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

Smoking is prevalent across Europe, but the severity and stage of the smoking epidemic, and policy responses to it, vary substantially between countries. Much progress is now being made in prohibition of paid-for advertising and in promotion of smoke-free policies, but mass media campaigns are widely underused, provision of services for smokers trying to quit is generally poor, and price policies are undermined by licit and illicit cheap supplies. Monitoring of prevalence is inadequate in many countries, as is investment in research and capacity to address this largest avoidable cause of death and disability across Europe. However, grounds for optimism are provided by progress in implementation of the WHO Framework Convention on Tobacco Control, and in the development of a new generation of nicotine-containing devices that could enable more widespread adoption of harm-reduction strategies. The effect of commercial vested interests has been and remains a major barrier to progress.

Objectives and Methods: A cross sectional study of HCPs working in public MCH clinics in Assiut city was conducted to explore their knowledge, attitudes and counselling practices regarding prevention of SHS exposure among pregnant women and children. Descriptive and regression analyses were performed. Results: 367 HCPs participated in the study, 12% of whom were smokers. The majority were nurses (45%). A considerable proportion of HCPs reported being exposed to SHS in workplace (70%) and home (52%). About half HCP reported high SHS knowledge (56%), supportive attitude towards preventing SHS exposure (53%), and having good counselling practice regarding SHS exposure (52%). Being a GP and serving urban communities were significantly associated with high knowledge. Being female, serving a rural population, receiving training on smoking cessation services, not being exposed to SHS at home, and having a supportive attitude towards prevention of SHS exposure were significantly associated with good counselling practice. Conclusion: Awareness, attitudes and counselling practice of HCPs should be improved. Training for HCPs and enforcement of smoke free polices are needed to improve awareness and facilitate changes in social norms.

Exposure to tobacco imagery in films causes young people to start smoking. Popular Indian films contain high levels of tobacco imagery, but those that do are required by law to display onscreen health warnings when smoking imagery occurs and to include other health promotion messaging before and during the film. We report a prospective cohort study of incident smoking in relation to exposure to film tobacco imagery and anti-tobacco messaging in a cohort of children in southern India. We carried out a one-year longitudinal follow up questionnaire survey in 2018 of a cohort of 39,282 students in grades 6, 7 and 8 (aged between 10 and 15 years) in schools in the Udupi district of Karnataka State in India who participated in a 2017 cross-sectional study of exposure to smoking in films and ever smoking status. We obtained usable linked data in 2018 from 33,725 of the 39,282 (86%) participants with data from 2017. Incident smoking was reported by 382 (1.1%) participants. After adjusting for age, sex and common confounders significantly associated with incident smoking there was no significant independent effect of exposure to film smoking, either as a binary (Odds Ratio 1.6, 95% Confidence Interval (CI) 0.5 to 4.9) or as a graded variable, on smoking uptake. An exploratory analysis indicated that the presence of on-screen health warnings that complied fully with Indian law was associated with a significantly lower odds of smoking uptake (Odds Ratio 0.8 (0.6 to 1.0, p = 0.031) relative to the same exposure sustained in absence of compliant warnings. Exposure to tobacco imagery in Indian films was not associated with a significantly increased risk of incident smoking in South Indian children. While it is possible that this finding is a false negative, it is also possible that the effect of film exposure has been attenuated by the presence of on-screen health warnings or other Indian tobacco-free film rules. Our findings therefore support the wider implementation of similar tobacco-free film measures in other countries.

ObjectivesIn December 2020, Derbyshire County Council in England introduced ‘walk-in’ asymptomatic community COVID-19 testing sites. Our study aimed to explore people’s views of the newly established COVID-19 community testing (CT) sites among those who attended and those who did not attend them, alongside gathering individuals’ experiences of attending a CT site to complete a lateral flow test.SettingThis qualitative research study comprised of one-to-one interviews with those attending a COVID-19 CT sites in Derbyshire and those from the surrounding area who did not attend.ParticipantsA combination of purposive and convenience sampling was used to recruit those who had (n=18) and those who had not attended (n=15) a walk-in asymptomatic CT site.ResultsEmployers played a key role in raising awareness of the testing sites, with most attending CT at the request of their workplace. The experience of attending a CT site was overwhelmingly positive and those who got tested spoke about the reassurance a negative result offered, knowing they were not passing on the virus when going about their daily lives. However, there was a perception that awareness of CT sites was low across the county and some confusion about who was eligible to attend and under what circumstances. Individuals linked this to low level of advertising they had seen, in addition to a lack of clarity in the information provided.ConclusionsPeople’s experience of attending a ‘walk-in’ asymptomatic CT site in Derbyshire was generally very positive; however, ensuring clear communication for future testing programmes is essential to maximise their uptake.

