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Background: States adopt different tax bases for smokeless tobacco (SLT), making tax incidence on SLT not directly comparable across states. In addition, how taxes are passed through to SLT prices among states that impose specific taxes, and whether the pass-through rates for SLT are affected by the uptake and evolution of e-cigarettes, is unknown., Objective: This study will calculate the tax incidence on SLT and investigate how SLT taxes are passed to prices at the 25th, 50th, and 75th percentile levels, as well as whether these pass-through rates vary by e-cigarette uptake and evolution., Methods: We regressed SLT prices on specific taxes using ordinary least square regressions while controlling for state-, year-, and quarter-fixed effects. We then tested the difference in tax pass-through rates by different periods., Findings: The average tax incidence on chewing tobacco, moist snuff, dry snuff, and snus was 22%, 22%, 23%, and 20%, respectively. For moist snuff, taxes were fully passed to prices at the 25th and 50th percentiles (rate = 1.01, p < 0.001) and overly passed to prices at the 75th percentile (rate = 1.25, p < 0.001). The e-cigarette uptake and evolution significantly raised taxes by 13 cents and 14 cents per ounce, respectively, for moist snuff at the 75th percentile prices ( p < 0.05)., Conclusions: If harm is considered a criterion for taxing tobacco products, the tax incidence on SLT could be further increased. Considering that lower-priced SLT have lower tax pass-through rates, price promotion restrictions and minimum pricing laws may be needed to increase the cost of lower-priced products. Additionally, we observed that tobacco companies tended to increase tax pass-through for premium SLT products as e-cigarettes gained popularity, which may indicate a strategic response to shifting consumer preferences.

Introduction: Globally, besides being the second largest consumer of tobacco, India is also the second largest tobacco producer. There are very few studies that give data on economic burden of tobacco consumption. We estimated the prevalence of tobacco consumption along with monthly expenditure for the same among adult males. Methodology: A community-based cross-sectional study was conducted among males aged ≥18 years residing in an urban area of Raipur city. Simple random sampling technique was applied and a total of 292 adult males participated in the study. Analysis was done on Statistical software package (STATA) software version 12. Results: The mean age [standard deviation (SD)] was 41 (13) years. The prevalence of tobacco consumption (smoke and/or smokeless) was 73.6%, where use of smokeless tobacco was 60.6% and use of smoke tobacco was 33.6%. Beedi was the most common type of smoke used (11%), followed by a mix of cigarette and beedi (10.4%). Among occasional smokers, mean (SD) number of days of occasional smoking in a month was 7.8 (5.1) whereas among smokeless tobacco users, nearly 83% use them daily with 2-5 times in a day (66%). Nearly 67% of them had seen someone smoking and/or chewing tobacco in public places in the last 7 days. Mean [interquartile range (IQR)] monthly expenditure on tobacco products among study participants was INR 367 (0-355). Mean (IQR) monthly expenditure on smoking tobacco products and smokeless tobacco products was INR 244 (0-150) and INR 123 (0-225), respectively. Conclusion: This study gives insight to both consumer prospects about how much money they are spending on something that is going to harm in future (health problems due to tobacco use) and also to the policymakers of tobacco control programs to implement stringent rules on tobacco sale., (© Journal of the Association of Physicians of India 2024.)

Background: The 2009 Tobacco Control Act granted the US Food and Drug Administration (FDA) regulatory authority over tobacco products, including the ability to authorise modified-risk tobacco product (MRTP) claims. In October 2019, the FDA authorised the first-ever MRTP claim for General Snus, which allowed the product to be marketed as reduced risk (relative to cigarettes). MRTP authorisation may increase otherwise low rates of snus use in the USA (<0.5% for children and adults)., Methods: Using 2017-2021 Nielsen sales data from 19 US states, we conducted a difference-in-differences analysis to determine whether logged unit sales of General Snus were affected by the MRTP authorisation, compared with (1) sales of other snus brands and (2) sales of non-snus smokeless products; we also examined (3) if sales of non-General Snus brands were affected by General Snus's MRTP authorisation, compared with sales of non-snus smokeless tobacco products., Results: Although sales declined in absolute terms, sales of General Snus relative to other snus brands were unchanged after MRTP authorisation (-9.0%, 95% CI -19.6% to 1.60%, p=0.098). However, compared with non-snus smokeless brand sales, sales of General Snus (+14.7%, 95% CI 5.23% to 24.2%, p=0.002) rose after MRTP authorisation. Compared with non-snus smokeless products, sales of non-General Snus brands also rose after MRTP authorisation (+23.7%, 95% CI 9.5% to 38.0%, p=0.001)., Conclusions: Although only General Snus received MRTP authorisation, this designation appears to have slowed declines for the entire snus category. This suggests consumers may make determinations regarding product risk to a product class rather than individual products., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: California Proposition 56 increased cigarette excise tax by $2 per pack with equivalent increases on non-cigarette tobacco products. We estimated the changes in cigarette price, cigarette use, and non-cigarette use following the implementation of Proposition 56 in California in 2017., Methods: Seven waves of Tobacco Use Supplements to the Current Population Survey (TUS-CPS) 2011-2019 data were used to obtain state-level aggregate self-reported outcomes, including cigarette price per pack, current and daily cigarette use, cigarette consumption per day, and current and daily use of non-cigarette tobacco products (hookah, pipe, cigar, and smokeless tobacco). A modified version of a synthetic control method was used to create a "synthetic" California that best resembled pre-policy sociodemographic characteristics and outcome trends in California while correcting time-invariant pre-policy differences. Various sensitivity analyses were also conducted., Results: The implementation of Proposition 56 was associated with an increase in self-reported cigarette price per pack in California ($1.844, 95%CI: $0.153, $3.534; p = 0.032). No evidence suggested that Proposition 56 was associated with the changes in the prevalence of current or daily cigarette use, cigarette consumption per day, or the prevalence of current or daily use of non-cigarette tobacco products., Conclusion: Most of the cigarette tax increase following Proposition 56 in California was passed on to consumers. There is a lack of evidence that the implementation of Proposition 56 was associated with the changes in the use of cigarettes and other tobacco products such as hookah, pipe, cigar, and smokeless tobacco., Competing Interests: The authors have declared that no competing interests exist.

Objectives: Compare the brand availability, pricing and presence of illicit products in semi-urban and rural areas in India across product types and states. Methods: In late 2017, 382 unique tobacco products were purchased from localities with populations under 50,000 in the states of Assam, Karnataka, Maharashtra, Rajasthan, and Uttar Pradesh. Brand, printed maximum retail price, price paid, tax, and health warning labels (HWLs) were used to compare the market for bidis, smokeless tobacco (SLT), and cigarettes. Results: Brand availability and pricing of SLT products was similar to cigarettes. Brand availability and pricing of bidis was consistent with having many small producers. Bidis and single serving SLT with spice mixtures were more affordable than cigarettes and SLT sold alone. 2% of SLT and 10% of cigarettes did not feature an India HWL. Conclusion: The elimination of single serving SLT packets and the removal of tax exemptions for small producers, often exploited by bidi producers, could reduce their respective affordability. State differences in illegal and illicit products could indicate a greater need for enforcement in some states., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Welding, Iacobelli, Saraf, Smith, Puntambekar, Gupta and Cohen.)

India is the second-largest consumer of tobacco in the world, second only to China. The World Health Organization's Framework Convention on Tobacco Control (WHO FCTC) is an evidence-based treaty which consists of demand reduction and supply reduction measures. Article 6 of the WHO FCTC requires the Parties to implement tax policies and where appropriate, price policies, on tobacco products so as to contribute to the health objectives aimed at reducing tobacco consumption. The article aimed to analyze the association between taxation structures of smokeless tobacco (SLT) and the prevalence of SLT use at the country level. The article concluded that just as cigarettes, SLT taxes, and prices are also key factors in controlling the demand for SLT products. It calls for uniform taxation across all types of tobacco products for effective and sustained impact and also to prevent product substitution., Competing Interests: None

The Asian-Eastern Mediterranean block has increased inhabitation of the smokeless tobacco users. Due to geopolitical reasons, Pakistan is one of the countries which is in danger of suffering from future smokeless tobaccorelated morbidity and mortality due to weak policy measures. This paper is an overview of smokeless tobacco control measures practised in Pakistan, in comparison to its neighbouring countries sharing similar socio-cultural parameters. Tobacco control reports confined only to smokeless tobacco control were extracted for the region of Southeast Asia and Eastern Mediterranean regions published under World Health Organisation. The selection of countries from each region was based upon the fulfilment of the criterion of sharing common borders with Pakistan and holding a signatory status under framework convention on tobacco control. There is a need to revise existing tobacco control strategy to include smokeless tobacco reforms over pricing, packaging and media communication in Pakistan.

