Classifying the comprehensiveness of flavoured tobacco sales restrictions: development and application of a tool to examine US state and local tobacco policies

ObjectivesComprehensive tobacco control policies with minimal exemptions can reduce tobacco use and sales. Many states and localities have adopted flavoured tobacco product (FTP) sales restrictions. This study describes the development and application of a schema to characterise the comprehensiveness of these FTP sales restrictions.DesignWe coded state and local FTP sales restrictions enacted June 2007–March 2021 for retailer, tobacco product, and flavour inclusions and exemptions. Guided by FTP literature, legal resources and meetings with FTP policy experts, we developed a six-level classification scheme to characterise coded FTP policies from least to most comprehensive. We present descriptive statistics of FTP policy features and comprehensiveness.ResultsAs of 31 March 2021, 7 state-level and 327 local-level FTP sales restrictions were enacted in the USA. Most state-level policies (71.4%) were categorised in the second lowest comprehensiveness category; local policies most commonly fell within the lowest (48.9%) or highest (26.0%) comprehensiveness categories. Across jurisdictions, adult-only retailers were most frequently exempted from the FTP sales restrictions (state: n=1, 14.3%; local: n=184, 56.3%); and most jurisdictions included electronic cigarettes (e-cigarettes) as a banned product (state: n=6, 87.5%; local: n=227, 100%). While just over half of state (n=4, 57.1%) and local (n=169, 51.7%) sales restrictions included menthol e-cigarettes, most excluded menthol cigarettes and/or menthol smokeless tobacco.ConclusionsComprehensiveness of FTP sales restrictions in the USA varies widely. Current and future FTP policies would be strengthened by including all flavours and all tobacco products—particularly menthol cigarettes—and by avoiding exemptions for certain retailers, particularly adult-only retailers.

Tobacco control policies and smoking cessation treatment utilization: A moderated mediation analysis

Background Tobacco policies, including clean indoor air laws and cigarette taxes, increase smoking cessation in part by stimulating the use of cessation treatments. We explored whether the associations between tobacco policies and treatment use varies across sociodemographic groups. Methods We used data from 62,165 U.S. adult participants in the 2003 and 2010/11 Tobacco Use Supplement to the Current Population Survey (TUS-CPS) who reported smoking cigarettes during the past-year. We built on prior structural equation models used to quantify the degree to which smoking cessation treatment use (prescription medications, nicotine replacement therapy, counseling/support groups, quitlines, and internet resources) mediated the association between clean indoor air laws, cigarette excise taxes, and recent smoking cessation. In the current study, we added selected moderators to each model to investigate whether associations between tobacco polices and smoking cessation treatment use varied by sex, race/ethnicity, education, income, and health insurance status. Results Associations between clean indoor air laws and the use of prescription medication and nicotine replacement therapies varied significantly between racial/ethnic, age, and education groups in 2003. However, none of these moderation effects remained significant in 2010/11. Higher cigarette excise taxes in 2010/2011 were associated with higher odds of using counseling among older adults and higher odds of using prescription medications among younger adults. No other moderator reached statistical significance. Smoking cessation treatments did not mediate the effect of taxes on smoking cessation in 2003 and were not included in these analyses. Conclusions Sociodemographic differences in associations between clean indoor air laws and smoking cessation treatment use have decreased from 2003 to 2010/11. In most cases, policies appear to stimulate smoking cessation treatment use similarly across varied sociodemographic groups.

Return on investment of Canadian tobacco control policies implemented between 2001 and 2016

ObjectivesTo determine the return on investment (ROI) associated with tobacco control policies implemented between 2001 and 2016 in Canada.MethodsCanadian expenditures on tobacco policies were collected from government sources. The economic benefits considered in our analyses (decrease in healthcare costs, productivity costs and monetised life years lost, as well as tax revenues) were based on the changes in smoking prevalence and attributable deaths derived from the SimSmoke simulation model for the period 2001–2016. The net economic benefit (monetised benefits minus expenditures) and ROI associated with these policies were determined from the government and societal perspectives. Sensitivity analyses were conducted to check the robustness of the result. Costs were expressed in 2019 Canadian dollars.ResultsThe total of provincial and federal expenditures associated with the implementation of tobacco control policies in Canada from 2001 through 2016 was estimated at $2.4 billion. Total economic benefits from these policies during that time were calculated at $49.2 billion from the government perspective and at $54.2 billion from the societal perspective. The corresponding ROIs were $19.8 and $21.9 for every dollar invested. Sensitivity analyses yielded ROI values ranging from $16.3 to $28.3 for every dollar invested depending on the analyses and perspective.ConclusionsThis analysis has found that the costs to implement the Canadian tobacco policies between 2001 and 2016 were far outweighed by the monetised value associated with the benefits of these policies, making a powerful case for the investment in tobacco control policies.

