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Purpose: To investigate age and sex-specific changes in rates, methods used and characteristics of suicide attempters receiving medical care, over a 15-year period in two European WHO catchment areas (Stockholm, Sweden; and Würzburg, Germany).Methods: The data for this study were obtained from the WHO/EURO Multicentre Study on Suicidal Behaviour for the period 1989-2003. Sex-specific, person-based suicide attempt rates were calculated for each year separately for the age groups 15-24 and 25 or above. The Chi-square test for trend was applied to estimate changes in proportions of socio-demographic and socio-economic variables.Results: Significantly, increasing trends in suicide attempt rates occurred in young females, and in males and females aged 25 or above in Würzburg. On the contrary, men 25 years and above showed a significant decrease in suicide attempt rates in Stockholm. Young females in Würzburg tended to use less violent methods for their attempts whereas in Stockholm young females were increasingly inclined to attempt suicide using violent methods. In Stockholm, young female suicide attempters tended to be more often economically inactive, particularly due to an increasing proportion of students. Young females in Würzburg were often less well educated, as were their young male counterparts. This contrasted with trends in the education of men and women of 25 or above in Stockholm.Conclusions: The results of this study suggest temporal changes in trends, methods used and in the social profile of suicide attempters. [ABSTRACT FROM AUTHOR]

Introduction: The United Kingdom has achieved reductions in illicit tobacco (IT) market size and share. However, there remains a 17.7% tobacco duty gap, contributing to health inequalities. In January 2024, the UK government announced a new strategy to control IT, along with provision of new funding., Methods: A representative cross-sectional survey of adults in England ran in April 2022 to evaluate attitudes and exposure to IT. Tobacco smokers were asked questions about encounters with IT, while all participants answered questions on knowledge and perspectives on IT., Results: Of 262 tobacco smokers, 18.3% (95% CI 13.8% to 23.6%) had come across IT in the past year. Men had four times the odds of encountering IT recently than women. Among 1767 adults responding to questions on IT, two-thirds agreed IT harmed children, and more than half agreed IT was linked to organized crime. Younger adults, smokers, and those in lower socioeconomic groups were less likely to agree IT was harmful., Conclusions: Exposure to IT, especially among younger males, remains a concern. While most of the public acknowledge its harm, this is not universal, and some population groups are less likely to do so., Implications: The study highlights persistent exposure to IT in England, especially among younger males, and varying perceptions of IT harm across socioeconomic groups. Tackling IT requires collaboration between health and enforcement agencies, independent of the tobacco industry's influence. Strategies should include components that shift demand for IT and denormalize its presence in communities, particularly in lower socioeconomic areas with higher smoking prevalence., (© The Author(s) 2024. Published by Oxford University Press on behalf of the Society for Research on Nicotine and Tobacco.)

Introduction: The prevalence of daily secondhand smoke (SHS) exposure among pregnant nonsmoking women and children in Egypt is estimated to be about 50% and 55%, respectively. This study aimed to explore barriers to preventing SHS exposure among pregnant women/children and smoking in the home in Egypt., Aims and Methods: Six focus group discussions with pregnant women or mothers of children residing in urban-rural areas (n = 61) were conducted. Data were managed and analyzed using the Framework Method., Results: Sixty-one participants aged 18-49 were recruited. They reported being never smokers and SHS exposure for themselves and their children was mainly at home. Pregnant women or mothers had some general knowledge of the dangers of SHS, but their knowledge appeared incomplete. The most commonly reported barriers to preventing SHS exposure/adopting a smoke-free home or workplace were social acceptance of smoking and SHS exposure, masculinity and gender norms of accepting smoking among men as a normative behavior, fear among women of damaging a relationship with family or even divorce, women resigning themselves to SHS exposure, and doctors not being supportive of smoking cessation. The majority of interviewees' families were reported to allow smoking anywhere in the home. Others implemented some measures to prevent SHS; however, these tended to be inconsistently implemented., Conclusions: Changing the norm of accepting smoking among men as a normative behavior within Egyptian society and better enforcement of smoke-free policies, will help to protect pregnant women and children from SHS., Implications: This study suggests promising approaches to support the promotion of smoke-free homes and the prevention of SHS exposure among pregnant women and children in public places in Egypt. Better enforcement of smoke-free policies is needed. Healthcare professionals should support smoking cessation services in primary health centers. SHS policy, practice, and research should focus on husbands/fathers as they are the main source of SHS. There is a need for denormalization of SHS exposure in Egyptian society., (© The Author(s) 2024. Published by Oxford University Press on behalf of the Society for Research on Nicotine and Tobacco. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site—for further information please contact journals.permissions@oup.com.)

Background: Adolescents are susceptible to using tobacco because of early exposure to tobacco through family members, easy access, or peer pressure. School-based educational programs are crucial for raising awareness of the harms of tobacco, thus preventing its uptake among adolescents. Studies conducted recently have recognized the need to bring change and reinforce ongoing school-based anti-tobacco education programs. Our study protocol aims to evaluate the effectiveness of a revised school-based anti-tobacco education on susceptibility to tobacco use among school-going adolescents., Method: Project TEACH (Tobacco Education and Awareness for Creating Healthier Adolescents) is an educational intervention that will comprise an animated video on the effects of tobacco on physical and mental health, along with dispelling myths about tobacco, which will be delivered along with a standard education program. The control group will only receive the standard school-based anti-tobacco education program. It will be conducted among students between 6 th to 10 th grade, with a sample size of 3,310 students., Results: Bivariate relations between the main socio-demographic characteristics and susceptibility to tobacco use will be tested using Pearson or Spearman's correlation coefficients. For multivariable analyses, the binary logistic regression analysis is used to establish a risk model to correlate the socio-demographic factors with susceptibility to tobacco use and awareness of the harms of tobacco., Conclusion: Project TEACH aims to provide a sustainable school-based anti-tobacco education intervention. It will help test the effectiveness of the revised intervention, which could be incorporated into the current school education program being conducted in the district., Competing Interests: The authors declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article., (© 2024 The Author(s).)

