Cross-sectional study of the associations between the implementation of the WHO FCTC tobacco advertising, promotion and sponsorship bans and current e-cigarette use among youth from countries with different income levels

BACKGROUND

The WHO Framework Convention on Tobacco Control (WHO FCTC) Article 13 requires countries to ban tobacco advertising, promotion and sponsorship (TAPS), and bans are recommended to cover electronic cigarettes (e-cigarettes). We examined youth e-cigarette prevalence by TAPS regulations in countries with different income levels.

METHODS

We analysed data on 165 299 respondents from 48 countries with 2016/2018 WHO FCTC implementation reports and 2016-2019 Global Youth Tobacco Survey. We used multilevel logistic regressions to examine associations between TAPS regulations and current e-cigarette use, stratified by country income.

RESULTS

About 1 in 10 respondents was currently using e-cigarettes. Respondents in countries with TAPS bans on the internet were less likely to use e-cigarettes (adjOR=0.58; 95% CI 0.39 to 0.86) than youth in countries without such bans. In lower middle-income and low-income countries, bans on displaying tobacco products at the point of sale (adjOR=0.55; 95% CI 0.34 to 0.90), bans on product placement (adjOR=0.44; 95% CI 0.28 to 0.69) and strength of additional TAPS measures were associated with lower prevalence of e-cigarette use among students. Being taught about the dangers of the use of tobacco in school was associated with lower odds of e-cigarette use. No differences in the use of e-cigarettes were observed by types of TAPS among respondents in high-income countries.

CONCLUSIONS

Strengthening implementation of TAPS policies and assuring they cover new and emerging products, online channels and points of sales are essential, especially in lower income countries. Maintaining tobacco health education is also important to protect youth from e-cigarette use.

Implementation of the Article 13 WHO FCTC measures and changes in cigarette smoking among youth in 42 countries

INTRODUCTION

Despite a decline in global smoking prevalence among adolescents, around 21 million youth report current cigarette smoking. Exposure to tobacco advertising, promotion and sponsorship (TAPS) is a risk factor for smoking initiation, and therefore the Article 13 of the WHO Framework Convention on Tobacco Control (WHO FCTC) requires comprehensive TAPS bans. We examined the associations between changes in youth cigarette smoking and implementation of Article 13.

METHODS

We used two rounds of cross-sectional data from the Global Youth Tobacco Survey (GYTS) for 42 countries: first between 2006 and 2015, and second between 2017 and 2020. The GYTS data were linked with the WHO FCTC implementation reports from 2016 and 2018. The outcome was current smoking. Multilevel binary logistic regression models, stratified by country income level, were used to test the prevalence differences between the latest and previous GYTS rounds and their associations with TAPS bans with postestimations using marginal analyses.

RESULTS

The percentage of students currently smoking decreased from 10.0% (95% CI 8.0 to 12.1) to 7.7% (95% CI 6.1 to 9.3) from first to second GYTS rounds (p<0.001), adjusting for country clustering. In low-income and lower-middle-income countries, the degree of decrease significantly differed between countries with versus without bans on display, partial internet TAPS ban, ban on depiction of tobacco products and by number of TAPS measures, adjusting for age and sex of the respondents. In high-income and upper-middle-income countries, the degree of decrease significantly differed by presence (or absence) of partial or full internet TAPS ban, ban on product placement and by number of TAPS measures.

CONCLUSION

Implementation of TAPS bans is associated with decreased smoking among adolescents both in high-income and low-income countries. Enhanced and continuous efforts are necessary to protect youth from the promotion of tobacco and nicotine products.

Health system characteristics and COVID-19 performance in high-income countries

BACKGROUND

The COVID-19 pandemic has shaken everyday life causing morbidity and mortality across the globe. While each country has been hit by the pandemic, individual countries have had different infection and health trajectories. Of all welfare state institutions, healthcare has faced the most immense pressure due to the pandemic and hence, we take a comparative perspective to study COVID-19 related health system performance. We study the way in which health system characteristics were associated with COVID-19 excess mortality and case fatality rates before Omicron variant.

METHODS

This study analyses the health system performance during the pandemic in 43 OECD countries and selected non-member economies through three healthcare systems dimensions: (1) healthcare finance, (2) healthcare provision, (3) healthcare performance and health outcomes. Health system characteristics-related data is collected from the Global Health Observatory data repository, the COVID-19 related health outcome indicators from the Our World in Data statistics database, and the country characteristics from the World Bank Open Data and the OECD statistics databases.

RESULTS

We find that the COVID-19 excess mortality and case fatality rates were systematically associated with healthcare system financing and organizational structures, as well as performance regarding other health outcomes besides COVID-19 health outcomes.

CONCLUSION

Investments in public health systems in terms of overall financing, health workforce and facilities are instrumental in reducing COVID-19 related mortality. Countries aiming at improving their pandemic preparedness may develop health systems by strengthening their public health systems.

