Tag: public health

Maximum cigarette pack size: a neglected aspect of tobacco control

Posted on by annablackwell

Written by Anna Blackwell, Senior Research Associate

The manufacturing or importing of packs of cigarettes with fewer than 20 cigarettes per pack was prohibited in the UK when the EU Tobacco Products Directive and standardised packaging legislation were fully implemented in May 2017. This change was aimed at reducing the affordability of cigarettes and thereby discouraging young people from smoking. This directive also required the removal of branding and established a standard shape and dark green colour for packaging, including pictorial health warnings, which prevented the use of packaging for promotion and reduced its appeal.

However, the tobacco industry has been able to exploit loopholes in recent packaging regulations, including the absence of a regulated maximum pack size, by introducing non-standard and larger pack sizes to the market to distinguish products. This is a public health concern given evidence that larger pack sizes are linked to increased smoking, and could undermine existing tobacco control success.

In a recent Addiction Opinion and Debate paper, we proposed that a cap on cigarette pack size should be introduced; a pragmatic solution would be to permit only a single pack size of 20, which is now the minimum in many countries. This approach would reduce the number of cigarettes in packs in several countries such as Australia – where packs up to sizes of 50 are available – and prevent larger sizes being introduced elsewhere.

Capping cigarette pack size therefore has the potential to both reduce smoking and prevent increased smoking. While the health benefits of reducing smoking alone are small, it may have important indirect effects on health through its role in facilitating quitting. Those smoking fewer cigarettes per day are more likely to attempt to quit and succeed in doing so. Trials of smoking-reduction interventions have also found that these can lead to increased quitting when combined with nicotine replacement therapy.

Our Opinion and Debate paper drew on evidence from a range of sources including industry documents and analyses, population surveys, intervention trials and Mendelian randomization analyses. Together these suggest that consumption increases with larger pack size, and cessation increases with reduced consumption. However, direct experimental evidence is not currently available to determine whether pack size influences the amount of tobacco consumed, or whether the association is due to other factors.

People who want to quit may be using smaller packs as a method of self-control, and smokers who successfully cut down and later quit may be more motivated to do so. Cost is also an important factor and larger packs may be linked to increased smoking because they have a lower cost per cigarette. Further research is needed to determine whether the associations between pack size, smoking and cessation are causal to estimate the impact of policies to cap cigarette pack size.

Commentaries on our Opinion and Debate paper, published in the May 2020 Issue of Addiction highlight the need to understand the mechanisms for the associations observed between pack size and smoking in order to identify the optimal cigarette pack size. Although mandating packs of 20 is a pragmatic approach, pack size regulation needs to achieve a compromise between tobacco affordability and smokers’ self-regulation. Nevertheless, the policy debate should start now to address this neglected aspect of tobacco control.

To find out more visit the Behaviour Change by Design website or follow us on Twitter @BehavChangeDsgn @BristolTARG

A Summary of the E-cigarette Summit US 2017

Posted on by annablackwell

By Jasmine Khouja

The first E-cigarette Summit US was held in Washington DC on the 8th May 2017. The one-day event brought together researchers, medical professionals and members of industry from all over the US as well as many from the UK (where the organisers have held E-cigarette Summits successfully for the past four years). A review of the safety of e-cigarettes was followed by a review of the regulations that have been proposed in the US. Throughout the day, comparisons were made between the UK and US, particularly in the approaches taken to health messages and regulation of e-cigarettes. In Professor Kenneth Warner’s opening address, he suggested that there are two types of researcher in the field of e-cigarette research: sceptics, who are focussed on potential harm and protecting children regardless of the potential harm reduction for adult smokers, and enthusiasts, who are focussed on potential benefits to public health due to smoking cessation which could outweigh the potential risk to children. By this definition, the majority of researchers who presented evidence appeared to be enthusiasts.

Here are some highlights from the summit:

Evidence Updates

The majority of presentations suggested that previous research has overestimated the health risks of e-cigarettes by using inappropriate methods such as testing the toxicants produced from vaping using temperatures which are not used by vapers. Recently, Dr Konstantinos Farsalinos and his team have attempted to replicate such findings with maximum temperatures used by vapers and are yet to find evidence that supports the previous findings.

Dual use was also a common theme in the presentations; dual use is the use of e-cigarettes alongside smoking (or other tobacco product use depending on the definition used). However, as Dr Andrea Villanti pointed out, context is key when researching dual use; two people defined as dual users may be extremely different. For example, one dual user may smoke one cigarette a week and vape daily and another may vape once a week and smoke 20 cigarettes a day. With this in mind, Dr Robin Mermelstein’s research focussed on dual users and found that common reasons for using e-cigarettes were using e-cigarettes as a substitute for cigarettes, to cut down their cigarette consumption, to curb their cravings in places they were not allowed to smoke and because they were trying to quit smoking.

Public health

Professor Linda Bauld provided evidence that public health messages can impact the effectiveness of e-cigarettes as a smoking cessation tool. In the UK, there is generally a positive stance taken towards the use of e-cigarettes for smoking cessation among the public health community, however this stance has not been adopted in the US. It was suggested numerous times that consensus among the public health community could help smokers to quit and could help the medical community to provide accurate advice.

Regulations

New regulations for e-cigarettes are being proposed for the US in the Cole-Bishop proposal. Under these regulations, the e-cigarette market would essentially be frozen, preventing improvements to devices in safety and efficacy according to Deborah Arnott. However, Matthew Myers would disagree and sees flexibility in the FDA regulations which he believes are absolutely necessary.

Overall, the summit was extremely informative and highlighted the need to clearly communicate the findings of well-designed research to the public in order to maximise the potential for reducing smoking rates with use of e-cigarettes.