Objective: This review aimed to assess interventions designed to reduce harm from illicit tobacco (IT). We evaluated health outcomes, cost-effectiveness, the advantages and disadvantages of interventions, and contextual factors affecting implementation., Data Sources: We searched MEDLINE and EMBASE databases from January 2002 to June 2024, the grey literature and undertook backward and forward citation searches of included studies without geographical restrictions., Study Selection: Eligible study types included non-randomised trials, interrupted time series, before-after studies, economic simulations and mixed-methods studies. Case studies providing outcome data linked to specific interventions were also included. Studies were screened by multiple reviewers for eligibility., Data Extraction: Data was extracted on geographical location and dates of interventions, descriptions of the interventions, contexts and outcome data relevant to review objectives which were checked by a second reviewer. Quality assessment was conducted using the Joanna Briggs Institute (JBI) critical appraisal tools appropriate for each study design., Data Synthesis: Five studies and 16 case studies were included. These reported on a range of interventions (including track-and-trace systems, anti-counterfeit measures and communications campaigns) and outcomes (including tax revenue and population attitudes toward IT). There was some evidence for the effectiveness of track-and-trace systems. Case studies, predominantly on national-level interventions, reported decreases in IT market share and increases in tax revenue suggesting potential benefits of multicomponent strategies., Conclusions: There is promising limited evidence for interventions to tackle IT but they are seldom systematically evaluated. Comprehensive, independent evaluations are required to support policymaking and avoid tobacco industry influence in IT research., Prospero Registration Number: CRD42023452732., Competing Interests: Competing interests: No, there are no competing interests., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: There is considerable interest in raising the age of sale of tobacco above the conventional age of 18. We systematically reviewed whether raising the minimum legal sales age of tobacco (MLSA) to 20 or above is associated with reduced prevalence of smoking compared to an MLSA set at 18 or below., Methods: Following a pre-registered protocol on PROSPERO (ref: CRD42022347604), six databases of peer-reviewed journals were searched from January 2015 to April 2024. Backwards and forwards reference searching was conducted. Included studies assessed the association between MLSAs ≥20 with cigarette smoking or cigarette sales for those aged 11-20. Assessments on e-cigarettes were excluded. Pairs of reviewers independently extracted study data. We used ROBINS-I to assess risk of bias and GRADE to assess quality of evidence. Findings were also synthesised narratively., Results: 23 studies were reviewed and 34 estimates of association were extracted. All extracted studies related to Tobacco 21 laws in the United States. Moderate quality evidence was found for reduced cigarette sales, moderate quality evidence was found for reduced current smoking for 18 - 20 year olds, and low quality evidence was found for reduced current smoking for 11 - 17 year olds. The positive association was stronger for those with lower education. Study bias was variable., Conclusions: There is moderate quality evidence that Tobacco 21 can reduce overall cigarette sales and current cigarette smoking amongst those aged 18- 20. It has potential to reduce health inequalities. Research in settings other than the United States is required., Implications: This systematic review on raising the minimum legal sale age of tobacco to 20 or above demonstrates there is moderate quality evidence that such laws reduce cigarette sales, and moderate quality evidence they reduce smoking prevalence amongst those aged 18-20 compared to a minimum legal sale age of 18 or below. The research highlights potential benefits in reducing health inequalities, especially individuals from lower educational backgrounds. Studies are limited to the United States, highlighting a need for more global research to assess the impact of these policies in other settings., (© The Author(s) 2024. Published by Oxford University Press on behalf of the Society for Research on Nicotine and Tobacco.)

Introduction: India has unique tobacco-free film and TV rules designed to prevent tobacco uptake. In this study, we examined the potential influence of exposure to smoking imagery in regionally famous films, on susceptibility to smoke in teenagers enrolled in schools in a district in Southern India., Methods: A longitudinal survey of students, in grades 6 to 8 at baseline in 2017 and grades 7 to 9 one year later in 2018, ascertained prospective incident susceptibility to smoking during the study period in relation to baseline exposure to 27 locally popular films with actual or implied smoking imagery., Results: We analyzed linked data from 33676 participants, and 3973 (11.8%) of the adolescents reported incident susceptibility. There was a significant increase in susceptibility to smoking with increasing exposure at baseline to smoking imagery in films on univariable analysis, highest tertile of exposure relative to no exposure (OR=1.4; 95% CI: 1.0 -2.1, p trend <0.001), and this trend remained significant (p=0.022) after mutual adjustment for recognized confounders, highest vs no exposure (AOR=1.3; 95% CI: 0.9-1.8). We found no statistically significant association between exposure to tobacco-free film rules and change in susceptibility., Conclusions: Prospectively, watching films featuring smoking imagery increases adolescents' vulnerability to smoking. Further research revealed no difference in susceptibility change between youth who saw partially compliant films and those who watched non-compliant films. Our findings, thus, underscore the need to incorporate comprehensive approaches to prevent the inclusion of smoking imagery in films., Competing Interests: The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none was reported., (© 2024 Kamath V.G. et al.)

Background: In May 2016, the UK announced standardising packaging legislation for tobacco products. There was a 12-month transition period with both branded and standardised packs on the market until May 2017. The aim of this study was to investigate whether the implementation of standardised packaging in England was associated with changes in illicit tobacco and cross-border purchasing., Methods: We used Smoking Toolkit Study data covering the time period from 2012 to 2020. We ran time-series analysis using Autoregressive Integrated Moving Average with Exogenous Variable models to investigate the monthly changes in illicit tobacco and cross-border purchasing in England. The model was adjusted for other tobacco control policies implemented during the relevant time period and tobacco pricing. We used May 2017 as an implementation point and run sensitivity analysis using July 2016 and February 2017 as alternative implementation points given phased introduction of the policy., Results: The average prevalence of illicit tobacco and cross-border purchasing in the past 6 months was 14.4%. The implementation of standardised tobacco packaging legislation was associated with a monthly decline in illicit tobacco and cross-border purchases after May 2017 by 0.16% per month (beta=-0.158, 95% CI -0.270 to -0.046). The results were robust to considering different implementation points for the policy (July 2016: beta=-0.109, 95% CI -0.213 to -0.005; February 2017: beta=-0.141, 95% CI -0.245 to -0.036)., Conclusions: In contrast to the tobacco industry's argument that the legislation would lead to an increase in the illicit tobacco and cross-border market, this study demonstrates that the implementation of the policy is associated with a decline in illicit tobacco and cross-border purchases in England., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: This study explored multistakeholder perspectives on existing adolescent-specific tobacco control policies and programmes, to advance India's transition towards a tobacco-free generation., Design: Qualitative semi-structured interviews., Setting: Interviews were conducted with officials involved in tobacco control at the national (India), state (Karnataka), district (Udupi) and village level. Interviews were audio recorded, transcribed verbatim and analysed thematically., Participants: Thirty-eight individuals representing national (n=9), state (n=9), district (n=14) and village (n=6) levels, participated., Results: The study findings highlighted the need to strengthen and amend the existing Tobacco Control Law (2003) provisions, particularly in the vicinity of schools (Sections 6a and 6b). Increasing the minimum legal age to buy tobacco from 18 to 21 years, developing an 'application' for 'compliance and monitoring indicators' in Tobacco-Free Educational Institution guidelines were proposed. Policies to address smokeless tobacco use, stricter enforcement including regular monitoring of existing programmes, and robust evaluation of policies was underscored. Engaging adolescents to co-create interventions was advocated, along with integrating national tobacco control programmes into existing school and adolescent health programmes, using both an intersectoral and whole-societal approach to prevent tobacco use, were recommended. Finally, stakeholders mentioned that when drafting and implementing a comprehensive national tobacco control policy, there is a need to adopt a vision striving toward a tobacco-free generation., Conclusion: Strengthening and developing tobacco control programmes and policies are warranted which are monitored and evaluated rigorously, and where adolescents should be involved, accordingly., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY. Published by BMJ.)

