GHD actors need to receive appropriate training to successfully negotiate the intersection of global health and foreign affairs. Participants suggested several areas of training that would benefit GHD actors: diplomacy and negotiation, applied science, and cross-cultural competency. Second, participants articulated the need for a career path for GHD practitioners, increased opportunities for on-the-job training and mentored experiences, and GHD competencies with defined levels of mastery that can be used in occupational evaluation and career development.

CONCLUSIONS

Our findings indicate that skills in diplomacy and negotiation, applied science, and cross cultural competency are essential for the statecraft of Health Attachés. Additionally, establishing a clear career pathway for Health Attachés is critical for future maturation of the profession and for fostering effective global health action that aligns public health and foreign diplomacy outcomes. Achieving these goals would ensure that this special cadre of diplomats could effectively practice GHD and would also better position Health Attachés to take the lead in advancing shared global health goals among nation states in a new era of twenty-first century diplomacy.

Tobacco industry responsibility for butts: a Model Tobacco Waste Act

Cigarette butts and other postconsumer products from tobacco use are the most common waste elements picked up worldwide each year during environmental cleanups. Under the environmental principle of Extended Producer Responsibility, tobacco product manufacturers may be held responsible for collection, transport, processing and safe disposal of tobacco product waste (TPW). Legislation has been applied to other toxic and hazardous postconsumer waste products such as paints, pesticide containers and unused pharmaceuticals, to reduce, prevent and mitigate their environmental impacts. Additional product stewardship (PS) requirements may be necessary for other stakeholders and beneficiaries of tobacco product sales and use, especially suppliers, retailers and consumers, in order to ensure effective TPW reduction. This report describes how a Model Tobacco Waste Act may be adopted by national and subnational jurisdictions to address the environmental impacts of TPW. Such a law will also reduce tobacco use and its health consequences by raising attention to the environmental hazards of TPW, increasing the price of tobacco products, and reducing the number of tobacco product retailers.

The environmental and health impacts of tobacco agriculture, cigarette manufacture and consumption

The health consequences of tobacco use are well known, but less recognized are the significant environmental impacts of tobacco production and use. The environmental impacts of tobacco include tobacco growing and curing; product manufacturing and distribution; product consumption; and post-consumption waste. The World Health Organization's Framework Convention on Tobacco Control addresses environmental concerns in Articles 17 and 18, which primarily apply to tobacco agriculture. Article 5.3 calls for protection from policy interference by the tobacco industry regarding the environmental harms of tobacco production and use. We detail the environmental impacts of the tobacco life-cycle and suggest policy responses.

Perspectives on Tobacco Product Waste: A Survey of Framework Convention Alliance Members' Knowledge, Attitudes, and Beliefs

Cigarette butts (tobacco product waste (TPW)) are the single most collected item in environmental trash cleanups worldwide. This brief descriptive study used an online survey tool (Survey Monkey) to assess knowledge, attitudes, and beliefs among individuals representing the Framework Convention Alliance (FCA) about this issue. The FCA has about 350 members, including mainly non-governmental tobacco control advocacy groups that support implementation of the World Health Organization’s (WHO) Framework Convention on Tobacco Control (FCTC). Although the response rate (28%) was low, respondents represented countries from all six WHO regions. The majority (62%) have heard the term TPW, and nearly all (99%) considered TPW as an environmental harm. Most (77%) indicated that the tobacco industry should be responsible for TPW mitigation, and 72% felt that smokers should also be held responsible. This baseline information may inform future international discussions by the FCTC Conference of the Parties (COP) regarding environmental policies that may be addressed within FCTC obligations. Additional research is planned regarding the entire lifecycle of tobacco’s impact on the environment.

The tobacco endgame: is it possible?

Reflecting on World No Tobacco Day 2015, Tom Novotny assesses the tobacco control landscape and considers how a tobacco endgame could be a reality.

