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Heated tobacco product marketing: a mixed-methods study examining exposure and perceptions among US and Israeli adults. HEALTH EDUCATION RESEARCH 2024:cyae018. [PMID: 38739472 DOI: 10.1093/her/cyae018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Revised: 03/06/2024] [Accepted: 04/17/2024] [Indexed: 05/16/2024]
Abstract
The marketing of heated tobacco products (HTPs), like IQOS, influences consumers' perceptions. This mixed-methods study analyzed (i) survey data (2021) of 2222 US and Israeli adults comparing perceptions of 7 IQOS attributes (design, technology, colors, customization, flavors, cost and maintenance) and 10 marketing messages (e.g. 'Go smoke-free…') across tobacco use subgroups and (ii) qualitative interviews (n = 84) regarding IQOS perceptions. In initial bivariate analyses, those never using HTPs (86.2%) reported the least overall appeal; those currently using HTPs (7.7%) reported the greatest appeal. Notably, almost all (94.8%) currently using HTPs also currently used cigarettes (82.0%) and/or e-cigarettes (64.0%). Thus, multivariable linear regression accounted for current cigarette/e-cigarette use subgroup and HTP use separately; compared to neither cigarette/e-cigarette use (62.8%), cigarette/no e-cigarette use (17.1%) and e-cigarette/no cigarette use (6.5%), those with dual use (13.5%) indicated greater overall IQOS appeal (per composite index score); current HTP use was not associated. Qualitative data indicated varied perceptions regarding advantages (e.g. harm, addiction and complexity) of IQOS versus cigarettes and e-cigarettes, and perceived target markets included young people, those looking for cigarette alternatives and females. Given the perceived target markets and particular appeal to dual cigarette/e-cigarette use groups, IQOS marketing and population impact warrant ongoing monitoring to inform regulation.
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Impact of exposures to Heated Tobacco Products in the media and through social connections on product perceptions and use. Tob Prev Cessat 2024; 10:TPC-10-20. [PMID: 38738210 PMCID: PMC11082655 DOI: 10.18332/tpc/187246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Revised: 04/16/2024] [Accepted: 04/16/2024] [Indexed: 05/14/2024]
Abstract
INTRODUCTION Little is known about media exposures to heated tobacco products (HTPs). In this study, we examined sources of HTP exposure, including from paid and unpaid media and social connections, in relation to HTP use and use intentions. METHODS In the fall of 2021, we conducted a cross-sectional survey among adult online panelists (aged 18-45 years) in the US and Israel, oversampling tobacco users. The current study analyzed data from participants who responded to the question about HTP awareness or use (n=2061). Multivariable linear and logistic regression analyses examined the relationship between sources of HTP exposure, HTP use, and use intentions. RESULTS Among those aware of HTPs, both Israelis and Americans reported past-month HTP media exposure via advertisements (58.2% vs 48.0%), non-advertisement sources (49.7% vs 30.7%), and social connections (51.5% vs 33.6%), respectively. Factors associated with HTP awareness (n=677/2061; 32.9%) included media use frequency (AOR=1.13; 95% CI: 1.01-1.28) and social connections using HTPs (AOR=2.45; 95% CI: 1.92-3.15). Among those aware of HTPs, past-month HTP exposure via digital media advertisements (AOR=2.06; 95% CI: 1.09-3.91) and non-advertising promotion via radio, podcast, movie, television or theatre (AOR=2.30; 95% CI: 1.19-4.44) and websites (AOR=2.36; 95% CI: 1.32-4.21) were associated with current HTP use. Exposure to digital media advertisements (β=0.35; 95% CI: 0.07-0.62) and non-advertising promotion via social media (β=0.62; 95% CI: 0.34-0.91) were correlated with higher use intentions. Having social connections using HTPs was correlated with higher use (AOR=2.21; 95% CI: 1.19-4.11) and intentions (β=0.66; 95% CI: 0.42-0.91). No significant differences were found across countries. CONCLUSIONS Digital media (e.g. online, social media) were particularly salient correlates of HTP intentions and use. Future studies are needed that further examine media exposures to these products, as well as that examine possible regulations to limit HTP promotion via these channels.
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Promotion of legume intake-Israeli dietitians' knowledge, beliefs and practices. J Public Health (Oxf) 2024:fdae055. [PMID: 38686928 DOI: 10.1093/pubmed/fdae055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Revised: 03/12/2024] [Accepted: 04/08/2024] [Indexed: 05/02/2024] Open
Abstract
BACKGROUND The health and environmental benefits of legume consumption are reflected in dietary guidelines worldwide. However, legume intake fails to meet recommendations. Dietitians' legume counseling practices can impact consumption patterns. This cross-sectional study assessed Israeli dietitians' knowledge, attitudes, perceptions and practices regarding legume counseling and identified pertinent barriers and facilitators. METHODS An electronic survey among Israeli dietitians (n = 309) was performed. Multivariable logistic regression assessed associations between recommending legumes with participants' socio-demographic and professional characteristics, knowledge, perceptions, attitudes toward legume counseling and personal legume intake. RESULTS Almost half (47.4%) of the participants recommended that 76% or more of their patients increase legume intake. Factors that were associated with recommending legumes were perceptions of fewer barriers to consumption [adjusted OR (aOR) 1.92 (95% CI 1.24-2.96)] and positive attitudes toward legume counseling pertaining to its importance [aOR 1.95 (95% CI 1.12-3.4)]. Negatively associated factors were a low level of personal legume consumption [aOR 0.38 (95% CI 0.15-0.94)] and working in hospitals [aOR 0.43 (95% CI 0.19-0.98)]. CONCLUSIONS Israeli dietitians' recommendations for legume consumption were well below current guidelines. These findings indicate the need for a tailored intervention for nutrition professionals to increase the frequency of legume counseling and overall consumption.
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IQOS and cigarette advertising across regulatory periods and population groups in Israel: a longitudinal analysis. Tob Control 2024; 33:e3-e10. [PMID: 36368887 PMCID: PMC10172385 DOI: 10.1136/tc-2022-057585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Accepted: 10/12/2022] [Indexed: 11/13/2022]
Abstract
BACKGROUND Tobacco regulation recently changed in Israel, including a partial advertisement ban. We assessed the impact of regulatory changes on Philip Morris International's (PMI) IQOS and cigarette advertisements. METHODS Weekly number of ads and weekly adspend of PMI's IQOS and cigarettes were analysed descriptively and using Quasi-Poisson regressions over time, across regulatory periods and in relation to subpopulations (general public, Arab, Russian and Ultra-Orthodox), from 25 December 2016 to 4 August 2020. Exponentiated coefficients (a value >1 indicates an increase) and 95% CIs are reported. RESULTS The average weekly number of ads and the average weekly adspend of IQOS were higher than cigarettes (42.22 vs 26.76 ads/week and 59 409 vs 45 613 new Israeli shekels/week; p<0.001 for both) during the study period, with exclusive IQOS advertisements during market penetration (December 2016 to May 2017). Variation in both outcomes was observed with regard to regulatory decisions. After the advertisement ban, there was a significant decrease in the weekly number of ads (IQOS: ß=0.04, 95% CI 0.002 to 0.20; cigarettes: ß=0.05, 95% CI 0.01 to 0.15) and weekly adspend (IQOS: ß=0.15, 95% CI 0.07 to 0.29; cigarettes: ß=0.31, 95% CI 0.17 to 0.53) for both products. The Ultra-Orthodox had significantly higher average weekly ads compared with the Arab population (IQOS: 0.67 vs 0.07; cigarettes: 2.74 vs 0.13; p=0.02 for both) but lower adspend. CONCLUSIONS IQOS and cigarette advertisements varied over time and appeared to have been impacted by regulatory changes. PMI invested more in IQOS advertisements than in cigarettes, with a partial advertisement ban decreasing both products' advertisements. PMI might be targeting the Ultra-Orthodox Jewish population which has a low smoking rate. Further research and surveillance are needed to better understand targeting strategies in order to inform tobacco control policy.
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PMI's IQOS and cigarette ads in Israeli media: a content analysis across regulatory periods and target population subgroups. Tob Control 2024; 33:e54-e61. [PMID: 36418166 PMCID: PMC10203057 DOI: 10.1136/tc-2022-057671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 11/11/2022] [Indexed: 11/24/2022]
Abstract
BACKGROUND IQOS, manufactured by Philip Morris International (PMI), is the highest selling heated tobacco product globally. IQOS went through several regulatory changes in Israel: from no oversight to minimal tobacco legislation, to progressive legislation that included a partial advertisement ban (exempting print media) and plain packaging. We examined how PMI's advertising messages changed during these regulatory periods for both IQOS and cigarettes. METHODS Content analysis of PMI's IQOS and cigarette ads was performed using a predefined framework. Ad characteristics included regulatory period, target population, setting, product presentation, age and use restrictions, retail accessibility, additional detail cues (eg, QR code) and promotions. Ad themes included product features, legislation-related elements, social norms and comparative claims. Comparisons between IQOS and cigarette ads, and across regulatory periods, were examined using χ2 test or Fisher's exact test. RESULTS The dataset included 125 IQOS ads and 71 cigarette ads. IQOS ads featured more age restrictions, retail accessibility and additional detail cues, compared with cigarette ads (93.6% vs 16.9%; 56.0% vs 0.0%; and 95.2% vs 33.8%, p<0.001 for all). Cigarette ads featured mostly price promotions (52.1% vs 10.1% of IQOS ads, p<0.001). The main ad themes were technology for IQOS (85.6%) and quality for cigarettes (50.7%). In later (vs earlier) restrictive regulatory periods, IQOS ads featured more direct comparisons to cigarettes, QR codes and indoor settings, and did not feature product packaging. CONCLUSIONS IQOS advertisement content shifted as more restrictions went into effect, with several elements used to circumvent legislation. Findings from this study point to the necessity of a complete advertisement ban and ongoing marketing surveillance.
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Impact of FDA endorsement and modified risk versus exposure messaging in IQOS ads: a randomised factorial experiment among US and Israeli adults. Tob Control 2024; 33:e69-e77. [PMID: 36428095 DOI: 10.1136/tc-2022-057639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Accepted: 11/15/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND IQOS was the first heated tobacco product to receive Food and Drug Administration (FDA) authorisation for 'reduced exposure' marketing claims, which has been exploited globally. METHODS In November-December 2021, we conducted a survey-based 3×3 factorial experiment among US (n=1128) and Israeli adults (n=1094). We presented: (1) reduced exposure, reduced risk and control messaging and (2) 2 variations of FDA endorsement and control messaging. Each participant was randomly assigned to evaluate 2 ads (displayed on different ad imagery), then completed assessments of perceived relative harm, exposure and disease risk and likelihood of personally trying or suggesting IQOS to smokers. Ordinal logistic regression examined messaging conditions and their interactions, on the 5 outcomes, respectively, adjusting for covariates. RESULTS Control (vs reduced exposure) messaging resulted in higher perceived relative harm (adjusted OR (aOR)=1.29, 95% CI=1.12 to 1.48), exposure (aOR=1.34, 95% CI=1.17 to 1.54) and disease risk (aOR=1.23; 95% CI=1.08 to 1.40), and lower likelihood of suggesting IQOS to smokers (aOR=0.85; 95% CI=0.74 to 0.97). Reduced risk (vs exposure) messaging resulted in lower perceived relative harm (aOR=0.86; 95% CI=0.75 to 0.99). One FDA endorsement message ('IQOS (completed) the US FDA examination of tobacco products. FDA concluded that IQOS is a better choice for adult smokers') was associated with greater likelihood of suggesting IQOS to smokers, relative to control (aOR=1.19; 95% CI=1.04 to 1.37). No interactions between risk/exposure messaging and FDA endorsement messaging were found. Additionally, Israeli participants, cigarette users and men perceived lower relative harm and exposure and greater likelihood of trying or suggesting IQOS to smokers. CONCLUSIONS Regulators must monitor direct and indirect advertising content of modified risk tobacco product-authorised products and prevent potentially harmful misinterpretations.
