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Background: Increasing tobacco prices through taxation is very effective for reducing smoking prevalence and inequalities. For optimum effect, understanding how the tobacco industry and smokers respond is essential. Tobacco taxation changes occurred in the UK over the study period, including annual increases, a shift in structure from ad valorem to specific taxation and relatively higher increases on roll-your-own tobacco than on factory-made cigarettes. Objectives: Understanding tobacco industry pricing strategies in response to tax changes and the impact of tax on smokers’ behaviour, including tax evasion and avoidance, as well as the effect on smoking inequalities. Synthesising findings to inform how taxation can be improved as a public health intervention. Design: Qualitative analysis and evidence synthesis (commercial and Nielsen data) and longitudinal and aggregate cross-sectional analyses (International Tobacco Control Policy Evaluation Project data). Setting: The UK, from 2002 to 2016. Data sources and participants: Data were from the tobacco industry commercial literature and retail tobacco sales data (Nielsen, New York, NY, USA). Participants were a longitudinal cohort (with replenishment) of smokers and ex-smokers from 10 surveys of the International Tobacco Control Policy Evaluation Project (around 1500 participants per survey). Main outcome measures: (1) Tobacco industry pricing strategies, (2) sales volumes and prices by segments over time and (3) smokers’ behaviours, including products purchased, sources, brands, consumption, quit attempts, success and sociodemographic differences. Review methods: Tobacco industry commercial literature was searched for mentions of tobacco products and price segments, with 517 articles extracted. Results: The tobacco industry increased prices on top of tax increases (overshifting), particularly on premium products, and, recently, the tobacco industry overshifted more on cheap roll-your-own tobacco than on factory-made cigarettes. Increasingly, price rises were from industry revenue generation rather than tax. The tobacco industry raised prices gradually to soften impact; this was less possible with larger tax increases. Budget measures to reduce cheap product availability failed due to new cheap factory-made products, price marking and small packs. In 2014, smokers could buy factory-made (roll-your-own tobacco) cigarettes at real prices similar to 2002. Exclusive roll-your-own tobacco and mixed factory-made cigarettes and roll-your-own tobacco use increased, whereas exclusive factory-made cigarette use decreased, alongside increased cheap product use, rather than quitting. Quitting behaviours were associated with higher taxes. Smokers consumed fewer factory-made cigarettes and reduced roll-your-own tobacco weight over time. Apparent illicit purchasing did not increase. Disadvantaged and dependent smokers struggled with tobacco affordability and were more likely to smoke cheaper products, but disadvantage did not affect quit success. Limitations: Different for each data set; triangulation increased confidence. Conclusions: The tobacco industry overshifted taxes and increased revenues, even when tax increases were high. Therefore, tobacco taxes can be further increased to reduce price differentials and recoup public health costs. Government strategies on illicit tobacco appear effective. Large, sudden tax increases would reduce the industry’s ability to manipulate prices, decrease affordability and increase quitting behaviours. More disadvantaged, and dependent, smokers need more help with quitting. Future work: Assessing the impact of tax changes made since 2014; changing how tax changes are introduced (e.g. sudden intermittent or smaller continuous); and tax changes on tobacco initiation. Funding: This project was funded by the National Institute for Health Research (NIHR) Public Health Research programme and will be published in full in Public Health Research; Vol. 8, No. 6. See the NIHR Journals Library website for further project information.