Extended Producer Responsibility and Product Stewardship for Tobacco Product Waste

This paper reviews several environmental principles, including Extended Producer Responsibility (EPR), Product Stewardship (PS), the Polluter Pays Principle (PPP), and the Precautionary Principle, as they may apply to tobacco product waste (TPW). The review addresses specific criteria that apply in deciding whether a particular toxic product should adhere to these principles; presents three case studies of similar approaches to other toxic and/or environmentally harmful products; and describes 10 possible interventions or policy actions that may help prevent, reduce, and mitigate the effects of TPW. EPR promotes total lifecycle environmental improvements, placing economic, physical, and informational responsibilities onto the tobacco industry, while PS complements EPR, but with responsibility shared by all parties involved in the tobacco product lifecycle. Both principles focus on toxic source reduction, post-consumer take-back, and final disposal of consumer products. These principles when applied to TPW have the potential to substantially decrease the environmental and public health harms of cigarette butts and other TPW throughout the world. TPW is the most commonly littered item picked up during environmental, urban, and coastal cleanups globally.

Dose-response association between salivary cotinine levels and Mycobacterium tuberculosis infection

SETTING

Tijuana, Mexico.

OBJECTIVE

To describe the association between salivary cotinine levels and interferon-gamma (IFN-γ) release assay results.

DESIGN

We conducted a cross-sectional study among injection drug users. Salivary cotinine levels were measured using NicAlert, a semi-quantitative dipstick assay. QuantiFERON©-TB Gold In-Tube (QFT-GIT) was used to determine Mycobacterium tuberculosis infection.

RESULTS

Among 234 participants, the prevalence of QFT-GIT positivity for NicAlert cotinine categories 0 (non-smoking), 1 (second-hand smoke exposure or low-level smoking) and 26 (regular smoking) were respectively 42.1%, 46.4% and 65.2% (Ptrend 0.012). We found increasing trends in QFT-GIT positivity (Ptrend 0.003) and IFN-γ concentrations (Spearman's r 0.200, P 0.002) across cotinine levels 0 to 6. In multivariable log-binomial regression models adjusted for education, cotinine levels were not associated with QFT-GIT positivity when included as smoking categories (1 and 26 vs. 0), but were independently associated with QFT-GIT positivity when included as an ordinal variable (prevalence ratio 1.09 per 1 cotinine level, 95%CI 1.021.16).

CONCLUSION

Our findings suggest that a dose-response relationship exists between tobacco smoke exposure and M. tuberculosis infection. Longitudinal studies that use biochemical measures for smoking status are needed to confirm our findings.

Tobacco Product Waste: An Environmental Approach to Reduce Tobacco Consumption

Cigarette butts and other tobacco product wastes (TPW) are the most common items picked up in urban and beach cleanups worldwide. TPW contains all the toxins, nicotine, and carcinogens found in tobacco products, along with the plastic nonbiodegradable filter attached to almost all cigarettes sold in the United States and in most countries worldwide. Toxicity studies suggest that compounds leached from cigarette butts in salt and fresh water are toxic to aquatic micro-organisms and test fish. Toxic chemicals have also been identified in roadside TPW. With as much as two-thirds of all smoked cigarettes (numbering in the trillions globally) being discarded into the environment each year, it is critical to consider the potential toxicity and remediation of these waste products. This article reviews reports on the toxicity of TPW and recommends several policy approaches to mitigation of this ubiquitous environmental blight.

The Association between active and passive smoking and latent tuberculosis infection in adults and children in the united states: results from NHANES

BACKGROUND

Few studies assessing the relationship between active and passive smoking and tuberculosis have used biomarkers to measure smoke exposure. We sought to determine the association between active and passive smoking and LTBI in a representative sample of US adults and children.

METHODS

We used the 1999-2000 US National Health and Nutrition Examination Survey (NHANES) dataset with tuberculin skin test (TST) data to assess the association between cotinine-confirmed smoke exposure and latent tuberculosis infection (LTBI) among adults ages ≥20 years (n = 3598) and children 3-19 years (n = 2943) and estimate the prevalence of smoke exposure among those with LTBI. Weighted multivariate logistic regression was used to measure the associations between active and passive smoking and LTBI.

RESULTS

LTBI prevalence in 1999-2000 among cotinine-confirmed active, passive, and non-smoking adults and children was 6.0%, 5.2%, 3.3% and 0.3%, 1.0%, 1.5%, respectively. This corresponds to approximately 3,556,000 active and 3,379,000 passive smoking adults with LTBI in the US civilian non-institutionalized population in 1999-2000. Controlling for age, gender, socioeconomic status, race, birthplace (US vs. foreign-born), household size, and having ever lived with someone with TB, adult active smokers were significantly more likely to have LTBI than non-smoking adults (AOR = 2.31 95% CI 1.17-4.55). Adult passive smokers also had a greater odds of LTBI compared with non-smokers, but this association did not achieve statistical significance (AOR = 2.00 95% CI 0.87-4.60). Neither active or passive smoking was associated with LTBI among children. Among only the foreign-born adults, both active (AOR = 2.56 (95% CI 1.20-5.45) and passive smoking (AOR = 2.27 95% CI 1.09-4.72) were significantly associated with LTBI.