Introduction: In May 2020, the EU Tobacco Products Directive ban on the sale of menthol cigarettes was implemented in England. This study examined the prevalence of menthol cigarette smoking after the ban, according to sociodemographic and smoking characteristics., Methods: Cross-sectional data came from a representative survey of current smokers (18+) in England (unweighted n=2681) between July 2020 and June 2021. The weighted prevalence of menthol cigarette smoking as a proportion of total cigarette smoking was calculated, log-binomial regression explored trends over time, and χ 2 statistics assessed the relationship between menthol smoking, sociodemographic and smoking characteristics. Sources of purchase of menthol cigarettes were explored., Results: Between July 2020 and June 2021, 15.7% (95% CI 14.5 to 17.1) of smokers reported smoking menthol cigarettes. The fitted non-linear trend supported no initial change followed by a possible reduction across April-June 2021 and fit the data better than linear and null (no change) models (χ 2 (2)=2519.7, p=0.06; χ 2 (3)=2519.7, p=0.006). Menthol cigarette smoking was more common among younger groups (16-24=25.2%; 25-34=19.9%) and women (19.4%). Menthol cigarette smokers showed lower cigarette dependence compared with other smokers. Past-6-month purchases of menthol cigarettes from any illicit or cross-border source declined from 30.1% in the last 6 months of 2020 to 17.5% in the first 6 months of 2021., Conclusions: A substantial minority of current smokers in England reported menthol cigarette smoking between July 2020 and June 2021, despite the ban, possibly reflecting mitigation of restrictions by a variety of licit means, such as legal menthol accessories. The reduction in menthol smoking across April-June 2021 warrants further monitoring., Competing Interests: Competing interests: Authors are members of the UK Prevention Research Partnership, an initiative funded by UK Research and Innovation Councils, the Department of Health and Social Care (England), and the UK devolved administrations and leading health research charities. JB reports receiving grants from Cancer Research UK during the conduct of the study and receiving unrestricted research funding from pharmaceutical companies who manufacture smoking cessation medications to study smoking cessation outside the submitted work. LS reports receiving honoraria for talks, receiving an unrestricted research grant and travel expenses to attend meetings and workshops by pharmaceutical companies that make smoking cessation products (Pfizer and Johnson & Johnson), and acting as a paid reviewer for grant-awarding bodies and as a paid consultant for health care companies. LK and IB have no competing interests to declare., (© Author(s) (or their employer(s)) 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: Falls are the most common cause of injury related deaths in people over 75 years. The aim of this study was to explore the experience of providers (instructors) and service users (clients) of a fall's prevention exercise programme and the impact of the COVID-19 pandemic in Derbyshire, UK., Methods: Ten one-to-one interviews with class instructors and five focus groups with clients (n=41). Transcripts were analysed using inductive thematic analysis., Results: Most clients were initially motivated to attend the programme to improve their physical health. All clients reported improvements in their physical health as a result of attending the classes; additional benefits to social cohesion were also widely discussed. Clients referred to the support provided by instructors during the pandemic (online classes and telephone calls) as a 'life-line'. Clients and instructors thought more could be done to advertise the programme, especially linking in with community and healthcare services., Conclusions: The benefits of attending exercise classes went beyond the intended purpose of improving fitness and reducing the risk of falls, extending into improved mental and social wellbeing. During the pandemic the programme also prevented feelings of isolation. Participants felt more could be done to advertise the service and increase referrals from healthcare settings., (Copyright: © 2023 Hylonome Publications.)

Electronic nicotine delivery systems (ENDS) (also known as 'e-cigarettes') can support smoking cessation, although the long-term health impacts are not yet known. In 2019, a cluster of lung injury cases in the USA emerged that were ostensibly associated with ENDS use. Subsequent investigations revealed a link with vitamin E acetate, an additive used in some ENDS liquid products containing tetrahydrocannabinol (THC). This became known as the EVALI (E-cigarette or Vaping product use Associated Lung Injury) outbreak. While few cases were reported in the UK, the EVALI outbreak intensified attention on ENDS in general worldwide. We aimed to describe and explore public commentary and discussion on Twitter immediately before, during and following the peak of the EVALI outbreak using text mining techniques. Specifically, topic modelling, operationalised using Latent Dirichlet Allocation (LDA) models, was used to discern discussion topics in 189,658 tweets about ENDS (collected April-December 2019). Individual tweets and Twitter users were assigned to their dominant topics and countries respectively to enable international comparisons. A 10-topic LDA model fit the data best. We organised the ten topics into three broad themes for the purposes of reporting: informal vaping discussion; vaping policy discussion and EVALI news; and vaping commerce. Following EVALI, there were signs that informal vaping discussion topics decreased while discussion topics about vaping policy and the relative health risks and benefits of ENDS increased, not limited to THC products. Though subsequently attributed to THC products, the EVALI outbreak disrupted online public discourses about ENDS generally, amplifying health and policy commentary. There was a relatively stronger presence of commercially oriented tweets among UK Twitter users compared to USA users., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2022 The Author(s).)

Objectives and Methods: A cross sectional study of HCPs working in public MCH clinics in Assiut city was conducted to explore their knowledge, attitudes and counselling practices regarding prevention of SHS exposure among pregnant women and children. Descriptive and regression analyses were performed. Results: 367 HCPs participated in the study, 12% of whom were smokers. The majority were nurses (45%). A considerable proportion of HCPs reported being exposed to SHS in workplace (70%) and home (52%). About half HCP reported high SHS knowledge (56%), supportive attitude towards preventing SHS exposure (53%), and having good counselling practice regarding SHS exposure (52%). Being a GP and serving urban communities were significantly associated with high knowledge. Being female, serving a rural population, receiving training on smoking cessation services, not being exposed to SHS at home, and having a supportive attitude towards prevention of SHS exposure were significantly associated with good counselling practice. Conclusion: Awareness, attitudes and counselling practice of HCPs should be improved. Training for HCPs and enforcement of smoke free polices are needed to improve awareness and facilitate changes in social norms., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Hassanein, Murray, Bogdanovica and Langley.)

Objectives: In December 2020, Derbyshire County Council in England introduced 'walk-in' asymptomatic community COVID-19 testing sites. Our study aimed to explore people's views of the newly established COVID-19 community testing (CT) sites among those who attended and those who did not attend them, alongside gathering individuals' experiences of attending a CT site to complete a lateral flow test., Setting: This qualitative research study comprised of one-to-one interviews with those attending a COVID-19 CT sites in Derbyshire and those from the surrounding area who did not attend., Participants: A combination of purposive and convenience sampling was used to recruit those who had (n=18) and those who had not attended (n=15) a walk-in asymptomatic CT site., Results: Employers played a key role in raising awareness of the testing sites, with most attending CT at the request of their workplace. The experience of attending a CT site was overwhelmingly positive and those who got tested spoke about the reassurance a negative result offered, knowing they were not passing on the virus when going about their daily lives. However, there was a perception that awareness of CT sites was low across the county and some confusion about who was eligible to attend and under what circumstances. Individuals linked this to low level of advertising they had seen, in addition to a lack of clarity in the information provided., Conclusions: People's experience of attending a 'walk-in' asymptomatic CT site in Derbyshire was generally very positive; however, ensuring clear communication for future testing programmes is essential to maximise their uptake., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: The objective of this review was to identify, appraise, and synthesize the evidence related to experiences and views of parents, children, and professionals on the prevention of second-hand smoke exposure to women and children in Middle Eastern countries., Introduction: Second-hand smoke exposure is a major health concern. It is problematic during pregnancy because of potential adverse reproductive effects and poor fetal outcomes. Childhood second-hand smoke exposure is linked to increased morbidity and mortality. Smoking prevalence is high among men in Middle Eastern countries and, as a result, large numbers of non-smoking men, women, and children are exposed to second-hand smoke daily., Inclusion Criteria: Studies were considered for inclusion if they explored experiences and views on the prevention of second-hand smoke exposure among women and children in homes, workplaces, schools, personal vehicles, and public places in 17 Middle Eastern countries. This review included studies that focused on qualitative data, including, but not limited to, designs such as phenomenology, grounded theory, ethnography, qualitative descriptive, and feminist research., Methods: MEDLINE, Embase, CINAHL, PsycINFO, Web of Science, and Scopus databases were searched to identify published studies from inception to January 2021. The search for unpublished studies included EThOS, OpenGrey, and ProQuest Dissertations and Theses. No language restrictions were applied. The JBI guidelines for qualitative systematic reviews were followed in conducting the review. The JBI process of meta-aggregation was used to identify categories and synthesize findings., Results: Of 5229 records identified, two qualitative studies (in three publications) met the eligibility criteria and were included in the review. One study was conducted in Turkey and the other study (reported in two papers) was conducted in Israel. The methodological quality of the studies was high. The participants in the included studies were parents (n = 118 participants) aged between 18 and 42 years. The methods used for data collection were interviews analyzed using thematic content analysis. A total of 50 findings were extracted and aggregated into eight categories, based on the similarity of meaning. Three synthesized finding were generated (all with moderate confidence): i) Parents were aware of second-hand smoke and that exposure to second-hand smoke is harmful, although the health dangers of second-hand smoke exposure were not commonly discussed with parents during pregnancy;ii) Smoking is a socially and culturally accepted norm, with parents reporting cultural beliefs about traditional values as a barrier to reducing second-hand smoke exposure in the home and personal psychological factors to quitting smoking; iii) Parents implemented different physical restrictions on smoking, such as having rules about where smoking can take place, with psychological motivators reported as drivers to decrease second-hand smoke exposure among children in the home, but tended to lack certainty or confidence regarding whether such protective measures were needed or would be effective., Conclusions: The findings of this study offer an insight into parents' views on second-hand smoke exposure and its prevention in Middle Eastern countries. Parents have conflicting views on second-hand smoke exposure and techniques to minimize it. Interventions are needed to increase parents' knowledge about the harms of second-hand smoke to reduce women's and children's exposure to second-hand smoke., Systematic Review Registration Number: PROSPERO CRD42019137006., Competing Interests: JL-B is a senior associate editor for JBI Evidence Synthesis but was not involved in the management or decision-making processes associated with the manuscript. The other authors declare no conflict of interest., (Copyright © 2022 JBI.)