Exploring the association between grandparental care and child development: Evidence from China

Grandparental care has become an involuntary choice in life for many families, mainly due to parents' unavailability to provide care and the lack of public or affordable private childcare. This phenomenon has raised concerns regarding the effects of grandparental care along the dimensions of child development. This study aims to test the association between grandparental care and child development in three dimensions: subjective wellbeing, behavioural traits and study performance. It used data from the 2018 China Family Panel Studies survey. First, the study outlines the data and the applied method with defined variables, on the basis of which an overview on the current stage of grandparental care is presented. It then examines the association of the impact of grandparental care in different dimensions using the general linear model, along with the other influencing factors. Finally, a cross-age group comparison is employed. The results of the study illustrate the difficulty of examining an overall picture of grandparental childcare, with its negative or positive associations. However, when evaluated using the features of different age groups of children's development, significant associations between grandparental care and child development are mainly found in the 6-11 age group, but the significant associations weaken or disappear in the 12-16 age group. Attachment theory and peer group theory are used to explain the difference between the two age groups.

Global Implementation of Tobacco Demand Reduction Measures Specified in Framework Convention on Tobacco Control

INTRODUCTION

The world's first global health treaty, WHO Framework Convention on Tobacco Control (FCTC) aims to reduce tobacco product demand by focusing on tobacco taxes, smoking bans, health warning labels, and tobacco advertising bans. Previous studies almost unanimously suggest that FCTC has prompted countries to implement more effective tobacco demand reduction policies.

AIMS AND METHODS

By taking into account the pre-FCTC status, country income level, and state capacity we studied if ratifying FCTC was associated with tobacco demand reduction measures in 2018/2019. We used logistic regression to assess the association of FCTC ratification with adoption demand reduction measures, accounting for years since ratification, baseline status, and other covariates.

RESULTS

Except for taxes, state of tobacco policy implementation before FCTC ratification did not predict adoption of FCTC policies. Time since FCTC ratification was associated with implementing smoking bans and pictorial HWLs. In contrast, while the tax rate prior to FCTC ratification was positively associated with increased taxes after FCTC ratification, time since FCTC ratification was marginally negatively associated with increases in tobacco taxes.

CONCLUSIONS

While the FCTC was followed by implementation of compliant demand reduction policies, there are still many parties that have not implemented the FCTC, particularly increasing taxes and ending tobacco advertising and promotions.

IMPLICATIONS

We assessed changes in tobacco demand reductions measures over 22 years in 193 countries. By using internal tobacco industry documents, we were able establish a baseline before the FCTC negotiations. Unlike previous studies, we included four tobacco demand reductions measures: tobacco taxes, smoking bans, health warning labels, and tobacco advertising ban. The limitation of the study is that we do not have data to describe if demand reduction measures are actually enforced or what their effect on tobacco consumption is.

Long-term Health and Social Outcomes in Children and Adolescents Placed in Out-of-Home Care

IMPORTANCE

Children who are placed in out-of-home care may have poorer outcomes in adulthood, on average, compared with their peers, but the direction and magnitude of these associations need clarification.

OBJECTIVE

To estimate associations between being placed in out-of-home care in childhood and adolescence and subsequent risks of experiencing a wide range of social and health outcomes in adulthood following comprehensive adjustments for preplacement factors.

DESIGN, SETTING, AND PARTICIPANTS

This cohort and cosibling study of all children born in Finland between 1986 and 2000 (N = 855 622) monitored each person from their 15th birthday either until the end of the study period (December 2018) or until they migrated, died, or experienced the outcome of interest. Cox and Poisson regression models were used to estimate associations with adjustment for measured confounders (from linked population registers) and unmeasured familial confounders (using sibling comparisons). Data were analyzed from October 2020 to August 2021.

EXPOSURES

Placement in out-of-home care up to age 15 years.

MAIN OUTCOMES AND MEASURES

Through national population, patient, prescription drug, cause of death, and crime registers, 16 specific outcomes were identified across the following categories: psychiatric disorders; low socioeconomic status; injuries and experiencing violence; and antisocial behaviors, suicidality, and premature mortality.

RESULTS

A total of 30 127 individuals (3.4%) were identified who had been placed in out-of-home care for a median (interquartile range) period of 1.3 (0.2-5.1) years and 2 (1-3) placement episodes before age 15 years. Compared with their siblings, individuals who had been placed in out-of-home care were 1.4 to 5 times more likely to experience adverse outcomes in adulthood (adjusted hazard ratio [aHR] for those with a fall-related injury, 1.40; 95% CI, 1.25-1.57 and aHR for those with an unintentional poisoning injury, 4.79; 95% CI, 3.56-6.43, respectively). The highest relative risks were observed for those with violent crime arrests (aHR, 4.16; 95% CI, 3.74-4.62; cumulative incidence, 24.6% in individuals who had been placed in out-of-home care vs 5.1% in those who had not), substance misuse (aHR, 4.75; 95% CI, 4.25-5.30; cumulative incidence, 23.2% vs 4.6%), and unintentional poisoning injury (aHR 4.79; 95% CI, 3.56-6.43; cumulative incidence, 3.1% vs 0.6%). Additional adjustments for perinatal factors, childhood behavioral problems, and traumatic injuries, including experiencing violence, did not materially change the findings.

