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Recent eLetters

Displaying 1-10 letters out of 385 published

  1. 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    NOT PEER REVIEWED I am writing in response to sight of an article published by you about my work for the International Tax and Investment Center (ITIC).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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  2. 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 www.aerzteinitiative.at, www.gamed.at, www.oeaw.ac.at/krl/ and www.oeghmp.at

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  3. 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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  4. 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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  5. 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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  6. 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.

    References

    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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  7. Other Possible Supplements to Cigarette Warning Labels?

    It is enormously helpful when researchers consider new, not-yet-tried tobacco control interventions (such as this study's consideration of warning messages on cigarette sticks), especially when researchers figure out effective ways to evaluate the not-yet-tried interventions.

    Some additional possibilities related to new warnings or pack changes that might be considered:

    (1) Put instructions for use in all cigarette packs that instruct smokers (with explanations) about how they can minimize the harms and risks to themselves and to others from their consumption of the cigarettes, such as:

    -- Do not smoke the cigarettes

    -- Do not smoke near anyone else

    -- Do not smoke in enclosed spaces

    -- Do not smoke by inhaling

    -- If inhaled, inhale as shallowly as possible

    -- Do not smoke more than a few puffs of each cigarette (or do not smoke more than halfway)

    -- Do not smoke in bed or when tired

    -- Make sure all smoked cigarettes are fully extinguished before discarding

    -- Discard of all cigarettes carefully (do not litter, do not discard in waterways, do not leave where children or pets might consume).

    (2) Make one cigarette in each pack a rolled-up scroll of information or instructions for use for smokers (which would also reduce the number of cigarettes that could be smoked in each pack, perhaps reducing consumption).

    (3) Audio warnings that play each time a pack is opened or a cigarette is extracted (now possible with available technologies).

    Conflict of Interest:

    None declared

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  8. Reply to Does smuggling negate the impact of a tobacco tax increase?

    NOT PEER REVIEWED This article is manifestly wrong in material content. Hong Kong has in fact, two current large domestic manufacturers of tobacco products, Hong Kong Tobacco Co Ltd and Nanyang Brothers Tobacco Co Ltd. Moreover the HK Customs Dept are all over the local dial-up-delivery smuggling syndicates to the extent that the tobacco funded front groups ITIC and Oxford Economics had to produce wildly false and flawed Information on the supposed level of illicit product availability (suitably decimated by the following reports). The HK Government gauges smoking prevalence from its Thematic Household survey reports; what is lacking in Hong Kong is the absence of questions in these Thematic Household Surveys seeking information on how many interviewees had purchased and / or used illicit tobacco in the previous year, the price they paid for it and the frequency of such DNP usage and whether they were concerned that the ingredients / nicotine/tar levels would most likely be far more toxic than the excise DP cancer sticks. Only with the incorporation of this relevant data could the claimed 10.7% prevalence levels be accurately gauged. In Singapore which has a lower cost of living than Hong Kong, a DP packet of Marlboro retails at HK$ 76 whereas the same DP packet in Hong Kong costs only HK$ 50, meaning tobacco remains affordable and available to HKG youth and there is no tobacco retailer license system, no POS display legislation and no onus on liquor /mahjong / sauna licensees to enforce the anti smoking legislation in their premises. The Health Department Policy Bureau failed to seek an excise increase in the last Budget, according to the Financial Secretary in an RTHK radio interview in Feb 2015. The Tobacco Control Office has just over 100 'enforcement' officers to cover Hong Kong, Kowloon, the New Territories and the Islands area over two shifts meaning they have insufficient manpower to patrol. http://seatca.org/dmdocuments/Asia%2014%20Critique_Final_20May2015.pdf http://tobaccocontrol.bmj.com/content/early/2015/01/05/tobaccocontrol-2014-051937.full http://www.legco.gov.hk/yr11-12/english/counmtg/hansard/cm0322-translate-e.pdf page 7400 http://www.customs.gov.hk/en/publication_press/press/index_current.html Shows the multiple seizures and arrests. Hong Kong Tobacco Company Ltd Address : 3/F Paramount Building, Hong Kong Tel 25618111 Owner Charles HO Tsu Kwok https://webb-site.com/dbpub/positions.asp?p=4462 http://www.bloomberg.com/research/stocks/people/person.asp?personId=8075652&ticker=1105:HK https://webb-site.com/articles/bauhiniafound.asp Nanyang Brothers Tobacco Co Ltd http://www.nbt-hk.com/ Location: Tuen Mun Hong Kong http://www.zigsam.at/B_Peel.htm http://www.scmp.com/news/hong-kong/law-crime/article/1846318/tobacco-worker-43-dies-industrial-accident-hong-kong Nan Yang also manufacture flavored tobaccos (PEEL)which are sold in the local market http://english.caijing.com.cn/2004-03-20/110030213.html Smuggling arrests http://www.siic.com/en_service_4.html Nanyang owners Nanyang Brothers Tobacco Co., Ltd. Nanyang Brothers Tobacco (short for "NBT")is the largest cigarette manufacturer in Hong Kong, of which main brand is "Double Happiness " and has a history of more than 100 years. At present, "Double Happiness" has been one of the most valuable trademarks in the tobacco industry. The production base of NBT is located in Tuen Mun, Hong Kong. NBT owns advanced manufacturing techniques, and its process of production is completely under computer control and management in order to guarantee the quality of products. The product of NBT is not only sold to China Mainland, Taiwan, Hong Kong and Macao, but also sold to Singapore, Thailand and Korea and so on. In 2011, its sales revenue and net profit reached 2,473 million HK dollars and 610 million HK dollars respectively. Cigarettes manufactured by Nanyang Brothers Tobacco Nanyang Brothers Tobacco Co. Ltd., located at Tuen Mun, New Territories, Hong Kong, China Nanyang Brothers Tobacco Co. Ltd., located at 9 Tsing Yeung Circuit, Hong Kong, China Founded in 1906. NANYANG means SOUTH PACIFIC. Current PRODUCTS: Alain Delon, Centori, Chunghwa, DJ Mix, Just Above, Peel, Polar Bear, Shuang Xi, Texas 5, (The Globe), Wealth

