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Abstract Background Prevalence of youth nicotine vaping has increased, heightening concerns around negative health effects. This study aimed to compare self-reported respiratory symptoms among youth by vaping behaviours. Methods Participants (n = 39,214) aged 16–19 from the 2020 and 2021 International Tobacco Control Policy Evaluation Project (ITC) Youth Tobacco and Vaping Surveys (Canada, England, US). Weighted multivariable logistic regression assessed associations between reporting any of five respiratory symptoms in the past week (shortness of breath, wheezing, chest pain, phlegm, cough) and: past 30-day smoking and/or vaping; lifetime/current vaping. Among past-30-day vapers (n = 4644), we assessed associations between symptoms and vaping frequency, use of nicotine salts, usual flavour and device type(s). Results Overall, 27.8% reported experiencing any of the five respiratory symptoms. Compared with youth who had only vaped, those who had only smoked had similar odds of symptoms [adjusted odds ratio, OR (95% confidence interval, CI): 0.97 (0.85–1.10)], those who both smoked and vaped had higher odds [1.26 (1.12–1.42)], and those who had done neither, lower odds [0.67 (0.61–0.72)]. Compared with those who had never vaped, past use, experimentation and current regular or occasional use were all associated with higher odds. Reporting usually using nicotine salts was associated with higher odds of symptoms [1.43 (1.22–1.68)] than non-salt but was often uncertain. Compared with tobacco flavour (including with menthol), menthol/mint and sweets flavours were associated with similar odds; fruit [1.44 (1.07–1.93)], multiple [1.76 (1.30–2.39)] and ‘other’ [2.14 (1.45–3.16)] flavours with higher odds. All device types were associated with similar odds. Conclusions Among youth, vaping was associated with increased reporting of past-week respiratory symptoms. Among those who vaped, some flavour types and potentially nicotine salts were associated with respiratory symptoms.

Abstract Background The National Health Service in England aims to implement tobacco dependency treatment services in all hospitals by 2024. We aimed to assess the uptake of a new service, adapted from the Ottawa Model of Smoking Cessation, and its impact on 6-month quit rates and readmission or death at 1-year follow-up. Methods We conducted a pragmatic service evaluation of a tobacco dependency service implemented among 2067 patients who smoked who were admitted to 2 acute hospitals in London, England, over a 12-month period from July 2020. The intervention consisted of the systematic identification of smoking status, automatic referral to tobacco dependence specialists, provision of pharmacotherapy and behavioural support throughout the hospital stay, and telephone support for 6 months after discharge. The outcomes were (i) patient acceptance of the intervention during admission, (ii) quit success at 6 months after discharge, (iii) death, or (iv) readmission up to 1 year following discharge. Multivariable logistic regression was used to estimate the impact of a range of clinical and demographic variables on these outcomes. Results The majority (79.4%) of patients accepted support at the first assessment. Six months after discharge, 35.1% of successfully contacted patients reported having quit smoking. After adjustment, odds of accepting support were 51–61% higher among patients of all non-White ethnicity groups, relative to White patients, but patients of Mixed, Asian, or Other ethnicities had decreased odds of quit success (adjusted odds ratio (AOR) = 0.32, 95%CI = 0.15–0.66). Decreased odds of accepting support were associated with a diagnosis of cardiovascular disease or diabetes; however, diabetes was associated with increased odds of quit success (AOR = 1.88, 95%CI = 1.17–3.04). Intention to make a quit attempt was associated with a threefold increase in odds of quit success, and 60% lower odds of death, compared to patients who did not intend to quit. A mental health diagnosis was associated with an 84% increase in the odds of dying within 12 months. Conclusions The overall quit rates were similar to results from Ottawa models implemented elsewhere, although outcomes varied by site. Outcomes also varied according to patient demographics and diagnoses, suggesting personalised and culturally tailored interventions may be needed to optimise quit success.

Abstract Background Electronic health records (EHRs) could identify long-term health effects of nicotine vaping. We characterised the extent to which vaping is recorded in primary care EHRs in the UK, on a population level. Methods We performed descriptive analysis of Clinical Practice Research Datalink (CPRD), primary care electronic health records of 25% of the UK population (~ 16 million patients). Patients aged ≥ 18 years whose vaping status was recorded using medical codes between 2006 and 2022 were identified. We reported the frequency of vaping codes; their distribution by patient age, gender, and ethnicity; trends in vaping recording over time (including interrupted time series analyses); and transitions in patient smoking status. Results Seven medical codes indicated current or former vaping, from 150,114 patients. When their vaping status was first recorded, mean patient age was 50.2 years (standard deviation: 15.0), 52.4% were female, and 82.1% were White. Of those recorded as currently vaping, almost all (98.9%) had records of their prior smoking status: 55.0% had been smoking, 38.3% had stopped smoking, 5.6% had never smoked. Of those who were smoking prior to being recorded as vaping, more than a year after the vaping record, over a third (34.2%) were still smoking, under a quarter (23.7%) quit smoking, 1.7% received a ‘never smoked’ status, and there was no smoking status for 40.4%. The ‘e-cigarette or vaping product use-associated lung injury’ (EVALI) outbreak was significantly associated with a declining trend in new records of current vaping between September 2019 and March 2020; and an immediate significant increase in new records of former vaping, followed by a declining trend. Conclusions Few patients are being asked about vaping. Most who vape had smoked, and many quit smoking after starting vaping. To enable electronic health records to provide stronger evidence on health effects, we recommend improved completeness, accuracy and consistency.

Abstract Background Rates of diseases and death from tobacco smoking are substantially higher among those with a mental health condition (MHC). Vaping can help some people quit smoking, but little is known about vaping among people with MHCs or psychological distress. We assessed the prevalence and characteristics (heaviness, product type) of smoking and/or vaping among those with and without a history of single or multiple MHC diagnoses and with no, moderate or serious psychological distress. Methods Data from 27,437 adults in Great Britain surveyed between 2020 and 2022. Multinomial regressions analysed associations between smoking, vaping and dual use prevalence, smoking/vaping characteristics and (a) history of a single or multiple MHC and (b) moderate or serious psychological distress, adjusted for age, gender, and socioeconomic status. Results Compared with people who had never smoked, those who currently smoked were more likely to report a history of a single (12.5% vs 15.0%, AOR=1.62, 95% CI=1.46–1.81, p

Abstract Background Internationally, there is an ‘evidence-practice gap’ in the rate healthcare professionals assess tobacco use and offer cessation support in clinical practice, including primary care. Evidence is needed for implementation strategies enacted in the ‘real-world’. Aim: To identify implementation strategies aiming to increase smoking cessation treatment provision in primary care, their effectiveness, cost-effectiveness and any perceived facilitators and barriers for effectiveness. Methods ‘Embase’, ‘Medline’, ‘PsycINFO’, ‘CINAHL’, ‘Global Health’, ‘Social Policy & Practice’, ‘ASSIA Applied Social Sciences Index and Abstracts’ databases, and grey literature sources were searched from inception to April 2021. Studies were included if they evaluated an implementation strategy implemented on a nation-/state-wide scale, targeting any type of healthcare professional within the primary care setting, aiming to increase smoking cessation treatment provision. Primary outcome measures: implementation strategy identification, and effectiveness (practitioner-/patient-level). Secondary outcome measures: perceived facilitators and barriers to effectiveness, and cost-effectiveness. Studies were assessed using the Risk Of Bias In Non-randomized Studies of Interventions (ROBINS-I) tool. A narrative synthesis was conducted using the Expert Recommendations for Implementing Change (ERIC) compilation and the Consolidated Framework for Implementation Research (CFIR). Results Of 49 included papers, half were of moderate/low risk of bias. The implementation strategy domains identified involved utilizing financial strategies, changing infrastructure, training and educating stakeholders, and engaging consumers. The first three increased practitioner-level smoking status recording and cessation advice provision. Interventions in the utilizing financial strategies domain also appeared to increase smoking cessation (patient-level). Key facilitator: external policies/incentives (tobacco control measures and funding for public health and cessation clinics). Key barriers: time and financial constraints, lack of free cessation medications and follow-up, deprioritisation and unclear targets in primary care, lack of knowledge of healthcare professionals, and unclear messaging to patients about available cessation support options. No studies assessed cost-effectiveness. Conclusions Some implementation strategy categories increased the rate of smoking status recording and cessation advice provision in primary care. We found some evidence for interventions utilizing financial strategies having a beneficial impact on cessation. Identified barriers to effectiveness should be reduced. More pragmatic approaches are recommended, such as hybrid effectiveness-implementation designs and utilising Multiphase Optimization Strategy methodology. Protocol registration PROSPERO:CRD42021246683

Abstract Triple negative breast cancer (TNBC) is a disease of poor prognosis, with the majority classified as the basal-like subtype associated with epithelial-mesenchymal transition and metastasis. Because basal breast cancers originate from proliferative luminal progenitor-like cells upon dysregulation of proper luminal differentiation, genes regulating luminal-basal transition are critical to elucidate novel therapeutic targets to improve TNBC outcomes. Herein we demonstrate that the tumor suppressor DEAR1/TRIM62 is a critical regulator of luminal cell fate. DEAR1 loss in human mammary epithelial cells results in significantly enhanced mammosphere formation that is accelerated in the presence of TGF-β/SMAD3 signaling. Mammospheres formed following DEAR1 loss are enriched for ALDH1A1 and CK5 expression, EpCAM−/CD49f+ and CD44high/24low basal-like epithelial cells, indicating that DEAR1 regulates stem/progenitor cell properties and luminal-basal progenitor transition. We show that DEAR1 maintains luminal differentiation as a novel ubiquitin ligase for SNAI2/SLUG, a master regulator driving stemness and generation of basal-like progenitor populations. We also identify a significant inverse correlation between DEAR1 and SNAI2 expression in a 103 TNBC case cohort and show that low DEAR1 expression significantly correlates with young age of onset and shorter time to metastasis, suggesting DEAR1 could serve as a biomarker to stratify early onset TNBCs for targeted stem cell therapies.

