New studies warn against complacency in efforts to tackle smoking

Three research papers published by The BMJ today examine smoking and efforts to deal with it, and highlight the importance of continued investment in international tobacco control, particularly in low and middle income countries.

The first study by Professor Steven J. Hoffman and colleagues examines how patterns in international cigarette consumption have changed since 1970.

Using data from 71 countries, representing over 95% of global cigarette consumption and 85% of the world's population, it shows cigarette consumption fell in most countries over the past three decades but trends in country specific consumption were highly variable.

For example, China consumed 2.5 million metric tons (MMT) of cigarettes in 2013, more than Russia (0.36 MMT), the United States (0.28 MMT), Indonesia (0.28 MMT), Japan (0.20 MMT), and the next 35 highest consuming countries combined.

The US and Japan achieved reductions of more than 0.1 MMT from a decade earlier, whereas Russian consumption plateaued, and Chinese and Indonesian consumption increased by 0.75 MMT and 0.1 MMT, respectively.

The authors say the findings "underscore the need for more robust processes in data reporting, ideally built into international legal instruments or other mandated processes."

Using this data, the second study by Professor Steven J. Hoffman and colleagues found no significant change in the rate at which global cigarette consumption had been decreasing after adoption of the World Health Organization's Framework Convention on Tobacco Control (FCTC) - an international treaty adopted in 2003 that aims to reduce harmful tobacco consumption.

After 2003, high income and European countries showed a decrease in annual consumption by more than 1000 cigarettes per adult, whereas low and middle income and Asian countries showed an increased annual consumption by more than 500 cigarettes per adult.

Although causal associations cannot be stated with certainty, the quasi-experimental designs used in the study provide robust evidence of shifting patterns in global cigarette consumption, which the researchers say "should motivate greater implementation of proven tobacco control policies" and "encourage more assertive responses to tobacco industry activities."

The third study examined differences in vaping and smoking among adolescents in Canada, England, and the United States using online surveys of 16 to 19 year olds in 2017 and 2018.

Prevalence of vaping (past 30 days, past week, and 15 days or more in the past month) increased among 16 to 19 year olds in Canada and the US, and smoking also increased among Canadian adolescents, while little change was seen in England.

The use of JUUL (a nicotine salt based electronic cigarette) increased in all countries, particularly the US and Canada.

Despite some study limitations, the authors say that vaping among adolescents increased in Canada and the US "in parallel with the rise of nicotine salt based vaping products and the introduction of more permissive vaping regulations in Canada."

Fewer changes were seen among adolescents in England, where there are stronger marketing restrictions and maximum nicotine limits, they conclude.

"Taken together, these new studies emphasise the value of comparative research for tobacco control across different countries," writes Professor Linda Bauld at the University of Edinburgh in a linked editorial. "They also warn against complacency in our attempts to address smoking, now and in the future."

She argues that continued investment in international tobacco control is more important than ever, particularly in low and middle income countries with limited capacity to combat industry attempts to delay or derail public health policies.

In an accompanying feature, Beijing-based reporters Flynn Murphy and Gabriel Crossley argue that state owned tobacco companies in China and Japan are at odds with their countries' commitments to reduce the immense toll of disease and death caused by tobacco.

But in a linked editorial, US and Canadian researchers, Joanna Cohen and Kelley Lee, say regardless of ownership, the answer lies in comprehensive regulation "that makes public health and not economic interests the top priority."