Background: Little is known about how policies and industry activities impact smokeless tobacco demand. We examined how tobacco control policies and retail promotion may affect smokeless tobacco sales., Methods: We used Nielsen market-level retail scanner data for smokeless tobacco sales in convenience stores in 30 US regions from 2005 to 2010. Tobacco policy variables, including excise taxes, state tobacco control program expenditures, and clean indoor air laws, were merged to Nielsen markets. We estimated regression models for per capita unit sales., Results: Higher cigarette tax was significantly associated with lower sales volume of smokeless tobacco. Sales of smokeless tobacco in markets with a weight-based SLT excise tax were higher than in markets with an ad valorem tax. A higher average product price was associated with decreased sales overall but results varied by package quantity and brand., Conclusions: This study observed that smokeless tobacco products were both complements and substitutes to cigarettes. Thus, smokeless tobacco may act as complements for some population segments and substitutes for others. A weight-based tax generally favors premium smokeless tobacco products.

Objective: To examine the potential impact of the goods and services tax (GST) on price, consumption and tax revenue from tobacco products in India and across states., Methods: Data on prices, tax rates and tax revenue are used to estimate a benchmark scenario prior to the GST implementation in 2017-2018. Using own-price elasticity of demand for tobacco products, we estimate the impact of GST at the state level and the aggregate state-wise impact to obtain the national level impact., Findings: We predict that the statutory GST rate of 28% plus compensation cess will increase the price of cigarettes, bidi and smokeless tobacco by 0.18%, 8.8% and 6%, respectively, and, as a result, it will reduce the weighted average consumption by 0.3%, 10% and 6% and increase tax revenue by 0.17%, 35% and 4.7%, respectively. Most states will experience a fall in tax revenue from tobacco products by more than 50% compared with the value-added tax revenue they collected pre-GST. The GST compensation cess will have to be used to compensate states' revenue shortfalls., Conclusions: The GST has increased the complexity of the tax system for tobacco products. In particular, for cigarettes, the specific cess constitutes the majority of tax revenue, and therefore, it must be revised regularly to protect revenue and keep real prices from falling. In addition, India should reintroduce excise taxation on all tobacco products, at least in part, on top of the GST, to make them less affordable and to smooth the transition after the expiration of the compensation cess., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. No commercial re-use. See rights and permissions. Published by BMJ.)

Purpose: Two previous studies indicate that prosmoking apps might encourage smoking behaviour via smoking cues. The current paper seeks to build on these studies and provide an updated overview of the characteristics of tobacco industry-sponsored apps., Methods: In November 2017, we identified 19 unique top-selling cigarette brands, 20 smokeless tobacco brands, 30 e-cigarette brands and 43 cigar brands based on Nielsen sales from 2016 Nielsen Scantrack data and 2016 Kantar advertising data from the Kantar Media Stradegy database. We searched for these brand-sponsored apps in the Google Play and Apple iTunes US online stores., Results: We identified four cigarette and one smokeless tobacco brand-sponsored apps on the Google Play store, but none in the Apple store. The apps sponsored by Grizzly, Newport, Skoal, Camel and Winston used the last four digits of the users' social security number to verify age. The Marlboro app offered another option in addition to providing a partial social security number-providing a valid home address. The main feature of all apps was location-based, time-sensitive coupons. Some apps had additional functions such as additional detailed product information, interactive help menus and games., Discussion: This paper provides an up-to-date description of apps that are sponsored by tobacco companies. Cessation interventions could consider reminding their target audience to delete these apps to support quit attempts., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. No commercial re-use. See rights and permissions. Published by BMJ.)

International and cross-cultural research is critical for understanding multilevel influences on health, health behaviors, and disease. A particularly relevant area of need for such research is tobacco control. The tobacco epidemic is one of the biggest public health threats globally, killing over 7 million people a year. Research critical to addressing this public health problem has leveraged variability in tobacco use, history, product market, and policies across different countries, settings, and populations, particularly in low- and middle-income countries (LMICs) where the tobacco burden is increasing. These efforts are needed in order to advance the science and inform practice and policy in various settings, including the US. Several funding agencies provide support for international research focused on tobacco control in LMICs because of the importance and implications of such research. This paper provides some concrete examples of how such research has advanced our knowledge-base and informed practice and policy globally, particularly in high-income countries including the US. Some prominent themes emphasized in this manuscript include: the development of knowledge regarding the diverse tobacco products on the market; better understanding of tobacco use and its impact among different populations; generating knowledge about the impacts including unintended consequences of tobacco control policy interventions; and better understanding tobacco industry strategies and informing advocacy efforts. In summary, international tobacco control research, particularly in LMICs, is critical in effectively and efficiently building the evidence base to advance tobacco control research, policy, and practice globally, including the US, with the ultimate goal of curbing the tobacco epidemic., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Background: The full extent of global smokeless tobacco (SLT) use and its association with key demographic factors such as gender, place of residence, and household or country income status is not yet known., Methods: The global burden of SLT use among adults was estimated using nationally representative data of 140 countries by gender and country income group. Countries were grouped in Group 1 (low and low-middle income countries combined) and Group 2 (upper middle and high income countries combined). The number of male and female SLT users was calculated using prevalence and population estimates of corresponding age groups., Results: Nearly one in 10 males and one in 20 females used SLT in some form. SLT use prevalence was significantly higher among males (p < .001) and females (p < .001) in Group 1 countries compared with their counterparts in Group 2 countries. However, for both Group 1 (p < .01) and Group 2 (p < .01), males were more likely to use SLT than females. Nearly 91% of a total 356 million adult SLT users resided in Group 1 countries, with 81.6% in countries of WHO South-East Asia region (SEAR). In SEAR and African region, SLT use was higher in rural areas and poorest communities., Conclusion: The majority of the burden of SLT use is on lower and lower middle income countries with the greatest burden on the poorest segments of the population in these countries., Implications: This study brings the comprehensive information on epidemiology of SLT use among adults at global level. Ninety percent of SLT burden is in low and low-middle income group of countries and more specifically among the poorest group in such countries. These countries need to have strategies to implement different provisions of the WHO Framework Convention on Tobacco Control. The program in such countries should be targeted towards the poorest communities for effective SLT control.

Introduction: This study estimated the health care utilization and expenditures attributable to the use of smokeless tobacco (ST) which includes chewing tobacco, snuff, dip, snus, and dissolvable tobacco among US adults aged 18 and older., Methods: We used data from the 2012-2015 National Health Interview Surveys (n = 139451 adults) to estimate a zero-inflated Poisson (ZIP) regression model on four health care utilization measures among US adults (hospital nights, emergency room [ER] visits, doctor visits, and home care visits) specified as a function of tobacco use status, and other covariates. Tobacco use status was classified into four categories: current ST users, former ST users, non-ST tobacco users, and never tobacco users. ST-attributable utilization was calculated based on the estimated ZIP model using an "excess utilization" approach. It was then multiplied by the unit cost estimated from the 2014 Medical Expenditures Panel Survey data to derive ST-attributable health care expenditures., Results: During 2012-2015, 2.1% of adults were current ST users and 7.7% were former ST users. ST-attributable health care utilization amounted to 681000 hospital nights, 624000 ER visits, and 4.6 million doctor visits per year (home care visits results were not significant). This resulted in annual excess expenditures of $1.8 billion for hospitalizations, $0.7 billion for ER visits, and $0.9 billion for doctor visits, totaling over $3.4 billion (in 2014 dollars)., Conclusion: Comprehensive tobacco control policies and interventions are needed to reduce ST use and the associated health care burden., Implications: This is the first study to assess the impact of ST use on health care burden in the United States. Findings indicate that excess annual health care expenditures attributable to ST use for US adults were $3.4 billion in 2014 dollars.