CONCLUSIONS AND RELEVANCE

Out-of-home care placement was associated with a wide range of adverse outcomes in adulthood, which persisted following adjustments for measured preplacement factors and unmeasured familial factors.

On social and psychological consequences of prolonged poverty–A longitudinal narrative study from Finland

By means of qualitative longitudinal material, this article explores meaningfulness during persistent monetary poverty through an integrative framework, which builds upon conceptualisations of meaning in life (coherence, significance, and purpose) and modes of being (labour, work, action). The material consists of 36 autobiographical accounts and their follow-up accounts from 2006 and 2012. The analysis reveals that in the developed welfare state of Finland, prolonged monetary poverty is connected with the propensity for incoherence and a feeling of insignificance, particularly if life is governed by a vicious cycle of scarcity. Prolonged poverty 1) turns aspirations from long-term to short-term goals and frames life as something characterised by negative anticipation and a circular sense of time. Life primarily takes place in private space. It also 2) weakens the sense of belonging and 3) reduces public participation. These are the domains where the meaning in life is constructed, deconstructed, and reconstructed. In a developed welfare state, the comprehensive and manageable social security scheme maintains coherence, yet universal social policy actions that enable participation in public activities nourish a sense of significance.

No causal associations between childhood family income and subsequent psychiatric disorders, substance misuse and violent crime arrests: a nationwide Finnish study of >650 000 individuals and their siblings

BACKGROUND

Childhood family income has been shown to be associated with later psychiatric disorders, substance misuse and violent crime, but the consistency, strength and causal nature of these associations remain unclear.

METHODS

We conducted a nationwide cohort and co-sibling study of 650 680 individuals (426 886 siblings) born in Finland between 1986 and 1996 to re-examine these associations by accounting for unmeasured confounders shared between siblings. The participants were followed up from their 15th birthday until they either migrated, died, met criteria for the outcome of interest or reached the end of the study period (31 December 2017 or 31 December 2018 for substance misuse). The associations were adjusted for sex, birth year and birth order, and expressed as adjusted hazard ratios (aHRs). The outcomes included a diagnosis of a severe mental illness (schizophrenia-spectrum disorders or bipolar disorder), depression and anxiety. Substance misuse (e.g. medication prescription, hospitalization or death due to a substance use disorder or arrest for drug-related crime) and violent crime arrests were also examined. Stratified Cox regression models accounted for unmeasured confounders shared between differentially exposed siblings.

RESULTS

For each $15 000 increase in family income at age 15 years, the risks of the outcomes were reduced by between 9% in severe mental illness (aHR = 0.91; 95% confidence interval: 0.90-0.92) and 23% in violent crime arrests (aHR = 0.77; 0.76-0.78). These associations were fully attenuated in the sibling-comparison models (aHR range: 0.99-1.00). Sensitivity analyses confirmed the latter findings.

CONCLUSIONS

Associations between childhood family income and subsequent risks for psychiatric disorders, substance misuse and violent crime arrest were not consistent with a causal interpretation.

Alcohol Industry Arguments for Liberalizing Alcohol Policy in Finland: Analysis of Twitter Data

OBJECTIVE

The aim of this study was to investigate the arguments used by the alcohol industry and actors aligning with it as a lobbying strategy on Twitter to influence the reform of the Finnish alcohol law during its preparation phase between 2014 and 2017, when the original purpose of the law reform was changed from reducing alcohol-related harm to liberalizing alcohol policy.

METHOD

Primary data were collected on Twitter between 2014 and 2017 from six alcohol industry actors (n = 1,085 tweets). The Twitter data were analyzed by coding using Microsoft Excel and by content and thematic analyses using a modified version of the European Centre for Monitoring Alcohol Marketing's (2011) seven key messages of the alcohol industry.

RESULTS

The findings identified three main arguments used on Twitter by the alcohol industry and actors aligning with it, namely: (1) application of liberal alcohol policies generates more revenue, (2) liberties should be generally prioritized above bureaucracy and control, and (3) education about responsibility is the best solution to alcohol-related problems.

CONCLUSIONS

Social media applications such as Twitter offer the alcohol industry unlimited opportunities for promoting its traditional public relations arguments.

Alcohol industry strategies to influence the reform of the Finnish Alcohol Law

Aim:

The aim of this study was to investigate the strategies used by the alcohol industry to influence the reform of the Alcohol Act in Finland during the preparation phase between 2016 and 2017. The study answers the following research question: what strategies were used by the alcohol industry to change the original purpose of the reform on alcohol in Finland?

Method:

Primary data were collected through 16 expert interviews with experts who had participated in the preparation of the alcohol reform in Finland, while secondary data were collected from prior literature, journal articles and Google databases.

