Prospective cohort study of exposure to tobacco imagery in popular films and smoking uptake among children in southern India

Background Exposure to tobacco imagery in films causes young people to start smoking. Popular Indian films contain high levels of tobacco imagery, but those that do are required by law to display onscreen health warnings when smoking imagery occurs and to include other health promotion messaging before and during the film. We report a prospective cohort study of incident smoking in relation to exposure to film tobacco imagery and anti-tobacco messaging in a cohort of children in southern India. Methods We carried out a one-year longitudinal follow up questionnaire survey in 2018 of a cohort of 39,282 students in grades 6, 7 and 8 (aged between 10 and 15 years) in schools in the Udupi district of Karnataka State in India who participated in a 2017 cross-sectional study of exposure to smoking in films and ever smoking status. Results We obtained usable linked data in 2018 from 33,725 of the 39,282 (86%) participants with data from 2017. Incident smoking was reported by 382 (1.1%) participants. After adjusting for age, sex and common confounders significantly associated with incident smoking there was no significant independent effect of exposure to film smoking, either as a binary (Odds Ratio 1.6, 95% Confidence Interval (CI) 0.5 to 4.9) or as a graded variable, on smoking uptake. An exploratory analysis indicated that the presence of on-screen health warnings that complied fully with Indian law was associated with a significantly lower odds of smoking uptake (Odds Ratio 0.8 (0.6 to 1.0, p = 0.031) relative to the same exposure sustained in absence of compliant warnings. Conclusion Exposure to tobacco imagery in Indian films was not associated with a significantly increased risk of incident smoking in South Indian children. While it is possible that this finding is a false negative, it is also possible that the effect of film exposure has been attenuated by the presence of on-screen health warnings or other Indian tobacco-free film rules. Our findings therefore support the wider implementation of similar tobacco-free film measures in other countries.

E-cigarette use and combustible tobacco cigarette smoking uptake among non-smokers, including relapse in former smokers: umbrella review, systematic review and meta-analysis

ObjectiveTo review and summarise the current evidence on the uptake of combustible cigarette smoking following e-cigarette use in non-smokers—including never-smokers, people not currently smoking and past smokers—through an umbrella review, systematic review and meta-analysis.DesignUmbrella review, systematic review and meta-analysis.Data sourcesPubMed, Scopus, Web of Science, PsychINFO (Ovid), Medline (Ovid) and Wiley Cochrane Library up to April 2020.ResultsOf 6225 results, 25 studies of non-smokers—never, not current and former smokers—with a baseline measure of e-cigarette use and an outcome measure of combustible smoking uptake were included. All 25 studies found increased risk of smoking uptake with e-cigarette exposure, although magnitude varied substantially. Using a random-effects model, comparing e-cigarette users versus non-e-cigarette users, among never-smokers at baseline the OR for smoking initiation was 3.25 (95% CI 2.61 to 4.05, I2 85.7%) and among non-smokers at baseline the OR for current smoking was 2.87 (95% CI 1.97 to 4.19, I2 90.1%). Among former smokers, smoking relapse was higher in e-cigarette users versus non-users (OR=2.40, 95% CI 1.50 to 3.83, I2 12.3%).ConclusionsAcross multiple settings, non-smokers who use e-cigarettes are consistently more likely than those avoiding e-cigarettes to initiate combustible cigarette smoking and become current smokers. The magnitude of this risk varied, with an average of around three times the odds. Former smokers using e-cigarettes have over twice the odds of relapse as non-e-cigarettes users. This study is the first to our knowledge to review and pool data on the latter topic.PROSPERO registration numberCRD42020168596.