Summary: Background: China has approximately 300 million current smokers, and smoking cessation services are limited. This study aimed to assess the efficacy of a Cognitive Behavioral Theory-based smoking cessation intervention (‘WeChat WeQuit’) via the most popular social media platform in China, WeChat. Methods: A parallel, single-blind, two-arm randomised controlled trial was conducted via WeChat between March 19, 2020 and November 16, 2022. Chinese-speaking adult smokers (n = 2000) willing to quit within one month were recruited and randomised in a 1:1 ratio. The intervention group (n = 1005) received the ‘WeChat WeQuit’ program and the control group (n = 955) received control messages for 14 weeks (2-week prequit and 12-week postquit). Participants were followed up to 26 weeks after the quit date. The primary outcome was self-reported continuous smoking abstinence rate, biochemically validated at 26 weeks. The secondary outcomes were self-reported 7-day and continuous abstinence rates at 6 months. All analyses were by intention to treat. The trial is registered at ClinicalTrials.gov (NCT03169686). Findings: By intention-to-treat analysis, the biochemically verified 26-week continuous abstinence rate was 11.94% in the intervention group and 2.81% in the control group (OR = 4.68, 95% CI: 3.07–7.13, p

Objectives Electronic vaping devices are being used to consume nicotine and non-nicotine psychoactive drugs. We aimed to determine the pattern and prevalence of using vaping devices for nicotine and/or non-nicotine drug administration in the United Kingdom and how these differ by drug type and individual sociodemographic characteristics. We explored reasons for vaping onset and continuation.Design An online cross-sectional surveyParticipants A convenience sample of adults (aged ≥18 years) in the UK.Primary and secondary outcome measures The primary outcome was prevalence of current use (within the last 30 days) of a vaping device to administer either nicotine or 18 types of non-nicotine drugs. We additionally evaluated reasons for onset and continuation of vaping. Sociodemographic characteristics were compared between the UK general population using census data and those vaping non-nicotine drugs.Results We recruited 4027 participants of whom 1637 (40.7%) had ever used an electronic vaping device; 1495 (37.1%) had ever vaped nicotine and 593 (14.7%) had ever vaped a non-nicotine drug. Overall, 574 (14.3%) currently vaped nicotine and 74 (1.8%) currently vaped a non-nicotine drug. The most common currently vaped non-nicotine drug was cannabis (n=58, 1.4%). For nicotine, people’s modal reasons to start and continue vaping was to quit smoking tobacco. For almost all other drugs, people’s modal reason to start vaping was curiosity and to continue was enjoyment. Compared with the general population, the population who had ever vaped a non-nicotine drug were significantly younger, had more disabilities and fewer identified as white, female, heterosexual or religious.Conclusions A non-trivial number of people report current use and ever use of an electronic vaping device for non-nicotine drug administration. As vaping technology advances and drug consumption changes, understanding patterns of use and associated behaviours are likely to be increasingly important to both users and healthcare professionals.

Introduction China has more than 300 million current smokers. There is a controversy over smokers’ risk of COVID-19 infection. Smoking is a risk factor for COVID-19 disease progression, and the outbreak of COVID-19 may change people’s smoking behaviors. This study assessed people’s attitudes towards ‘smoking and COVID-19’ and changes of smoking behaviors before and after the outbreak of COVID-19. Material and Methods A cross-sectional web survey of 11009 adults in China was conducted between 7 May and 3 August 2020. Attitudes towards ‘smoking and COVID-19’ were compared among non-smokers (n=8837), ex-smokers (n=399) and current smokers (n=1773), and changes in smoking behaviors before and after the outbreak of COVID-19 were assessed among current smokers. Results Fewer current smokers (26.2%) agreed with the statement that ‘Current smokers are more likely than ex-smokers or non-smokers to contract COVID-19’ compared with non-smokers (53%) or ex-smokers (41.4%); fewer current smokers (55.9%) agreed with the statement ‘If contracted, current smokers are more likely than ex-smokers or non-smokers to risk disease progression’ compared with nonsmokers (75.5%) or ex-smokers (68.7%). There were no changes in cigarettes smoked per day (mean ± SD: 13.3 ± 9.55 vs 13.4 ± 9.69, p=0.414), percentage of daily smokers (70.8% vs 71.1%, p=0.882) and percentage of smokers with motivation to quit (intend to quit within the next 6 months, 9.4% vs 10.9%, p=0.148) before and after the outbreak of COVID-19. Conclusions The survey found that fewer current smokers agreed that smoking is a risk-factor for COVID-19 compared with non-smokers or ex-smokers. Among current smokers, there were no changes in their cigarette consumption and motivation to quit before and after the outbreak of COVID-19. More efforts are needed to educate smokers about the health risks of smoking, as well as efforts to promote their motivation to quit.

BackgroundThe world witnessed a highly contagious and deadly disease, COVID-19, toward the end of 2019. India is one of the worst affected countries. We aimed to assess anxiety and depression levels among adult tobacco users and people who recently quit tobacco during COVID-19 lockdown in India.Materials and methodsThe study was conducted across two Indian cities, Delhi and Chennai (July-August, 2020) among adult tobacco users (n = 801). Telephonic interviews were conducted using validated mental health tools (Patient Health Questionnaire-PHQ-9 and Generalized Anxiety Disorder-GAD-7) to assess the anxiety and depression levels of the participants. Descriptive analysis and multiple logistic regression were used to study the prevalence and correlates of depression and anxiety.ResultsWe found that 20.6% of tobacco users had depression symptoms (3.9% moderate to severe); 20.7% had anxiety symptoms (3.8% moderate to severe). Risk factors associated with depression and anxiety included food, housing, and financial insecurity.ConclusionDuring COVID-19 lockdown, mental health of tobacco users (primarily women) was associated with food, housing and financial insecurity. The Indian Government rightly initiated several health, social and economic measures to shield the most vulnerable from COVID-19, including a ban on the sale of tobacco products. It is also necessary to prioritize universal health coverage, expanded social security net, tobacco cessation and mental health services to such vulnerable populations during pandemic situations.

Abstract Background Harm perceptions of tobacco and nicotine products can influence their use and could be targeted by policies to change behaviour. IQOS was introduced to the UK in 2016, and there is little independent qualitative research on IQOS harm perceptions. This study explored the perceived health harms of IQOS to users and those exposed to the emissions, what shapes these perceptions, and what participants wanted to know about the harms of IQOS. Methods Qualitative interviews in London, UK, with 30 adult current and former IQOS users who currently smoked or quit smoking in the last 2 years. Results IQOS was perceived as less harmful than smoking but not risk-free, although there was great uncertainty. Influences on harm perceptions were consolidated into six themes: (1) dominance of manufacturer claims influenced perceptions that IQOS is less harmful than smoking to users and those around them, although mistrust of the tobacco industry heightened scepticism about harms; (2) limited independent and long-term research led to uncertainty about harms, although some participants trusted IQOS would not be marketed if it were very harmful. Participants wanted more independent and long-term studies into harm; (3) appearance of HEETS (tobacco sticks) packaging conveyed reduced harm because packets were ‘pretty’, without graphic/specific warnings, although written warnings conveyed some harm. Participants wanted more information on HEETS packets about harms; (4) process of heating and HEETS contents—heating, compared with burning, tobacco was perceived to produce fewer harmful chemicals, while tobacco, nicotine, and chemicals in HEETS were perceived to cause some harm. Participants wanted clarification about the harms of heating tobacco and HEETS ingredients; (5) improvements in physical health and personal appearance reduced perceptions of harm; (6) differences in sensory experiences (taste, sight, smell) when using IQOS over smoking reduced perceptions of harm, while ‘black’ deposits inside IQOS led to perceptions of some harm. Reduced volume and smell of IQOS emissions also reduced perceptions of harm to non-users exposed to the emissions. Conclusions IQOS was perceived as less harmful than smoking but not risk-free, although there was great uncertainty. Participants wanted clarification about IQOS harms from independent sources in accessible forms, specifically related to HEETS ingredients, heating tobacco, and emissions to others.

Background: Smokeless tobacco (ST) use is common among youth in South Asia where 85% of the world’s 300 million ST users live and use the most lethal ST forms. Little is known about the impact of tobacco control policies on the youth ST uptake in those countries. We planned to conduct longitudinal surveys among school going adolescents to evaluate existing tobacco control policies on tobacco uptake and use, and a feasibility study for that prospective, observational cohort study. Study objectives: (1) To demonstrate the feasibility of selection, recruitment and retention of schools and of study participants; (2) To assess the feasibility and acceptability of the study procedure and study tool (questionnaire); (3) To evaluate if the questionnaire can assess tobacco uptake and use, and their potential predictors. Methods and analysis: The feasibility study will be conducted in two administrative areas within each of three South Asian countries: Bangladesh, India and Pakistan. We will use both quantitative and qualitative data collection methods. Eight eligible schools will be randomly selected within purposively selected sub-districts from each country. We plan to conduct one baseline and one follow up survey among students of grade 6-8, one year apart. At each time point, data on tobacco uptake and potential predictors will be collected from students via self-administered questionnaires that were designed for the longitudinal study. The qualitative component will be embedded into the study with each round of data collection to assess the acceptability of the study instrument (questionnaire) and data collection methods, via focus group discussions with students and semi-structured interviews with schoolteachers. Recruitment and retention rates, completeness of the questionnaires, frequencies and associations of tobacco use and explanatory variables will be reported. Data gathered from the focus group and interviews will be analysed using the framework approach.

