Development of an integrated tobacco endgame strategy

Which countries are ready for a tobacco endgame? A scoping review and cluster analysis

Various countries have set tobacco endgame targets to eliminate tobacco use by a certain year. Tobacco endgames are generally considered more feasible in countries with advanced tobacco control measures and a smoking prevalence of 15% or less. We conducted a scoping review of 563 articles sourced from news, academic literature, and grey literature to examine global tobacco endgame progress, and grouped 153 countries into clusters based on their tobacco policy implementation score and smoking prevalence to systematically identify countries that might be well positioned to succeed in a tobacco endgame. The EU, Pacific Islands, and 18 other individual countries have set tobacco endgame targets, with another seven countries described as well positioned for an endgame. These were mostly high-income countries with higher smoking prevalence. We identified 28 endgame-ready countries with advanced tobacco policies and a low smoking prevalence. Of these, only five were part of tobacco endgame movements; the remaining 23 were all low-income or middle-income countries in Africa, Latin America, or Asia. Therefore, the global tobacco endgame movement should focus more on low-income and middle-income countries with low smoking rates and advanced tobacco policies, particularly in Africa, Latin America, and Asia.

How do New Zealand youth perceive the smoke-free generation policy? A qualitative analysis

INTRODUCTION

Aotearoa New Zealand (NZ) plans to introduce a smoke-free generation (SFG) policy, alongside denicotinisation and reducing the availability of tobacco products. The SFG has a clear rationale, yet we know little about how young people, those the policy targets, perceive it. To inform policy design, communication and implementation, we explored how NZ youth perceived the SFG.

METHODS

We undertook in-depth interviews with a sample of 20 youth aged 17 or 18 and explored their knowledge of the SFG, and how they perceived its individual and societal implications. We interpreted the data using a reflexive thematic analysis approach.

RESULTS

We identified two overarching themes. The first theme, 'societal good and protection from harm', reflected benefits participants associated with the SFG, which outweighed perceptions of lost freedoms. The second theme, 'privileging personal choice', corresponded to two small groups within the sample. The first preferred measures they considered less restrictive, such as increasing the purchase age, and some came to support the SFG as they rationalised their views. The second subgroup expressed more entrenched opposition and felt the SFG deprived them of a choice.

CONCLUSIONS

Young people's deep reflection on the SFG led most to view it as liberating rather than restrictive. Communications that avoid prompting heuristic-based responses could encourage youth to reflect on the policy and elicit strong support from the group the SFG aims to benefit.

Pharmaceuticalisation as the tobacco industry's endgame

CONTEXT

Declining smoking prevalence and denormalisation of tobacco in developed countries reduced transnational tobacco company (TTC) profit during 1990s and 2000s. As these companies faced increasingly restrictive policies and lawsuits, they planned to shift their business to socially acceptable reduced-harm products. We describe the internal motivations and strategies to achieve this goal.

METHODS

We analysed previously secret tobacco industry documents available through the Truth Tobacco Documents Library. These documents were triangulated with TTCs' investor and other professional reports, websites and public statements.

FINDINGS

Mimicking pharmaceutical business models, tobacco companies sought to refurbish their image and ensure long-term profitability by creating and selling pharmaceutical-like products as smoking declined. These products included snus, heated tobacco products, e-cigarettes, nicotine gums and inhalers. Tobacco companies created separate divisions to develop and roll out these products, and the majority developed medical research programmes to steer these products through regulatory agencies, seeking certification as reduced-harm or pharmaceutical products. These products were regarded as key to the survival of the tobacco industry in an unfriendly political and social climate.

CONCLUSIONS

Pharmaceuticalisation was pursued to perpetuate the profitability of tobacco and nicotine for tobacco companies, not as a sincere search to mitigate the harms of smoking in society. Promotion of new pharmaceuticalised products has split the tobacco control community, with some public health professionals and institutions advocating for the use of 'clean' reduced-harm nicotine and tobacco products, essentially carrying out tobacco industry objectives.

