Exploring associations of population characteristics and tobacco and vape retailer density and proximity in Australia: a scoping review.

OBJECTIVE: This scoping review synthesises Australian evidence on associations between tobacco and vape retailer density/proximity and various population measures and smoking behaviour to identify research gaps and inform future policy and strategies. DATA SOURCES: Following Joanna Briggs Institute methodology, relevant studies published in English since 2003 were identified via searches of eight databases in March and August 2023. STUDY SELECTION: Two reviewers independently completed screening procedures. Eligible studies were from Australia and described associations between tobacco or vape retailer density/proximity and adult or youth smoking/vaping prevalence or behaviours, neighbourhood socioeconomic status, geographic location, school locations and/or Indigenous status. DATA EXTRACTION: Results are reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews checklist. DATA SYNTHESIS: Of 794 publications screened, 12 studies from 6 Australian states were included. Six studies from five states reported statistically significant associations between neighbourhood-level socioeconomic disadvantage and tobacco retailer density, yet only two studies from two states found a significant relationship between retailer density and adult smoking prevalence. Increasing retailer density was consistently significantly associated with increasing geographical remoteness in three states. No studies explored associations with tobacco retailer proximity or vape retailer density/proximity. CONCLUSIONS: Despite a moderate number of studies overall, state-level evidence is limited, and unknown for Australian territories. Evidence from five Australian states reflects the international evidence that increasing retailer density is significantly associated with increasing socioeconomic disadvantage and remoteness, supporting the need for tobacco supply-based policies. Further research is required to understand the impact of retailer density and adult and youth smoking prevalence in Australia.

Census-Dependent Mortality of Ventilated Patients With COVID-19 in Israel: Noninterventional Observational Cohort Study.

BACKGROUND: The COVID-19 pandemic led to several surges in the mass hospitalization rate. Extreme increases in hospital admissions without adequate medical resources may increase mortality. No study has addressed the impact of daily census of ventilated patients on mortality in the context of the pandemic in a nationwide setting. OBJECTIVE: This study aimed to determine whether daily census of ventilated patients affected COVID-19 mortality rates nationwide in Israel. METHODS: We conducted a cohort study using nationwide, public-domain, population-based COVID-19 data of hospitalized patients from an Israeli database from March 11, 2020, until February 11, 2021. We included all COVID-19 hospital admissions, classified as mild to severe per the Centers for Diseases Control and Prevention classification irrespective of whether they were mechanically ventilated. Outcome measures were daily death rates and death rates expressed as a percentage of ventilated patients. RESULTS: During the study period (338 days from March 11, 2020, to February 11, 2021), 715,743 patients contracted and were clinically confirmed as having COVID-19. Among them, 5577 (0.78%) patients died. In total, 3398 patients were ventilated because of severe COVID-19. Daily mortality correlated with daily census of ventilated patients (R2=0.828, P<.001). The daily percent mortality of ventilated patients also correlated with the daily census of ventilated patients (R2=0.365, P<.001)-backward multiple regression analysis demonstrated that this positive correlation was still highly significant even when correcting for the average age or gender of ventilated patients (R2=0.4328, P<.001) or for the surge in their number. Overall, 40% of the variation in mortality was explained by variations in the daily census of ventilated patients. ANOVA revealed that at less than 50 ventilated patients per day, the daily mortality of ventilated patients was slightly above 5%, and it nearly doubled (10%) with 50-149 patients; moreover, in all categories of ≥200 patients ventilated per day, it more than tripled at ≥15% (P<.001). CONCLUSIONS: Daily mortality rates per ventilated patient increased with an increase in the number of ventilated patients, suggesting the saturation of medical resources. Policy makers should be aware that expanding medical services without adequate resources may increase mortality. Governments should perform similar analyses to provide indicators of system saturation, although further validation of these results might be needed to use this indicator to drive public policy.

Cigarette smoking decline among US young adults from 2000 to 2019, in relation to state-level cigarette price and tobacco control expenditure.