E-cigarette use and combustible tobacco cigarette smoking uptake among non-smokers, including relapse in former smokers: umbrella review, systematic review and meta-analysis

Introduction: Combustible tobacco smoking is a leading cause of death and disability worldwide. E-cigarettes are promoted for smoking cessation, but evidence on how their use relates to smoking uptake is limited. Methods: We searched PubMed, Scopus, Web of Science, PsychINFO (Ovid), Medline (Ovid) and Wiley Cochrane Library in April 2020. Studies of non-smokers - never, not current, and former smokers - with a baseline measure of e-cigarette use and an outcome measure of combustible smoking uptake were included. Results: Of 6,225 studies identified, 3 systematic reviews (incorporating 13 primary research studies) and 12 additional studies were included in umbrella and top-up systematic reviews, respectively. All 25 studies found increased risk of smoking uptake with e-cigarette exposure, although magnitude varied substantially. Using a random-effects model, comparing e-cigarette users versus non-e-cigarette users, among never-smokers at baseline the odds ratio (OR) for smoking initiation was 3.25 (95%CI 2.61-4.05, I2 85.7%) and among non-smokers at baseline the OR for current smoking was 2.87 (95%CI 1.97-4.19, I2 90.1%). Among former smokers, smoking relapse was higher in e-cigarette users versus non-users (OR=2.40, 95% CI 1.50-3.83, I2 12.3%). Conclusions: Across multiple settings, non-smokers who use e-cigarettes are consistently more likely than non-e-cigarettes users to initiate combustible cigarette smoking and become current smokers; risk magnitude varied, with an average of around three times the odds. Former smokers using e-cigarettes have over twice the odds of relapse as non-e-cigarettes users. This study is the first to our knowledge to review and pool data on the latter topic.

Tobacco and tobacco branding in films most popular in the UK from 2009 to 2017

BackgroundExposure to tobacco content in films is a cause of smoking uptake in young people. In an earlier study, we reported that tobacco content occurred in 70% of UK box office films popular between 1989 and 2008. We now report an analysis of tobacco content in a sample of the top grossing UK box office films between 2009 and 2017, and of population exposure resulting from audience exposure to the 2017 films.MethodsOccurrence of tobacco intervals (actual tobacco use, implied use, appearance of smoking paraphernalia or branding) was measured by 5 min interval coding in the 15 most commercially successful films in the UK in each year from 2009 to 2017. A nationally representative survey was used to estimate population exposure to the top 15 films from 2017.ResultsWe coded 3248 intervals from the 135 films. Tobacco content appeared in 245 intervals (8%, 95% CI 7% to 9%) across 56 (41%, 95% CI 33% to 49%) films. Tobacco content occurred in films in all BBFC age ratings, and 36 (64%, 95% CI 51% to 77%) of films containing tobacco imagery were classified as suitable for viewing by people aged under 15 years. Although less prevalent than in our earlier study, there was no evidence of a secular decline in tobacco content during this study period. The top 15 films from 2017 delivered approximately 21.6 (95% CI 21.06–22.14) million tobacco impressions to young people aged 10–18 years in the UK.ConclusionsTobacco content continues to appear in UK Box Office films and is widely seen by young people, representing a major driver of smoking uptake.

Exposure to tobacco imagery in popular films and the risk of ever smoking among children in southern India

BackgroundExposure to smoking in films is a recognised cause of smoking uptake among children. In India, in an attempt to protect children, films containing smoking are required to include tobacco control messaging including audiovisual disclaimers, on-screen health warnings when tobacco imagery is displayed and antitobacco ‘health spots’ before and during the film. We report a study of the association between ever smoking and exposure to tobacco imagery in locally popular films among children in Udupi district of Karnataka state in southern India.MethodsA cross-sectional questionnaire survey of all students in grades 6–8 in schools in the Udupi district ascertained smoking status and potential confounders of smoking uptake, and whether children had seen any of 27 locally popular films we had coded and found to contain imagery of actual or implied tobacco use. Ever-smoking status was defined as any reported smoking of cigarettes, beedis or other tobacco products currently or at any time in the past. Independent effects on ever-smoking status were estimated using multiple logistic regression.ResultsOf 46 706 students enrolled in grades 6–8 in 914 participating schools, 39 282 (84.1%) provided questionnaire responses sufficiently complete for analysis. Ever smoking was reported by 914 (2.3%) participants and in a mutually adjusted model was significantly related to age, male sex, living in a home where smoking is allowed, having parents or siblings who smoke, low paternal education, low levels of family wealth, low self-esteem, rebelliousness and poor school performance. After allowing for these effects, the odds of ever smoking were not increased among students who had seen any of the listed films containing tobacco imagery when included in the analysis as a binary exposure (OR 0.9, 95% CI 0.4 to 2.0), and decreased in relation to level of exposure graded into tertiles of tobacco intervals seen.ConclusionsIn this cross-sectional study, children in southern India who had seen films containing tobacco imagery are no more likely to smoke than those who had not, indicating that the tobacco control messaging mandated by Indian law may be attenuating the effect of tobacco imagery in films on smoking uptake.

