Recent eLetters

Displaying 1-10 letters out of 389 published

  1. Intent-to-treat analysis of observational studies assessing electronic cigarettes' efficacy as an aid to smoking cessation.

    NOT PEER REVIEWED In the last decade, electronic cigarettes (EC) have become increasingly popular in particular among smokers. Most EC users choose to use nicotine containing liquids (electronic nicotine delivery system, ENDS); these ENDS can be considered as similar to nicotine replacement therapies. Among the several questions EC use raises, one is of major importance: Are EC a smoking cessation aid and if yes to what extent compared to existing pharmacotherapies such as nicotine replacement therapies, varenicline or bupropion? Several systematic reviews tried to approach the role of EC as a smoking cessation aid. As of today, only two randomized trials assessed the efficacy of EC with controversial results (1,2). As an editorial (3) and the last systematic review (4) concluded, because of the absence of well- designed and sufficiently powered randomized, controlled, head-to-head therapeutic trials the current accumulation of data originating essentially from observational studies does not allow us to make any conclusion as to EC's therapeutic efficacy in smoking cessation. Manzoli et al. (5, 6) assessed abstinence from tobacco cigarettes or tobacco and electronic cigarettes ('any product') in a prospective cohort study. They included at baseline EC only users, individuals using tobacco cigarettes and EC (dual use) and those using only tobacco cigarettes. They reported the 12-month (5) and 24-month (6) results in two separate papers the latter published online in the June 2016 issue of Tobacco Control. For both papers, the analyses were restricted to individuals whose data were available at 12 or 24 months (completers). This study raises the question whether observational studies assessing efficacy should be analyzed similarly to randomized efficacy trials for which the gold standard approach is the intent-to treat-analysis (ITT) (7) which defines the population submitted to the main data analysis. Table 1. compares Manzoli et al. results for the 12-month and 24-month abstinence outcomes (5,6). For all baseline categories, completers' abstinence rates are higher than abstinence rates of the baseline population that we can call here as the "ITT" population i.e. of all individuals included. Of particular interest is that EC only users had higher tobacco cigarettes but not 'any product' abstinence rates both at 12 and 24 months than the two other groups. The (unadjusted) "ITT" tobacco cigarettes abstinence rates are 42% and 40.8 % versus the completers abstinence rates of 61.9% and 61.1 % at 12 and 24 months, respectively; all higher than among dual users or tobacco cigarette only users suggesting that EC can be an aid to quit smoking. Unfortunately, both papers report only confounder adjusted odds ratios for completers and not for the "ITT" population. Observational studies looking for treatment efficacy could be analyzed like randomized efficacy trials (8,9) to narrow the gap between randomized clinical trials and observational data (8). Non-ITT, usually completer analyses, aim to estimate the effect of treatments received as opposed to treatments assigned under the ITT approach and by this exclude all factors contributing to non-completion of the trial (lost to follow up, adverse events, discontinuation for any reasons). The advantage of the ITT analysis is that it evaluates the true treatment effect which is the sum of the biological effects, positive or negative such as adverse events, and study adherence. The limitation of the ITT analysis of randomized efficacy trials is the underestimation of efficacy because of non- treatment related confounders (e.g. lost to follow-up for moving to another city). On the other hand, completer analysis overestimates efficacy by ignoring e.g. discontinuation because of adverse events and cannot, therefore, help to assess the benefit/risk ratio of a given intervention. Until results of high-quality, large-scale, comparative, randomized trials of EC' efficacy will be available, data of well conducted prospective observational studies as that of Manzoli at al. (5,6) could estimate EC's efficacy by analyzing "ITT" data and not completers' data while adjusting for all available and potential confounders. Thus, in the Manzoli et al. study (5,6) adjusted "ITT" population abstinence rates would have provided more convincing results about EC's efficacy as an aid for smoking cessation than completers' adjusted abstinence rates. REFERENCES 1. Caponnetto P, Campagna D, Cibella F, et al. EffiCiency and Safety of an eLectronic cigAreTte (ECLAT) as tobacco cigarettes substitute: a prospective 12-month randomized control design study. PLoS One. 2013 Jun 24;8(6):e66317. doi: 10.1371/journal.pone.0066317. Print 2013. 2. Bullen C, Howe C, Laugesen M, et al. Electronic cigarettes for smoking cessation: a randomised controlled trial. Lancet. 2013 Nov 16;382(9905):1629-37. doi: 10.1016/S0140-6736(13)61842-5. Epub 2013 Sep 9. 3. Bernstein SL. Electronic cigarettes: more light, less heat needed. Lancet Respir Med. 2016; Feb;4(2):85-7. doi: 10.1016/S2213-2600(16)00010- 2. Epub 2016 Jan 14 4. Malas M, van der Tempel J, Schwartz R, et al. Electronic Cigarettes for Smoking Cessation: A Systematic Review. Nicotine Tob Res. 2016 Apr 25. pii: ntw119. [Epub ahead of print] Review. 5. Manzoli L, Flacco ME, Fiore M, et al. , Electronic cigarettes efficacy and safety at 12 months: Cohort Study. PLoS One. 2015 Jun 10;10(6):e0129443. doi: 10.1371/journal.pone.0129443. eCollection 2015. 6. Manzoli L, Flacco ME, Ferrante M, et al. Cohort study of electronic cigarette use: effectiveness and safety at 24 months. Tob Control. 2016 Jun 6. pii: tobaccocontrol-2015-052822. doi: 10.1136/tobaccocontrol-2015- 052822. [Epub ahead of print] 7. Detry MA, Lewis RJ. The Intention-to Treat principle. How to assess the true effect of choosing a medical treatment. JAMA 2014; 312:85-86. 8.Wilcox A, Wacholder S. Observational data and clinical trials. Narrowing the gap? Editorial. Epidemiology 2008;19: 765. 9. Herna?n MA, Alonso A, Logan R, et al. Observational studies analyzed like randomized experiments: an application to postmenopausal hormone therapy and coronary heart disease. Epidemiology. 2008;19:766-779.

