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Background and Objectives: The tobacco industry (TI) has undermined tobacco control policy for decades. The WHO Framework Convention on Tobacco Control Article 5.3 implementation guidelines provide guidance for preventing TI interference. Government officials responsible for policy implementation must understand these guidelines to manage TI tactics. This study assessed awareness, attitudes and practices of Article 5.3 guidelines among members of District Level Coordination Committees (DLCC) in Karnataka mandated with overseeing tobacco control activity., Method: A semistructured questionnaire survey of awareness, attitudes and adherence to Article 5.3 guidelines among 102 DLCC members carried out between January and July 2019., Result: Responses were received from 82 members, comprising 51 (62%) from health and 31 (38%) from non-health departments. Our study demonstrates a lack of understanding of Article 5.3 and its guidelines, even among those actively involved in tobacco control at the district level. Nearly 80% of respondents were aware that corporate social responsibility (CSR) by tobacco companies is an indirect form of promoting tobacco. However, 44% of members felt that CSR funding from the TI should be used to combat tobacco-related harm. A higher proportion (12%) of health respondents agreed that subsidies should be provided to tobacco agriculture compared with non-health (3%)., Conclusion: Awareness of international guidance designed to prevent the TI influence on health policy among policymakers in this Indian state is low. Respondents from non-health departments were less aware of TI CSR. Those in health departments were more receptive towards taking a TI role in the future ., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Exposure to smoking in films is a recognised cause of smoking uptake among children. In India, in an attempt to protect children, films containing smoking are required to include tobacco control messaging including audiovisual disclaimers, on-screen health warnings when tobacco imagery is displayed and antitobacco 'health spots' before and during the film. We report a study of the association between ever smoking and exposure to tobacco imagery in locally popular films among children in Udupi district of Karnataka state in southern India., Methods: A cross-sectional questionnaire survey of all students in grades 6-8 in schools in the Udupi district ascertained smoking status and potential confounders of smoking uptake, and whether children had seen any of 27 locally popular films we had coded and found to contain imagery of actual or implied tobacco use. Ever-smoking status was defined as any reported smoking of cigarettes, beedis or other tobacco products currently or at any time in the past. Independent effects on ever-smoking status were estimated using multiple logistic regression., Results: Of 46 706 students enrolled in grades 6-8 in 914 participating schools, 39 282 (84.1%) provided questionnaire responses sufficiently complete for analysis. Ever smoking was reported by 914 (2.3%) participants and in a mutually adjusted model was significantly related to age, male sex, living in a home where smoking is allowed, having parents or siblings who smoke, low paternal education, low levels of family wealth, low self-esteem, rebelliousness and poor school performance. After allowing for these effects, the odds of ever smoking were not increased among students who had seen any of the listed films containing tobacco imagery when included in the analysis as a binary exposure (OR 0.9, 95% CI 0.4 to 2.0), and decreased in relation to level of exposure graded into tertiles of tobacco intervals seen., Conclusions: In this cross-sectional study, children in southern India who had seen films containing tobacco imagery are no more likely to smoke than those who had not, indicating that the tobacco control messaging mandated by Indian law may be attenuating the effect of tobacco imagery in films on smoking uptake., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY. Published by BMJ.)

