Despite 20 years of sustained engagement and reductions in smoking prevalence rates globally, smoke free policy implementation remains inconsistently applied in low- and middle-income countries where there are high smoking prevalence rates and where >80% of the 1.3 billion smokers reside.1-2 Merrit’s study3 is a stark reminder that despite the forward steps of the Framework Convention on Tobacco Control,2,4-5 variations in achieving smoke free policies in specialist settings persist. Acknowledged challenges in implementing smoke free hospital policies include a lack of data, inadequate reporting, and reduced prioritisation of tobacco control at governmental level.1,3 The lack of an intersectional lens and co development with communities continues with policy development. 6
Inconsistencies in application of smoke free policies are balanced by reporting of positive implementations demonstrating improvements in some hospital systems evidenced by reductions in smoking rates and improved access to smoking cessation services underpinned by longitudinal data. 7-9
Previously, Chan 10 indicated that ‘tobacco use … threatens development in every country on every level and across many sectors — economic growth, health, education, poverty and the environment — with women and children bearing the brunt of the consequences’, - this continues today intensifying the impact of the social, structural and commercial determinants of health and n...
Despite 20 years of sustained engagement and reductions in smoking prevalence rates globally, smoke free policy implementation remains inconsistently applied in low- and middle-income countries where there are high smoking prevalence rates and where >80% of the 1.3 billion smokers reside.1-2 Merrit’s study3 is a stark reminder that despite the forward steps of the Framework Convention on Tobacco Control,2,4-5 variations in achieving smoke free policies in specialist settings persist. Acknowledged challenges in implementing smoke free hospital policies include a lack of data, inadequate reporting, and reduced prioritisation of tobacco control at governmental level.1,3 The lack of an intersectional lens and co development with communities continues with policy development. 6
Inconsistencies in application of smoke free policies are balanced by reporting of positive implementations demonstrating improvements in some hospital systems evidenced by reductions in smoking rates and improved access to smoking cessation services underpinned by longitudinal data. 7-9
Previously, Chan 10 indicated that ‘tobacco use … threatens development in every country on every level and across many sectors — economic growth, health, education, poverty and the environment — with women and children bearing the brunt of the consequences’, - this continues today intensifying the impact of the social, structural and commercial determinants of health and need for increased pricing, incentivizing quitting and raising taxes. 11,12 The inequalities in the wider health systems will undoubtedly compound the ability of Vietnam to meet the global sustainable development goals target. 3,13
The new evidence base supports the evidence from a Cochrane system review examining the impact of no-smoking policies at the meso level in three specialist settings - hospitals, prisons and universities/ colleges. 14 An inconsistent evidence base from observational studies, with no validated biochemical measure of cotinine reported reductions in staff smoking rates in prisons and university settings post introducing smoking policies.14 However pooled data (12,485 participants) indicated a 29% reduction in active smoking rates in staff in hospitals only (risk ratio (RR) 0.71, 95% confidence interval (CI) 0.64 to 0.78) and a 14% reduction for patients (RR 0.86, 95% CI 0.76 to 0.98)- extreme heterogeneity in pooled 11 studies. Reduced mortality rates associated with smoking-related illnesses after the introduction of a smoking ban were noted in prison settings, but inconsistent evidence exists supports an effect on reducing smoking rates (1 study, RR 0.99, 95% CI 0.84 to 1.16).
Smoking rates in prisons are 63 times higher than the general population 15 and despite successful policy implementation in some jurisdictions, smoking rates in prisons remain high, especially reported in low and middle-income countries. 16-18 Slow policy development in this specialist setting continues.
Despite the increasing number of countries with enacted legislation banning smoking in fulfilment of Article 8 of FCTC development remains unpredictable. 4,5,19 The difficulties in implementing smoke free policies in hospital settings continue to inform policy makers and practitioners. 3,20 Enforcing smoke free policies in hospital settings are critical to reducing the gap in the nexus of policy and practice to counter systemic inequity. We know that gender and ethnicity are associated with at least twice the all-cause mortality rate of never smoking; 21 therefore, the development of smoke free policies and systems-wide responses in specialist settings remain evermore critical.
References
1. Frazer K. Commentary on Wu et al.: Sustaining and advancing the global war on tobacco. Addiction. 2021 Aug;116(8):2185-6.
2. World Health Organization. The WHO framework convention on tobacco control: 10 years of implementation in the African region. World Health Organization; 2015. https://fctc.who.int/publications/m/item/the-who-framework-convention-on... [Accessed 8th October 2023]
3. Merritt JD, Yen PN, Thu-Anh N, Ngo CQ, Van Giap V, Nhung NV, Ha BT, Thuy MT, Anh NT, An NT, Marks GB. Smoking behaviour, tobacco sales and tobacco advertising at 40 ‘Smoke Free Hospitals’ in Vietnam. Tobacco Control. 2023 Sep 5.
4. World Health Organization (WHO). Factsheet. Tobacco. May 2020. Available at: https://www.who.int/news-room/fact-sheets/detail/tobacco (accessed October 2023).
5. Shibuya K, Ciecierski C, Guindon E, Bettcher DW, Evans DB, Murray CJ. WHO Framework Convention on Tobacco Control: development of an evidence based global public health treaty. Bmj. 2003 Jul 17;327(7407):154-7.Available from: http://www.ncbi.nlm.nih.gov/pubmed/12869461.