Abstract Background Tobacco control strategies have engendered overall declines in smoking; however, a large gap remains between people with and without mental health problems, causing substantial health inequalities. Population-level information on barriers and opportunities for improvements is scarce. We aimed to assess mental health status of cigarette smokers and recent ex-smokers (‘past-year smokers’) in England, and smoking and harm reduction behaviour and quit attempts by mental health status. Methods Data were collected from 5637 current and 434 recent ex-smokers in 2016/17 in household surveys of representative samples of adults. We calculated weighted prevalence of different indicators of mental health problem: a) ever diagnosis, b) none, moderate, serious past-month distress, c) past-year treatment. We compared weighted smoking status, cigarette type, dependence, motivation to stop smoking, cutting down, use of nicotine replacement therapy or e-cigarettes, short-term abstinence, and quit attempts according to mental health status. Results Among past-year smokers: 35.9% ever had a diagnosis; 24.3% had experienced moderate, an additional 9.7% serious, past-month distress; 21.9% had had past-year treatment. Those with an indication of a mental health problem were more highly dependent and more likely to smoke roll-your-own cigarettes but also more likely to be motivated to stop smoking, to cut down, use nicotine replacement therapy or e-cigarettes and to have attempted to quit in the past year. Conclusions About a third of cigarette smokers in England have mental health problems. Interventions should address their increased dependence and leverage higher prevalence of harm reduction behaviours, motivation to stop and attempts to stop smoking.

Abstract Aims Switching from smoking to using nicotine replacement therapy (NRT), electronic cigarettes (e-cigarettes) or heated tobacco products can reduce tobacco-related health risks. However, not all smokers in Great Britain have tried these products. This study aimed to identify and describe smokers who have never tried alternative nicotine products. Methods We analysed cross-sectional survey data of smokers (n = 1777) from a representative adult sample from Great Britain. The online survey was run in March 2019. The proportion of smokers who had never used alternative nicotine products was measured. A multivariate logistic regression assessed the association between never having used alternative nicotine products and sociodemographic and smoking characteristics and motivation to stop smoking. Results One in four smokers (27.8%, 95% CI 25.8–29.9%) had never tried NRT, e-cigarettes or heated tobacco products. These smokers were more commonly from Black and Minority than White ethnic groups (AOR = 1.55; 95% CI 1.02–2.31), were more likely to smoke up to 10 versus more cigarettes per day (AOR = 1.52; 95% CI 1.14–2.03) and to report low versus moderate or high motivation to stop smoking (AOR = 1.79; 95% CI 1.20–2.74). Conclusion Light smokers, those unmotivated to stop and smokers from Black and Minority ethnic groups are less likely to have ever tried alternative nicotine products. Different approaches are needed to facilitate harm reduction and smoking cessation among these groups of smokers.

Abstract Background To reduce inequalities between individuals with and without mental health problems, a better understanding is required of triggers and success of quit attempts among the third of smokers with mental health problems. The aim was to assess whether there are differences by mental health status in (i) triggers for quit attempts, (ii) use of evidence-based support (iii) and quit success. Methods Monthly cross-sectional household surveys of representative samples of the adult population in England. In 2016/2017, 40,831 adults were surveyed; 1956 who had attempted to stop smoking cigarettes in the past year were included. Logistic regressions assessed associations between mental health (ever diagnosis, past-year treatment, past-month distress), triggers, support used and quit success, adjusting for sociodemographic and smoking characteristics. Results Concern about future health, current health problems and expense of smoking were the most common triggers overall. For respondents with an ever diagnosis, past-year treatment or serious past-month distress, quit attempts were more frequently triggered by current health problems. Non-evidence-based support and e-cigarettes were used most often, and this did not differ by mental health status. Respondents with an ever diagnosis and moderate or serious distress were less likely to have used non-prescription nicotine replacement therapy (NRT). Respondents with past-year treatment or serious distress were more likely to have used prescription medication/behavioural support. Quit success did not differ by mental health status. Compared with non-evidence-based support, non-prescription NRT conferred no benefit. There was some evidence that prescription medication/behavioural support was beneficial (depending on outcome and adjustment, ORs ranged from 1.46, 95% CI 0.92–2.31, to 1.69, 1.01–2.86). E-cigarettes were associated with higher success rates after adjustment for different indicators of mental health (ORs ranged from 2.21, 1.64–2.98, to 2.25, 1.59–3.18). Conclusions Smokers with mental health problems were more likely to have attempted to quit because of health problems and were more likely to have used gold standard support (medication and behavioural support) than other smokers. E-cigarettes were strongly associated with increased success and were used similarly by those with and without mental health problems, indicating that improved uptake of e-cigarettes for smoking cessation among smokers with mental health problems could help address inequalities.

Abstract Background Smoking prevalence among people with psychosis remains high. Providing Very Brief Advice (VBA) comprising: i) ASK, identifying a patient’s smoking status ii) ADVISE, advising on the best way to stop and iii) ACT (OFFER), offering a referral to specialist smoking cessation support, increases quit attempts in the general population. We assessed whether system-level changes in a UK mental health organisation improved the recording of the provision of ASK, ADVISE, ACT (OFFER) and consent to referral to specialist smoking cessation support (ACT (CONSENT)). Methods We conducted a study using a regression discontinuity design in four psychiatric hospitals with patients who received treatment from an inpatient psychosis service over 52 months (May 2012–September 2016). The system-level changes to facilitate the provision of VBA comprised: A) financially incentivising recording smoking status and offer of support (ASK and ACT (OFFER)); B) introduction of a comprehensive smoke-free policy; C) enhancements to the patient electronic healthcare record (EHCR) which included C1) a temporary form to record the financial incentivisation of ASK and ACT (OFFER) C2) amendments to how VBA was recorded in the EHCR and C3) the integration of a new electronic national referral system in the EHCR. The recording of ASK, ADVISE, ACT (OFFER/CONSENT) were extracted using a de-identified psychiatric case register. Results There were 8976 admissions of 5434 unique individuals during the study period. Following A) financial incentive, the odds of recording ASK increased (OR: 1.56, 95%CI: 1.24–1.95). Following B) comprehensive smoke-free policy, the odds of recording ADVICE increased (OR: 3.36, 95%CI: 1.39–8.13). Following C1) temporary recording form, the odds of recording ASK (OR:1.99, 95%CI:1.59–2.48) and recording ACT (OFFER) increased (OR: 4.22, 95%CI: 2.51–7.12). Following C3) electronic referral system, the odds of recording ASK (OR:1.79, 95%CI: 1.31–2.43) and ACT (OFFER; OR: 1.09, 95%CI: 0.59–1.99) increased. There was no change in recording VBA outcomes following C2) amendments to VBA recording. Conclusions Financial incentives and the recording of incentivised outcomes, the comprehensive smoke-free policy, and the electronic referral system, were associated with increases in recording individual VBA elements, but other changes to the EHCR were not. System-level changes may facilitate staff recording of VBA provision in mental health settings.

Abstract Background Most smokers attempting to quit relapse. There is little evidence whether the use of e-cigarettes (‘vaping’) increases or decreases relapse. This study aimed to assess 1) whether vaping predicted relapse among ex-smokers, and 2) among ex-smokers who vaped, whether vaping characteristics predicted relapse. Methods Longitudinal web-based survey of smokers, recent ex-smokers and vapers in the UK, baseline in May/June 2016 (n = 3334), follow-up in September 2017 (n = 1720). Those abstinent from smoking ≥ 2 months at baseline and followed up were included. Aim 1: Relapse during follow-up was regressed onto baseline vaping status, age, gender, income, nicotine replacement therapy use and time quit smoking (n = 374). Aim 2: Relapse was regressed onto baseline vaping frequency, device type, nicotine strength and time quit smoking (n = 159). Results Overall, 39.6% relapsed. Compared with never use (35.9%), past/ever (45.9%; adjOR = 1.13; 95% CI, 0.61–2.07) and daily vaping (34.5%; adjOR = 0.61; 95% CI, 0.61–1.89) had similar odds of relapse, for non-daily vaping evidence of increased relapse was inconclusive (65.0%; adjOR = 2.45; 95% CI, 0.85–7.08). Among vapers, non-daily vaping was associated with higher relapse than daily vaping (adjOR = 3.88; 95% CI, 1.10–13.62). Compared with modular devices (18.9% relapse), tank models (45.6%; adjOR = 3.63; 95% CI, 1.33–9.95) were associated with increased relapse; evidence was unclear for disposable/cartridge refillable devices (41.9%; adjOR = 2.83; 95% CI, 0.90–8.95). Nicotine strength had no clear association with relapse. Conclusion Relapse to smoking is likely to be more common among ex-smokers vaping infrequently or using less advanced devices. Research into the effects of vaping on relapse needs to consider vaping characteristics.