Results:

The results identified three main political strategies used by the alcohol industry to influence the reform of the law on alcohol in Finland during the preparation phase between 2016 and 2017: “information”, under which the alcohol industry lobbied politicians in Parliament through Members of Parliament of the National Coalition Party due to the close ties between the two; “constituency building”, under which the alcohol industry formed alliances with interest groups in the grocery-retail business in Finland, to advocate for liberalisation of the law, as well as the use of social media – specifically Twitter – to lobby the public; and lastly, “policy substitution” to promote self-regulation.

Conclusions:

The results suggest that the involvement of the alcohol industry in political decision-making following Finland’s EU membership has given the industry legitimacy and new opportunities to influence alcohol policy, while limiting policies to protect the public from alcohol-related harms. The results may be useful to alcohol policy-makers.

Determinants of long-term unemployment in early adulthood: A Finnish birth cohort study

Cumulative contributions of social and health-related determinants to long-term unemployment during early working life among young adults are poorly understood. Therefore, we used four cumulative indices of both parental and own social and health-related determinants of such unemployment among a cohort which comprised a complete census of children born in Finland in 1987. The cohort participants were registered in the Medical Birth Register, and they were followed-up through 2015 (N = 46 521). We calculated predicted probabilities for long-term unemployment (> 12 months) when participants were 25–28 years. Moreover, we examined whether the associations differed by unemployment at the municipal level.

During the follow-up, 4.5% of women and 7.1% of men experienced long-term unemployment. All cumulative indices of parental and own social and health-related determinants predicted the probability of long-term unemployment. The greatest probabilities were observed for own social determinants, both in municipalities with high and low unemployment although the probabilities were higher in the high-unemployment municipalities. Of the individual determinants, poor school performance showed the strongest association with long-term unemployment among women (OR 6.65, 95% CI 5.21–8.55) and men (OR 3.70, 95% CI 2.96–4.67), after adjusting for other own social determinants. The results highlight the importance of life course social equality in the prevention of long-term unemployment in early adulthood.

•

Parental and own social and health-related factors predict long-term unemployment.

•

Particularly poor school performance increases the odds for long-term unemployment.

•

With high municipal unemployment rates, effects of social disadvantage are emphasized.

•

Those better off have a lower risk of unemployment even in high unemployment areas.

Pathways from parental mental disorders to offspring's work disability due to depressive or anxiety disorders in early adulthood-The 1987 Finnish Birth Cohort

BACKGROUND

Parental mental disorders have been shown to predict offspring's mental health problems. We examined whether pathways from parental mental disorders to offspring's psychiatric work disability in early adulthood are mediated through offspring's mental disorders and social disadvantage in adolescence.

METHODS

Study population consisted of the 1987 Finnish Birth Cohort. Data on parents' psychiatric care or work disability due to mental diagnosis between 1987 and 2000 and the cohort participants' health and social factors between 2001 and 2005 were derived from administrative national registers. From 2006 through 2015, 52,182 cohort participants were followed for admittance of psychiatric work disability due to depressive or anxiety disorders. First, we applied a pathway analysis to examine the occurrence of each path. We then used mediation analysis to assess the proportion of association between parental mental disorders and work disability mediated by offspring's health and social disadvantage.

RESULTS

The pathway model indicated that the association from parental mental disorders to offspring's work disability due to depressive or anxiety disorder is through mental disorders and social disadvantage in adolescence. Odds Ratio for the total effect of parental mental disorders on offspring's psychiatric work disability was 1.85 (95% confidence interval [CI] 1.46-2.34) in the model including offspring's mental disorders that mediated this association by 35%. Corresponding results were 1.86 (95% CI 1.47-2.35) and 28% for social disadvantage in adolescence.

CONCLUSIONS

These findings suggest that intergenerational determination of work disability due to mental disorders could be addressed by actions supporting mental health and social circumstances in adolescence.

Toimeentulotuen saajien lääkekorvausoikeudet ja lääkkeiden käyttö

Eriarvoisuus terveyspalvelujen laadussa ja saatavuudessa voi vahvistaa sosioekonomisia terveyseroja. Toimeentulotuen saajat sairastavat ja käyttävät julkisia terveyspalveluja muuta saman ikäistä väestöä enemmän. Tutkimuksessa vertailtiin rekisteriaineiston avulla toimeentulotuen saajien (N=37 836) ja ei-toimeentulotuen saajien (N=430 997) lääkekorvausoikeuksia ja lääkkeiden käyttöä Helsingissä vuonna 2010. Menetelminä käytettiin vakiointia ja logistista regressioanalyysia. Kun erot ikä- ja sukupuolirakenteessa, maahanmuuttajataustassa, tulotasossa ja opiskelijoiden osuudessa vakioidaan, toimeentulotuen saajilla on ei-toimeentulotuen saajia useammin lääkekorvausoikeuksia (20 % vs. 15 %) sekä psyykensairauksiin (34 % vs. 14 %), astmaattisiin sairauksiin (11 % vs. 5 %), diabetekseen (6 % vs. 3 %) ja sydän- ja verisuonisairauksiin (21 % vs. 13 %) liittyviä lääkeostoja. Psyykenlääkkeiden käyttö yleistyy toimeentulotuen saantikuukausien määrän kasvaessa, mutta psyyken sairauden vuoksi erityiskorvaukseen oikeutetut saavat toimeentulotukea yleisimmin vain muutaman kuukauden. Psyykenlääkityksen (korvausoikeus tai lääkeosto) ja toimeentulotuen saannin yhteys on samansuuntainen kantaväestöllä ja maahanmuuttajilla (toimeentulotukea 1–3 kuukautta ja 10–12 kuukautta saaneilla ristitulosuhteet (OR) 2,8 [2,7–2,9] ja 5,3 [5,0–5,5] kantaväestöllä; 2,4 [1,9–3,2] ja 7,8 [6,4–9,5] OECD-maista saapuneilla; 2,3 [1,8–3,0] ja 3,6 [2,9–4,3] entisen Neuvostoliiton alueelta saapuneilla; ja 2,0 [1,6–2,6] ja 5,1 [4,4–6,0] muista kuin em. maista saapuneilla, kun vertailuryhmänä ei-toimeentulotuen saajat). Tutkimus vahvistaa käsitystä sairaudesta osana huono-osaisuutta. Terveysongelmien yleisyys on syytä ottaa huomioon toimeentulotuen saajien palveluita suunniteltaessa.