    Conflict of Interest:

    None declared

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  2. Impact of e-cigarette adverts on children's perceptions of smoking

    NOT PEER REVIEWED The study conducted in England by Petrescu and colleagues [1] concludes that there is a "potential for e-cigarette adverts to undermine tobacco control efforts by reducing a potential barrier (i.e. beliefs about harm) to occasional smoking". Clearly it is important to keep monitoring the impact of advertising, particularly on children, and this research paper is a welcome contribution. However, it is important to put this in context.

    The most recent survey of smoking among children in England found the lowest recorded smoking rates among youth aged 11-15 since records began in 1982.[2] It's worth noting that rates have continued to fall since e- cigarette use and marketing of products began to take off in Great Britain after 2010.[3][4] In 2010, 5% of 11-15 year olds were regular smokers falling to 3% in 2014. Also, in 2010 27% had ever tried smoking, falling to 18% in 2014.

    So it doesn't appear that e-cigarette advertising in England has had an impact so far on the number of children trying smoking, or becoming regular smokers. Furthermore from May 2016 all cross border advertising including TV, radio, internet and newspaper advertising has been banned throughout the European Union, thereby limiting advertising to that with local impact.

    It should also be noted that in the UK e-cigarette manufacturers are required to adhere to strict rules on advertising content.[5] These rules specify in particular that advertisers must ensure ads do not target, feature or appeal to children; that they do not confuse e-cigarettes with tobacco products; that they do not mislead with regard to product ingredients.

    In jurisdictions where e-cigarette ads are unregulated and resemble tobacco promotion, it's reasonable to assume that they could affect children's perceptions of both e-cigarettes and smoking. This study underlines the need to monitor e-cigarette marketing but the potential risks that e-cigarette advertisements are undermining tobacco control efforts in England are likely to be over-stated.

    [1] D C Petrescu, M Vasiljevic, J K Pepper, K M Ribisl, T M Marteau. What is the impact of adverts on children's perceptions of tobacco smoking? Tobacco Control published online 6 Sept. 2016. Doi: 10.1136/tobaccocontrol-2016-052940

    [2] Smoking, drinking and drug use among young people in England in 2014. Health & Social Care Information Centre, 2015.

    [3] ASH Fact sheet. Use of electronic cigarettes (vapourisers) among adults in Great Britain. ASH, 2016

    [4] De Andrade M et al. The marketing of e-cigarettes in the UK. Cancer Research UK, 2013.