Association of tobacco use with the tobacco-related built environment: an ecological study from urban slums of Bhopal, India

INTRODUCTION

Tobacco is one of the biggest public health problems and a major risk factor for various non-communicable diseases (NCDs). An important aspect of tobacco control strategy could include modifications in the tobacco-related built environment. This study investigated the association between tobacco shop density and tobacco use prevalence in the urban slums of Bhopal city, India.

METHODS

We conducted a cross-sectional survey to obtain the distribution of tobacco-related built environment (tobacco shops) in the neighbourhood (400-m service area) of 32 urban slum clusters of Bhopal. We plotted this distribution using the 'network service area analysis' in ArcMap 10.7.1 software. Then, we used an ecological design to determine the association between tobacco shop density and tobacco use prevalence in these 32 clusters (N = 6214 adult inhabitants). We used multiple linear regression analysis to estimate the regression coefficient (adjusted for socio-demographic variables) between tobacco use and tobacco shop density at the cluster level.

RESULTS

The prevalence of tobacco use among all 32 slum clusters ranged from 22.1 to 59.6% (median 40.9% with IQR 31.8-44.2). There were 194 tobacco shops situated in the neighbourhood of all clusters. The median density of tobacco shops was 59.40/km² (IQR 39.9-108.1/km²) in the neighbourhoods of slum clusters. Tobacco use prevalence was significantly associated with tobacco shop density (estimate or B = 0.071, p value = 0.002) after adjusting for age, literacy, wealth index, and gender ratio.

CONCLUSIONS

Tobacco use prevalence is significantly associated with tobacco shop density in the slums of Bhopal city in central India. We need to develop appropriate built environment interventions to control rampant tobacco use.

The Lebanese Regie state-owned tobacco monopoly: lessons to inform monopoly-focused endgame strategies

Background

Many countries have started pursuing tobacco ‘endgame’ goals of creating a ‘tobacco-free’ country by a certain date. Researchers have presented models to attain this goal, including shifting the supply of tobacco to a monopoly-oriented endgame model (MOEM), wherein a state-owned entity controls the supply and distribution of tobacco products. Although not designed to end tobacco use, the Regie in Lebanon exhibits some of the key features identified in MOEM and hence can serve as a practical example from which to draw lessons.

Methods

We comprehensively review previous literature exploring tobacco endgame proposals featuring a MOEM. We distil these propositions into core themes shared between them to guide a deductive analysis of the operations and actions of the Regie to investigate how it aligns (or does not) with the features of the MOEM.

Results

Analysing the endgame proposals featuring MOEM, we generated two main themes: the governance of the organisation; and its operational remit. In line with these themes, the investigation of the Regie led to several reflections on the endgame literature itself, including that it: (i) does not seem to fully appreciate the extent to which the MOEM could end up acting like Transnational Tobacco Companies (TTC); (ii) has only vaguely addressed the implications of political context; and (iii) does not address tobacco growing despite it being an important element of the supply chain.

Conclusion

The implementation of tobacco endgame strategies of any type is now closer than ever. Using the Regie as a practical example allows us to effectively revisit both the potential and the pitfalls of endgame strategies aiming to introduce some form of monopoly and requires a focus on: (i) establishing appropriate governance structures for the organisation; and (ii) adjusting the financial incentives to supress any motivation for the organisation to expand its tobacco market.

Closing the gaps in tobacco endgame evidence: a scoping review

OBJECTIVE

Tobacco endgame policies aim to rapidly and permanently reduce smoking to minimal levels. We reviewed evidence syntheses for: (1) endgame policies, (2) evidence gaps, and (3) future research priorities.

DATA SOURCES

Guided by JBI scoping review methodology, we searched five databases (PubMed, CINAHL, Scopus, Embase and Web of Science) for evidence syntheses published in English since 1990 on 12 policies, and Google for publications from key national and international organisations. Reference lists of included publications were hand searched.

STUDY SELECTION

Two reviewers independently screened titles and abstracts. Inclusion criteria were broad to capture policy impacts (including unintended), feasibility, public and stakeholder acceptability and other aspects of policy implementation.

DATA EXTRACTION

We report the results according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews checklist.