Introduction: Subnational, supralocal (or "regional") approaches to tobacco control are often central federal nation tobacco control and can be superfluous for very small nations. However, their relevance to countries with weak intermediate tiers of governance are less clear. This study explores expert and policymaker perceptions on the function, form, footprint, and funding of regional tobacco control (RTC) in England., Aims and Methods: One-to-one semistructured interviews (n = 16) and four focus groups (n = 26) exploring knowledge and perceptions of the past, present, and future of RTC in England were conducted with public health leaders, clinicians, tobacco control practitioners, civil servants, and politicians. Interviews were audio-recorded, transcribed verbatim, and analyzed thematically., Results: Participants reported several key functions for RTC, including illicit tobacco control, media campaigns, advocacy, policy development, and network facilitation for local actors. A small minority of participants reported little role for RTC. Broader perceived features of effective RTC included subject expertise, strong regional ties, systems leadership, and a distinctive program of work. Views varied on whether regional programs should be developed nationally or locally, and their optimal footprint. Participants generally agreed stable funding was a prerequisite for success, although there was lesser agreement on funding sources., Conclusions: Pooling resources at the regional level in countries with weak intermediate tiers of governance may increase reach, cost-effectiveness and impact of campaigns, policy interventions, and advocacy, whilst retaining the ability to tailor approaches to regional populations., Implications: There are likely to be greater funding and governance challenges associated with introducing or strengthening RTC in countries with weak intermediate tiers of governance. Despite this, evidence from England shows it is possible to develop RTC approaches reported as effective by key stakeholders. Possible benefits of regional approaches in this context include cost-effective delivery of illicit tobacco control, media campaigns, advocacy, research, policy development, and coordinated support for local action on tobacco., (© The Author(s) 2022. Published by Oxford University Press on behalf of the Society for Research on Nicotine and Tobacco. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Introduction: Although most of the disease burden internationally is due to tobacco smoking, smokeless tobacco (SLT) use contributed to an estimated 76 000 deaths in 2017. We have studied the potential risk factors for SLT use among adolescents in South India., Methods: A cross-sectional questionnaire survey of all students in grades 6-8 in schools in the Udupi district of Karnataka State ascertained SLT use status and potential determinants of SLT uptake. Ever SLT use was defined as any reported consumption of any SLT products, currently or at any time in the past. Independent effects on ever SLT use status were estimated using multiple logistic regression., Results: Of 46 706 students from 914 participating schools, 39 282 (84.1%) provided questionnaire responses sufficiently complete for analysis. Ever SLT use was reported by 775 (2.0%) participants and in a mutually adjusted model was significantly related to age, male sex, family use, or friend's use of SLT, low socioeconomic status, high rebelliousness, and low self-esteem. After controlling for these effects, the odds of ever-SLT use were significantly higher among students who had least awareness of the harmful effects of tobacco use (odds ratio 3.7, 95% confidence interval [2.9, 4.7]) and significantly lower among those not exposed to tobacco advertising (odds ratio 0.7, 95% confidence interval [0.5, 0.8])., Conclusions: The prevalence of SLT use among children in Karnataka is relatively low when compared with other studies in India. The significant potential risk factors of SLT use include low awareness of the harmful effects of tobacco and tobacco control policies and exposure to tobacco advertising., Implications: The prevalence of SLT use among school going adolescents in South India is relatively low. The potential risk factors for SLT use among adolescents in southern India are similar to those for smoked tobacco. It includes age, male gender, family or friend's use of SLT, low socioeconomic status, high rebelliousness, low self-esteem, exposure to tobacco advertisement and least awareness about the harmful effects of tobacco and of tobacco control policies. The present study lays emphasis regarding creating awareness about tobacco harms and control policies for further reducing tobacco use among adolescents., (© The Author(s) 2022. Published by Oxford University Press on behalf of the Society for Research on Nicotine and Tobacco.)

Background and Aims: Smoking prevalence has been falling in England for more than 50 years, but remains a prevalent and major public health problem. This study used an age-period-cohort (APC) approach to measure lifecycle, historical and generational patterns of individual smoking behaviour., Design: APC analysis of repeated cross-sectional smoking prevalence data obtained from three nationally representative surveys., Setting: England (1972-2019)., Participants: Individuals aged 18-90 years., Measurements: We studied relative odds of current smoking in relation to age in single years from 18 to 90, 24 groups of 2-year survey periods (1972-73 to 2018-19) and 20 groups of 5-year birth cohorts (1907-11 to 1997-2001). Age and period rates were studied for two groups of birth cohorts: those aged 18-25 years and those aged over 25 years., Findings: Relative to age 18, the odds of current smoking increased with age until approximately age 25 [odds ratio (OR) = 1.48, 95% confidence interval (CI) = 1.41-1.56] and then decreased progressively to age 90 (OR = 0.06, 95% CI = 0.04-0.08). They also decreased almost linearly with period relative to 1972-73 (for 2018-19: OR = 0.30, 95% CI = 0.26-0.34) and with birth cohort relative to 1902-06, with the largest decreased observed for birth cohort 1992-96 (OR = 0.44, 95% CI = 0.35-0.46) and 1997-2001 (OR = 0.35, 95% CI = 0.74-0.88). Smoking declined in the 18-25 age group by an average of 7% over successive 2-year periods and by an average of 5% in those aged over 25., Conclusions: Smoking in England appears to have declined over recent decades mainly as a result of reduced smoking uptake before age 25, and to a lesser extent to smoking cessation after age 25., (© 2021 The Authors. Addiction published by John Wiley & Sons Ltd on behalf of Society for the Study of Addiction.)

Background: Exposure to smoking in films is a recognised cause of smoking uptake among children. In India, in an attempt to protect children, films containing smoking are required to include tobacco control messaging including audiovisual disclaimers, on-screen health warnings when tobacco imagery is displayed and antitobacco 'health spots' before and during the film. We report a study of the association between ever smoking and exposure to tobacco imagery in locally popular films among children in Udupi district of Karnataka state in southern India., Methods: A cross-sectional questionnaire survey of all students in grades 6-8 in schools in the Udupi district ascertained smoking status and potential confounders of smoking uptake, and whether children had seen any of 27 locally popular films we had coded and found to contain imagery of actual or implied tobacco use. Ever-smoking status was defined as any reported smoking of cigarettes, beedis or other tobacco products currently or at any time in the past. Independent effects on ever-smoking status were estimated using multiple logistic regression., Results: Of 46 706 students enrolled in grades 6-8 in 914 participating schools, 39 282 (84.1%) provided questionnaire responses sufficiently complete for analysis. Ever smoking was reported by 914 (2.3%) participants and in a mutually adjusted model was significantly related to age, male sex, living in a home where smoking is allowed, having parents or siblings who smoke, low paternal education, low levels of family wealth, low self-esteem, rebelliousness and poor school performance. After allowing for these effects, the odds of ever smoking were not increased among students who had seen any of the listed films containing tobacco imagery when included in the analysis as a binary exposure (OR 0.9, 95% CI 0.4 to 2.0), and decreased in relation to level of exposure graded into tertiles of tobacco intervals seen., Conclusions: In this cross-sectional study, children in southern India who had seen films containing tobacco imagery are no more likely to smoke than those who had not, indicating that the tobacco control messaging mandated by Indian law may be attenuating the effect of tobacco imagery in films on smoking uptake., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY. Published by BMJ.)