CONCLUSIONS

Active adult smokers and both foreign-born active and passive smokers in the United States are at elevated risk for LTBI. Targeted smoking prevention and cessation programs should be included in comprehensive national and international TB control efforts.

Perceived discrimination and smoking among rural-to-urban migrant women in China

Smoking may be a coping mechanism for psychosocial stress caused by discrimination. We conducted a cross-sectional survey of rural-to-urban migrant women working as restaurant/hotel workers (RHWs) and those working as sex workers (FSWs) in 10 Chinese cities to investigate whether perceived discrimination is associated with smoking. We interviewed RHWs at medical examination clinics and FSWs at entertainment venues. Modified Poisson regression was used to estimate prevalence ratios. Of the 1,696 RHWs and 532 FSWs enrolled, 155 (9.1%) and 63 (11.8%) reported perceived discrimination, respectively. Perceived discrimination was independently associated with ever tried smoking (prevalence ratio [PR], 1.71; 95% confidence interval [CI], 1.31-2.23) and current smoking (PR, 2.52; 95% CI, 1.32-4.79) among RHWs and ever tried smoking (PR, 1.36; 95% CI, 1.16-1.61) and current smoking (PR, 1.63; 95% CI, 1.28-2.06) among FSWs. Perceived discrimination is associated with higher prevalence of smoking among rural-to-urban migrant women in China.

Cigarette smoking and quit attempts among injection drug users in Tijuana, Mexico

INTRODUCTION

Injection drug use and cigarette smoking are major global health concerns. Limited data exist regarding cigarette smoking behavior and quit attempts among injection drug users (IDUs) in low- and middle-income countries to inform the development of cigarette smoking interventions. We conducted a cross-sectional study to describe cigarette smoking behavior and quit attempts among IDUs in Tijuana, Mexico.

METHODS

IDUs were recruited through community outreach and administered in-person interviews. Multivariable Poisson regression models were constructed to determine prevalence ratios (PRs) for quit attempts.

RESULTS

Of the 670 participants interviewed, 601 (89.7%) were current smokers. Of these, median number of cigarettes smoked daily was 10; 190 (31.6%) contemplated quitting smoking in the next 6 months; 132 (22.0%) had previously quit for ≥1 year; and 124 (20.6%) had made a recent quit attempt (lasting ≥1 day during the previous 6 months). In multivariable analysis, recent quit attempts were positively associated with average monthly income (≥3,500 pesos [US$280] vs. <1,500 pesos [US$120]; PR = 2.30; 95% CI = 1.57-3.36), smoking marijuana (PR = 1.38; 95% CI = 1.01-2.90), and smoking heroin (PR = 1.85; 95% CI = 1.23-2.78), and they were negatively associated with number of cigarettes smoked daily (PR = 0.96; 95% CI = 0.94-0.98).

CONCLUSIONS

One out of 5 IDUs attempted to quit cigarette smoking during the previous 6 months. Additional research is needed to improve the understanding of the association between drug use patterns and cigarette smoking quit attempts, including the higher rate of quit attempts observed among IDUs who smoke marijuana or heroin compared with IDUs who do not smoke these substances.

Acceptability and adoption of handheld computer data collection for public health research in China: a case study

Background

Handheld computers for data collection (HCDC) and management have become increasingly common in health research. However, current knowledge about the use of HCDC in health research in China is very limited. In this study, we administered a survey to a hard-to-reach population in China using HCDC and assessed the acceptability and adoption of HCDC in China.

Methods

Handheld computers operating Windows Mobile and Questionnaire Development Studio (QDS) software (Nova Research Company) were used for this survey. Questions on tobacco use and susceptibility were drawn from the Global Adult Tobacco Survey (GATS) and other validated instruments, and these were programmed in Chinese characters by local staff. We conducted a half-day training session for survey supervisors and a three-day training session for 20 interviewers and 9 supervisors. After the training, all trainees completed a self-assessment of their skill level using HCDC. The main study was implemented in fall 2010 in 10 sites, with data managed centrally in Beijing. Study interviewers completed a post-survey evaluation questionnaire on the acceptability and utility of HCDC in survey research.