6. Marteau T. M., Rutter H., Marmot M. Changing behaviour: an essential component of tackling health inequalities. BMJ 2021; 372: n332. https://doi.org/10.1136/bmj.n332
7. Mattson A, Doherty K, Lyons A, Douglass A, Kerley M, Stynes S, Fitzpatrick P, Kelleher C. Evidence from a Smoking Management Service in a University Teaching Hospital in Dublin, Ireland monitored by repeat surveys, 1997-2022. Preventive Medicine Reports. 2023 Sep 13:102415. https://doi.org/10.1016/j.pmedr.2023.102415
8. Malone V, McLennan J, Hedger D. Smoke-free hospital grounds. Australian Health Review. 2020 Jan 20;44(3):405-9.
9. Fu M, Castellano Y, Feliu A, Saura J, Estrada J, Galimany-Masclans J, Moreno C, Fernández E, Martínez C. Compliance with the smoke-free policy in hospitals in Spain: the patients’ perspective. European Journal of Cancer Prevention. 2023 Jan 1;32(1):81-8.https://doi.org/10.1097/CEJ.0000000000000757
11. Hoffman SJ, Tan C. Overview of systematic reviews on the health-related effects of government tobacco control policies. BMC public health. 2015 Dec;15(1):1-1 https://doi.org/10.1186/s12889-015-2041-6
13. United Nations. The Sustainable Development Goals 2016. eSocialSciences; 2016 Nov.
14. Frazer K, McHugh J, Callinan JE, Kelleher C. Impact of institutional smoking bans on reducing harms and secondhand smoke exposure. Cochrane Database of Systematic Reviews. 2016(5).https://doi.org/10.1002/14651858.CD011856.pub2
15. Plugge E, Leclerc E. Smoking bans in prisons. The Lancet Public Health. 2021 Nov 1;6(11):e781-2.
16. Semple S, Dobson R, Sweeting H, Brown A, Hunt K. The impact of implementation of a national smoke-free prisons policy on indoor air quality: results from the Tobacco in Prisons study. Tobacco control. 2020 Mar 1;29(2):234-6.
17. Tweed EJ, Mackay DF, Boyd KA, Brown A, Byrne T, Conaglen P, Craig P, Demou E, Graham L, Leyland AH, McMeekin N. Evaluation of a national smoke-free prisons policy using medication dispensing: an interrupted time-series analysis. The Lancet Public Health. 2021 Nov 1;6(11):e795-804.
20. Lyons A, Bhardwaj N, Masalkhi M, Fox P, Frazer K, McCann A, Syed S, Niranjan V, Kelleher CC, Kavanagh P, Fitzpatrick P. Specialist cancer hospital-based smoking cessation service provision in Ireland. Irish Journal of Medical Science (1971-). 2023 Sep 23:1-0.
21. Thomson B, Emberson J, Lacey B, Lewington S, Peto R, Jemal A, Islami F. Association between smoking, smoking cessation, and mortality by race, ethnicity, and sex among US adults. JAMA Network Open. 2022 Oct 3;5(10):e2231480- doi: 10.1001/jamanetworkopen.2022.31480. PMID: 36279139; PMCID: PMC9593233.
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He et al cite (ref 43 in their paper) our meta-analysis of the association between e-cigarette use and smoking cessation [1} to support the statement, "[e-cigarettes] have demonstrated potential in recent years in helping smoking cessation." Quite the contrary, the abstract of this paper concludes, "As consumer products, in observational studies, e-cigarettes were not associated with increased smoking cessation in the adult population."
A subsequent meta-analysis [2] concluded the same thing.
Both these meta-analyses include the other paper (ref 44 in their paper) He et al cite to support their statement that e-cigarettes assist smoking cessation [3].
The authors need to accurately represent the literature and stop promoting the myth that e-cigarettes as consumer products increase cigarette smoking cessation. They also need to correct their paper to avoid perpetuating the literature.
REFERENCES
1. Wang RJ, Bhadriraju S, Glantz SA. E-cigarette use and adult cigarette smoking cessation: a meta-analysis. Am J Public Health 2021;111:230–46. doi:10.2105/AJPH.2020.305999
2. Hedman L, Galanti MR, Ryk L, et al. Electronic cigarette use and smoking cessation in cohort studies and randomized trials: a systematic review and meta-analysis.
Tob Prev Cessat 2021;7:62.
3. Zhuang Y-L, Cummins SE, Sun JY, et al . Long-term E-cigarette use and smoking cessation: a longitudinal study w...
NOT PEER REVIEWED
He et al cite (ref 43 in their paper) our meta-analysis of the association between e-cigarette use and smoking cessation [1} to support the statement, "[e-cigarettes] have demonstrated potential in recent years in helping smoking cessation." Quite the contrary, the abstract of this paper concludes, "As consumer products, in observational studies, e-cigarettes were not associated with increased smoking cessation in the adult population."
A subsequent meta-analysis [2] concluded the same thing.
Both these meta-analyses include the other paper (ref 44 in their paper) He et al cite to support their statement that e-cigarettes assist smoking cessation [3].
The authors need to accurately represent the literature and stop promoting the myth that e-cigarettes as consumer products increase cigarette smoking cessation. They also need to correct their paper to avoid perpetuating the literature.
REFERENCES
1. Wang RJ, Bhadriraju S, Glantz SA. E-cigarette use and adult cigarette smoking cessation: a meta-analysis. Am J Public Health 2021;111:230–46. doi:10.2105/AJPH.2020.305999
2. Hedman L, Galanti MR, Ryk L, et al. Electronic cigarette use and smoking cessation in cohort studies and randomized trials: a systematic review and meta-analysis.
Tob Prev Cessat 2021;7:62.
3. Zhuang Y-L, Cummins SE, Sun JY, et al . Long-term E-cigarette use and smoking cessation: a longitudinal study with US population. Tob Control 2016;25:i90–5. doi:10.1136/tobaccocontrol-2016-053096
Regarding the first two questions, the analyses were based on the public use data from both the PATH Study and the MCS, with links to their archives, and the PATH study sample was drawn from the original cohort, the replenishment cohort, and the shadow cohorts (see 1st and 2nd paragraphs of Methods Section). Regarding the remaining questions, please note that our stated goal was to make the MCS and PATH analytical samples as comparable as possible when testing our hypotheses using both cohorts (3rd paragraph of Methods section). As we note in the limitations section (5th paragraph of Discussion section), the MCS had relatively limited items on e-cigarette use and tobacco smoking compared to PATH. The MCS did not assess other combustible tobacco product consumption in early adolescence, nor did MCS measure the sequencing of early adolescent tobacco and e-cigarette use (noted in the limitation section). Also, MCS youth answered survey questions about ever using e-cigarettes from 2015 to 2016 (3rd paragraph of Methods section), which gave us limited variability to test for a wave x e-cigarette interaction in both datasets.