Background and Aim: In 2016, England initiated the implementation of standardised tobacco packaging, introduced in conjunction with minimum pack sizes and other measures included in the 2014 European Tobacco Products Directive, over the course of a 1-year sell-off period ending in May 2017. These measures have been shown to have been associated with increases in tobacco prices and product diversity. We now investigate the association between implementation of the new legislation and smoking status in England., Design: Segmented regression analysis of repeated cross-sectional surveys using a generalised linear model with individual-level data to test for a change in trend and immediate step change., Setting: England., Participants: Participants in the Smoking Toolkit Study, which involves repeated, cross-sectional household surveys of individuals aged 16 years and older in England. The sample included 278 219 individual observations collected between November 2006 and December 2019., Intervention: Implementation of standardised packaging legislation (May 2016 and May 2017)., Measurements: Individual-level current smoking status adjusted for implementation of tobacco control policies, cigarette price, seasonality and autocorrelation., Findings: The implementation of standardised packaging was associated with a significant step reduction in the odds of being a smoker after May 2017 (OR: 0.93; 95% CI 0.87 to 0.99). The magnitude of the association was similar when modelling the step change in May 2016 at the start of the 1-year policy implementation period (OR: 0.90; 95% CI: 0.83 to 0.97)., Conclusions: This is the first independent study demonstrating that implementation of standardised packaging was associated with a reduction in smoking in England which occurred in anticipation of, rather than after, full policy implementation. It appears that the odds of being a smoker were affected by the prospect of the move to standardised packs and accompanying legislation., Competing Interests: Competing interests: JB and EB have received unrestricted research grants from Pfizer related to smoking cessation. JB, MOB and IB have no competing interests to declare. All authors declare no financial links with tobacco companies or e-cigarette manufacturers or their representatives., (© Author(s) (or their employer(s)) 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Plain packaging and minimum pack size legislation for tobacco products was introduced in the UK in May 2016, with a 1-year sell-off period until May 2017, during which both fully branded and plain packs of various sizes were legally available. This study investigates trends in prices of roll-your-own tobacco (RYO) before, during and after implementation of this legislation, and compares trends with those observed in the cigarette market., Methods: We used Nielsen Scantrack data for the period from March 2013 to June 2018 to describe trends in UK inflation-adjusted prices and volumes of both RYO and cigarettes, and linear regression to estimate changes in prices associated with the introduction of plain packaging and the minimum pack sizes of 30 g RYO and 20 cigarettes., Results: In contrast to a downward trend in cigarette sales volumes, RYO volumes rose throughout the study period. By the time plain packs accounted for 75% or more of sales, the average price of products sold in equivalent pack sizes had increased, relative to average prices in the year before implementation and with adjustment for tax changes, from 34.9 to 38.8 pence per gram for RYO (mean difference 4.26, 95% CI 3.99 to 4.53 pence, 12% increase), and from 38.6 to 41.13 pence for cigarettes (mean difference 2.53, 95% CI 2.24 to 2.83 pence, 7% increase) per cigarette., Conclusions: New legislation resulted in higher prices for RYO and manufactured cigarettes. However, sales volumes of RYO continued to increase throughout the study period, perhaps because RYO remains a less expensive means of smoking tobacco., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY. Published by BMJ.)

Background: Exposure to smoking in films causes smoking uptake among adolescents. Investigation of the extent to which tobacco imagery appears, or tobacco control laws are complied with in Indian films is limited, and especially so for films in regional languages. This study presents an analysis of tobacco content and compliance with tobacco control laws in popular films in several languages from the Karnataka state of India., Methods: We used 5 min interval coding to measure actual tobacco use, implied tobacco use, tobacco paraphernalia and tobacco branding in the top 10 films identified from national box office ratings and regional distributor reports in Karnataka in 2015 and 2016. We also assessed compliance with tobacco-free film rules in India., Findings: A total of 47 films, in English, Hindi, Malayalam, Tamil, Telugu and Tulu languages were coded. Any tobacco imagery was observed in 72% of films, and actual tobacco use in 50%. Tobacco imagery was equally prevalent in films classified as suitable for universal viewing (U category) or at age 12 or more (U/A category) films; and significantly more common in films made in regional than national language (Hindi). None of the films were fully compliant with legal requirements on health spots, audiovisual disclaimers and health warnings., Conclusions: Tobacco content was common in films classified as suitable for viewing by children, more among regional than national languages. Compliance with tobacco control laws was low. Stricter enforcement of tobacco-free film rules will protect children and adolescents from exposure to tobacco use on screen., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY. Published by BMJ.)