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IQOS point-of-sale marketing: a comparison between Arab and Jewish neighborhoods in Israel. RESEARCH SQUARE 2024:rs.3.rs-3953025. [PMID: 38464035 PMCID: PMC10925470 DOI: 10.21203/rs.3.rs-3953025/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/12/2024]
Abstract
Background Philip Morris International's (PMI) IQOS, with its heatsticks (HEETS), is the heated tobacco product with the largest global market share. IQOS and/or electronic cigarettes use rate is higher among Arabs vs. Jews in Israel. This paper aims to compare IQOS point-of-sale (POS) marketing strategies, and regulatory compliance in Arab vs. Jewish neighborhoods in Israel. Methods We integrated data from two separate studies including a cross-sectional survey with IQOS retailers (December 2020-April 2021) and audits of POS that sold IQOS/HEETS (April 2021-July 2021) in 5 large cities in Israel, after marketing restrictions including a POS display ban and plain packaging became effective in Israel (January 2020). The survey included 69 POS (21 Arab, 48 Jewish neighborhoods) and the audits included 129 POS (48 Arab, 81 Jewish neighborhoods). Comparisons of IQOS marketing strategies between POS in Arab and Jewish neighborhoods were conducted using Chi-Square test, Fisher's exact test or Mann-Whitney test, as appropriate. Thematic analysis was used to analyze open-ended questions. Results Most marketing strategies, such as promotions to customers, were uniform across POS in Arab and Jewish neighborhoods. The most noteworthy differences were that a higher proportion of retailers from Arab neighborhoods were invited to IQOS parties (47.6% vs. 21.7%, p<0.05) and reported personal communication with a PMI representative (80.0% vs. 51.2%, p<0.05). Additionally, PMI representatives assisted POS in both Arab and Jewish neighborhoods in implementing the display ban by providing free compliant cabinets and product placement instructions, and directly interacted with customers. POS in Arab neighborhoods were more compliant with the display ban (25.5% vs. 8.8%, p<0.05), but less compliant with plain packaging (62.5% vs. 79.3%, p<0.05). Conclusions There were not many notable differences in IQOS marketing across POS in Arab vs. Jewish neighborhoods, but PMI utilized marketing elements of cultural significance, especially for POS in Arab neighborhoods, such as more personal communication and invitation to social events. Continuous surveillance of tobacco POS marketing and legislation compliance is needed, with a special focus on demographic/location-based differences.
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SRNT Europe debate: Nicotine use is hardly rational. Nicotine Tob Res 2024:ntae028. [PMID: 38366689 DOI: 10.1093/ntr/ntae028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2024] [Indexed: 02/18/2024]
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Driving under the influence of cannabis versus alcohol: A mixed-methods study examining perceptions and related risk behaviors among US and Israeli adults. Addict Behav 2024; 148:107843. [PMID: 37660497 PMCID: PMC10591998 DOI: 10.1016/j.addbeh.2023.107843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 08/11/2023] [Accepted: 08/28/2023] [Indexed: 09/05/2023]
Abstract
BACKGROUND Despite the dangers of driving under the influence (DUI), little is known about DUI substance-specific risk perceptions or risk factors for riding with drunk/drugged drivers (RDD). METHODS In this sequential exploratory mixed-methods study, we conducted: 1) multivariable analyses of cross-sectional survey data from 2222 US and Israeli adults to identify correlates of perceived cannabis- vs. alcohol-related DUI risks (linear regression) and past-month RDD involving alcohol-only, cannabis-only, or both (alcohol-cannabis) (multinomial logistic regression); and 2) deductive-inductive thematic analyses of qualitative interview data from 84 participants to identify themes elaborating on survey findings regarding DUI-related risk perceptions. RESULTS 54.0 % reported past-month alcohol use, 16.7 % cannabis use, 4.2 % alcohol-only RDD, 5.5 % cannabis-only RDD, and 7.9 % alcohol-cannabis RDD. Being from the US, not having children at home, and cannabis non-use correlated with lower perceived cannabis vs. alcohol DUI risk. Lower perceived cannabis vs. alcohol DUI risk correlated with cannabis-only and alcohol-cannabis (vs. no) RDD, and with alcohol-cannabis (vs. cannabis-only) RDD. Alcohol use correlated with alcohol-only (vs. no) RDD and alcohol-cannabis (vs. cannabis-only) RDD. Cannabis use correlated with cannabis-only and alcohol-cannabis (vs. no) RDD, and with alcohol-cannabis (vs. alcohol-only) RDD. Being from the US correlated with alcohol-only (vs. alcohol-cannabis and none) RDD and cannabis-only (vs. alcohol-cannabis) RDD; being from Israel correlated with alcohol-cannabis (vs. no) RDD. Qualitative data indicated most participants perceived greater risk of DUI of alcohol vs. cannabis and desired more effective DUI-related prevention and regulatory efforts. CONCLUSIONS Prevention interventions targeting DUI- and RDD-related risk perceptions are needed, particularly for high-risk populations.
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Barriers and Enablers to Implementing a Smoke-free Home and Car During Pregnancy: A Qualitative Study Among Expectant Israeli Fathers. Nicotine Tob Res 2024; 26:94-101. [PMID: 37565607 DOI: 10.1093/ntr/ntad149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Revised: 08/01/2023] [Accepted: 08/04/2023] [Indexed: 08/12/2023]
Abstract
INTRODUCTION Secondhand smoke exposure during pregnancy is a significant cause of negative health effects. This study aims to identify barriers and facilitators for implementing a smoke-free home and car among expectant Israeli fathers. AIMS AND METHODS Twenty-four qualitative semistructured telephone interviews were audio-recorded, transcribed, and analyzed according to a reflexive and collaborative thematic approach. Inclusion criteria were being male, Hebrew speaker, age ≥18 years, smoking at least one cigarette a day, and living with their nonsmoking pregnant spouse. The Capability, Opportunity and Motivation for Behavior (COM-B) model was used as a theoretical model for analysis. RESULTS Participants reported feeling a strong responsibility for their pregnant spouse's comfort and health, stating that they are doing the best they can to reduce their spouse's secondhand smoke exposure (Motivation). Participants had a low level of knowledge about specific secondhand smoke health consequences, effective strategies to reduce secondhand smoke exposure, with incorrect perceptions about what constitutes exposure (Capability). Couple relationships were not affected by the husband's smoking habits, and participants expressed mutual consideration and understanding (Opportunity). Participants also expressed positive attitudes regarding smoke-free home and car implementation but emphasized that any changes have to be their own decision (Motivation). CONCLUSIONS The present study identified principal Capability, Opportunity and Motivation barriers and facilitators that influence Israeli expectant fathers' decision to implement a smoke-free home and car. Those findings will inform the development of a digital behavioral intervention targeting expectant fathers to reduce prenatal secondhand smoke exposure. IMPLICATIONS Secondhand smoke exposure during pregnancy is a significant cause of negative health effects. Interventions among expectant fathers that focus on creating a smoke-free home and car may be effective because pregnancy has been identified as a "window of opportunity" that generates a strong motivation and creates a sense of urgency to change smoking behavior, while being considered more achievable than smoking cessation. Interventions might be effective if they focus on strengthening the parental responsibility among expectant fathers and emphasize the benefits of a smoke-free home and car, while maintaining male autonomy and increasing skills to effectively implement a smoke-free home and car.
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Big tobacco's dirty tricks: Seven key tactics of the tobacco industry. Tob Prev Cessat 2023; 9:39. [PMID: 38124801 PMCID: PMC10731746 DOI: 10.18332/tpc/176336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Revised: 12/03/2023] [Accepted: 12/05/2023] [Indexed: 12/23/2023]
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Exposure to e-cigarette advertisements and non-advertising content in relation to use behaviors and perceptions among US and Israeli adults. Tob Prev Cessat 2023; 9:35. [PMID: 38033881 PMCID: PMC10685321 DOI: 10.18332/tpc/173558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Revised: 11/08/2023] [Accepted: 11/13/2023] [Indexed: 12/02/2023]
Abstract
INTRODUCTION As e-cigarette marketing strategies diversify, it is important to examine exposure to and impact of e-cigarette advertisements and non-advertising content (e.g. on social media) via multiple media channels among adults in different regulatory contexts. METHODS Using 2021 cross-sectional data among 2222 adults in the US (n=1128) and Israel (n=1094), multivariable regression examined past-month e-cigarette advertisement and non-advertising content exposure in relation to past-month e-cigarette use (logistic regression), as well as use intentions and risk perceptions (linear regressions), controlling for sociodemographics and tobacco use. RESULTS Overall, 20.3% reported past-month e-cigarette use (15.5% US, 25.2% Israel), 46.1% any advertisement exposure (28.7% digital media, 25.2% traditional media, 16.8% retail settings), and 34.1% any non-advertising exposure (19.4% social media, 13.6% websites, 12.3% movie/television/theater, 5.8% radio/podcasts). Exposure to digital media advertisements (AOR=1.95; 95% CI: 1.42-2.66), traditional media advertisements (AOR=2.00; 95% CI=1.49-2.68), and social media non-advertising (AOR=1.72; 95% CI: 1.25-2.36) correlated with e-cigarette use. Exposure to traditional media advertisements (β=0.23; 95% CI: 0.08-0.38) and social media non-advertising (β=0.26; 95% CI: 0.09-0.43) correlated with use intentions. Exposure to digital media advertisements (β= -0.32; 95% CI: -0.57 - -0.08), retail setting advertisements (β= -0.30; 95% CI: -0.58 - -0.03), and radio/podcast non-advertising (β= -0.44; 95% CI: -0.84 - -0.03) correlated with lower perceived addictiveness. Radio/podcast non-advertising exposure (β= -0.50; 95% CI: -0.84 - -0.16) correlated with lower perceived harm. However, retail setting advertisement exposure was associated with e-cigarette non-use (AOR=0.61; 95% CI: 0.42-0.87), and traditional media advertisement (β=0.38; 95% CI: 0.15-0.61) and social media non-advertising exposure (β=0.40; 95% CI: 0.14-0.66) correlated with greater perceived addictiveness. CONCLUSIONS E-cigarette-related promotional content exposure across media platforms impacts perceptions and use, thus warranting regulation.