    [5] Committee on Advertising Practice. Database/Electronic-cigarettes.aspx#.V86Snf_6uvE

    Conflict of Interest:

    None declared

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  3. Indoor air laws and hookah smoking

    The authors rightly point out that loopholes exist in some smoke-free air laws, exempting smoking of "tobacco-free or herbal hookah products" in public places.
    In New York City, where this study took place, the governing laws are: (1) New York State Clean Indoor Air Act, and (2) New York City Smoke Free Air Act.[1] Between 2002-2003, both laws were amended to "prohibit smoking in virtually all indoor places in New York State where people work or socialize."[2] The changes were made "in response to mounting scientific evidence that links exposure to the airborne smoke that is a by-product of smoking . . . to serious health risks to non-smokers."[3] Unfortunately, smoking was narrowly defined as "the burning of a lighted cigar, cigarette, pipe or any other matter or substance which contains tobacco."[4] Thus, giving rise to New York's loophole allowing non-tobacco hookah smoking.
    By comparison, the situation is different in neighboring New Jersey. In 2006, the state legislature enacted the New Jersey Smoke-Free Air Act prohibiting smoking in public places.[5] In the Act, smoking is defined as "the burning of, inhaling from, exhaling the smoke from, or the possession of a lighted cigar, cigarette, pipe or any other matter or substance which contains tobacco or any other matter that can be smoked."[6] New Jersey courts have interpreted the Act to include regulation of hookah bars - even when non-tobacco products are used in these devices. [7] Constitutional challenges to overturn this statute have failed underscoring its strength.
    Weakly worded "smoking" definitions are a chief source of statutory loopholes allowing public use of hookahs, as well as electronic cigarettes. Advocates for stronger clean indoor air laws should consider developing a model rule with commentary containing explanations and examples. This lays a foundation to assist legislators in statutory creation and helps judges with interpretation. Such model rules exist for many other areas of the law. States are free to adopt model rules in whole or in part. Smoking in the "new age" encompasses modalities not in existence when many smoking prohibitions were enacted. Vigilance is needed to ensure anti-smoking laws keep pace with the times.

    References [1] New York City C.L.A.S.H. v. City of New York, 315 F. Supp. 2d 461, 465 (2004).
    [2] Id. at 466.
    [3] Id. at 466-67.
    [4] N.Y. Pub Health Law 1399n(8) (Consol. 2003) (emphasis added).
    [5] N.J. Stat. 26:3D-55-64.
    [6] N.J.S.A. 26:3D-57
    [7] See State v. Badr, 415 N.J. Super 455 (2009).

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  4. Addiction refuses to allow discussion of industry ties to criticism of our paper

    NOT PEER REVIEWED In June 2015 we published our paper "The smoking population in the USA and EU is softening not hardening" in the journal Tobacco Control. We showed that as smoking prevalence has declined over time, quit attempts increased in the USA and remained stable in Europe, US quit ratios increased (no data for EU), and consumption dropped in the USA and Europe. These results contradict the hardening hypothesis which is often used as part of the tobacco industry's strategy to avoid meaningful regulation and protect its political agenda and markets, claiming that there is a need for harm reduction among those smokers who "cannot or will not quit." Indeed, rather than "hardening" the remaining smoking population is "softening."

    In February 2016 we received an email from Robert West, editor of the journal Addiction, informing us that Addiction was about to publish an article by Plurphanswat and Rodu entitled "A Critique of Kulik and Glantz: Is the smoking population in the US really softening?" whose sole purpose was to critique our Tobacco Control paper, and offered to let us respond to the criticism. (The full collection of emails is available at criticism-our-%E2%80%9Csoftening-paper%E2%80%9D)

    The fact that Plurphanswat and Rodu sent their paper to Addiction was unusual because normal scientific procedure would have had them sending a letter to the editor of the journal that originally published the work (Tobacco Control).

    As detailed below, we did respond, noting that Plurphanswat and Rodu's paper fits into a well-established pattern of tobacco industry- funded researchers trying, without any proper scientific justification, to create controversy about research inconsistent with industry interests, the fact that Rodu had understated his financial ties to the industry, and, of course, showing how their criticism was based on statistical error that they made.