Limited implementation of the framework convention on tobacco control's tobacco tax provision: global comparison

OBJECTIVE

To quantify changes in tobacco tax rates and cigarette affordability after countries ratified the WHO Framework Convention on Tobacco Control (FCTC) using with the WHO MPOWER standards.

METHODS

We used logistic regression to assess the association of FCTC ratification with adoption of at least 50% and 75% (high) of retail price tobacco tax rates for the most sold brands in countries, accounting for years since ratification and other covariates. We also compared cigarette affordability in 2014 with 1999.

RESULTS

By 2014, 44% of high-income countries had taxes above 75% of retail value compared with 18% in 1998/1999. In 15 years, 69 countries increased the tobacco tax rate, 33 decreased it and one had the same tax rate. FCTC ratification was not associated with implementing high tobacco taxes. More fragile countries in terms of security, political, economic and social development were less likely to have at least 50% and 75% tobacco tax rates in 2014 compared with 1999. The higher the cigarette prices in 1999 the less likely the countries were to have at least 75% tobacco tax rates in 2014. However, cigarettes were less affordable in 2014 than in 1999 in countries that had ratified FCTC earlier.

CONCLUSIONS

Despite widespread FCTC ratification, implementing higher tobacco taxes remains incomplete. Guidelines for FCTC Article 6 implementation should assign definite targets for tobacco taxes and for implementation of a tax escalator that gradually increases taxes to match rising income levels. Fragile countries are less likely to have high tobacco taxes and less affordable cigarettes. The tobacco control community should intensify efforts to help fragile countries improve performance in FCTC implementation both through strengthening their administrative and technical capacity and through supporting basic functions of government.

FCTC followed by accelerated implementation of tobacco advertising bans

OBJECTIVES

We sought to evaluate changes in countries' enacting advertising bans after the effect of ratifying the WHO Framework Convention on Tobacco Control (FCTC).

METHODS

We compared adoption of advertising bans on five areas (TV and radio, print media, billboards, point-of-sale, sponsorship) in countries that did versus did not ratify the FCTC, accounting for years since the ratification of the Convention.

RESULTS

On average, passage of complete advertising bans accelerated after FCTC ratification. The development was strongest among lower middle-income countries. Lack of state capacity was associated with lower likelihood of countries implementing complete advertising bans. Implementation of complete advertising bans slowed after 2007.

CONCLUSIONS

Implementation of FCTC Article 13 was followed by increased progress towards complete advertising bans, but progress is incomplete, especially among low-income countries. Low-income countries need comprehensive support to implement FCTC as part of a broad effort to reinvigorate progress on global implementation of the FCTC. Enforcing complete bans requires constant monitoring and attacking of tobacco industry efforts to circumvent them.

Accelerated Adoption of Smoke-Free Laws After Ratification of the World Health Organization Framework Convention on Tobacco Control

OBJECTIVES

We sought to evaluate the effect of ratifying the World Health Organization Framework Convention on Tobacco Control (FCTC) on countries enacting smoke-free laws covering indoor workplaces, restaurants, and bars.

METHODS

We compared adoption of smoke-free indoor workplace, restaurant, and bar laws in countries that did versus did not ratify the FCTC, accounting for years since the ratification of the FCTC and for countries' World Bank income group.

RESULTS

Ratification of the FCTC significantly (P < .001) increased the probability of smoke-free laws. This effect faded with time, with a half-life of 3.1 years for indoor workplaces and 3.8 years for restaurants and bars. Compared with high-income countries, upper-middle-income countries had a significantly higher probability of smoke-free indoor workplace laws.

CONCLUSIONS

The FCTC accelerated the adoption of smoke-free indoor workplace, restaurant, and bar laws, with the greatest effect in the years immediately following ratification. The policy implication is that health advocates must increase efforts to secure implementation of FCTC smoke-free provisions in countries that have not done so.