Abstract Background Smoking has played a significant role in the historical culture of mental healthcare settings. Mental health professionals (MHPs) often hold dismissive attitudes regarding the importance of smoking cessation in the context of mental healthcare. In 2007, English mental health inpatient buildings were required by law to become smoke-free, and healthcare trusts have more recently begun to implement comprehensive policies (i.e. smoke-free grounds and buildings) and staff training in response to national guidance. It is therefore important to explore MHPs practice around smoking, smoking cessation, and smoke-free policy adherence. This study aimed to explore these issues by using the COM-B (capability, opportunity, motivation, behaviour) model to systematically identify barriers to, and facilitators for, MHPs addressing smoking with their patients. Methods Five focus groups with a total of 36 MHPs were conducted between March and August 2017. MHPs were recruited from one of the largest mental health trusts in Europe. Discussions were guided by a semi-structured guide. Responses were audio recorded, transcribed and coded using thematic analysis and the COM-B framework. Results Addressing smoking with patients was undermined by MHPs’ 1) psychological capability to recall training content, misunderstand the potential benefits of addressing patient smoking and harm reduction approaches; 2) physical opportunity in terms of time constraints, and easy accessibility of tobacco in the community; 3) social opportunity in terms of increased cultural value of tobacco following inpatient smoke-free policy implementation, and lack of support from colleagues to enforce the smoke-free policy; 4) automatic motivation, including intrinsic biases regarding patients abilities and motivations to quit, and 5) reflective motivation, including perceived job role and decision making processes related to addressing behaviours deemed more important than smoking. The main facilitating factors identified were MHPs’ having opportunity in the form of patients asking directly for support, and MHPs having access to resources such as stop smoking services and spirometers. Conclusion Multiple barriers were identified across all key domains of the COM-B framework that undermine MHPs’ practice regarding smoking cessation. Few facilitators were identified which may have implications for future smoke-free policy and clinical practice.

The main causes of non-communicable diseases (NCDs), health inequalities and health inequity include consumption of unhealthy commodities such as tobacco, alcohol and/or foods high in fat, salt and/or sugar. These exposures are preventable, but the commodities involved are highly profitable. The economic interests of ‘Unhealthy Commodity Producers’ (UCPs) often conflict with health goals but their role in determining health has received insufficient attention. In order to address this gap, a new research consortium has been established. This open letter introduces the SPECTRUM (Shaping Public hEalth poliCies To Reduce ineqUalities and harM) Consortium: a multi-disciplinary group comprising researchers from 10 United Kingdom (UK) universities and overseas, and partner organisations including three national public health agencies in Great Britain (GB), five multi-agency alliances and two companies providing data and analytic support. Through eight integrated work packages, the Consortium seeks to provide an understanding of the nature of the complex systems underlying the consumption of unhealthy commodities, the role of UCPs in shaping these systems and influencing health and policy, the role of systems-level interventions, and the effectiveness of existing and emerging policies. Co-production is central to the Consortium’s approach to advance research and achieve meaningful impact and we will involve the public in the design and delivery of our research. We will also establish and sustain mutually beneficial relationships with policy makers, alongside our partners, to increase the visibility, credibility and impact of our evidence. The Consortium’s ultimate aim is to achieve meaningful health benefits for the UK population by reducing harm and inequalities from the consumption of unhealthy commodities over the next five years and beyond.

IntroductionCOVID-19 is primarily a respiratory illness, and smoking adversely impacts the respiratory and immune systems; this confluence may therefore incentivize smokers to quit. The present study, conducted in four high-income countries during the first global wave of COVID-19, examined the association between COVID-19 and: (1) thoughts about quitting smoking; (2) changes in smoking (quit attempt, reduced or increased smoking, or no change); and (3) factors related to a positive change (making a quit attempt or reducing smoking) based on an adapted framework of the Health Belief Model.MethodsThis cross-sectional study included 6870 adult smokers participating in the Wave 3 (2020) ITC Four Country Smoking and Vaping Survey conducted in Australia, Canada, England, and United States (US). These four countries had varying responses to the pandemic by governments and public health, ranging from advising voluntary social distancing to implementing national and subnational staged lockdowns. Considering these varying responses, and the differences in the number of confirmed cases and deaths (greatest in England and the US and lowest in Australia), smoking behaviours related to COVID-19 may have differed between countries. Other factors that may be related to changes in smoking because of COVID-19 were also explored (e.g., sociodemographics, nicotine dependence, perceptions about personal and general risks of smoking on COVID-19). Regression analyses were conducted on weighted data.ResultsOverall, 46.7% of smokers reported thinking about quitting because of COVID-19, which differed by country (pConclusionsThough nearly half of smokers reported thinking about quitting because of COVID-19, the vast majority did not change their smoking behaviour. Smokers were more likely to try and quit or reduce their smoking if they had greater concern about susceptibility and severity of COVID-19 related to smoking. Smokers in Australia were least likely to reduce or try to quit smoking, which could be related to the significantly lower impact of COVID-19 during the early phase of the pandemic relative to the other countries.

Background: Relapse remains an unresolved issue in smoking cessation. Extended stop smoking medication use can help, but uptake is low and several behavioural relapse prevention interventions have been found to be ineffective. However, opportunistic ‘emergency’ use of fast-acting nicotine replacement treatment or electronic cigarettes may be more attractive and effective, and an online behavioural Structured Planning and Prompting Protocol has shown promise. The present trial aimed to evaluate the clinical effectiveness and cost-effectiveness of these two interventions. Design: A randomised controlled trial. Setting: English stop smoking services and Australian quitlines, Australian social media and St Vincent’s Hospital Melbourne, Fitzroy, VIC. Participants: Ex-smokers abstinent for at least 4 weeks, with some participants in Australia also recruited from 1 week post quit date. The planned sample size was 1400, but the trial was curtailed when 235 participants were recruited. Interventions: Participants were randomised in permuted blocks of random sizes to (1) oral nicotine replacement treatment/electronic cigarettes to use if at risk of relapse, plus static text messages (n = 60), (2) the Structured Planning and Prompting Protocol and interactive text messages (n = 57), (3) oral nicotine replacement treatment/electronic cigarettes plus the Structured Planning and Prompting Protocol with interactive text messages (n = 58) or (4) usual care plus static text messages (n = 59). Outcome measures: Owing to delays in study set-up and recruitment issues, the study was curtailed and the primary outcome was revised. The original objective was to determine whether or not the two interventions, together or separately, reduced relapse rates at 12 months compared with usual care. The revised primary objective was to determine whether or not number of interventions received (i.e. none, one or two) affects relapse rate at 6 months (not biochemically validated because of study curtailment). Relapse was defined as smoking on at least 7 consecutive days, or any smoking in the last month at final follow-up for both the original and curtailed outcomes. Participants with missing outcome data were included as smokers. Secondary outcomes included sustained abstinence (i.e. no more than five cigarettes smoked over the 6 months), nicotine product preferences (e.g. electronic cigarettes or nicotine replacement treatment) and Structured Planning and Prompting Protocol coping strategies used. Two substudies assessed reactions to interventions quantitatively and qualitatively. The trial statistician remained blinded until analysis was complete. Results: The 6-month relapse rates were 60.0%, 43.5% and 49.2% in the usual-care arm, one-intervention arm and the two-intervention arm, respectively (p = 0.11). Sustained abstinence rates were 41.7%, 54.8% and 50.9%, respectively (p = 0.17). Electronic cigarettes were chosen more frequently than nicotine replacement treatment in Australia (71.1% vs. 29.0%; p = 0.001), but not in England (54.0% vs. 46.0%; p = 0.57). Of participants allocated to nicotine products, 23.1% were using them daily at 6 months. The online intervention received positive ratings from 63% of participants at 6 months, but the majority of participants (72%) completed one assessment only. Coping strategies taught in the Structured Planning and Prompting Protocol were used with similar frequency in all study arms, suggesting that these are strategies people had already acquired. Only one participant used the interactive texting, and interactive and static messages received virtually identical ratings. Limitations: The inability to recruit sufficient participants resulted in a lack of power to detect clinically relevant differences. Self-reported abstinence was not biochemically validated in the curtailed trial, and the ecological momentary assessment substudy was perceived by some as an intervention. Conclusions: Recruiting recent ex-smokers into an interventional study proved problematic. Both interventions were well received and safe. Combining the interventions did not surpass the effects of each intervention alone. There was a trend in favour of single interventions reducing relapse, but it did not reach significance and there are reasons to interpret the trend with caution. Future work: Further studies of both interventions are warranted, using simpler study designs. Trial registration: Current Controlled Trials ISRCTN11111428. Funding: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 68. See the NIHR Journals Library website for further project information. Funding was also provided by the National Health and Medical Research Council, Canberra, ACT, Australia (NHMRC APP1095880). Public Health England provided the funds to purchase the nicotine products in England.

Introduction Ghana has a partial smoking ban with smoking allowed in designated smoking areas. Studies evaluating smoke-free laws are scarce in Sub-Saharan Africa. Evaluation of smoke-free laws is an effective means of measuring progress towards a smoke-free society. This study assessed the level of compliance to the provisions of the current smoke-free policy using air quality measurements for fine particulate matter (PM 2.5 ) in hospitality venues in Ghana. Methods This was a cross-sectional observational study conducted in 2019 using a structured observational checklist complemented with air quality measurements using Dylos monitors across 152 randomly selected hospitality venues in three large cities in Ghana. Results Smoking was observed in a third of the venues visited. The median indoor PM 2.5 concentration was 14.6 μg/m3 (range: 5.2–349). PM 2.5 concentrations were higher in venues where smoking was observed (28.3 μg/m3) compared to venues where smoking was not observed (12.3 μg/m3) (p

Tobacco use is the leading cause of preventable deaths in the world, with most of these deaths now occurring in low and middle-income countries (LMICs). Sub-Saharan Africa (SSA) is at an early stage of a tobacco epidemic and is, therefore, particularly vulnerable to rapid growth in tobacco consumption. More than a decade into the implementation of the World Health Organization's Framework Convention on Tobacco Control (FCTC), State Parties in several countries in SSA, such as Ghana, have yet to fully fulfil their obligations. Despite early ratification of the FCTC in 2004, progress in implementing tobacco control measures in Ghana has been slow and much work remains to be done. The aim of this paper is to critically reflect on tobacco control implementation in Ghana, identify significant research priorities and make recommendations for future action to support tobacco control implementation. We emphasize the need for stronger implementation of the FCTC and its MPOWER policy package, particularly in the area of tobacco taxes, illicit trade and industry interference.

