A Cross-Sectional Study of the Impact of Standardized Tobacco Packaging Legislation on University Students

Background: European Union and national legislation implemented from May 2016 mean that from May 2017 all tobacco products in the United Kingdom must be sold in standardized packs without external branding and with prominent graphic health warnings. This study investigates the level of awareness and acceptability of the legislation in students during the implementation period, and how the legislation may impact on student perceptions of pack attributes, health warning effectiveness, student smokers' willingness to pay for cigarette packs, and intentions to quit.Methods: An online survey link was e-mailed to randomly selected University of Nottingham students in autumn 2016. Descriptive statistics and multivariate logistic regression models were used to investigate awareness, acceptability, and potential quitting behavior.Results: 546 students (175 smokers, 371 nonsmokers) responded. Very few of students had seen a standardized pack. Smokers were more likely to be aware of the new legislation than non-smokers. More smokers noticed the warnings on standardized packs than on branded ones. Fewer smokers were willing to pay current prices for standardized packs than for 20 branded packs. Just under half of smokers anticipated quitting in response to the new legislation, with those who smoke infrequently being more likely to anticipate quitting than daily smokers.Conclusions: Few students had seen a standardized pack, suggesting that the level of implementation of the legislation was low five to six months into the implementation period. However, the findings suggest that the legislation has the potential to increase quitting behavior in smoking students

The use of existing data sources to evaluate the impact of tobacco control policies on quitting behaviour

Background In England there is a comprehensive framework of tobacco control policies to reduce smoking-related harm. Policy evaluation helps to ascertain how policies may be improved so that they have the greatest impact; ineffective policies can be dropped or improved, while effective policies can be kept and improved further in order to optimise their impact. The evaluation of tobacco control policy requires high quality and timely data on smoking and smoking cessation behaviour. Time series analysis (TSA) is a robust way of evaluating policy, as it takes existing trends into account, but requires frequently collected data in large samples over long time periods. The aims of this thesis were to investigate the suitability of a range of existing data sources for evaluating the impact of tobacco control policies in England on quitting behaviour, validate potentially suitable measures, and use validated measures to evaluate the impact of recent tobacco control initiatives in England using TSA. Methods A range of data sources which provide information on smoking cessation behaviour were analysed to determine their adequacy for evaluating tobacco control policies, and previously unvalidated measures were validated. Different approaches to TSA – interrupted time series analysis and multiple time series analysis - were employed to evaluate the impact of the introduction of a new smoking cessation medication, varenicline, the broadening of the indications for nicotine replacement therapy (NRT) to include people with cardiovascular disease and adolescents, and the effect of anti-tobacco mass media campaigns on quitting behaviour. Results Two key indicators of quitting behaviour are quit attempts and smoking prevalence; however, there are currently no frequently collected data from large enough samples covering a long time period on these measures. Survey data are generally not suitable for policy evaluation because they are infrequently carried out and often have small sample sizes, making it difficult to detect small and transient changes in behaviour. In contrast, routine sources of data such as electronic medical records data are often frequently collected in large samples over long time periods. A validation study showed that primary care data from The Health Improvement Network are an accurate source of data on prescribing of smoking cessation medication. Time series analyses of these data showed that both the introduction of varenicline, and the broadening of the indications for NRT, did not increase rates of prescribing for smoking cessation medication. Another study found that tobacco control mass media campaigns appear to be more effective at triggering quitting behaviour than pharmaceutical company NRT campaigns. Conclusions Although there are significant gaps in the existing data available, there are some high quality time series data which can be used to evaluate the impact of tobacco control policies in England. There is a need for regular collection of data on key indicators of quitting behaviour, and the use of time series analysis in policy evaluation can play a vital role in strengthening the evidence for the effectiveness of policies, both in tobacco control, and in other areas of public health. The time series studies in this thesis suggest that recent changes to the availability of pharmacological smoking cessation aids have not had a significant impact on public health, and that recent cuts in tobacco control advertising are likely to have reduced quitting behaviour