    Addiction rejected our response because we would not delete the first two points and limit our response only to the statistical issue. Here is our full response:


    Consider the Source

    "Harm reduction" is a key part of the tobacco industry's strategy to avoid meaningful regulation and protect its political agenda and markets.[1] This agenda is premised on the existence of "hard core" smokers who "cannot or will not" quit.[2-4] Our paper, "The smoking population in the USA and EU is softening not hardening",[5] undermined this agenda because it showed that, contrary to the hardening hypothesis, as smoking prevalence has declined over time, quit attempts increased in the USA and remained stable in Europe, US quit ratios increased (no data for EU), and consumption dropped in the USA and Europe.

    There is a longstanding pattern of tobacco industry-funded experts writing letters criticizing work that threatens the industry's position, first described in 1993 by then-JAMA Deputy Editor Drummond Rennie.[6] Rodu and various co-authors have written several such letters.[7-10] Another similarity to past efforts is industry-linked experts submitting critiques of a paper published in one journal to another,[11-15] which is also the case here, with this critique of our paper published in Tobacco Control being published in Addiction. One would have expected any criticism to have been published as a letter in Tobacco Control.

    Addiction requires "full disclosure of potential conflicts of interest, including any fees, expenses, funding or other benefits received from any interested party or organisation connected with that party, whether or not connected with the letter or the article that is the subject of discussion." As with another investigator supported by the tobacco industry,[16] the conflict of interest statement Plurphanswat and Rodu provide may not truly reflect the extent of Rodu's involvement with the tobacco industry. For example:

    * Rodu's Endowed Chair in Tobacco Harm Reduction Research at the University of Louisville is funded by the U.S. Smokeless Tobacco Company (US Tobacco) and Swedish Match North America, Inc.[17]

    * Rodu is a Senior Fellow at the Heartland Institute, which has received tobacco industry funding.[18-20]

    * Rodu is a Member and Contributor to the R Street Institute, which has received tobacco industry funding.[19,21]

    * Before moving to Louisville, Dr. Rodu was supported in part by an unrestricted gift from the United States Smokeless Tobacco Company to the Tobacco Research Fund of the University of Alabama at Birmingham.[8]

    * Rodu was a keynote speaker at the 2013 Tobacco Plus Expo International, a tobacco industry trade fair to discuss "How has the tobacco retail business evolved; where was it fifteen years ago, where is it today and where is it going".[22]

    * Rodu has worked with RJ Reynolds executives between at least 2000 and 2009 to help promote industry positions on harm reduction, including specific products.[23-26]

    The substance of Plurphanswat and Rodu's criticism is that the statistically significant negative association between smoking prevalence and quit attempts and the positive association between prevalence and cigarettes smoked per day both become non-significant when more tobacco control variables are included in the model (state fixed effects, cigarette excise taxes, workplace smoking bans and home smoking bans). The problem with including all these variables is that it results in a seriously overspecified model, which splits any actual effects between so many variables that all the results become nonsignificant. The regression diagnostic for this multicollinearity is the Variance Inflation Factor (VIF); values of the VIF above 4 indicate serious multicollinearity. For the United States, adding all the other variables increases the VIF for the effect of changes in smoking prevalence from 1.8 in our model for quit attempts to 16.7, and from 1.8 in our model to 17.9 for cigarettes per day, respectively. Plurphanswat and Rodu's model is a textbook case of why one has to be careful not to put too many variables in a multiple regression.

    The Plurphanswat and Rodu criticism misrepresents our conclusions. We did not argue that drops in prevalence caused increased quit attempts and reduced consumption; we simply present the observation that, as prevalence falls, quit attempts increase or remain constant and consumption falls, which is the exact opposite of what the hardening hypothesis predicts.


    This work was supported by National Cancer Institute Grants CA-61021 and CA-113710. The sponsor played no role in the conduct of the research or preparation of the manuscript.


    1. Peeters S, Gilmore AB (2015) Understanding the emergence of the tobacco industry's use of the term tobacco harm reduction in order to inform public health policy. Tob Control 24: 182-189.

    2. Abrams DB (2014) Promise and peril of e-cigarettes: can disruptive technology make cigarettes obsolete? JAMA 311: 135-136.

    3. Polosa R, Rodu B, Caponnetto P, Maglia M, Raciti C (2013) A fresh look at tobacco harm reduction: the case for the electronic cigarette. Harm Reduct J 10: 19.

    4. Nitzkin JL (2014) The case in favor of E-cigarettes for tobacco harm reduction. Int J Environ Res Public Health 11: 6459-6471.

