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January 1st, 2016:

Cancer burden with ageing population in urban regions in China

Cancer burden with ageing population in urban regions in China: projection on cancer registry data from World Health Organization.

China is facing the challenges of an expanding ageing population and the impact of rapid urbanization, cancer rates are subsequently increasing. This study focuses on the changes of the ageing population and projects the incidence of common ageing-related cancers in the urban regions in China up to 2030.

Cancer incidence data and population statistics in China were extracted from the International Agency for Research on Cancer.

Due to improving longevity in China, continuous and remarkable increasing trends for the lung, colorectal and prostate cancers are expected.

The rate of expanding ageing population was taken into account when predicting the trend of cancer incidence; the estimations of ageing-related cancers were more factual and significant than using the conventional approach of age standardization.

The incidence rates of lung, colorectal and prostate cancers will continue to rise in the future decades due to the rise of ageing population. Lifestyle modification such as cutting tobacco smoking rates and promoting healthier diets as well as cancer screening programs should be a health system priority in order to decrease the growing burden of cancer-related mortality and morbidity.

British medical bulletin. 2016 Jan 01 [Epub ahead of print]

Kelvin K F Tsoi, Hoyee W Hirai, Felix C H Chan, Sian Griffiths, Joseph J Y Sung

E-cigarettes: effective cessation tools or public health threat?

L. Clancy1 and K. Babineau1
From the 1TobaccoFree Research Institute Ireland, Focas Research Institute, DIT, Kevin Street, Dublin 8, Ireland
Address correspondence to Prof Luke Clancy, TobaccoFree Research Institute Ireland, Focas Research Institute, DIT, Kevin Street, Dublin 8, Ireland.

In a short time, electronic cigarettes have become a multi-billion dollar industry. Since their introduction to the market, prevalence of ever-use among smokers in the USA appears to have increased from 2% in 2010 to >30% in 2012, and the rate of increase appears to be similar in the United Kingdom, Ireland and other Western countries according to a special Eurobarometer survey in 2014.1 The e-cigarette market is estimated to be worth over $3 billion. However, there is no consensus on the role of e-cigarettes and their contribution to the provision of smoking cessation (SC) services, nor to global tobacco control.

At the Conference of the Parties to the WHO Framework Convention on Tobacco Control in September 2014, the secretariat presented a report outlining the current facts concerning ecigarettes, put forth an opinion on these devices, and offered considerations on options for regulation.2 This was on the tail of two contrasting letters to Margaret Chan, Director General of the WHO, submitted by scientists from many disciplines including tobacco control, public health, epidemiology, pharmacology and the clinical sciences (Letters to Dr Chan; June 2014). One letter stated that e-cigarettes offer huge prospective gains by reducing the prevalence of cigarette smoking and subsequently, the harm done by smoking. Those in favour of this position therefore requested support for the introduction and widespread availability of e-cigarettes. The other letter cautioned restraint, citing the possible damage that e-cigarettes could have on tobacco control.

For those favouring the widespread proliferation of ecigarettes, the main considerations appear to be the efficacy and safety of e-cigarettes with regards to SC and potential for harm reduction. For those cautioning restraint the main consideration seems to be the possible effects these products may have on broad tobacco control measures such as smoking prevalence among children and young people, the possibility of relapse among ex-smokers, the impact on smokefree laws, the effects on advertising and sponsorship and the feared influence of the tobacco industry. Although both groups are, of course, concerned about all these issues, the discourse suggests that priorities may be somewhat different for different scientists.

So what does the evidence say? On the whole, it remains inconclusive.

With regard to the potential efficacy of e-cigarettes as a smoking cessation tool, two randomized controlled trial (RCT) studies suggest that e-cigarettes may be helpful. One study found that e-cigarettes containing nicotine are as effective as nicotine patches for smoking cessation when used as directed.3

In this study [n¼657], one group of participants received vouchers for nicotine patches by post and were encouraged to use them, while the other groups were given e-cigarettes—one with and one without nicotine. In another RCT [n¼300], smokers were randomized to three groups (patches, e-cigarettes with nicotine, e-cigarettes without nicotine). This study found that at 2, 4 and 12 weeks, there was a statistically significant difference between the two groups with e-cigarettes containing nicotine and the group with non-nicotine containing devices. However, there was no difference between the groups with regard to the overall reduction in the number cigarettes smoked at 24 or 52 weeks.4 In addition to these, there are many other small-scale trials, some of which show positive and some of which have negative results which may be considered inconclusive. These studies often address particular aspects of efficacy which are of concern (e.g. efficacy in key sub-populations), but they do not resolve the overall question of the efficacy of e-cigarettes for cessation. An interesting ‘real world’ study which was part of the continuing English Smoking Toolkit Study found that ecigarette users had a better quit rate than those who used ‘over the counter’ nicotine replacement products, or than those who succeeded in quitting without any form of nicotine.5 The survey reports high e-cigarette use among ex-smokers, which raises questions regarding the role of e-cigarettes in maintaining abstinence or as a gateway to relapse.