Exploration of Policy Makers’ Views on the Implementation of the Framework Convention on Tobacco Control in the Gambia: A Qualitative Study

Background: The World Health Organization’s Framework Convention on Tobacco Control (WHO FCTC) is the first international health treaty and has now been ratified by 181 countries. However, there are concerns that in many countries, particularly in Sub-Saharan African countries, FCTC legislations and implementation are weak. In this study we report a qualitative study undertaken to assess policy makers’ awareness of the FCTC and national tobacco control policies, and assessed the achievements and challenges to the implementation of the FCTC in The Gambia. Methods: The study involved semi-structured one-to-one interviews with 28 members of the National Tobacco Control Committee in The Gambia, which is responsible for formulating tobacco control policies and making recommendations for tobacco control. We used the Framework method and NVivo11 software for data analysis. Results: Our findings demonstrate that The Gambia has made modest progress in tobacco control before and since ratification of the FCTC, particularly in the areas of policy formulation, bans on tobacco advertising and promotion, smoke free laws and tobacco taxation. Whilst several pieces of tobacco control legislation exist, enforcement and implementation remain a major challenge. We found that policy makers’ awareness of polices covered in the FCTC was limited. Conclusion: Our findings highlight several challenges to the FCTC implementation and the need to step up efforts that will help to accomplish the obligations of the FCTC. To achieve the obligations of the FCTC, The Gambia should develop specific public awareness interventions, establish cessation services, mobilise adequate resources for tobacco control and strengthen tobacco surveillance and research

The use of existing data sources to evaluate the impact of tobacco control policies on quitting behaviour

Background In England there is a comprehensive framework of tobacco control policies to reduce smoking-related harm. Policy evaluation helps to ascertain how policies may be improved so that they have the greatest impact; ineffective policies can be dropped or improved, while effective policies can be kept and improved further in order to optimise their impact. The evaluation of tobacco control policy requires high quality and timely data on smoking and smoking cessation behaviour. Time series analysis (TSA) is a robust way of evaluating policy, as it takes existing trends into account, but requires frequently collected data in large samples over long time periods. The aims of this thesis were to investigate the suitability of a range of existing data sources for evaluating the impact of tobacco control policies in England on quitting behaviour, validate potentially suitable measures, and use validated measures to evaluate the impact of recent tobacco control initiatives in England using TSA. Methods A range of data sources which provide information on smoking cessation behaviour were analysed to determine their adequacy for evaluating tobacco control policies, and previously unvalidated measures were validated. Different approaches to TSA – interrupted time series analysis and multiple time series analysis - were employed to evaluate the impact of the introduction of a new smoking cessation medication, varenicline, the broadening of the indications for nicotine replacement therapy (NRT) to include people with cardiovascular disease and adolescents, and the effect of anti-tobacco mass media campaigns on quitting behaviour. Results Two key indicators of quitting behaviour are quit attempts and smoking prevalence; however, there are currently no frequently collected data from large enough samples covering a long time period on these measures. Survey data are generally not suitable for policy evaluation because they are infrequently carried out and often have small sample sizes, making it difficult to detect small and transient changes in behaviour. In contrast, routine sources of data such as electronic medical records data are often frequently collected in large samples over long time periods. A validation study showed that primary care data from The Health Improvement Network are an accurate source of data on prescribing of smoking cessation medication. Time series analyses of these data showed that both the introduction of varenicline, and the broadening of the indications for NRT, did not increase rates of prescribing for smoking cessation medication. Another study found that tobacco control mass media campaigns appear to be more effective at triggering quitting behaviour than pharmaceutical company NRT campaigns. Conclusions Although there are significant gaps in the existing data available, there are some high quality time series data which can be used to evaluate the impact of tobacco control policies in England. There is a need for regular collection of data on key indicators of quitting behaviour, and the use of time series analysis in policy evaluation can play a vital role in strengthening the evidence for the effectiveness of policies, both in tobacco control, and in other areas of public health. The time series studies in this thesis suggest that recent changes to the availability of pharmacological smoking cessation aids have not had a significant impact on public health, and that recent cuts in tobacco control advertising are likely to have reduced quitting behaviour