Results

Twenty-nine trainees completed post-training surveys, and 20 interviewers completed post-data collection questionnaires. After training, more than 90% felt confident about their ability to collect survey data using HCDC, to transfer study data from a handheld computer to a laptop, and to encrypt the survey data file. After data collection, 80% of the interviewers thought data collection and management were easy and 60% of staff felt confident they could solve problems they might encounter. Overall, after data collection, nearly 70% of interviewers reported that they would prefer to use handheld computers for future surveys. More than half (55%) felt the HCDC was a particularly useful data collection tool for studies conducted in China.

Conclusions

We successfully conducted a health-related survey using HCDC. Using handheld computers for data collection was a feasible, acceptable, and preferred method by Chinese interviewers. Despite minor technical issues that occurred during data collection, HCDC is a promising methodology to be used in survey-based research in China.

Evolution of tobacco labeling and packaging: international legal considerations and health governance

Numerous national governments have recently adopted packaging and labeling legislation to curb global tobacco uptake. This coincides with the World Health Organization's 2011 World No Tobacco Day, which recognized the extraordinary progress of the Framework Convention on Tobacco Control (FCTC). The tobacco industry has presented legal challenges to countries, including Australia, Uruguay, and the United States, for enacting legislation meeting or exceeding FCTC obligations. We argue that national governments attempting to meet the obligations set forth in public health treaties such as the FCTC should be afforded flexibilities and protection in developing tobacco control laws and regulations, because these measures are necessary to protect public health and should be explicitly recognized in international trade and legal agreements.

Irreconcilable conflict: the tobacco industry and the public health challenge of tobacco use

Thomas Novotny reflects on new research by Stanton Glantz and colleagues and the implications of their findings for engaging the tobacco industry on tobacco product regulation.

Feasibility study of a smoking cessation intervention in Directly Observed Therapy Short-Course tuberculosis treatment clinics in Rio de Janeiro, Brazil

A pilot feasibility study was conducted to determine whether Directly Observed Therapy Short-Course (DOTS) workers could be trained to deliver smoking cessation counseling and referral interventions, identify potential barriers to a full-scale randomized controlled trial on the effectiveness of integrated smoking cessation in DOTS, and determine whether tuberculosis (TB) patients who smoke would agree to participate in such a program. DOTS providers in two Rio de Janeiro primary health clinics received 1-day training in cessation counseling. They completed pre- and post-training surveys and participated in post-program focus groups. Patients were surveyed 3 months after program completion, and semiquantitative urine assays for cotinine were used to confirm cessation. Providers' mean self-efficacy scores for cessation counseling improved significantly (advise to quit, assess readiness, assist with quitting, and arrange follow-up) from scores (on a scale of 1-5) of 2-3 pre-training to 3-4 post-training (P < 0.05), with only ability to change motivation not significant. Providers' knowledge about cessation (withdrawal, nicotine replacement therapy, precontemplation) was low before training and did not improve after training (P > 0.1 for all comparisons). Implementation of a smoking cessation intervention by DOTS providers in TB clinics in Brazil is feasible. Randomized controlled trials to test intervention effectiveness in reducing TB-related morbidity must include cross-training for tobacco control and TB providers. Smoking cessation in DOTS programs may be important in reducing the global burden of TB, improving the health of TB patients, and reducing TB transmission in households.

Environmental health impacts of tobacco farming: a review of the literature

OBJECTIVE

To review the literature on environmental health impacts of tobacco farming and to summarise the findings and research gaps in this field.

METHODS

A standard literature search was performed using multiple electronic databases for identification of peer-reviewed articles. The internet and organisational databases were also used to find other types of documents (eg, books and reports). The reference lists of identified relevant documents were reviewed to find additional sources.

RESULTS

The selected studies documented many negative environmental impacts of tobacco production at the local level, often linking them with associated social and health problems. The common agricultural practices related to tobacco farming, especially in low-income and middle-income countries, lead to deforestation and soil degradation. Agrochemical pollution and deforestation in turn lead to ecological disruptions that cause a loss of ecosystem services, including land resources, biodiversity and food sources, which negatively impact human health. Multinational tobacco companies' policies and practices contribute to environmental problems related to tobacco leaf production.