I respectfully request answers to the following questions:
1. Was public use or restricted PATH data used. This is important, since Table 2 contains a cell, n=7, that is not generally approved by NAHDAP.
2. Was the PATH cohort drawn from Waves 1 and 4, with follow-ups to age 17 years as needed from the other waves?
3. There were significant differences in youth smoking-vaping between Wave 1 (2013-14) and Wave 4 (2016-18) that might have affected the results. Was each wave analyzed separately as well as together?
4. The analysis included a variable relating to “parent(s) smoking of cigarettes, cigars, or pipes.” Did the analysis include other combustible tobacco product consumption by the subjects themselves?
5. Did the authors account for age at first smoking or vaping (public use, < 12 years and 12-14 years) or which product(s) had been used first?
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Pichon-Riviere et al concluded that the four tobacco control interventions analyzed could successfully avert deaths and disability and significantly ease the tobacco-attributable economic burden, but are not enough, as smoking remains a leading cause of health and economic burden in Latin America (1). According to the Global Burden of Disease Project (2), regardless of the relative decrease in tobacco prevalence in the last decades, age-standardized rates of deaths and DALYs for smoking-attributable diseases remain high in Latin America, a region hard hit by the epidemic (3). Unfortunately, in most of the countries in Latin America, there are other problems related to the main strategy to reduce tobacco consumption (i.e., taxation falls short of WHO recommendations) for example cigarettes remain affordable mainly due to the commercialization of illegal tobacco products and smuggled cigarettes, an important distractor for public health authorities, as the real number of users is hidden, access for younger people is easier and health risks are surely higher (4).
In addition, as in not all countries among our region there are available pharmacological alternatives to help current smokers, cessation strategies may be adapted for novel products, and treatment recommendations for tobacco use disorder should be made within the context of a harm reduction framework wherein alternative product use may be the desired outcome (5). Also, nicotine e‐cigare...
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Pichon-Riviere et al concluded that the four tobacco control interventions analyzed could successfully avert deaths and disability and significantly ease the tobacco-attributable economic burden, but are not enough, as smoking remains a leading cause of health and economic burden in Latin America (1). According to the Global Burden of Disease Project (2), regardless of the relative decrease in tobacco prevalence in the last decades, age-standardized rates of deaths and DALYs for smoking-attributable diseases remain high in Latin America, a region hard hit by the epidemic (3). Unfortunately, in most of the countries in Latin America, there are other problems related to the main strategy to reduce tobacco consumption (i.e., taxation falls short of WHO recommendations) for example cigarettes remain affordable mainly due to the commercialization of illegal tobacco products and smuggled cigarettes, an important distractor for public health authorities, as the real number of users is hidden, access for younger people is easier and health risks are surely higher (4).
In addition, as in not all countries among our region there are available pharmacological alternatives to help current smokers, cessation strategies may be adapted for novel products, and treatment recommendations for tobacco use disorder should be made within the context of a harm reduction framework wherein alternative product use may be the desired outcome (5). Also, nicotine e‐cigarettes probably do help people to stop smoking for at least six months. They probably work better than nicotine replacement therapy and nicotine‐free e‐cigarettes. They may work better than no support, or behavioral support alone, and they may not be associated with serious unwanted effects (6).
As member of the Latin-American Network for Tobacco Harm Reduction (www.reldat.org) we are actively working on reach the decision-makers to let them better understand the “harm reduction” concept for tobacco consumption, as it applies for other medical conditions.
1. Pichon-Riviere A, Bardach A, Rodríguez Cairoli F, et al. Tob Control Epub ahead of print: Health, economic and social burden of tobacco in Latin America and the expected gains of fully implementing taxes, plain packaging, advertising bans and smoke-free environments control measures: a modelling study. doi:10.1136/tc-2022-057618
2. He H, Pan Z, Wu J, et al. Health effects of tobacco at the global, regional, and national levels: results from the 2019 global burden of disease study. Nicotine & Tobacco Research 2022;24:864–70.
3. GBD. Tobacco collaborators. spatial, temporal, and demographic patterns in prevalence of smoking tobacco use and attributable disease burden in 204 countries and territories, 1990-2019: a systematic analysis from the global burden of disease study 2019. Lancet 2021;397:2337–60.
4. Ortiz-Prado E, Teran E, Cevallos-Sierra G, Villacres T, Alcivar C, Vasconez E. Anti-tobacco policy and the smuggled cigarettes, a hidden problem in Ecuador. J Public Health Emerg 2022;6:10.
5. Palmer AM, Toll BA, Carpenter MJ, et al. Reappraising Choice in Addiction: Novel Conceptualizations and Treatments for Tobacco Use Disorder. Nicotine Tob Res 2022;24(1):3-9
6. Hartmann-Boyce J, McRobbie H, Butler AR, Lindson N, Bullen C, Begh R, Theodoulou A, Notley C, Rigotti NA, Turner T, Fanshawe TR, Hajek P. Electronic cigarettes for smoking cessation. Cochrane Database of Systematic Reviews 2021, Issue 9. Art. No.: CD010216. DOI: 10.1002/14651858.CD010216.pub6. Accessed 10 May 2022.
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I read with interest the article "Global tobacco advertising, promotion, and sponsorship regulation: what’s old, what’s new, and where to next?[1]" published in Tobacco Control. As a psychiatrist specializing in addiction treatment at Taoyuan Psychiatric Center in Taiwan, I wish to share our institution's experience in implementing a successful smoke-free hospital program, which may serve as a model for other psychiatric centers.
Since 2014, Taoyuan Psychiatric Center has made significant progress in promoting a smoke-free environment through a comprehensive tobacco control program. Our program's objectives include creating a smoke-free hospital, increasing smoking cessation services for outpatients and inpatients, and improving patient smoking status documentation. Furthermore, we prioritize smoking cessation counseling for adolescents, pregnant women, and their families.
In psychiatric settings, smoking cessation is crucial as tobacco use can influence the blood concentration of psychotropic medications, potentially destabilizing psychiatric symptoms. Assisting patients in quitting smoking not only lowers the risk of tobacco-related diseases but also contributes to stabilizing their psychiatric conditions.