Aims: To analyse content and emission data submitted by manufacturers for nicotine-containing vaping products in the United Kingdom (UK) in accordance with the European Union Tobacco Products Directive., Design: Analysis of ingredient and emission data reported for all e-liquid-containing e-cigarettes, cartridges or refill containers notified to the Medicines and Healthcare Regulatory Agency (MHRA) from November 2016 to October 2017., Setting: United Kingdom CASES: A total of 40 785 e-liquid containing products., Measurements: The average number of ingredients per product, nicotine concentrations, frequency of occurrence ingredients and frequency and levels of chemical emissions., Findings: Reports were not standardised in relation to units of measurement or constituent nomenclature. Products listed an average of 17 ingredients and 3.3% were reported not to contain nicotine. A total of 59% of products contained <12 mg nicotine per mL, and <1% were reported to have nicotine concentrations above the legal limit of 20 mg/mL. Over 1500 ingredients were reported, and other than nicotine the most commonly reported non-flavour ingredients were propylene glycol (97% of products) and glycerol (71%). The most common flavour ingredients were ethyl butyrate (42%), vanillin (35%) and ethyl maltol (33%). The most frequently reported chemical emissions were nicotine (65%), formaldehyde (48%) and acetaldehyde (40%). The reporting of the concentration of emissions was not standardised; emissions were reported in a format allowing analysis of median estimated concentration for between 13% and 100% of products for each reported emission. Most of the frequently reported emissions, other than nicotine, were present in median estimated concentrations below 1 μg/L of inspired air, and with the exception of nicotine, acrolein and diacetyl, at median levels below European Chemicals Agency Long Term Exposure and United States (US) Department of Labor Occupational Safety and Health Administration (OSHA) limits, where these were available., Conclusions: An analysis of reports to the United Kingdom's Medicines and Healthcare products Regulatory Agency by manufacturers of vaping products shows that (i) these products have a large range of ingredients and emissions, (ii) the reporting system is unstandardized in terms of reporting requirements, and (iii) for quantified emissions, median levels are for the most part below published safe limits for ambient air., (© 2021 Society for the Study of Addiction.)

Background: E-cigarette regulations vary considerably between countries though a standard approach for comparing regulatory frameworks does not exist. Additionally, there is no evidence on whether regulatory variations are associated with differences in e-cigarette use and smoking cessation. This study aims to develop a regulatory scale to measure and compare e-cigarette regulations between European Union countries and investigate whether scores are associated with e-cigarette use and smoking cessation., Methods: Data from a range of sources, such as ECigIntelligence, were used to develop a scale and score countries in the respective areas of e-cigarette scale. We used correlation analysis to investigate association between scale scores and e-cigarettes market, e-cigarette prevalence and use of e-cigarettes for smoking cessation., Results: An e-cigarette scale consisting of 10 domains was developed. Our analysis suggests that higher e-cigarette scale scores were associated with significantly greater use of e-cigarettes within countries, and greater increases in the prevalence of former smoking smokers between 2014 and 2017., Conclusions: Whilst further work is needed to develop the scale in line with rapidly changing regulatory landscape and product development, the current findings suggest that countries that have implemented e-cigarette regulations might be more successful in obtaining public health gains such as increase in the proportion of former smokers compared to countries where e-cigarette market and sales is not regulated., Competing Interests: No potential conflict of interest was reported by the author(s)., (© 2021 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group.)

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

Background and Aim: In 2016, England initiated the implementation of standardised tobacco packaging, introduced in conjunction with minimum pack sizes and other measures included in the 2014 European Tobacco Products Directive, over the course of a 1-year sell-off period ending in May 2017. These measures have been shown to have been associated with increases in tobacco prices and product diversity. We now investigate the association between implementation of the new legislation and smoking status in England., Design: Segmented regression analysis of repeated cross-sectional surveys using a generalised linear model with individual-level data to test for a change in trend and immediate step change., Setting: England., Participants: Participants in the Smoking Toolkit Study, which involves repeated, cross-sectional household surveys of individuals aged 16 years and older in England. The sample included 278 219 individual observations collected between November 2006 and December 2019., Intervention: Implementation of standardised packaging legislation (May 2016 and May 2017)., Measurements: Individual-level current smoking status adjusted for implementation of tobacco control policies, cigarette price, seasonality and autocorrelation., Findings: The implementation of standardised packaging was associated with a significant step reduction in the odds of being a smoker after May 2017 (OR: 0.93; 95% CI 0.87 to 0.99). The magnitude of the association was similar when modelling the step change in May 2016 at the start of the 1-year policy implementation period (OR: 0.90; 95% CI: 0.83 to 0.97)., Conclusions: This is the first independent study demonstrating that implementation of standardised packaging was associated with a reduction in smoking in England which occurred in anticipation of, rather than after, full policy implementation. It appears that the odds of being a smoker were affected by the prospect of the move to standardised packs and accompanying legislation., Competing Interests: Competing interests: JB and EB have received unrestricted research grants from Pfizer related to smoking cessation. JB, MOB and IB have no competing interests to declare. All authors declare no financial links with tobacco companies or e-cigarette manufacturers or their representatives., (© Author(s) (or their employer(s)) 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

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 ( S haping  P ublic h E alth poli C ies  T o  R educe ineq U alities and har M) 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., Competing Interests: Competing interests: JB has received unrestricted research funding to study smoking cessation from companies who manufacture smoking cessation medications. He declares no financial links with tobacco companies or e-cigarette manufacturers or their representatives. JC has, in the past, received honoraria from Wellcome Trust for participation in their Humanities & Social Science Selection Panels. LS has received honoraria for talks, an unrestricted research grant and travel expenses to attend meetings and workshops from manufactures of smoking cessation medications (Pfizer; Johnson&Johnson), and has acted as a paid consultant for health care companies, broadcasters and governmental organisations (Atlantis Healthcare; BBC; PHE). MRM has received funding from Pfizer and Rusan Pharmaceuticals, which manufacture smoking cessation medications., (Copyright: © 2021 Horton M et al.)

Objective: This systematic review aims to identify and explore the experiences and views of women, children, and professionals regarding second-hand smoke exposure prevention in the home, workplace, school, personal vehicles, and public places in Middle Eastern countries., Introduction: Exposure to second-hand smoke is a significant public health problem globally, but particularly in Middle Eastern countries. Whilst many Middle Eastern countries have implemented tobacco-control programs and have legislation that bans smoking in public places, the legislation is not always comprehensively implemented or enforced. Therefore, women and children continue to be exposed to second-hand smoke in public and private settings., Inclusion Criteria: This review will consider studies that include the views and experiences of any of the following three groups: (i) women (including pregnant women and mothers), (ii) children (primary and secondary school age), and (iii) professionals (including health professionals and policy makers), regarding the prevention of second-hand smoke exposure in women and children in Middle Eastern countries., Methods: MEDLINE, Embase, CINAHL, PsycINFO, Web of Science, and Scopus, and sources of gray literature will be searched for eligible studies. Databases will be searched from their inception dates and no language restrictions will be applied. Two reviewers will independently screen studies and assess methodological quality and extract data from the included studies following JBI systematic review guidelines. The JBI process of meta-aggregation will be used to identify categories and synthesize findings. The ConQual approach will be used to assess confidence in the findings., Systematic Review Registration Number: PROSPERO (CRD42019137006)., Competing Interests: JL-B is a senior associate editor of JBI Evidence Synthesis and had no involvement with the decision-making processes associated with the manuscript. The other authors declare no conflicts of interest., (Copyright © 2021 JBI.)