CONCLUSIONS

Development and implementation of interventions against the negative environmental impacts of tobacco production worldwide are necessary to protect the health of farmers, particularly in low-income and middle-income countries. Transitioning these farmers out of tobacco production is ultimately the resolution to this environmental health problem. In order to inform policy, however, further research is needed to better quantify the health impacts of tobacco farming and evaluate the potential alternative livelihoods that may be possible for tobacco farmers globally.

UN resolution on the prevention and control of non-communicable diseases: an opportunity for global action

In May 2010, the United Nations (UN) General Assembly unanimously adopted a resolution on non-communicable diseases (NCDs) that called for high-level meetings to address the global burden of NCDs. This paper highlights the growing global burden of NCDs (cardiovascular diseases, cancer, chronic obstructive pulmonary diseases and diabetes), provides a brief historical background on the adoption of the UN NCDs resolution and argues that the resolution provides a remarkable new opportunity for improved international collaboration to address NCDs. Additionally, the paper argues that while the existing World Health Organisation programme on NCDs be continued and expanded, the UN can provide the expanded political leadership that is necessary for multi-sectoral collaboration and can serve as a respected forum for dealing with the issue across numerous key UN agencies.

Increasing hookah use in California

Hookah use is gaining popularity nationwide. We determined the correlates and trends for hookah use from the California Tobacco Survey. Between 2005 and 2008 hookah use increased more than 40%, and in 2008, 24.5% of young men reported ever using a hookah. Hookah use was more common among the young (18-24 years), the educated, the non-Hispanic Whites, and the cigarette smokers. Hookah use is increasing in California, especially among young adults, and in 2008 reached the highest prevalence ever reported for both genders.

Smoking among young rural to urban migrant women in China: a cross-sectional survey

Background

Rural-to-urban migrant women may be vulnerable to smoking initiation as they are newly exposed to risk factors in the urban environment. We sought to identify correlates of smoking among rural-to-urban migrant women in China.

Methods/Principal Findings

A cross-sectional survey of rural-to-urban migrant women working in restaurants and hotels (RHW) and those working as commercial sex workers (CSW) was conducted in ten provincial capital cities in China. Multiple logistic regression was conducted to identify correlates of smoking. We enrolled 2229 rural-to-urban migrant women (1697 RHWs aged 18–24 years and 532 CSWs aged 18–30 years). Of these, 18.4% RHWs and 58.3% CSWs reported ever tried smoking and 3.2% RHWs and 41.9% CSWs reported current smoking. Participants who first tried smoking after moving to the city were more likely to be current smokers compared to participants who first tried smoking before moving to the city (25.3% vs. 13.8% among RHWs, p = 0.02; 83.6% vs. 58.6% among CSWs, p = <0.01). Adjusting for other factors, “tried female cigarette brands” had the strongest association with current smoking (OR 5.69, 95%CI 3.44 to 9.41) among participants who had ever tried smoking.

Conclusions/Significance

Exposure to female cigarette brands may increase the susceptibility to smoking among rural-to-urban migrant women. Smoke-free policies and increased taxes may be effective in preventing rural-to-urban migrant women from smoking initiation.

Geographic patterns of cigarette butt waste in the urban environment

Background

This reports the initial phase of a study to quantify the spatial pattern of cigarette butt waste in an urban environment.

Methods

Geographic Information Systems (GIS) was used to create a weighted overlay analysis model which was then applied to the locations of businesses where cigarettes are sold or are likely to be consumed and venues where higher concentrations of butts may be deposited. The model's utility was tested using a small-scale litter audit in three zip codes of San Diego, California.

Results

We found that cigarette butt waste is highly concentrated around businesses where cigarettes are sold or consumed. The mean number of butts for predicted high waste sites was 38.1 (SD 18.87), for predicted low waste sites mean 4.8 (SD 5.9), p<0.001.

Conclusions

Cigarette butt waste is not uniformly distributed in the urban environment, its distribution is linked to locations and patterns of sales and consumption. A GIS and weighted overlay model may be a useful tool in predicting urban locations of greater and lesser amounts of cigarette butt waste. These data can in turn be used to develop economic cost studies and plan mitigation strategies in urban communities.