Our program encompasses various initiatives, including staff training, community tobacco harm prevention promotion, provision of second-generation smoking cessation treatments for outpatients and inpatien...
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I read with interest the article "Global tobacco advertising, promotion, and sponsorship regulation: what’s old, what’s new, and where to next?[1]" published in Tobacco Control. As a psychiatrist specializing in addiction treatment at Taoyuan Psychiatric Center in Taiwan, I wish to share our institution's experience in implementing a successful smoke-free hospital program, which may serve as a model for other psychiatric centers.
Since 2014, Taoyuan Psychiatric Center has made significant progress in promoting a smoke-free environment through a comprehensive tobacco control program. Our program's objectives include creating a smoke-free hospital, increasing smoking cessation services for outpatients and inpatients, and improving patient smoking status documentation. Furthermore, we prioritize smoking cessation counseling for adolescents, pregnant women, and their families.
In psychiatric settings, smoking cessation is crucial as tobacco use can influence the blood concentration of psychotropic medications, potentially destabilizing psychiatric symptoms. Assisting patients in quitting smoking not only lowers the risk of tobacco-related diseases but also contributes to stabilizing their psychiatric conditions.
Our program encompasses various initiatives, including staff training, community tobacco harm prevention promotion, provision of second-generation smoking cessation treatments for outpatients and inpatients with mental disorders, and organizing smoking cessation support groups and counseling. These efforts have led to a substantial increase in patients receiving smoking cessation services and a considerable decline in smoking rates among staff and patients.
In conclusion, Taoyuan Psychiatric Center's experience can serve as a valuable example for psychiatric institutions aiming to implement successful tobacco control programs. By addressing psychiatric patients' unique challenges, we can significantly impact their physical and mental well-being while contributing to global tobacco control efforts.
Sincerely,
Dr. LienChung Wei
Psychiatrist specializing in Addiction Treatment
Taoyuan Psychiatric Center, Taiwan
Reference:
[1] Freeman B, Watts C, Astuti PAS. Global tobacco advertising, promotion and sponsorship regulation: what’s old, what’s new and where to next? 2022;31(2):216-221.
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We acknowledge receipt of a private e-mail message from JLI regarding our paper (Yassine et al., 2022). Given the industry‘s long history of industry obfuscation, interference, and deception regarding research on tobacco products, we decided that the most transparent approach to the private e-mail that we received from an employee of a tobacco product manufacturer would be for us to report our results independently and respond to any public discussion of our work if and when it arose. Now that public discussion has arisen, we are pleased to respond to it.
We very recently analyzed the menthol and nicotine content of samples of liquid from six menthol flavor pods purchased in 2020. Three of these were liquids extracted from the pods in June 2021 for our paper and had been stored since in sealed amber glass containers at 5°C in the dark. The other three pods had been stored in their original sealed packages and were taken from the same batches as the pods analyzed in June 2021. These unopened packages were stored in the dark at room temperature over the intervening 18 months. The data from this small sample demonstrate a 24% reduction in menthol content over that period (12.01±0.46 vs 9.15±0.22 mg/ml), which helps to explain the results we reported (Yassine et al., 2022). We also found a 5% reduction in nicotine content (62.47±0.63 vs 59.52±0.49 mg/ml), as well as discoloration of the liquid in the pods that were stored at room temperatur...
NOT PEER REVIEWED
We acknowledge receipt of a private e-mail message from JLI regarding our paper (Yassine et al., 2022). Given the industry‘s long history of industry obfuscation, interference, and deception regarding research on tobacco products, we decided that the most transparent approach to the private e-mail that we received from an employee of a tobacco product manufacturer would be for us to report our results independently and respond to any public discussion of our work if and when it arose. Now that public discussion has arisen, we are pleased to respond to it.
We very recently analyzed the menthol and nicotine content of samples of liquid from six menthol flavor pods purchased in 2020. Three of these were liquids extracted from the pods in June 2021 for our paper and had been stored since in sealed amber glass containers at 5°C in the dark. The other three pods had been stored in their original sealed packages and were taken from the same batches as the pods analyzed in June 2021. These unopened packages were stored in the dark at room temperature over the intervening 18 months. The data from this small sample demonstrate a 24% reduction in menthol content over that period (12.01±0.46 vs 9.15±0.22 mg/ml), which helps to explain the results we reported (Yassine et al., 2022). We also found a 5% reduction in nicotine content (62.47±0.63 vs 59.52±0.49 mg/ml), as well as discoloration of the liquid in the pods that were stored at room temperature that suggests the possibility of other time-dependent changes in liquid constituents that we have not had an opportunity to evaluate comprehensively.
We acknowledge that the differences in menthol concentrations in JUUL products that were purchased across a three-year period, reported in Yassine et al., 2022, are consistent with changes in product composition that can occur during storage. A correction to the manuscript is now being published.
Our findings highlight that tobacco product manufacturers should be required to release to the public and the scientific community everything they know about their products, including product ingredients, abuse liability, potential adverse health consequences, and time- and temperature-dependent degradation of quality. For example, much of this information may be available in Premarket Tobacco Product Applications submitted to the Food and Drug Administration’s Center for Tobacco Products, and thus could be shared easily on each company’s website. This vital information should be available to all. In the meantime, our original article (Yassine et al., 2022), the industry response (Gillman, 2022), and this reply provide needed archival documentation for the scientific record.
References
Yassine A, El Hage R, El-Hellani A, Salman R, Talih S, Eissenberg T, Shihadeh A, Saliba N. Did JUUL alter the content of menthol pods in response to US FDA flavour enforcement policy? Tob Control. 2022 Nov;31(Suppl 3):s234-s237. doi: 10.1136/tc-2022-057506. PMID: 36328458; PMCID: PMC9641543.
Clive Bates’ commentary on our paper repeats claims we previously addressed [1]. Here, we address seven points, the first is contextual and the remaining are raised in his letter.