Introduction: Limited information exists about strategies and methods used on brand marketing websites to transmit pro-tobacco messages to tobacco users and potential users. This study compared age verification methods, themes, interactive activities and links to social media across tobacco brand websites., Methods: This study examined 12 tobacco brand websites representing four tobacco product categories: cigarettes, cigar/cigarillos, smokeless tobacco, and e-cigarettes. Website content was analyzed by tobacco product category and data from all website visits (n = 699) were analyzed. Adult smokers (n = 32) coded websites during a one-year period, indicating whether or not they observed any of 53 marketing themes, seven interactive activities, or five external links to social media sites., Results: Most (58%) websites required online registration before entering, however e-cigarette websites used click-through age verification. Compared to cigarette sites, cigar/cigarillo sites were more likely to feature themes related to "party" lifestyle, and e-cigarette websites were much more likely to feature themes related to harm reduction. Cigarette sites featured greater levels of interactive content compared to other tobacco products. Compared to cigarette sites, cigar/cigarillo sites were more likely to feature activities related to events and music. Compared to cigarette sites, both cigar and e-cigarette sites were more likely to direct visitors to external social media sites., Conclusion: Marketing methods and strategies normalize tobacco use by providing website visitors with positive themes combined with interactive content, and is an area of future research. Moreover, all tobacco products under federal regulatory authority should be required to use more stringent age verification gates., Implications: Findings indicate that the Food and Drug Administration (FDA) should require brand websites of all tobacco products under its regulatory authority use more stringent age verification gates by requiring all visitors be at least 18 years of age and register online prior to entry. This is important given that marketing strategies may encourage experimentation with tobacco or deter quit attempts among website visitors. Future research should examine the use of interactive activities and social media on a wide variety of tobacco brand websites as interactive content is associated with more active information processing.

Background: Tobacco control mass media campaigns are cost-effective in reducing tobacco consumption in high-income countries, but similar evidence from low-income countries is limited. An evaluation of a 2009 smokeless tobacco control mass media campaign in India provided an opportunity to test its cost-effectiveness., Methods: Campaign evaluation data from a nationally representative household survey of 2898 smokeless tobacco users were compared with campaign costs in a standard cost-effectiveness methodology. Costs and effects of the Surgeon campaign were compared with the status quo to calculate the cost per campaign-attributable benefit, including quit attempts, permanent quits and tobacco-related deaths averted. Sensitivity analyses at varied CIs and tobacco-related mortality risk were conducted., Results: The Surgeon campaign was found to be highly cost-effective. It successfully generated 17 259 148 additional quit attempts, 431 479 permanent quits and 120 814 deaths averted. The cost per benefit was US$0.06 per quit attempt, US$2.6 per permanent quit and US$9.2 per death averted. The campaign continued to be cost-effective in sensitivity analyses., Conclusion: This study suggests that tobacco control mass media campaigns can be cost-effective and economically justified in low-income and middle-income countries. It holds significant policy implications, calling for sustained investment in evidence-based mass media campaigns as part of a comprehensive tobacco control strategy., 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.)

Introduction: Cancer has a high mortality rate and morbidity burden in Sri Lanka. This study estimated the economic cost of smoking and smokeless tobacco (ST) related to cancers in Sri Lanka in 2015., Methods: Prevalence-based cost of illness is calculated according to the guidelines of the WHO (2011). The direct costs are costs of curative care (costs of inward patients and outpatient care borne by the state and out of pocket expenditure by households) for tobacco-related cancers, weighted by the attributable fractions for these cancers. Indirect costs are lost earnings due to mortality and morbidity (absenteeism of both patient and carers resulting from seeking care and recuperation).Data were obtained from the Registrar General's Department, National Cancer Registry, Department of Census and Statistics and the Central Bank of Sri Lanka. Household and systemic costs and relative risks were extracted from research studies. Oncologists (working in both public and private sectors), other clinical specialists, medical administrators and economists were consulted during the estimation and validation processes., Results: The total economic cost of tobacco-related cancers for Sri Lanka in 2015 was estimated to be US$121.2 million. The direct cost of smoking and ST-related cancers was US$42.1 million, which was 35% of the total cost, while the indirect cost was US$79.1 million, which was 65% of the total cost., Conclusion: Burden of tobacco smoking and ST-related cancers as reflected in these economic costs is enormous: affecting the healthcare system and country's economy. Policymakers should take note of this burden and address tobacco consumption control as a priority., 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.)

Southeast Asia accounts for nearly 86 per cent of the smokeless tobacco (SLT) consumers in the world. The heterogeneous nature of SLT is a major impediment to using taxation as a tool to regulate SLT. This study was aimed to review issues around fiscal policies on SLT with the objective of providing clarity on the use of taxation as an effective policy instrument to regulate SLT use. Descriptive statistics and graphical representations were used to analyze published data from different sources. An analysis of prices and tax between smoke and SLT products was done to understand the impact of tax policies on SLT consumption. India, Bangladesh and Myanmar together account for 71 per cent of the world SLT users. The retail prices (PPP$) and tax were lower for SLT in low- and lower-middle-income countries and higher in high-income countries, on an average, suggesting a direct relationship between the two. Evidence from India and Bangladesh suggested that taxation had significantly reduced SLT use among adults. The compounded levy scheme used in India to tax SLT was found effective after incorporating speed of packing machines into the assessment of deemed production and tax on SLT products. The current analysis shows that taxation can be an effective instrument to regulate SLT consumption if tax rates are harmonized across SLT products and in a manner not to encourage substitution with other tobacco products. It is also imperative to set a minimum floor price on all tobacco products including SLT., Competing Interests: None

Background & Objectives: Over the past decade, the World Health Organization (WHO) Framework Convention on Tobacco Control (FCTC) has served as a powerful tool to initiate and advance global tobacco control efforts. However, the control strategies have mainly targeted demand-side measures. The goal of a tobacco-free world by 2040 cannot be achieved if the supply-side measures are not addressed. This analysis was undertaken to examine the tobacco control legislations of various Parties ratifying WHO FCTC with an objective to ascertain the status of prohibition of importation, sale and manufacturing of smokeless tobacco products., Methods: All 180 Parties to WHO FCTC were included for the study. A comprehensive database of all the parties to FCTC was created and tobacco control legislations and regulations of all parties were studied in detail., Results: Overall, the sale of smokeless tobacco (SLT) products was prohibited in 45 Parties. Eleven Parties prohibited manufacturing of SLT products and six Parties imposed a ban on importation of SLT products. Australia, Bhutan, Singapore and Sri Lanka banned all three., Interpretation & Conclusions: Comprehensive tobacco control strategy with effective tobacco cessation programme should complement strong legal actions such as prohibition on trade in SLT products to meet the public health objective of such laws and regulations. In addition, multisectoral efforts are needed for effective implementation of such restrictions imposed by the governments., Competing Interests: None

Introduction: Flavors can mask the harshness of tobacco and make it appealing to young people. This study assessed flavored and menthol tobacco product sales at the national and state levels., Methods: Universal Product Code tobacco sales data collected by Nielsen were combined for convenience stores and all-outlets-combined during October 22, 2011-January 9, 2016. Products were characterized as flavored, menthol, or non-flavored/non-menthol. Total unit sales, and the proportion of flavored and menthol unit sales, were assessed nationally and by state for seven tobacco products. Joinpoint regression was used to assess trends in average monthly percentage change., Results: Nationally, the proportion of flavored and menthol sales in 2015 was as follows: cigarettes (32.5% menthol), large cigars (26.1% flavored), cigarillos (47.5% flavored, 0.2% menthol), little cigars (21.8% flavored, 19.4% menthol), chewing tobacco (1.4% flavored, 0.7% menthol), moist snuff (3.0% flavored, 57.0% menthol), and snus (88.5% menthol). From 2011 to 2015, sales increased for flavored cigarillos and chewing tobacco, as well as for menthol cigarettes, little cigars, moist snuff, and snus. Sales decreased for flavored large cigars, moist snuff, and snus, and for menthol chewing tobacco. State-level variations were observed by product; for example, flavored little cigar sales ranged from 4.4% (Maine) to 69.3% (Utah) and flavored cigarillo sales ranged from 26.6% (Maine) to 63.0% (Maryland)., Conclusions: Menthol and flavored sales have increased since 2011, particularly for the products with the highest number of units sold, and significant state variation exists. Efforts to restrict flavored tobacco product sales could reduce overall U.S. tobacco consumption., Implications: Flavors in tobacco products can mask the harshness of tobacco and make these products more appealing to young people. This is the first study to assess national and state-level trends in flavored and menthol tobacco product sales. These findings underscore the importance of population-based interventions to address flavored tobacco product use at the national, state, and local levels. Additionally, further monitoring of flavored and menthol tobacco product sales can inform potential future regulatory efforts at the national, state, and local levels.