    5. Kulik MC, Glantz SA (2015) The smoking population in the USA and EU is softening not hardening. Tob Control doi:10.1136/tobaccocontrol-2015 -052329 Published online 24 June 2015.

    6. Rennie D (1993) Smoke and letters. JAMA 270: 1742-1743.

    7. Rodu B, Phillips CV (2015) Letter by Rodu and Phillips regarding article, "Discontinuation of smokeless tobacco and mortality risk after myocardial infarction". Circulation 131: e422.

    8. Rodu B, Cole P (2006) A deficient study of smokeless tobacco use and cancer. Int J Cancer 118: 1585; author reply 1586-1587.

    9. Rodu B, Plurphanswat N, Phillips CV (2015) Discrepant results for smoking and cessation among electronic cigarette users. Cancer. 121(13):2286-7. doi: 10.1002/cncr.29307. Epub 2015 Mar 4.

    10. Rodu B, Heavner KK (2009) Errors and omissions in the study of snuff use and hypertension. J Intern Med 265: 507-508; author reply 509- 510.

    11. Glantz SA, Parmley WW (1992) Passive smoking causes heart disease and lung cancer. J Clin Epidemiol 45: 815-819.

    12. Mantel N (1992) Dubious evidence of heart and cancer deaths due to passive smoking. J Clin Epidemiol 45: 809-813.

    13. Glantz SA, Parmley WW (1991) Passive smoking and heart disease. Epidemiology, physiology, and biochemistry. Circulation 83: 1-12.

    14. Jensen RP, Luo W, Pankow JF, Strongin RM, Peyton DH (2015) Hidden formaldehyde in e-cigarette aerosols. N Engl J Med 372: 392-394.

    15. Bates CD, Farsalinos KE (2015) Research letter on e-cigarette cancer risk was so misleading it should be retracted. Addiction 110: 1686- 1687.

    16. Bero LA, Glantz S, Hong MK (2005) The limits of competing interest disclosures. Tob Control 14: 118-126.

    17. University of Louisville. Available at, accessed February 2016.

    18. The Heartland Institute. Available at, accessed February 2016.

    19. Nitzkin email string "Dialogue with Tobacco Industry re 3d Party Research". Available at s..., accessed February 2016.

    20. The Center for Media and Democracy. Available at o... alecs-annual-meeting-salt-lake, accessed February 2016.

    21. The R Street Institute. Avaliable at, accessed February 2016.

    22. Tobacco Plus Expo 2013. Available at, accessed February 2016.

    23. University of Alabama, Debethizy JD, Doolittle DJ, Rodu B. Followup from Brad Rodu. 2000 April 26. RJ Reynolds.

    24. RJR, University of Alabama, Burger GT, Lyalls TM, Doolittle D, Moskowitz SW, Rodu B, Smith C, Williard S. ECLIPSE and Dr. Brad Rodu. 2000 April 20; 2000 April 26. RJ Reynolds.

    25. Hawkins SC. TTM - Brad Rodu for 122006 (20061200).PPT. 2008 December 01. RJ Reynolds.

    26. Reynolds American, Payne TJ, Rodu B. Thanks. The following studies (attached) provide almost identical evidence that appropriate marketing of smokeless products would result in a 10% drop in smoking prevalence. 2009 February 27; 2009 March 02. RJ Reynolds.

    Conflict of Interest:

    None declared

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  5. Response to article

    NOT PEER REVIEWED I am writing in response to sight of an article published by you about my work for the International Tax and Investment Center (ITIC). The ITIC guidebook published in 2011 "The Illicit Trade in Tobacco Products and How to Tackle it" makes it clear in the Executive Summary that it is "a compilation of facts and views from a wide range of sources including respected academics, private sector consultants, journalists, international enforcement organizations, government revenue authorities and industry". It also states in the very first footnote that the case studies were provided by industry, consultants and academics and other references include the Framework Convention Alliance, the World Bank Economic of Tobacco Toolkit, ASH Action on Smoking and Health and the WHO and Framework Convention Alliance are listed under "Interesting Links". I wrote this guidebook for ITIC as an independent consultant with academic freedom to ensure it presented a balanced picture of the issues and attributed input to the appropriate sources. I have never lobbied on behalf of an industry or individual company. As the former UK senior civil servant in a revenue authority who was privileged to lead the first UK Alcohol and Tobacco Fraud Review in 1997, my motivation in writing this guidebook has been to pass on my knowledge and experience of the illegal tobacco trade to assist officials in developing countries in improving their administration of excise taxation and anti-smuggling controls. I do not work for the tobacco industry and I have never smoked - in fact, I have suffered from asthma all my life and was delighted to see workplace smoking bans in the UK. I have never sought to undermine tobacco control policies. Rather, I have sought to help the tax and enforcement authorities to reduce opportunities for illegal trade, reduce demand and detect and prosecute the criminals and terrorists who profit from illegal trade drawing heavily on the UK experience in successfully reducing illegal trade in tobacco products from over 20% in 2000 to around 10% currently whilst maintaining one of the highest tax rates in the world. It is undeniable that products that are light, portable and subject to high levels of tax attract criminals. The guidebook (and the second edition published in 2013) makes it clear that there are, however, several drivers and facilitators of illegal trade in tobacco products including tobacco taxation policy, corruption, protectionist measures, inadequate legislation such as penalties, inadequate enforcement and public tolerance though it is my personal view that the economic drivers of supply and demand are the most important. Whilst advocating balanced tax policies in the guidebook, I went on to explain that sustaining high tax rates and maintaining manageable rates of illegal trade can only be achieved through a comprehensive strategic approach encompassing all legitimate stakeholders both public and private sector, national and international - as in the various refreshed versions of the UK Tobacco Strategy. As a former administrator I was trained and required to treat all taxpayers fairly without favouring one industry or one company over another. This has to be a key feature of effective tax and customs administration all over the world. The tobacco industry is a significant payer of excise revenue - second only to the hydrocarbon oil industry - and as long as it sells legal products and complies with legislative requirements it deserves the same treatment as any other industry. It is a feature of good tax administration to have dialogue with taxpayers and their representative associations and I have no hesitation in recommending this way of working to senior officials in Ministries of Finance and Revenue Authorities/Customs around the world. Indeed, the UK has long had and published Memoranda of Agreement with the tobacco industry as well as with other excise industries. I am puzzled by the article's criticism of a reference to Codentify in the 2011 edition of the guidebook as I do not see any such reference. The case study box on page 28 refers to International Track and Trace Standards and the information attributed to the four major international tobacco companies but Codentify is not mentioned as this is merely an illustration of the standards in place among key players in the industry. It is placed after a much more lengthy page on Article 15 of the WHO Framework Convention on Tobacco Control which the conclusions in para. 7.5 fully support but point out that rigorous enforcement, international cooperation and cooperation with the private sector are essential as legislation alone cannot eliminate illicit trade. With trillions of movements of tobacco products across the world daily there are never going to be sufficient enforcement resources to detect all illicit movements. Seizure rates, even in those countries that pride themselves on top class enforcement, do not exceed 20% to 23% and in the EU (see page 9 of the 2013 edition of the guidebook) were around 7% in 2011. Seizure rates can be expected to be considerably less in relation to illicit trade in most developing countries. So, enforcement authorities need all the help they can get from others in the public sector. This includes health and education authorities who are best placed to provide awareness campaigns and develop strategies to reduce demand and it includes help from legitimate industry who can provide additional intelligence on the markets, trends and those suspected of undermining their legal sales in the marketplace i.e. the international criminal organizations and terrorists. Moving on to the criticism of the WCO for allowing me to present a two day course on excise taxation policy, administration and enforcement, I would challenge anyone to present a meaningful course on excise taxation, administration and enforcement without referring to tobacco taxation or to illicit trade in excise products. The course included material on alcohol with input from the Spirits industry and the Beer industry and material on fuel taxation with input from the Oils industry as well as input on tobacco taxation from a representative of the tobacco industry. Customs officials have to deal with numerous products and legislation and their national training rarely provides them with material on excise taxes which they are tasked with protecting on imports, exports and transit shipments. Providing customs officials with basic broad awareness of the key excise taxes, how they work, good administrative and enforcement practices as well as stakeholder perspectives is really important in improving the performance of customs officials around the world. All the course material was thoroughly vetted by the WCO before the course so delegates were assured of receiving balanced and useful material.

