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April, 2016:

Contribution of smoking to socioeconomic inequalities in mortality

A study of 14 European countries, 1990–2004



Smoking contributes to socioeconomic inequalities in mortality, but the extent to which this contribution has changed over time and driven widening or narrowing inequalities in total mortality remains unknown. We studied socioeconomic inequalities in smoking-attributable mortality and their contribution to inequalities in total mortality in 1990–1994 and 2000–2004 in 14 European countries.


We collected, harmonised and standardised population-wide data on all-cause and lung-cancer mortality by age, gender, educational and occupational level in 14 European populations in 1990–1994 and 2000–2004. Smoking-attributable mortality was indirectly estimated using the Preston-Glei-Wilmoth method.


In 2000–2004, smoking-attributable mortality was higher in lower socioeconomic groups in all countries among men, and in all countries except Spain, Italy and Slovenia, among women, and the contribution of smoking to socioeconomic inequalities in mortality varied between 19% and 55% among men, and between −1% and 56% among women. Since 1990–1994, absolute inequalities in smoking-attributable mortality and the contribution of smoking to inequalities in total mortality have decreased in most countries among men, but increased among women.


In many European countries, smoking has become less important as a determinant of socioeconomic inequalities in mortality among men, but not among women. Inequalities in smoking remain one of the most important entry points for reducing inequalities in mortality.

Celebrating 10 years of smoke-free Uruguay

Uruguay is celebrating 10 years as a smoke-free (SF) country in 2016. When it banned smoking in public spaces and workplaces a decade ago, it became the first county in the Americas, and only the fourth in the world, to do so.

President Dr Tabaré Vázquez, an oncologist, is rightly credited for pushing Uruguay’s tobacco control agenda to the forefront globally, but 10 years ago inspiration was provided by a variety of sources inside and outside the country – with civil society leading – likely boosted by Uruguay’s tiny size, which made it easier to ‘spread the word’, and a surprisingly receptive public.

Today I am proud to have participated in this agenda-setting campaign, which has had a major impact on public health in my country. In the early 2000s, Uruguay had one of the highest rates of smoking in Latin America and the highest rate of male deaths caused by lung cancer. In the region, young Uruguayans faced among the highest rate of exposure to tobacco smoke indoors.

A 1996 decree banned smoking in government offices and all enclosed premises, but it included designated smoking areas, which we now know are ineffective. No matter – the regulation was not enforced nor monitored.

External influences

Encouraged by ongoing negotiations on the WHO Framework Convention on Tobacco Control (FCTC) and by a SF regional initiative of the Pan-American Health Organization (PAHO) in 2001, some Uruguayans began imagining a smoke-free country.

In March 2003, PAHO held a capacity-building workshop in Jamaica. Three Uruguayans attended as observers: Dr Diego Estol (Director General of the Ministry of Health [MoH]), myself (representing the National Medical Association) and Dr Adriana Blanco (from the Municipality of Montevideo). There, the idea of Uruguay becoming Latin America’s first smoke-free country was born.

In December 2003, PAHO held a SF workshop in Uruguay. There, representatives of the MOH and civil society organizations – united in the National Tobacco Control Alliance (ANCT) – agreed on a project aimed to make government, health and educational facilities 100-percent SF in two years.

In January 2004, a MoH decree banned smoking in education and health facilities, but there was only moderate enforcement and compliance. Also in 2004, a national SF network (RULTA) was launched.

Smoke-free dancing

On 24 August 2004, a new non-smokers’ association (FPU) organized the first 100-percent SF dinner-dance, which attracted over 400 people. A few weeks later, the Uruguayan Society of Cardiology (SUC) held its first congress, also with a SF dinner-dance. These events were “pilot projects” to prove that smokers would respect a ban.

In September 2004, Uruguay ratified the FCTC, and later that year the MOH created a tobacco control advisory commission (that included civil society).

On 1 March 2005, Dr Vázquez took office as President. Later that month, the advisory commission advised the Minister of Health on measures for implementing the FCTC.

Shopping malls go SF

Things began to move quickly. On 31 May the President issued various decrees, including one regulating smoking in indoor places. In July, two shopping malls surveyed their customers: only 3.6 percent of them said they would stop visiting if the malls completely banned smoking. They chose to go 100-percent SF. That same month, MOH banned smoking in all government facilities.