Introduction: Rural Americans are particularly vulnerable to tobacco price reducing promotions are known to be directed to and used by vulnerable populations. Tobacco purchasing decisions, such as unit quantity purchased, may vary by rurality, by price promotion use, and possibly by the interaction between the two. Purchase decisions are likely to affect tobacco use behavior. Therefore, explanation of variation in tobacco purchase quantity by factors associated with rural vulnerability and factors that fall under the regulatory scope of the Tobacco Control Act (TCA) of 2009 could be of value to regulatory proposals intended to equitably benefit public health., Methods: Our sample included 54 combustible tobacco users (298 purchase events) and 27 smokeless tobacco users (112 purchase events), who were asked to report all tobacco purchases on a smartphone application. We used an ecological momentary assessment methodology to collect data about tobacco users' purchasing patterns, including products, quantity purchased, and use of price promotions. A parent cohort study provided relevant data for home-outlet distance calculation and covariates. Our analysis examined associations between our outcome-purchase quantity per purchase event-and distance from participant's home to the nearest outlet, whether a price reducing promotion was used, and the interaction of these two factors., Results: Combustible users showed an increased cigarette pack purchase quantity if they lived further from an outlet and used a price promotion (i.e., an interaction effect; RR = 1.70, 95% CI [1.11, 2.62]). Smokeless users purchased more units of snuff when they used price promotions (RR = 1.81, 95% CI [1.02, 3.20])., Conclusions: Regulatory action that imposes restrictions on the availability or use of price promotions could alter the purchasing behavior of rural Americans in such a way that makes it easier to reduce tobacco use or quit. Such action would also restrict flexibility in the price of tobacco products, which is known as a powerful tobacco control lever., (Copyright © 2018. Published by Elsevier Ltd.)

Introduction: Tobacco control actors increasingly recognise the importance of supply-side issues in seeking to address the problem of global tobacco consumption. However, research in this field often depicts tobacco production as a problem for farmers and as a malaise of the global industry. This paper the case of chewing tobacco producers in South India to explore why tobacco remains so resilient in this region., Methods: Semi-structured interviews with 68 tobacco farmers and traders in 38 villages across five districts of Tamil Nadu, triangulated with informal discussions with over 100 agrarian actors both connected and unconnected to tobacco, extensive ethnographic field notes, and interviews with state and NGO actors. Representative sampling was not possible due to a lack of data on what constituted the 'population'. Therefore interviews were based on snowballing methods, with the aim being to capture the general scenario across five districts where tobacco is produced., Results: The case highlighted the lack of a clear 'industry' which was exploiting farmers. Instead, tobacco was favoured by producers due to its drought resistance in a region of water scarcity, and it offered high levels of remuneration in certain circumstances where farmers are able to cure the leaf. It also afforded increased bargaining power to farmers in relation to traders as it is able to be stored and sold in low seasons by some. Finally, where exploitation of farmers by traders was evident, this was not necessarily unique to tobacco., Discussion: The paper ultimately advocates further research on locally specific settings to better understand why tobacco cash crop remains so resilient in the Global South today, and a move beyond problematisations of the tobacco industry alone when looking at production., 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: While increasing cigarette taxes has been a major policy driver to decrease smoking, taxes on other tobacco products have received less attention. Our aims were to evaluate the impact of chewing tobacco/cigar taxes, cigarette taxes, and smoke-free legislation on adolescent male and female use of smokeless tobacco and cigars., Methods: We analyzed data on 499,381 adolescents age 14-18 years from 36 US states in the Youth Risk Behavior Surveys (1999-2013) linked to state-level tobacco control policies. We conducted difference-in-differences regression models to assess whether changes in taxes and the enactment of smoke-free legislation were associated with smokeless tobacco use and, separately, cigar use. Models were stratified by adolescent sex., Results: We found that chewing tobacco taxes had no effect on smokeless tobacco use and cigar taxes had no effect on cigar use. In contrast, among males a 10% increase in cigarette taxes was associated with a 1.0 percentage point increase (0.0010, 95% CI 0.0003-0.0017) in smokeless tobacco use. A 10% increase in cigarette taxes was also associated with a 1.5 percentage point increase (0.0015, 95% CI 0.0006-0.0024) in cigar use among males and a 0.7 percentage point increase (0.0007, 95% CI 0.0001-0.0013) in cigar use among females. There was some evidence that smoke-free legislation was associated with an 1.1 percentage point increase (0.0105, 95% CI 0.0015-0.0194) in smokeless tobacco use among males only, but no effect of smoke-free legislation on cigar use for males or females., Conclusions: Higher state cigarette taxes are associated with adolescents' use of cheaper, alternative tobacco products such as smokeless tobacco and cigars. Reducing tobacco use will require comprehensive tobacco control policies that are applied equally to and inclusive of all tobacco products.

Introduction: Snus may present lower health risks than cigarettes, but its harm reduction potential may be undermined if used dually with cigarettes. The likelihood of exclusive snus use compared with dual use may depend in part on the capacity of snus to deliver nicotine in doses that are satisfactory to smokers. We examined characteristics of "American snus" products, including nicotine levels, and compared to snus products that are more typical of Sweden., Methods: Tobacco industry reports for snus products submitted to the Massachusetts Department of Public Health for the year 2014 were used to assess moisture (%), pH, total nicotine, and unionized (free) nicotine (both mg/g and percent of total). A total of 14 ("American") snus products made by American manufacturers Philip Morris USA (n = 6), R.J. Reynolds Tobacco Company (n = 6), and US Smokeless Tobacco Company (n = 2), were compared with Swedish-style ("Swedish") snus products (n = 10) made by Swedish Match North America., Results: Compared with Swedish snus, American snus brands contained significantly lower concentrations of unionized nicotine (median: 0.52 mg/g vs. 6.52 mg/g; p < .001) and proportion of unionized nicotine (median: 3.17% vs. 81.8%; p < .001). American snus brands also had significantly lower pH (median: 6.54 vs. 8.68; p < .001) and moisture (median: 30.3% vs. 53.4%; p < .001)., Conclusions: Swedish-made snus has higher unionized nicotine, measured by concentration and proportion of total nicotine, compared with snus products made by American manufacturers. These findings suggest that American snus products have lower addiction potential than Swedish snus, and may be more likely to be used dually with cigarettes than as a sole source of nicotine., Implications: American snus products contain significantly lower unionized nicotine, lower pH, and lower moisture, compared with Swedish snus products. Snus addiction potential and patterns of usage, including co-use with cigarettes, may differ between American and Swedish snus products due to differences in snus product characteristics., (© The Author(s) 2016. Published by Oxford University Press on behalf of the Society for Research on Nicotine and Tobacco. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Purpose: To examine the sources of tobacco coupons and their influence on susceptibility to snus use., Design: Cohort study., Setting: Minnesota Adolescent Community Cohort Study., Subjects: A population-based sample of US Midwest young adults in 2011 to 2012 and 2012 to 2013 (aged 22-28; n = 2384)., Measures: Exposure to coupons for various tobacco products through various sources in the past 6 months, susceptibility to snus use., Analysis: Multiple logistic regressions., Results: During the 6 months prior to 2012 to 2013 survey, 11% of the sample received coupons for cigarettes, 5% received coupons for snus, 3% received coupons for other smokeless tobacco products, and <1% received coupons for little cigars. Direct mail was the most commonly cited source of cigarette and snus coupons. Tobacco product packaging provided the highest number of tobacco coupons for current and former smokers. Participants without a 4-year college education (compared to those who had a 4-year college education) were more likely to have received coupons for cigarettes and snus and received more coupons for both products ( P < .05). Racial/ethnic minority young adults (vs non-Hispanic white) received more cigarette and snus coupons ( P < .05). Receiving snus coupons was positively associated with susceptibility to snus use ( P < .05)., Conclusion: Tobacco companies are successful in reaching young adults using coupons for various tobacco products. Snus coupons may influence snus use, similar to how cigarette coupons influence smoking.