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Health warning labels on heated tobacco products and their impact on use intentions and risk perceptions: a cross-sectional study of adult tobacco users in the US and Israel. Isr J Health Policy Res 2023; 12:33. [PMID: 37957696 PMCID: PMC10644544 DOI: 10.1186/s13584-023-00582-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2023] [Accepted: 11/08/2023] [Indexed: 11/15/2023] Open
Abstract
BACKGROUND Health warning labels (HWLs) represent an evidence-based tobacco control strategy; however, their application to heated tobacco products (HTPs) and related impacts are understudied. This study examined the impact of HTP HWLs on HTP use intentions and risk perceptions among current tobacco users. METHODS We analyzed cross-sectional survey data from adults in the US and Israel reporting past-month tobacco use and awareness of HTPs (N = 424). Multivariate analyses examined: (1) sociodemographics in relation to self-reported impact of HTP HWLs (i.e., more concerned about HTP use, reassured, no effect [referent]) among those who noticed HTP HWLs (multinomial regressions); and (2) HWL impacts in relation to HTP use intentions and perceived addictiveness and harm (linear regressions). RESULTS Among participants who noticed HTP HWLs (n = 372, 87.7%), 27.7% reported HWLs increased their concerns about HTP use, 22.6% were reassured about use, and 49.7% reported no effect. Factors associated with increased concern (vs. no effect) included other tobacco product use (aOR = 2.10, 95% CI 1.21-3.64) and being female (aOR = 1.77, 95% CI 1.03-3.05). Factors associated with being reassured about HTPs use (vs. no effect) included current HTP use (aOR = 2.11, 95% CI 1.11-4.00) and being from Israel (vs. US: aOR = 3.85, 95% CI 1.85-7.69), female (aOR = 1.91, 95% CI 1.07-3.42), and less educated (< college education: aOR = 2.57, 95% CI 1.42-4.63). Reporting that HWLs on HTPs increased concern (β = 0.46, 95% CI 0.03-0.89) and reassured of use (β = 0.94, 95% CI 0.47-1.41) were positively associated with HTP use intentions; no associations with risk perceptions were found. CONCLUSIONS Findings indicate that most tobacco users noticed HWLs on HTPs, but the majority reported no effect or being reassured of using HTPs, effects that were magnified for specific subgroups. Both increased concern and reassurance correlated with greater use intentions. Additional research should evaluate HTP HWL impacts and ensure effectiveness in communicating risks and discouraging use.
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The impacts of electronic cigarette health warning labels on use intentions and perceptions: A cross-sectional study of US and Israeli adults who use tobacco. J Public Health Res 2023; 12:22799036231214396. [PMID: 38020219 PMCID: PMC10666698 DOI: 10.1177/22799036231214396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2023] [Accepted: 10/30/2023] [Indexed: 12/01/2023] Open
Abstract
Background Health warning labels (HWLs) are evidence-based tobacco control strategies; however, their application to e-cigarettes and related impacts (e.g. on perceived risk), including across countries with different regulations, are understudied. Design and Methods Using 2021 survey data from 927 US and Israeli adults reporting past-month tobacco use, multivariate analyses examined: (1) sociodemographics in relation to self-reported impact of e-cigarette HWLs (i.e. more concerned about e-cigarette use, reassured, no effect) among those who noticed e-cigarette HWLs (multinomial regressions); and (2) HWL impacts in relation to use intentions and perceived addictiveness and harm (linear regressions). Results Among those who noticed HWLs (n = 835, 90.1%), 34.1% reported HWLs resulted in greater concern about e-cigarette use, 45.5% no effect, and 20.4% reassurance. Factors associated with greater concern (vs no effect) included e-cigarette non-use (vs use; aOR = 1.69, 95% CI:1.22, 2.38), US (vs Israel) resident (aOR = 1.65, 95% CI:1.16, 2.34), age 18-25 (vs 36-45; aOR = 1.72, 95% CI:1.11, 2.67), and more education (aOR = 1.85, 95% CI:1.30, 2.63). Factors associated with being reassured (vs no effect) included use of cigarettes (aOR = 1.71, 95% CI:1.06, 2.75), e-cigarettes (aOR = 2.64, 95% CI:1.77, 3.94), and other tobacco (aOR = 2.11, 95% CI:1.39, 3.21), and Israeli resident (aOR = 2.33, 95% CI:1.47, 3.70). Not noticing HWLs (vs no effect) correlated with lower intentions (β = -0.44, 95% CI:-0.87, -0.01), perceived addictiveness (β = -0.61, 95% CI:-1.05, -0.18), and harm (β = -0.56, 95% CI:-0.95, -0.18); reassurance correlated with greater use intentions (β = 0.48, 95% CI:0.12, 0.83); and greater concern was unassociated with use intentions or perceived risk. Conclusion Effects of differing e-cigarette HWLs in distinct subpopulations warrant research. Despite being noticed, they may have no effect or encourage e-cigarette use.
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Theory-based correlates of cannabis use and intentions among US and Israeli adults: a mixed methods study. Subst Abuse Treat Prev Policy 2023; 18:54. [PMID: 37674246 PMCID: PMC10483868 DOI: 10.1186/s13011-023-00562-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2023] [Accepted: 08/28/2023] [Indexed: 09/08/2023] Open
Abstract
BACKGROUND In the US and Israel, non-medical ('recreational') cannabis use is illegal at the national level; however, use rates are high and decriminalization and legalization is spreading. Thus, theory-based intervention efforts, especially for youth prevention, are crucial. METHODS This mixed-methods study of adults in the US (n = 1,128) and Israel (n = 1,094) analyzed: 1) cross-sectional survey data (Fall 2021) to identify theory-based correlates (risk perceptions, social norms) of past-month cannabis use, next-year use intentions, and intentions to use in the home or among children if non-medical cannabis was legal, using multivariable regression; and 2) qualitative interviews regarding perceptions of cannabis policies and use (US n = 40, Israel n = 44). RESULTS 16.7% reported past-month use; 70.5%, 56.3%, and 82.6% indicated "not at all likely" regarding next-year use and use in the home and among children if legal. Lower perceived risk and greater social norms were associated with past-month use, greater use intentions, and greater intentions to use in the home or among children. Past-month use was more prevalent among US (vs. Israeli) participants (22.0% vs. 11.2%); however, in multivariable regression controlling for past-month use, being from Israel was associated with greater use intentions (next-year; in the home/among children). Qualitative themes indicated: concerns about use (e.g., increasing use, health risks, driving-related risks) and legalization (e.g., impact on society/economy, marketing), and perceived benefits of use (e.g., medical) and legalization (e.g., access/safety, economic, individual rights). CONCLUSIONS Despite differences in cannabis perceptions and use across countries, perceived risk and social norms are relevant intervention targets regardless of sociopolitical context.
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IQOS Marketing Strategies and Expenditures in the United States From Market Entrance in 2019 to Withdrawal in 2021. Nicotine Tob Res 2023; 25:1798-1803. [PMID: 37338204 PMCID: PMC10475495 DOI: 10.1093/ntr/ntad096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 04/10/2023] [Accepted: 06/15/2023] [Indexed: 06/21/2023]
Abstract
INTRODUCTION IQOS entered the U.S. market in October 2019, then received the Food and Drug Administration (FDA)'s modified risk tobacco product authorization (MRTPA) allowing use of "reduced exposure" claims in marketing in July 2020. A May 2021 court decision regarding patent infringement required IQOS' removal from the U.S. market in November 2021. AIMS AND METHODS Using 2019-2021 Numerator marketing data, this study characterized ad occurrences and expenditures-including allocation per ad content (headline theme, imagery) and media type and channel-pre- and post-MRTPA; exploratory analyses characterized the post-court to withdrawal period separately. RESULTS The study period entailed 685 occurrences and $15 451 870 in expenditures. The proportions of occurrences across the three periods (pre-MRTPA, post-MRTPA, and post-court) were 39.3%, 48.8%, and 12.0%, respectively (p < .001); the proportions of expenditures were 8.6%, 30.0%, and 61.5%. Overall, 73.1% of ad occurrences were via online display; 99.6% of expenditures occurred in print. Per occurrences, prominent pre-MRTPA headline themes included "future" (40.2%), "real tobacco" (38.7%), "get IQOS" (35.3%), and "innovation or technology" (20.1%); post-MRTPA, prominent themes included "not burned or heat control" (32.7%), "reduced exposure" (26.4%), and "distinct from e-cigarettes" (20.7%). Visuals mainly depicted the product alone (pre-MRTPA: 86.6%; post-MRTPA: 76.1%), but increasingly featured women (pre-MRTPA: 8.6%; post-MRTPA: 21.5%). The most prominent media channel theme pre-MRTPA was "technology" (19.7%), but post-MRTPA included "women's fashion" (20.4%) and "entertainment or pop culture/gaming" (19.0%). CONCLUSIONS IQOS leveraged MRTPA in ads, continued marketing post-court decision, and targeted key consumer groups (ie, women). Marketing surveillance of products granted MRTPA is needed, domestically and in other countries, to assess its use and impact. IMPLICATIONS Philip Morris (PM) leveraged IQOS' MRTPA from the U.S. FDA, and continued marketing IQOS after its withdrawal from the U.S. market due to a patent-infringement-related court decision. Notably, IQOS marketing increasingly targeted key consumer groups (eg, women). Given IQOS' potential return to the United States, PM's use of FDA's MRTPA to promote IQOS as a risk reduction product in other countries, and FDA's MRTPA for other products, it is crucial to monitor products receiving MRTPA, their marketing, and their population impact, domestically and in other countries.
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IQOS marketing strategies in the USA before and after US FDA modified risk tobacco product authorisation. Tob Control 2023; 32:418-427. [PMID: 34667105 PMCID: PMC9016087 DOI: 10.1136/tobaccocontrol-2021-056819] [Citation(s) in RCA: 20] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Accepted: 09/27/2021] [Indexed: 11/03/2022]
Abstract
INTRODUCTION Given that the US Food and Drug Administration (FDA) authorised reduced exposure messaging to be used in IQOS marketing, we examined: (1) IQOS ad content; (2) advertising media channels and (3) changes in advertising efforts over time. METHODS We conducted a mixed-methods study regarding IQOS ad content (headlines, themes, images), ad occurrence characteristics (including content, media channels and adspend) in the USA from August 2019 to April 2021 using Numerator advertising/marketing data. RESULTS Across 24 unique ads and 591 occurrences (84.6% online, 8.0% print, 7.4% mobile), there was $4 902 110 total adspend (98.9% allocated to print). Across unique ads, occurrences and adspend, prominent themes included 'real tobacco' (45.8%, 47.4%, 30.1%, respectively), less odour/ash (29.2%, 21.0%, 29.9%) and switching from cigarettes (25.0%, 19.5%, 69.4%), and images mainly featured the product alone (58.2%, 61.4%, 99.5%) or with women (25.0%, 19.1%, 0.3%). Per occurrences and adspend, the most prominent media channel themes (eg, magazine/website topics) were technology (19.3%, 10.6%), women's fashion (18.1%, 26.2%), weather/news (9.0%, 15.3%) and entertainment/pop culture/gaming (8.5%, 23.1%). Ad themes appearing only post-FDA authorisation included switching from traditional cigarettes, same-day/home-delivery, convenience (eg, use indoors), reduced exposure to some dangerous substances, science/research and distinction from e-cigarettes. Overall adspend per occurrence increased postauthorisation (p=0.016); the highest adspend per unique ad (69.3% of total) focused on ads featuring reduced exposure. CONCLUSIONS Regulatory efforts must be informed by ongoing surveillance of IQOS marketing efforts and its impacts, particularly how specific consumer subgroups (eg, tobacco non-users, women, young people) are impacted by marketing exposure.
