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Recent eLetters

Displaying 1-10 letters out of 357 published

  1. An analysis of limitations of tax policy is not a policy fix

    It is important for tobacco control policymakers to know the advantages and disadvantages of different tax policies. It is quite another thing to move a tax system to optimize tax policy for tobacco control since there are multiple obstacles to systems change. In addition, health advocates often do not invest enough time and effort to understanding the economics of tax systems and the structural impediments in existing laws and policies to improve the tax structure. Consider for a moment the huge amount the tobacco industry invests in the economics of tobacco, and how it gives big money to lobby and influence tax policy. I applaud economists who are willing to study and fight for strong tobacco control tax policies, but in LMIC they are usually far too few. It is time for local/national health professionals to realize they better invest in working with economic leaders if they really wish to influence tax and health investment policies over the long term. Only then will there be health in all policies, including tax policies on tobacco and many other products that are necessary to sustain and promote health.

    Conflict of Interest:

    None declared

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  2. Re:KPMG response to 'Towards a greater understanding of illicit tobacco trade in Europe: a review of the PMI funded 'Project Star' report', published in Tobacco Control (BMJ) on 11th December 2013

    Dear Editor

    Cartwright (1) has clearly mis-read our article on PMI's Project Star report(2). The central premise of our article is not that illicit is overestimated but that the Project Star report cannot be relied on as a source of data on illicit until there is significantly greater transparency over the underlying methodology and data inputs and the contractual arrangements under which it is conducted. KPMG itself would appear to acknowledge this stating clearly in a disclaimer in each of its Project Star reports that the data cannot be relied on: "KPMG wishes all parties to be aware that KPMG's work for Philip Morris International was performed to meet specific terms of reference agreed between PMI and KPMG and that there were particular features determined for the purposes of the engagement. The Report should not therefore be regarded as suitable to be used or relied on by any other person for any other purpose."

    This lack of transparency is again underlined by Cartwright's failure to mention in his letter that KPMG receives ?10million from PMI to produce Project Star, his largest contract (http://www.kpmg.com/uk/en/about/aboutkpmg/kpmgfoundation/pages/robin- cartwright.aspx). He also claims this is a project for the European Commission and Philip Morris yet the Commission denies this. It is increasingly difficult to see where the truth lies here. KPMG's claim that the Project Star reports are recognised across Europe as the most "comprehensive" study of its kind is not disputed. No-one else has the financial backing or the political self-interest, in the case of PMI, to produce a report of this size. But comprehensive does not equal accurate, reliable and transparent. It doesn't matter how many cigarette packs are collected if the empty pack survey is designed to overestimate illicit as growing evidence suggests industry empty pack surveys are(2). Our paper clearly acknowledges that the model used in the Project Star report has merit but while PMI are so closely involved in the report and supply the majority of data to be used in the model, it cannot be relied on. Overwhelming evidence shows the extent to which the tobacco industry is prepared to manipulate science and data in its own interest(3). The illicit trade in tobacco is no exception(2,4). Anna B Gilmore1, Silvano Gallus2, Andy Rowell1, Luk Joossens3 1Department for Health and UK Centre for Tobacco and Alcohol Studies (UKCTAS), University of Bath, Claverton Down Road, Bath, UK 2Department of Epidemiology, IRCCS--Istituto di Ricerche Farmacologiche Mario Negri,Milan, Italy 3Association of the European Cancer Leagues and Foundation Against Cancer, Brussels, Belgium

    Competing interests: The authors of this letter authored the paper being criticised by Cartwright and ABG, SG & LJ were part of the PPACTE study which Cartwright also criticises.