The approach to establishing safety has included demands for accurate information on e-cigarette contents and basic ingredients, which was initially very limited but is now increasing thanks to labelling by makers and analysis by independent scientists.

However, the wide range of available devices (some estimates exceed 500 variants) reduces confidence that the contents are reliably known. For the purpose of this article, only nicotine containing devices are relevant to this discussion.

Within these products, the main constituents are reported to be nicotine, propylene glycol, glycerine and flavours which of course when vaporized are released as particles of varying sizes which have not been well characterized. Particle size may be a consideration in itself, distinct from the actual composition of the particles. All of these substances have toxicity and when vaporized are inhaled into the lungs and released into the atmosphere.

The relevance of animal studies showing potential toxicity from e-cigarettes are uncertain but to date, they are thought to be low.6 At least two human-based studies show acute but mild toxicity on lung function: one demonstrates an increase in airway resistance with active e-cigarette usage7 and one indicates a decrease in FEV1/FVC ratio, but only in passive exposure to e-cigarettes.8 It is too soon to be confident about long-term toxicity. A knowledge of the constituents indicates that the effects may not be severe, with one estimate suggesting that in comparative terms it may be as little as 5% that due to cigarette smoking.9 However, this estimate is based on a modelling study where the inputs for the effects of e-cigarettes are reported to be largely unknown for these relatively new devices.

The possible long-term effects on tobacco control are also largely unknown. Prevalence studies referred to earlier suggest that adolescences and young adults are using e-cigarettes in increasing numbers.10 Most studies find that young people who use e-cigarettes also use tobacco products, though there are instances where young people try e-cigarettes without having tried tobacco.11 The possible gateway effect to cigarette smoking is not resolved. Studies conducted in the UK have not shown a link to date but research from the USA is starting to indicate that e-cigarettes may serve as a gateway in some circumstances. 12, 13

The effects that e-cigarette use may have on smokefree laws are no less complex. Many purport that the vapour released from e-cigarettes is harmless and therefore should not be banned in indoor/public places. However, the possibility that the vapour may be confused with smoke has led some authorities to ban ‘vaping’ where smoking is banned with the aim of ensuring continued support for Article 8 of the WHO FCTC and avoiding the confusion that e-cigarette use in public may affect attitudes and implementation of smokefree laws. Countries contemplating policies towards the tobacco ‘endgame’ (e.g. Ireland, Finland, Scotland, New Zealand and Singapore) are also grappling with the policy implications that e-cigarettes may have on smokefree legislation.14

Perhaps the greatest challenge that e-cigarettes may pose for tobacco control would be the actions and reactions of the tobacco industry. With the e-cigarette market, we see a revival of the difficulties that marketing, advertising, sponsorship and promotion of cigarettes posed for tobacco control and that were subsequently reflected in WHO FCTC Article 13. Perhaps even more concerning is the threat posed by the consequences of ownership of a large and seemingly increasing proportion of the e-cigarette industry by the tobacco industry, which directly challenges implementation of WHO Article 5.3, requiring governments to refuse the tobacco industry access to policy formation in public health and is regarded among the most important of tobacco control measures. It seems possible that the proposed provisions of the Transatlantic Trade and Investment Partnership (TTIP) may also be used to threaten TC. In the European Union, multinational corporations may try to use TTIP to challenge the EU Tobacco Products Directive regulations on e-cigarettes, further muddling the already unclear circumstances surrounding the right of Member States to legislate for public health of their citizens.

Data to support or refute these growing hopes for, or concerns regarding, e-cigarettes are yet not available and will likely not become available during this rapidly evolving situation.