DATA SYNTHESIS

Eight policies have progressed to evidence synthesis stage (49 publications): mandatory very low nicotine content (VLNC) standard (n=26); product standards to substantially reduce consumer appeal or remove the most toxic products from the market (n=1); moving consumers to reduced risk products (n=8); tobacco-free generation (n=4); ending sales (n=2); sinking lid (n=2); tax increases (n=7); and restrictions on tobacco retailers (n=10). Based on published evidence syntheses, the evidence base was most developed for a VLNC standard, with a wide range of evidence synthesised.

CONCLUSIONS

VLNC cigarettes have attracted the most attention, in terms of synthesised evidence. Additional focus on policies that reduce the availability of tobacco is warranted given these measures are being implemented in some jurisdictions.

What facilitates policy audacity in tobacco control? An analysis of approaches and supportive factors for innovation in seven countries

BACKGROUND

Tobacco control policy audacity can make radical ideas seem possible, and set in motion a 'domino' effect, where precedents in one jurisdiction are followed by others. This review examines tobacco control policy audacity from seven countries to identify and compare factors that facilitated it.

METHODS

A targeted search strategy and purposive sampling approach was used to identify information from a range of sources and analyse key supportive factors for policy audacity. Each case was summarised, then key themes identified and compared across jurisdictions to identify similarities and differences.

RESULTS

Included cases were Mauritius' ban on tobacco industry corporate social responsibility, Uruguay's tobacco single brand presentation regulations, New Zealand's Smokefree Aotearoa 2025 Action Plan proposals and 2010 parliamentary Māori Affairs Select Committee Inquiry into the Tobacco Industry, Australia's plain packaging legislation, Balanga City's (Philippines) tobacco-free generation ordinance, Beverly Hills City Council's (USA) ordinance to ban tobacco sales and the Netherlands' policy plan to phase out online and supermarket tobacco sales. Each case was one strategy within a well-established comprehensive tobacco control and public health approach. Intersectoral and multijurisdiction collaboration, community engagement and public support, a strong theoretical evidence base and lessons learnt from previous tobacco control policies were important supportive factors, as was public support to ensure low political risk for policy makers.

CONCLUSIONS

Tobacco control policy audacity is usually an extension of existing measures and typically appears as 'the next logical step' and therefore within the risk appetite of policy makers in settings where it occurs.

Comparison of End Tidal Carbon Monoxide Levels between Conventional Cigarette, Electronic Cigarette and Heated Tobacco Product among Asiatic Smokers

Electronic nicotine delivery systems (ENDS) and heated tobacco products (HTPs) are noncombustible tobacco products which have been found to generate aerosols containing lower levels of Harmful and Potentially Harmful Constituents (HPHCs) in comparison to conventional cigarettes. Objective: This quasi experimental study measured and compared the end tidal carbon monoxide (eCO) levels of participants after use of ENDS, HTPs and conventional cigarettes. Methods: In total 45 smokers, each smoking at least 10 conventional cigarettes per day for 5 years participated in the study. Based on their preference, participants used only one of the tobacco products (ENDS, HTPs, or conventional cigarette) and were briefed about the product use based on manufacturer's instructions. The eCO levels were obtained at baseline, followed by 5, 10, 15, 30 and 45 min respectively after the product use. Results: There was significant increase in eCO levels for conventional cigarettes as compared to other modes. Peak eCO levels of 20.2 ± 0.86 ppm, 8.8 ± 1.56 ppm and 6.0 ± 1.36 ppm was achieved at 30 min, 15 min and 10 min for conventional cigarettes, ENDS and HTPs respectively. However, the levels were significantly lower in ENDS and HTPs. Conclusion: Even though ENDS and HTPs may have produced significantly lower eCO than conventional cigarettes, the significantly increasing levels over time from baseline which was not shown before is a cause of concern. As of now, their use as an alternate to cigarettes needs to be considered under regulatory framework.