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Impact of different health warning label and reduced exposure messages in IQOS ads on perceptions among US and Israeli adults. Prev Med Rep 2023; 33:102209. [PMID: 37223575 PMCID: PMC10201851 DOI: 10.1016/j.pmedr.2023.102209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 12/16/2022] [Accepted: 04/12/2023] [Indexed: 05/25/2023] Open
Abstract
Heated tobacco products (HTPs; e.g., IQOS) are advertised as safer than cigarettes or an alternative, yet required health warning labels (HWLS) in many countries, including the US and Israel, do not consider whether HTP ads undermine HWLs, particularly those that do not explicitly address HTPs. In 2021, a randomized 4 × 3 factorial experiment among 2,222 US and Israeli adults examined IQOS ads with differing: 1) HWLs (i.e., smoking risks, prompt to quit, HTP-specific, control); and 2) ad messages (i.e., slight distancing: "cigarette-like satisfaction, no odor", clear distancing: "looking for an alternative?", control). Outcomes were perceived relative harm (vs cigarettes), exposure to harmful chemicals, and disease risk and likelihood of trying or suggesting IQOS to smokers. Ordinal logistic regression was used, adjusted for covariates. One HWL effect was found: risk (vs control) increased perceived relative harm (aOR = 1.21, CI = 1.03-1.41) and exposure (aOR = 1.22, CI = 1.04-1.42) and decreased likelihood of trying IQOS (aOR = 0.82, CI = 0.69-0.97). Both slight and clear distancing ads (vs control) decreased perceived harm (aOR = 0.85, CI = 0.75-0.97; aOR = 0.63, CI = 0.55-0.72, respectively) and increased likelihood of suggesting IQOS to smokers (aOR = 1.23, CI = 1.07-1.41; aOR = 1.28, CI = 1.11-1.47); slight distancing decreased perceived disease risk (aOR = 0.85, CI = 0.75-0.97); and clear distancing decreased perceived exposure (aOR = 0.73, CI = 0.64-0.83). Clear (vs slight) distancing decreased perceived relative harm (aOR = 0.74, CI = 0.65-0.85) and exposure (aOR = 0.82, CI = 0.71-0.93). One interaction effect was found: the quitting HWL and clear distancing led to particularly low perceived relative harm (aOR = 0.63, CI = 0.43-0.93). Regulatory agencies must monitor the impacts of advertising, including reduced risk/exposure messaging on perceptions of HWL messages, to inform future regulatory efforts.
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Which Way? Indigenous-led Smoking Cessation Care: Knowledge, Attitudes and Practices of Aboriginal and Torres Strait Islander Health Workers and Practitioners - A National Cross-sectional Survey. Nicotine Tob Res 2023; 25:788-795. [PMID: 36334273 PMCID: PMC10032178 DOI: 10.1093/ntr/ntac256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Revised: 10/09/2022] [Accepted: 11/04/2022] [Indexed: 11/08/2022]
Abstract
INTRODUCTION Tobacco is the leading preventable cause of morbidity and mortality for Aboriginal and Torres Strait Islander people. Accordingly, the provisions of culturally safe and effective smoking cessation strategies are crucial. While previous research has suggested Aboriginal Health Workers/Practitioners are well placed to provide smoking cessation care, no research to date has explored the workforce knowledge, attitudes and practices in offering best practice cessation care. METHODS A cross-sectional study was conducted among Aboriginal Health Workers/Practitioners from June to September 2021. Descriptive and inferential statistics were conducted to examine participant characteristics, provision of smoking cessation care, and explore the factors associated with smoking cessation care. RESULTS Out of 1052 registered Aboriginal Health Workers/Practitioners, 256 participants completed the full survey (24.3%). Smoking cessation counseling was always provided by 41.9%; provided some of the time by 42.4%, and never provided by 12.9%. Combination NRT and Quitline referral were always offered by 23.1% and 44.9% of participants, respectively. Those that received training, felt smoking cessation care was part of their role, and were based in Aboriginal Community Controlled Health Organization were significantly more likely to offer best practice smoking cessation care. CONCLUSION Aboriginal Health Workers/Practitioners and Aboriginal Community Controlled Health Organizations play a critical role in delivering high quality, evidence based and culturally safe care to Aboriginal and Torres Strait Islander people. Aboriginal Health Workers/Practitioners are well placed to offer smoking cessation care. Ongoing funding and implementation of a targeted smoking cessation workforce with appropriate training and resources are urgently required. IMPLICATIONS Aboriginal Health Workers/Practitioners are well placed to offer culturally safe, best practice smoking cessation care. However, due to the magnitude and complexity of Aboriginal Health Workers/Practitioners roles, it is challenging for smoking cessation care to be consistently and feasibly integrated into usual care. Acknowledging Australia's National Preventative Health Strategy target of 27% or less Aboriginal and Torres Strait Islander people smoking by 2030, urgent investment and resourcing must be directed to building a skilled workforce to support quitting and maintaining smokefree behaviors, ensuring equitable access to smoking cessation care for Aboriginal and Torres Strait Islander peoples.
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Industry marketing of tobacco products on social media: case study of Philip Morris International's IQOS. Tob Control 2023:tc-2022-057833. [PMID: 36927516 DOI: 10.1136/tc-2022-057833] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Accepted: 03/01/2023] [Indexed: 03/18/2023]
Abstract
SIGNIFICANCE Newer tobacco products might be particularly likely to use social media as they emerge in the global market. Little is known about the official use of social media in marketing heated tobacco products (HTPs). This study examined Philip Morris International's (PMI) social media marketing globally of its leading HTP, IQOS. METHODS PMI IQOS country-specific official websites were accessed (N=59) in May to September 2022 and social media accounts listed were recorded. Accounts were then coded for their number of posts in the past month and year and for their number of subscribers. Posts on online accounts with at least one past-month post were categorised to describe the post's function: instructional, general advertising, price promotions or event promotions. RESULTS Of the 59 country websites, 45 (76.3%) listed at least one social media account; of these, an average of 2.5 accounts (SD=0.8) were listed. Across websites, 111 accounts were identified: 42 Facebook, 23 YouTube, 21 Twitter, 19 Instagram, 2 Telegram, 1 LinkedIn, 1 KakaoTalk, 1 VK and 1 LINE. Across YouTube, Twitter and Instagram, accounts made 2550 past-year posts and had ~490 961 subscribers. Of the 165 past-month posts, 101 (60.1%) functioned as general advertising, 30 (17.9%) instructional, 29 (17.3%) event promotions and 8 (4.8%) price promotions. CONCLUSION Social media posts were used to engage consumers with advertising, event promotions, product use instructions and price promotions. The study provides evidence of the company-sponsored official marketing of an HTP via social media globally, underscoring the need for monitoring and tobacco control regulatory efforts in the digital arena.
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'A war of a different kind': local municipalities' experiences in managing the COVID-19 pandemic in Israel-a qualitative study. BMJ Open 2023; 13:e068226. [PMID: 36921952 PMCID: PMC10030277 DOI: 10.1136/bmjopen-2022-068226] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/17/2023] Open
Abstract
OBJECTIVES In Israel, in 2020, 57/257 local municipalities were part of the Healthy Cities Network (HCN). HCN municipalities have a strong political commitment to health promotion and reducing health inequalities. This research aimed to (1) explore local municipalities' management of the pandemic and (2) assess whether belonging to the HCN impacted this management. DESIGN, SETTING AND PARTICIPANTS Fourteen municipalities were chosen-seven HCN municipalities, matched to seven non-HCN municipalities. In each municipality, semistructured telephone interviews were conducted with three to four officials. Interviews were recorded, transcribed and analysed using inductive thematic coding, both in general and specifically to compare HCN and non-HCN municipalities. RESULTS Forty-two interviews were conducted, with five main themes: (1) relationship with the government; with the transference of information to the local municipalities found to be challenging and a strong need for more independence at the local level; (2) contact with residents which was divided into several actions, such as mapping the city population, supporting vulnerable populations and managing volunteers; (3) relationships within the municipality which included a sense of collaboration and community but also a feeling of wear out; (4) difference between the first lockdown compared with following lockdowns; within these themes, no significant differences were found between HCN municipalities and non-HCN municipalities and (5) the role of the Healthy City (HC) coordinator which was critical in several municipalities. They served as brokers, had a pre-existing intersectoral network and held a broader vision of health. CONCLUSIONS Local municipalities in Israel played an important role in the pandemic response. Municipalities requested a central information source and more independence at the local level. Challenges and responses were similar across municipalities and residents, regardless of their HCN status. However, in some municipalities, the role of the HC coordinator was crucial for the pandemic response due to pre-existing interprofessional and intersectoral networks.
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IQOS Use and Interest by Sociodemographic and Tobacco Behavior Characteristics among Adults in the US and Israel. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:3141. [PMID: 36833831 PMCID: PMC9961058 DOI: 10.3390/ijerph20043141] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 02/04/2023] [Accepted: 02/06/2023] [Indexed: 06/18/2023]
Abstract
Heated tobacco products (HTPs) have expanded globally. IQOS, a global HTP leader, was launched in Israel in 2016 and the US in 2019. To inform tobacco control efforts, it is critical to understand who is likely to use HTPs in different countries with distinct regulatory and marketing contexts. Thus, we conducted a cross-sectional survey among adult (ages 18-45) online panelists in the US (n = 1128) and Israel (n = 1094), oversampling tobacco users, in the fall of 2021, and used multivariable regression to identify correlates of (1) ever using IQOS; (2) past-month vs. former among ever users; and (3) interest in trying IQOS among never users. Among US adults, correlates of ever use included being Asian (aOR = 3.30) or Hispanic (aOR = 2.83) vs. White, and past-month use of cigarettes (aOR = 3.32), e-cigarettes (aOR = 2.67), and other tobacco (aOR = 3.34); in Israel, correlates included being younger (aOR = 0.97), male (aOR = 1.64), and cigarette (aOR = 4.01), e-cigarette (aOR = 1.92) and other tobacco use (aOR = 1.63). Among never users, correlates of greater interest included cigarette and e-cigarette use in the US (β = 0.57, β = 0.90) and Israel (β = 0.88, β = 0.92). IQOS use prevalence was low (US: 3.0%; Israel: 16.2%) but represented in vulnerable subpopulations (younger adults, racial/ethnic minorities).