1. We note the failure of the author to acknowledge Māori perspectives, in particular their support for endgame measures, concerns in relation to harm minimisation [2] as outlined in his “all in” strategy, and ethical publishing of research about Indigenous peoples. [3]
2. We reject the assertion that the basis of our modelling is “weak”. While there is uncertainty around the potential effect of denicotinisation, as this policy hasn’t been implemented, there are strong grounds to believe that it will have a profound impact on reducing smoking prevalence. This is based on both theory and logic (i.e., nicotine is the main addictive component of cigarettes and why most people smoke), and the findings of multiple randomized controlled trials (RCTs) showing that smoking very low nicotine cigarettes (VLNCs) increases cessation rates for diverse populations of people who smoke [4-7].
Our model’s estimated effect on smoking prevalence had wide uncertainty, namely a median of 85.9% reduction over 5 years with a 95% uncertainty interval of 67.1% to 96.3% that produced (appropriately) wide uncertainty in the health impacts. The derivation of this input parameter through expert knowledge elicitation (EKE) is described in the Appendix of our paper. Univariate se...
Clive Bates’ commentary on our paper repeats claims we previously addressed [1]. Here, we address seven points, the first is contextual and the remaining are raised in his letter.
1. We note the failure of the author to acknowledge Māori perspectives, in particular their support for endgame measures, concerns in relation to harm minimisation [2] as outlined in his “all in” strategy, and ethical publishing of research about Indigenous peoples. [3]
2. We reject the assertion that the basis of our modelling is “weak”. While there is uncertainty around the potential effect of denicotinisation, as this policy hasn’t been implemented, there are strong grounds to believe that it will have a profound impact on reducing smoking prevalence. This is based on both theory and logic (i.e., nicotine is the main addictive component of cigarettes and why most people smoke), and the findings of multiple randomized controlled trials (RCTs) showing that smoking very low nicotine cigarettes (VLNCs) increases cessation rates for diverse populations of people who smoke [4-7].
Our model’s estimated effect on smoking prevalence had wide uncertainty, namely a median of 85.9% reduction over 5 years with a 95% uncertainty interval of 67.1% to 96.3% that produced (appropriately) wide uncertainty in the health impacts. The derivation of this input parameter through expert knowledge elicitation (EKE) is described in the Appendix of our paper. Univariate sensitivity analyses comparing the 67.1% and 96.3% estimates (all other input parameters held at their median value) produced HALY gains ranging from 545,000 to 653,000. Our paper presents this uncertainty transparently.
3. The assertion that the effect size estimate of denicotinisation is based on one randomized trial is incorrect. The author has been informed that this assertion is false on several occasions but even so continues to repeat this claim. We used an EKE process, which is described in the Appendix of our paper. The experts considered many ‘inputs’ to their estimation, of which just one was the evidence from the multiple existing RCTs.
4. We disagree with the author’s characterisation of the EKE process as “arbitrary guesswork”. As Bates himself has noted, expert judgement can provide valuable insight in situations of uncertainty and can “provide a risk-perception ‘anchor’ … following assessment of the evidence that exists.” [8] We believe that ≥ 5 RCTs demonstrating a relationship between VLNCs and increased smoking cessation constitute a reasonable evidence base to draw upon, particularly when supported by theory/logic and other lines of evidence.[9]
Policy-making often occurs in a context of uncertainty. Denicotinisation is one such example, as we will not know its ‘real world’ impact until it has been implemented. To inform that policy making, it is astute to have estimates of the likely health impact – which requires EKE. Over time, as evidence accrues, such modelling should be updated.
5. As stated in our paper, we did not explicitly model an illicit market. Tight border security in an island nation with no land borders within 1,000 km, reduces the potential of a significant illicit tobacco market. Furthermore, the Aotearoa/New Zealand (A/NZ) Government announced new measures against tobacco smuggling in preparation for the introduction of its ‘endgame’ legislation. [10] The impact of an illicit tobacco market may be greater in other countries. In A/NZ, the illicit market is small (around 5-6% max) and has not increased greatly despite 10 years of above inflation tobacco excise increases and the introduction of plain packs – interventions which the tobacco industry routinely claims will result in an explosion in the illicit market. This suggests enforcement measures work well in the A/NZ context. Furthermore, given the widespread availability and use by people who smoke of nicotine-containing vaping products in A/NZ, seeking to replace VLNCs with illicit cigarettes is likely to be significantly less common than in jurisdictions where vaping products are not available.
6. It is possible – as Bates asserts – that we have overestimated the health gains from denicotinisation and other endgame policies because the smoking prevalence since 2020, appears to be falling more rapidly than we modelled (meaning the ‘room’ for health gains from an endgame policy is less). We discussed this in our paper.
7. Discussing the public health philosophy of denicotinisation was beyond the scope of our paper. Our focus was only on evaluating the potential health and equity impacts of four interventions included the A/NZ Smoke-free Action Plan 2025.
[2] Waa A, Robson B, Gifford H, Smylie J, Reading J, Henderson JA, Henderson PN, Maddox R, Lovett R, Eades S, Finlay S. Foundation for a smoke-free world and healthy Indigenous futures: an oxymoron?. Tobacco Control. 2020 Mar 1;29(2):237-40.
[3] Maddox R, Drummond A, Kennedy M, et al. Ethical publishing in ‘Indigenous’ contextsTobacco Control Published Online First: 13 February 2023. doi: 10.1136/tc-2022-057702
[4] Donny EC, Denlinger RL, Tidey JW, Koopmeiners JS, Benowitz NL, Vandrey RG, Al’Absi M, Carmella SG, Cinciripini PM, Dermody SS, Drobes DJ. Randomized trial of reduced-nicotine standards for cigarettes. New England Journal of Medicine. 2015 Oct 1;373(14):1340-9.
[5] Smith TT, Koopmeiners JS, Tessier KM, Davis EM, Conklin CA, Denlinger-Apte RL, Lane T, Murphy SE, Tidey JW, Hatsukami DK, Donny EC. Randomized trial of low-nicotine cigarettes and transdermal nicotine. American journal of preventive medicine. 2019 Oct 1;57(4):515-24.