Recommendations on how to achieve tobacco-free nations in Europe

European countries vary widely in the development and implementation of effective tobacco-control programs and policies. Why some countries lag behind others is inherently a political matter. National-level policymakers struggle between the need to protect public health and the need to recognize economic and ideological considerations. Within this context, use of scientific evidence plays an important role in the policy making process. Articles 20 and 22 of the World Health Organisation's Framework Convention of Tobacco Control (FCTC) oblige countries to develop and coordinate research on aspects of tobacco control and require of them to facilitate knowledge transfer and capacity building between countries. This paper considers various ways how EU and national policy makers may accomplish this. We conclude that progress in three areas is needed: 1) generation of more scientific evidence relevant for each country; 2) facilitation of policy learning between countries; and 3) building capacity and collaborations between researchers and tobacco-control advocates to bridge the gap from research to policy, especially in countries with weak tobacco-control infrastructures.

Strategies and barriers to achieving the goal of Finland's tobacco endgame

Objectives

Finland boldly legislated the end of tobacco use in its 2010 Tobacco Act, and subsequently expanded the goal in 2016 to eradicate other nicotine-containing products. This study explored stakeholders’ perceptions about the strengths, barriers, solutions and rationale for Finland’s comprehensive but conventional strategy to achieve its nicotine-free goal.

Design

Study participants were selected based on expertise in policy or practice of tobacco control (n=32). Semi-structured interviews, conducted in 2017 and 2018, covered topics ranging from consensus among stakeholders to Finland’s ranking on the 2016 Tobacco Control Scale. The framework method was chosen for analysing interview transcripts.

Results

A perceived strength of Tobacco-Free Finland 2030 was the consensus and cooperation among members of the tobacco control community. The objective of becoming a nicotine- versus smoke-free society had almost unanimous support, challenged by a small minority who argued for greater discussion of harm reduction approaches. The need for maintaining legitimacy and historical successes in tobacco control were reasons for using a conventional strategy. Barriers to achieving the endgame goal included insufficient funding and over-reliance on non-governmental organisations, political/legal constraints, impact of institutional practices on tobacco disparities, ambivalence about the role of mass media and lack of prioritising smoking cessation.

Conclusions

Stakeholders’ broad confidence in reaching the goal of Finland’s tobacco endgame suggests that future policy initiatives will reflect the current, conventional strategy. If the Finnish government chooses to continue this approach, then it should designate separate funds for Tobacco-Free Finland 2030 and implement structural changes that will facilitate tobacco control initiatives.

Lifestyle Vaccines and Public Health: Exploring Policy Options for a Vaccine to Stop Smoking

Experimental vaccines are being developed for the treatment of 'unhealthy lifestyles' and associated chronic illnesses. Policymakers and other stakeholders will have to deal with the ethical issues that this innovation path raises: are there morally justified reasons to integrate these innovative biotechnologies in future health policies? Should public money be invested in further research? Focusing on the case of an experimental nicotine vaccine, this article explores the ethical aspects of 'lifestyle vaccines' for public health. Based on findings from a qualitative study into a vaccine for smoking cessation, the article articulates possible value conflicts related to nicotine vaccination as an intervention in tobacco control. The 'vaccinization' of lifestyle disease piggybacks on the achievements of classic vaccines. Contrary to expectations of simplicity and success, quitting smoking with a vaccine requires a complex supportive network. Social justice and public trust may become important ethical challenges when deciding whether to use further public funds for research or whether to implement these innovative vaccines in the future.

The effects of maximising the UK's tobacco control score on inequalities in smoking prevalence and premature coronary heart disease mortality: a modelling study

Background

Smoking is more than twice as common among the most disadvantaged socioeconomic groups in England compared to the most affluent and is a major contributor to health-related inequalities. The United Kingdom (UK) has comprehensive smoking policies in place: regular tax increases; public information campaigns; on-pack pictorial health warnings; advertising bans; cessation; and smoke-free areas. This is confirmed from its high Tobacco Control Scale (TCS) score, an expert-developed instrument for assessing the strength of tobacco control policies. However, room remains for improvement in tobacco control policies.

Our aim was to evaluate the cumulative effect on smoking prevalence of improving all TCS components in England, stratified by socioeconomic circumstance.