    Conflict of Interest:

    None declared

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  6. Cigarette butt removal turned into business

    Any cooperation of municipalities with the tobacco industry is problematic. In Vienna, the capital of Austria, the department responsible for waste made a deal with the tobacco industry. This resulted in the installation of metal tubes for cigarette butts at every tram station, resembling huge cigarettes. Now there are still butts on the floor (usually extinguished by foot), but in addition, smoke is escaping from many of these ash cylinders, contaminating sheltered waiting space for passengers. Because the ash tubes look like an oversize cigarette, they remind smokers waiting for a tram or bus to light up. So the main benefit of this deal was for the tobacco industry an additional form of advertising without warnings.

    Conflict of Interest:

    unpaid board member of,, and

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  7. Re:Reply to Does smuggling negate the impact of a tobacco tax increase?

    NOT PEER REVIEWED Thanks for Mr. Middleton's information that there are local tobacco manufacturers in Hong Kong. I made a mistake when reading the materials. I have amended this in the updated version.

    It does not affect the analysis as the government taxes based on number of cigarettes sold rather than manufactured, but I sincerely appreciate your valuable advice.

    For the analysis part, it is not easy to have an "official figure" of illicit cigarette consumption. During the peer review stage, I indeed have discussed with the reviewers which source is preferable. I adopt the figures provided by the tobacco sellers, but also list the Euromonitor a reviewer suggested for readers' reference. Noted that these figures lead to the same result, as the total tobacco consumption (tax + illicit) drops after the tax increasing, which rebuts the traditional economic view that tobacco duty is not an effective method because of smuggling.

    It is also not an easy job to determine how much price is affordable for people esp youngsters. However when we find out that smuggling shall not be a concern when the government increases the tax rate, it is clear that tobacco duty is a powerful tool to control cigarette consumption.

    Conflict of Interest:

    None declared

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  8. a possible solution?

    NOT PEER REVIEWED Pressure the CDC and FDA to pressure state legislatures to outlaw the sale of filtered cigarettes. As I see it, this is the only viable solution for ending this litter problem. Cigarette smoking should be made as unappealing as possible to all concerned.

    Conflict of Interest:

    None declared

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  9. Missing the point

    NOT PEER REVIEWED The author appears to believe that the main problem with the FDA is that it is not doing enough to prevent new niche cigarette products reaching the market. This focus of concern is misplaced, given several thousand cigarette products are readily available and smokers are spoilt for choice with or without these new products. I have no great desire to see new cigarette products coming on the market, but is this really the most pressing agenda?

    There are important issues for FDA and Congress to address, but on which the author did not comment. Allow me to suggest five:

    1. FDA's governing framework for tobacco, the Tobacco Control Act, is unfit for the purpose of managing reduced risk products. It is designed to raise a high regulatory barrier to entry to a market dominated by worst products and to suppress innovation in better products. At the same time, it has protected the existing cigarette trade by 'grandfathering' the thousands of products that were on the market at 17 Feb 2007 and offering them an easy ride for subsequent modifications. A new legislative framework for recreational nicotine products is required.

    2. FDA regulation is unlikely to offer a feasible route to market for most vapour products. ?Its approach will cause chaos in the marketplace, even though these products are helping many to quit smoking. The vapour category would be largely wiped out and confined to the tobacco industry's high volume commodity products if FDA proceeds on its present course. That would provide further protection for the cigarette trade and stimulate a black market. Workarounds, a change in the predicate date or simply doing nothing would be an improvement.

    3. FDA's approach does little that supports and a lot that suppresses innovation, regardless of whether particular innovations are desirable for consumers. For example, under the proposed framework for vapour products to access the market, a third generation e-cigarette manufacturer would likely need to go through a new and hugely burdensome authorisation (PMTA) to introduce new safety features like temperature control or to improve nicotine delivery through better aerosol science. A notification regime with an FDA right to intervene if the evidence justifies it would be preferable to a cumbersome authorisation regime.

    4. FDA applies a bizarre approach to communicating the far lower risk of products like snus to consumers. This starts with a default FDA-imposed warning that is technically correct but not truthful because it is highly misleading ("this product is not a safe alternative to smoking"). It then requires tobacco companies to calculate if they are rich enough, the data extensive enough and whether it is sufficiently in their commercial interest to go through an arduous process to convince the FDA to allow them to change the warning to something more truthful ("No tobacco product is safe, but this product presents substantially lower risks to health than cigarettes") - and face hostile resistance from tobacco control campaigner such as the author. FDA and CDC should be assessing the relative risks of these products, and communicating them clearly - so that public risk perceptions become, as far as possible, aligned with scientific reality.