OBJECTIVE: To investigate the association of state-level cigarette price and tobacco control expenditure with the large 2000-2019 decline in cigarette smoking among US 18-24 year-olds. METHODS: Smoking behaviour was assessed in the 24 most populous US states using the 1992-2019 Tobacco Use Supplements to the Current Population Survey; association with price and expenditure was tested using adjusted logistic regression. States were ranked by inflation-adjusted average price and tobacco control expenditure and grouped into tertiles. State-specific time trends were estimated, with slope changes in 2001/2002 and 2010/2011. RESULTS: Between 2000 and 2010, the odds of smoking among US young adults decreased by a third (adjusted OR, AOR 0.68, 95% CI 0.56 to 0.84). By 2019, these odds were one-quarter of their 2000 level (AOR 0.24, 95% CI 0.19 to 0.31). Among states in the lowest tertile of price/expenditure tobacco control activity, initially higher young adult smoking decreased by 13 percentage points from 2010 to 2018-2019, to a prevalence of 5.6% (95% CI 4.5% to 6.8%), equal to that in the highest tobacco-control tertile of states (6.5%, 95% CI 5.2% to 7.8%). Neither state tobacco control spending (AOR 1.0, 95% CI 0.999 to 1.002) nor cigarette price (AOR 0.96, 95% CI: 0.92 to 1.01) were associated with young adult smoking in statistical models. In 2019, seven states had prevalence over 3 SDs higher than the 24-state mean. CONCLUSION: National programmes may have filled a gap in state-level interventions, helping drive down the social acceptability of cigarette smoking among young adults across all states. Additional interventions are needed to assist high-prevalence states to further reduce smoking.

New Zealand's world-first smokefree legislation 'goes up in smoke': A setback in ending the tobacco epidemic.

For several decades, Aotearoa New Zealand has maintained a relatively strict regulatory approach towards tobacco. In response to the significant impact of tobacco-related illnesses, many countries worldwide have worked to enhance tobacco control measures. These efforts include introducing plain tobacco packaging with graphic health warnings, improving access to smoking cessation services and offering supportive treatments for tobacco dependence. In December 2022, New Zealand enacted world-leading tobacco control legislation aimed at leading the nation towards a 'smokefree' future by 2025, a future where the smoking prevalence falls below 5 percent across all population groups. To achieve this goal, revolutionary measures were needed. These measures included denicotinising cigarettes, reducing the number of tobacco retail outlets, and implementing a generational ban on smoked products. Despite receiving support from academics, clinicians, leaders of local indigenous communities, and the general public, the sixth National-led coalition government remained resolute in repealing the law and did so through parliamentary urgency on 27 February 2024. The reversal of this health policy is anticipated to result in thousands of lives lost and widen life expectancy gaps between indigenous and non-indigenous populations. This decision, driven by political agenda objectives and interference from the tobacco industry, has not only impeded New Zealand's progress but also weakened global efforts in tobacco control.

ASPEN survey of parenteral nutrition access issues: How the system fails the patient.

BACKGROUND: Product shortages and a lack of qualified providers to manage care may impact the safety and efficacy of parenteral nutrition (PN). This survey assessed the frequency and extent to which limitations to PN-related access affects patients. METHODS: Outpatient/patients receiving home PN were surveyed. Questions were developed to characterize the population and determine the extent and severity of PN access issues with components, devices, healthcare professionals, and transfers of care. Reimbursement issues surveyed included insurance coverage, contribution of healthcare costs to annual income, and the extent to which adjunctive therapy was reimbursed. Burdens surveyed included impact on disease symptoms and medical outcomes as well as the types and frequency of medical or system errors experienced, adverse events, or resultant nutrition problems. RESULTS: Respondents (N = 170) were well educated, rented or owned their own home, and were either employed or retired. All age populations were represented. Patients made frequent contact with care providers. Most were able to manage PN costs but feared losing insurance or changes to insurance. Patients used additional prescribed therapies that are poorly covered by insurance. Patients reported symptoms or exacerbation of disease, development or worsening of malnutrition, and episodes of nutrient deficiency. Patients noted errors occur, especially during periods of transitions of care, when they also often encounter clinicians with little understanding of PN. These are high-acuity patients who have difficulty finding providers for their care. CONCLUSION: This patient survey provides evidence that access issues can result in the "failure of the PN system" to assure care is consistently safe and effective.