On 5 September, President Vázquez issued a new decree, establishing a complete smoking ban from 1 March 2006.

Media campaigns played an important role. In 2004, the National Resource Fund (FNR), a wealthy and well known public institution, got involved in SF, launching a media campaign to increase public awareness of the risks of smoking and second-hand smoke.

Thanks a million

In late 2005, supported by PAHO, the civil society alliance, ANCT, conducted another campaign to increase awareness about the health risks of second-hand smoke. And in February 2006, President Vázquez launched Thanks a million – a campaign aimed at involving smokers themselves in the movement and at preparing the ground for the coming complete ban.

Thanks a million attracted 1.3 million participants, who thanked smokers for not lighting up indoors. In November 2006, an opinion poll showed that 94 percent of Uruguayans supported SF workplaces.

Ten years later, what has been the impact of Uruguay’s SF campaign?

Two international studies compared indoor air contamination levels, and nicotine levels, before and after the smoking ban. They found a roughly 90-percent reduction in both.

A 2010 national study revealed a 22-percent drop in admissions to hospitals for heart attacks after the ban came into force.

Following Uruguay´s lead, in less than 10 years 12 other Latin America countries have become SF.

What’s next for SF Uruguay?

Despite this impressive record, Uruguay should not relax but continue building on these achievements. For example in 2010, 81 percent of smokers who had a family car reported that smoking was “never allowed” when children were in the vehicle; that number grew to 84 percent in 2012. Also in 2012, 88 percent of smokers said they would support a law banning smoking in vehicles carrying children.

Uruguay should also consolidate and deepen its SF policy by:

Conducting periodic awareness media campaigns;
Improving enforcement of SF workplaces;
Banning smoking in areas next to access doors to educational , health facilities and restaurants.
* FCA Director, Americas region and President, Tobacco Epidemic Research Centre of Uruguay (CIET)

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Tobacco lobbyists demand say in EU debate on … tobacco lobbying

When European Ombudsman Emily O’Reilly announced she would host a public conference on how to improve transparency in tobacco lobbying, her office quickly found itself grappling with an ethical predicament: Should tobacco lobbyists be let in?

It may sound counter-intuitive to prevent the industry that this Wednesday’s conference will discuss from having an official role in it. Yet the organizers of a similar event in the European Parliament earlier this month did just that, arguing that they were required to keep tobacco lobbyists out by an international treaty.

In the past, the ombudsman has expressed concerns about the lack of transparency surrounding tobacco lobbying, causing some anti-tobacco campaigners to expect a strong statement from her which would set a standard for other EU institutions. But tobacco lobbyists were equally worried that they would be shut out altogether from a debate directly involving them.

“What could be more transparent than a public debate?” — Tobacco lobbyist

The issue is how the EU chooses to implement the Framework Convention on Tobacco Control (FCTC), a United Nations deal signed by EU institutions that seeks to keep the tobacco industry out of the health policy process. The language in the treaty is open to interpretation, but lobbyists insist it should not be used to ban them from public events.

“Keeping the industry off the panel while they talk about our business doesn’t make any sense and has nothing to do with FCTC,” one tobacco lobbyist said. “For an event supposedly about transparency, what could be more transparent than a public debate?”

The ombudsman ultimately chose a compromise likely to please nobody: Tobacco lobbyists can attend as audience members, but will not be invited to join the panel discussion. Anti-tobacco and transparency campaigners will be unhappy about policymakers and lobbyists sharing a venue; lobbyists argue they are being denied their right to free expression.

In any case, the upshot is that when European Commissioner for Health Vytenis Andriukaitis arrives at the event in Brussels, he will be surrounded by tobacco lobbyists — although not all of them will be immediately recognizable as such.

According to a preliminary list of participants, some lobbyists who plan to attend have not signed up to the EU Transparency Register and, therefore, should be barred from having any interaction with the commissioner and his staff.

The controversy is forcing EU health bureaucrats to figure out how to implement provisions regarding industry lobbyists, and to decide whether a hard-line stance will expose them to the accusation they are stifling debate on the future of a legal product.

No blanket ban

The dispute focuses on an article in the convention which states that when “setting and implementing” public health policies, officials should “protect these policies from commercial … interests of the tobacco industry.”