Background: Socioeconomic differentials of tobacco smoking in high-income countries are well described. However, studies to support health policies and place monitoring systems to tackle socioeconomic inequalities in smoking and smokeless tobacco use common in low-and-middle-income countries (LMICs) are seldom reported. We aimed to describe, sex-wise, educational and wealth-related inequalities in tobacco use in LMICs., Methods: We analysed Demographic and Health Survey data on tobacco use collected from large nationally representative samples of men and women in 54 LMICs. We estimated the weighted prevalence of any current tobacco use (including smokeless tobacco) in each country for 4 educational groups and 4 wealth groups. We calculated absolute and relative measures of inequality, that is, the slope index of inequality (SII) and relative index of inequality (RII), which take into account the distribution of prevalence across all education and wealth groups and account for population size. We also calculated the aggregate SII and RII for low-income (LIC), lower-middle-income (lMIC) and upper-middle-income (uMIC) countries as per World Bank classification., Findings: Male tobacco use was highest in Bangladesh (70.3%) and lowest in Sao Tome (7.4%), whereas female tobacco use was highest in Madagascar (21%) and lowest in Tajikistan (0.22%). Among men, educational inequalities varied widely between countries, but aggregate RII and SII showed an inverse trend by country wealth groups. RII was 3.61 (95% CI 2.83 to 4.61) in LICs, 1.99 (95% CI 1.66 to 2.38) in lMIC and 1.82 (95% CI 1.24 to 2.67) in uMIC. Wealth inequalities among men varied less between countries, but RII and SII showed an inverse pattern where RII was 2.43 (95% CI 2.05 to 2.88) in LICs, 1.84 (95% CI 1.54 to 2.21) in lMICs and 1.67 (95% CI 1.15 to 2.42) in uMICs. For educational inequalities among women, the RII varied much more than SII varied between the countries, and the aggregate RII was 14.49 (95% CI 8.87 to 23.68) in LICs, 3.05 (95% CI 1.44 to 6.47) in lMIC and 1.58 (95% CI 0.33 to 7.56) in uMIC. Wealth inequalities among women showed a pattern similar to that of men: the RII was 5.88 (95% CI 3.91 to 8.85) in LICs, 1.76 (95% CI 0.80 to 3.85) in lMIC and 0.39 (95% CI 0.09 to 1.64) in uMIC. In contrast to men, among women, the SII was pro-rich (higher smoking among the more advantaged) in 13 of the 52 countries (7 of 23 lMIC and 5 of 7 uMIC)., Interpretation: Our results confirm that socioeconomic inequalities tobacco use exist in LMIC, varied widely between the countries and were much wider in the lowest income countries. These findings are important for better understanding and tackling of socioeconomic inequalities in health in LMIC., Competing Interests: Competing interests: None declared., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.)

Despite the high prevalence of smokeless tobacco (SLT) use among adults in Bangladesh, SLT was not included in the Tobacco Control Law till 2013. Information on SLT use among Bangladeshi people is inadequate for policymaking and implementing effective control measures. With the aim to identify the prevalence and trends of different SLT products, health and economic impacts, manufacture, and sale of and policies related to SLT in Bangladesh, we carried out a literature review, which involved literature search, data extraction, and synthesis. Evidence suggests that in Bangladesh, SLTs range from unprocessed to processed or manufactured products including Sada Pata, Zarda, Gul, and Khoinee. Over 27% of Bangladeshi adults aged 15 years and older use SLT in one form or other. SLT use is associated with age, sex, education, and socioeconomic status. SLT consumption has reportedly been associated with increased prevalence of heart diseases, stroke, and oral cancer and led to around 320,000 disability adjusted life years lost in Bangladesh in 2010. No cessation service is available for SLT users in public facilities. Compared to cigarettes, taxation on SLT remains low in Bangladesh. The amendment made in Tobacco Control Law in 2013 requires graphic health warnings to cover 50% of SLT packaging, ban on advertisement of SLT products, and restriction to sale to minors. However, implementation of the law is weak. As the use of SLT is culturally accepted in Bangladesh, culturally appropriate public awareness program is required to curb SLT use along with increased tax and cessation services.

Rationale: Behavioral economic measures of demand provide estimates of tobacco product abuse liability and may predict effects of policy-related price regulation on consumption of existing and emerging tobacco products., Objective: In the present study, we examined demand for snus, a smokeless tobacco product, in comparison to both cigarettes and medicinal nicotine. We used both a naturalistic method in which participants purchased these products for use outside the laboratory, as well as laboratory-based self-administration procedures., Methods: Cigarette smokers (N = 42) used an experimental income to purchase their usual brand of cigarettes and either snus or gum (only one product available per session) across a range of prices, while receiving all products they purchased from one randomly selected price. In a separate portion of the study, participants self-administered these products during laboratory-based, progressive ratio sessions., Result: Demand elasticity (sensitivity of purchasing to price) was significantly greater for snus than cigarettes. Elasticity for gum was intermediate between snus and cigarettes but was not significantly different than either. Demand intensity (purchasing unconstrained by price) was significantly lower for gum compared to cigarettes, with no significant difference observed between snus and cigarettes. Results of the laboratory-based, progressive ratio sessions were generally discordant with measures of demand elasticity, with significantly higher "breakpoints" for cigarettes compared to gum and no significant differences between other study products. Moreover, breakpoints and product purchasing were generally uncorrelated across tasks., Conclusions: Under naturalistic conditions, snus appears more sensitive to price manipulation than either cigarettes or nicotine gum in existing smokers.

Introduction: National data from 2004 to 2010 showed that despite decreases in non-menthol cigarette use prevalence, menthol cigarette use prevalence remained constant in adolescents and adults and increased in young adults. The purpose of the current study was to extend these analyses through 2014., Methods: We estimated the prevalence of menthol cigarette smoking in the USA during 2004-2014 using annual cross-sectional data on persons aged ≥12 years from the National Survey on Drug Use and Health. Self-reported menthol status for selected brands that were either exclusively menthol or non-menthol were adjusted based on retail sales data. Data were weighted to provide national estimates., Results: Although overall smoking prevalence has decreased, the proportion of past 30-day cigarette smokers using menthol cigarettes was higher (39%) in 2012-2014 compared to 2008-2010 (35%). Youth smokers remain the most likely group to use menthol cigarettes compared to all other age groups. Menthol cigarette prevalence has increased in white, Asian and Hispanic smokers since 2010. Menthol cigarette prevalence exceeded non-menthol cigarette prevalence in youth and young adult smokers in 2014. Among smokers, menthol cigarette use was positively correlated with co-use of cigars. Menthol cigarette and smokeless tobacco co-use also increased from 2004 to 2014., Conclusions: The youngest smokers are most likely to use menthol cigarettes. Among smokers, increases in overall menthol cigarette use and menthol cigarette use in whites, Asians and Hispanics since 2010 are of concern. There is tremendous urgency to limit the impact of menthol cigarettes on public health, particularly the health of youth and young adults., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.)

Background: In 2010, the global adult tobacco survey (GATS) for India revealed that nearly 40% of current smokers and 42% of current chewers had initiated tobacco use before they were of the legal age (18 years old or over). Global evidence shows that those who initiate earlier have a lower probability of quitting the use of tobacco during their lifetime. In order to sustain its profits, the tobacco industry will make every effort to recruit underage users who become lifelong users of their products., Aims and Objectives: We estimate the consumer expenditure on tobacco products by underage users in India., Methodology: Using nationally representative data we estimated the number of daily underage tobacco users for a year and their annual expenditure on different types of smoked and chewed tobacco products., Results: There are nearly 4.4 million underage daily tobacco users (age group 15-17 years old) in India. Approximately 7.2% of the population in the 15-17 age group are current daily users of tobacco (0.1% cigarette smokers, 0.5% bidi smokers and 6.6% tobacco chewers). Underage users spend nearly US$16.9 million and US$270.8 million respectively on smoking and chewing tobacco products., Conclusion: There is a substantial expenditure on tobacco products by underage individuals in India. A significant number of new users are added every year that provide an estimate for the size and nature of the future of the tobacco epidemic, one on which the tobacco industry depends on for its sustenance. The government of India's efforts to reduce sale to underage users has had limited effect and needs to be strengthened., (© The Author(s) 2015.)

Introduction: Regulatory imbalances exist in the treatment of cigarettes and non-cigarette tobacco products in the USA. We assessed whether declines in cigarette consumption during 2002-2012 were offset by increased use of non-cigarette tobacco products-cigars, pipes, roll-your-own (RYO) and smokeless tobacco., Methods: Industry-reported taxable removals (actual sales) were converted into packs for cigarettes and cigarette pack equivalents (CPEs) for loose tobacco (RYO plus pipe tobacco) and moist snuff. Cigars were not converted to CPEs because of their heterogeneity in size/tobacco content. Per capita sales were calculated for the US adult population aged ≥18 years based on the US Census Bureau data. Self-reported data on current (past 30-day) tobacco use among US adults aged ≥18 years were from the National Survey on Drug Use and Health (NSDUH). Joinpoint and logistic regression were used to assess linear trends during 2002-2012., Results: During 2002-2012, cigarette sales declined from 96.91 to 59.85 cigarette packs per capita; increases occurred for sale of cigars (30.51-57.42 cigars per capita), loose tobacco (2.50-5.63 CPEs per capita) and moist snuff (10.64-14.58 CPEs per capita; all p<0.05 for trend). Self-reported current cigarette smoking declined during 2002-2012 (27.4-23.6%); increases were noted for current RYO (2.6-3.6%) and smokeless tobacco use (3.5-3.7%; all p<0.05 for trend)., Conclusions: The increase in non-cigarette tobacco consumption is a public health concern because all tobacco products are harmful. Eliminating imbalances in tax structure and regulations between cigarettes and non-cigarette tobacco products may help reduce aggregate tobacco consumption., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/)

Tobacco companies have begun to acquire pharmaceutical subsidiaries and recently started to market nicotine replacement therapies, such as Zonnic nicotine gum, in convenience stores. Conversely, tobacco companies are producing tobacco products such as tobacco chewing gum and lozenges that resemble pharmaceutical nicotine replacement products, including a nicotine pouch product that resembles snus pouches. This convergence of nicotine and tobacco product marketing has implications for regulation and tobacco cessation.