    5. FDA suffers from mission creep - a regulator should not be involved in campaigning. FDA should function, and be seen to function, as a neutral technocratic regulatory agency, leaving the hype to public health bodies like the CDC. In this case, there is a further problem - the scientific foundations of the new smokeless campaign are very poor and undermine FDA's credibility more generally. FDA should stick to its core mission and do it better.

    Matthew L. Myers and his campaign would do better to consider the important issues in nicotine regulation, not expend time, money and credibility on marginal issues with negligible public health value.

    Conflict of Interest:

    I am a long-standing advocate for tobacco harm reduction and run the Counterfactual blog. I have no competing interests with respect to any relevant industry.

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  10. Corroborating experimental study finds no effect of e-cigarette advertisements on interest in or susceptibility to tobacco smoking or e-cigarette use

    In a smaller sample of older teenagers, I recently extended and replicated some of Vasiljevic and colleagues' findings [1]. In line with their results, I found that e-cigarette advertisements did not increase interest in tobacco smoking, interest in using e-cigarettes or susceptibility to either behaviour.

    In this experimental study, 65 UK non-smokers aged 16-19 years were randomised to viewing either six e-cigarette advertisements cleared for television broadcast in the UK in 2014/15 or recent nicotine replacement therapy (NRT) adverts. The e-cigarette adverts featured five different brands and varied in content, setting, people portrayed, type of e- cigarette and whether flavours were a focus. Participant completed a baseline survey, watched the three-minute videos and completed a distractor task and a post-exposure survey in their own time on individual computers using headphones.

    The main outcome measures were interest in using e-cigarettes and interest in smoking tobacco cigarettes measured using visual analogue scales from 0 'no interest at all' to 100 'most interest ever' completed at baseline and post-exposure [2]. Additionally, at both time-points, four items measured susceptibility to use e-cigarettes/smoke cigarettes by asking participants if they would use an e-cigarette/smoke a cigarette if offered one by a friend and if they thought they would use/smoke in the next month [3]. Those ticking anything other than 'definitely not' on a 4- point scale were considered susceptible to e-cigarette use or smoking, respectively.

    Ethical approval was granted from a Research Ethics Subcommittee at King's College London (PNM 1415 61).

    The majority of participants were female (63%), British (83%), and of non-white ethnicities (65%). The NRT group was on average a few months older than the e-cigarette group (p=0.02) and the e-cigarette group indicated higher baseline interest in using e-cigarettes than the NRT group (p=0.04). Mixed two-way analyses of variance therefore adjusted for baseline differences between groups.

    There was no significant group by time interaction for interest in using e-cigarettes [F(1,62)=0.81, p=0.372, partial eta-squared=0.013] or smoking tobacco cigarettes [F(1, 61)=0.30, p=0.86, partial eta-squared <0.001], indicating that interest was not affected by exposure to the adverts. Non-parametric tests showed no significant change in the proportion susceptible to using e-cigarettes or smoking (all p>0.1), any small changes were towards a reduction in susceptibility.

    In conclusion, these results from an older age group of adolescents and using a different control condition corroborate Vasiljevic and colleagues' finding that there is no evidence of renormalisation of smoking due to e-cigarette advertising.


    1. Vasiljevic M, Petrescu DC, Marteau TM. Impact of advertisements promoting candy-like flavoured e-cigarettes on appeal of tobacco smoking among children: an experimental study. Tobacco control 2016 doi: 10.1136/tobaccocontrol-2015-052593.

    2. King AC, Smith LJ, McNamara PJ, Matthews AK, Fridberg DJ. Passive exposure to electronic cigarette (e-cigarette) use increases desire for combustible and e-cigarettes in young adult smokers. Tobacco control 2015;24(5):501-4 doi: 10.1136/tobaccocontrol-2014-051563.

    3. Bogdanovica I, Szatkowski L, McNeill A, Spanopoulos D, Britton J. Exposure to point-of-sale displays and changes in susceptibility to smoking: findings from a cohort study of school students. Addiction (Abingdon, England) 2014 doi: 10.1111/add.12826.

    Conflict of Interest:

    None declared

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