Background: Increasing tobacco prices through taxation is very effective for reducing smoking prevalence and inequalities. For optimum effect, understanding how the tobacco industry and smokers respond is essential. Tobacco taxation changes occurred in the UK over the study period, including annual increases, a shift in structure from ad valorem to specific taxation and relatively higher increases on roll-your-own tobacco than on factory-made cigarettes. Objectives: Understanding tobacco industry pricing strategies in response to tax changes and the impact of tax on smokers’ behaviour, including tax evasion and avoidance, as well as the effect on smoking inequalities. Synthesising findings to inform how taxation can be improved as a public health intervention. Design: Qualitative analysis and evidence synthesis (commercial and Nielsen data) and longitudinal and aggregate cross-sectional analyses (International Tobacco Control Policy Evaluation Project data). Setting: The UK, from 2002 to 2016. Data sources and participants: Data were from the tobacco industry commercial literature and retail tobacco sales data (Nielsen, New York, NY, USA). Participants were a longitudinal cohort (with replenishment) of smokers and ex-smokers from 10 surveys of the International Tobacco Control Policy Evaluation Project (around 1500 participants per survey). Main outcome measures: (1) Tobacco industry pricing strategies, (2) sales volumes and prices by segments over time and (3) smokers’ behaviours, including products purchased, sources, brands, consumption, quit attempts, success and sociodemographic differences. Review methods: Tobacco industry commercial literature was searched for mentions of tobacco products and price segments, with 517 articles extracted. Results: The tobacco industry increased prices on top of tax increases (overshifting), particularly on premium products, and, recently, the tobacco industry overshifted more on cheap roll-your-own tobacco than on factory-made cigarettes. Increasingly, price rises were from industry revenue generation rather than tax. The tobacco industry raised prices gradually to soften impact; this was less possible with larger tax increases. Budget measures to reduce cheap product availability failed due to new cheap factory-made products, price marking and small packs. In 2014, smokers could buy factory-made (roll-your-own tobacco) cigarettes at real prices similar to 2002. Exclusive roll-your-own tobacco and mixed factory-made cigarettes and roll-your-own tobacco use increased, whereas exclusive factory-made cigarette use decreased, alongside increased cheap product use, rather than quitting. Quitting behaviours were associated with higher taxes. Smokers consumed fewer factory-made cigarettes and reduced roll-your-own tobacco weight over time. Apparent illicit purchasing did not increase. Disadvantaged and dependent smokers struggled with tobacco affordability and were more likely to smoke cheaper products, but disadvantage did not affect quit success. Limitations: Different for each data set; triangulation increased confidence. Conclusions: The tobacco industry overshifted taxes and increased revenues, even when tax increases were high. Therefore, tobacco taxes can be further increased to reduce price differentials and recoup public health costs. Government strategies on illicit tobacco appear effective. Large, sudden tax increases would reduce the industry’s ability to manipulate prices, decrease affordability and increase quitting behaviours. More disadvantaged, and dependent, smokers need more help with quitting. Future work: Assessing the impact of tax changes made since 2014; changing how tax changes are introduced (e.g. sudden intermittent or smaller continuous); and tax changes on tobacco initiation. Funding: This project was funded by the National Institute for Health Research (NIHR) Public Health Research programme and will be published in full in Public Health Research; Vol. 8, No. 6. See the NIHR Journals Library website for further project information.

BackgroundTo estimate the potential gain in life expectancy from addressing modifiable risk factors for all-cause mortality (excluding suicide and deaths from accidents or violence) across specific serious mental illness (SMI) subgroups, namely schizophrenia, schizoaffective disorders, and bipolar disorders in a Western population.MethodsWe have used relative risks from recent meta-analyses to estimate the population attribution fraction (PAF) due to specific modifiable risk factors known to be associated with all-cause mortality within SMI. The potential gain in life expectancy at birth, age 50 and age 65 years were assessed by estimating the combined effect of modifiable risk factors from different contextual levels (behavioural, healthcare, social) and accounting for the effectiveness of existing interventions tackling these factors. Projections for annual gain in life expectancy at birth during a two-decade was estimated using the Annual Percentage Change (APC) formula. The predicted estimates were based on mortality rates for year 2014-2015.ResultsBased on the effectiveness of existing interventions targeting these modifiable risk factors, we estimated potential gain in life expectancy at birth of four (bipolar disorders), six (schizoaffective disorders), or seven years (schizophrenia). The gain in life expectancy at age 50 years was three (bipolar disorders) or five (schizophrenia and schizoaffective disorders) years. The projected gain in life expectancy at age 65 years was three (bipolar disorders) or four (schizophrenia and schizoaffective disorders) years.ConclusionsThe implementation of existing interventions targeting modifiable risk factors could narrow the current mortality gap between the general and the SMI populations by 24% (men) to 28% (women). These projections represent ideal circumstances and without the limitation of overestimation which often comes with PAFs.

Background: Smoking prevalence remains significantly higher among individuals with mental health conditions compared with the general population. Tobacco harm reduction (THR) in the form of replacing cigarettes for electronic cigarettes (ECs) is an alternative approach which may prove useful for these smokers who find it difficult to quit. Exploring how mental health professionals' (MHPs) perceive ECs, and how these influence decision making regarding their use in clinical settings is essential to determine the feasibility of incorporating ECs into the treatment pathway. Methods: We conducted six focus groups between March and August 2017. A total of 39 MHPs were recruited from mental healthcare services in England. Discussions were guided by a semi-structured guide, and responses were recorded, transcribed and coded using thematic framework analysis. Results: MHPs generally adopt a risk-averse approach when judging the safety and suitability of ECs. Risk-aversion was influenced by perceived obscurity surrounding ECs and THR, as well as high exposure to adverse and unreliable information regarding ECs, and perceived analogies between ECs and conventional cigarettes. Some MHPs adopt a pragmatic approach when making decisions based on THR and EC use in daily practice by considering the context of treatment and patient circumstances. However, this is often accompanied by a high degree of caution and misconceptions which limits the potential benefit this intervention could have in mental healthcare settings. Conclusion: Improved dissemination of national guidance and scientific literature regarding THR and ECs is essential in mental healthcare to eliminate misconceptions and better inform MHPs evidence-based decision-making practices. Keywords: Tobacco harm reduction, Electronic cigarettes, E-cigarettes, Mental healthcare, Qualitative research

Objective To assess the attitudes of flavored and unflavored cigarette smokers towards tobacco control policies, including the EU flavors ban and to explore the ban impact on smoking behaviors. Methods The research analysis include data from Wave 1 of the EUREST PLUS-ITC Europe Survey Project in Germany, Greece, Hungary, Poland, Romania, and Spain, and data from other ITC surveys conducted in England and the Netherlands. All cross-sectional data were collected in 2016 among 10,760 adult current smokers. The attitudes towards various tobacco control policies have been compared among menthol, other flavored and unflavored cigarette smokers. The univariate data analysis adjusted to few confounding factors was made with the use of SPSS Complex Samples Package. Results Findings show that menthol smokers are much less likely to support a ban on tobacco additives and flavors than other cigarette smokers but they are more supportive of smoking ban in public places. After the enforcement of the ban, 16% of menthol cigarette smokers and 10% of other flavored cigarette smokers reported the intention to quit smoking. However, the percentage of those menthol and other flavored smokers who declare quitting smoking after the ban implementation varies substantially with countries. Furthermore, almost one of three menthol cigarette smokers (27%) say they will find a way to get menthol tobacco product banned. Conclusions Attitudes of menthol and other flavored cigarettes towards various tobacco control policies differ substantially in the analyzed countries. Therefore, tobacco control and smoking cessation programs should be adapted to country needs. A special attention must be focused on smoking cessation offer addressed to those menthol cigarette smokers who intend to quit smoking after the flavors ban and on preventing the risk of illicit trade in menthol cigarettes.

ObjectivesTo estimate tobacco use prevalence in healthcare workers (HCW) by country income level, occupation and sex, and compare the estimates with the prevalence in the general population.MethodsWe systematically searched five databases; Medline, EMBASE, CINHAL Plus, CAB Abstracts, and LILACS for original studies published between 2000 and March 2016 without language restriction. All primary studies that reported tobacco use in any category of HCW were included. Study extraction and quality assessment were conducted independently by three reviewers, using a standardised data extraction and quality appraisal form. We performed random effect meta-analyses to obtain prevalence estimates by World Bank (WB) country income level, sex, and occupation. Data on prevalence of tobacco use in the general population were obtained from the World Health Organisation (WHO) Global Health Observatory website. The review protocol registration number on PROSPERO is CRD42016041231.Results229 studies met our inclusion criteria, representing 457,415 HCW and 63 countries: 29 high-income countries (HIC), 21 upper-middle-income countries (UMIC), and 13 lower-middle-and-low-income countries (LMLIC). The overall pooled prevalence of tobacco use in HCW was 21%, 31% in males and 17% in females. Highest estimates were in male doctors in UMIC and LMLIC, 35% and 45%, and female nurses in HIC and UMIC, 21% and 25%. Heterogeneity was high (I2 > 90%). Country level comparison suggest that in HIC male HCW tend to have lower prevalence compared with males in the general population while in females the estimates were similar. Male and female HCW in UMIC and LMLIC tend to have similar or higher prevalence rates relative to their counterparts in the general population.ConclusionsHCW continue to use tobacco at high rates. Tackling HCW tobacco use requires urgent action as they are at the front line for tackling tobacco use in their patients.