History, however, suggests caution. Both in Europe and the USA, efforts by scientists to collaborate with the tobacco industry in the 1950s, 1960s and 1970s to find safer nicotine delivery devices had the net effect of only delaying the inevitable conclusion that the tobacco industry’s aims are incompatible with public health.15, 16 Will history repeat itself with this new, sophisticated, less toxic device or will public health learn the lessons from history and reject the extravagant hopes placed in a technology which, at its most benign can be seen as another nicotine replacement therapy with unpredictable prospects of success?


The authors, Prof Luke Clancy and Dr Kate Babineau are employed and funded by Tobacco Free Research Institute Ireland (TFRI), Dublin.
Conflict of interest: None declared.


1. TNS Opinion & Social. Special Eurobarometer 429. Attitudes of Europeans towards tobacco and electronic cigarettes. 2015 [Online].
2. Conference of the parties to the WHO Framework Convention on Tobacco Control. Electronic nicotine delivery systems, including electronic cigarettes, Moscow. (13–18 October 2012, date last accessed).
3. Bullen C, Howe C, Laugesen M, McRobbie H, Parag V, et al. Electronic cigarettes for smoking cessation: a randomised controlled trial. Lancet 2013; 382:1629–37.
4. Caponnetto P, Campgna D, Cibella F, Morjaria JB, Caruso M, Russo C, et al. EffiCiency and Safety of an eLectronic cigAreTte (ECLAT) as tobacco cigarettes substitute: a prospective 12-month randomized control design study. PLoS One 2013; 8: e66317.
5. Brown J, Beard E, Kotz D, Michie S, West R. Real-world effectiveness of e-cigarettes when used to aid smoking cessation: a cross-sectional population study. Addiction 2014; 109: 1531–40.
6. Hajek P. Electronic cigarettes: review of use, content, safety, effects on smokers and potential for harm and benefit. Addiction 2014; 109: 1801–10.
7. Chorti M, Poulianti K, Jamurtas A, et al. Effects of active and passive electronic and tobacco cigarette smoking on lung function. Abstracts/Toxicol Lett 2012; 21: 64.
8. Vansickel AR, Cobb CO, Weaver MF. A clinical laboratory model for evaluating the acute effects of electronic cigarettes: nicotine delivery profile and cardiovascular and subjective effects. Cancer Epidemiol Biomark 2010; 19: 1945–53.
9. Grana R, Benowitz N, Glantz SAE-. cigarettes a scientific review. Circulation 2014; 129: 1972–86.
10.Cooper M, Case KR, Loukas A. Ecigarette use among Texas youth: results from the 2014 Texas Youth Tobacco Survey. Addict Behav 2015; 50:173–7.
11.Babineau K, Taylor K, Clancy L. Electronic cigarette use among Irish youth: a cross sectional study of prevalence and associated factors. PloS One 2015; 10: e0126419.
12.Dutra LM, Glantz SA. Electronic cigarettes and conventional cigarette use among US adolescents: a cross-sectional study. JAMA Pediatr 2014; 168: 610–7.
13.ASH. Electronic cigarettes (also known as vapourisers). A Briefing. 2014.
14.Beaglehole R, Bonita R, Yach D, Mackay J, Reddy KS. A tobacco-free world: a call to action to phase out the sale of tobacco products by 2040. Lancet 2015; 385: 1011–8.
15.Berridge V. Marketing Health. Smoking and the discourse of public health in Britain, 1945-2000. Oxford University Press, Oxford, 2007.
16.Parascandola M. Lessons from the history of tobacco harm reduction: the National Cancer Institute’s Smoking and Health Program and the “less hazardous cigarette”. Nicotine Tob Res 2005; 7: 779–89.

Report on Tobacco Control for the Region of the Americas

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Earmarked tobacco taxes – lessons learnt from nine countries

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Electronic cigarette awareness and use among adults in Hong Kong



Electronic cigarettes (e-cigarettes) have gained popularity rapidly in theWestern world but data in the East are scarce. We examined the awareness and ever use of e-cigarettes, and reasons for e-cigarette use in a probability sample of adults in Hong Kong.


Cross-sectional data were collected in 2014 from Chinese adults aged 15–65 in Hong Kong (819 never smokers, 800 former smokers, 800 current smokers) via computer-assisted telephone interviews (response rate: 73.8%). Analysis was limited to a subset of 809 respondents (i.e., 357 never smokers, 269 former smokers, 183 current smokers) who were randomly selected to answer questions on e-cigarettes. Chi-square analyses compared e-cigarette awareness and ever use by gender, age, education, and cigarette smoking status. Multivariable logistic regression examined if e-cigarette awareness was associated with demographic variables and cigarette smoking status.