Methods

Effect sizes and socioeconomic gradients for all six types of smoking policy in the UK setting were adapted from systematic reviews, or if not available, from primary studies.

We used the IMPACT Policy Model to link predicted changes in smoking prevalence to changes in premature coronary heart disease (CHD) mortality for ages 35–74. Health outcomes with a time horizon of 2025 were stratified by quintiles of socioeconomic circumstance.

Results

The model estimated that improving all smoking policies to achieve a maximum score on the TCS might reduce smoking prevalence in England by 3 % (95 % Confidence Interval (CI): 1–4 %), from 20 to 17 % in absolute terms, or by 15 % in relative terms (95 % CI: 7–21 %). The most deprived quintile would benefit more, with absolute reductions from 31 to 25 %, or a 6 % reduction (95 % CI: 2–7 %).

There would be some 3300 (95 % CI: 2200–4700) fewer premature CHD deaths between 2015–2025, a 2 % (95 % CI: 1.4–2.9 %) reduction. The most disadvantaged quintile would benefit more, reducing absolute inequality of CHD mortality by about 4 % (95 % CI: 3–9 %).

Conclusions

Further, feasible improvements in tobacco control policy could substantially improve population health, and reduce health-related inequalities in England.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-016-2962-8) contains supplementary material, which is available to authorized users.

The tobacco endgame: a qualitative review and synthesis

The tobacco endgame concept reorients discussion away from the persistent control of tobacco toward plans for ending the tobacco epidemic, and envisions a tobacco-free future. A variety of policy approaches have been proposed, with many offered prior to the introduction of the unifying term ‘endgame’. We conducted a qualitative synthesis of the literature on tobacco control endgames, and drew on media accounts and discussion of analogous ideas for illustrative purposes. We identified proposals focused on the product, user, market/supply or larger institutional structures. Research on public support for these proposals was limited, but suggestive of some public appetite for endgame ideas. Advocates should be encouraged to explore new policy options and consider the goal of a tobacco-free future.

Tobacco policy in Israel: 1948-2014 and beyond

BACKGROUND

Tobacco is the only consumer product known to kill half of its users, and is a significant cause of death and disability to exposed nonsmokers. This presents a unique conundrum for modern democracies, which emphasize personal liberty, yet are obligated to protect citizens. In Israel, the death toll in 2014 from smoking is expected to reach 8000 deaths; nearly a fifth of the population smokes, and over two-thirds of the population are exposed to tobacco smoke.

AIM

This paper provides an overview of tobacco policy in Israel since the inception of the State, presents the development of the National Tobacco Control Plan, and recommends future actions.

METHODS

Sources for this article included the Knesset (Israeli Parliament) and Ministry of Health websites, Health Minister Reports to the Knesset on Smoking, and the scientific literature.

RESULTS

Israel has an impressive record on tobacco control policy, beginning with taxation in 1952, landmark smoke-free air and marketing legislation in the early 1980's, tax increases and expansions of smoke-free air and marketing legislation in the ensuing years, and the addition of subsidized smoking cessation technologies in 2010. Until 2011, actions were taken by various organizations without formal coordination; since the passage of the National Tobacco Control Plan in 2011, the Ministry of Health has held responsibility for coordinating tobacco control, with an action plan. The plan has been partially implemented. Smoke-free air laws were expanded, but enforcement is poor. Passage of critical marketing and advertising restrictions is stalled. Requested funds for tobacco control did not materialize.

RECOMMENDATIONS

In order to prevent hundreds of thousands of preventable premature deaths in the coming decades, Israel should considerably strengthen tobacco control policies to include: guaranteed funding for tobacco control; strong curbs on advertising, promotion and sponsorship of tobacco and smoking products; public education; law enforcement; protection of children from exposure to tobacco; regulation of electronic cigarettes and other alternative harm-reducing products; tobacco control research; and systematic monitoring of, and periodic updates to, the National Tobacco Control Plan. Israel should also begin discussions of Endgame scenarios, and consider abolition of tobacco, as it continues its progress towards making smoking history.