    (1) Cartwright RM. KPMG response to 'Towards a greater understanding of illicit tobacco trade in Europe: a review of the PMI funded 'Project Star' report'. Tobacco Control Published Online First 5 March 2014 http://tobaccocontrol.bmj.com/content/early/2014/01/16/tobaccocontrol-2013 -051240.full?sid=ffae5533-cd43-46d0-ae48-3f2d6c0d9b00#responses. (2) Gilmore AB, Rowell A, Gallus S et al. Towards a greater understanding of the illicit tobacco trade in Europe: a review of the PMI funded 'Project Star'. Tobacco Control Published Online First 11 December 2013 doi:10.1136/tobaccocontrol-2013-051240. (3) Michaels D. Doubt is our Product. New York: Oxford University Press, 2008. (4) Rowell A, Evans-Reeves K, Gilmore AB. Tobacco Industry Manipulation of Data on and Press Coverage of the Illicit Tobacco Trade in the UK. Tobacco Control (in press).

    Conflict of Interest:

    The authors of this letter authored the paper being criticised by Cartwright and ABG, SG & LJ were part of the PPACTE study which Cartwright also criticises.

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  3. KPMG response to 'Towards a greater understanding of illicit tobacco trade in Europe: a review of the PMI funded 'Project Star' report', published in Tobacco Control (BMJ) on 11th December 2013

    Significant factual inaccuracies relating to KPMG's annual report into the European trade in illicit tobacco were made in a recent article published in Tobacco Control by the BMJ. The report, which KPMG's Strategy Group has been producing since 2005, is recognised by the UK National Audit Office, OLAF and the OECD (and by other numerous national customs authorities and government departments) as the most comprehensive study of its kind. The report has earned its solid, international reputation because it is produced by an independent, professional advisory firm, using a robust and consistently applied methodology.

    The central premise of the article was that the KPMG report overstates the illicit tobacco trade. However, KPMG estimates since 2005 have correlated within a range given by other organisations, including the UK National Audit Office, Euromonitor, Joossens and the IARC, amongst many others. For example, in 2007, Joossens estimated total consumption of illicit tobacco within the EU to be 8.5%, while the KPMG report estimated consumption at 8.4%.

    Critically, the article misrepresented the methodology KPMG applies in estimating the consumption of illicit tobacco. The research considers a number of factors, including empty pack surveys. It is certainly true that empty pack surveys do not provide the full picture but they do form an important factor in the equation as they rely purely on physical evidence, avoiding the variability of consumer bias in interview based methods. An additional advantage of empty pack surveys is that they provide a statistically robust and comparable volume of data as they are conducted consistently across all European markets. In 2010 approximately 430,000 packs were collected throughout Europe in 1,400 population centres. Additional analysis identifies if the empty pack survey may have over or under-reported the level of non-domestic packs with the samples being re-weighted to correct this.

    The KPMG report also factors in consumer surveys (conducted by Ipsos and Nielsen) which drill into the detail of consumers' travel habits, overall consumption, gender and age to assess the level of legal non- domestic purchases. Approximately 10% of the 160,000 survey respondents both travel and purchase cigarettes abroad. These respondents are asked about the country of purchase and brands purchased. This data can also be adjusted where it appears to be under-reporting legal tobacco consumption. For example, correction of under-reporting increased the allocation of legally purchased packs from Spain to France and from Poland and the Czech Republic to Germany.

    The article goes on to offer an alternative estimation methodology: the PPACTE study. However, it is prudent to consider the limitations of this study; notably, the reliance on consumer studies which both under- report tobacco consumption overall and, in particular, illicit tobacco consumption. The PPACTE study also uses a substantially smaller sample size e.g. the methodology used to calculate the illicit volumes equates to an average of less than 200 per country.

    The consumption of tobacco - illicit or otherwise - is understandably a concerning issue for many people and organisations. While it may be superficially appealing to discount a report funded by a tobacco company, the methodology of the 'Project Star' report is robust and unbiased. This data set is an important source of knowledge for the tobacco industry and health campaigners alike. An issue can only be tackled, whether for commercial or health reasons, if its nature and scale is understood. The Project Star report is widely regarded, by companies and health and government organisations, as the leading source of data on illicit tobacco consumption in the EU.

