Global impact of tobacco control policies on smokeless tobacco use: A systematic review protocol

Introduction Smokeless tobacco (ST) was consumed by 356 million people globally in 2017. Recent evidence shows that ST consumption is responsible for an estimated 652 494 all-cause deaths across the globe annually. The WHO Framework Convention on Tobacco Control (FCTC) was negotiated in 2003 and ratified in 2005 to implement effective tobacco control measures. While the policy measures enacted through various tobacco control laws have been effective in reducing the incidence and prevalence of smoking, the impact of ST-related policies (within WHO FCTC and beyond) on ST use is under-researched and not collated. Methods and analysis A systematic review will be conducted to collate all available ST-related policies implemented across various countries and assess their impact on ST use. The following databases will be searched: Medline, EMBASE, PsycINFO, Cumulative Index to Nursing and Allied Health Literature, Scopus, EconLit, ISI Web of Science, Cochrane Library (CENTRAL), African Index Medicus, LILACS, Scientific Electronic Library Online, Index Medicus for the Eastern Mediterranean Region, Index Medicus for South-East Asia Region, Western Pacific Region Index Medicus and WHO Library Database, as well as Google search engine and country-specific government websites. All ST-related policy documents (FCTC and non-FCTC) will be included. Results will be limited to literature published since 2005 in English and regional languages (Bengali, Hindi and Urdu). Two reviewers will independently employ two-stage screening to determine inclusion. The Effective Public Health Practice Project's 'Quality Assessment Tool for Quantitative Studies' will be used to record ratings of quality and risk of bias among studies selected for inclusion. Data will be extracted using a standardised form. Meta-analysis and narrative synthesis will be used. Ethics and dissemination Permission for ethics exemption of the review was obtained from the Centre for Chronic Disease Control's Institutional Ethics Committee, India (CCDC-IEC-06-2020; dated 16 April 2020). The results will be disseminated through publications in a peer-reviewed journal and will be presented in national and international conferences. PROSPERO registration number CRD42020191946. **Please note that there are multiple authors for this article therefore only the name of the first 5 including Federation University Australia affiliate “Muhammad Aziz Rahman” is provided in this record*

Understanding the dynamics of notification and implementation of Article 5.3 across India's states and union territories

INTRODUCTION: In federal systems, state and local governments may offer opportunities for innovation in implementing the WHO Framework Convention on Tobacco Control (FCTC). This paper explores the implementation of WHO FCTC Article 5.3 within India’s federal system, examining how its guidelines have been operationalised across states and union territories. METHODS: Interviews with officials from government and civil society organisations across key states, and a document review of state government and district administration notifications adopting Article 5.3 guidelines between 2015 and 2019. RESULTS: The data reveal subnational leadership in formulating intersectoral committees, which are designed to limit interactions with the tobacco industry, and corresponding measures to reject partnership and conflicts of interest for government officials. There are notable omissions across states and union territories in adoption of key Article 5.3 guidelines; only four districts and state governments refer to regulating aspects of ‘socially responsible’ industry activities, and no notifications include measures to prevent the tobacco industry receiving preferential treatment or requiring that information provided by industry actors be transparent and accountable. Interview data indicate that dynamics of notification across states have been shaped by lesson drawing and the catalytic role of civil society. The adoption of protocols is impacting on the practices of health officials, but there are concerns about engagement by other departments and the regulatory capacity of empowered committees. CONCLUSION: The spread of state- and district-level policies illustrates opportunities federal structures can provide for accelerating tobacco control. Given significant omissions and policy tensions, there remains a need for national action to build on these innovations, including in revisions to India’s tobacco control legislation

Advancing whole-of-government approaches to tobacco control:Article 5.3 and the challenge of policy coordination in Bangladesh, Ethiopia, India and Uganda

INTRODUCTION: Despite an extensive evidence base on the diverse economic, environmental and social benefits of tobacco control, difficulties in establishing coordinated national approaches remain a defining challenge for Framework Convention on Tobacco Control (FCTC) implementation. Minimising tobacco industry interference is seen as key to effective coordination, and this paper analyses implementation of Article 5.3 guidelines, exploring implications for whole-of-government approaches to tobacco control in Bangladesh, Ethiopia, India and Uganda. METHODS: Based on 131 semistructured interviews with government officials and other key stakeholders, we explore barriers and facilitators for promoting: (1) horizontal coordination across health and other policy spheres, and (2) vertical coordination across national and subnational governments on Article 5.3 implementation. RESULTS: Our analysis identifies common barriers to coordination across diverse geographical contexts and varying approaches to implementation. They highlight broadly shared experiences of limited understanding and engagement beyond health agencies; restricted responsibility and uncertainty amid conflicting mandates; tensions with wider governance practices and norms; limited capacity and authority of coordination mechanisms; and obstacles to vertical coordination across local, state and national governments. Interview data also indicate important opportunities to advance coordination across sectors and government levels, with Article 5.3 measures capable of informing changes in practices, building support in other sectors, allowing for ‘bottom-up’ innovation and being shaped by engagement with civil society. CONCLUSION: Supporting effective implementation of Article 5.3 is key to advancing multisectoral approaches to FCTC implementation and tobacco control’s contributions to global health and sustainable development