[6] Walker N, Howe C, Bullen C, Grigg M, Glover M, McRobbie H, Laugesen M, Parag V, Whittaker R. The combined effect of very low nicotine content cigarettes, used as an adjunct to usual Quitline care (nicotine replacement therapy and behavioural support), on smoking cessation: a randomized controlled trial. Addiction. 2012 Oct;107(10):1857-67.
[7] Higgins ST, Tidey JW, Sigmon SC, Heil SH, Gaalema DE, Lee D, Hughes JR, Villanti AC, Bunn JY, Davis DR, Bergeria CL. Changes in cigarette consumption with reduced nicotine content cigarettes among smokers with psychiatric conditions or socioeconomic disadvantage: 3 randomized clinical trials. JAMA network open. 2020 Oct 1;3(10):e2019311-.
I am writing in response to the article "Smoke-free law compliance and predictive factors in Ethiopia: observational assessment of public places and workplaces" published in Tobacco Control. As a psychiatrist from Taiwan, I would like to commend the authors for shedding light on the low compliance rates of smoke-free laws in public places and workplaces in Ethiopia.
The study's findings highlight the urgent need to strengthen smoke-free laws and promote compliance to reduce tobacco use and its related health consequences. As a country that has implemented comprehensive smoke-free laws for over a decade, Taiwan has faced similar challenges in enforcing the ban in indoor environments. However, our government has taken various measures to address non-compliance, including increasing penalties and expanding the scope of smoke-free areas.
In addition to government efforts, collaboration between businesses, civil society organizations, and public health advocates is crucial in promoting compliance and a smoke-free culture. The Ethiopian government and civil society can learn from our experiences in Taiwan and other countries that have successfully implemented smoke-free laws.
The study's findings provide a valuable framework for policymakers and public health advocates to address the challenges of enforcement and promote a smoke-free culture. I urge the Ethiopian government and civil society to work together to im...
I am writing in response to the article "Smoke-free law compliance and predictive factors in Ethiopia: observational assessment of public places and workplaces" published in Tobacco Control. As a psychiatrist from Taiwan, I would like to commend the authors for shedding light on the low compliance rates of smoke-free laws in public places and workplaces in Ethiopia.
The study's findings highlight the urgent need to strengthen smoke-free laws and promote compliance to reduce tobacco use and its related health consequences. As a country that has implemented comprehensive smoke-free laws for over a decade, Taiwan has faced similar challenges in enforcing the ban in indoor environments. However, our government has taken various measures to address non-compliance, including increasing penalties and expanding the scope of smoke-free areas.
In addition to government efforts, collaboration between businesses, civil society organizations, and public health advocates is crucial in promoting compliance and a smoke-free culture. The Ethiopian government and civil society can learn from our experiences in Taiwan and other countries that have successfully implemented smoke-free laws.
The study's findings provide a valuable framework for policymakers and public health advocates to address the challenges of enforcement and promote a smoke-free culture. I urge the Ethiopian government and civil society to work together to implement and enforce smoke-free laws to protect the health of their citizens.
In conclusion, the study's findings are crucial in highlighting the need for improved compliance rates of smoke-free laws in Ethiopia and other countries. Strengthening smoke-free laws and promoting compliance is vital in reducing the burden of tobacco use on public health.
Sincerely,
Lien-Chung Wei, M.P.H.
Department of Addiction Psychiatry,
Republic of China Ministry of Health and Welfare,
Taiwan.
I have published a summary critique of this modelling exercise on PubPeer. [1] This summarises concerns raised in post-publication reviews of this paper while it was in pre-print form by experts from New Zealand and Canada, and me. [2][3]
By way of a brief summary:
1. All the important modelled findings flow from a single assumption that denicotinisation will reduce smoking prevalence by 85% over five years. Yet the basis for this assumption is weak and disconnected from the reality of the market system being modelled.
2. The central assumption is based partly on a smoking cessation trial that bears no relation to the market and regulatory intervention that is the subject of the simulation. Even so, the trial findings do not support the modelling assumption.
3. The central assumption also draws on expert elicitation. Yet, there is no experience with this measure as it would be novel, and there is no relevant expertise in this sort of intervention. Where experts have been asked to assess the impacts, their views diverge widely, suggesting that their estimates are mainly arbitrary guesswork.
4. The authors have only modelled benefits and have not included anything that might be a detriment or create a trade-off. The modelling takes no account of the black market or workarounds. These are inevitable consequences of such 'endgame' prohibitions, albeit of uncertain size. Though it may be challenging to mo...
I have published a summary critique of this modelling exercise on PubPeer. [1] This summarises concerns raised in post-publication reviews of this paper while it was in pre-print form by experts from New Zealand and Canada, and me. [2][3]
By way of a brief summary:
1. All the important modelled findings flow from a single assumption that denicotinisation will reduce smoking prevalence by 85% over five years. Yet the basis for this assumption is weak and disconnected from the reality of the market system being modelled.
2. The central assumption is based partly on a smoking cessation trial that bears no relation to the market and regulatory intervention that is the subject of the simulation. Even so, the trial findings do not support the modelling assumption.
3. The central assumption also draws on expert elicitation. Yet, there is no experience with this measure as it would be novel, and there is no relevant expertise in this sort of intervention. Where experts have been asked to assess the impacts, their views diverge widely, suggesting that their estimates are mainly arbitrary guesswork.
4. The authors have only modelled benefits and have not included anything that might be a detriment or create a trade-off. The modelling takes no account of the black market or workarounds. These are inevitable consequences of such 'endgame' prohibitions, albeit of uncertain size. Though it may be challenging to model, the simulation does not account for the negative behavioural or perceptual impacts of trying to force people to quit or switch by using the law to remove their regular cigarettes. It should not be assumed that these are zero or immaterial to policy assessment.
5. The real-world progress in reducing smoking in New Zealand through tobacco harm reduction and the rise of vaping has been rapid and highly positive, outpacing both the business-as-usual baseline assumptions in the modelling and the impact of the intervention. This suggests the modelled benefits are greatly overstated.