Old wine in new bottles: tobacco industry's submission to European Commission tobacco product directive public consultation

Between September and December 2010 the European Commission Health & Consumer Protection Directorate-General (DGSANCO) held a public consultation on a possible revision of the European Union Tobacco Products Directive (2001/37/EC). We used content analysis of the tobacco industry's and related parties' 300 submissions to the public consultation to determine if tobacco industry and its allies in Europe are prepared to reduce harm of the tobacco products as their public statements assert. The industry submission resorted to traditional tobacco industry arguments where illicit trade and freedom of choice were emphasized and misrepresented the conclusions of a DGSANCO-commissioned scientific report on smokeless tobacco products. Retailers and wholesalers referred to employment and economic growth more often than respondents from other categories. The pattern of responses in the submission differed dramatically from independent public opinion polls of EU citizens' support for tobacco control policies. None of the major tobacco manufacturers or their lobbying organizations supported any of the DGSANCO's proposed evidence based interventions (pictorial health warnings, plain packaging or point-of-sale display bans) to reduce harms caused by cigarette smoking.

Implementation of effective cigarette health warning labels among low and middle income countries: state capacity, path-dependency and tobacco industry activity

We investigates the effects of ratifying the WHO Framework Convention of Tobacco Control (FTCT), state capacity, path-dependency and tobacco industry activity on the implementation of effective health warning labels (HWL) on cigarette packs among low and middle income countries (LMIC). Using logistic regression in separate analyses for FCTC Article 11 compliant HWLs and graphic HWLs (GHWL), we found that the odds of FCTC compliance increased by a factor of 1.31 for each year after FCTC entered into force in the country (p < 0.01). The odds of passing GHWLs increased by a factor of 1.46 (p < 0.05) per year after FCTC entered into force. The weaker the capacity of the states were, the less likely they were to have implemented FCTC compliant HWLs (p < 0.05). The countries with voluntary HWLs in 1992 were less likely (OR = 0.19, p < 0.01) to comply with FCTC 21 years later (in 2013). The FCTC has promoted HWL policies among LMICs. Public health regulations require investments in broader state capacity. As the theory of path-dependency predicts voluntary agreements have long lasting influence on the direction of tobacco control in a country. Adopting voluntary HWL policies reduced likelihood of having FCTC compliant HWLs decades later. The fact that voluntary agreements delayed effective tobacco regulations suggests that policymakers must be careful of accepting industry efforts for voluntary agreements in other areas of public health as well, such as alcohol and junk food.

Waiting for the opportune moment: the tobacco industry and marijuana legalization

CONTEXT

In 2012, Washington State and Colorado legalized the recreational use of marijuana, and Uruguay, beginning in 2014, will become the first country to legalize the sale and distribution of marijuana. The challenge facing policymakers and public health advocates is reducing the harms of an ineffective, costly, and discriminatory "war on drugs" while preventing another public health catastrophe similar to tobacco use, which kills 6 million people worldwide each year.

METHODS

Between May and December 2013, using the standard snowball research technique, we searched the Legacy Tobacco Documents Library of previously secret tobacco industry documents (http://legacy.library.ucsf.edu).

FINDINGS

Since at least the 1970s, tobacco companies have been interested in marijuana and marijuana legalization as both a potential and a rival product. As public opinion shifted and governments began relaxing laws pertaining to marijuana criminalization, the tobacco companies modified their corporate planning strategies to prepare for future consumer demand.

CONCLUSIONS

Policymakers and public health advocates must be aware that the tobacco industry or comparable multinational organizations (eg, food and beverage industries) are prepared to enter the marijuana market with the intention of increasing its already widespread use. In order to prevent domination of the market by companies seeking to maximize market size and profits, policymakers should learn from their successes and failures in regulating tobacco.

Implementation of graphic health warning labels on tobacco products in India: the interplay between the cigarette and the bidi industries

OBJECTIVES

To understand the competition between and among tobacco companies and health groups that led to graphical health warning labels (GHWL) on all tobacco products in India.

METHODS

Analysis of internal tobacco industry documents in the Legacy Tobacco Document Library, documents obtained through India's Right to Information Act, and news reports.

RESULTS

Implementation of GHWLs in India reflects a complex interplay between the government and the cigarette and bidi industries, who have shared as well as conflicting interests. Joint lobbying by national-level tobacco companies (that are foreign subsidiaries of multinationals) and local producers of other forms of tobacco blocked GHWLs for decades and delayed the implementation of effective GHWLs after they were mandated in 2007. Tobacco control activists used public interest lawsuits and the Right to Information Act to win government implementation of GHWLs on cigarette, bidi and smokeless tobacco packs in May 2009 and rotating GHWLs in December 2011.

CONCLUSIONS

GHWLs in India illustrate how the presence of bidis and cigarettes in the same market creates a complex regulatory environment. The government imposing tobacco control on multinational cigarette companies led to the enforcement of regulation on local forms of tobacco. As other developing countries with high rates of alternate forms of tobacco use establish and enforce GHWL laws, the tobacco control advocacy community can use pressure on the multinational cigarette industry as an indirect tool to force implementation of regulations on other forms of tobacco.