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Profiles of tobacco product use and related consumer characteristics in the US and Israel: A multiple-group latent class analysis. Glob Public Health 2023; 18:2267652. [PMID: 37885277 PMCID: PMC10683865 DOI: 10.1080/17441692.2023.2267652] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Accepted: 09/29/2023] [Indexed: 10/28/2023]
Abstract
Despite tobacco marketing diversification, limited research has examined use profiles across countries, particularly in relation to consumer values (e.g. appeal of innovation, conscientiousness). Using 2021 data, latent class analysis assessed past-month use of seven tobacco products (cigarettes, electronic cigarettes [e-cigarettes], heated tobacco products, cigars, hookah, pipe, smokeless) among adults reporting past-month use in the United States (US n = 382) and Israel (n = 561). Multivariable multinomial regression examined consumer values and sociodemographics in relation to country-specific class membership. US classes included: primarily cigarette 58.1%; e-cigarette-no cigarette 17.5%; primarily cigar 14.9%; and poly-product 9.9%. Higher innovation correlated with e-cigarette-no cigarette and poly-product (vs. primarily cigarette) use. Other correlates included being: younger with e-cigarette-no cigarette; male, Black, and more educated with primarily cigar; and Black and Asian (vs. White) with poly-product. Israel classes included: primarily cigarette 39.0%; moderate poly-product 40.3%; high poly-product 13.4%; and hookah 7.3%. Lower conscientiousness correlated with moderate poly-product (vs. primarily cigarette) use; higher innovation correlated with high poly-product; lower innovation correlated with hookah. Other correlates included being: younger, male, and more educated with moderate poly-product; male and sexual minority with high poly-product; and Arab with hookah. Tobacco consumer segments within and across countries likely reflect different consumer values and industry marketing targets.
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"It Needs a Full-Time Dedicated Person to Do This Job in Our Local Communities with Our Aboriginal Health Services"-Aboriginal and Torres Strait Islander Health Workers and Practitioners Perspectives on Supporting Smoking Cessation during Pregnancy. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 20:28. [PMID: 36612349 PMCID: PMC9819709 DOI: 10.3390/ijerph20010028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/05/2022] [Revised: 11/29/2022] [Accepted: 12/07/2022] [Indexed: 06/17/2023]
Abstract
BACKGROUND Aboriginal and Torres Strait Islander women deserve improved smoking cessation support. Aboriginal health workers (AHW) and practitioners (AHP) can be central to the provision of culturally safe smoking cessation care (SCC). The objective of this study is to explore attitudes and the perceived role of AHWs/AHPs toward providing SCC to Aboriginal and Torres Strait Islander pregnant women. METHOD A mixed-method study using quantitative and qualitative data was conducted among AHW/AHPs in 2021 across Australia. Descriptive and analytical statistics were used to characterise AHWs'/AHPs' attitudes towards SCC and to evaluate the factors associated with perceptions of who is best placed to provide SCC. RESULTS From the total AHW/AHP workforce, 21.2% (223) completed the survey. Less than half (48.4%) believed that AHW/AHP were best placed to provide SCC for pregnant women. The majority believed that group-based supports (82.5%) and cultural support programs (63.7%) were the best strategies to support Aboriginal and Torres Strait Islander pregnant women to quit smoking. CONCLUSION This study highlights the need to enhance SCC offered to Aboriginal and Torres Strait Islander pregnant women. A targeted workforce dedicated to smoking cessation should be resourced, including funding, standardised training, and ongoing SCC support tailored to Aboriginal and Torres Strait Islander pregnant women.
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'It's like if a vape pen and a cigarette had a baby': a mixed methods study of perceptions and use of IQOS among US young adults. HEALTH EDUCATION RESEARCH 2022; 37:364-377. [PMID: 36036655 PMCID: PMC9502850 DOI: 10.1093/her/cyac019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Revised: 07/26/2022] [Accepted: 07/27/2022] [Indexed: 06/15/2023]
Abstract
Young adults' perceptions and use of heated tobacco products (HTPs) are understudied. This mixed methods study analyzed (i) Fall 2020 survey data from 2470 US young adults (meanage = 24.67; 19.5% and 25.2% past-month cigarette and e-cigarette use; 4.1% ever HTP use) assessing HTP use intentions and perceptions (1 = not at all to 7 = extremely) and (ii) Spring 2021 interview data regarding IQOS (most widely available HTP) in a subset of 40 e-cigarette users. Among survey participants, HTPs versus cigarettes and e-cigarettes showed lower use intentions (mean = 1.27 vs. mean = 1.73, mean = 2.16) but were perceived as less addictive (mean = 5.11 vs. mean = 6.28, mean = 5.82) and harmful (mean = 5.37 vs. mean = 6.65, mean = 5.62). HTPs were perceived more socially acceptable than cigarettes but less than e-cigarettes (mean = 3.39 vs. mean = 3.13, mean = 4.37). Among interviewees, most reported limited HTP knowledge. A few perceived IQOS as a hybrid of traditional cigarettes and e-cigarettes. Most perceived IQOS as harmful but less harmful than cigarettes and were uncertain in relation to e-cigarettes. Over half reported minimal interest in trying IQOS; common reasons included IQOS containing tobacco, limited flavors and use complexity. The varied perceptions of IQOS versus cigarettes and e-cigarettes underscore the need for continued surveillance of perceptions, use and marketing of IQOS to inform regulatory oversight and potential interventions.
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Correlates of Perceptions, Use, and Intention to Use Heated Tobacco Products Among US Young Adults in 2020. Nicotine Tob Res 2022; 24:1968-1977. [PMID: 35901840 PMCID: PMC9653079 DOI: 10.1093/ntr/ntac185] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 06/09/2022] [Accepted: 07/25/2022] [Indexed: 01/03/2023]
Abstract
INTRODUCTION Despite the increased heated tobacco product (HTP) marketing in the United States, little is known about HTP perceptions and correlates of HTP use and use intentions among young adults. AIMS AND METHODS Using 2020 cross-sectional data from 2,470 young adults (ages 18-34) from 6 US metropolitan areas, we conducted exploratory factor analysis to identify factors regarding perceived utility/appeal of HTPs, specifically IQOS, and examined these factors in relation to lifetime HTP use and use intentions, using multivariable logistic and linear regression, respectively. RESULTS 19.1% had heard of HTPs and 4.1% ever used HTPs; 14.7% had heard of IQOS specifically and 2.8% were ever-users. Use intentions were low (M = 1.27, scale: 1 = not at all to 7 = extremely). Factor analysis identified five perceived utility/appeal factors: innovation (M = 3.17, scale: 1 = not at all to 7 = extremely), cigarette substitute (M = 2.99), and youth appeal (M = 2.82), e-cigarette/nicotine substitute (M = 2.36), and fashionable (M = 2.04). Controlling for sociodemographics and other tobacco use, perceiving IQOS as more fashionable and e-cigarette substitutes positively correlated with lifetime HTP use (aOR = 1.60, 95%CI = 1.17, 2.17; aOR = 1.48, 95%CI = 1.11, 1.97, respectively) and use intentions (β = 0.26, 95%CI = 0.21, 0.30; β = 0.14, 95%CI = 0.09, 0.18); perceiving IQOS as cigarette substitutes negatively correlated with ever use (aOR = 0.74, 95%CI = 0.56, 0.97) and use intentions (β = -0.06, 95%CI = -0.10, -0.03). Correlation patterns were similar among past-month cigarette, e-cigarette, and any-tobacco users. CONCLUSIONS Although HTP awareness and use were low, monitoring HTP perceptions and reasons for use as HTPs become more prominent is critical in anticipating their potential impact, particularly as more products seek FDA authorization to use reduced risk or exposure marketing claims. IMPLICATIONS Awareness, ever use, and intentions to use heated tobacco products (HTPs) were low among US young adults in 2020. Perceiving IQOS as fashionable and an e-cigarette substitute were positively correlated with ever use and intention to use HTPs. In addition, perceiving IQOS as a cigarette substitute was negatively correlated with ever use of HTPs and HTP use intentions. Continued surveillance on perceptions and use behaviors is needed to better understand use patterns, intentions to use, and reasons for using HTPs.
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Unclear role for e-cigarettes during pregnancy. Nat Med 2022; 28:900-901. [PMID: 35577965 DOI: 10.1038/s41591-022-01795-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Drivers and Passengers in Vehicles Driven Under the Influence of Alcohol or Marijuana: Behavior Profiles and Risk Factors Among Young Adults in a Longitudinal Study. J Stud Alcohol Drugs 2022. [DOI: 10.15288/jsad.2022.83.342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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Drivers and Passengers in Vehicles Driven Under the Influence of Alcohol or Marijuana: Behavior Profiles and Risk Factors Among Young Adults in a Longitudinal Study. J Stud Alcohol Drugs 2022; 83:342-351. [PMID: 35590174 PMCID: PMC9135000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Accepted: 10/29/2021] [Indexed: 05/03/2023] Open
Abstract
OBJECTIVE Little research has examined psychosocial influences differentially associated with driving under the influence of alcohol and marijuana (DUIA/DUIM) or of being a passenger in a vehicle driven by someone under the influence of alcohol or marijuana (PVA/PVM). METHOD Using 2019 survey data among 2,375 young adults (M age = 24.66, 57.7% female, 51.2% in states with legal marijuana retail) in a longitudinal study examining vaping retail, we conducted latent class analysis (LCA) to identify classes of DUI-related behaviors and multinomial logistic regression to identify correlates of classes (e.g., individual, interpersonal, policy related). RESULTS A total of 22.6% reported past-month DUIA, 24.1% DUIM, 29.7% PVA, and 27.7% PVM. Of those reporting DUIA, 41.4% reported DUIM, 71.8% PVA, and 40.7% PVM. Of those reporting DUIM, 47.7% reported DUIA, 49.6% PVA, and 83.8% PVM. LCA indicated four classes: alcohol and marijuana risk takers (5.9%), all of whom reported DUIA and DUIM, 81.2% PVA, and 89.2% PVM; marijuana risk takers (14.2%), 45.1% DUIM, 100% PVM, 7.8% PVA, and 0% DUIA; alcohol risk takers (24.1%), 40.1% DUIA, 98.6% PVA, 2.6% DUIM, and 33.8% PVM; and low risk takers (55.8%), 8.7% DUIA, 4.5% DUIM, and 0% PVA/PVM. Relative to the other classes, alcohol and marijuana risk takers were more likely male, heterosexual, and White, and alcohol and marijuana risk takers reported greater depressive symptoms. Influences of parent/peer alcohol versus marijuana use were specific to the respective DUI risk behaviors. No differences emerged for legal marijuana retail. CONCLUSIONS Findings regarding those at particular risk, social influences, and situations under which DUI-related behaviors occur should inform future interventions and research.