Rapidly increasing trend of recorded alcohol consumption since the end of the armed conflict in Sri Lanka

Aim: To evaluate temporal changes in recorded alcohol consumption in Sri Lanka during and after the armed conflict 1998 – 2013. Methods: District level alcohol sales, and mid-year population data for the whole study period (1998-2013) were consistently available from the Department of Excise and the Department of Census and Statistics for 18 of 25 districts. These data were used to estimate the recorded per capita consumption for the areas that were not directly exposed to the armed conflict. An interrupted time series design was employed to estimate the impact of the end of the armed conflict on recorded adult per capita alcohol consumption of population lived in the 18 districts. Results: Adult per capita recorded alcohol consumption among Sri Lankans living in the 18 districts was 1.59 litres of pure alcohol in 1998. This increased up to 2.07 litres in 2009 and 2.55 litres in 2013. Prior to the end of the conflict in 2009 adult per capita recorded consumption increased by 0.051 litres of pure alcohol per year (95% CI 0.029-0.074, p<0.001); after 2009 this was 0.166 litres per year (95% CI 0.095-0.236, p<0.001). Beer consumption showed the highest per capita growth compared with other beverages. Conclusions: Adult per capita recorded alcohol consumption among Sri Lankans living in areas that were not directly exposed to the conflict increased markedly after the end of the conflict. Rapid socio-economic development, alcohol industry penetration and lack of alcohol control strategies during the post-conflict period may have driven this increase

Awareness of standardised tobacco packaging among adults and young people during the final phase of policy implementation in Great Britain

Background: In May 2016, along with the latest European Tobacco Products Directive (TPD), standardised packaging legislation was implemented in the UK. During the following 12-month transition period, both new and old types of packaging were allowed on the market. This study aimed to assess awareness of standardised packaging and other TPD changes in the UK population in March 2017, when both forms of packaging were in widespread use. Methods: We conducted two surveys—one in adults and one in young people—investigating awareness of plain packaging legislation. In young people, we also measured susceptibility to smoking using previously validated questions. We asked smokers whether they had recently changed the product they used and also whether they used any of the products that are banned by the new legislation. Results: In the adult survey, 73.5% (95% CI: 71.5–75.5%) of the participants were aware of the new legislation and 32.4% (95% CI: 30.3–34.5%) had noticed changes in tobacco packaging, this proportion being considerably higher among smokers (83.7%; 95% CI: 78.9–87.5%) than never smokers (20.7%; 95% CI: 18.2–23.4%). More than half (52.4%; 95% CI: 46.5–58.4%) were using pack sizes or shapes (typically less than 20 cigarettes or 30 g loose tobacco), that would become illegal after full TPD implementation, and 31.4% (95% CI: 26.2–37.1%) reported switching to a different product since October 2016, in most cases to a cheaper brand. Among young people, 20.2% (95% CI: 17.8–22.7%) reported that they had noticed standardised packaging, comprising 16.2% (95% CI: 13.7–19.0%) of non-susceptible never smokers, 25.6% (95% CI: 18.0–35%) of susceptible never smokers, and 49% (95% CI: 37.8–60.2%) of ever smokers. Conclusions: In the final stages of implementation, awareness of the introduction of standardised packs was highest among smokers. The TPD will cause nearly half of adult smokers to purchase larger packs, and may cause many smokers to switch to cheaper brands

Measuring alcohol consumption in population surveys: a review of international guidelines and comparison with surveys in England