6. The denicotinisation policy should not be compared to a flawed and inflated hypothetical business-as-usual baseline but to an alternative policy that embraces a different public health philosophy. The denicotinisation measure uses the power of the law to try to force behaviour change onto smokers by removing their regular cigarettes from the market. This may be effective, but it also carries risks of black market activity and a public or political backlash once the consequences are understood by those affected. The alternative would position the state as an enabler, maximising support, encouragement and incentives to switch to smoke-free alternatives or quit. This is not business as usual but would mean going “all in” on tobacco harm reduction, with the goal of reducing smoking as rapidly as possible but without resorting to using the coercive power of the law. Such a policy may prove effective but also have lower risks and be less susceptible to unintended consequences.
[2] Bates, C., Youdan, B., Bonita, R., Laking, G., Sweanor, D., Beaglehole, R. (2022). Review of: “Tobacco endgame intervention impacts on health gains and Māori:non-Māori health inequity: a simulation study of the Aotearoa-New Zealand Tobacco Action Plan.” Qeios. https://doi.org/10.32388/8WXH0J
[3] Bates, C., Youdan, B., Bonita, R., Sweanor, D., & Beaglehole, R. (2022). Review of: “The case for denicotinising tobacco in Aotearoa NZ remains strong: response to online critique.” Qeios. https://doi.org/10.32388/ZZAUQM
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Despite 20 years of sustained engagement and reductions in smoking prevalence rates globally, smoke free policy implementation remains inconsistently applied in low- and middle-income countries where there are high smoking prevalence rates and where >80% of the 1.3 billion smokers reside.1-2 Merrit’s study3 is a stark reminder that despite the forward steps of the Framework Convention on Tobacco Control,2,4-5 variations in achieving smoke free policies in specialist settings persist. Acknowledged challenges in implementing smoke free hospital policies include a lack of data, inadequate reporting, and reduced prioritisation of tobacco control at governmental level.1,3 The lack of an intersectional lens and co development with communities continues with policy development. 6
Inconsistencies in application of smoke free policies are balanced by reporting of positive implementations demonstrating improvements in some hospital systems evidenced by reductions in smoking rates and improved access to smoking cessation services underpinned by longitudinal data. 7-9
Previously, Chan 10 indicated that ‘tobacco use … threatens development in every country on every level and across many sectors — economic growth, health, education, poverty and the environment — with women and children bearing the brunt of the consequences’, - this continues today intensifying the impact of the social, structural and commercial determinants of health and n...
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He et al cite (ref 43 in their paper) our meta-analysis of the association between e-cigarette use and smoking cessation [1} to support the statement, "[e-cigarettes] have demonstrated potential in recent years in helping smoking cessation." Quite the contrary, the abstract of this paper concludes, "As consumer products, in observational studies, e-cigarettes were not associated with increased smoking cessation in the adult population."
A subsequent meta-analysis [2] concluded the same thing.
Both these meta-analyses include the other paper (ref 44 in their paper) He et al cite to support their statement that e-cigarettes assist smoking cessation [3].
The authors need to accurately represent the literature and stop promoting the myth that e-cigarettes as consumer products increase cigarette smoking cessation. They also need to correct their paper to avoid perpetuating the literature.
REFERENCES
1. Wang RJ, Bhadriraju S, Glantz SA. E-cigarette use and adult cigarette smoking cessation: a meta-analysis. Am J Public Health 2021;111:230–46. doi:10.2105/AJPH.2020.305999
2. Hedman L, Galanti MR, Ryk L, et al. Electronic cigarette use and smoking cessation in cohort studies and randomized trials: a systematic review and meta-analysis.
Tob Prev Cessat 2021;7:62.
3. Zhuang Y-L, Cummins SE, Sun JY, et al . Long-term E-cigarette use and smoking cessation: a longitudinal study w...
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Regarding the first two questions, the analyses were based on the public use data from both the PATH Study and the MCS, with links to their archives, and the PATH study sample was drawn from the original cohort, the replenishment cohort, and the shadow cohorts (see 1st and 2nd paragraphs of Methods Section). Regarding the remaining questions, please note that our stated goal was to make the MCS and PATH analytical samples as comparable as possible when testing our hypotheses using both cohorts (3rd paragraph of Methods section). As we note in the limitations section (5th paragraph of Discussion section), the MCS had relatively limited items on e-cigarette use and tobacco smoking compared to PATH. The MCS did not assess other combustible tobacco product consumption in early adolescence, nor did MCS measure the sequencing of early adolescent tobacco and e-cigarette use (noted in the limitation section). Also, MCS youth answered survey questions about ever using e-cigarettes from 2015 to 2016 (3rd paragraph of Methods section), which gave us limited variability to test for a wave x e-cigarette interaction in both datasets.
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I respectfully request answers to the following questions:
1. Was public use or restricted PATH data used. This is important, since Table 2 contains a cell, n=7, that is not generally approved by NAHDAP.
2. Was the PATH cohort drawn from Waves 1 and 4, with follow-ups to age 17 years as needed from the other waves?
3. There were significant differences in youth smoking-vaping between Wave 1 (2013-14) and Wave 4 (2016-18) that might have affected the results. Was each wave analyzed separately as well as together?
4. The analysis included a variable relating to “parent(s) smoking of cigarettes, cigars, or pipes.” Did the analysis include other combustible tobacco product consumption by the subjects themselves?
5. Did the authors account for age at first smoking or vaping (public use, < 12 years and 12-14 years) or which product(s) had been used first?
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Show MorePichon-Riviere et al concluded that the four tobacco control interventions analyzed could successfully avert deaths and disability and significantly ease the tobacco-attributable economic burden, but are not enough, as smoking remains a leading cause of health and economic burden in Latin America (1). According to the Global Burden of Disease Project (2), regardless of the relative decrease in tobacco prevalence in the last decades, age-standardized rates of deaths and DALYs for smoking-attributable diseases remain high in Latin America, a region hard hit by the epidemic (3). Unfortunately, in most of the countries in Latin America, there are other problems related to the main strategy to reduce tobacco consumption (i.e., taxation falls short of WHO recommendations) for example cigarettes remain affordable mainly due to the commercialization of illegal tobacco products and smuggled cigarettes, an important distractor for public health authorities, as the real number of users is hidden, access for younger people is easier and health risks are surely higher (4).