Tobacco smoking is a major risk factor for a wide range of diseases, and smoking cessation significantly reduces these risks. Clinical guidelines for diseases associated with smoking should therefore include guidance on smoking cessation. This review updated evidence on the proportion of clinical guidelines that do so. We conducted a systematic review investigating clinical guidelines and recommendations developed by UK national or European transnational medical specialty associations and societies between January 2014 and October 2019 on 16 diseases to be at least twice as common among smokers than non-smokers. Outcomes of interest were the reporting of smoking as a risk factor, and the inclusion either of smoking cessation advice or referral to other cessation guidance. We compared our findings with an earlier review of guidelines published between 2000 and 2013. We identified 159 clinical guidelines/recommendations. Over half (51%) made no mention of smoking, while 43% reported smoking as a risk factor for the development of the disease, 31% recommended smoking cessation and 19% provided detailed information on how to deliver smoking cessation support. These proportions were similar to those in our earlier review. Smoking cessation continues to be neglected in clinical management guidance for diseases caused by smoking., (© Royal College of Physicians 2020. All rights reserved.)

Background and Aims: The introduction of plain tobacco packaging and minimum pack size legislation in the United Kingdom between May 2016 and May 2017 was accompanied by substantial changes in tobacco product diversity and pricing. This study investigates the extent to which these changes were associated with consumer switching between tobacco product types and price segments, and from tobacco to non-tobacco nicotine products., Design: Longitudinal study (changing trends in product and price choices) and survey (reasons for consumer choices)., Setting: Great Britain PARTICIPANTS: We used 11 695 British households from Kantar Worldpanel who purchased tobacco and non-tobacco nicotine products from March 2011 to December 2017., Measurements: Product choice was defined using household's monthly purchases of tobacco (cigarettes, roll-your-own (RYO) tobacco, cigar/cigarillo and pipe tobacco) and non-tobacco nicotine products (e-cigarettes and nicotine replacement therapy), while price was defined using price paid by pack size and by price quartiles. Our switching analysis considered three switching alternatives: switching to a different tobacco product or to a combination of tobacco products, switching to any non-nicotine tobacco product, and switching out of our dataset. We explored changes in price quartile purchasing behaviour using binary variables for whether a household purchased or not from each price quartile monthly. Finally, self-declared consumer's choice was assessed through survey responses., Findings: The introduction of plain packaging and minimum pack sizes coincided with major switching to purchasing of pack sizes of 20 cigarettes or 30 g or larger RYO tobacco (>99% of purchases in December 2017) and a migration towards lower-price cigarettes, as for cigarettes, around 80% of purchases were in the lowest price quartiles at the end of the study period compared to about 50% at the start of the study period. During the first 6 months of implementation there was also a marked increase in the likelihood that cigarette smokers would switch to non-tobacco nicotine (OR 1.74, 95% CI: 1.18 to 2.57), predominantly e-cigarettes, compared with the period before May 2016. Survey results suggest that price was the main driver of changes in purchasing behaviour., Conclusions: Implementation of plain packaging and minimum pack size legislation in the UK appears to have been associated with tobacco users switching to lower price tobacco products and to e-cigarettes., (© 2020 The Authors. Addiction published by John Wiley & Sons Ltd on behalf of Society for the Study of Addiction.)

Background: Plain packaging and minimum pack size legislation for tobacco products was introduced in the UK in May 2016, with a 1-year sell-off period until May 2017, during which both fully branded and plain packs of various sizes were legally available. This study investigates trends in prices of roll-your-own tobacco (RYO) before, during and after implementation of this legislation, and compares trends with those observed in the cigarette market., Methods: We used Nielsen Scantrack data for the period from March 2013 to June 2018 to describe trends in UK inflation-adjusted prices and volumes of both RYO and cigarettes, and linear regression to estimate changes in prices associated with the introduction of plain packaging and the minimum pack sizes of 30 g RYO and 20 cigarettes., Results: In contrast to a downward trend in cigarette sales volumes, RYO volumes rose throughout the study period. By the time plain packs accounted for 75% or more of sales, the average price of products sold in equivalent pack sizes had increased, relative to average prices in the year before implementation and with adjustment for tax changes, from 34.9 to 38.8 pence per gram for RYO (mean difference 4.26, 95% CI 3.99 to 4.53 pence, 12% increase), and from 38.6 to 41.13 pence for cigarettes (mean difference 2.53, 95% CI 2.24 to 2.83 pence, 7% increase) per cigarette., Conclusions: New legislation resulted in higher prices for RYO and manufactured cigarettes. However, sales volumes of RYO continued to increase throughout the study period, perhaps because RYO remains a less expensive means of smoking tobacco., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY. Published by BMJ.)

Aims: To determine whether nicotine-containing vaping products submitted to the Medicines and Healthcare products Regulatory Agency (MHRA) under the Tobacco and Related Products Regulations 2016 contain tetrahydrocannabinol or vitamin E acetate., Methods: Analysis of data on ingredients for all products submitted for notification for the UK market by October 2017 to assess whether any were reported to contain vitamin E acetate or tetrahydrocannabinol (THC). The analysis was not pre-registered and the results should therefore be considered exploratory., Results: Vitamin E acetate and THC were not listed as an ingredient or emission in any of the 41 809 products that were submitted for notification., Conclusions: In the United Kingdom, vapers and those considering switching from tobacco to vaping can be reassured that licit products available on the UK market do not contain tetrahydrocannabinol or vitamin E acetate., (© 2019 Society for the Study of Addiction.)

Background : Taxing tobacco products is one of the most effective tobacco control measures, and most countries apply a combination of specific taxes, which comprise a fixed amount per cigarette or gram of hand-rolling tobacco, and ad valorem taxes, which increase in proportion to the cost of the product. Since specific taxes reduce price differentials across tobacco product ranges while ad valorem taxes amplify them, we hypothesised that tobacco companies seeking to minimise the effect of tax increases on sales across a range of products will tend to favour, and hence lobby for, ad valorem rather than specific taxes; and that relatively corrupt governments would be more susceptible to such lobbying and hence, more likely to favour ad valorem taxes. Methods : We searched for cigarette tax data and Transparency International Corruption Perceptions Index (CPI) scores for current 28 EU Member States for the years 1995 to 2017/8. Trends in cigarette tax levels and the ratio of ad valorem to specific taxes at a national and mean EU level were analysed by visual inspection, the within-country relation between the ad valorem to specific tax ratio and CPI scores over time by time-series regression analysis, and at EU level, for which complete data were available from 1995 to 2017, using a multi-level regression model. Results : Within most Member States, the ad valorem to specific cigarette tax ratio declined over the study period and was not significantly associated with corruption score. However, at an aggregate EU-level, our multi-level model indicated that reduced corruption was associated with a significant increase in the ad valorem to specific cigarette tax ratio, by 0.04 (95% confidence interval: 0.003-0.077, p < 0.036) per unit increase in CPI score. Conclusions : The ratio of ad valorem to specific taxes declined in most EU Member States over the study period, with no evidence that those with higher levels of perceived corruption tended to favour ad valorem taxes.