    Conflict of Interest:

    None declared

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  9. Response to McDaniel re: Endgame Review and Wake-up Call to the Tobacco Control Community

    NOT PEER REVIEWED The recent endgame review by McDaniel et al1 demonstrates a major flaw in thinking within the tobacco control community. The industry is seen as dominated by the "big tobacco" cigarette companies. The real life industry is intensely competitive and highly fragmented. There are, within the industry, many who could effectively partner with the public health community, if given the opportunity to do so. Because of this flaw in thinking, the tobacco control community has been unwilling to consider any role for tobacco harm reduction or electronic cigarettes in any public health initiative. E-cigarettes have the potential to substantially reduce smoking-related illness and death and do so without recruiting significant numbers teens or other non-smokers to nicotine use. .2-5

    The McDaniel paper1 lists sixteen end-game proposals, fourteen of which consist of partial or total bans on aspects of the manufacture or sale of non-pharmaceutical nicotine delivery products. Only two, one referencing e-cigarettes and another "advantage cleaner nicotine products over combustibles" make any reference to tobacco industry participation in pursuit of tobacco control objectives. Both are discouraged as unproven and impractical despite substantial scientific evidence to the contrary.

    The time has come for the public health community to engage in dialogue with those stakeholders in tobacco-related industries who are ready, willing and able to partner with public health in pursuit of shared public health objectives. The purpose of this dialogue would be to help secure reductions in tobacco-related illness and death not likely achievable by other means.

    Experience to date with e-cigarettes gives us grounds for optimism that this could easily be done without recruitment of teens and other non- users to nicotine use. .2-4

    A world in which tobacco-related addiction, illness and death have been reduced to trivial public health problems could be achieved within our lifetimes. Achieving this goal will require re-orienting tobacco control from a crusade against all things "tobacco," to a public health initiative considering all options for the prevention of addiction, illness and death. This is a goal not likely achievable by any other means. A seemingly small change in the wording of our tobacco control goal from "a tobacco-free society" to "a smoke-free society" would get us most of the way there. References