Pre-implementation Assessment of Tobacco Cessation Interventions in Substance Use Disorder Residential Programs in California

Background: Across the United States, substance use disorder (SUD) treatment programs vary in terms of their tobacco-related policies and cessation services offered to clients. Guided by the Consolidated Framework for Implementation Research (CFIR), the current study identified key factors that may influence the implementation of tobacco related cessation policies and services in residential SUD programs. Methods: We conducted semi-structured qualitative interviews with sixteen residential treatment program directors in California. The analysis was guided by a deductive approach using CFIR domains and constructs to develop codes and identify themes. ATLAS.ti software was used to facilitate thematic analysis of interview transcripts.Findings: Guided by the CFIR constructs, themes that arose as facilitators for implementation included the relative advantage of the intervention compared with current practice, external policies/incentives to support tobacco related policy, program directors strong commitment and high self-efficacy to incorporate cessation into SUD treatment, and recognizing the importance of planning and engaging opinion leaders. Potential barriers included the SUD recovery culture, low stakeholder engagement, organizational culture, lack of workforce expertise and, lack of reimbursement for smoking cessation services.Conclusion: The CFIR provided a valuable framework for evaluating factors that may influence implementation of tobacco policies and services in SUD treatment. In order to support successful implementation, residential SUD programs (staff and clients) require extensive education on the effectiveness of tobacco cessation efforts on health outcomes and publicly funded SUD treatment programs should receive support through expanded reimbursement for tobacco cessation services.

Pre-Implementation Assessment of Tobacco Cessation Interventions in Substance Use Disorder Residential Programs in California

Background: Across the United States, substance use disorder (SUD) treatment programs vary in terms of their tobacco-related policies and cessation services offered to clients. Guided by the Consolidated Framework for Implementation Research (CFIR), the current study identified key factors that may influence the implementation of tobacco related cessation policies and services in residential SUD programs. Methods: We conducted semi-structured qualitative interviews with sixteen residential treatment program directors in California. The analysis was guided by a deductive approach using CFIR domains and constructs to develop codes and identify themes. ATLAS.ti software was used to facilitate thematic analysis of interview transcripts. Findings: Guided by the CFIR constructs, themes that arose as facilitators for implementation included the relative advantage of the intervention compared with current practice, external policies/incentives to support tobacco related policy, program directors strong commitment and high self-efficacy to incorporate cessation into SUD treatment, and recognizing the importance of planning and engaging opinion leaders. Potential barriers included the SUD reovery culture, low stakeholder enagement, organizational culture, lack of workforce expertise and, lack of reimbursement for smoking cessation services.Conclusion: The CFIR provided a valuable framework for evaluating factors that may influence implementation of tobacco policies and services in SUD treatment. In order to support successful implementation, residential SUD programs (staff and clients) require extensive education on the effectiveness of tobacco cessation efforts on health outcomes and publicly funded SUD treatment programs should receive support through expanded reimbursement for tobacco cessation services.

A qualitative study to assess perceptions, barriers, and motivators supporting smokeless tobacco cessation in the US fire service

While firefighters currently have low smoking rates, rates of smokeless tobacco (SLT) use among this population are remarkably high and substantially greater than similar occupational groups, and the general population. This study explored determinants associated with SLT use, barriers to cessation, and motivators for SLT cessation in the fire service. Key informant interviews were conducted in 23 career firefighters who were current (n = 14) and former (n = 9) SLT users from across the U.S. Discussions were recorded and independently coded according to questions and themes. Major themes that developed among firefighters regarding SLT use determinants included positive perceptions of SLT products, social influences from their peers and family members, acceptability of SLT use in the fire service, and a coping resource for job stress. Firefighters discussed several barriers to SLT cessation, including intrapersonal barriers such as SLT use habits and its dependency, concerns about withdrawal symptoms; and social-environmental barriers including lack of support from health and other services providers, and lack of enforcement of existing tobacco policies regarding SLT use. Firefighters also mentioned both internal and external motivators for cessation. Internal motivators included self-motivation and their health concerns while external motivators included friends and family support, incentives or rewards, and price of SLT products. Findings provide unique perspectives from firefighters on factors that influence SLT use and barriers and motivators to SLT cessation. These are insufficiently assessed and considered by the fire service organizations and their health care providers. Thus, the organizations must understand these issues in order to mitigate barriers and motivate the personnel to quit using SLT. Information gained from firefighters who were current and former SLT users can be used to develop an effective, culturally-tailored intervention that is acceptable to fire service personnel.

Adolescent Use and Perceptions of JUUL and Other Pod-Style e-Cigarettes: A Qualitative Study to Inform Prevention

JUUL, a discrete pod-style e-cigarette, popular among adolescents, delivers high levels of nicotine. Limited research has assessed social and environmental influences that contribute to use of JUUL and other pod-style devices. We examined how these factors, as well as individual characteristics, shape adolescent use. Twenty-nine middle and high school students participated in six focus groups in June 2019 (58.6% female, 65.5% White, 27.6% Hispanic). Groups were stratified by e-cigarette use status and grade to understand perceptions and experiences among groups. Transcripts were coded using thematic analysis for individual, social, and environmental factors contributing to use. Users (n = 13) described their first experience with JUUL as mostly negative, mentioning reactions such as burning in the throat, coughing, wheezing, and headaches. Despite a negative first experience, stress relief and addiction were mentioned as reasons for continued use. Users and non-users identified vaping as a source of disruption to their daily life. Social factors included peer and parental influences, lack of support for quitting, and accessibility. Environmental factors included contrasting messages about long- and short-term health effects of e-cigarettes, as well as a lack of school vaping policy enforcement, health education, medical screenings, and cessation resources. Findings highlight the complex social system that influences adolescent e-cigarette use and have important implications for school and community responses. Strategies to prevent or reduce use may include reviewing existing school tobacco policies, providing counseling and cessation resources, training staff, and increasing knowledge through public education campaigns.