In addition, as in not all countries among our region there are available pharmacological alternatives to help current smokers, cessation strategies may be adapted for novel products, and treatment recommendations for tobacco use disorder should be made within the context of a harm reduction framework wherein alternative product use may be the desired outcome (5). Also, nicotine e‐cigare...
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I read with interest the article "Global tobacco advertising, promotion, and sponsorship regulation: what’s old, what’s new, and where to next?[1]" published in Tobacco Control. As a psychiatrist specializing in addiction treatment at Taoyuan Psychiatric Center in Taiwan, I wish to share our institution's experience in implementing a successful smoke-free hospital program, which may serve as a model for other psychiatric centers.
Since 2014, Taoyuan Psychiatric Center has made significant progress in promoting a smoke-free environment through a comprehensive tobacco control program. Our program's objectives include creating a smoke-free hospital, increasing smoking cessation services for outpatients and inpatients, and improving patient smoking status documentation. Furthermore, we prioritize smoking cessation counseling for adolescents, pregnant women, and their families.
In psychiatric settings, smoking cessation is crucial as tobacco use can influence the blood concentration of psychotropic medications, potentially destabilizing psychiatric symptoms. Assisting patients in quitting smoking not only lowers the risk of tobacco-related diseases but also contributes to stabilizing their psychiatric conditions.
Our program encompasses various initiatives, including staff training, community tobacco harm prevention promotion, provision of second-generation smoking cessation treatments for outpatients and inpatien...
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We acknowledge receipt of a private e-mail message from JLI regarding our paper (Yassine et al., 2022). Given the industry‘s long history of industry obfuscation, interference, and deception regarding research on tobacco products, we decided that the most transparent approach to the private e-mail that we received from an employee of a tobacco product manufacturer would be for us to report our results independently and respond to any public discussion of our work if and when it arose. Now that public discussion has arisen, we are pleased to respond to it.
We very recently analyzed the menthol and nicotine content of samples of liquid from six menthol flavor pods purchased in 2020. Three of these were liquids extracted from the pods in June 2021 for our paper and had been stored since in sealed amber glass containers at 5°C in the dark. The other three pods had been stored in their original sealed packages and were taken from the same batches as the pods analyzed in June 2021. These unopened packages were stored in the dark at room temperature over the intervening 18 months. The data from this small sample demonstrate a 24% reduction in menthol content over that period (12.01±0.46 vs 9.15±0.22 mg/ml), which helps to explain the results we reported (Yassine et al., 2022). We also found a 5% reduction in nicotine content (62.47±0.63 vs 59.52±0.49 mg/ml), as well as discoloration of the liquid in the pods that were stored at room temperatur...
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Clive Bates’ commentary on our paper repeats claims we previously addressed [1]. Here, we address seven points, the first is contextual and the remaining are raised in his letter.
1. We note the failure of the author to acknowledge Māori perspectives, in particular their support for endgame measures, concerns in relation to harm minimisation [2] as outlined in his “all in” strategy, and ethical publishing of research about Indigenous peoples. [3]
2. We reject the assertion that the basis of our modelling is “weak”. While there is uncertainty around the potential effect of denicotinisation, as this policy hasn’t been implemented, there are strong grounds to believe that it will have a profound impact on reducing smoking prevalence. This is based on both theory and logic (i.e., nicotine is the main addictive component of cigarettes and why most people smoke), and the findings of multiple randomized controlled trials (RCTs) showing that smoking very low nicotine cigarettes (VLNCs) increases cessation rates for diverse populations of people who smoke [4-7].
Our model’s estimated effect on smoking prevalence had wide uncertainty, namely a median of 85.9% reduction over 5 years with a 95% uncertainty interval of 67.1% to 96.3% that produced (appropriately) wide uncertainty in the health impacts. The derivation of this input parameter through expert knowledge elicitation (EKE) is described in the Appendix of our paper. Univariate se...
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I am writing in response to the article "Smoke-free law compliance and predictive factors in Ethiopia: observational assessment of public places and workplaces" published in Tobacco Control. As a psychiatrist from Taiwan, I would like to commend the authors for shedding light on the low compliance rates of smoke-free laws in public places and workplaces in Ethiopia.
The study's findings highlight the urgent need to strengthen smoke-free laws and promote compliance to reduce tobacco use and its related health consequences. As a country that has implemented comprehensive smoke-free laws for over a decade, Taiwan has faced similar challenges in enforcing the ban in indoor environments. However, our government has taken various measures to address non-compliance, including increasing penalties and expanding the scope of smoke-free areas.
In addition to government efforts, collaboration between businesses, civil society organizations, and public health advocates is crucial in promoting compliance and a smoke-free culture. The Ethiopian government and civil society can learn from our experiences in Taiwan and other countries that have successfully implemented smoke-free laws.
The study's findings provide a valuable framework for policymakers and public health advocates to address the challenges of enforcement and promote a smoke-free culture. I urge the Ethiopian government and civil society to work together to im...
Show MoreNOT PEER REVIEWED
I have published a summary critique of this modelling exercise on PubPeer. [1] This summarises concerns raised in post-publication reviews of this paper while it was in pre-print form by experts from New Zealand and Canada, and me. [2][3]
By way of a brief summary:
1. All the important modelled findings flow from a single assumption that denicotinisation will reduce smoking prevalence by 85% over five years. Yet the basis for this assumption is weak and disconnected from the reality of the market system being modelled.
2. The central assumption is based partly on a smoking cessation trial that bears no relation to the market and regulatory intervention that is the subject of the simulation. Even so, the trial findings do not support the modelling assumption.
3. The central assumption also draws on expert elicitation. Yet, there is no experience with this measure as it would be novel, and there is no relevant expertise in this sort of intervention. Where experts have been asked to assess the impacts, their views diverge widely, suggesting that their estimates are mainly arbitrary guesswork.
4. The authors have only modelled benefits and have not included anything that might be a detriment or create a trade-off. The modelling takes no account of the black market or workarounds. These are inevitable consequences of such 'endgame' prohibitions, albeit of uncertain size. Though it may be challenging to mo...
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