75.4% of adults had heard of e-cigarettes, and 2.3% reported having used e-cigarettes. Greater awareness was associated with male gender and higher education. Ever use of e-cigarettes was higher among males (3.6%, p=.03), younger adults (aged 15–29, 5.2%, p=.002), and current cigarette smokers (11.8%, p b .001). Common reasons for using e-cigarettes were curiosity (47.4%), the stylish product design (25.8%), and quitting smoking (13.6%).


Awareness of e-cigarettes was widespread in Hong Kong. Although the use of e-cigarettes was low, its relation with younger age and current smoking is of concern. Health surveillance of e-cigarette use is needed. Interventions should target young adults and cigarette smokers, and address the marketing messages, especially the effect of e-cigarettes on smoking cessation.

Sin Tax Reform in the Philippines

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The Battle for Breath – The Impact of Lung Disease in the UK

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Systematic Review and Meta-Analysis of Inhaled Toxicants from Waterpipe and Cigarette Smoking

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Truth about illicit tobacco reveals decline

BUT IT still needs robust enforcement to keep it in check, says Sheila Duffy

Illicit tobacco is one of those subjects (like e-cigarettes) where the quantity of the media coverage is not always matched by the quality.

To be fair to hard-pressed journalists it is hard to resist a succession of helpful public relations companies providing them with ready-made news stories which can support dramatic headlines on the “booming” illicit trade, corner shops closing, “unhealthy” fake fags and international crime networks.

At the same time leaked documents have revealed details of tobacco industry plans to use the media to scaremonger over illicit as part of their effort to oppose plain, standardised packaging for tobacco.

Those seeking an unbiased estimate of the scale and trends in illicit tobacco should use the annual figures from Her Majesty’s Revenue and Customs (HMRC), which is as close as we’re going to get to an expert, unbiased voice. So we’re always keen to see the annual Tax Gaps report from HMRC, and the 2014-15 figures were published recently.

Anyone who had been following the tobacco-industry sourced media stores must have found the figures a bit surprising. So let’s set them out clearly.

The best estimate of the illicit market remains static at 10 per cent of manufactured cigarette sticks.

The best estimate of the illicit share of the hand-rolling tobacco market was down from 39 per cent to 35 per cent.

These are percentages of an overall tobacco market which continues to decline.

So a static percentage of the market actually relates to a decline in the amount of illicit tobacco used (for example, the reported rise in illicit market share in cigarette sticks from 9 per cent to 10 per cent in 2013-14 actually related to a 7 per cent drop in numbers of illicit cigarettes).

These figures indicate that the illicit tobacco market is at historically low levels – in 2000-1 HMRC estimates were that 22 per cent of cigarettes and 61 per cent of hand-rolling tobacco was illicit.

The decline in overall volume since then has been 76 per cent in illicit cigarette sticks and 33 per cent in illicit hand-rolling tobacco. Could any unbiased observer conclude that these figures are “booming”?

This is not to play down the importance of illicit tobacco, which brings criminal elements into communities, bypasses health regulations we have worked long and hard to achieve and deprives the Exchequer of much-needed tax revenue.

Nor is it to say that everything’s in hand – the reduction in illicit tobacco is the planned and deliberate result of robust enforcement measures, including restrictions on the tobacco companies themselves.

To keep the lid on illicit tobacco we need to ensure that robust enforcement is not hampered by budget cuts and austerity.

And we need to generate a community discussion, to lower the demand for the product, with NHS Greater Glasgow and Clyde having created useful tools to support that. What it does mean is that the idea of a “booming illicit trade” at the centre of tobacco company campaigns against public health measures is, appropriately enough, not the real deal.

• Sheila Duffy is chief executive of ASH Scotland

Australia tobacco clash reverberates in EU trade talks

Tribunal decision could undermine opposition to TTIP.

The end of a complex court case on the other side of the world could wreak havoc on a campaign in Europe against a proposed trade deal between the EU and the United States.

An international arbitration tribunal in December 2015 wound up a four-year dispute between the Australian government and tobacco company Philip Morris by announcing it was unable to rule on the matter — effectively siding with Australia’s position in the dispute.

The case has resonated in Europe, where for some time opponents of the proposed Transatlantic Trade and Investment Partnership (TTIP) have used the legal challenge as a cautionary tale against signing investment deals.

