Tobacco Control
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Published By Bmj

1468-3318, 0964-4563

2022 ◽  
pp. tobaccocontrol-2021-056879
Marko Vladisavljevic ◽  
Jovan Zubović ◽  
Olivera Jovanovic ◽  
Mihajlo Djukic ◽  
Natasa Trajkova Najdovska ◽  

Background and objectiveTobacco tax evasion undermines the goal of tobacco taxes as a tobacco control measure to make tobacco products less affordable, increases the health risks for those who smoke and decreases the government revenue. This paper analyses the tobacco tax evasion in six Western Balkan (WB) countries: Albania, Bosnia and Herzegovina, Kosovo, Montenegro, North Macedonia and Serbia. The aim of this research is to estimate the size of the illicit market and identify the main determinants of tax evasion activities in the Southeastern European region.Data and methodsData from 2019 Survey on Tobacco Consumption in Southeastern Europe (STC-SEE) are used. STC-SEE provides uniquely comparable nationally representative data on smoking behaviour for adult (18–85 years old) population for each country. Tax evasion is defined on the basis of available information on tax stamps, health warnings, price and the place of purchase, in accordance with the previous research on tax evasion. In order to estimate the determinants of illicit purchases we use binary choice model of tax evasion.ResultsThe study finds that 20.4% of all current smokers in WB countries evade taxes on tobacco products, with evasion being much more frequent for hand-rolled (HR) tobacco (86.7%) than for the manufactured cigarettes (MC) (8.6%). While HR is predominantly illicit in all six countries, MC evasion varies significantly, with evasion being significantly higher in Montenegro and Bosnia and Herzegovina. Results further suggest that tax evasion is higher in the statistical regions where institutional capacities to tackle illicit trade are lower, in municipalities bordering countries with high MC evasion, as well as among smokers with low income, women and elderly. We also provide evidence that higher tobacco taxes and prices do not increase illicit consumption.ConclusionThe findings from the research suggest that in order to decrease tax evasion, governments should put additional effort to strengthen institutional capacities to tackle illicit tobacco markets. Furthermore, improving regional coordination in development and implementation of tobacco control policies, including the prevention of illicit market, is essential in lowering evasion in all WB countries. Finally, WB countries should regulate and enforce excise tax stamp requirements on the HR tobacco market to a much higher degree.

2022 ◽  
pp. tobaccocontrol-2021-056938
Stefanie K Gratale ◽  
Ollie Ganz ◽  
Olivia A Wackowski ◽  
M Jane Lewis

BackgroundNatural American Spirit (NAS) is a cigarette brand distinguished by supposed ‘natural’, ‘additive-free’ characteristics, marketing of which is tied to misperceptions of reduced harm. In 2017, NAS’s manufacturer agreed (with the Food and Drug Administration) to remove ‘natural’/‘additive-free’ from US marketing. Prior research has explored NAS marketing immediately post-agreement. This study sought to identify prominent post-agreement terms and themes and analyse how they had been used in pre-agreement ads.MethodsWe conducted a content analysis of NAS ads from 2000 to 2020 (N=176), documenting prominent pre-agreement and post-agreement terms/themes and examining how they are used in NAS ads. We coded for descriptors, themes, imagery and promotions, and extended prior research by analysing how leading post-agreement terms were used in conjunction and thematically associated with ‘additive-free’ and ‘natural’ before the agreement.ResultsResults indicated ‘tobacco and water’ and ‘Real. Simple. Different.’ increased post-agreement, as did environmental imagery. ‘Organic’ was prominent pre-agreement and post-agreement. The descriptors used most often in post-agreement ads almost always appeared in conjunction with (and were thematically linked to) ‘natural’ and ‘additive-free’ in pre-agreement ads.ConclusionsIn the years since the agreement, NAS ads have heavily relied on still-allowable descriptors that may invite reduced risk misperceptions. Notably, these descriptors were consistently used alongside the banned terminology before the agreement and presented as if affiliated conceptually, possibly prompting similar connotations. Findings indicate a continuing need for research into NAS advertising effects and a potential role for additional regulatory action.