Although tobacco smoking is very common among people with schizophrenia and has devastating effects on health, strategies to ameliorate the risk are lacking. Some studies have reported promising results yet quit rates are much lower than in the general population. There is a need to advance research into smoking cessation efforts among people with schizophrenia. We posed the following question to five leading international experts in the field: “What are the top three research ideas we need to prioritize in order to advance the field of reducing smoking amongst people with schizophrenia?” They identified three broad priorities: (i) deeper understanding about the relationship between smoking, smoking cessation and symptomatology; (ii) targeted, adaptive and responsive behavioral interventions evaluated with smarter methodologies; and (iii) improvements in delivery of interventions. Efforts should be made to establish a collaborative international research agenda.

Abstract Background Evidence from the US Truth campaign suggests that interventions focusing on tobacco industry tactics can be effective in preventing smoking uptake by children. Operation Smoke Storm is the first school-based intervention based on this premise and comprises three classroom sessions in which students act as secret agents uncovering tobacco industry tactics through videos, quizzes, discussions, and presentations. We report a qualitative evaluation of its acceptability. Methods We conducted eight focus groups with 79 students aged 11-12 who participated in Operation Smoke Storm at two UK schools in Autumn 2013, and 20 interviews with teachers who delivered the intervention. These were digitally audio-recorded, transcribed verbatim and analysed using the framework method. Results Students enjoyed the secret agent scenario and reported acquiring new knowledge about smoking and the tobacco industry, which seemed to strengthen their aversion to smoking. Teachers felt confident delivering the ‘off the shelf’ resource, although they would have welcomed more background information about the topic and guidance on steering discussions. Teachers highlighted a need for the resource to be flexible and not dependent on lesson length, teacher confidence, or expertise. Students and teachers endorsed the idea of developing a booster component for older students and supported the development of printed information complementing the resource to encourage parents to support their child not to smoke. Conclusions These findings demonstrate that Operation Smoke Storm can be delivered by teachers to raise awareness about smoking-related issues. The ideas and issues raised are now being used to improve and extend the resource for further evaluation.

Aim: To explore tobacco profit margins and sales among small retailers in England. Methods: Interviews with managers/owners of 62 small retail shops that sold tobacco in disadvantaged areas of Newcastle and London, England. The interviews included questions about tobacco sales and profit margins, and interest in reducing reliance on tobacco sales. Results: The majority of retailers (89%) reported low overall profit margins on tobacco sales (< 6%). The most common response was a profit margin of 4–6%,with some reporting lower margins for price-marked packs of cigarettes (1–6%) and higher margins for non-price marked or premium brands (7% to over 10%). A few mentioned higher profit margins for e-cigarettes. Despite this, most thought tobacco sales were important (90%), and attributed this reliance to footfall (81%), i.e., customers purchasing tobacco also purchasing other products. 42% of retailers expressed interest in reducing their reliance on tobacco sales. Conclusions: Small retailers report low tobacco profit margins, but high reliance on tobacco sales because of footfall. Retailer interest in reducing reliance on tobacco sales warrants further research into opportunities for disinvestment. Additionally, retailers’ belief that they are reliant on tobacco sales because of footfall should be further investigated.

Public health campaigns have the potential to correct vaping misperceptions. However, campaigns highlighting vaping harms to youth may increase misperceptions that vaping is equally/more harmful than smoking. Vaping campaigns have been implemented in the United States and Canada since 2018 and in England since 2017 but with differing focus: youth vaping prevention (United States/Canada) and smoking cessation (England). We therefore examined country differences and trends in noticing vaping campaigns among youth and, using 2022 data only, perceived valence of campaigns and associations with harm perceptions. Seven repeated cross-sectional surveys of 16-19 year-olds in United States, Canada and England (2018-2022, n = 92 339). Over half of youth reported noticing vaping campaigns, and noticing increased from August 2018 to February 2020 (United States: 55.2% to 74.6%, AOR = 1.21, 95% CI = 1.18-1.24; Canada: 52.6% to 64.5%, AOR = 1.13, 1.11-1.16; England: 48.0% to 53.0%, AOR = 1.05, 1.02-1.08) before decreasing (Canada) or plateauing (England/United States) to August 2022. Increases were most pronounced in the United States, then Canada. Noticing was most common on websites/social media, school and television/radio. In 2022 only, most campaigns were perceived to negatively portray vaping and this was associated with accurately perceiving vaping as less harmful than smoking among youth who exclusively vaped (AOR = 1.46, 1.09-1.97). Consistent with implementation of youth vaping prevention campaigns in the United States and Canada, most youth reported noticing vaping campaigns/messages, and most were perceived to negatively portray vaping.

Introduction The current study explores quitting behaviours and use of cessation assistance among adult tobacco users with probable anxiety or depression (PAD) and in six European (EU) Member States (MS). Material and Methods The EUREST-PLUS ITC Wave 1 Europe Survey was conducted with a nationally representative cross-sectional sample of 6,011 adult cigarette smokers from six European Union (EU) Member States (MS) (Germany, Greece, Hungary, Poland, Romania, Spain) in 2016. Results Our study found that one in five smokers sampled from six EU MS had a diagnosis, treatment or positive screen for anxiety or depression, with rates of PAD varying between EU MS. Results of the multivariable logistic regression analysis showed that respondents with PAD were more likely to have made a quit attempt in the last 12 months (AOR 1.75; 95%CI 1.45-2.11), compared to respondents without PAD. Among those respondents with PAD who used support the most frequently reported quit method was prescription-based quit smoking pharmacotherapy (15.4%) followed by e-cigarettes (13.7%) and NRT (11.3%). Person-to-person behavioral support (i.e. local quit services, face-to-face advice from a doctor or other health care professional, telephone or quitline services) was reported significantly more frequently among respondents with PAD compared to those without PAD. Conclusions Given both pharmacological and non-pharmacological quit smoking aids have been shown to be safe, acceptable and effective for people with and without mental illness it is important that their use be promoted among smokers with anxiety and depression alongside behavioral counseling. Our findings support the need for interventions targeting health care professionals in providing smoking cessation assistance among this population of smokers. Acknowledgements EUREST-PLUS is a Horizon2020 project conducted by researchers throughout Europe from both the six participating countries as well as other institution partners within Europe and abroad. Partnering organizations include the European Network on Smoking Prevention (Belgium), Kings College London (United Kingdom), German Cancer Research Centre (Germany), University of Maastricht (The Netherlands), University of Athens (Greece), Aer Pur Romania (Romania), European Respiratory Society (Switzerland), the University of Waterloo (Canada), the Catalan Institute of Oncology (Catalonia, Spain), Smoking or Health Hungarian Foundation (Hungary), Health Promotion Foundation (Poland), University of Crete (Greece), and Kantar Public Brussels (Belgium). Funding The EUREST-PLUS Project takes place with the financial support of the European Commission, Horizon 2020 HCO-6-2015 program (EUREST-PLUS: 681109; C. Vardavas) and the University of Waterloo (GT. Fong). Additional support was provided to the University of Waterloo by the Canadian Institutes of Health Research (FDN-148477). GT. Fong was supported by a Senior Investigator Grant from the Ontario Institute for Cancer Research. E. Fernández is partly supported by Ministry of Universities and Research, Government of Catalonia (2017SGR139) and by the Instituto Carlos III and co-funded by the European Regional Development Fund (FEDER) (INT16/00211 and INT17/00103), Government of Spain.

Efforts to mitigate the devastation of tobacco-attributable morbidity and mortality in the European Union (EU) consist of its newly adopted Tobacco Products Directive (TPD) along with the first-ever health treaty, the WHO Framework Convention on Tobacco Control (FCTC). The aim of this Horizon 2020 project entitled European Regulatory Science on Tobacco: Policy Implementation to Reduce Lung Disease (EUREST-PLUS) is to monitor and evaluate the impact of the implementation of the TPD across the EU, within the context of WHO FCTC ratification. The EUREST-PLUS ITC cohort study of adult smokers in six EU MS (Germany, Greece, Hungary, Poland, Romania, Spain), uses a pre- vs. post-TPD implementation study design, evaluating the impact of several tobacco control policy provisions, including but not limited to health warning labels, smoke free areas and electronic cigarettes. The study is designed to generate strong inferences about the effectiveness of tobacco control policies, as well as to elucidate the mechanisms and factors by which policy implementation translates to population impact. Findings from EUREST-PLUS have potential global implications for implementation of innovative tobacco control policies and its impact on the prevention of lung diseases. Acknowledgements EUREST-PLUS is a Horizon2020 project conducted by researchers throughout Europe from both the six participating countries as well as other institution partners within Europe and abroad. Partnering organizations include the European Network on Smoking Prevention (Belgium), Kings College London (United Kingdom), German Cancer Research Centre (Germany), University of Maastricht (The Netherlands), University of Athens (Greece), Aer Pur Romania (Romania), European Respiratory Society (Switzerland), the University of Waterloo (Canada), the Catalan Institute of Oncology (Catalonia, Spain), Smoking or Health Hungarian Foundation (Hungary), Health Promotion Foundation (Poland), University of Crete (Greece), and Kantar Public Brussels (Belgium). Funding The EUREST-PLUS Project takes place with the financial support of the European Commission, Horizon 2020 HCO-6-2015 program (EUREST-PLUS: 681109; C. Vardavas) and the University of Waterloo (GT. Fong). Additional support was provided to the University of Waterloo by the Canadian Institutes of Health Research (FDN-148477). GT. Fong was supported by a Senior Investigator Grant from the Ontario Institute for Cancer Research. E. Fernández is partly supported by Ministry of Universities and Research, Government of Catalonia (2017SGR139) and by the Instituto Carlos III and co-funded by the European Regional Development Fund (FEDER) (INT16/00211 and INT17/00103), Government of Spain.