Tracing the refinement of policy tools for disability rights: a content analysis of how the granting process of state-funded personal assistance in Sweden is aligned with the LSS Act.

PURPOSE: According to the Swedish Act concerning Support and Service for Persons with Certain Functional Impairments (The LSS Act), personal assistance (PA) aims to enhance good living conditions for people with disability. The Act is operationalised by a policy tool, an instruction developed and refined by the Swedish Social Insurance Agency (SSIA) to grant PA. The study explores how this instruction is aligned with the LSS rationale and goals. MATERIAL AND METHOD: Qualitative content analysis was applied on the material i.e., a government bill preceding the LSS Act and the policy tool, i.e., the SSIA instruction, versions 1994 and 2019. RESULTS: The result shows that the instruction has deviated from the LSS Act over time, by decreasing users' access to community life, a shift towards health care activities, lack of support for the PA user, increased control and service-granting criteria. CONCLUSION: This paper emphasises that the selection of policy tools goes beyond mere pragmatism, as they are subject to refinement procedures that have significant impacts over time. The deviations observed in fulfilling the objectives of the LSS Act highlights the importance of ongoing adjustments to policy tools to align with the original policy goals in order to promote disability rights.

The study explored how policy tools, which serve as compulsory guidance by outlining the personal assistance granting process for local caseworkers, align with the rationale and policy goals of the Swedish Disability Act and policy goals, aiming to enhance good living conditions for people with disabilities.The designs of policy tools are frequently revised and adjusted and consequently influence policy outcome over time.Since policy tools are important for the implementation of government policy they need to be reviewed and monitored in order to secure original policy goals with the ultimate aim of enhancing good living conditions and advancing disability rights.

Rotation of tobacco health warnings and messages: challenges and recommendations for implementation.

Health warnings and messages-or health warning labels (HWLs)-are integral to tobacco control efforts, but their sustained impact necessitates regular rotation. This paper explores challenges in HWL rotation implementation across six diverse countries: Chile, Guyana, Indonesia, Jamaica, Mexico, and Vietnam. 19 in-depth interviews were conducted with government officials and representatives from civil society organisations and academia. Interviews explored the effectiveness of HWL regulations, the processes involved in their execution, and any challenges encountered along the way. Interviews were analysed thematically, using a combination of deductive and inductive approaches. Interviews revealed critical challenges that fall into two categories: specific and overarching. Government priorities and transitions, political will, time and bureaucracy, legal loopholes, lack of images, evaluation, and economic and human resources constitute HWL-specific challenges. Broad tobacco control challenges included tobacco industry interference and enforcement difficulties. To address HWL rotation challenges, international bodies such as WHO could establish extensive image banks, pre-evaluated for effectiveness and cultural relevance. In addition, countries must institutionalise the rotation process by establishing mechanisms that avoid having to pass complex legal instruments with each new round of warnings, delegating responsibilities to stable government institutions, addressing legal loopholesand planning for multiple rounds within a single legal instrument. Further, partnerships at national and international levels, along with systematic evaluations, are crucial for successful HWL implementation. These recommendations form a comprehensive framework for global collaboration, aiming to strengthen tobacco prevention through impactful HWLs on a sustainable basis.

Enhancing affordability and profit in a non-cooperative, coordinated, hypothetical pediatric vaccine market via sequential optimization.