Aims: Exposure to audiovisual tobacco content in media is a risk factor for smoking in young people. While tobacco content in films has been extensively documented, content in mainstream television has received relatively little attention. We report an analysis of tobacco content in a sample of UK free-to-air prime-time television broadcasts in 2015, and compare this with a similar analysis from 2010., Design: Content analysis of all programmes and advertisements or trailers broadcast on the five national UK free-to-air channels in the UK between 18:00 and 22:00 during three separate weeks in September, October and November 2015., Setting: Great Britain., Participants: None (media analysis only)., Measurements: Occurrence of any tobacco, tobacco use, implied use, other tobacco reference/related objects and branding in every 1 min coding interval., Findings: Tobacco content occurred in 33% of all programmes and 8% of all adverts or programme trailer breaks. Actual tobacco use occurred in 12% of all programmes broadcast. Tobacco-related objects, primarily no smoking signs, occurred in 2% of broadcasts; implied tobacco use and tobacco branding were also rare. The majority of tobacco content occurred after the 21:00 watershed., Conclusions: These findings are virtually unchanged from our earlier analysis of programme content from 2010. Audiovisual tobacco content remains common in UK television programmes., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Reality television shows are popular with children and young adults; inclusion of tobacco imagery in these programmes is likely to cause smoking in these groups. Series 3 of the UK reality show Love Island, broadcast in 2017, attracted widespread media criticism for high levels of smoking depicted. We have quantified this tobacco content and estimated the UK population exposure to generic and branded tobacco imagery generated by the show., Methods: We used 1-min interval coding to quantify actual or implied tobacco use, tobacco paraphernalia or branding, in alternate episodes of series 3 of Love Island, and Census data and viewing figures from Kantar Media to estimate gross and per capita tobacco impressions., Results: We coded 21 episodes comprising 1001 min of content. Tobacco imagery occurred in 204 (20%) intervals; the frequency of appearances fell significantly after media criticism. An identifiable cigarette brand, Lucky Strike Double Click, appeared in 16 intervals. The 21 episodes delivered an estimated 559 million gross tobacco impressions to the UK population, predominantly to women, including 47 million to children aged <16 and 44 million gross impressions of Lucky Strike branding, including 4 million to children <16., Conclusion: Despite advertising legislation and broadcasting regulations intended to protect children from smoking imagery in UK television, series 3 of Love Island delivered millions of general and branded tobacco impressions both to children and adults in the UK. More stringent controls on tobacco content in television programmes are urgently needed., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Objectives: Exposing children to secondhand tobacco smoke (SHS) causes significant harm and occurs predominantly through smoking by caregivers in the family home. We report a trial of a complex intervention designed to reduce secondhand smoke exposure of children whose primary caregiver feels unable or unwilling to quit smoking., Design: An open-label, parallel, randomised controlled trial., Setting: Deprived communities in Nottingham City and County, England PARTICIPANTS: Caregivers resident in Nottingham City and County in England who were at least 18 years old, the main caregiver of a child aged under 5 years living in their household, and reported that they were smoking tobacco inside their home., Interventions: We compared a complex intervention combining personalised feedback on home air quality, behavioural support and nicotine replacement therapy for temporary abstinence with usual care., Main Outcomes: The primary outcome was change in air quality in the home, measured as average 16-24  hours levels of particulate matter of  < 2.5  µm diameter (PM 2.5 ), between baseline and 12 weeks. Secondary outcomes included changes in maximum PM 2.5 , proportion of time PM 2.5 exceeded WHO recommended levels of maximum exposure of 25  µg/mg 3 , child salivary cotinine, caregivers' cigarette consumption, nicotine dependence, determination to stop smoking, quit attempts and quitting altogether during the intervention., Results: Arithmetic mean PM 2.5 decreased significantly more (by 35.2 %; 95%  CI 12.7% to 51.9 %) in intervention than in usual care households, as did the proportion of time PM 2.5 exceeded 25  µg/mg 3 , child salivary cotinine concentrations, caregivers' cigarette consumption in the home, nicotine dependence, determination to quit and likelihood of having made a quit attempt., Conclusions: By reducing exposure to SHS in the homes of children who live with smokers unable or unwilling to quit, this intervention offers huge potential to reduce children's' tobacco-related harm., Trial Registration Number: ISRCTN81701383.This trial was funded by the UK National Institute for Health Research (NIHR): RP-PG-0608-10020., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Background: Smoking is the largest preventable cause of death in the UK and imposes a huge economic burden on society. Both the prevalence and extent of smoking are significantly higher among people with mental disorders than among the general population., Aims: To estimate the economic costs of the health effects of cigarette smoking among people with mental disorders in the UK from a societal perspective., Methods: This study uses the WHO's economics of tobacco toolkit to assess the costs of the health effects of cigarette smoking among people with mental disorders in 2009/10 in the UK. Based on the cost of illness approach, direct healthcare costs, indirect morbidity costs and