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IQOS marketing strategies at point-of-sales: a cross-sectional survey with retailers. Tob Control 2022:tobaccocontrol-2021-057083. [PMID: 35140170 DOI: 10.1136/tobaccocontrol-2021-057083] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 01/25/2022] [Indexed: 12/11/2022]
Abstract
BACKGROUND The point-of-sale (POS) is adapting to marketing restrictions, societal changes and the inclusion of new products, such as heated tobacco products (eg, Philip Morris International's (PMI) IQOS device and HEETS sticks). We aimed to assess (1) PMI's influences on IQOS/HEETS POS marketing and (2) the implications of the new legislation (POS display ban and plain packaging) for retailers. METHODS A cross-sectional survey of 43 IQOS/HEETS POS owners/managers in five Israeli cities assessed POS and participant characteristics, marketing strategies, attitudes towards IQOS, and POS implications of the legislation and COVID-19, including industry reactions. Bivariate analysis explored differences between POS selling of the IQOS device versus POS selling of HEETS only. RESULTS A higher proportion of those carrying IQOS (n=15) (vs HEETS only) had special displays (100% vs 17.9%, p<0.001) and interacted with specific IQOS salespersons (73.3% vs 28.6%, p=0.013). Common promotions were financial incentives based on HEETS sales for retailers (37.5%) and price discounts on HEETS for customers (48.7%). Most indicated positive attitudes towards IQOS (72.1%; eg, 'less harmful'), opposition to the legislation (62.7%), limited government assistance to implement the legislation (62.8%), and industry provision of display cases and/or signage to comply with the legislation (67.4%). CONCLUSION PMI uses similar tactics to promote IQOS at POS as they previously used for combustible products, including direct promotional activities with retailers, and circumvented legislation by using special displays and signage. Governments need to ban these measures and support retailers with clear practical guidance regarding the implementation of marketing restrictions at POS.
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Anticipating IQOS market expansion in the United States. Tob Prev Cessat 2022; 8:04. [PMID: 35174298 PMCID: PMC8792994 DOI: 10.18332/tpc/144650] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Revised: 12/07/2021] [Accepted: 12/09/2021] [Indexed: 11/24/2022]
Abstract
IQOS is sold globally in over 60 countries and entered the US market in 2019 and by 17 May 2021, it was sold in four states: Georgia (Atlanta, Buford), Virginia (Richmond, Tysons), North Carolina (Charlotte, Raleigh), and South Carolina (Charleston, Myrtle Beach), and had 52 specialty stores and 400 retail outlets. While US sales stopped on 29 November 2021 due to a patent lawsuit, they may resume in the near future. As IQOS distribution will likely expand in the future throughout the US, surveillance systems are needed to inform local and national regulatory efforts. Key decision-driving factors for IQOS expansion likely include: 1) general market factors such as larger population/market size and higher median household income; 2) specific IQOS target market factors such as higher consumer spending and smoker prevalence; and 3) more lenient tobacco control context (e.g. cigarette excise taxes, smoke-free policies, state cessation/prevention funding). Likely targets for expansion are markets in Nashville, Tennessee; St. Louis, Missouri; and Louisville, Kentucky. Public health surveillance efforts should monitor IQOS market expansion (e.g. new markets, online direct-toconsumer sales) and IQOS marketing activities (e.g. advertisements, direct marketing, social media, point-of-sale promotions, product trials).
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Changes in Smoking Behavior, Stress, and Sleep Duration Among Israeli Hospital Workers During the COVID-19 Pandemic: A Cross-sectional Study. Nicotine Tob Res 2022; 25:274-281. [PMID: 35029653 PMCID: PMC9383236 DOI: 10.1093/ntr/ntac014] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 12/12/2021] [Accepted: 01/12/2022] [Indexed: 01/11/2023]
Abstract
INTRODUCTION Being on the COVID-19 frontline could negatively impact healthcare workers mental health. AIMS AND METHODS We examined smoking behavior changes and the association with changes in stress levels and sleeping patterns among hospital workers during the pandemic. An online survey was conducted among employees of a large tertiary medical center in Israel. Data collected included sociodemographic characteristics, smoking status, changes in smoking behavior (for smokers only), stress levels, and sleeping duration during the pandemic, perceptions of risk for COVID-19 infection and disease severity, presence of a chronic illness, COVID-19 exposure and infection status, and involvement in treating COVID-19 patients. Multinominal logistic regression modeling assessed the effects of covariates on smoking behavior change. RESULTS Overall, 920 healthcare workers participated. More than half (59%) reported an increase in stress and 28% reported changes in sleep duration. Thirty-five percent of current smokers (n = 132), reported smoking more. Increased stress was associated with an increase in smoking (odds ratio [OR] = 3.45, 95% confidence interval [CI] 1.2-9.4, p = .016), and an increase in sleeping hours was significantly associated with a decrease in smoking (OR = 6.42, 95% CI 1.2-32, p = .02). Among smokers who reported perceived levels of stress to be the same or slightly higher than prepandemic, a strong inverse association was observed between sleep and smoking. CONCLUSIONS The mental health consequences of the pandemic, specifically for health workers, could lead to negative changes in smoking behaviors. Together with offering stress-management skills and coping strategies, mental health support should target smoking behaviors and sleep disturbances. IMPLICATIONS A high proportion of healthcare employees working in a large tertiary medical center in Israel reported increased stress levels during the COVID-19 pandemic. Among smokers, increased stress levels were associated with increased smoking, suggesting that smoking may be a coping mechanism for COVID-19-related stress. Offering stress-management skills and coping strategies can mitigate the negative impact on health workers' smoking behavior, and reduce stress-related increases in smoking behavior.
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Tobacco legislation reform and industry response in Israel. Tob Control 2021; 30:e62-e64. [PMID: 32887740 PMCID: PMC8191540 DOI: 10.1136/tobaccocontrol-2020-056041] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 07/27/2020] [Accepted: 08/04/2020] [Indexed: 11/04/2022]
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Local municipalities experiences in managing the covid19 pandemic in Israel – a qualitative study. Eur J Public Health 2021. [DOI: 10.1093/eurpub/ckab164.480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
Local municipalities have played a central role in the management of the COVID19 pandemic and the mitigation of its grave health, economic and social consequences. In Israel, 57 local municipalities (out of 257) are part of the Healthy Cities Network (HCN). HCN Municipalities have a strong commitment to health promotion and reducing health inequalities. This study explores Israeli local municipalities' management of the pandemic and assesses whether belonging to the HCN impacted this management.
Methods
Fourteen municipalities were chosen - seven HCN municipalities, matched to seven non-HCN municipalities. Matching was based on geographical location, socio-economic status, size and ethnicity. In each municipality semi-structured telephone interviews were conducted with the Mayor or CEO, Head of the Welfare Department, and the person responsible for health (in HCN municipalities this would be the HCN coordinator). Interviews were transcribed and coded using inductive thematic coding.
Results (preliminary)
Themes that emerged from all municipalities included: a) difference in the management during the first lockdown compared to following lockdowns and pandemic ‘routine'; b) difficulties with data management within the municipality; c) need for a central governmental contact; d) desire for more independence and control at the local level; e) distinct regional characteristics impact pandemic management. The Healthy Cities coordinator played a key role in some municipalities, but not in others.
Conclusions
Local municipalities in Israel had an essential role in the pandemic response, adapting their actions as the pandemic and governmental measures unfolded. Challenges and responses were similar across municipalities, regardless of their HCN status. However, in some municipalities, the role of the HCN coordinator was crucial for the pandemic response.
Key messages
Challenges and responses were similar across municipalities, regardless of their HCN status. In some municipalities, the role of the HCN coordinator was crucial for the pandemic response.
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Changes in smoking, stress, and sleep duration among Israeli hospital workers during COVID-19. Eur J Public Health 2021. [PMCID: PMC8574784 DOI: 10.1093/eurpub/ckab164.717] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Mental health impacts of the COVID-19 pandemic, especially among frontline health workers, have been widely noted. The aim of this study was to explore smoking behaviour changes and associations with perceived changes in stress levels and sleep duration among Israeli hospital workers during the COVID-19 pandemic. Methods An online cross-sectional survey was conducted (May-June, 2020) among employees of a large tertiary medical centre. Data collected included socio-demographic characteristics, smoking status, perceptions of risk for COVID-19 infection and disease severity, presence of a chronic illness, COVID-19 exposure and infection status, involvement in treating COVID-19 patients, changes in stress levels, sleep duration, and in smoking behaviour during the pandemic. Multi-nominal logistic regression modelling assessed the effect of covariates on smoking behaviour changes. Results More than half (59%) of the 920 respondents, reported an increase in stress levels, and 28% reported changes in sleep duration. One-third (35%) of current smokers (n = 132) reported smoking more during COVID-19. Increased smoking was associated with increased stress (OR = 3.45; 95% CI 1.2-9.4). In addition, a significant association was demonstrated between an increase in sleeping hours and a decrease in smoking (OR = 6.62, 95% CI 1.2-32). The negative association between changes in smoking and sleep duration was strongest among smokers who reported perceived levels of stress to be the same or slightly higher than pre-COVID-19. Conclusions The mental health implications of the COVID-19 pandemic, specifically for health workers, include negative changes in smoking behaviours and sleep patterns. Mental health support for health workers should address smoking behaviours alongside stress-management skills and coping strategies. Lessons learned from the current pandemic should guide us as the world prepares for a future health crisis. Key messages Increased stress was linked with increased smoking among Israeli hospital workers during COVID-19. Mental health support should target smoking together with offering stress-management skills.
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IQOS Marketing in the US: The Need to Study the Impact of FDA Modified Exposure Authorization, Marketing Distribution Channels, and Potential Targeting of Consumers. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:10551. [PMID: 34639851 PMCID: PMC8508084 DOI: 10.3390/ijerph181910551] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Revised: 09/22/2021] [Accepted: 10/02/2021] [Indexed: 02/01/2023]
Abstract
IQOS, the leading heated tobacco product globally, recently received 'reduced exposure' authorization from the US Food and Drug Administration. Independent research focusing on IQOS marketing and potential impact on consumers' perceptions and behavior, and ultimately public health, is critical. The literature to date has underscored several concerns. First, Philip Morris's (PM's) marketing distribution requires scrutiny, particularly given its innovative promotional strategies. For example, IQOS is distributed via unique points-of-sale (POS; e.g., specialty and pop-up stores, "corners" in convenience stores) and uses various other opportunities (e.g., social media, sponsored events, direct-to-consumer). Second, although PM claims that IQOS' target market is current combustible tobacco users and not young people, the literature indicates that in some populations, IQOS use is equally prominent among smokers and nonsmokers, and that specific subgroups (e.g., young adults, women) are targeted. Third, the impact of IQOS' use of ad content promoting IQOS health benefits must be studied (e.g., how consumers interpret modified exposure messages). In conclusion, surveillance of IQOS marketing, particularly following reduced exposure authorization, is critical for obtaining valuable data to estimate population impact, particularly among population subgroups (e.g., young adults), and inform future tobacco regulation. These considerations have implications beyond IQOS-to other products and companies.