Health effects of indebtedness: a systematic review

Background

In the aftermath of the global financial crisis, millions of households have been left with debts that they are unable to manage. Indebtedness may impair the wellbeing of those affected by it for years to come. This systematic review focuses on the long-term consequences of indebtedness on health.

Methods

The method used in the paper is a systematic review. First, bibliographic databases were searched for peer-reviewed articles. Second, the references and citations of the included articles were searched for additional articles.

Results

The results from our sample of 33 peer-reviewed studies demonstrate serious health effects related to indebtedness. Individuals with unmet loan payments had suicidal ideation and suffered from depression more often than those without such financial problems. Unpaid financial obligations were also related to poorer subjective health and health-related behaviour. Debt counselling and other programmes to mitigate debt-related stress are needed to alleviate the adverse effects of indebtedness on health.

Conclusions

The results demonstrate that indebtedness has serious effects on health.

Is income inequality 'toxic for mental health'? An ecological study on municipal level risk factors for depression

Most inequality research on the relationship between inequality and mental health has focused on cross-country variation. Findings from within-country data are mixed. We examined whether changes in municipal Gini index or in the share of people living in relative poverty were linked to changes in the use of antidepressants in several Finnish municipalities between 1995 and 2010. We found that more young adult females used antidepressants in municipalities where relative poverty had increased. Changes in municipal-level Gini index were not positively associated with changes in the use of antidepressants in the municipalities between 1995 and 2010. However, fewer elderly females used antidepressants in municipalities where the Gini index increased. In addition, more young adults used antidepressants in municipalities where the number of those not being educated or trained had also increased. An increase in the number of persons over 65 years of age living alone was positively associated with an increase in the use of antidepressants among elderly females.

The evolution of health warning labels on cigarette packs: the role of precedents, and tobacco industry strategies to block diffusion

OBJECTIVE

To analyse the evolution and diffusion of health warnings on cigarette packs around the world, including tobacco industry attempts to block this diffusion.

METHODS

We analysed tobacco industry documents and public sources to construct a database on the global evolution and diffusion of health warning labels from 1966 to 2012, and also analysed industry strategies.

RESULTS

Health warning labels, especially labels with graphic elements, threaten the tobacco industry because they are a low-cost, effective measure to reduce smoking. Multinational tobacco companies did not object to voluntary innocuous warnings with ambiguous health messages, in part because they saw them as offering protection from lawsuits and local packaging regulations. The companies worked systematically at the international level to block or weaken warnings once stronger more specific warnings began to appear in the 1970s. Since 1985 in Iceland, the tobacco industry has been aware of the effectiveness of graphic health warning labels (GWHL). The industry launched an all-out attack in the early 1990s to prevent GHWLs, and was successful in delaying GHWLs internationally for nearly 10 years.

CONCLUSIONS

Beginning in 2005, as a result of the World Health Organisation Framework Convention on Tobacco Control (FCTC), GHWLs began to spread. Effective implementation of FCTC labelling provisions has stimulated diffusion of strong health warning labels despite industry opposition.

Effect of the Framework Convention on Tobacco Control and voluntary industry health warning labels on passage of mandated cigarette warning labels from 1965 to 2012: transition probability and event history analyses

OBJECTIVES

We quantified the pattern and passage rate of cigarette package health warning labels (HWLs), including the effect of the Framework Convention on Tobacco Control (FCTC) and HWLs voluntarily implemented by tobacco companies.

METHODS

We used transition probability matrices to describe the pattern of HWL passage and change rate in 4 periods. We used event history analysis to estimate the effect of the FCTC on adoption and to compare that effect between countries with voluntary and mandatory HWLs.

RESULTS

The number of HWLs passed during each period accelerated, from a transition rate among countries that changed from 2.42 per year in 1965-1977 to 6.71 in 1977-1984, 8.42 in 1984-2003, and 22.33 in 2003-2012. The FCTC significantly accelerated passage of FCTC-compliant HWLs for countries with initially mandatory policies with a hazard of 1.27 per year (95% confidence interval = 1.11, 1.45), but only marginally increased the hazard for countries that had an industry voluntary HWL of 1.68 per year (95% confidence interval = 0.95, 2.97).

CONCLUSIONS

Passage of HWLs is accelerating, and the FCTC is associated with further acceleration. Industry voluntary HWLs slowed mandated HWLs.

Cross-temporal and cross-national poverty and mortality rates among developed countries

A prime objective of welfare state activities is to take action to enhance population health and to decrease mortality risks. For several centuries, poverty has been seen as a key social risk factor in these respects. Consequently, the fight against poverty has historically been at the forefront of public health and social policy. The relationship between relative poverty rates and population health indicators is less self-evident, notwithstanding the obvious similarity to the debated topic of the relationship between population health and income inequality. In this study we undertake a comparative analysis of the relationship between relative poverty and mortality across 26 countries over time, with pooled cross-sectional time series analysis. We utilize data from the Luxembourg Income Study to construct age-specific poverty rates across countries and time covering the period from around 1980 to 2005, merged with data on age- and gender-specific mortality data from the Human Mortality Database. Our results suggest not only an impact of relative poverty but also clear differences by welfare regime that partly goes beyond the well-known differences in poverty rates between welfare regimes.