The industry argues that the ombudsman’s conference, which has nothing to do with formulating health policy, does not fall under the remit of the article. What’s more, it says the thrust of the convention is to bring about transparency in tobacco lobbying — something most industry representatives accept.

This argument gets some unlikely support from the framework convention itself: Officials at the FCTC Secretariat point to the accompanying guidelines as the key to understanding how governments should handle day-to-day interaction with lobbyists.

“The Convention calls [on] parties to limit their interactions with the tobacco companies and their interests as much as possible, but does not mandate a blanket ban,” said Tibor Szilágyi at the secretariat in Geneva. “However, the [FCTC] calls for transparency of interactions that still occur.”

The largest tobacco industry association, the Confederation of European Community Cigarette Manufacturers, is relieved to be let in but is still angry at being excluded from a panel including Giovanni La Via, who chairs the European Parliament’s public health, food safety and environment committee.

The group wrote to O’Reilly on April 19 to protest, according to a redacted version of the correspondence released by the ombudsman’s office. An uncensored version of the letter, seen by POLITICO, was signed by Ronan Barry, a British American Tobacco executive and president of the industry body.

Tobacco manufacturers were “disappointed” by O’Reilly’s decision not to invite them, Barry said, urging her to “reconsider our request to allow a representative [to] participate fully in the event as a speaker” or at least to ensure that the industry be “provided with adequate time to present our position and address any queries” raised in the debate.

The response from ombudsman spokesperson Gundi Gadesmann made it clear officials were taking a strict interpretation of the tobacco control treaty, meaning they could not involve the industry in the official discussion.
“It would be harmful if they started taking the floor all the time and hijacked the discussion” — Florence Berteletti, director of Smoke-Free Partnership, an anti-tobacco NGO

In line with the convention, they did not invite in industry representative, she wrote, adding that the event “is not about the tobacco industry. It is about how the EU institutions comply with their transparency obligations as regards their dealings with representatives from the industry.”

That left the tobacco industry fuming. One tobacco lobbyist said the letter proves how indefensible the ombudsman’s position is, because it conceded the conference was not about the formulation or implementation of health policy.

Yet Article 5.3 of the tobacco convention, which Gadesmann invoked in her justification to exclude industry panelists, refers specifically to the “setting and implementing” of public health policies.


Industry sources said Barry planned to try to speak from the audience to confront the ombudsman about her decision to exclude tobacco manufacturers from the panel.

“It would be harmful if they started taking the floor all the time and hijacked the discussion,” said Florence Berteletti, director of Smoke-Free Partnership, an anti-tobacco NGO. “I would hope they would intervene just once and that the discussion would then move on.”

Tobacco lobbyists are dismayed but not surprised. In February, O’Reilly took aim at the European Commission for not making its dealings with the tobacco industry “more transparent” and for lacking “proactivity” in implementing the convention

However, the ombudsman’s decision to let lobbyists attend the conference gives the industry an opportunity to make its presence felt. The preliminary list of attendees, obtained by POLITICO, suggests at least 17 industry representatives have already signed up.

The list highlights the challenge of enforcing the requirement that signatories to the convention “ensure that all operations and activities of the tobacco industry are transparent.” Under EU transparency rules, it’s possible for some lobbyists to avoid disclosing their activities.

For example, Brussels lawyer Kathryn Davies, from the firm Berwin Leighton Paisner, will be in the audience, according to the list. When contacted, Davies declined to reveal whether her firm was working for tobacco companies.

Lawyers are not required to sign up to the European Parliament and Commission Joint Transparency Register, even if they are working as lobbyists. As a result, the names of their clients often remain secret, protected by attorney-client confidentiality.

Some lobbyists who will be in the audience are also not signed up to the Register, which means that under EU rules they will not be allowed to interact in any way with Andriukaitis or members of his cabinet.

Lobbyist Finn Meunier, who works for German firm Concilius AG, would not disclose whether he would attend on behalf of a tobacco company. Another German lobby firm called 365 Sherpas did not respond to requests for information.

Among the lobbyists who are listed on the Register and will therefore be able to speak to the commissioner and his staff are those from Bernstein Public Policy and Red Flag, representing British American Tobacco; lobby firm Pantarhei Advisors Europe, for Philip Morris; and Kreab, representing Swedish Match. Imperial Tobacco and British American Tobacco will also be represented by in-house lobbyists.