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Correction to: Health providers' and pregnant women's perspectives about smoking cessation support: a COM-B analysis of a global systematic review of qualitative studies. BMC Pregnancy Childbirth 2021; 21:613. [PMID: 34496776 PMCID: PMC8427828 DOI: 10.1186/s12884-021-04094-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Health providers' and pregnant women's perspectives about smoking cessation support: a COM-B analysis of a global systematic review of qualitative studies. BMC Pregnancy Childbirth 2021; 21:550. [PMID: 34384387 PMCID: PMC8359058 DOI: 10.1186/s12884-021-03773-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Accepted: 04/05/2021] [Indexed: 12/15/2022] Open
Abstract
Background Smoking cessation in pregnancy has unique challenges. Health providers (HP) may need support to successfully implement smoking cessation care (SCC) for pregnant women (PW). We aimed to synthesize qualitative data about views of HPs and PW on SCC during pregnancy using COM-B (Capability, Opportunity, Motivation, Behaviour) framework. Methods A systematic search of online databases (MEDLINE, EMBASE, PsycINFO and CINAHL) using PRISMA guidelines. PW’s and HPs’ quotes, as well as the authors’ analysis, were extracted and double-coded (30%) using the COM-B framework. Results Thirty-two studies included research from 5 continents: twelve on HPs’ perspectives, 16 on PW’s perspectives, four papers included both. HPs’ capability and motivation were affected by role confusion and a lack of training, time, and resources to provide interventions. HPs acknowledged that advice should be delivered while taking women’s psychological state (capability) and stressors into consideration. Pregnant women’s physical capabilities to quit (e.g., increased metabolism of nicotine and dependence) was seldom addressed due to uncertainty about nicotine replacement therapy (NRT) use in pregnancy. Improving women’s motivation to quit depended on explaining the risks of smoking versus the safety of quit methods. Women considered advice from HPs during antenatal visits as effective, if accompanied by resources, peer support, feedback, and encouragement. Conclusions HPs found it challenging to provide effective SCC due to lack of training, time, and role confusion. The inability to address psychological stress in women and inadequate use of pharmacotherapy were additional barriers. These findings could aid in designing training programs that address HPs’ and PW’s attitudes and supportive campaigns for pregnant smokers. Supplementary Information The online version contains supplementary material available at 10.1186/s12884-021-03773-x.
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Assessment of IQOS Marketing Strategies at Points-of-Sale in Israel at a Time of Regulatory Transition. Nicotine Tob Res 2021; 24:100-108. [PMID: 34216461 DOI: 10.1093/ntr/ntab142] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Accepted: 07/01/2021] [Indexed: 11/13/2022]
Abstract
INTRODUCTION IQOS, a tobacco heating system, and accompanying tobacco sticks (HEETS) entered the Israeli market in 2016, prior to rapid regulatory change. This study assessed IQOS marketing strategies and regulatory compliance at IQOS/HEETS point-of-sale (POS) in Israel in December 17, 2019-January 7, 2020, after the ban on advertisement went into effect in March 8, 2019. METHODS Research staff audited 80 randomly-selected IQOS/HEETS POS in 4 cities using a structured form to assess store types, product placement, price, promotional strategies, and regulatory compliance. POS data was linked to neighbourhood characteristics, including socioeconomic status (SES), ethnicity, and proximity (under 300 meters) to schools. RESULTS Almost half of the stores (48.7%) were convenience stores. HEETS were visible to the customers in 46.1% of POS, 35% carried at least four HEETS colours, 20.0% had IQOS/HEETS special displays, and 13.8% displayed HEETS near youth-oriented merchandise. Mean HEETS pack price was 8.7 USD (range: 7.5-11.3 USD), 27% more than the least expensive cigarette pack, and 39% less than the most expensive cigarette. HEETS promotions were uncommon. Compliance with the newly-introduced advertisement ban was fairly high for HEETS (94.8%). Only one POS was located in a low-SES area; 68.7% were in close proximity to a school. CONCLUSION The relatively limited IQOS/HEETS marketing at POS suggests that, with regulatory changes, online or other forms of marketing might be prioritized. IQOS may be promoted to higher SES populations, as indicated by pricing and POS neighbourhood characteristics. Access near schools and placement near youth-oriented merchandise are potential concerns necessitating further research. IMPLICATIONS Globally, the point-of-sale is considered the least regulated channel for advertising and marketing of tobacco products. Assessing IQOS marketing strategies at the point-of-sale provides valuable findings that can inform regulatory efforts in Israel and other countries as well. Limited IQOS/HEETS marketing at point-of-sale suggests that primary marketing strategies may shift to online or other forms/channels as regulatory contexts become more progressive/restrictive. Ongoing surveillance of IQOS via online marketing and point-of-sales, specifically with regard to product placement and proximity to schools, is needed.
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Commentary on Simons et al. Public health implications of the suggested association between nicotine, smoking and infection with SARS-CoV-2. Addiction 2021; 116:1369-1370. [PMID: 33368844 DOI: 10.1111/add.15356] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 11/19/2020] [Indexed: 12/16/2022]
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Changes in Smoking Behaviour and Home-Smoking Rules during the Initial COVID-19 Lockdown Period in Israel. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18041931. [PMID: 33671203 PMCID: PMC7922914 DOI: 10.3390/ijerph18041931] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Revised: 01/29/2021] [Accepted: 02/11/2021] [Indexed: 02/07/2023]
Abstract
The COVID-19 pandemic has caused devastating impacts globally. To mitigate virus spread, Israel imposed severe restrictions during March–April 2020. An online cross-sectional survey was conducted in April 2020 among current and ex-smokers to explore changes in smoking behaviour and home-smoking rules during this period. Bivariate analysis and multivariate logistic regression examined associations between sociodemographic characteristics and perceived risk of infection and quitting smoking during the initial COVID-19 period. Current smoking was reported by 437 (66.2%) of the 660 participants, 46 (7%) quit during the initial restriction period, and 177 (26.8%) were ex-smokers. Nearly half (44.4%) of current smokers intensified their smoking, and 16% attempted to quit. Quitting during the COVID-19 period was significantly associated with higher education (adjusted odds ratio (aOR): 1.97, 95% CI: 1.0–3.8), not living with a smoker (aOR: 2.18, 95% CI: 1.0–4.4), and having an underlying chronic condition that increases risk for COVID-19 complications (aOR: 2.32, 95% CI: 1.1–4.6). Both an increase in smoking behaviour and in attempts to quit smoking during the initial COVID-19 pandemic were evident in this sample of adult Israeli smokers. Governments need to use this opportunity to encourage smokers to attempt quitting and create smoke-free homes, especially during lockdown conditions, while providing mental and social support to all smokers.
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[PREVALENCE OF TOBACCO SMOKING AMONG MENTAL HEALTH INPATIENTS IN ISRAEL]. HAREFUAH 2021; 160:98-103. [PMID: 33760411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
INTRODUCTION Tobacco smoking is the worldwide leading preventable cause of morbidity [1]. The prevalence of current smoking among individuals with mental illnesses is more than twice as that of the general population [2]. Despite it being a primary cause of morbidity and mortality in Israel too, there is little information and research on the features of smoking among people with mental illnesses in Israel. OBJECTIVES To present an up-to-date estimation of the prevalence of smoking among hospitalized patients with mental illness in Israel and to compare the prevalence of comorbidities among smokers and non-smokers in this population. METHODS Analyzing data obtained from an electronic medical-records database, consisting of 4646 patients with mental illness, aged 18-90 years, who were hospitalized at Geha Mental Health Center during 2005-2013. RESULTS The smoking rate among hospitalized patients with mental illness was significantly higher than the general population (51.3% versus 19.7%, respectively). The smoking rate among male hospitalized patients with mental illness was higher than that of the females (58.2% versus 42.7%, respectively), however, the difference between men and women is smaller compared to this difference in the general population. Smoking rates were highest among those with personality disorder (65.1%), bipolar disorder (58.8%) and schizophrenia (53.81%). The prevalence of comorbid substance use (alcohol or drug abuse) among hospitalized patients with mental illness was found to be higher in the smokers group than in the non-smokers group (37.4% versus 4.6%, respectively, p<0.0001). CONCLUSIONS The prevalence of smoking among hospitalized patients with mental illness in Israel is 2.74 times that of the general population in 2013, in line with the reported worldwide rate. In addition, among hospitalized patients with mental illness the prevalence of comorbid substance use (alcohol or drug abuse) was higher among the smokers than among the non-smokers.
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Feasibility of Audio-Recording Consultations with Pregnant Australian Indigenous Women to Assess Use of Smoking Cessation Behaviour Change Techniques. J Smok Cessat 2021; 2021:6668748. [PMID: 34306229 PMCID: PMC8279198 DOI: 10.1155/2021/6668748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Revised: 11/21/2020] [Accepted: 12/06/2020] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION Behavioural counselling is an effective method to improve smoking cessation during pregnancy. Audio recordings of consultations have been used previously to assess fidelity in specialized smoking cessation services, but not in primary care. AIMS The study is aimed at assessing the feasibility of audio-recording smoking cessation counselling as part of an intervention in primary care settings and exploring the number and type of behaviour change techniques (BCTs) delivered. METHODS This study was a nested feasibility study within a larger trial. Health providers (HPs) and pregnant women were asked to agree or decline audio recording their smoking-related consultations. Data collected included percentage providing consent, number of recordings performed, HP type, and date (pre/post intervention). Interviews were conducted to assess the trial procedures' acceptability. RESULTS Two services provided seven recordings, all pre-intervention. Of the 22 recruited women, 14 consented to being audio recorded (64%) and five provided recordings; of the 23 recruited HPs, 16 agreed (69%), and two provided recordings. Qualitative data suggest that HPs found audio recording difficult to remember. HPs spent on average two minutes discussing smoking and used few BCTs. CONCLUSIONS Audio recordings of smoking-related counselling were not feasible as planned. Future research will need to explore acceptable methods to assess BCT use in primary care.
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Ngu-ng-gi-la-nha (to exchange) knowledge. How is Aboriginal and Torres Strait Islander people's empowerment being upheld and reported in smoking cessation interventions during pregnancy: a systematic review. Aust J Prim Health 2020; 25:395-401. [PMID: 31586502 DOI: 10.1071/py18186] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Accepted: 08/01/2019] [Indexed: 11/23/2022]
Abstract
Smoking during pregnancy is a national priority to improve Aboriginal health. Empowerment approaches underpin the priorities set by the government to improve Aboriginal health and wellbeing; however, empowerment is seldom evaluated within interventions for Aboriginal people. Literature was searched to April 2018 and data was extracted using an assessment tool with domains of individual and community empowerment in smoking cessation during pregnancy studies with Aboriginal women. Three interventions were found in published and grey literature. Elements of individual empowerment were embedded in all interventions. Interventions considered barriers for Aboriginal women to quit smoking and areas for capacity building. Interventions used health education resources. There was limited reporting of community empowerment domains. Aboriginal ethics and capacity building was the only criterium addressed by all studies. Interventions are incorporating individual empowerment, but seldom report community empowerment. The development of reporting guidelines or extensions of current guidelines would be beneficial to set a consistently high standard reporting across Aboriginal health interventions, similar to the work conducted to develop the extension of Preferred Reporting Items for Systematic Reviews and Meta-Analyses-Equity (PRISMA-E) for health equity in systematic review reporting. Reporting empowerment domains would reflect the government priority of empowerment to improve Aboriginal health, as well as enhancing knowledge translation into practice.