This investigation provides an updated survey measuring the levels of N'-nitrosonornicotine (NNN) and water content of a select number of smokeless tobacco products sold in the United States in 2015. A total of 34 smokeless tobacco products were collected and analyzed for NNN and water content using LC-MS/MS and GC-TCD, respectively. Smokeless tobacco products were chosen to obtain a representative sample of the different types of products on the U.S. market. These smokeless products represent 12 of the 25 top-selling smokeless tobacco products according to 2013 Nielsen net sales data while five of the smokeless tobacco products are of lower selling smokeless tobacco products. The NNN levels and the water content of the smokeless tobacco products were determined and compared to previous studies. Although the range of NNN levels found was broad for the examined smokeless tobacco products (0.64-12.0 μg/g dry weight), dry snuff had the highest levels of NNN observed (>5 μg/g dry weight). We observed a general decrease in NNN levels for the same six moist snuff products that were analyzed in 2004 compared to our current 2015 study. The water content of the smokeless tobacco products surveyed ranged from 3.92 to 54.8%.

Introduction: The US Food and Drug Administration can require changes in warning statements for modified risk tobacco products. We report an independent analysis of a consumer perception survey sponsored by Swedish Match as part of a Modified Risk Tobacco Product application to change warning labels for Swedish snus products., Methods: The survey exposed each of 4324 daily exclusive cigarette smokers, 1033 daily smokeless tobacco users, 1205 daily other tobacco users, 726 former users, and 5915 triers/never users to one of four current warnings and two proposed relative-risk labels (No tobacco product is safe, but this product presents lower risks to health than cigarettes, or No tobacco product is safe, but this product presents substantially lower risks to health than cigarettes) for snus. Descriptive and logistic regression analyses examined four outcomes: believability, harmfulness, motivation to use, and intention to buy snus., Results: Compared with the current not-safe-alternative warning, adult tobacco users who viewed the proposed labels perceived them as less believable, perceived snus as less harmful and were more likely to use and buy snus. The proposed labels had no impact on former smokers' likelihood to use and buy snus; triers/never users viewing the substantially lower risk label were more likely to buy snus., Conclusions: Tobacco users viewing the proposed labels perceived snus as less harmful than cigarettes and may be more likely to use and buy snus. If labeling changes lead to increased snus use and cigarette reduction or abstinence, public health may benefit. If the opposite occurs, public health could suffer., (© The Author 2015. Published by Oxford University Press on behalf of the Society for Research on Nicotine and Tobacco. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Introduction: Most South Asian countries are signatories to the WHO Framework Convention for Tobacco Control (FCTC). However, there is little information on the extent to which FCTC standards are effectively implemented for controlling smokeless tobacco (SLT)-used by over 250 million people in the region. We assessed the feasibility of a novel approach based on interviewing the key actors of SLT supply chain and analyzing its findings using standards set by FCTC., Methods: Using a snowball-sampling technique, we interviewed point-of-sale vendors, wholesale retailers, manufacturers, raw-tobacco retailers, and farmers involved in the supply chain of SLT in Bangladesh, Nepal, and Pakistan. Using a structured-questionnaire, participants were asked about their customer profiles; product types; marketing practices; suppliers; profit margins, awareness and adherence to legislation., Results: We recruited 72% (130/180) of all supply chain actors approached. Findings indicate several loopholes in the existing taxation, regulatory, and inspection systems. A significant proportion of smuggled and counterfeit SLT products are available in the market. Most SLT products are sold without recommended warnings, information on their ingredients, and manufacturers' details. There appear to be no restrictions on sale of SLT products to minors. On the other hand, there are also several incentives built-in the supply chain that makes tobacco farming, SLT manufacturing, and its sale a profitable business., Conclusions: Our novel approach to study SLT control was successful in identifying and interviewing actors involved in its supply chain. The analysis using FCTC could provide valuable information to policy makers and enable them to effectively regulate SLT products., (© The Author 2015. Published by Oxford University Press on behalf of the Society for Research on Nicotine and Tobacco. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: In 2013, the State of Minnesota Legislature passed a tobacco tax increase that increased the combined cigarette excise and sales tax by US$1.75 (from US$1.60 to US$3.35) and increased the tax on non-cigarette tobacco products from 70% to 95% of the wholesale price. The current study explores the change in tobacco prices in retail locations and whether the tax increase was fully passed to consumers., Methods: An observational study of tobacco retail prices was performed in a sample of 61 convenience stores in Minnesota, North Dakota, South Dakota and Wisconsin. Six rounds of data were collected between May 2013 and January 2014. In each round, purchases were made at the same stores for the same four tobacco products (Camel Blue cigarettes, Marlboro Gold cigarettes, Grizzly Wintergreen moist smokeless tobacco and Copenhagen Wintergreen moist smokeless tobacco)., Results: For all studied tobacco products, prices in Minnesota increased significantly after the tax increase (Round 1-Round 6). After controlling for price changes in neighbouring states, the average price difference in Minnesota for the two cigarette brands increased by US$1.89 and US$1.81, which are both more than the US$1.75 tax increase. For moist smokeless, the average price difference increased by US$0.90 and US$0.94. Significant price changes were not observed in the comparison states. After the introduction of the minimum moist smokeless tax, a significantly higher proportion of Minnesota stores offered price promotions on smokeless tobacco., Conclusions: A large tobacco tax resulted in an average retail cigarette price exceeding the tax, suggesting the industry over-shifted the cigarette tax increase to consumers in Minnesota. The findings support the known public health benefit of tobacco tax increases while highlighting the need for additional information about how, or if, tobacco companies use price promotions to blunt the impact of tax increases., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/)

Although the primary form of tobacco use worldwide is cigarette smoking, the large majority of users in India consume smokeless forms of tobacco. There is little evidence on the role of policy-related factors in shaping the demand for smokeless tobacco (ST) in India. This study evaluates the relationship between two such factors, prices and advertising, and ST use in India, using data on 67,737 individuals from the Global Adult Tobacco Survey (GATS) India 2009. We find that ST advertising is more likely to influence ST consumption in women than men, while men are more likely to respond to changes in ST price. We estimate that among adult males in India, the total price elasticity of ST demand is -0.212, which is close to estimates reported for males in the U.S. We do not find strong direct evidence on the economic substitutability or complementarity of smoked and smokeless products. However, the positive association between former smoking and current smokeless use may point to temporal substitutability at the individual level. The findings have implications on the relative effectiveness of policy tools across genders in India - increasing the prices of ST products may discourage ST use particularly among men, and advertising restrictions may play a relatively larger role in the consumption behavior of women in India., (Published by Elsevier Ltd.)