    Conflict of Interest:

    Author of the report under examination in the paper published in December 2013, entitled 'Towards a greater understanding of the illicit tobacco trade in Europe: a review of the PMI funded 'Project Star''

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  4. Cultural considerations for tobacco control strategies in rural China

    NOT PEER REVIEWED Dear Editor,

    The recent article by Cai et al, reported that male gender, young age, low educational attainment, and tobacco cultivation are predictors of tobacco use and second-hand smoke (SHS) exposure in rural China [1]. Neighborhood-level income was the only contextual predictor of tobacco use and SHS exposure identified. Hence, the authors suggested that "future interventions to reduce smoking and exposure to SHS in China should focus more on tobacco farmers, less-educated individuals and on poor rural communities." (pg. ii19)

    Nevertheless, Cai and colleagues also found that the Han majority had higher prevalence of smoking and SHS exposure when compared to ethnic minorities (p<0.05). Differences in health outcomes and risk factors have been reported among the Han population when compared to other Chinese ethnic minorities [2,3]. Stratified analysis might elucidate unique risk factors to smoking and SHS exposure between ethnic groups important for the design of tobacco control strategies.

    In addition, Cai et al. showed that townships varied widely in the proportion of the population who were ethnic minorities (3.1% to 97.1%). In the study of contextual determinants of health, results and implications should not ignore such vast differences in ethnic composition between areas. Important information might be conveyed if results were stratified by the proportion of ethnic minorities in the area (e.g. high, medium, low). Ethnic minorities living in areas with a high proportion of the population of the same ethnic minority may experience better health [4]. Therefore, it might also be important to compare the risk of smoking and SHS exposure among individuals living in areas highly populated by their ethnic group versus those residing in areas where they are the minority group.

    Cultural differences and ethnic composition of a geographic area should be considered in the design and implementation of tobacco control programs and in the allocation of resources. Resources may be better spent in areas with a high proportion of the Han population; while areas with a high minority population may be at decreased risk. Interventions should be culturally appropriate to minimize the expenditure of resources on ineffective strategies.

    Diana M. Sheehan, MPH

    References

    1. Cai L, Wu X, Goyal A, et al. Multilevel analysis of the determinants of smoking and second-hand smoke exposure in a tobacco- cultivating rural area of southwest China. Tob Control 2013;22(suppl2):ii16-20.

    2. Ruixing Y, Hui L, Jinzhen W, et al. Association of diet and lifestyle with blood pressure in the Guangxi Hei Yi Zhuang and Han populations. Public Health Nutr 2009;12(4):553-561.

    3. Sun H, Zhang Q, Luo X, et al. Changes of adult population health status in China from 2003 to 2008. PLoS One 2011;6(12):e28411.

    4. Inagami S, Borell LN, Wong MD, et al. Residential segregation and Latino, black and white mortality in New York City. J Urban Health 2006;83(3):406-20.

    Conflict of Interest:

    None declared

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  5. CARCINOGEN EXPOSURE WITH WATER PIPE SMOKING

    NOT PEER REVIEWED To the Editor: The habit of water pipe smoking is rapidly extending in all occidental countries. This rise in popularity appears to be correlated with the advent on store shelves of an array of fruit-flavored tobacco mixtures, which list ''molasses'' as a primary ingredient. Also there is a widespread misperception among smokers that the water through which the smoke bubbles acts as a filter, rendering it considerably less harmful than that of cigarettes [1]. A recent systematic review showed that the main motives for water pipe tobacco smoking were socializing, relaxation, pleasure and entertainment. Peer pressure, fashion, and curiosity were additional motives for university and school students [2]. However, the habit of smoking tobacco in water pipes is an old practice in the Eastern Mediterranean countries like Egypt, Jordan, Syria, Lebanon and Iraq [3]. Recently, Jaboc and collaborators (2013) published a crossover study about biomarkers of toxicant exposure with water pipe compared with cigarettes. The study included 13 volunteers from San Francisco (USA) who smoked both cigarettes and water pipes. The results showed that water pipe was associated with greater exposure to carbon monoxide, polycyclic aromatic hydrocarbons and benzene compared with cigarette smoking. Finally, the authors concluded that water pipe smoking is associated with a high risk of leukemia related to high levels of benzene exposure [4]. If Jaboc and collaborators' (2013) conclusions were right, we would expect higher prevalence of leukemia in the Eastern Mediterranean region compared with the Occidental Countries. Reviewing cancer registries in GLOBOCAN 2008, we can notice that adjusted standardized mortality rates of leukemia in males are comparable in the European Region (5.0 per 100.000) to the Eastern Mediterranean Region (4.7 per 100.000). A similar rate is noticed in the Americas Region (5.0 per 100.000) [5]. Deficient registration systems could not be the explanation. Neoplasms principally attributed to smoking like lung, laryngeal and oro-pharyngeal cancers have similar prevalence in Egypt like many of the occidental countries [5]. Water pipe tobacco brands used in the study of Jacob and collaborators (2013) were Nakhla and Al-Waha. These are the same brands usually consumed in the Eastern Mediterranean countries, like Egypt. On examining the box of Nakhla Double Apple brand, widely consumed in Spain, we can find a clear notice that it contains 0% tar. During the smoking process cigarette tobacco burns directly, whereas water pipe tobacco does not burn in a self-sustaining manner and requires an external heat source such as charcoal. I think that the high level of polycyclic aromatic hydrocarbon and benzene in the urine samples of water pipe smokers in the study of Jaboc and collaborators (2013) could be attributed to the charcoal disks used in many occidental countries. These quick lighting charcoal disks are impregnated in gasoil rich in polycyclic aromatic hydrocarbons and benzene. Smoke from these impregnated charcoal disks is inhaled by water pipe smokers [1]. In Eastern Mediterranean countries like Egypt, natural charcoal is used and is burned slowly in special clay or metallic receptacles [1,3]. This could explain the comparable prevalence of leukemia in Egypt and Occidental Countries. Examining quick lighting charcoal disk tubes available in Spain, we can notice that they lack labeling about the hazards of their use for water pipe smoking. Regulations and control for the use of these impregnated charcoal disks in the European Countries are urgently needed.

    REFERENCES 1. Shihadeh A. Investigation of mainstream smoke aerosol of the argileh water pipe. Food Chem Toxicol 2003;41(1):143-52. 2. Akl EA, Jawad M, Lam WY, Co CN, Obeid R, Jihad Irani J. Motives, beliefs and attitudes towards waterpipe tobacco smoking: a systematic review. Harm Reduct J 2013;10:12. 3. Chaouachi K. The medical consequences of narghile (hookah, shisha) use in the world. Rev Epidemiol Sante Publique 2007;55(3):165-170. 4. Jacob P 3rd, Abu Raddaha AH, Dempsey D, Havel C, Peng M, Yu L, Benowitz NL. Comparison of nicotine and carcinogen exposure with water pipe and cigarette smoking. Cancer Epidemiol Biomarkers Prev 2013;22(5):765-72. 5. International Agency for Research on Cancer. GLOBOCAN 2008. Available at: http://globocan.iarc.fr/ (Accessed 31 August 2013).

    Conflict of Interest:

    None declared

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  6. Taking Breaks: are smokers examples of model employees?

    NOT PEER REVIEWED The article by Berman et al "Estimating the cost of a smoking employee" has attempted to quantify the costs associated with employing smokers. As the article indicates several companies are now actively discriminating against smokers so it is important that any costs are fully justified. One area that concerns me about this is a tendency towards oversimplification of a complex situation. In particular the assumption that the breaks a smoker takes from work are a cost to the employer. Clearly a smoking break is time away from workplace tasks, but the assumption that this is just about time at the desk ignores a growing body of evidence that taking regular breaks from work is beneficial to individual health (1), which might counter some of the negative health risks associated with smoking, and that breaks are also beneficial to workplace productivity. Research has suggested that people taking regular breaks are more creative, more focussed and ultimately more productive (2,3). Prolonged attention to an individual task has, somewhat counter-intuitively, been shown to hinder performance. Taking a break from the task improves overall focus (2). Similarly breaks that have a positive association for the person taking the break are linked to positive performance effects and lower levels of negative emotions (3). All of this suggests that smokers taking breaks might actually increase their performance and benefit employers. Not taking such effects into account is potentially unfair to smokers and also risks breaks being associated by employers with negative effects for all of us. References: 1) Levene: http://dx.doi.org/10.2337%2Fdb10-1042 2) Ariga: http://dx.doi.org/10.1016/j.cognition.2010.12.007 3) Trougakos: http://dx.doi.org/10.1108/S1479-3555(2009)0000007005