Quentin Ariès contributed reporting to this article.

James Panichi

Tobacco firm Philip Morris pleads not guilty to huge Thai tax dodge

Tobacco giant Philip Morris on Monday pleaded not guilty to dodging hundreds of millions of dollars in import tax to Thailand, a crime carrying a massive fine of up to US$2.27 billion.

Thai prosecutors accuse the local unit of the company, which owns the Marlboro and L&M brands, of evading some 20 billion baht (US$568 million) tax by under declaring import prices for cigarettes from the Philippines between 2003 and 2006.

In fact the duty-free end price of the cigarettes was much higher, according to prosecutors.

The company and seven Thai staff pleaded not guilty according to a written statement read out by a judge at a pretrial hearing at a Bangkok court on Monday.

If convicted prosecutors say the company could be fined up to four times of the sum of unpaid tax, while the employees face a maximum of 10 years in jail.

Four foreign executives have also been charged but have left the country in a case that dragged for a decade.

The company “vigorously” denies the “baseless” allegations, Alejandro Paschalides, managing director of Philip Morris Thailand, said after the hearing.

“We would like to encourage the Thai government to reconsider these meritless charges which will harm Thailand’s standing in the trade community and ultimately cause damage to the Thai economy and thus the Thai people,” he added in a statement.

The cigarette manufacturer insists that its import valuations complied with World Trade Organization agreements and had been cleared by local Thai customs officials.

We would like to encourage the Thai government to reconsider these meritless charges which will harm Thailand’s standing in the trade community

Alejandro Paschalides, managing director of Philip Morris Thailand

The legal issue has simmered since 2006 under the administration of prime minister Thaksin Shinawatra, shortly before his ousting in a military coup.

Thailand has since been hit by a decade of political instability with frequent government changes and a second coup in 2014.

In 2011, the attorney general at the time recommended against charging the tobacco giant, but the prosecution was restarted two years later.

The next hearing will be in October but the trial is likely to drag out for a number of years.
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Teenage e-cigarette use ‘clustered’ in certain schools, study finds

Since 2011, the prevalence of adolescent electronic cigarette use has drastically increased in the U.S. Certain school environments have an impact on electronic cigarette use among teenagers, a new study concludes.

A new study from the University of Colorado Denver finds that certain school environments have an impact on electronic cigarette use among teenagers.

The study was led by Adam Lippert, an assistant professor in the Department of Sociology in the College of Liberal Arts and Sciences, and published in the journal Health and Place.

Since 2011, the prevalence of adolescent electronic cigarette use has drastically increased in the U.S. This month, the Centers for Disease Control and Prevention reported that e-cigarette use has surpassed the use of other tobacco products and that over 3 million middle and high school students used e-cigarettes in 2015.

Lippert’s study examined data collected by the CDC in the 2011 and 2013 National Youth Tobacco study to determine if individual e-cigarette use coincides with total use at the school level over time.

Lippert’s research showed that students attending schools where e-cigarette use was very common were more likely to use themselves, regardless of personal risk factors including whether they smoked regular cigarettes or knew someone who did.

Furthermore, Lippert found that school-to-school differences in e-cigarette use rates have increased over time, suggesting that certain schools have fueled the rise in teen e-cigarette use while in others, use has remained low. Lippert argues that there is something in the culture of some schools that encourages students to use e-cigarettes.

“Our results indicate that there are certain types of schools that facilitate higher rates of e-cigarette use among students,” said Lippert. “Since our data was collected over several years, we can determine something is happening within these school environments that contributes to e-cigarette use.”

One reason for electronic cigarette use clustered in particular schools may be the pervasive perception that e-cigarettes are less harmful than conventional cigarettes. Lippert notes that educators should take these types of perceptions, as well as the number of individuals using e-cigarettes, into account when implementing initiatives to curb e-cigarette use.

Teen’s ‘e-cigarette explodes in his face in car’ leaving him with burns and missing bottom teeth

Daniel McClelland had just told his mum that morning that he was planning on vaping more to help him quit smoking

A teen has been rushed to hospital after he says the electronic cigarette he was using exploded in his face.