indirect mortality costs due to smoking-related diseases were calculated to estimate the avoidable economic burden of smoking in people with mental disorders., Results: The estimated economic cost of smoking in people with mental disorders was £2.34 billion in 2009/10 in the UK, of which, about £719 million (31% of the total cost) was spent on treating diseases caused by smoking. Productivity losses due to smoking-related diseases were about £823 million (35%) for work-related absenteeism and £797 million (34%) was associated with premature mortality., Conclusions: Smoking in people with mental disorders in the UK imposes significant economic costs. The development and implementation of smoking cessation interventions in this group should therefore be a high economic and clinical priority., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Background: Smoking in films is a common and well documented cause of youth smoking experimentation and uptake and hence a significant health hazard. The extent of exposure of young people to tobacco imagery in television programming has to date been far less investigated. We have therefore measured the extent to which tobacco content occurs in prime time UK television, and estimated exposure of UK youth., Methods: The occurrence of tobacco, categorised as actual tobacco use, implied tobacco use, tobacco paraphernalia, other reference to tobacco, tobacco brand appearances or any of these, occurring in all prime time broadcasting on the five most popularly viewed UK television stations during 3 separate weeks in 2010 were measured by 1-minute interval coding. Youth exposure to tobacco content in the UK was estimated using media viewing figures., Findings: Actual tobacco use, predominantly cigarette smoking, occurred in 73 of 613 (12%) programmes, particularly in feature films and reality TV. Brand appearances were rare, occurring in only 18 programmes, of which 12 were news or other factual genres, and 6 were episodes of the same British soap opera. Tobacco occurred with similar frequency before as after 21:00, the UK watershed for programmes suitable for youth. The estimated number of incidences of exposure of the audience aged less than 18 years for any tobacco, actual tobacco use and tobacco branding were 59 million, 16 million and 3 million, respectively on average per week., Conclusions: Television programming is a source of significant exposure of youth to tobacco imagery, before and after the watershed. Tobacco branding is particularly common in Coronation Street, a soap opera popular among youth audiences. More stringent controls on tobacco in prime time television therefore have the potential to reduce the uptake of youth smoking in the UK.

Background: In England, point-of-sale (PoS) displays in larger shops were prohibited in April 2012, with an exemption for smaller retailers until 2015. The aim of this study was to examine the association between tobacco displays and brand communication at the PoS and adolescent smoking behaviour, and to assess the potential benefits likely to accrue from this legislation., Methods: Self-completion questionnaire survey in students aged 11-15 years in March 2011., Results: The odds of ever-smoking doubled for those visiting shops almost daily relative to less than once a week (OR 2.23, 95% CI 1.40 to 3.55), and susceptibility increased by around 60% (OR 1.62, 95% CI 1.25 to 2.10). Noticing tobacco on display every time during store visits increased the odds of susceptibility more than threefold compared with never noticing tobacco (OR 3.15, 95% CI 1.52 to 6.54). For each additional tobacco brand recognised at the PoS, the adjusted odds of being an ever-smoker increased by 5% (OR 1.05, 95% CI 1.03 to 1.06) and of susceptibility by 4% (OR 1.04, 95% CI 1.02 to 1.05). The association between frequency of visiting stores and susceptibility was predominantly due to exposure in small shops., Conclusions: Exposure to and awareness of PoS displays and brands in displays were associated with smoking susceptibility. The association between PoS display exposure and smoking susceptibility was predominantly due to exposure in small shops. These findings suggest that a one-off, comprehensive tobacco display ban is the recommended approach for countries considering a display ban.

Aims: To use association rule mining methods to investigate prescribing of smoking cessation medication in the UK primary care and to identify the characteristics of numerically important groups of patients who typically do, or do not, receive cessation therapy., Design: An association rule mining study using The Health Improvement Network Database., Settings and Participants: 282 433 patients aged 16 years and over from 419 UK general practices, who were registered with the practice throughout 2008 and recorded as a current smoker during that year., Outcome: Prescription for any type of smoking cessation medications in 2008 (nicotine replacement therapy, bupropion or varenicline)., Variables: Age, gender, lifestyle indicators and co-morbidity., Results: Of the current smokers, 37 731 (13.4%) were given prescriptions for smoking cessation treatment during 2008. Prescriptions were particularly likely to be given to women, those aged 31-60 years, and people with diagnoses of chronic obstructive pulmonary disease and depression. On the contrary, of patients with dementia, with alcohol intake over recommended levels, atrial fibrillation or chronic kidney disease was extremely unlikely to be prescribed a smoking cessation medication. However, the largest group of patients who did not receive therapy was young and otherwise healthy individuals., Conclusions: This novel approach identified sizeable and easily definable groups of patients who are systematically failing to receive support for smoking cessation in primary care. Association rule mining can be used to identify key numerically important groups at high or low risk of receiving treatment and hence potentially to improve healthcare delivery.