Background Free or lower cost cessation medication is reported more often as a trigger to think about quitting by smokers with low education and/or income, but it is not clear whether this leads to actual quitting of smoking. The aim of this study was to investigate whether reporting free medication as trigger is related to medication use, reported quit attempts and quit success and whether this association is modified by education and income. Methods Data were derived from the 2013 and 2014 surveys of the International Tobacco Control (ITC) Netherlands (n=1164) and United Kingdom (n=768) cohort. From the 2013 survey, current smokers were selected who also participated in the 2014 follow-up survey. Logistic regression analyses were used to assess associations between free medication as a trigger to think about quitting in 2013 and the use of smoking cessation medication, quit attempts and smoking cessation in 2014. Results 37.0% of smokers in the UK and 24.9% of smokers in the Netherlands reported free or lower cost medication as trigger to think about quitting. Smokers who reported this trigger were more likely to have used cessation medication during a quit attempt both in the UK (OR = 4.19, p < 0.001) and in the Netherlands (OR = 2.14, p = 0.033). The association between free medication as trigger to think about quitting and quit attempts was significant in the UK (OR = 1.45, p = 0.030), but not in the Netherlands (OR = 1.10, p = 0.587). There was no significant association with quit success. Associations did not differ across income and education groups. Conclusions Free or lower cost smoking cessation medication may stimulate quit attempts and increase the use of cessation medication among smokers with low, moderate, and high socioeconomic status.

Background Cigarettes with flavour-changing capsules in the filter have experienced phenomenal global growth in the last decade. However, very few studies have explored the use of these products. Our objective was to explore which smokers in the United Kingdom use these products, and why. Methods An online survey was conducted between April-May 2016 with a sample of 6234 factory-made (FM) and/or hand-rolled cigarette smokers. This analysis focused on the 3548 smokers (aged 18 years and over) of FM cigarettes. We explored socio-demographic and smoking-related factors associated with smoking capsule cigarettes, reasons for using them, and whether users burst the capsule. Results 13% of FM smokers (n=454) smoked capsule cigarettes, with younger smokers more likely than older smokers to use them (30% of 18-24 year olds compared with 5% of those 55+). Capsule use was significantly more common among those from other white backgrounds (22%) than among white British (12%), and among those planning to quit in the next six months (16%) than those not planning to quit (11%). Most capsule users crushed the capsule always or most of the time (70%), with some never crushing it (9%). The most common reasons for using capsule cigarettes were that they taste better (52%), are smoother (41%), provide a choice of flavours (32%), the enjoyment of clicking the capsule (25%) and that they are more interesting than regular cigarettes (21%). For those who never crushed the capsule, almost half (49%) smoked capsules because their brand only had capsule variants. Capsule and non-capsule smokers did not differ in their perceptions of the harmfulness of their brand relative to other brands, or their concern about the effect of smoking on their health. Conclusions Approximately one in eight FM cigarette smokers used capsule cigarettes, with the key drivers of use related to taste, having a choice of flavours and interactivity.

Background Articles 11 and 13 of the WHO FCTC call for the elimination of logos, colours, brand images and promotional information on tobacco packaging that make tobacco products more attractive. We aimed to assess, using a systematic review, the effect of standardised tobacco packaging (STP) on tobacco attitudes and behaviours, including, for the first time, population-level outcomes from Australia where STP was implemented in 2012. The review was published in 2017, but not yet presented at a conference. Methods Using standard Cochrane methods, we searched nine databases for peer-reviewed articles evaluating STP prior to January 2016, extracted relevant data and also assessed risk of bias. Results We identified 51 peer-reviewed studies, with over 800,000 participants, a variety of methods and designs, and assessing a range behavioural and non-behavioural outcomes; these were conducted predominantly in high-income countries. We found that overall, STP had a positive effect on behavioural and non-behavioural outcomes; while we also found some null results, there were no negative effects. Australian evidence suggested that STP reduced smoking prevalence, but certainty this outcome was limited by the concurrent introduction of enhanced pictorial warnings. The impact on non-behavioural outcomes was clearer (e.g. STP consistently reduced the appeal of tobacco products), and provided plausible mechanisms of effect consistent with the finding on prevalence. The impact of STP was affected by the detail of the regulations (e.g. whether they banned descriptors and controlled pack shape). Conclusions STP reduced the promotional appeal of tobacco packs in line with regulatory objectives, and the available evidence also showed it may reduce smoking prevalence. There is an urgent need for research to be conducted among low and middle-income countries where 80% of the world's smokers live. Cochrane reviews are evolving documents, updated as other studies become available.

Background Future developments in tobacco control are likely to involve personalisation of treatment to improve efficiency. Pharmacotherapy provision based on Nicotine Metabolite Ratio (NMR) status has been shown to improve outcomes in clinical trials: normal relative to slow metabolisers benefit more from varenicline than nicotine replacement therapy (NRT) treatment. However, it is unknown whether this effect translates to other settings. Methods Data come from 1,563 participants attending English Stop Smoking Services in 2012/13. Sociodemographic, mental/physical health, smoking (dependence, determination to quit) and treatment characteristics (varenicline vs. NRT; group vs. one-to-one behavioural support) were assessed at baseline. Baseline salivary nicotine metabolites were measured and NMR (3-hydroxycotinine/cotinine) status computed, characterising smokers as slow (NMR< 0.31, N=454) or normal (NMR≥0.31, N=1,109) metabolisers. Carbon-monoxide verified 2-week and 50-week continuous abstinence was assessed at 4-week and 52-week follow-up post-quit, respectively. The association between abstinence rates and predictor variables was determined using log-binomial generalised linear models that included a pharmacotherapy by NMR status interaction term and controlled for all covariates. All analyses were intention-to-treat. Results Of participants, 44.2% (95% confidence interval (CI) 41.8-46.7%) and 8.0% (95%CI 6.8-9.5%) were continuously abstinent at 4-week and 52-week follow-up, respectively. There was no evidence of a pharmacotherapy by NMR status interaction on either outcome in adjusted analysis (see Figure). Higher abstinence rates were independently associated with higher socio-economic group, treatment with varenicline, lower dependence and greater age at both follow-ups and with greater determination to quit and group support at 4-week follow-up, only. [Figure] Conclusions Our study did not replicate clinical trial data, indicating that NMR status does not substantially contribute to differential pharmacotherapy effectiveness in Stop Smoking Services. As this was an observational study, self-selection or unmeasured confounders may have influenced results. However, this suggests the effect of NMR in real-world settings is likely to be small, context-dependent and therefore may not translate globally.

Background The tobacco industry (TI) can undermine the public health gains realised from tobacco taxation through its pricing strategies. This study aims to examine contemporary TI pricing strategies in the UK and the implications for tobacco tax policy. Methods Review of commercial and TI literature, and analysis of 2009 to 2015 Nielsen Scantrak electronic point of sale systems (EPOS) data on tobacco sales and price data. The study was set in a high income country with comprehensive tobacco control policies and high tobacco taxes (UK). The main outcome measures were: tobacco price segmentation; monthly prices, sales volumes of and net revenue from roll your own and factory made (RYO and FM) cigarettes by price segment; use of price-marking; and pack sizes. Results The literature review and sales data concurred that both RYO and FM cigarettes were segmented by price into premium, mid-price and value segments, with an additional sub-value FM segment introduced in 2012. Despite regular tax increases, average real prices for RYO value and FM sub-value segments remained steady from 2013 whilst their volumes grew. The TI maintains low prices through reducing the number of cigarettes per pack, price-marking (forcing retailers to sell cheaper products at low prices) and absorbing tax increases. Each year, at the point the budget is implemented, the TI drops its revenue by up to 18 pence per pack, absorbing the tax increases (undershifting). Later in the year it gradually passes the tax increase onto consumers, effectively smoothing the price change consumers face across the year. Undershifting of taxes is most marked for the cheapest products. Conclusions The TI employs a variety of strategies to keep tobacco cheap and minimise the impact of tobacco tax increases. The implementation of standardised packaging can prevent small pack sizes and price-marking but further changes in tax policy are needed to minimise undershifting.

Background: Smokers who start smoking at an early age are less likely to quit and more likely to die from their habit. Evidence from the US Truth® campaign suggests that interventions focusing on tobacco industry practices and ethics may be effective in preventing smoking uptake. Objectives: In an exploratory study, to develop, pilot and provide preliminary evidence of the acceptability and effectiveness of Operation Smoke Storm, a school-based intervention based on the premise of the Truth® campaign, to prevent smoking uptake. Design: Mixed-methods, non-randomised controlled study. Component 1 was delivered to Year 7 students, and student focus groups and teacher interviews were conducted to refine the lessons and to develop components 2 and 3. The revised Year 7 lessons and accompanying family booklet were delivered to new Year 7 students 1 year later in one school only; Year 8 students in both schools received the booster session. Setting and participants: Students in Years 7–8 (aged 11–13 years) in two UK schools. Intervention: A three-component intervention comprising (1) three 50-minute classroom-based sessions in Year 7 in which students acted as secret agents to uncover industry practices through videos, quizzes, discussions and presentations; (2) an accompanying family booklet containing activities designed to stimulate discussions about smoking between parents and students; and (3) a 1-hour interactive classroom-based booster session for Year 8 students, in which students learnt about tobacco marketing strategies from the perspectives of an industry executive, a marketing company and a health campaigner. Main outcome measures: Odds ratios to compare the self-reported prevalence of ever smoking and susceptibility to smoking in Year 8 students after the delivery of the booster session in study schools compared with students in local control schools. Qualitative data on acceptability of the intervention. Results: The combined prevalence of ever smoking and susceptibility increased from 18.2% in Year 7 to 33.8% in Year 8. After adjusting for confounders there was no significant difference in the odds of a Year 8 student in an intervention school being an ever smoker or susceptible never smoker compared with controls [adjusted odds ratio (aOR) 1.28, 95% confidence interval (CI) 0.83 to 1.97; p = 0.263] and no significant difference in the odds of ever smoking (aOR 0.82, 95% CI 0.42 to 1.58; p = 0.549). Students mostly enjoyed the intervention and acquired new knowledge that appeared to strengthen their aversion to smoking. Teachers liked the ‘off-the-shelf’ nature of the resource, although they highlighted differences by academic ability in the extent to which students understood the messages being presented. Use of the family component was low but it was received positively by those parents who did engage with it. Limitations: Logistical difficulties meant that students’ responses in Year 7 and Year 8 could not be linked; however, baseline smoking behaviours differed little between intervention and control schools, and analyses were adjusted for confounders measured at follow-up. Conclusions: Operation Smoke Storm is an acceptable resource for delivering smoking-prevention education but it does not appear to have reduced smoking and susceptibility. Future work: The lack of a strong signal for potential effectiveness, considered alongside logistical difficulties in recruiting and working with schools, suggests that a fully powered cluster randomised trial of the intervention is not warranted. Funding: The National Institute for Health Research (NIHR) Public Health Research programme.