This study considers a hypothetical global pediatric vaccine market where multiple coordinating entities make optimal procurement decisions on behalf of countries with different purchasing power. Each entity aims to improve affordability for its countries while maintaining a profitable market for vaccine producers. This study analyzes the effect of several factors on affordability and profitability, including the number of non-cooperative coordinating entities making procuring decisions, the number of market segments in which countries are grouped for tiered pricing purposes, how producers recover fixed production costs, and the procuring order of the coordinating entities. The study relies on a framework where entities negotiate sequentially with vaccine producers using a three-stage optimization process that solves a MIP and two LP problems to determine the optimal procurement plans and prices per dose that maximize savings for the entities' countries and profit for the vaccine producers. The study's results challenge current vaccine market dynamics and contribute novel alternative strategies to orchestrate the interaction of buyers, producers, and coordinating entities for enhancing affordability in a non-cooperative market. Key results show that the order in which the coordinating entities negotiate with vaccine producers and how the latter recuperate their fixed cost investments can significantly affect profitability and affordability. Furthermore, low-income countries can meet their demands more affordably by procuring vaccines through tiered pricing via entities coordinating many market segments. In contrast, upper-middle and high-income countries increase their affordability by procuring through entities with fewer and more extensive market segments. A procurement order that prioritizes entities based on the descending income level of their countries offers higher opportunities to increase affordability and profit when producers offer volume discounts.

Bitter taste of the tobacco industry interference in Brazil.

OBJECTIVE: Although Brazil became the first country worldwide to ban the sale of all tobacco products with any additive that could alter their flavours and tastes in 2012, its implementation was effectively halted by tobacco industry lawsuits, including a constitutional challenge filed in the Federal Supreme Court in 2013. This study aimed at examining, for the first time in the country, the evolution over time of the new registrations of tobacco products with additives that would have been banned if not for the tobacco industry's interference ('counterfactual scenario'). METHODS: We used the newly available public database on the registration of tobacco products developed by the Health Regulatory Agency (from 2008 onwards). All types of tobacco products intended for the domestic market that contained 'banned additives in a counterfactual scenario' and were registered between January 1 and December 31 of each year were selected. RESULTS: Between 2012 and 2023, a total of 1112 new registrations of tobacco products with 'banned additives' were recorded. The spread of hookah tobacco registrations started in 2014, and by 2023, the cumulative incidence of registrations containing 'banned additives' was 641. Both manufactured cigarettes and hookah products reached their peaks in new registrations in 2020. CONCLUSIONS: After 12 years since the resolution intended to ban all additives that change the aroma and taste of tobacco products in Brazil, primarily to prevent smoking initiation, the tobacco industry's interference continues to successfully block its implementation. Countries facing similar challenges in tobacco control could consider generating comparable national data that might help expose the adverse impacts of tobacco industry interference on public health.

Anticipatory gaps challenge the public governance of heritable human genome editing.

Considering public moral attitudes is a hallmark of the anticipatory governance of emerging biotechnologies, such as heritable human genome editing. However, such anticipatory governance often overlooks that future morality is open to change and that future generations may perform different moral assessments on the very biotechnologies we are trying to govern in the present. In this article, we identify an 'anticipatory gap' that has not been sufficiently addressed in the discussion on the public governance of heritable genome editing, namely, uncertainty about the moral visions of future generations about the emerging applications that we are currently attempting to govern now. This paper motivates the relevance of this anticipatory gap, identifying the challenges it generates and offering various recommendations so that moral uncertainty does not lead to governance paralysis with regard to human germline genome editing.

This year sees an opportunity for long-needed oral health reforms. Cancer patients, in particular, stand to benefit.

The long-standing divide in Australia between medicine and dentistry has left many with inequitable access to dental care. People with oral cancer, in particular, may have few options for dental rehabilitation after cancer treatment, even with private health insurance. However, 2024 could finally see health care reforms that address these inequities, with significant momentum building in Australia. In this Perspective, we argue for a national approach to reforms that incorporate aspects of preventive health, primary health care, Medicare Benefits Schedule item review, and the value of Private Health Insurance rebates for dental care.

Tobacco Taxation in Spain: A tax laggard with a brighter possible future.