Background: We assessed how varying definitions of adult current smokeless tobacco (SLT) use affected overall prevalence estimates., Methods: National prevalence estimates were from five surveys: 2009-2010 National Health and Nutrition Examination Survey (NHANES), 2009-2010 National Adult Tobacco Survey (NATS), 2010-2011 Tobacco Use Supplement of the Current Population Survey (TUS-CPS), 2010 National Survey on Drug Use and Health (NSDUH), and 2010 National Health Information Survey (NHIS). State-specific prevalence estimates were from three surveys: 2009-2010 NATS, 2010-2011 TUS-CPS, and 2010 Behavioral Risk Factor Surveillance System (BRFSS). Current SLT use definitions were as follows: past 5-day use (NHANES), past 30-day use (NATS and NSDUH), and "every day" or "some days" use (TUS-CPS, NHIS, and BRFSS). Inter-survey variations further existed in number and types of SLT products assessed., Results: National prevalence estimates of current SLT use were as follows: NATS (3.9%), NSDUH (3.6%), NHIS (2.8%), NHANES (2.3%), and TUS-CPS (1.6%). State-specific prevalence estimates of SLT use were generally lower for TUS-CPS (median=2.1%, range: 0.5% in California and New York, to 7.2% in Wyoming) compared to either BRFSS (median=4.0%: range: 0.9% in Washington D.C., to 8.2% in Wyoming) or NATS (median=4.7%; range: 1.3% in New Jersey, to 9.8% in Wyoming)., Conclusion: Concerted efforts are needed among interagency groups to harmonize SLT definition within different surveys., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Background: Sales of smokeless tobacco products have increased in the USA. More than one in eight males in the 12th grade are current users of smokeless tobacco. Surveillance data examining nicotine levels of smokeless tobacco subsequent to 2006 have not been reported in the literature., Methods: Data on nicotine levels and design features (eg, pH, moisture content, leaf cut and flavour) of smokeless tobacco products sold in Massachusetts were obtained from manufacturers between 2003 and 2012. Design features, levels and temporal trends in unionised (free) nicotine and nicotine content of smokeless tobacco products were analysed overall and by manufacturer and product type., Results: The annual total number of moist snuff products increased from 99 in 2003 to 127 in 2012. The annual total number of reported snus products increased from 4 in 2003 to the highest level of 62 in 2011, before decreasing to 26 in 2012. Overall, mean unionised (free) nicotine remained relatively stable (β=0.018 (95% CI -0.014 to 0.050) mg/g dry weight/year) from 2003 to 2012. However, both levels and temporal trends of mean free nicotine varied significantly among manufacturers (p<0.001). Since 2003, the free nicotine content of snus has increased at an overall rate of 0.192 (95% CI 0.138 to 0.246) mg/g dry weight/year, but varied by manufacturer (p<0.001)., Conclusions: The number of smokeless tobacco products increased in the Massachusetts market. Further, mean unionised (free) nicotine levels in smokeless tobacco products of several manufacturers continued to rise despite decreasing levels from other manufacturers. The current success in tobacco control is very likely undermined without government surveillance, regulation and widespread public disclosure of nicotine levels in these products., (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.)

The time has come for the world to acknowledge the unacceptability of the damage being done by the tobacco industry and work towards a world essentially free from the sale (legal and illegal) of tobacco products. A tobacco-free world by 2040, where less than 5% of the world's adult population use tobacco, is socially desirable, technically feasible, and could become politically practical. Three possible ways forward exist: so-called business-as-usual, with most countries steadily implementing the WHO Framework Convention on Tobacco Control (FCTC) provisions; accelerated implementation of the FCTC by all countries; and a so-called turbo-charged approach that complements FCTC actions with strengthened UN leadership, full engagement of all sectors, and increased investment in tobacco control. Only the turbo-charged approach will achieve a tobacco-free world by 2040 where tobacco is out of sight, out of mind, and out of fashion--yet not prohibited. The first and most urgent priority is the inclusion of an ambitious tobacco target in the post-2015 sustainable development health goal. The second priority is accelerated implementation of the FCTC policies in all countries, with full engagement from all sectors including the private sector--from workplaces to pharmacies--and with increased national and global investment. The third priority is an amendment of the FCTC to include an ambitious global tobacco reduction goal. The fourth priority is a UN high-level meeting on tobacco use to galvanise global action towards the 2040 tobacco-free world goal on the basis of new strategies, new resources, and new players. Decisive and strategic action on this bold vision will prevent hundreds of millions of unnecessary deaths during the remainder of this century and safeguard future generations from the ravages of tobacco use., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Introduction: Smokeless tobacco use occupies a significant portion of overall tobacco consumption in Bangladesh. Yet very little is known about the effectiveness of tax and price policy in controlling the use of smokeless tobacco use in the country., Methods: The paper examines the price distribution of various smoked (cigarette, bidi) and smokeless tobacco products (zarda, gul) using the univariate Epanechnikov kernel density function. It estimates the own and cross price elasticity of demand for the most widely used smokeless tobacco product zarda using two-step regression analysis. The analysis is based on data from the ITC Bangladesh Wave 3 Survey which is a nationally representative cohort survey of tobacco users and nonusers conducted in in Bangladesh during 2011-12., Results: The price elasticity of lower price brands of zarda is estimated at -0.64 and of higher priced brands at -0.39, and the cross price elasticity of zarda with respect to cigarette price at 0.35. The tax increase on smokeless tobacco needs to be greater than the tax increase on smoked tobacco to bridge the wide price differential between the two types of products that currently encourages downward substitution from smoked to smokeless tobacco and discourages quitting behavior., Conclusions: This paper argues that increasing tax on smokeless tobacco simultaneously with the tax increase on smoked tobacco can have significant negative impact on the prevalence of smokeless tobacco use in Bangladesh. Finally, a specific excise system replacing the existing ad valorem excise tax can substantially contribute to the revenue collection performance from smokeless tobacco products.

Background: The role of fiscal policy, especially taxation, though has been proved to be an effective instrument of tobacco control, its application is limited in India due to several reasons. This paper examines the tax structure, price and affordability of SLT products in order to provide evidence on how to strengthen the role of fiscal policy in tobacco control., Method: Secondary data on tax structure and revenue from tobacco products were collected from the Ministry of Finance, Government of India. In order to measure the rise of prices corresponding to the increase in tax rate, the retail price index (RPI) and Whole Price Index (WPI) of SLT products were compared with the price index for all commodities for the period 2006-2012. The affordability of tobacco products is calculated by dividing prices of tobacco products by per capita income., Results: During the last 6 years, the tax rate on SLT has gone up leading to a rise in the prices of SLT products more than the general price rise. However, the price rise is less than the per capita income growth indicating increasing affordability. The study observed a decline in the consumption of zarda and kahini due to the price increase during 2008-2013. However, the decline in the consumption of zarda is less compared with khaini due to a very low rise in its price., Conclusion: The prices should be raised more than the growth in income to influence consumption. Tax administration is a major challenge for SLT products and strengthening it could enhance revenue collection from SLT products.

Introduction: The developing world, including countries like India, has become a major target for the tobacco industry to market its products. This study examines the influence of the marketing (advertising and promotion) of tobacco products on the use of tobacco by adults (ages 15 and over) in India., Method: Data from Global Adult Tobacco Survey 2009-2010 was analyzed using methods for complex (clustered) sample designs. Multivariate logistic regression was employed to predict the use of different tobacco products by level of exposure to tobacco marketing using adults who have never used tobacco as the reference category. Odds ratios (ORs) were adjusted for education, gender, age, state of residence, wealth index, and place of residence (urban/rural)., Results: Adults in India were almost twice as likely to be current smokers (versus never users) when they were exposed to a moderate level of bidi or cigarette marketing. For bidis, among adults with high exposure, the OR for current use was 4.57 (95% confidence interval [CI]: 1.6, 13.0). Adults were more likely to be current users of smokeless tobacco (SLT) with even a low level of exposure to SLT marketing (OR = 1.24 [95% CI: 1.1, 1.4]). For SLT, the ORs showed an increasing trend (P for trend < 0.001) with greater level of exposure (moderate, OR = 1.55 [95% CI: 1.1, 2.2]; high, OR = 2.05 [95% CI: 0.8, 5.1]). The risk of any current tobacco use rose with increasing level of exposure to any marketing (minimum, OR = 1.25 [1.1-1.4]; moderate, OR = 1.38 [1.1-1.8]; and high, OR = 2.73 [1.8-4.2]), with the trend highly significant (P < 0.001)., Conclusion: Exposure to the marketing of tobacco products, which may take the form of advertising at the point of sale, sales or a discounted price, free coupons, free samples, surrogate advertisements, or any of several other modalities, increased prevalence of tobacco use among adults. An increasing level of exposure to direct and indirect advertisement and promotion is associated with an increased likelihood of tobacco use.