    Conflict of Interest:

    None declared

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  7. Re:Measuring mass media coverage of tobacco: prominence over quantity

    We appreciate Dr. Blum's interest in our study and his comments. Data used for our study were collected and coded based on the public health surveillance model, which is more fully described elsewhere (1). Only a carefully selected set of items from tobacco news stories were coded over an extended period of time, with editorial cartoons and letters to the editor not included in the system. The newspapers were specifically chosen based on their larger circulation numbers and geographic representation. As often occurs with surveillance system data, they can be more useful for generating than testing specific research hypotheses (2).

    We agree it would be valuable to assess the level of news coverage for tobacco issues in the broader context of media coverage for other topics; unfortunately, doing so was far beyond the scope this project.

    There were, of course, many more tobacco activities or events over the 7-year period contributing to higher levels of news coverage than we could possibly highlight in the figures. We agree that prominence accorded to tobacco news stories by news media gatekeepers, as assessed by whether they appear on the front page of a newspaper or are mentioned early in television broadcasts, or if they appear in elite media outlets such as the New York Times, is important (3).

    Additional items were added to the system beginning in 2007 that allowed for some analyses of prominence from 2007-2010, and these findings were mentioned in our paper. More research about prominence along the lines suggested by Dr. Blum is warranted, and such research would, ideally, confirm or deny his impression that there were only been a handful of significant tobacco stories in recent years.

    We believe the prominence versus quantity argument as it pertains to news media coverage of tobacco represents a false choice: both are important and they are interrelated. Tobacco control and prevention activities or events that result in news stories in elite media are likely to generate a large quantity of news coverage over time in other media outlets. Conversely, if a large number of news stories about a specific tobacco-related topic appear in other media outlets, they will likely gain the attention of elite media gatekeepers and result in increased coverage in their news venues.

    1. Nelson DE, Evans WD, Pederson LL, et al. A national surveillance system for tracking tobacco news stories. Am J Prev Med. 2007;32:79-85.

    2. Lee LM, Teutsch SM, Thacker SB, St. Louis, ME (eds). Principles & Practice of Public Health Surveillance (3rd ed). New York: Oxford University Press; 2010.

    3. Gorman L, McLean D. Media and Society into the 21st Century: A Historical Introduction (2nd ed). Hoboken, NJ: Wiley-Blackwell; 2009.

    Conflict of Interest:

    None declared

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  8. Measuring mass media coverage of tobacco: prominence over quantity

    NOT PEER REVIEWED Because the authors cite just seven major tobacco-related news events in the seven year period they reviewed (Figure 2), I question whether their tabulation of the "volume of news media stories on tobacco" (page 6) provides a meaningful representation of the coverage of tobacco-related issues in the mass media. Is not a front-page article on a tobacco- related subject in The New York Times or The Washington Post--or a lead story on NBC NIghtly News or The Today Show--of far greater importance, in terms of both content and readership, than the publication of any number of brief items? In other words, missing from this analysis is a year-by- year list of nationally significant news stories on tobacco.

    One measure that could be used to quantify the relative importance of tobacco stories in a given year is the daily Index to Businesses in The Wall Street Journal (WSJ). By this indicator (and by my daily reading of the print editions of the WSJ, The New York Times, The Financial Times, USA Today, and two local US dailies), my impression is that in recent years there has been a relative handful of significant tobacco news stories. This is at odds with the authors' finding of an average of 3 tobacco-related newspaper stories, 4 newswire stories, and 1 television news story each day for seven years. Although the authors attempted to correct for duplication, I suspect a large percentage of these stories were variations on a theme or the same news thread.