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Tobacco industry tactics in response to extensive tobacco control legislation in Israel. Eur J Public Health 2020. [DOI: 10.1093/eurpub/ckaa166.1292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Issue
Tobacco control in Israel has been lagging, and smoking rates have remained stable in the last decade (∼20%). In 2018, landmark legislation was passed to go into effect during 2019- 2020. The tobacco and vaping industry employed several tactics to circumvent and test the ability to enforce the new legislation. Examining industry responses to legislative reform in Israel may inform policy and enforcement internationally.
Description of the Problem
Resulting from strong political will, supportive media, and a strong coalition of tobacco control advocates, the legislation involves: 1) advertising bans in all media, excluding print press; 2) point-of-sales display bans; 3) plain packaging with textual health warning labels; and 4) extending the legislation to include also vaping products. Industry tactics to circumvent/test this legislation were communicated through an active social media group of tobacco control coalition members who shared information regarding such tactics in all geographical areas in Israel and via different media outlets.
Results
Various measures employed by the industry included, for example, print media advertisements with branded elements in the background (prohibited by law); new signs and display boxes for heated tobacco products and e-cigarettes, at the point-of-sale, that say “An alternative to cigarettes”; distributing branded tin cases for cigarettes; Highlighting different brands online and in print media using colors and fonts that are not allowed as part of plain packaging, and including branded elements inside the cigarette package
Lessons
Anything not specifically covered or detailed or verbiage that is open to interpretation provides an opening for the industry to circumvent the legislation intentions. It is crucial that legislation be as specific and detailed as possible, anticipate industry efforts to identify such 'loopholes', and compel industry compliance through efficient enforcement.
Key messages
In response to extensive tobacco control legislation in Israel, the tobacco industry employed various tactics to bypass legislative efforts. Tobacco control legislation and regulation need to use detailed wording to prevent alternative interpretations by the tobacco industry.
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Historic tobacco legislation in Israel: a moment to celebrate. Isr J Health Policy Res 2020; 9:22. [PMID: 32366296 PMCID: PMC7199353 DOI: 10.1186/s13584-020-00384-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Accepted: 04/27/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Israel was once a leader in tobacco control, but fell behind other countries, particularly during the past decade, as smoking rates stagnated. TEXT: Landmark tobacco control legislation, which banned advertising (with the exception of the print press) and limited marketing, was passed in Israel on Dec. 31rst, 2018. The changes occurred following years of attempts which culminated in successful last-minute efforts to promote the legislation just before the early disbanding of the 20th Knesset (Israeli Parliament). Regulations concerning marketing and advertising were substantially strengthened to address all tobacco, nicotine and smoking products. Digital media was included for the first time. Electronic cigarettes, which were previously largely unregulated, now fall under existing tobacco legislation. The changes overcame intense opposition from the tobacco lobby, and occurred despite the fact that the basic elements for prevention policy postulated by the Richmond model were not in place. CONCLUSIONS This legislation represents an important and long-awaited change in Israeli tobacco control policy. Many deficiencies in existing tobacco control regulation were overcome, and some measures went beyond current international regulations. The cohesive partnership between legislators, public health organizations and professionals, advocacy groups, academia, and leading journalists was critical to this success. The progress was lauded by the World Health Organization with its highest award for tobacco control, which was presented to Smoke Free Israel. This case study provides important lessons for up-to-date tobacco control policy, in the age of rapid global changes in the tobacco, vaping and nicotine landscape.
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Informing iQOS Regulations in the United States: A Synthesis of What We Know. SAGE OPEN 2020; 10:10.1177/2158244019898823. [PMID: 32719733 PMCID: PMC7384757 DOI: 10.1177/2158244019898823] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
Abstract
The tobacco industry offers various products, including heated tobacco products (HTPs). Philip Morris International's (PMI) "iQOS" has the greatest HTP market share, as well as research on its use and impact. iQOS was released in 2014 and is now in more than 40 countries. The U.S. Food and Drug Administration announced permission for PMI to sell iQOS in the United States in April 2019, and iQOS was launched in October 2019. Decisions pending its modified risk tobacco product (MRTP) application will occur subsequently. The U.S. regulatory efforts regarding iQOS could be informed by examining (a) Philip Morris USA other product marketing efforts and (b) the iQOS market in countries where it is available. This article briefly addresses these two points with extant literature and suggests that future research should address important gaps in what is currently known, including strategic international collaborations and research, which historically has been critical for advancing tobacco control globally.
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Feasibility of a text-messaging smoking cessation program for soldiers in Israel. BMC Public Health 2019; 19:715. [PMID: 31238914 PMCID: PMC6593531 DOI: 10.1186/s12889-019-6958-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Accepted: 05/08/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Cigarette smoking is a main cause of preventable morbidity and mortality. Many young adults begin smoking in the military, with smoking rates higher among soldiers than in the general population. Among other health effects, smoking impairs performance among soldiers. Smoking cessation programs in the military are challenging due to the unique settings and low access to smoking cessation resources. Studies have shown that text-messaging smoking cessation programs are feasible and effective, but there is a lack of studies on soldiers. OBJECTIVE To evaluate the feasibility of a text-messaging smoking cessation program tailored for soldiers. METHODS We recruited 81 soldiers who smoked, 76.5% of whom were male. Following enrollment, participants filled out a baseline survey and were given a text messaging program for 6 months. Participants could send predetermined keywords and immediately receive a response from a list of messages that were constructed as a response to the specific keyword. Participants filled out a follow-up survey at 1 month. Additionally, we retrieved and analyzed program usage data, including keywords sent and received, for the entire program period. Based on the follow-up survey and the program usage data, we assessed feasibility of the recruitment methods, participants' engagement and satisfaction and technical usability of the program. RESULTS At 1 month, 20.6% reported that they had not smoked in the past week. A high percentage of the participants were engaged in the program, with 82.5% sending at least one valid keyword. The lowest self-efficacy group had higher chances of leaving the program (50.0%) while for the highest group there were much lower chances (4.8%). Most of the soldiers (96.8%) found the program easy to use and would recommend it to a friend (84.1%). CONCLUSIONS The study demonstrates that a text-messaging smoking cessation program is feasible in a military setting. Further development and evaluation of digital smoking cessation tools tailored for soldiers are warranted.
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Improving smoking cessation care in pregnancy at Aboriginal Medical Services: 'ICAN QUIT in Pregnancy' step-wedge cluster randomised study. BMJ Open 2019; 9:e025293. [PMID: 31167863 PMCID: PMC6561434 DOI: 10.1136/bmjopen-2018-025293] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVES This study aimed to examine the impact of the 'ICAN QUIT in Pregnancy' intervention on individual health providers (HPs) smoking cessation care (SCC) knowledge, attitudes and practices in general, and specifically regarding nicotine replacement therapy (NRT) prescription. DESIGN Step-wedge clustered randomised controlled study. HPs answered a preintervention and 1-6 months postintervention survey. SETTING Six Aboriginal Medical Services (AMSs) in three states of Australia. PARTICIPANTS All HPs were invited to participate. Of 93 eligible, 50 consented (54%), 45 completed the presurvey (90%) and 20 the post (40%). INTERVENTION Included three 1-hour webinar sessions, educational resource package and free oral NRT. OUTCOMES HPs knowledge was measured using two composite scores-one from all 24 true/false statements, and one from 12 NRT-specific statements. Self-assessment of 22 attitudes to providing SCC were measured using a five-point Likert scale (Strongly disagree to Strongly agree). Two composite mean scores were calculated-one for 15 general SCC attitudes, and one for 7 NRT-specific attitudes. Self-reported provision of SCC components was measured on a five-point Likert scale (Never to Always). Feasibility outcomes, and data collected on the service and patient level are reported elsewhere. RESULTS Mean knowledge composite scores improved from pre to post (78% vs 84% correct, difference 5.95, 95% CI 1.57 to 10.32). Mean NRT-specific knowledge composite score also improved (68% vs 79% correct, difference 9.9, 95% CI 3.66 to 16.14). Mean attitude composite score improved (3.65 (SD 0.4) to 3.87 (SD 0.4), difference 0.23, 95% CI 0.05 to 0.41). Mean NRT-specific attitudes composite score also improved (3.37 (SD 0.6) to 3.64 (SD 0.7), difference 0.36, 95% CI 0.13 to 0.6). Self-reported practices were unchanged, including prescribing NRT. CONCLUSIONS A multicomponent culturally sensitive intervention in AMSs was feasible, and might improve HPs provision of SCC to pregnant Aboriginal women. Changes in NRT prescription rates may require additional intensive measures. TRIAL REGISTRATION NUMBER ACTRN 12616001603404; Results.
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Improving health providers smoking cessation care in pregnancy: A systematic review and meta-analysis. Addict Behav 2019; 93:29-38. [PMID: 30684819 DOI: 10.1016/j.addbeh.2019.01.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Revised: 01/03/2019] [Accepted: 01/03/2019] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Health providers are lacking in their provision of smoking cessation care during pregnancy. The aim of this study was to systematically review all available global studies on the effectiveness of interventions in improving health providers' provision of smoking cessation care during pregnancy. METHODS Five databases were searched, Inclusion criteria included all intervention study types. Two reviewers screened abstracts and full texts independently. Interventions were characterized according to the Effective Practice Of Care taxonomy. Random-effects meta-analyses examined intervention effects on smoking cessation care components based on the 5As. Estimates were number of participants reporting each outcome, or mean score, transformed into Cohen's d. Crude meta-regressions, and meta-analysis subgrouping, were performed to examine whether intervention effects for 'Ask', 'Advise' and 'Assist' differed by intervention components. RESULTS Of 3165 manuscripts, 16 fulfilled inclusion criteria. Pooled analysis showed significant small to large intervention effects on the different care components (Cohen's d ranging from 0.47 for 'Ask' (95%CI 0.13-0.81) to 1.12 (95%CI 0.45-1.79) for 'Setting a quit date'). Crude meta-regression suggested that for 'Ask', having a theoretical basis may improve effectiveness (Cohen's d difference 0.62, 95% CI 0.12-1.1). Subgrouping the meta-analysis suggested that audit and feedback possibly increases intervention effectiveness for 'Advise' and 'Assist'. CONCLUSION Interventions designed to improve provision of smoking cessation care during pregnancy show a small increase in care components. Studies vary substantially in design, intervention components, and outcome measurement, impacting ability to synthesize available data. Audit and feedback and enhancing intervention design by using behaviour change theories may improve effectiveness. REGISTRATION PROSPERO CRD42016030143.
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