BACKGROUND AND OBJECTIVES:Standardised or 'plain' tobacco packaging was introduced in Australia in December 2012 and is currently being considered in other countries. The primary objective of this systematic review was to locate, assess and synthesise published and grey literature relating to the potential impacts of standardised tobacco packaging as proposed by the guidelines for the international Framework Convention on Tobacco Control: reduced appeal, increased salience and effectiveness of health warnings, and more accurate perceptions of product strength and harm. METHODS:Electronic databases were searched and researchers in the field were contacted to identify studies. Eligible studies were published or unpublished primary research of any design, issued since 1980 and concerning tobacco packaging. Twenty-five quantitative studies reported relevant outcomes and met the inclusion criteria. A narrative synthesis was conducted. RESULTS:Studies that explored the impact of package design on appeal consistently found that standardised packaging reduced the appeal of cigarettes and smoking, and was associated with perceived lower quality, poorer taste and less desirable smoker identities. Although findings were mixed, standardised packs tended to increase the salience and effectiveness of health warnings in terms of recall, attention, believability and seriousness, with effects being mediated by the warning size, type and position on pack. Pack colour was found to influence perceptions of product harm and strength, with darker coloured standardised packs generally perceived as containing stronger tasting and more harmful cigarettes than fully branded packs; lighter coloured standardised packs suggested weaker and less harmful cigarettes. Findings were largely consistent, irrespective of location and sample. CONCLUSIONS:The evidence strongly suggests that standardised packaging will reduce the appeal of packaging and of smoking in general; that it will go some way to reduce consumer misperceptions regarding product harm based upon package design; and will help make the legally required on-pack health warnings more salient.

Since the implementation of the 2002 Tobacco Advertising and Promotion Act, point-of-sale (PoS) tobacco displays are one of few remaining means of communication between the tobacco industry and customers in the UK. This study aimed to explore the characteristics of tobacco displays in a UK city, and particularly to assess the tobacco prices and promotional offers, types and pack sizes on display.Digital pictures of PoS displays were taken in 117 small retail shops in Nottingham in mid 2010. Data were analysed using Windows Photo Gallery software and SPSS version 16.Just over half (52%) of cigarette packs on display were packs of 20, and 43% packs of 10. Cigarette prices differed substantially between brands, ranging from £4.19 to £6.85 for 20-packs, and from £2.12 to £3.59 for 10-packs. Forty four percent of cigarette packs and 40% of RYO (Roll-Your-Own) tobacco pouches, almost exclusively lower priced brands, were displayed with a pricemark, implying a promotional price offer. Eighty percent of 20-pack cigarette brand or brand variants on sale were priced below the EU-defined Most Popular Price Category (MPPC) for the UK in 2010; 45% were priced below the Weighted Average Price (WAP), which replaced the MPPC in 2011.PoS displays communicate value by displaying a high proportion of lower cost brands, and smaller and hence lower-cost packs, and by displaying price discounts on packs. The MPPC substantially overestimated the prices at which most 20-cigarette packs were available. Removal of PoS displays will prevent this means of price marketing but our study also suggests that minimum pricing of 20-pack cigarettes, prohibition of sale of cigarettes in packs less than 20, and plain packaging to prevent pricemarking are necessary if price is to be used effectively as a tobacco control measure.

Smoking prevention should be a primary public health priority for all governments, and effective preventive policies have been identified for decades. The heterogeneity of smoking prevalence between European Union (EU) Member States therefore reflects, at least in part, a failure by governments to prioritise public health over tobacco industry or possibly other financial interests, and hence potentially government corruption. The aims of this study were to test the hypothesis that smoking prevalence is higher in countries with high levels of public sector corruption, and explore the ecological association between smoking prevalence and a range of other national characteristics in current EU Member States.Ecological data from 27 EU Member States were used to estimate univariate and multivariate correlations between smoking prevalence and the Transparency International Corruption Perceptions Index, and a range of other national characteristics including economic development, social inclusion, quality of life and importance of religion. We also explored the association between the Corruption Perceptions Index and measures of the extent to which smoke-free policies have been enacted and are enforced.In univariate analysis, smoking prevalence was significantly higher in countries with higher scores for corruption, material deprivation, and gender inequality; and lower in countries with higher per capita Gross Domestic Product, social spending, life satisfaction and human development scores. In multivariate analysis, only the corruption perception index was independently related to smoking prevalence. Exposure to tobacco smoke in the workplace was also correlated with corruption, independently from smoking prevalence, but not with the measures of national smoke-free policy implementation.Corruption appears to be an important risk factor for failure of national tobacco control activity in EU countries, and the extent to which key tobacco control policies have been implemented. Further research is needed to assess the causal relationships involved.

BackgroundBreast cancer in young women tends to have a natural history of aggressive disease for which rates of recurrence are higher than in breast cancers detected later in life. Little is known about the genetic pathways that underlie early-onset breast cancer. Here we report the discovery of DEAR1 (ductal epithelium-associated RING Chromosome 1), a novel gene encoding a member of the TRIM (tripartite motif) subfamily of RING finger proteins, and provide evidence for its role as a dominant regulator of acinar morphogenesis in the mammary gland and as an independent predictor of local recurrence-free survival in early-onset breast cancer.Methods and findingsSuppression subtractive hybridization identified DEAR1 as a novel gene mapping to a region of high-frequency loss of heterozygosity (LOH) in a number of histologically diverse human cancers within Chromosome 1p35.1. In the breast epithelium, DEAR1 expression is limited to the ductal and glandular epithelium and is down-regulated in transition to ductal carcinoma in situ (DCIS), an early histologic stage in breast tumorigenesis. DEAR1 missense mutations and homozygous deletion (HD) were discovered in breast cancer cell lines and tumor samples. Introduction of the DEAR1 wild type and not the missense mutant alleles to complement a mutation in a breast cancer cell line, derived from a 36-year-old female with invasive breast cancer, initiated acinar morphogenesis in three-dimensional (3D) basement membrane culture and restored tissue architecture reminiscent of normal acinar structures in the mammary gland in vivo. Stable knockdown of DEAR1 in immortalized human mammary epithelial cells (HMECs) recapitulated the growth in 3D culture of breast cancer cell lines containing mutated DEAR1, in that shDEAR1 clones demonstrated disruption of tissue architecture, loss of apical basal polarity, diffuse apoptosis, and failure of lumen formation. Furthermore, immunohistochemical staining of a tissue microarray from a cohort of 123 young female breast cancer patients with a 20-year follow-up indicated that in early-onset breast cancer, DEAR1 expression serves as an independent predictor of local recurrence-free survival and correlates significantly with strong family history of breast cancer and the triple-negative phenotype (ER(-), PR(-), HER-2(-)) of breast cancers with poor prognosis.ConclusionsOur data provide compelling evidence for the genetic alteration and loss of expression of DEAR1 in breast cancer, for the functional role of DEAR1 in the dominant regulation of acinar morphogenesis in 3D culture, and for the potential utility of an immunohistochemical assay for DEAR1 expression as an independent prognostic marker for stratification of early-onset disease.

Background: Smokeless tobacco (ST) use is common among youth in South Asia where 85% of the world’s 300 million ST users live and use the most lethal ST forms. Little is known about the impact of tobacco control policies on the youth ST uptake in those countries. We planned to conduct longitudinal surveys among school going adolescents to evaluate existing tobacco control policies on tobacco uptake and use, and a feasibility study for that prospective, observational cohort study. Study objectives: (1) To demonstrate the feasibility of selection, recruitment and retention of schools and of study participants; (2) To assess the feasibility and acceptability of the study procedure and study tool (questionnaire); (3) To evaluate if the questionnaire can assess tobacco uptake and use, and their potential predictors. Methods and analysis: The feasibility study will be conducted in two administrative areas within each of three South Asian countries: Bangladesh, India and Pakistan. We will use both quantitative and qualitative data collection methods. Eight eligible schools will be randomly selected within purposively selected sub-districts from each country. We plan to conduct one baseline and one follow up survey among students of grade 6-8, one year apart. At each time point, data on tobacco uptake and potential predictors will be collected from students via self-administered questionnaires that were designed for the longitudinal study. The qualitative component will be embedded into the study with each round of data collection to assess the acceptability of the study instrument (questionnaire) and data collection methods, via focus group discussions with students and semi-structured interviews with schoolteachers. Recruitment and retention rates, completeness of the questionnaires, frequencies and associations of tobacco use and explanatory variables will be reported. Data gathered from the focus group and interviews will be analysed using the framework approach.