Tobacco content in video on demand services in low- and middle-income countries

Background There is clear evidence that exposure to tobacco is linked to smoking uptake. The economic and social burden of diseases associated with smoking is particularly high in low-and middle-income countries, where smoking uptake is high and exposure to tobacco use and branded content is widespread. Streamed content exhibits consistently higher levels of tobacco content than broadcast media and these levels have increased. The prevalence of smoking and tobacco content in video-on-demand (VOD) services is troubling given their popularity with youth audiences and the ease with which content can be accessed by children. This is because barriers to youth consumption that exist for film or broadcast media, including content gatekeepers, are absent. Methods The most popular VOD series from 10 low- and middle-income countries (Bangladesh, Brazil, China, India, Indonesia, Mexico, Pakistan, Philippines, Ukraine and Vietnam) were identified based on demand expressions and coded for individual depictions of tobacco. 18 series were analysed, representing a mix of international content in several languages. 111 episodes, totalling 81.4 hours of coded content, were analysed for tobacco depictions and characterisation of smoking characters. Results Tobacco content was prevalent and particularly prominent in non-English language series, where readily identifiable “stars” frequently partook in smoking. Cigarettes dominated tobacco imagery, with other forms (pipes and electronic nicotine delivery systems) rarely appearing. Notably, there were several incidents featuring well-known brands. Given that access to VOD services is difficult to moderate, youth audiences can easily access programming featuring high levels of tobacco use by identifiable characters, played by well-known actors. A lack of control regarding consumption of streamed content means that it is extremely important for content producers like Netflix and Amazon to ensure VOD content is suitable for youth audiences. Key messages Tobacco content in video-on demand services is increasing. Tobacco exposure is linked to smoking uptake.

Impact of UK Tobacco Control Policies on Inequalities in Youth Smoking Uptake: A Natural Experiment Study

Introduction UK countries implemented smoke-free public places legislation and increased the legal age for tobacco purchase from 16 to 18 years between 2006 and 2008. We evaluated the immediate and long-term impacts of these UK policy changes on youth smoking uptake and inequalities therein. Aims and Methods We studied 74 960 person-years of longitudinal data from 14 992 youths (aged 11–15 years) in annual UK household surveys between 1994 and 2016. Discrete-time event history analyses examined whether changes in rates of youth smoking transitions (initiation, experimentation, and escalation to daily smoking or quitting) or their inequalities (by parental education) were associated with policy implementation. Parallel analyses examined smoke-free legislation and the change in legal age. We interpret the results as a combined effect of the two pieces of legislation as their implementation dates were too close to identify separate effects. Models were adjusted for sex, age, UK country, historical year, tobacco taxation, and e-cigarette prevalence, with multiple imputation for missing data. Results For both policies, smoking initiation reduced following implementation (change in legal age odds ratio [OR]: 0.67; 95% confidence interval [CI]: 0.55 to 0.81; smoke-free legislation OR: 0.68; 95% CI: 0.56 to 0.82), while inequalities in initiation narrowed over subsequent years. The legal age change was associated with annual increases in progression from initiation to occasional smoking (OR: 1.26; 95% CI: 1.07 to 1.50) and a reduction in quitting following implementation (OR: 0.57; 95% CI: 0.35 to 0.94). Similar effects were observed for smoke-free legislation but CIs overlapped the null. Conclusions Policies such as these may be highly effective in preventing and reducing socioeconomic inequalities in youth smoking initiation. Implications UK implementation of smoke-free legislation and an increase in the legal age for tobacco purchase from 16 to 18 years were associated with an immediate reduction in smoking initiation and a narrowing of inequalities in initiation over subsequent years. While the policies were associated with reductions in the initiation, progression to occasional smoking increased and quitting decreased following the legislation.