Background: Tobacco use is common in India and a majority of users are in rural areas. We examine tobacco use and smoking quit rates along gender and socioeconomic dimensions in rural Andhra Pradesh., Design and Methods: Data come from a cross-sectional survey. Markers of socioeconomic status (SES) were education, occupation, and income. Regression analyses were undertaken to examine determinants of current smoking, smoking quit rates, tobacco use by type (cigarettes, bidis, and chewing), and quantity consumed (number per day, pack-years)., Results: The weighted prevalence of current smoking and tobacco chewing was higher in men (50.3%, 95% confidence interval, CI, 48.1-52.6 and 5.0%, 95% CI 4.1-5.9, respectively) compared with women (4.8%, 95% CI 3.9-5.7 and 1.0%, 95% CI 0.6-1.4, respectively) and higher among older age groups. The quit rate was higher in women (45.5%, 95% CI 38.7-52.2) compared to men (18.8%, 95% CI 16.7-20.9). Illiterate individuals were more likely to be current smokers of any type compared to those with secondary/higher education (odds ratio, OR, 3.25, 95% CI 2.54-4.16), although cigarette smoking was higher in men of high SES. Smoking quit rates were positively associated with SES (OR 2.56, 95% CI 1.76-3.71) for secondary/higher education vs. illiterates. Level of consumption increased with SES and those with secondary/higher education smoked an additional 1.93 (95% CI 1.08-2.77) cigarettes or bidis per day and had an additional 1.87 (95% CI 0.57-3.17) pack-years vs. illiterates., Conclusions: The social gradients in cigarette smoking and level of consumption contrasted those for indigenous forms of tobacco (bidi smoking and chewing). International prevention and cessation initiatives designed at modifying Western-style cigarette usage will need to be tailored to the social context of rural Andhra Pradesh to effectively influence the use of cigarettes and equally harmful indigenous forms of tobacco., (© The European Society of Cardiology 2013 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav.)

Discount snuff, known for its cheap price, high nicotine content, and popularity among youth, has increased substantially in market share in the United States. As a likely result, the leading manufacturer of premium snuff has supported legislation changing the basis for taxing snuff from price to weight. To determine which public health issues arose in legislative debates, we transcribed 17 of 52 bills from US state legislatures and coded for arguments broadly categorized into public health, fair taxation, tax revenue, tax efficiency, and anti-competitiveness. State legislators expressed frustration that equitable taxation, revenue generation, and prevention of youth tobacco use were frequently conflated in the debates. Public health advocates expressed concerns over youths' incentives to purchase low-weight snuff, but seldom discussed youths' growing preference for discount snuff. The evolving market of moist snuff is a critical consideration for US state legislators as well as policy makers from other countries who may evaluate taxation methods for alternate tobacco products.

Introduction: Almost a fifth of the world's tobacco is consumed in smokeless form. Its consumption is particularly common in South Asia, where an increasing array of smokeless tobacco (SLT) products is widely available. Mindful of the growing public health threat from SLT, a group of international academics and policy makers recently gathered to identify policy and knowledge gaps and proposed strategies to address these., Methods: We reviewed key policy documents and interviewed policy makers and representatives of civil society organizations in 4 South Asian countries: Bangladesh, India, Nepal, and Pakistan. We explored if SLT features in existing tobacco control policies and, if so, the extent to which these are implemented and enforced. We also investigated barriers to effective policy formulation and implementation. The findings were presented at an international meeting of experts and were refined in the light of the ensuing discussion in order to inform policy and research recommendations., Results: We found that the existing SLT control policies in these 4 South Asian countries were either inadequate or poorly implemented. Taxes were low and easily evaded; regulatory mechanisms, such as licensing and trading standards, either did not exist or were inadequately enforced to regulate the composition and sales of such products; and there was little or no cessation support for those who wanted to quit., Conclusions: Limited progress has been made so far to address the emerging public health threat posed by SLT consumption in South Asia. International and regional cooperation is required to advocate for effective policy and to address knowledge gaps.

Background: While cigarette consumption in the USA continues to decline, promotion for and consumption of smokeless tobacco (SLT) is growing. However, little research has explored what product features are driving SLT growth, despite awareness that product-level factors may be important in SLT use. This study analyses national sales data to better understand the impact of product features on SLT sales., Methods: Data on sales of SLT in US convenience stores from 2005 to 2011 were obtained from Nielsen Research Company. Each listed product was coded for attributes such as type, brand, flavouring and form to calculate their respective total sales, market share and contribution to overall SLT growth., Results: Sales of moist snuff products (including snus) increased by 65.6% between 2005 and 2011. Sales of pouched and flavoured forms of moist snuff increased by 333.8% and 72.1%, respectively, and contributed to 28% and 59.4% of the total growth in the moist snuff category, respectively. Value/discount brands accounted for 42% of moist snuff sales in 2011 among the top 10 selling brands, largely driven by Grizzly. After 2 years on the national market, Camel Snus was also one of the top 10 selling moist snuff brands., Conclusions: Sales of moist snuff, both overall and for particular styles, are increasing. Growing pouch use may be attributed to new SLT users, which may include cigarette smokers using them as starter SLT products. Increased sales of flavoured and discounted snuff raise concerns about use and appeal to youth. Continued surveillance of SLT sales trends is warranted.

Introduction: The isolated island nation of Madagascar has substantial prevalence of both smoking and smokeless tobacco use, although not of dual use. Madagascar's tobacco market, much like its historical and cultural underpinnings, appears to have both Asian and African influences. Additionally, it has a unique market structure that plays an important role in influencing patterns of tobacco use. This study analyzes the determinants of smoking and smokeless tobacco use in Madagascar., Methods: We used the 2008 Madagascar Demographic and Health Survey to analyze both smoking tobacco and smokeless tobacco use, stratified by gender. Multivariate log binomial models were used to evaluate the relationship between tobacco use and age, residence (urban/rural), province, marital status, and education., Results: Our analysis indicates that two distinctly different groups of people use two distinctly different tobacco products. Smoking is almost exclusively used by men and does not appear to be related to socioeconomic status. Conversely, smokeless tobacco is consumed by large proportions of both men and women, who are less educated and live in rural areas of the country. This disparate pattern in consumption is a reflection of the different market structures for smokeless tobacco (a cottage industry) and smoking tobacco (a near monopoly)., Conclusions: Distinct market-based, geographic, and socioeconomic disparities in tobacco use are explored in order to begin the classification of Madagascar's tobacco epidemic as more African, more Asian, or as a distinctly different environment.

Context: The European Union (EU) Tobacco Products Directive that bans sales of snus (a form of oral tobacco) in EU countries other than Sweden is currently under review. Major tobacco companies favour the ban being overturned. This study aims to explore compliance with the current ban on snus sales and examines the conduct of online snus vendors, including their compliance with two other EU Directives on excise and tobacco advertising and Swedish legislation banning sales of snus outside Sweden., Methods: To determine who is currently distributing snus via the internet in the EU, searches were carried out in Google, followed by searches in the WHOIS and Amadeus databases. Five online test purchases of snus were made in each of 10 EU Member States using a standardised protocol. Feedback from the test purchases and further analysis of the websites accessed for test purchases were used to critically examine snus retailers' conduct., Results: The majority of online vendors operate from Sweden and target non-Swedish EU citizens. Test purchases were successfully made in all 10 EU Member States; of 43 orders placed, only two failed. Age verification relied only on self-report. The majority of sales applied Swedish taxes, contrary to EU requirements. Copious sales promotion activities, many price based, are incorporated in these websites contravening the EU regulation, and three test purchases were delivered with gifts., Conclusions: Snus is currently being sold on the single market via the internet in contravention of Swedish legislation and three EU Directives. The apparent willingness of the tobacco industry to contravene EU and Swedish legislation and profit from unlawful sales raises questions about their status as stakeholders in consultations on future policy developments. The findings highlight how national and regional tobacco control legislation can be undermined in an increasingly globalised world.

While the prevalence of smokeless tobacco (ST) is low relative to smoking, the distribution of ST use is highly skewed with consumption concentrated among certain segments of the population (rural residents, males, whites, low-educated individuals). Furthermore, there is suggestive evidence that use has trended upwards recently for groups that have traditionally been at low risk of using ST, and thus started to diffuse across demographics. This study provides the first estimates, at the national level, of the effects of magazine advertising on ST use. The focus on magazine advertising is significant given that ST manufacturers have been banned from using other conventional media since the 1986 Comprehensive ST Act and the 1998 ST Master Settlement Agreement. This study is based on the 2003-2009 waves of the National Consumer Survey (NCS), a unique data source that contains extensive information on the reading habits of individuals, matched with magazine-specific advertising information over the sample period. This allows detailed and salient measures of advertising exposure at the individual level and addresses potential bias due to endogeneity and selective targeting. We find consistent and robust evidence that exposure to ST ads in magazines raises ST use, especially among males, with an estimated elasticity of 0.06. There is suggestive evidence that both ST taxes and cigarette taxes reduce ST use, indicating contemporaneous complementarity between these tobacco products. Sub-analyses point to some differences in the advertising and tax response across segments of the population. The effects from this study inform the debate on the cost and benefits of ST use and its potential to be a tool in overall tobacco harm reduction., (Copyright © 2013 Elsevier B.V. All rights reserved.)