Tobacco use has resulted in a staggering number of illnesses and premature deaths worldwide. India has the world's second-highest level of tobacco consumption. The study aimed to explore the reasons of initiation among adolescents and understand community stakeholders' perceptions about the current tobacco control policies and challenges faced in implementing it for youth along with future recommendations. Focus Group Discussions (FGDs) were conducted with adolescents in grades 7th-9th, teachers, parents, and police officers, along with in-depth interviews (IDI) with tobacco vendors. These were digitally audio-recorded and transcribed verbatim. Data was analyzed using inductive thematic analysis. Twenty-two focus groups were conducted with adolescents, 10 with parents, 10 with teachers (  = 83), 5 with police (  = 42) and 10 tobacco vendors completed one-to-one interviews. Stakeholders identified gaps in tobacco control policy implementation and recommended stricter enforcement. Solutions such as modifying on-screen health warnings, developing novel ways like live demonstration of patients suffering from tobacco use which creates awareness about tobacco harms, countering tobacco industry marketing strategies, restricting tobacco product sales, lowering affordability, and prominently displaying tobacco-free film rules were recommended. The study provides a thorough understanding of factors that lead to tobacco initiation and stakeholder's opinion on youth-related tobacco legislation that provides direction for strengthening existing tobacco control efforts. There is a need for novel ways to educate the child's microenvironment, specifically in school and family environment. The findings also emphasize the importance of multi-sector involvement and better enforcement of tobacco control laws.

ObjectiveThis study explored multistakeholder perspectives on existing adolescent-specific tobacco control policies and programmes, to advance India’s transition towards a tobacco-free generation.DesignQualitative semi-structured interviews.SettingInterviews were conducted with officials involved in tobacco control at the national (India), state (Karnataka), district (Udupi) and village level. Interviews were audio recorded, transcribed verbatim and analysed thematically.ParticipantsThirty-eight individuals representing national (n=9), state (n=9), district (n=14) and village (n=6) levels, participated.ResultsThe study findings highlighted the need to strengthen and amend the existing Tobacco Control Law (2003) provisions, particularly in the vicinity of schools (Sections 6a and 6b). Increasing the minimum legal age to buy tobacco from 18 to 21 years, developing an ‘application’ for ‘compliance and monitoring indicators’ in Tobacco-Free Educational Institution guidelines were proposed. Policies to address smokeless tobacco use, stricter enforcement including regular monitoring of existing programmes, and robust evaluation of policies was underscored. Engaging adolescents to co-create interventions was advocated, along with integrating national tobacco control programmes into existing school and adolescent health programmes, using both an intersectoral and whole-societal approach to prevent tobacco use, were recommended. Finally, stakeholders mentioned that when drafting and implementing a comprehensive national tobacco control policy, there is a need to adopt a vision striving toward a tobacco-free generation.ConclusionStrengthening and developing tobacco control programmes and policies are warranted which are monitored and evaluated rigorously, and where adolescents should be involved, accordingly.

Smoking prevention should be a primary public health priority for all governments, and effective preventive policies have been identified for decades. The heterogeneity of smoking prevalence between European Union (EU) Member States therefore reflects, at least in part, a failure by governments to prioritise public health over tobacco industry or possibly other financial interests, and hence potentially government corruption. The aims of this study were to test the hypothesis that smoking prevalence is higher in countries with high levels of public sector corruption, and explore the ecological association between smoking prevalence and a range of other national characteristics in current EU Member States. Ecological data from 27 EU Member States were used to estimate univariate and multivariate correlations between smoking prevalence and the Transparency International Corruption Perceptions Index, and a range of other national characteristics including economic development, social inclusion, quality of life and importance of religion. We also explored the association between the Corruption Perceptions Index and measures of the extent to which smoke-free policies have been enacted and are enforced. In univariate analysis, smoking prevalence was significantly higher in countries with higher scores for corruption, material deprivation, and gender inequality; and lower in countries with higher per capita Gross Domestic Product, social spending, life satisfaction and human development scores. In multivariate analysis, only the corruption perception index was independently related to smoking prevalence. Exposure to tobacco smoke in the workplace was also correlated with corruption, independently from smoking prevalence, but not with the measures of national smoke-free policy implementation. Corruption appears to be an important risk factor for failure of national tobacco control activity in EU countries, and the extent to which key tobacco control policies have been implemented. Further research is needed to assess the causal relationships involved.