    1. McDaniel PA, Smith EA, Malone RE. The tobacco endgame: A qualitative review and synthesis. Tob Control 2015 28 August; Special Communication Published On Line:1-11. 2. Nitzkin JL. The case in favor of e-cigarettes for tobacco harm reduction. International Journal of Environmental Research and Public Health 2014;11:6459-71. 3. Nitzkin JL. E-cigarettes: A life-saving technology or a way for tobacco companies to re-normalize smoking in American society? FDLI's Food and Drug Policy Forum 2014 30 June;4(6):1-17. 4. McNeill A, Brose L, Calder R, Hitchman S. E-cigarettes: An evidence update. A report commissioned by Public Health England [https://www.gov.uk/government/publications/e-cigarettes-an-evidence- update]. A an Evidence Update Plus Policy Implications. London, England, August, 2015. 19 August 2015. 5. Farsalinos K, Polosa R. Safety evaluation and risk assessment of electronic cigarettes as tobacco cigarette substitutes: A systematic review. Therapeutic Advances in Drug Safety 2014;5(20):67-86

    Conflict of Interest:

    I currently serve as Senior Fellow for Tobacco Policy for the R Street Insitute

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  10. Re: Raising the Minimum tobacco sales age to 21- worth a try?

    To the Editor,

    Despite the seemingly decline in tobacco use, the habit is picked up by youths on a daily basis. According to the CDC fact sheet, tobacco use is established primarily during adolescence where 9 out of 10 cigarette smokers first initiate smoking by age 18. In the United States, more than 3,800 youths aged 18 years or younger try their first cigarette every day [1]. If the trend continues, about 5.6 million Americans that are less than 18 years will die early from a smoking-related illness i.e. 1 of every 13 young Americans will lose their lives to tobacco use [1]. These figures are disturbing, and though tobacco control is at the forefront in trying to reduce these mortalities from tobacco use, the road ahead seems long and weary.

    In 2007, a study using modelling techniques showed that increasing the smoking age would lead to a drop in youth smoking prevalence from 22% to under 9% for the 15- 17 year old age [2]. Another study done in England, also found that increasing the age for legal purchase of tobacco was associated with reduction in smoking [3]. According to a study done in 1996, "adopting the tobacco policy of raising the legal age would delaying the initiation of smoking if it succeeds"[4]. And that it might also contribute to the reduction of smoking-related mortality and morbidity in the youth[4].

    In this current study, the authors showed that the Needham community in Massachusetts has achieved success with this policy by comparing the youth smoking trends in this community with surrounding nearby communities that have not raised the legal age for tobacco purchase [5]. Their results showed that there was a greater decline in youth smoking in Needham due to an increase in the legal smoking age relative to the other communities. Although this study shows promising results for the immediate effects of decline in tobacco use, it should be noted that present day youths now have the leisure of purchasing alternative tobacco products in the form of e-cigarettes, hookahs and smokeless tobacco. It is reported that nearly 4 of every 100 middle school students in 2014 use e-cigarettes, 3 in 100 had used hookah and more than 5 in 100 currently use smokeless tobacco [1].

    Enacting the policy on increasing the legal age to purchase tobacco should be thoroughly comprehensive to include alternative tobacco products as well. Though, the future of tobacco control seems daunting, it is still worth a try to raise the legal age of tobacco purchase in order to curb the sequelae of a lifelong addiction that has deleterious health effects.

    References

    1.http://www.cdc.gov/tobacco/data_statistics/fact_sheets/youth_data/tobacco_use/index.htm#background

    2. Ahmad. (2007). Limiting youth access to tobacco: Comparing the long-term health impacts of increasing cigarette excise taxes and raising the legal smoking age to 21 in the united states. Health Policy (Amsterdam), 80(3), 378; 378-391; 391.

    3. Millett, C., Lee, J. T., Gibbons, D. C., & Glantz, S. A. (2011). Increasing the age for the legal purchase of tobacco in England: Impacts on socio-economic disparities in youth smoking. Thorax, 66(10), 862-865.

    4. Breslau, N. (1996). Smoking cessation in young adults: Age at initiation of cigarette smoking and other suspected influences. American Journal of Public Health (1971), 86(2), 214.

    5. Schneider, S. K., Buka, S. L., Dash, K., Winickoff, J.P., O'Donell, L. (2015). Community reductions in youth smoking after raising the minimum tobacco sales age to 21. Tobacco Control doi:10.1136/tobaccocontrol-2014-052207

    Conflict of Interest:

    None declared

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