Last Mile Delivery of Cold Chain Medicines – Challenges and Recommendations

Cold chain medicines are those that require special temperature-controlled cold storage to maintain their quality and efficacy. Cold chain management is important to ensure that the right quality is maintained throughout the supply chain. There lies a variety of reasons why cold chain management continues to be the challenge in India like lack of the consolidated list of cold chain medicines, lack of standard refrigeration guidelines for retail pharmacies, non-uniformity in storage temperature instructions on the label, patient education and lack of awareness. The study aims to identify the challenges faced in the last mile delivery of such medicines in India and suggest practical recommendations for improvement that confirms the international best practices. More than 100 interviews were conducted with healthcare professionals like doctors, pharmacists, retail pharmacy experts, logistic partners, distributors and ex-regulators to understand the storage conditions and the possible solutions, especially at retail and customer level. An exhaustive list of cold chain medicines was framed with the databases of Indian hospitals, local drug distributors and drug retailers. Given the complexity of cold chain system in India, the guidelines for maintaining and managing the cold chain should be clearly available and then be mandatorily followed, in order to avoid the deleterious effects on such medicines due to storage and handling issues as elaborated in this study

Impact of tobacco price and taxation on affordability and consumption of tobacco products in the Southeast Asia Region : a systematic review

Introduction: The objective of the review was to study the impact of tobacco taxes or prices on affordability and/or consumption of tobacco products in WHO-South East Asia Region (SEAR) countries, overall, and by socioeconomic status; and change in consumption of one tobacco product for a given change in price/tax on other tobacco product. Methods: The searches were run on five databases (Medline, Embase, Cinahl, EconLit, Tobacconomics) using keywords such as ‘tobacco’, ‘tax’, ‘price’, ‘impact’ with their synonyms. Additionally, first 100 articles through google search and e-reports from targeted sources were also reviewed. Studies illustrating the impact of prices/taxes on consumption/affordability of tobacco products in SEAR, available in English language, with no limitation on time were included in the review. After two steps of screening, data from 28 studies were extracted using a structured, and pre-tested data extraction form. Results: Out of the total twenty-eight studies, twelve studies reported an inverse association between price and consumption/affordability while 11 studies reported no or positive association between price and consumption/affordability of tobacco products. Five studies had unclear interpretations. Majority of studies estimated that the less affluent group were more price responsive as compared to the more affluent group. Some studies indicated increased consumption of one product in response to price rise of other product, although, the findings were inconsistent. Conclusions: The findings of our review support the use of tobacco tax and price measures as effective tools to address the tobacco epidemic. Our findings however also emphasise the importance of increasing tobacco product taxes and prices sufficiently to outweigh the effects of income growth, in order for the measures to be effective in reducing the affordability and consumption of tobacco products

Global impact of tobacco control policies on smokeless tobacco use : A systematic review protocol

Introduction Smokeless tobacco (ST) was consumed by 356 million people globally in 2017. Recent evidence shows that ST consumption is responsible for an estimated 652 494 all-cause deaths across the globe annually. The WHO Framework Convention on Tobacco Control (FCTC) was negotiated in 2003 and ratified in 2005 to implement effective tobacco control measures. While the policy measures enacted through various tobacco control laws have been effective in reducing the incidence and prevalence of smoking, the impact of ST-related policies (within WHO FCTC and beyond) on ST use is under-researched and not collated. Methods and analysis A systematic review will be conducted to collate all available ST-related policies implemented across various countries and assess their impact on ST use. The following databases will be searched: Medline, EMBASE, PsycINFO, Cumulative Index to Nursing and Allied Health Literature, Scopus, EconLit, ISI Web of Science, Cochrane Library (CENTRAL), African Index Medicus, LILACS, Scientific Electronic Library Online, Index Medicus for the Eastern Mediterranean Region, Index Medicus for South-East Asia Region, Western Pacific Region Index Medicus and WHO Library Database, as well as Google search engine and country-specific government websites. All ST-related policy documents (FCTC and non-FCTC) will be included. Results will be limited to literature published since 2005 in English and regional languages (Bengali, Hindi and Urdu). Two reviewers will independently employ two-stage screening to determine inclusion. The Effective Public Health Practice Project's 'Quality Assessment Tool for Quantitative Studies' will be used to record ratings of quality and risk of bias among studies selected for inclusion. Data will be extracted using a standardised form. Meta-analysis and narrative synthesis will be used. Ethics and dissemination Permission for ethics exemption of the review was obtained from the Centre for Chronic Disease Control's Institutional Ethics Committee, India (CCDC-IEC-06-2020; dated 16 April 2020). The results will be disseminated through publications in a peer-reviewed journal and will be presented in national and international conferences. PROSPERO registration number CRD42020191946