Tobacco companies in most European Union countries have to rely heavily on point-of-sale (PoS) displays to promote their products, and many countries are considering prohibiting this medium of marketing. To assess whether exposure to PoS displays affects smoking susceptibility (absence of a decision not to smoke) or uptake among young people, we surveyed PoS exposure and smoking behaviour, prospectively over 1 year, in a cohort of secondary school students in Nottinghamshire. The study was undertaken immediately before legislation prohibiting PoS displays in large retailers was implemented in England, in April, 2012. We used data obtained from a cohort survey in eight schools undertaken in March, 2011, and March, 2012. In 2012, we received questionnaires from more than 4000 children (response rate ∼64%) and individually identified and linked responses from 2300 children for matched analysis. The questionnaire obtained data for demographic and socioeconomic variables, smoking status (never vs ever) and susceptibility to smoking among never smokers, rebelliousness, academic performance, smoking among family members and friends, exposure to and awareness of PoS displays, and number of brands of tobacco products recognised at PoS. We defined susceptibility to smoking using three questions on intentions to try smoking or to smoke within the next year and whether a respondent would smoke if one of their best friends were to offer a cigarette. We used multivariate logistic regression to examine the association between exposure variables and changes in susceptibility to smoking between 2011 and 2012. Likelihood ratio tests were used to identify which of the variables should be included in the final model. To avoid possible bias, we selected a sample of schools that are representative of the population. Questionnaires were filled in during school activities to avoid external influences. We also made efforts to guarantee respondents that the information provided would not be available to anyone outside the research group. We used multivariate models to adjust for a range of variables that are probably confounders and thus aimed to avoid any overestimates of the effect. In 2011, of 2090 children who were never smokers, 1589 were non-susceptible and 501 susceptible. Of the non-susceptible, 313 became susceptible in 2012, and 253 changed their status from being non-susceptible or susceptible never smokers to smokers. After adjustment for potential confounding, PoS exposure was independently associated with an increased risk of becoming susceptible to smoking (odds ratio [OR] 1·65, 95% CI 1·16–2·35). However, there was no significant association between frequency of noticing PoS displays (most or every time vs sometimes or less) and smoking uptake (OR 1·55, 95% CI 0·84–2·85 for non-susceptible never smokers and 0·81, 0·43–1·51 for susceptible never smokers). Additionally, a higher number of cigarette brands recognised at the PoS seemed related to a higher risk of becoming susceptible to smoking, but not a smoker. Although we found some evidence at univarite level suggesting that more frequent exposure to PoS displays is related to higher risk of becoming a smoker, the effect was not significant at multivariate level. Exposure to PoS displays increased the likelihood that young people became susceptible to smoking, but was not a predictor of progression from susceptibility to uptake of smoking. Although we used only self-reported data and the number of children whose susceptibility or smoking status changed during the 1 year of the study was small, these findings suggest that PoS displays may cause young people to become likely to experiment with smoking, and hence in some cases progress to becoming a smoker. Removal of PoS displays is therefore likely to reduce smoking among young people. This study was supported by funding from the Cancer Research UK, Department of Health, Nottingham City PCT, and UK Centre for Tobacco Control Studies, with core funding from the British Heart Foundation, Cancer Research UK, Economic and Social Research Council, Medical Research Council, and the Department of Health under the auspices of the UK Clinical Research Collaboration.

IntroductionIn May 2020, the EU Tobacco Products Directive ban on the sale of menthol cigarettes was implemented in England. This study examined the prevalence of menthol cigarette smoking after the ban, according to sociodemographic and smoking characteristics.MethodsCross-sectional data came from a representative survey of current smokers (18+) in England (unweighted n=2681) between July 2020 and June 2021. The weighted prevalence of menthol cigarette smoking as a proportion of total cigarette smoking was calculated, log-binomial regression explored trends over time, and χ2 statistics assessed the relationship between menthol smoking, sociodemographic and smoking characteristics. Sources of purchase of menthol cigarettes were explored.ResultsBetween July 2020 and June 2021, 15.7% (95% CI 14.5 to 17.1) of smokers reported smoking menthol cigarettes. The fitted non-linear trend supported no initial change followed by a possible reduction across April–June 2021 and fit the data better than linear and null (no change) models (χ2(2)=2519.7, p=0.06; χ2(3)=2519.7, p=0.006). Menthol cigarette smoking was more common among younger groups (16–24=25.2%; 25–34=19.9%) and women (19.4%). Menthol cigarette smokers showed lower cigarette dependence compared with other smokers. Past-6-month purchases of menthol cigarettes from any illicit or cross-border source declined from 30.1% in the last 6 months of 2020 to 17.5% in the first 6 months of 2021.ConclusionsA substantial minority of current smokers in England reported menthol cigarette smoking between July 2020 and June 2021, despite the ban, possibly reflecting mitigation of restrictions by a variety of licit means, such as legal menthol accessories. The reduction in menthol smoking across April–June 2021 warrants further monitoring.