Philip Morris used an obscure investment agreement which Australia signed with Hong Kong in 1993 in an attempt to scuttle Australia’s “plain packaging” tobacco legislation, which has removed all branding from cigarette packets sold in the country.

But Australia’s ability to fend off the legal challenge could undermine the argument that legal provisions contained in international investment agreements leave legitimate legislative reform vulnerable to big corporations.

“It will be back to the drawing board for anti-TTIP campaigners,” said Hosuk Lee-Makiyama, director of the European Center for International Political Economy, adding that the parallels between Australia’s deal with Hong Kong and TTIP had always been overstated.

“Philip Morris was only able to sue Australia because of a technicality,” Lee-Makiyama said. “In free-trade agreements you always include an exception for public health, which Australia forgot to do. This entire case was the result of a drafting error by Australian negotiators.”

However, anti-tobacco campaigners in Brussels say the decision by the Permanent Court of Arbitration in Singapore does nothing for TTIP’s credibility.

“The arbitration court declined to hear the case on the grounds that it was not competent, as Philip Morris had shifted its commercial identity during the course of the case,” said Catherine Hartmann, vice president of the European Public Health Alliance.

“There is nothing in the outcomes of the arbitration attempt that validates or questions plain packaging in Australia or anywhere else,” Hartmann said.

Tobacco wars

The clash between Philip Morris and the Australian federal government began in 2011, when health authorities in Canberra drafted legislation to remove all branding from tobacco packets. The laws, designed to discourage people from taking up smoking, were implemented at the end of 2012.

The legislation was a world first and Philip Morris Asia Limited, a Hong Kong-based subsidiary of the tobacco company, launched a legal challenge. The company argued that the laws “forced removal of trademarks and other valuable intellectual property.”

The legal action was possible because the agreement between Australia and Hong Kong contained an “investor-state dispute settlement” provision (ISDS), an arbitration mechanism which enables investors to take legal action if they feel their interests have been harmed by government policy.

In 2012 the High Court of Australia, the country’s supreme court, found against Philip Morris, arguing the plain packaging legislation was not in violation of the constitution. The tobacco company then took its concerns to the international arbitrator, which effectively ruled against Philip Morris.

Yet Nina Renshaw, the secretary general of the European Public Health Alliance, is adamant the risks of industry using ISDS to challenge health reforms remain.

“The inclusion of an ISDS … in an EU agreement could raise the likelihood of such cases being brought against all kinds of public interest and health protecting policies in the future,” Renshaw said.

In an unusual alliance, Philip Morris agreed with anti-tobacco campaigners. Company vice president Marc Firestone argued that the Australian government’s win was “entirely procedural” with no bearing on either the merits of plain packaging legislation or the ISDS itself.

However, Lee-Makiyama said opposition in Europe to both ISDS and TTIP is based not on fact but misconceptions about American corporate culture.

“This is coming from business interests that are concerned with American market share and from outdated ideas of multinational corporations which may have been OK in the 1920s but are meaningless today,” Lee-Makiyama said.

“Opposition to the ISDS in Europe is also coming from national governments like Germany, which do not want a legal mechanism to stop them discriminating against foreign investors,” he said.

Packaging problems

The controversy has fed into a broader lobbying clash between the tobacco industry and anti-smoking campaigners in Europe, where plain packaging legislation is being hotly contested.

The EU’s revised Tobacco Products Directive, which entered into force in 2014, steered clear of plain packaging reforms after the European Commission came under pressure from the tobacco industry. However, the directive allowed EU member countries to adopt national plain packaging laws.

A number of EU governments have now done so. In December 2015, France passed tobacco legislation and will start to introduce plain packaging in May 2016.

However, the tobacco industry is maintaining its opposition to such laws. Australia’s legislation is also being challenged by a number of tobacco-producing countries at the World Trade Organization.

Meanwhile, on the other side of the Atlantic the EU’s soul-searching over the implications of an ISDS is being observed with interest by those opposing the inclusion of an arbitration mechanism in TTIP on the grounds that it is unnecessary.

“A company entering into a contract with a foreign government can accomplish the same objectives as an ISDS simply by insisting on including an arbitration clause,” said Dan Pearson from the Washington-based Cato Institute, a libertarian think-tank.

“Business associations in the U.S. would support TTIP without an ISDS because the reality is that they don’t need it,” Pearson said. “It mystifies me that the Obama administration has placed so much emphasis on an ISDS.”

This article was corrected to clarify details of the 2012 Australian High Court finding.