2022 ◽  
pp. tobaccocontrol-2021-056825
Vincy Huang ◽  
Anna Head ◽  
Lirije Hyseni ◽  
Martin O'Flaherty ◽  
Iain Buchan ◽  

BackgroundPolicy simulation models (PSMs) have been used extensively to shape health policies before real-world implementation and evaluate post-implementation impact. This systematic review aimed to examine best practices, identify common pitfalls in tobacco control PSMs and propose a modelling quality assessment framework.MethodsWe searched five databases to identify eligible publications from July 2013 to August 2019. We additionally included papers from Feirman et al for studies before July 2013. Tobacco control PSMs that project tobacco use and tobacco-related outcomes from smoking policies were included. We extracted model inputs, structure and outputs data for models used in two or more included papers. Using our proposed quality assessment framework, we scored these models on population representativeness, policy effectiveness evidence, simulated smoking histories, included smoking-related diseases, exposure-outcome lag time, transparency, sensitivity analysis, validation and equity.FindingsWe found 146 eligible papers and 25 distinct models. Most models used population data from public or administrative registries, and all performed sensitivity analysis. However, smoking behaviour was commonly modelled into crude categories of smoking status. Eight models only presented overall changes in mortality rather than explicitly considering smoking-related diseases. Only four models reported impacts on health inequalities, and none offered the source code. Overall, the higher scored models achieved higher citation rates.ConclusionsWhile fragments of good practices were widespread across the reviewed PSMs, only a few included a ‘critical mass’ of the good practices specified in our quality assessment framework. This framework might, therefore, potentially serve as a benchmark and support sharing of good modelling practices.

2022 ◽  
pp. tobaccocontrol-2021-056846
Guillermo Cruces ◽  
Guillermo Falcone ◽  
Jorge Puig

Increasing tobacco taxes is considered the most effective an cost-effective policy to reduce tobacco consumption. However, a common objection to tobacco taxes is that they tend to rely disproportionately on the poorest individuals since less affluent smokers incur proportionately greater expenditures on cigarettes compared with more affluent smokers. Such objections usually assume that all smokers throughout the income distribution react similarly to an increase in tobacco prices. But, if less affluent smokers are more sensitive to price changes (ie, they have a higher demand price elasticity), reductions in tobacco consumption should be higher at the bottom of the income distribution. This paper uses data from Argentina’s Household Expenditure Survey to estimate demand price elasticities for tobacco by income and age groups. Results indicate that less affluent smokers present higher demand price elasticities for cigarettes than more affluent ones. A 10% increase in cigarette prices would decrease consumption by 8.5% (4.4%) for the poorest (richest) smokers. In addition, young people are the most elastic group. These differential elasticities have relevant implications in terms of the distributional incidence of increasing tobacco taxes. As less well-off individuals reduce consumption relatively more, they bear a relatively lower tax burden. Thus, tobacco tax increases may not be regressive as is often believed. As a whole, this paper provides policymakers with relevant arguments for policy discussion and the public debate on common objections to increasing tobacco taxes.

2022 ◽  
pp. tobaccocontrol-2021-056905
Jennifer L Brown ◽  
Graziele Grilo ◽  
Joanna E Cohen ◽  
Katherine Clegg Smith ◽  
Luz Myriam Reynales-Shigematsu ◽  

BackgroundFlavoured cigarettes are popular in Mexico. We examined how cigarette packaging design features used to communicate flavour influence perceptions of appeal, harm, perceived interest and pack preference among Mexico City residents.MethodsWe conducted an experimental survey. Participants aged 13–34 years were randomly assigned to one of three conditions, viewed packs with systematically manipulated design features (colour, capsule image and flavour name) and answered questions on appeal, perceived harm, perceived interest and pack preference. Data were analysed using mixed effects and conditional logistic regression.Results1500 adolescents and 950 adults participated. Regardless of flavour, cigarette packs with a background colour and capsule image were more appealing to adolescents (OR=13.19, 95% CI 11.53 to 15.10; OR=1.68, 95% CI 1.45 to 1.88) and adults (OR=4.18, 95% CI 3.73 to 4.69; OR=1.66, 95% CI 1.49 to 1.85) than packs without. Among adolescents, ‘Tropical Burst’ named packs were more appealing (OR=1.43, 95% CI 1.20 to 1.72) than packs without a flavour name and among adults, ‘Arctic Air’ named packs were more appealing (OR=1.20, 95% CI 1.02 to 1.14). Adolescents and adults reported a preference for trying packs that displayed a flavour name, background colour or capsule image (b=0.104, b=0.702, b=1.316, p<0.001 and b=0.126, b=0.619, b=0.775, p<0.001).ConclusionsColours and flavour capsule images appeal to adolescents and adults in Mexico. Mexico should consider adopting plain packaging to reduce appeal and interest.