INTRODUCTION: In recent years tobacco taxation in Spain has regressed, with its Tobacconomics tax scorecard falling from 3.9 points (out of 5) in 2014, to only 2.625 in 2020. The objective of this research is to provide a detailed analysis of the causes behind this deterioration and identify possible ways forward for reversing this trend. METHODS: A retrospective 2014-2022 analysis of manufactured cigarettes (FM) and roll-your-own tobacco (RYO) markets including tax structure/rates, affordability, retail price gaps across products, and price differentials with bordering countries. A market level simulation model to 2028 studied the impact of various tax policy scenarios on smoking prevalence, premature deaths averted, smoking intensity, product substitution, government revenue, sales, and industry profit. RESULTS: A lack of tax increases in a context of inflation and income growth during the past 8 years means FM and RYO have become 13% more affordable, with a constant differential of €2 between 20 FM and RYO sticks, and the price gap between Spain and neighbouring France increased. Modelling of two realistic reform scenarios that reduce/eliminate the price gap between FM and RYO suggest substantial increases in government revenues and up to 700,000 fewer smokers and 210,000 fewer premature deaths. CONCLUSIONS: Current European Union legislation on tobacco taxes leaves ample room for much needed tobacco tax reform. For the sake of both public health and the economy, Spain should increase its Minimum Excise Tax. This would not only save lives, but also bring much needed revenue for the government. IMPLICATIONS: The stance of Spain on tobacco taxes has deteriorated recently. This study argues that the failure of successive governments to raise minimum taxes in an inflationary context has made tobacco products more affordable, and quantifies the improvements in smoking prevalence and excise revenue that would accrue if the authorities act urgently increasing rates within realistic limits.Spain is representative of European countries where government inaction has rendered minimum tobacco taxes obsolete. Given the postponement of the revision of the European Union Tobacco Tax Directive, this study highlights the need to act unilaterally within the existing legal framework.

Universal smoking machine adaptor for tobacco product testing.

SIGNIFICANCE: Historically, tobacco product emissions testing using smoking machines has largely focused on combustible products, such as cigarettes and cigars. However, the popularity of newer products, such as electronic cigarettes (e-cigarettes), has complicated emissions testing because the products' mouth-end geometries do not readily seal with existing smoking and vaping machines. The demand for emissions data on popularly used products has led to inefficient and non-standardised solutions, such as laboratories making their geometry-specific custom adaptors and/or employing flexible tubing, for each unique mouth-end geometry tested. A user-friendly, validated, universal smoking machine adaptor (USMA) is needed for testing the variety of tobacco products reflecting consumer use, including e-cigarettes, heated tobacco products, cigarettes, plastic-tipped cigarillos and cigars. METHODS: A prototype USMA that is compatible with existing smoking/vaping machines was designed and fabricated. The quality of the seal between the USMA and different tobacco products, including e-cigarettes, cigars and cigarillos, was evaluated by examining the leak rate. RESULTS: Unlike commercial, product-specific adaptors, the USMA seals well with a wide range of tobacco product mouth-end geometries and masses. This includes e-cigarettes with non-cylindrical mouth ends and cigarillos with cuboid-like plastic tips. USMA leak rates were lower than or equivalent to commercial, product-specific adaptors. CONCLUSION: This report provides initial evidence that the USMA seals reliably with a variety of tobacco product mouth-end geometries and can be used with existing linear smoking/vaping machines to potentially improve the precision, repeatability and reproducibility of machine smoke yield data. Accurate and reproducible emissions testing is critical for regulating tobacco products.

IQOS news media coverage in Israel: a comparison across three subpopulations.