Are Danish vocational schools ready to implement “smoke-free school hours”? A qualitative study informed by the theory of organizational readiness for change

Background The smoking prevalence is high among students enrolled in vocational education and training, which is considered a lower level of education. The school tobacco policy regarding smoke-free school hours stipulates that students and staff are not allowed to smoke during school hours—inside or outside school premises—and it might be an effective intervention for reducing smoking in vocational schools. For school tobacco policies to be effective, they must be appropriately implemented. A primary predictor for successful implementation is organizational readiness for change. This study seeks to identify and understand the barriers to and facilitators for developing organizational readiness to implement smoke-free school hours in Danish vocational schools. Methods Semi-structured interviews and focus groups were carried out with managers and teachers (n = 22 participants) from six vocational schools. The interview guides were informed by “A theory of organizational readiness for change” developed by Weiner, which was also used as a framework to analyze the data. Results We identified 13 facilitators and barriers. Nine factors acted as facilitators, including the following: believing that health promotion is a school role and duty; believing that society and workplaces are becoming more smoke-free, and believing that smoke-free school hours is a beneficial strategy to achieve fewer educational interruptions. Additional facilitators include establishing clear rules for sanctioning and enforcement, developing a joint understanding about smoke-free school hours, developing skills to deal with student responses to smoke-free school hours, establishing social alternatives to smoking, offering smoking cessation help, and mandating smoke-free school hours by law. Four organizational norms, practices, or discourses acted as barriers: believing that smoke-free school hours violate personal freedom, believing that students have more important problems than smoking, believing that it is difficult to administer the level of enforcement, and believing that the enforcement of smoke-free school hours negatively influences student-teacher relations. Discussion Our results suggest that developing organizational readiness before adopting a comprehensive tobacco policy such as smoke-free school hours is important for successful implementation. Further research should investigate how to strengthen the facilitators for and counter the barriers to developing readiness for implementing smoke-free school hours.

Association of alcohol and tobacco with changes in overall cancer mortality

Alcohol use clearly raises the risk of cancer many times more than drinking or smoking alone. Alcohol may also limit how cells can repair damage to their DNA caused by the chemicals in tobacco. However, exactly how alcohol affects cancer risk isn’t completely understood. In fact, there are likely several different ways it can raise risk, and this might depend on the type of cancer. Total cancer mortality data from the 1990s to 2018 were collected from the Bialystok, Poland of Statistics and Cancer Council, the WHO Cancer Mortality Database. The policies with significant relations to changes in alcohol and tobacco consumption were identified in an initial model. Intervention dummies with estimated lags were then developed based on these key alcohol and tobacco policies and events and inserted into time-series models to estimate the relation of the particular policy changes with cancer mortality. The aim of this study is to examine the effectiveness of smoking and alcohol cancer outcomes.

Do Regulations on Smoking Limit Cigarette Demand? An Empirical Evidence from Pakistan

Enacting Ordinance No LXXIV 2002, Pakistan has developed crucial anti-tobacco policies in the last two decades. We, therefore, examine in this paper effects of both price (cigarette taxation) and non-price (public regulations on cigarette smoking) anti-tobacco policies on cigarette demand. To accomplish this objective, we examine the short and long run dynamics of cigarette demand in Pakistan using auto-regressive distributed lag (ARDL) estimator covering the period 1981-2018 (annual observations). The study compares price elasticity estimated with and without regulations on cigarette smoking. The result obtained shows that when price increases by 10%, cigarette consumption decreases by 5% in the short run while it decreases by 6.9% in the long run. This finding confirms that cigarette demand model, in Pakistan, is in-elastic. More interestingly, the study finds that non-price regulations on smoking and cigarette demand have negative and statistically significant association. This finding confirms that non-price regulations influences the long-term dynamics of cigarette smoking in Pakistan. Furthermore, we obtain low price elasticity with non-price regulations and high price elasticity without non-price regulations while estimating cigarette demand equation. This empirical result is an evident of the fact that estimated cigarette price elasticity without incorporating non-price regulations into the demand model, are upward biased. The study therefore, concludes that smoking regulation policy based on overstated cigarette price elasticity would produce ambiguous outcomes. Hence, relying only on cigarette taxation (price policy) to regulate cigarette smoking would not produce desirable outcome. In addition, university education is positively and significantly associated with cigarette consumption. This finding show that our university education do not properly convey anti-smoking message to students. To reduce cigarette smoking, Pakistan will have to implement stronger, more comprehensive and better enforced non-price regulations along with taxes on cigarettes.