Price of tobacco products has traditionally been relevant both for the industry, to respond to policy changes, and for governments, as an effective tobacco control measure. However, monitoring prices across a wide range of brands and brand variants requires access to expensive commercial sales databases. This study aims to investigate the comparability of average tobacco prices from two commercial sources and an in-house monitoring database which provides daily data in real time at minimal cost. We used descriptive and regression analysis to compare the monthly average numbers of brands, brand variants, products and prices of cigarettes and hand-rolling tobacco using commercial data from Nielsen Scantrack and Kantar Worldpanel , and an online price database (OPD) created in Nottingham, for the period from May 2013 to February 2017. There were marked differences in the number of products tracked in the three data sources. Nielsen was the most comprehensive and Kantar Worldpanel the least. Though average prices were very similar between the three datasets, Nottingham OPD prices were the highest and Kantar Worldpanel the lowest. However, regression analysis demonstrated that after adjustment for differences in product range, price differences between the datasets were very small. After allowing for differences in product range these data sources offer representative prices for application in price research. Online price tracking offers an inexpensive and near real-time alternative to the commercial datasets.

Background and Aim: Plain packaging of cigarettes appeared in the United Kingdom in July 2016 and was ubiquitous by May 2017. The change coincided with another legislative change, raising the minimum pack size from 10 to 20 cigarettes. Laws imposing plain packaging on cigarette packs remove another promotional route from tobacco companies, but the effect of such laws on brand diversity, pricing and sales volume is unknown. This study aimed to (1) describe and quantify changes in brand diversity, price segmentation and sales volumes and (2) estimate the association between the introduction of plain cigarette packaging and cigarette pricing in the United Kingdom., Design: We used a natural experiment design to assess the impact of plain packaging legislation on brand diversity and cigarette prices. The data comprised a sample of 76% of sales of cigarettes in the UK between March 2013 and June 2017., Setting: United Kingdom., Measurements: Cigarette prices, number of brands and products and volumes of sales., Findings: During the period analysed, there was a slight decrease in the number of cigarette brands. There was also an initial increase observed in the number of cigarette products, due mainly to an increase in the number of products in packs of fewer than 20 cigarettes sold before July 2016, which was then followed by a rapid decrease in the number of products that coincided with the implementation of the new legislation. Cigarette sales volumes during this period did not deviate from the preceding secular trend, but prices rose substantially. Regression results showed that price per cigarette, regardless of pack size, was 5.0 [95% confidence interval (CI) = 4.8-5.3] pence higher in plain than in fully branded packs. For packs of 20 cigarettes, price increases were greater in the lower price quintiles, ranging from 2.6 (95% CI = 2.4-2.7) GBP in the lowest to 0.3 (95% CI = 0.3-0.4) GBP per pack in the highest quintile., Conclusions: The implementation of standardized packaging legislation in the United Kingdom, which included minimum pack sizes of 20, was associated with significant increases overall in the price of manufactured cigarettes, but no clear deviation in the ongoing downward trend in total volume of cigarette sales., (© 2018 The Authors. Addiction published by John Wiley & Sons Ltd on behalf of Society for the Study of Addiction.)

Background : In May 2016, along with the latest European Tobacco Products Directive (TPD), standardised packaging legislation was implemented in the UK. During the following 12-month transition period, both new and old types of packaging were allowed on the market. This study aimed to assess awareness of standardised packaging and other TPD changes in the UK population in March 2017, when both forms of packaging were in widespread use. Methods : We conducted two surveys-one in adults and one in young people-investigating awareness of plain packaging legislation. In young people, we also measured susceptibility to smoking using previously validated questions. We asked smokers whether they had recently changed the product they used and also whether they used any of the products that are banned by the new legislation. Results : In the adult survey, 73.5% (95% CI: 71.5-75.5%) of the participants were aware of the new legislation and 32.4% (95% CI: 30.3-34.5%) had noticed changes in tobacco packaging, this proportion being considerably higher among smokers (83.7%; 95% CI: 78.9-87.5%) than never smokers (20.7%; 95% CI: 18.2-23.4%). More than half (52.4%; 95% CI: 46.5-58.4%) were using pack sizes or shapes (typically less than 20 cigarettes or 30 g loose tobacco), that would become illegal after full TPD implementation, and 31.4% (95% CI: 26.2-37.1%) reported switching to a different product since October 2016, in most cases to a cheaper brand. Among young people, 20.2% (95% CI: 17.8-22.7%) reported that they had noticed standardised packaging, comprising 16.2% (95% CI: 13.7-19.0%) of non-susceptible never smokers, 25.6% (95% CI: 18.0-35%) of susceptible never smokers, and 49% (95% CI: 37.8-60.2%) of ever smokers. Conclusions : In the final stages of implementation, awareness of the introduction of standardised packs was highest among smokers. The TPD will cause nearly half of adult smokers to purchase larger packs, and may cause many smokers to switch to cheaper brands., Competing Interests: The authors declare no conflict of interest.

Objective: A prospective evaluation of the effect of 2012 point-of-sale (PoS) display ban in supermarkets in England on perceived exposure to PoS displays, and on changes in susceptibility and smoking uptake among young people., Design: Cohort study., Settings: Seven schools in Nottinghamshire, England., Participants: 1035 11-16-year-old school children., Primary and Secondary Outcome Measures: Changes in reported exposure to PoS displays before and after prohibition, and the association between exposure to and awareness of PoS displays and change in susceptibility to smoking and smoking status between 2011 and 2012 (before the ban) and 2012 and 2013 (after the ban)., Results: The proportion of children noticing tobacco PoS displays in supermarkets most or every time they visited a shop changed little between 2011 and 2012 (59.6% (95% CI 56.6% to 62.6%) and 58.8% (95% CI 55.8% to 61.8%), respectively); but decreased by about 13 percentage points to 45.7% (95% CI 42.7% to 48.7%) in 2013, after the ban. However, after adjusting for confounders, implementation of the first stage of the PoS ban in 2012 did not result in significant changes in the relation between susceptibility to smoking and smoking status and exposure to and awareness of PoS displays., Conclusions: Prohibition of PoS in large supermarkets resulted in a decline in the proportion of young people noticing PoS displays in large shops, but little or no change in smoking uptake or susceptibility. It remains to be seen whether extension of the PoS ban to all shops in 2015 has a more marked effect., Competing Interests: Conflicts of Interest: None declared., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.)

Introduction: Tobacco use is the leading cause of preventable death in the UK. However, research spending on tobacco-related disease, and particularly smoking prevention, is thought to be low. We therefore aimed to assess the relation between tobacco-related research investment and disease burden from 2008 to 2012., Methods: We used the Health Research Classification System to classify UK government and charitable research funding by broad health category and then by tobacco prevention research and 18 WHO defined tobacco-related diseases. We used UK mortality figures to calculate disease-specific tobacco attributable deaths and then compared disease specific and tobacco prevention research investment with all cause and tobacco attributable mortality over the 5-year period and as annual averages., Results: 12 922 research grants were identified with a total value of £6.69bn, an annual average of £1.34bn. Annually an average of 110 000 people die from tobacco-related disease, approximately 20% of total deaths. £130m is invested in researching tobacco-related disease each year and £5m on tobacco prevention, 10.8% and 0.42% of total annual research funding, respectively. Prevention research equated to an annual average of £46 per tobacco attributable death or one pound for every £29 spent on tobacco-related disease. Funding varied widely for diseases with different numbers of deaths (eg, lung cancer £68 per all cause death, cervical cancer £2500), similar numbers of deaths (leukaemia £983 per death, stomach cancer £43) or similar numbers of tobacco attributable deaths (eg, colorectal cancer £5k, pancreatic cancer £670, bladder cancer £340)., Conclusions: Tobacco-related research funding is not related to burden of disease or level of risk. As a result certain diseases receive a disproportionately low level of research funding and disease prevention funding is even lower., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/)

Smoking is a major risk factor for a range of diseases, and quitting smoking provides considerable benefits to health. It therefore follows that clinical guidelines on disease management, particularly for diseases caused by smoking, should include smoking cessation. The aim of this study was to determine the extent to which this is the case. We conducted a systematic review investigating clinical guidelines and recommendations issued by UK national or European transnational medical speciality associations and societies issued between 2000 and 2012 on a range of diseases caused by smoking. We then investigated whether selected guidelines contained reference to smoking cessation and smoking cessation advice. Although the extent to which smoking and smoking cessation was mentioned in the guidelines varied between diseases, only 60% of guidelines identified recognised that smoking is a risk factor for the development of the disease and 40% recommended smoking cessation. Only 19% of guidelines provided detailed information on how to deliver smoking cessation support. Smoking cessation is not comprehensively addressed in current UK and transnational European clinical practice guidelines and recommendations., (© Royal College of Physicians 2015. All rights reserved.)

