Tobacco price and use following California Proposition 56 tobacco tax increase.

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.

The Market for Bidis, Smokeless Tobacco, and Cigarettes in India: Evidence From Semi-Urban and Rural Areas in Five States.

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.

Taxation and prices of smokeless tobacco products in India: A success story.

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.

Inadequate checks on smokeless tobacco usage in Pakistan: cultural heritage or policy neglect?

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.

The Role of Marketing Practices and Tobacco Control Initiatives on Smokeless Tobacco Sales, 2005-2010.

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.

Estimated impact of the GST on tobacco products in India.

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.

Cigarette and smokeless tobacco company smartphone applications.

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.

Smokeless tobacco taxation: Lessons from Southeast Asia.

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.

A review of trade practices of smokeless tobacco products in terms of prohibition on sale, manufacturing & importation in Framework Convention on Tobacco Control ratified Parties.

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.

The impact and relevance of tobacco control research in low-and middle-income countries globally and to the US.

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.

The role of travel distance and price promotions in tobacco product purchase quantity.

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.

Impact of tobacco control policies on adolescent smokeless tobacco and cigar use: a difference-in-differences approach.

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.

The Poorest of Poor Suffer the Greatest Burden From Smokeless Tobacco Use: A Study From 140 Countries.

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.

Trends in Sales of Flavored and Menthol Tobacco Products in the United States During 2011-2015.

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.

Educational and wealth inequalities in tobacco use among men and women in 54 low-income and middle-income countries.

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.

Health Care Utilization and Expenditures Attributable to Smokeless Tobacco Use Among US Adults.

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.

Monitoring Tobacco Brand Websites to Understand Marketing Strategies Aimed at Tobacco Product Users and Potential Users.

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.

Sources and Number of Coupons for Cigarettes and Snus Received by a Cohort of Young Adults.

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.

Economic cost of tobacco-related cancers in Sri Lanka.

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.

Cost-effectiveness of a smokeless tobacco control mass media campaign in India.

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.