Local Nordic tobacco interests collaborated with multinational companies to maintain a united front and undermine tobacco control policies

OBJECTIVE

To analyse how local tobacco companies in the Nordic countries, individually and through National Manufacturers' Associations, cooperated with British American Tobacco and Philip Morris in denying the health hazards of smoking and undermining tobacco control.

METHODS

Analysis of tobacco control policies in the Nordic countries and tobacco industry documents.

RESULTS

Nordic countries were early adopters of tobacco control policies. The multinational tobacco companies recognised this fact and mobilised to oppose these policies, in part because of fear that they would set unfavourable precedents. Since at least 1972, the Nordic tobacco companies were well informed about and willing to participate in the multinational companies activities to obscure the health dangers of smoking and secondhand smoke and to oppose tobacco control policies. Cooperation between multinational companies, Nordic national manufacturer associations and local companies ensured a united front on smoking and health issues in the Nordic area that was consistent with the positions that the multinational companies were taking. This cooperation delayed smoke-free laws and undermined other tobacco control measures.

CONCLUSIONS

Local tobacco companies worked with multinational companies to undermine tobacco control in distant and small Nordic markets because of concern that pioneering policies initiated in Nordic countries would spread to bigger market areas. Claims by the local Nordic companies that they were not actively involved with the multinationals are not supported by the facts. These results also demonstrate that the industry appreciates the global importance of both positive and negative public health precedents in tobacco control.

The Philip Morris Nordic journalist program: strategies, implementation and outcomes

OBJECTIVES

To describe media strategies for the Nordic countries outlined in internal Philip Morris documents and to evaluate their implementation and outcomes.

METHODS

Systematic search of internal tobacco industry documents from the databases available on the Internet and retrieval of newspaper and magazine articles from Sweden and Finland.

RESULTS

The Philip Morris Nordic journalist program contained a broad range of strategies to communicate company views and to counteract negative publicity, including trips for journalists, media briefings and special events. While several of these strategies were implemented, the efforts were largely unsuccessful in that the media in Sweden and Finland carried few tobacco industry friendly articles. Articles defending the tobacco industry appeared mainly in business papers. However, support of smokers' rights' groups and sponsoring of cultural events generated positive publicity for Philip Morris.

CONCLUSIONS

Despite minor transient victories The Philip Morris Nordic journalist program was largely unsuccessful in providing the anticipated media coverage to question the health hazards of environmental tobacco smoke (ETS) and in preventing ETS regulation in the Nordic countries. The study further supports the notion that the internal corporate documents may expose the intents of the industry, but do not include enough information to evaluate implementation of industry's strategies or their outcomes.

Tobacco industry documents from outside sources: new perspectives on industry strategies on local levels

The internal tobacco industry documents have also been used to study tobacco industry operations outside the United States. The scope of the documents on a country outside the US is decided mainly by the extent to which documents and reports were transmitted from the abroad offices of the US tobacco companies to headquarters. We explored whether the material from a private archive of a Finnish public relation consultant to Philip Morris will augment or revise the earlier reports on tobacco industry manipulation in Finland. The private records add more details to previously published reports. The new information mainly concerned implementation of the tobacco industry strategies. A general conclusion is that tobacco industry documents may not give a detailed picture of tobacco industry activities in distant markets, which would be of interest locally, even if they provide sufficient information to convey a general view of tobacco industry strategies.

Tobacco industry strategy to undermine tobacco control in Finland

OBJECTIVE

To identify and explain tobacco industry strategy in undermining tobacco control measures in Finland and results of these interferences in tobacco policy development during the 1980s and early 1990s.

METHODS

Tobacco industry documents, which have been publicly available on the internet as a result of litigation in the USA, were analysed. Documents were sought by Finland and by names of organisations and tobacco control activists. Documents were accessed and assessed between September 2000 and November 2002. Tactics of the tobacco industry activities were categorised as presented by Saloojee and Dagli.

RESULTS

The international tobacco companies utilised similar strategies in Finland as in other industrial markets to fight tobacco control and legislation, the health advocacy movement, and litigation. These activities slowed down the development and implementation of the Tobacco Act in Finland. However, despite the extensive pressure, the industry was not able to prevent the most progressive tobacco legislation in Europe from being passed and coming into force in Finland in 1977 and in 1995.

CONCLUSION

Denying the health hazards caused by tobacco-despite indisputable scientific evidence-decreased the credibility of the tobacco industry. Strategy of denial was falsely chosen, as health advocacy groups were active both in society and the parliamentary system. The strong influence of the tobacco industry may have in fact increased the visibility of tobacco control in Finland as the litigation process was also drawing attention to negative health effects of tobacco. Therefore the tobacco industry did not manage to convince public opinion. However, the tobacco industry did obtain experience in Finland in how to object to tobacco control measures.