Introduction Article 20 of the European Union (EU) Tobacco Products Directive (TPD) sets forth provisions on electronic cigarette (e-cigarette) product regulation, such as child-proof packaging and protection against e-liquid refilling without leakage. The aim of the current study was to examine frequencies and correlates of experiencing undesirable events during e-cigarette use related to e-cigarette product design parameters prior to the implementation of the EU TPD. Material and Methods The EUREST-PLUS ITC Europe Wave 1 survey was conducted with adult cigarette smokers from June to September 2016 across Germany, Greece, Hungary, Poland, Romania, Spain. Results Among our sample of adult cigarette smokers, one in five reported having ever used e-cigarettes. Prevalence of current e-cigarette use (daily or weekly) was very low (1.5%). Major undesirable events, such as battery exploding or catching fire (1.9%) or overheating (11%) were uncommon. Among those reporting at least monthly use and whose usual/current brand has a tank that you fill with liquids, 18.8% experienced spilling during refill and 18.5% experienced e-liquid leaking during use. Nearly one-quarter reported that the e-liquid cap was easy for a child to open. Conclusions In light of the EU TPD establishing standards around e-cigarette design parameters to mitigate undesirable events and risks during e-cigarette use, these findings further support the need for its implementation, as well as for monitoring undesirable events experienced during e-cigarette use once Article 20 is fully implemented. Acknowledgements EUREST-PLUS is a Horizon2020 project conducted by researchers throughout Europe from both the six participating countries as well as other institution partners within Europe and abroad. Partnering organizations include the European Network on Smoking Prevention (Belgium), Kings College London (United Kingdom), German Cancer Research Centre (Germany), University of Maastricht (The Netherlands), University of Athens (Greece), Aer Pur Romania (Romania), European Respiratory Society (Switzerland), the University of Waterloo (Canada), the Catalan Institute of Oncology (Catalonia, Spain), Smoking or Health Hungarian Foundation (Hungary), Health Promotion Foundation (Poland), University of Crete (Greece), and Kantar Public Brussels (Belgium). Funding The EUREST-PLUS Project takes place with the financial support of the European Commission, Horizon 2020 HCO-6-2015 program (EUREST-PLUS: 681109; C. Vardavas) and the University of Waterloo (GT. Fong). Additional support was provided to the University of Waterloo by the Canadian Institutes of Health Research (FDN-148477). GT. Fong was supported by a Senior Investigator Grant from the Ontario Institute for Cancer Research. E. Fernández is partly supported by Ministry of Universities and Research, Government of Catalonia (2017SGR139) and by the Instituto Carlos III and co-funded by the European Regional Development Fund (FEDER) (INT16/00211 and INT17/00103), Government of Spain.

Background Cigarettes with flavour-changing capsules in the filter have experienced phenomenal global growth in the last decade. However, very few studies have explored the use of these products. Our objective was to explore which smokers in the United Kingdom use these products, and why. Methods An online survey was conducted between April-May 2016 with a sample of 6234 factory-made (FM) and/or hand-rolled cigarette smokers. This analysis focused on the 3548 smokers (aged 18 years and over) of FM cigarettes. We explored socio-demographic and smoking-related factors associated with smoking capsule cigarettes, reasons for using them, and whether users burst the capsule. Results 13% of FM smokers (n=454) smoked capsule cigarettes, with younger smokers more likely than older smokers to use them (30% of 18-24 year olds compared with 5% of those 55+). Capsule use was significantly more common among those from other white backgrounds (22%) than among white British (12%), and among those planning to quit in the next six months (16%) than those not planning to quit (11%). Most capsule users crushed the capsule always or most of the time (70%), with some never crushing it (9%). The most common reasons for using capsule cigarettes were that they taste better (52%), are smoother (41%), provide a choice of flavours (32%), the enjoyment of clicking the capsule (25%) and that they are more interesting than regular cigarettes (21%). For those who never crushed the capsule, almost half (49%) smoked capsules because their brand only had capsule variants. Capsule and non-capsule smokers did not differ in their perceptions of the harmfulness of their brand relative to other brands, or their concern about the effect of smoking on their health. Conclusions Approximately one in eight FM cigarette smokers used capsule cigarettes, with the key drivers of use related to taste, having a choice of flavours and interactivity.