2022 ◽  
pp. tobaccocontrol-2021-056780
Divya Ramamurthi ◽  
Cindy Chau ◽  
Hannah Y Berke ◽  
Afnan M Tolba ◽  
Lu Yuan ◽  

BackgroundIn January 2020, the US Food and Drug Administration prohibited the sale of flavours (except for menthol and tobacco) in prefilled pod devices such as JUUL to decrease youth vaping. Excluded from the prohibition were disposable devices.ObjectivesTo determine the scope and scale of flavours marketed by Puff Bar, a leading disposable brand, and related products.MethodsDisposable e-cigarette flavours were identified via online searches encompassing vendor websites, wholesale distributors, manufacturers (eg,, and social media channel, Instagram, between June and August 2020.ResultsThe ‘Puff’ brand name and iconic cloud logo appear on a variety of products of differing sizes and nicotine e-liquid volumes. Among Puff Bar and its copycats (Puff-a-Likes), 139 flavours were identified. Fruit flavours predominated comprising 82.2% of the flavour varieties (fruit 50%, fruit and menthol/mint 23.6%, and fruity drinks 8.6%). A prevalent new flavour category which combines fruit with menthol/mint (Ice) was offered in 33 varieties such as Lychee Ice, Lush Ice and Banana Ice. Disposable e-cigarette brands are undertaking measures to escape tobacco regulation (eg, non-tobacco-sourced nicotine) and flavour limitations via post-market flavour additions to unflavoured nicotine e-liquid.ConclusionsThe proliferation of flavoured disposable e-cigarette products, many of which are designed to emulate popular pod devices, illustrates that narrowly limited flavour regulations covering only a single category are destined to fail. To be effective in youth protection, flavour regulations need to apply to all recreational nicotine-containing products and need to include measures to counter post-market flavour addition.

2022 ◽  
pp. tobaccocontrol-2021-056805
Bukola Usidame ◽  
Yanmei Xie ◽  
James F Thrasher ◽  
Paula Lozano ◽  
Michael R Elliott ◽  

SignificanceThis study examines the differential effects of Canadian point-of-sale (POS) tobacco display bans across provinces on quit attempts and smoking cessation, by sex, education and income.MethodsWe analysed survey data from five waves (waves 4–8) of the International Tobacco Control Canada Survey, a population-based, longitudinal survey, where provinces implemented display bans between 2004 and 2010. Primary outcomes were quit attempts and successful cessation. We used generalised estimating equation Poisson regression models to estimate associations between living in a province with or without a POS ban (with a 24-month threshold) and smoking outcomes. We tested whether these associations varied by sex, education and income by including interaction terms.ResultsAcross survey waves, the percentage of participants in provinces with POS bans established for more than 24 months increased from 5.0% to 95.8%. There was no association between POS bans and quit attempts for provinces with bans in place for 0–24 months or more than 24 months, respectively (adjusted relative risk (aRR)=0.99, 95% CI: 0.89 to 1.10; 1.03, 95% CI: 0.88 to 1.20). However, we found a differential impact of POS bans on quit attempts by sex, whereby bans were more effective for women than men for bans of 0–24 months. Participants living in a province with a POS ban for at least 24 months had a higher chance of successful cessation (aRR=1.49; 95% CI: 1.08 to 2.05) compared with those in a province without a ban. We found no differences in the association between POS bans and quit attempts or cessation by education or income, and no differences by sex for cessation.ConclusionPOS bans are associated with increased smoking cessation overall and more quit attempts among women than men.

2022 ◽  
pp. tobaccocontrol-2021-057068
Sukriti KC ◽  
Filippos T Filippidis ◽  
Anthony A Laverty