    Another measure is newspaper editorial cartoons. Even taking into consideration the decimation in the ranks of political cartoonists at US dailies due to the steep decline in newspaper readership, editorial cartoons on tobacco issues are now rare. In the heady days of anti- tobacco activism in the US in the 1980s and 1990s, I catalogued more than 700 editorial cartoons on tobacco.

    I wonder if the best way to gauge the weight given to the coverage of tobacco-related issues in a given year would be to compare it to the attention given to other issues, both health-related (eg, AIDS, obesity, gun control, alcohol problems) and less directly health-related (eg, the economy, unemployment, terrorism).

    Ultimately, I am unconvinced that quantity beats quality when it comes to reports on tobacco in the mass media. What matters is the prominence of news coverage of significant issues, not the number of articles all counted as equal.

    Conflict of Interest:

    None declared

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  9. Re:Re:Large-scale unassisted smoking cessation over 50 years: lessons from history for endgame planning in tobacco control

    NOT PEER REVIEWED I really welcome this kind of discussion.

    I acknowledge your 'why and how' argument, however you may find that things like telephone counselling and many group programs will however then fall into your unassisted quitting category as well. This is because they are simply being coached to enhance those natural skills they already have.

    I am aware you are conducting an interview style 'unassiSted attempt' project, and I think this is really useful for workers in the field. What I am convinced you are going to find is that people use a range of positive self talk strategies, and challenging negative thoughts at times of cravings to overcome them. Things such "I can do this', 'Just say no', and/or visualising the long term consequences of smoking, to name a few. These cognitive strategies that people naturally use are great, and it's what telephone counsellors and group clinicians would support in any drug and alcohol envronment, or even clincians that work solely with psychopathologies. There is nothing wrong with this, except that in group and individual counselling, you can practice and enhance these cognitive processes - and add more of them. In addition, you can offer other strategies, dare I say - NRT, in combination. This is what makes group behaviour therapy for example so useful.

    There is nothing new about congnitive restructuring techniques. Psychologists have been assisting clients for years as part of any CBT strategy. Your study, although I'm not aware of the details, seems to be collection of natural cognitive processes. Again, all this is fine, but wht not build on this as part of treatment? After all, you say you are not against treatment.

    Your have linked your statement about pharmaceutical companies in with services like mine. i.e 'you spend a lot, with little proportional return.' This is an apples and oranges argument. Firstly, I personally can't see the problem in a pharmaceutucal company (or any company for that matter) spending their own money to advertise their own products. I also can't see any problem with them making a profit from this, as long as the evidence supports their products' use.

    Importantly, the last time I looked, almost nothing has been spent by the government or by anyone else on our service up until recently, and yet I receive hundreds of enquiries each year for assistance, usually from desperate workplaces.

    Your final point is a good one. There is a lack of motivation by the majority of smokers to take up professional assistance. Yet if interventions like group behaviour therapy, for example, doubles cessation, and treatment really is supported by public health teams, then why aren't public health experts continually studying and supporting ways to effectively enhance uptake? This is where I see failure.

    It would be fantastic if all smokers could quit with 'unassisted' self talk strategies by 30-35. Yet in NSW more than 60% of smokers are over 35 as of 2011 (Health stats data). Their unassisted quit attempts did not work, but maybe treatment would have.

    Conflict of Interest:

    None declared

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  10. start a broader movement targeted at WTO

    NOT PEER REVIEWED The warning of this article is important, but not limited to the Trans-Pacific Partnership. Switzerland and USA, as countries which have not ratified, are not obliged to follow Article 5.3 of the WHO Framework Convention on Tobacco Control. One of the reasons for the largest tobacco companies to move their headquarters to Switzerland was the location of the World Trade Organisation in this country. Some time ago I attempted to draw attention to this danger: https://secure.avaaz.org/en/petition/exclude_tobacco_nicotine_from_free_trade_agreements/. I hope that Fooks and Gilmore will succeed in starting a broader movement.

    Conflict of Interest:

    None declared

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