Background and challenges to implementation The UK is now a 'dark market' as such the supply chain and availability of tobacco has become a more important part of the marketing mix for tobacco companies. A key tactic of tobacco companies has been to seek to persuade small tobacco retailers that their interests align with those of tobacco manufacturers and to encourage them to oppose tobacco regulations and participate in the promotion of products. This project sought to better understand the extent to which tobacco retailers and tobacco manufacturers share interests and identify where they diverge. Intervention or response A report and infographic was produced using three sources: Analysis of retail trade publications to assess the claims being made by tobacco companies regarding the retail environment. Analysis of point of sale data from independent tobacco retailers testing the claims of tobacco companies regarding the importance of tobacco sales to small retailers. Survey of independent tobacco retailers in Britain. This sought to better understand the existing relationship between retailers and manufacturers, attitudes of retailers towards tobacco control policies and the extent to which they agreed with the positions taken by tobacco manufacturers regarding the retail environment. Results and lessons learnt While tobacco sales accounted for 25% of total income, margins were around 6% compared to an average 24% for the other products. As such average weekly profit was only 1.6% of income. Little evidence to support manufacturers claims that tobacco drives footfall or that retailers should stock full range of brand variants. Conclusions and key recommendations We demonstrated that the existing and future interests of small retailers and manufacturers are not aligned. We identified opportunities to encourage a more responsible approach to tobacco retailing aligning with public health interests.

Background Articles 11 and 13 of the WHO FCTC call for the elimination of logos, colours, brand images and promotional information on tobacco packaging that make tobacco products more attractive. We aimed to assess, using a systematic review, the effect of standardised tobacco packaging (STP) on tobacco attitudes and behaviours, including, for the first time, population-level outcomes from Australia where STP was implemented in 2012. The review was published in 2017, but not yet presented at a conference. Methods Using standard Cochrane methods, we searched nine databases for peer-reviewed articles evaluating STP prior to January 2016, extracted relevant data and also assessed risk of bias. Results We identified 51 peer-reviewed studies, with over 800,000 participants, a variety of methods and designs, and assessing a range behavioural and non-behavioural outcomes; these were conducted predominantly in high-income countries. We found that overall, STP had a positive effect on behavioural and non-behavioural outcomes; while we also found some null results, there were no negative effects. Australian evidence suggested that STP reduced smoking prevalence, but certainty this outcome was limited by the concurrent introduction of enhanced pictorial warnings. The impact on non-behavioural outcomes was clearer (e.g. STP consistently reduced the appeal of tobacco products), and provided plausible mechanisms of effect consistent with the finding on prevalence. The impact of STP was affected by the detail of the regulations (e.g. whether they banned descriptors and controlled pack shape). Conclusions STP reduced the promotional appeal of tobacco packs in line with regulatory objectives, and the available evidence also showed it may reduce smoking prevalence. There is an urgent need for research to be conducted among low and middle-income countries where 80% of the world's smokers live. Cochrane reviews are evolving documents, updated as other studies become available.

Background The tobacco industry (TI) can undermine the public health gains realised from tobacco taxation through its pricing strategies. This study aims to examine contemporary TI pricing strategies in the UK and the implications for tobacco tax policy. Methods Review of commercial and TI literature, and analysis of 2009 to 2015 Nielsen Scantrak electronic point of sale systems (EPOS) data on tobacco sales and price data. The study was set in a high income country with comprehensive tobacco control policies and high tobacco taxes (UK). The main outcome measures were: tobacco price segmentation; monthly prices, sales volumes of and net revenue from roll your own and factory made (RYO and FM) cigarettes by price segment; use of price-marking; and pack sizes. Results The literature review and sales data concurred that both RYO and FM cigarettes were segmented by price into premium, mid-price and value segments, with an additional sub-value FM segment introduced in 2012. Despite regular tax increases, average real prices for RYO value and FM sub-value segments remained steady from 2013 whilst their volumes grew. The TI maintains low prices through reducing the number of cigarettes per pack, price-marking (forcing retailers to sell cheaper products at low prices) and absorbing tax increases. Each year, at the point the budget is implemented, the TI drops its revenue by up to 18 pence per pack, absorbing the tax increases (undershifting). Later in the year it gradually passes the tax increase onto consumers, effectively smoothing the price change consumers face across the year. Undershifting of taxes is most marked for the cheapest products. Conclusions The TI employs a variety of strategies to keep tobacco cheap and minimise the impact of tobacco tax increases. The implementation of standardised packaging can prevent small pack sizes and price-marking but further changes in tax policy are needed to minimise undershifting.