Aims: To investigate the association between frequency of visiting shops and noticing of tobacco point-of-sale (PoS) displays and the development of susceptibility to smoking, or smoking uptake, in secondary school students., Design: Two surveys of a school based cohort study carried out in 2011 and 2012., Settings: Nottinghamshire, UK., Participants: A total of 2270 children aged 11-16 years from eight schools in Nottinghamshire., Measurements: We investigated changes in susceptibility to smoking and smoking status in relation to frequency of visiting shops and noticing PoS displays and number of tobacco brands recognized, controlling for a range of potential confounders. Susceptibility to smoking was defined using a set of three questions covering intentions to try smoking, to smoke within the next year and likelihood of smoking if a best friend offered a cigarette. For the analysis we used multinomial logistic regression., Findings: Among non-susceptible never smokers, noticing PoS displays more frequently was associated independently with an increased risk of becoming susceptible to smoking [adjusted relative risk ratio (RRR) = 1.74; 99% confidence interval (CI) = 1.13-2.69], but was not associated with smoking uptake. Recognizing a higher number of brands among non-susceptible never smokers doubled the risk of becoming susceptible to smoking and of becoming a smoker, but this did not have a significant effect on transition to smoking among susceptible never smokers. Frequency of noticing tobacco PoS displays was not associated significantly with smoking uptake among those who were susceptible never smokers at baseline., Conclusions: Noticing tobacco point-of-sale displays more often and recognizing a higher number of tobacco brands is associated with an increased risk of becoming susceptible to smoking among adolescents in the United Kingdom, and recognizing a higher number of brands is associated positively with an increased risk of smoking uptake., (© 2014 Society for the Study of Addiction.)

Background: Exposure to secondhand smoke is associated with an increased risk of adverse health effects among children. Although smoking in the home is an established major source of exposure, less is known about rules on smoking in cars., Methods: In a survey including a sample of secondary school students in Nottingham (UK) in 2012, participants were asked whether smoking was allowed in the family car, and how often the respondent travelled in a car in which smoking was allowed. Rules on smoking in cars were investigated in relation to socio-demographic variables and whether children had ever smoked themselves using logistic regression., Results: Of 4,190 students aged 11-16 who provided data, approximately 12% reported that smoking was allowed in their family car and 35% that they travelled in a car where smoking was allowed at least sometimes. Absence of smoke free rules in the family car was more likely to be reported by children from more disadvantaged families, if parents and friends were smokers and if smoking was allowed in the main home. These factors, and having a sibling who smokes, were also independently associated with an increased risk of travelling in a car in which smoking was allowed at least sometimes. Respondents who were not protected from secondhand smoke in the car were also more likely to have ever smoked (adjusted odds ratio 1.59, 95% CI 1.18-2.14)., Conclusions: Absence of smoke free rules in a family car and travelling in a car where smoking was allowed was relatively common among secondary school students, was strongly related to social disadvantage and a higher risk of smoking experimentation. Measures to prevent such exposure are therefore indicated.

Smoking is prevalent across Europe, but the severity and stage of the smoking epidemic, and policy responses to it, vary substantially between countries. Much progress is now being made in prohibition of paid-for advertising and in promotion of smoke-free policies, but mass media campaigns are widely underused, provision of services for smokers trying to quit is generally poor, and price policies are undermined by licit and illicit cheap supplies. Monitoring of prevalence is inadequate in many countries, as is investment in research and capacity to address this largest avoidable cause of death and disability across Europe. However, grounds for optimism are provided by progress in implementation of the WHO Framework Convention on Tobacco Control, and in the development of a new generation of nicotine-containing devices that could enable more widespread adoption of harm-reduction strategies. The effect of commercial vested interests has been and remains a major barrier to progress., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

Aims: To describe current and recent changes in cigarette affordability across the current 27 European Union (EU) Member States, and to assess the impact of these changes on smoking prevalence in countries that were EU members in 2004 (old Member States) compared to countries that have joined since 2004 (new Member States)., Design: Investigation of cigarette affordability using the minutes of labour measure, and comparisons of changes in affordability, tax and smoking prevalence in old and new EU Member States., Participants: Current 27 EU Member States., Settings: European Union., Measurements: Cigarette prices, overall tax yield and incidence, hourly wages and smoking prevalence in the EU were obtained from published sources, and the affordability of the EU Most Popular Price Category (MPPC) cigarettes estimated as the number of minutes of labour required to earn the price of 20 cigarettes in the years 2003, 2006 and 2009., Findings: The mean [standard deviation (SD)] number of minutes of labour required to purchase 20 MPPC cigarettes in EU Member States in 2009 was 31.3 (SD 10.7), but ranged fourfold across the EU, and was significantly higher in new than old Member States. The number of minutes of labour measure increased more, although not significantly so, between 2003 and 2009 in new [mean (SD) 12.1 (10.9)] than in old [6.7 (4.0)] Member States, largely because of proportionately higher increases in taxation. However, there was no correlation between change in affordability and change in smoking prevalence in recent years., Conclusions: Cigarette affordability varies substantially and cigarettes are generally becoming less affordable in European Union Member States. However, these reductions in affordability do not appear to have impacted substantially on smoking prevalence in recent years., (© 2011 The Authors, Addiction © 2011 Society for the Study of Addiction.)

Background: 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., Methods: 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., Results: 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., Conclusions: 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.

Objectives: To determine whether the European Commission Eurobarometer survey of 27 European Union (EU) member states produces reliable smoking prevalence estimates when compared to national prevalence survey data, and to identify approaches to standardising the measurement of smoking prevalence in the EU., Methods: This was a direct comparison of questions, sampling methods and smoking prevalence estimates, between the 2006 Eurobarometer study and contemporaneous national surveys. All 27 EU member states were included. Participants were people surveyed in the 2006 Eurobarometer study and in various national surveys in the closest year to 2006 for which data were available. The main outcome measures were the mean and range of differences in prevalence estimates between the Eurobarometer and national surveys., Results: Most national surveys used similar multistage sampling methods and involved sample sizes of 3000 or more, but the phrasing of the questions used to define smoking, the inclusion or exclusion of occasional smokers, the age ranges of participants and the frequency of national surveys varied substantially between countries. The Eurobarometer study used the same questions in all countries but in sample sizes of 1000, or in 3 countries, 500. Eurobarometer 2006 smoking prevalence estimates were on average 0.37 percentage points higher than those in national surveys, but with a 95% range from -10.49 to +11.23 percentage points. At the extremes, the equivalent national prevalence estimate for Slovakia was 13.0% higher and for the UK 10.0% lower than the Eurobarometer figure., Conclusions: Measurements of the prevalence of smoking, the biggest avoidable public health threat in the European Union, are highly discrepant within countries between national and European Commission survey estimates. Monitoring national smoking prevalence on a regular basis, using standardised methods in representative population samples, is an urgent priority for the EU.