Daniel McClelland was using the device as normal while he was in friend’s car, he says – but was stunned when it suddenly blew up.

The impact of the blast reportedly cracked the windows of the car he was in and left him in need of medical attention.

Bleeding, he says he ran home to his mum’s where she called for the emergency services.

The 17-year-old of Fresno, California, was rushed to Twin Cities Community Hospital by emergency crews called to the scene.

Read more: Users lose teeth and need skin grafts after exploding e-cigarettes

As well as losing many of his bottom teeth, a small hole was blown through Daniel’s tongue, his family have revealed.

His tongue was also severely swollen and he was needed help with breathing. He was later taken by air for treatment at a specialist burn unit.

Jesus Matias, a friend who was in the car, told Paso Robles Daily News : “We were just sitting in my girlfriend’s sister’s car, listening to music, laughing and joking around like always and we just heard a sound like a gun shot.

“I look up and I see flames, we all got out of the car and my ears were ringing, then I realised Daniel was hurt.”

Daniel’s mum Gina Skove Krasnow has been posting updates on her Facebook page.

“It was just that morning that Daniel told me he planned to quit smoking cigarettes by switching to that vape.

“I told him, I really don’t like either of them but if that’s what it took to help him quit smoking cigarettes then that was that,” she said.

Daniel took to his own account on Monday to thank his friends for their support.

“Tears coming to my eyes in reality of everything that’s happened but mostly how many people are here for me in support and love,” he wrote.

“Life is a very precious thing and I am more than grateful to still have mine. I want to thank every single individual person that’s done anything to help my recovery process.”

He told his loved ones they were “all miracles and a blessing to my life” and asked that they keep praying for him.

“I promise you all I’m not going to give up on this fight until I’m back to healthy me I was. I love you all so dearly thank you.”

The family have launched fundraising online which is currently at £645.

Benefits of smoking bans on preterm and early-term births

A natural experimental design in Switzerland



Birth outcomes are relevant for future children’s heath. Capitalising on a natural experimental design in Switzerland, we evaluated how regional smoking bans introduced at different time points affected birth outcomes, including preterm and early-term births.


We used birth registry data of all singleton neonates born in Switzerland (2007–2012). We developed canton-specific interrupted time-series followed by random meta-analysis to evaluate the benefits of smoking bans on preterm (<37 gestational weeks) and early-term (37–38 gestational weeks) births. Heterogeneity across type of ban and contextual characteristics was explored through metaregression. A time-to-event approach was used for evaluating duration of pregnancy under the smoking bans and effects, taking into account individual maternal factors.


We observed a decrease in the risk of preterm birth of 3.6% (95% CI, −9.3% to 2.5%), and early-term birth of 5.0% (95% CI −7.5% to −2.5%). Results showed a clear dose–response relationship. Greater risk reductions were obtained for preterm births in areas with more comprehensive bans (−6.8%; 95% CI −12.1% to 0.1%), and for pregnancies with the longest gestational time under smoking bans (HR, 0.991; 95% CI 0.984 to 0.997 per 10% increase in duration). Benefits were unequal across outcomes and characteristics of cantons and mothers.


Smoking bans resulted in improved birth outcomes in Switzerland with cantons that adopted more comprehensive smoking bans achieving greater benefits. Early-term births constitute a previously ignored though important group.

The Pleasure Principle

Sarah Jakes, a Trustee at the New Nicotine Alliance (NNA), proposes vaping as a recreational alternative to smoking – an holistic approach to tobacco harm reduction and smoking cessation (and pleasure).

The UK is now a world leader in recognising the health benefits for smokers of switching to vaping on both an individual and population level. As a result, the UK  Government is taking a relatively liberal approach to implementation of the EU Tobacco Products Directive (the ‘TPD’) and seeks to impose only the bare minimum requirements therein. Despite this the new regulations will still be extremely damaging to public health, but the situation is better than it might have been. The achievements in the UK, such that they are, are largely down to a huge effort by vapers to educate politicians, regulators and those who influence them about the ways in  which vaping has improved their health, lives and outlook.