Background: Sponsorship of Formula One (F1) motor racing, which has been used as an indirect medium of tobacco advertising for several decades, was prohibited by the 2005 European Union Tobacco Advertising Directive. Most F1 tobacco sponsorship of motor racing in the EU has since ceased, with the exception of the Scuderia Ferrari team, which continues to be funded by Philip Morris. In 2007, the Marlboro logo on Ferrari cars and other race regalia was replaced by an evolving 'barcode' design, which Ferrari later claimed was part of the livery of the car, and not a Marlboro advertisement., Objective: To determine whether the 'barcode' graphics used by Ferrari represent 'alibi' Marlboro advertising., Methods: Academic and grey literature, and online tobacco industry document archives, were searched using terms relevant to tobacco marketing and motorsport., Results: Tobacco sponsorship of F1 motor racing began in 1968, and Philip Morris has sponsored F1 teams since 1972. Phillip Morris first used a 'barcode' design, comprising red vertical parallel lines below the word Marlboro on the British Racing Motors F1 car in 1972. Vertical or horizontal 'barcode' designs have been used in this way, latterly without the word Marlboro, ever since. The modern 'barcode' logos occupied the same position on cars and drivers' clothing as conventional Marlboro logos in the past. The shared use of red colour by Marlboro and Ferrari is also recognised by Philip Morris as a means of promoting brand association between Marlboro and Ferrari., Conclusion: The Ferrari 'barcode' designs are alibi Marlboro logos and hence constitute advertising prohibited by the 2005 EU Tobacco Advertising Directive.

Objectives: To determine whether the European Commission Eurobarometer survey of 27 European Union (EU) member states produces reliable smoking prevalence estimates when compared to national prevalence survey data, and to identify approaches to standardising the measurement of smoking prevalence in the EU., Methods: This was a direct comparison of questions, sampling methods and smoking prevalence estimates, between the 2006 Eurobarometer study and contemporaneous national surveys. All 27 EU member states were included. Participants were people surveyed in the 2006 Eurobarometer study and in various national surveys in the closest year to 2006 for which data were available. The main outcome measures were the mean and range of differences in prevalence estimates between the Eurobarometer and national surveys., Results: Most national surveys used similar multistage sampling methods and involved sample sizes of 3000 or more, but the phrasing of the questions used to define smoking, the inclusion or exclusion of occasional smokers, the age ranges of participants and the frequency of national surveys varied substantially between countries. The Eurobarometer study used the same questions in all countries but in sample sizes of 1000, or in 3 countries, 500. Eurobarometer 2006 smoking prevalence estimates were on average 0.37 percentage points higher than those in national surveys, but with a 95% range from -10.49 to +11.23 percentage points. At the extremes, the equivalent national prevalence estimate for Slovakia was 13.0% higher and for the UK 10.0% lower than the Eurobarometer figure., Conclusions: Measurements of the prevalence of smoking, the biggest avoidable public health threat in the European Union, are highly discrepant within countries between national and European Commission survey estimates. Monitoring national smoking prevalence on a regular basis, using standardised methods in representative population samples, is an urgent priority for the EU.

Background: Smoking is common in young people, particularly in disadvantaged groups, and continued smoking has a major impact on quality and quantity of life. Although many young smokers want to stop smoking, little is known about the design and effectiveness of cessation services for them., Objective: To determine whether nicotine replacement therapy (NRT) when combined with counselling is effective in young smokers in a deprived area of Nottingham, UK., Methods and Subjects: We surveyed smoking prevalence and attitudes to smoking and quitting in young people accessing an open access youth project in a deprived area of Nottingham, and used the information gained to design a community based smoking cessation service incorporating a randomised controlled trial of nicotine patches against placebo given in association with individual behavioural support. We resurveyed smoking prevalence among project attendees after completing the pilot study., Results: Of 264 young people surveyed (median age 14 years, range 11-21), 49% were regular smokers. A total of 98 young people were recruited and randomised to receive either active nicotine patches on a six week reducing dose regimen (49 participants), or placebo (49 participants). Adherence to therapy was low, the median duration being one week, and 63 participants did not attend any follow up. At four weeks, five subjects receiving active NRT and two receiving placebo were abstinent, and at 13 weeks none were. Adverse effects were more common in the active group but none were serious. Smoking prevalence among 246 youth project attendees surveyed after the trial was 44%., Conclusions: This study suggests that NRT in this context is unlikely to be effective in young smokers, not least because of low adherence to therapy. It also suggests that young smokers want help with smoking cessation, but that establishing the efficacy of smoking cessation services for young people who need them most will be very difficult.