Socio-Economic Status (SES) differences in changing affordability of tobacco products from 2011-12 to 2018-19 in India

INTRODUCTION We studied the change in affordability of tobacco products, an important determinant of tobacco use, across the different socio-economic status (SES) in India. METHODS We calculated affordability in the form of relative income price (RIP-cost of tobacco products relative to income) for years 2011-12 and 2018-19 using three different denominators, i.e., per capita Gross Domestic Product (GDP) and Net State Domestic Product (NSDP) at national and state levels, respectively; monthly per capita consumer expenditure (MPCE); and individual wages. We investigated RIP for cigarettes, bidis and smokeless tobacco (SLT) across different SES groups (caste groups, type of employment and education). RESULTS RIP increased marginally for cigarettes, bidis and remained almost constant for SLT across casual workers. However, when RIP was adjusted with SES variables, there was no significant change (p>0.05) in affordability of products for casual workers in year 2018-19 as compared to 2011-12. For regular workers, cigarettes and bidis became marginally less affordable (βvariables SLT reported no change in affordability. There was a marginal increase in affordability for all products when RIP was calculated with GDP. CONCLUSION Although implementation of GST has increased the price of tobacco products, it is still not sufficient to reduce the affordability of tobacco products, particularly SLT and especially for the lower SES group

The global impact of tobacco control policies on smokeless tobacco use : a systematic review

Background Smokeless tobacco (ST), used by more than 300 million people globally, results in substantial morbidity and mortality. For ST control, many countries have adopted policies beyond the World Health Organization’s (WHO) Framework Convention on Tobacco Control (FCTC), which has been instrumental in reducing smoking prevalence. The impact of these ST related policies (FCTC and non-FCTC) on ST remains unclear. Methods We systematically searched 11 electronic databases and grey literature from 2005 to September 2021 in English and key south Asian languages, to summarise ST policies and their impact. Two reviewers independently screened articles; data were extracted after standardisation . Quality of studies was appraised using the Effective Public Health Practice Project Quality Assessment Tool. Outcomes for impact assessment included ST prevalence, uptake, cessation, and health. Due to substantial heterogeneity in the descriptions of policies and outcomes, data were descriptively and narratively synthesised. Findings We identified 252 eligible studies describing ST policies. Fifty-seven countries had policies targeting ST of which 17 had non-FCTC policies for ST (e.g., spitting bans). Eighteen studies evaluated the impact. These were of variable quality (6 strong, 7 moderate and 5 weak) and reported mainly on prevalence of ST use. The body of work evaluating FCTC-based policy initiatives found that these were associated with reductions in ST prevalence: between -4.4% to -30.3% for taxation and -22.2% to -70.9% for multi-faceted policies. Two studies evaluating the non-FCTC policy of sales bans reported significant reductions in ST sale (-6.4%) and use (-17.6%); one however reported an increased trend in ST use in the youth after total sales ban, likely due to cross-border smuggling. The one study reporting on cessation found 13.3% increase in quit attempts in those exposed (47.5%) to FCTC policy: Education, communication, training, and public awareness, compared to non-exposed (34.2%). Interpretation Many countries have implemented ST control policies, including those that extend beyond FCTC. The available evidence suggests that taxation and multifaceted policy initiatives are associated with meaningful reductions in ST use

Changing the global obesity narrative to recognize and reduce weight stigma: A position statement from the World Obesity Federation.

Weight stigma, defined as pervasive misconceptions and stereotypes associated with higher body weight, is both a social determinant of health and a human rights issue. It is imperative to consider how weight stigma may be impeding health promotion efforts on a global scale. The World Obesity Federation (WOF) convened a global working group of practitioners, researchers, policymakers, youth advocates, and individuals with lived experience of obesity to consider the ways that global obesity narratives may contribute to weight stigma. Specifically, the working group focused on how overall obesity narratives, food and physical activity narratives, and scientific and public-facing language may contribute to weight stigma. The impact of weight stigma across the lifespan was also considered. Taking a global perspective, nine recommendations resulted from this work for global health research and health promotion efforts that can help to reduce harmful obesity narratives, both inside and outside health contexts