This might not have been possible were it not for the fact that among the public health community in the UK there are a number of individuals and key influencers who listened to consumers and were brave enough to step outside of the tobacco control party line and take a pragmatic view of tobacco harm reduction in order to achieve the potentially massive public health gains on offer via vaping. However, as time has gone by the discussions have been dominated by arguments over often misleading reports of trivial potential harms and the efficacy of vaping products for cessation. We stand a good chance of losing sight of the very essence of why vaping works as a way of reducing smoking. This would be a shameful waste of a great opportunity.

Vaping is a consumer driven free market solution to the problems inherent in smoking tobacco. Naturally the public health community, including many of those who are provaping, seize upon harm to health being the problem to be solved and a casual observer could be forgiven for thinking that is the only issue. This leads to a disproportionate amount of time and resources being expended on arguing the toss over whether vapour devices are efficacious as smoking cessation tools (millions of vapers worldwide are proof that they are) or whether they will annihilate generations to come through nicotine addiction and the so far mythical gateway effects. Of course health is the most important consideration for those who come from a medical or health background, and indeed for many smokers, but it is not the only consideration for the ordinary smoker on the street.

Tobacco taxes have made smoking extraordinarily expensive. Smokefree laws have made it inconvenient. Those policies, together with messaging around denormalisation, have led to the stigmatisation of not only smoking, but also of smokers such that there are now those within otherwise polite society who think nothing of abusing smokers and painting them as selfish, stupid, stinking child / cat killers. The ‘untermensch’ to be despised, the lepers without bells.

A rethink is required. Smokers are fellow human beings who make choices in life based on risks and benefits just as everyone else does, albeit free choice is made more difficult in the context of tobacco dependence. Like it or not, for many people smoking has value which outweighs the risks and that value cannot be replaced by bland medicinalised products. Concentrating on health benefits and promoting vapour devices purely as tools of smoking cessation whilst simultaneously brow beating smokers into submission fails to capitalise on many of the reasons smokers may have to switch to the safer alternative and may be off putting for those who do not see smoking as a medical problem, or themselves as patients.

An holistic approach to vaping would recognise that its success as a popular alternative to smoking is not simply down to whether particular devices deliver sufficient nicotine to relieve cravings (although that is an important factor). To pretend otherwise is a mistake. Vaping is a thing of many parts, and the neglect of any one of them is to the detriment of the whole. It is a recreational activity in its own right and brings pleasures of its own. It is also both a movement and a community with its own peer to peer support mechanisms. It is a hobby, an opportunity for socialising and a way to relax. Switching to vaping is empowering for many smokers, who often feel alienated by the constant nagging from the medical community, and would prefer to find their own solution with the help of those who have trodden the same path.

At a recent meeting of the All Party Parliamentary Group on E-cigarettes Professor Gerry Stimson asserted that vapour product manufacturers, vendors and vapers themselves are the new frontline in smoking cessation. I’m sure that statement rings alarm bells in certain public health circles. Decades of tax, prohibition and denormalisation have had an effect on smoking prevalence but at great cost – both financial and social – which smokers bear more than anyone. And yet nearly one in five people in the UK still smoke.

Gerry is of course absolutely right in his assertion above, but this was never the main intention of vapers or the vapour industry. They have filled a gap left by the failure of public health to deliver a solution. Why are they succeeding where others have failed, and without the need for stigma or cost to the public purse? Because of their holistic approach. Because they recognise the benefit of offering an attractive alternative instead of coercion. Because they were smokers themselves.

If public health wants to capitalise on the health benefits of smokers switching to vaping it must accept all that it entails and not just the parts that suit its own agenda. It must accept vaping for what it is and not what it would wish it to be, and stand alongside vapers in the fight against those who would deny them the choices they’ve made.

It must listen to vapers when they describe the damage the TPD will do, they have first-hand knowledge of the issues and no vested interest other than their own wellbeing.

Vaping is the sum of its parts and any attempt to separate those parts will end in public health failure.

Early symptoms of nicotine dependence among adolescent waterpipe smokers



Although waterpipe smoking is increasingly popular among youth and can lead to nicotine dependence (ND), no studies have documented how ND develops in waterpipe smokers. We examined the emerging symptoms of ND among adolescent waterpipe smokers in Lebanon.


Individual confidential interviews were used to evaluate ND in 160 waterpipe smokers and 24 cigarette smokers from a sample of 498 students enrolled in 8th and 9th grades in Lebanon.