BackgroundGlobal adoption of standardised packaging requirements for tobacco products is a victory for public health, but their proliferation and impacts rely partly on public support. How this is related to legislation remains underassessed. This study explored change over time in public support for standardised packaging in countries with varying degrees of legislative provisions.MethodsWe used data from 27 European countries, collected from 2017 (n=28, 300) and 2020 (n=27, 901) waves of the Eurobarometer survey, to assess self-reported support for standardised packaging regulations among both smokers and non-smokers. Countries were grouped into three categories of policy adoption (policy implemented; policy legislated; no legislation) and changes in support were assessed using multilevel Poisson regression models.ResultsIn 2020, public support for standardised packaging was 71% (95% CI 68% to 74%) in countries that implemented standardised packaging legislation, 57% (55% to 60%) in countries that had legislated but not yet implemented legislation and 41% (40%to 42%) in countries with no legislation. Compared with 2017, this represented a relative change of +8% (1% to 15%), +12% (5% to 21%) and −5% (95% CI −2% to −8%), respectively, in the three country categories. Among smokers, there was no indication of change in support across the three groups. Among non-smokers, support increased in countries with existing legislation (adjusted prevalence ratio [aPR]=1.14, 95% CI 1.06 to 1.23) and decreased in countries with no legislation (aPR=0.93, 0.90 to 0.97).ConclusionsPublic support for standardised packaging regulations increased in countries implementing and legislating for these measures, particularly among non-smokers. An overall increase in support provides reassurance for policymakers defending policy action on tobacco packaging, as well as for those seeking to implement standardised packaging in their own countries. 

2022 ◽  
pp. tobaccocontrol-2021-056627
Mathieu JP Poirier ◽  
Gigi Lin ◽  
Leah K Watson ◽  
Steven J Hoffman

ObjectivesTo systematically code and classify longitudinal cigarette consumption trajectories in European countries since 1970.DesignBlinded duplicate qualitative coding of periods of year-over-year relative increase, plateau, and decrease of national per capita cigarette consumption and categorisation of historical cigarette consumption trajectories based on longitudinal patterns emerging from the data.Setting41 countries or former countries in the European region for which data are available between 1970 and 2015.ResultsRegional trends in longitudinal consumption patterns identify stable or decreasing consumption throughout Northern, Western and Southern European countries, while Eastern and Southeastern European countries experienced much greater instability. The 11 emergent classes of historical cigarette consumption trajectories were also regionally clustered, including a distinctive inverted U or sine wave pattern repeatedly emerging from former Soviet and Southeastern European countries.ConclusionsThe open-access data produced by this study can be used to conduct comparative international evaluations of tobacco control policies by separating impacts likely attributable to gradual long-term trends from those more likely attributable to acute short-term events. The complex, regionally clustered historical trajectories of cigarette consumption in Europe suggest that the enduring normative frame of a gently sloping downward curve in cigarette consumption can offer a false sense of security among policymakers and can distract from plausible causal mechanisms among researchers. These multilevel and multisectoral causal mechanisms point to the need for a greater understanding of the political economy of regional and global determinants of cigarette consumption.

2022 ◽  
pp. tobaccocontrol-2021-056952
Jeroen L A Pennings ◽  
Anne Havermans ◽  
Charlotte G G M Pauwels ◽  
Erna J Z Krüsemann ◽  
Wouter F Visser ◽  

ObjectivesRecent years have seen an increase in e-liquids containing nicotine salts. Nicotine salts are less harsh and bitter than free-base nicotine and therefore can facilitate inhalation. Because inhalation-facilitating ingredients are banned in the European Union, we assessed the occurrence and characteristics of nicotine salt-containing e-liquids notified for the Netherlands.MethodsWe analysed data for 39 030 products, submitted by manufacturers in the European Union Common Entry Gate system, as extracted on 30 June 2020.ResultsNicotine salts were present in 13% of e-liquids, especially in pod-related e-liquids (73%) and e-liquids registered from 2018 onwards (over 25%). We found six nicotine salt ingredients (NSIs): nicotine lactate, salicylate, benzoate, levulinate, ditartrate and malate. Nicotine salts also occurred as nicotine–organic acid ingredient combination (NAIC), like nicotine and benzoic acid. Nicotine concentrations were twofold higher in e-liquids with NSI (median 14 mg/mL) and NAIC (11 mg/mL) than for free-base nicotine (6 mg/mL). E-liquids with NSI contained a fourfold higher number (median n=17) and concentration (median 31.0 mg/mL) of flavour ingredients than e-liquids with free-base nicotine (n=4, 7.4 mg/mL). In NAIC-containing e-liquids, these were threefold higher (n=12, 21.5 mg/mL). E-liquids with nicotine salts were less often tobacco flavoured but more often had fruity or sweet flavours.ConclusionsA substantial and increasing share of e-liquids in the Netherlands contains nicotine salts. Their characteristics can make such e-liquids more addictive and more attractive, especially to young and beginning users. Policymakers are advised to consider regulating products containing nicotine salts.

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