BACKGROUND: Philip Morris International's (PMI) IQOS, a leading heated tobacco product globally, entered the Israeli market in 2016. IQOS and/or electronic cigarette use is higher in Israel's Arab population (2.8% vs 1.2% of Jews). However, previous research indicated possible targeting of the Ultra-orthodox Jewish population with more IQOS paid ads. This paper examined how IQOS is framed in news media articles directed at three subpopulations in Israel: Arab, Ultra-orthodox Jews and general public. METHODS: Media articles (January-October 2020) were obtained from Ifat media and were coded using abductive coding. Characteristics of articles (photo and article content) targeting each subpopulation were compared using χ2, Fisher's exact test, one-way analysis of variance and median test, as appropriate. RESULTS: Of the 63 unique articles identified, 16 targeted Arab, 24 Ultra-orthodox Jews and 23 general public. Arab and Ultra-orthodox Jewish media significantly differed from the general public's media in their positive framing of PMI (100% Arab and 75% Ultra-orthodox Jews vs 52% general public, p=0.004), and IQOS (100% Arab and 88% Ultra-orthodox Jews vs 61% general public, p=0.006). Arab media differed from others by highlighting IQOS' retail locations (81% vs 17% Ultra-orthodox Jews and 13% general public), social benefits (88% vs 8% Ultra-orthodox Jews and 17% general public) and reflecting content from PMI's press release (100% vs 46% Ultra-orthodox Jews and 35% general public; ps <0.001). CONCLUSIONS: IQOS was framed more positively in media targeting minority populations (Arab and Ultra-orthodox Jews), compared with general public. Arabic media in particular emphasised IQOS' retail accessibility and social benefits. These findings highlight the need for media surveillance and regulation, especially of minority-oriented media.

The ethics of natural immunity exemptions to vaccine mandates: the Supreme Court petition.

The Supreme Court of the United States has recently been petitioned to revisit legal issues pertaining to the lawfulness of imposing a vaccine mandate on individuals with proof of natural immunity during the COVID-19 pandemic. While the petition accepts that the protection of public health during COVID-19 was an important governmental interest, the petitioners maintain that the imposition of a vaccine mandate on individuals with natural immunity was not 'substantially related' to accomplishing that purpose. In this short report, we outline how some of the petition's general arguments interact with points we raised in a 2022 article in this journal defending natural immunity exemptions, in light of new evidence. In particular, we reflect on new evidence pertaining to differences between vaccine-induced immunity, natural immunity, and so-called 'hybrid' immunity. We suggest that the nuanced nature of this evidence highlights the importance of making fine-grained judgements about proportionality and necessity when considering vaccine mandates. We conclude by claiming that if future pandemics necessitate the imposition of vaccine mandates, then those seeking to justify them should clearly articulate the relevance (and the evidence) for the comparative protection of vaccine-induced, natural, and hybrid immunity.

Awareness and perceived behaviour changes following the New York state vaping flavour ban, 2021-2022.

SIGNIFICANCE: Despite an electronic cigarette (e-cigarette) flavour ban in New York (NY) since May 2020, most youth who vape continue to report vaping restricted flavours. This study aims to examine youth awareness and perceived behaviour change associated with the NY vaping flavour ban. METHODS: NY cross-sectional data from 2021 and 2022 ITC Youth Survey were combined and analysed (N=1014). Weighted analyses were used to describe awareness and understanding of the e-cigarette flavour ban, as well as changes in tobacco use behaviour. RESULTS: Only 0.9% (n=8) of NY youth understood the flavour ban, in that they were both aware of the flavour ban in all stores and accurately reported that all non-tobacco flavours were banned. Awareness and understanding of the flavour ban differed by vaping status (p<0.01): respondents who had vaped in the past 12 months or 30 days were more likely (adjusted OR (aOR)=2.15, 95% CI 1.34, 3.45; aOR=2.07, 95% CI 1.17, 3.64, respectively) to be aware of the flavour ban but misunderstand the stores or flavours included. Of the majority of youth who reported awareness of a flavour ban and vaped (n=122) or smoked (n=78) in the past 12 months reported no changes in behaviour (64.0% and 69.7%, respectively). CONCLUSIONS: Less than one-third of NY youth, regardless of vaping status, reported that an e-cigarette flavour ban was present where they live. Further, most youth who were aware of the ban misunderstood which flavours were restricted and/or that the ban applied to all stores that sold e-cigarettes. Increased enforcement and educational efforts could improve awareness and understanding of the NY e-cigarette flavour ban.