Among waterpipe smokers, 71.3% endorsed at least one Hooked on Nicotine Checklist (HONC) symptom and 38.1% developed the full syndrome of ND (≥3 criteria using the International Classification of Diseases, 10th revision). The early symptoms of ND among waterpipe smokers were craving (25%), feeling addicted (22.5%), and failed quit attempts (14.3%). Among those who reached the respective milestones, median tobacco use when the first HONC symptom emerged was 7.5 waterpipes/month with smoking frequency of 6 days/month; the median tobacco use for the full syndrome of ND was 15 waterpipes/month with smoking frequency of 15 days/month. Among those who had already reached these milestones, the first HONC symptom appeared 10.9 months after the initiation of waterpipe smoking, and the full syndrome of ND was reached at 13.9 months. In addition, cues such as seeing or smelling waterpipe, and the café environment triggered craving in most waterpipe smokers with symptoms of ND.


Symptoms of ND develop among adolescent waterpipe smokers at low levels of consumption and frequency of use. Craving for nicotine triggered by waterpipe-specific cues is reported even at this young age. Waterpipe-specific ND prevention and intervention programmes for youth are needed.

Philip Morris, health company?

TOBACCO companies specialise in contradiction. They herald the decline of smoking among youngsters, for example, then flaunt their sales to callow puffers. The most skilled contortionist in the industry may be Philip Morris

International, the world’s biggest tobacco firm. To date, any good news for shareholders has been bad news for lungs. But the firm now says it wants to improve profits and health alike.

It may seem an odd goal for a company that last year sold 850 billion cigarettes. But it boss, André Calantzoupolos, insists Philip Morris is on the verge of a revolution. He touts “reduced-risk products”: on April 19th the firm said its top offering in this category, iQOS, accounted for one in 30 cigarette sales in Tokyo, a test market.

The new product resembles a pen. A user inserts a cigarette-lookalike called a HeatStick; iQOS then warms the stick’s tobacco, but doesn’t burn it. That produces an aerosol that carries a traditional cigarette’s taste but, the company hopes, eliminates much of the nasty stuff that comes with combustion. “For the first time in history,” Mr Calantzoupolos declared recently, “we have products with the real potential to both accelerate harm reduction and grow our business.”

This is hardly the first time tobacco firms have peddled healthier-seeming goods. Some have dubious benefits. Consumers have long bought “light” cigarettes to lower their risk of disease, despite evidence they do nothing of the kind.
E-cigarettes are less risky than traditional ones, but bring their own challenges. Some fear they will reduce the stigma around smoking. Debate rages over whether e-cigarettes help smokers quit. What is more, many smokers simply don’t like them. Complaints range from faulty batteries to poor taste—e-cigarettes deliver vapour with nicotine, but no tobacco. Their share of the cigarette market remains tiny: 0.4% last year, estimates Euromonitor, a research firm.

Philip Morris’s new products might have broader appeal. Its research staff now includes some 300 scientists, many poached from pharmaceutical and medical-device companies. The company has several alternatives to combustible cigarettes, but iQOS is its most prominent. Bonnie Herzog of Wells Fargo estimates that by 2025 the product could displace 30% of cigarette sales in rich markets.

Philip Morris says that early evidence is promising. It reports that the vapour created by iQOS contains just one-tenth as much “harmful or potentially harmful” chemicals as a standard cigarette.

So far iQOS has been launched in only a few places, including parts of Japan and Italy. There are plans to expand quickly. That will eat into Philip Morris’s cigarette sales, but evidence from Japan suggests consumers might switch not just from the firm’s own brands, but from cigarettes made by rivals too. All in all, iQOS could be a boon: Wells Fargo expects combined profits for iQOS and traditional cigarettes in 2025 to be nearly 50% higher than they would have been for traditional cigarettes alone.

Sales could rise even further if Philip Morris can sway health officials. The company will soon ask American regulators to designate iQOS as a “modified risk tobacco product”. Such a title would let the firm’s partner in America, Altria, hawk iQOS’s claimed lower risks. But regulatory approval is by no means assured. Katie McMahon, a policy expert at the American Cancer Society’s advocacy arm, is sceptical of tobacco firms as allies, given their history of misleading the public. After decades of distrust, it can be hard to know when a tobacco company is advancing health and when it is blowing smoke.