Aims: To review the international guidelines and recommendations on survey instruments for measurement of alcohol consumption in population surveys, and to examine how national surveys in England meet the core recommendations. Methods: A systematic search for international guidelines for measuring alcohol consumption in population surveys was undertaken. The common core recommendations for alcohol consumption measures and survey instruments were identified. Alcohol consumption questions in national surveys in England were compared with these recommendations for specific years and over time since 2000. Results: Four sets of international guidelines and three core alcohol consumption measures (alcohol consumption status, average volume of consumption, frequency and volume of binge drinking) with another optional measure (drinking context) were identified. English national surveys have been inconsistent over time in including questions that provide information on average volume of consumption but have not included questions on another essential alcohol consumption measure, frequency of heavy episodic drinking. Instead they have used questions that focus only on maximum volume of alcohol consumed on any day in the previous week. Conclusions: International guidelines provide consistent recommendations for measuring alcohol consumption in population surveys. These recommendations have not been consistently applied in English national surveys and this has contributed to the inadequacy of survey measurements for monitoring vital aspects of alcohol consumption in England over recent years

‘I Felt Welcomed in Like They’re a Little Family in There, I Felt Like I Was Joining a Team or Something’: Vape Shop Customers’ Experiences of E-Cigarette Use, Vape Shops and the Vaping Community

Background: Specialist electronic cigarette (e-cigarette) shops, known as vape shops, provide access to a less harmful alternative to smoking. This study aimed to understand customers’ experiences of vaping and vape shops, and the extent to which smoking cessation advice is and should be provided in these shops. Methods: We conducted telephone interviews with 22 customers recruited in vapeshops in the East Midlands region of England. Interviews explored participants’ smoking histories, reasons for using e-cigarettes, the role of vape shops in their e-cigarette use, and whether smoking cessation was discussed in vape shops. Interviews were analysed following framework approach principles. Results: Most respondents regarded e-cigarettes as a quitting tool and reported very positive experiences of vaping. Vape shops were central to participants’ positive experiences, in that they provided access to a wide variety of high-quality products and reliable product information and advice. The shop staff engendered a sense of loyalty in customers which, together with the community of other vapers, created a network that helped to support e-cigarette use. Vape shops were not regarded as a setting in which cessation advice was generally provided but were acknowledged as potentially appropriate places to provide quitting support. Conclusions: Vape shops have the potential to play an important role in tobacco harm reduction, which could be increased if their service model were to extend to help smokers to quit

The effect of tobacco and alcohol consumption on poverty in the UK

Background and Aims: Tobacco and alcohol use are major risk factors for premature mortality and morbidity. Tobacco and alcohol expenditure may also exacerbate poverty. This study aimed to estimate the financial impact of tobacco and alcohol consumption in low income households in the UK.Design: Cross-sectional study.Setting: UK.Participants: A sample of 5,031 households participating in the 2016-17 Living Costs and Food Survey. Measurements: Weekly household income and expenditure on tobacco and alcohol; proportion of households with expenditure on tobacco and alcohol overall, by income decile and in households in relative poverty (below 60% of the median household income). Estimates were extrapolated using population data to estimate the number of UK households, adults and children that would be classified as living in relative poverty on the basis of net income after subtracting tobacco or alcohol expenditure (‘tobacco and alcohol expenditure-adjusted poverty’).Findings: Spending on alcohol was more common in high income groups; 83% of households in the highest and 47% in the lowest income decile purchased alcohol. The reverse was true for tobacco, which was purchased by 8% and 24% of households in the highest and lowest income deciles respectively. Twenty-three percent of households in relative poverty purchased tobacco and 49% alcohol, with a median expenditure of £12.50 and £9.55 per week respectively. A total of 320,000 households comprising 590,000 adults and 175,000 children were in alcohol expenditure-adjusted poverty, and 230,000 households, comprising 400,000 adults and 180,000 children in tobacco-expenditure adjusted poverty.Conclusions: Tobacco and alcohol expenditure appear to exacerbate poverty in low income households in the UK. Hundreds of thousands of additional households would be defined as living in relative poverty based on their income after subtracting their tobacco and alcohol expenditure