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November 2nd, 2016:

Electronic-cigarette Use and Respiratory Symptoms in Adolescents

Dr. Rob McConnell; Ms. Jessica L Barrington-Trimis; Ms. Kejia Wang; Mr. Robert Urman; Dr. Hanna Hong; Ms. Jennifer Unger; Dr. Jonathan Samet; Mr. Adam Leventhal; Dr. Kiros Berhane;

Background: Rates of adolescent electronic (e-) cigarette use are increasing, but there has been little study of the chronic effects of use. Components of e-cigarette aerosol have known pulmonary toxicity.

Methods: Associations of self-reported use of e-cigarettes with chronic bronchitic symptoms (chronic cough, phlegm or bronchitis) and of wheeze in the previous 12 months were examined in 2086 Southern California Children’s Health Study participants completing questionnaires in 11th and 12th grade in 2014.

Results: Ever e-cigarette use was reported by 502 (24.0%), of whom 201 (9.6%) used e-cigarettes during the last 30 days (current users). Risk of bronchitic symptoms was increased by almost two-fold among past users (odds ratio (OR) 1.85 [95% confidence interval (CI) 1.37,2.49]), compared to never users, and by 2.02-fold (95%CI 1.42,2.88) among current users. Risk increased with frequency of current use (OR 1.66 (95%CI 1.02,2.68) for 1-2 days and 2.52 (95%CI 1.56,4.08) for 3 or more days in past 30 days) compared with never users. Associations were attenuated by adjustment for lifetime number of cigarettes smoked and secondhand smoke exposure. However, risk of bronchitic symptoms among past e-cigarette users remained elevated after adjustment for relevant potential confounders, and was also observed among never cigarette users (OR 1.70 [95%CI 1.11,2.59]). There were no statistically significant associations of e-cigarette use with wheeze after adjustment for cigarette use.

Conclusions: Adolescent e-cigarette users had increased rates of chronic bronchitic symptoms. Further investigation is needed to determine the long-term effects of e-cigarettes on respiratory health.

It looks like the tobacco industry found a way around Australia’s tough plain packaging laws

Australia’s tough tobacco regulations are acting as a catalyst for the industry to develop sophisticated marketing practices. These companies are gaming the system by anticipating regulatory impact and then using unregulated marketing elements to overcome it.

Australia has been a guiding light for countries looking to improve public health through the effective regulation of tobacco, which remains the world’s biggest cause of preventable illness and death, and still kills around 15,000 Australians annually.

December 2012 saw the implementation of Australia’s innovative plain packaging legislation, this was followed by four 12.5% annual tobacco tax excise increases. As a result the number of Australian smokers has fallen to a record low.

However the tobacco industry has used several strategies, including price reduction, brand differentiation and promoting the idea of healthier cigarettes, to undermine Australia’s new regulatory environment.

To offset price hikes manufacturers have expanded lower priced product ranges, with new ultra low priced brands. One example of this is the British American Tobacco Australia’s (BATA) Just Smokes, which sells for around 70% of the premium brand prices. BATA has also shifted Rothmans, previously a premium brand, into the economy segment by cutting its price by more than 30%.

Another pricing initiative is twin pack promotion. Most consumers recognise that progressively larger packs offer progressively lower unit prices – a lower cost per single item or single pack.

This used to be true for tobacco, with the largest cartons (usually with 200 cigarettes) offering best value. However, since 2012 discounted twin packs represent best value.

A supermarket twin pack, per cigarette price, is up to 10% cheaper than single packs – effectively discouraging single pack purchases. Australia’s leading brand Winfield twin pack, per cigarette price, is equal to or below that of larger cartons.

Regulatory price increases are financial deterrents to smoking. The low price branding and discounting strategies in Australia are clear attempts to get around these, and reduce smokers’ financial motivation to quit or cut down.

Heavily discounted twin packs also teach smokers, through financial reward and penalty, to buy twin rather than single packs. This is of particular concern since research shows that larger purchases trigger higher consumption.

In 2014 the industry claimed tobacco consumption had actually increased after plain packaging. While this was disproved, it suggests big tobacco anticipated increased consumption as smokers switched to twin pack purchase behaviour.

New tobacco products and promotions

Plain packaging was expected to restrict tobacco brands. However, after 2012 manufacturers introduced numerous new products, and brand ranges actually expanded.

For example, Australia’s leading brand Winfield supported more than 20 brand variants in 2015-2016 compared to just 12 in 2012-2013. Brand differentiation is a proven marketing approach for generating greater sales, with each variant targeting a specific consumer market segment.

Since plain packaging was introduced, tobacco companies have varied the names of brands as well. Names have evolved to include the information previously covered by packaging, such as colour and new product features. For example, Dunhill Infinite is now Dunhill Infinite White + Taste Flow Filter.

Today around 80% of Australia’s leading brands’ variant names include a colour, compared to less than half before plain packaging. Tobacco companies are also using colours to mislead consumers that certain product ranges are “healthier” options.

A universal colour code has been promoted by the industry in which smokers interpret lighter colours (white, silver, gold, yellow and blue) as being less harmful, and darker colours (red and black) as more harmful. Before plain packaging colour hues were a pack design component, now the myth of healthier tobacco options is perpetuated by colour names. This is disturbing from a public health perspective as it represents industry efforts to lessen smokers’ health motivations for quitting.

The effects of clever marketing

Australia’s tobacco regulations have significantly reduced smoking. However, their impact would be greater without unscrupulous industry initiatives to overcome and thwart them.

Industry response to plain packaging and excise increases have not been simple marketing efforts to increase sales, but illustrate cynical attempts to reduce financial and health motivations for quitting, and to encourage smokers to smoke more. Australian regulators, and those in other countries, should therefore consider further regulation.

Research suggests that future effective controls might include:

  • Introducing a standard fixed per stick price for all cigarettes – preventing differentiation by price and cheaper brand options
  • Prohibiting price variation by pack size – preventing volume discounting or twin pack promotion that encourage smokers to make larger purchases and smoke more
  • Restricting pack size to a maximum of 10 or 20 cigarettes to limit increased consumption associated with larger pack sizes
  • Banning colour variant names – removing colour-health connotations
  • Restricting brand variant ranges, for example to one variant or representation per brand, to limit the way tobacco companies use differentiation to increase sales.

The tobacco industry is committed to gaming regulations, like plain packaging and tax excise increases, and developing approaches to undermine their impact. However, the Australian government is equally committed to reducing the national adult daily smoking rate to 10% by 2018. The additional tobacco controls outlined above should help the government achieve this.

Steven Greenland is an Associate professor at the Swinburne University of Technology.

Secondhand Smoke From Multiple Sources

Secondhand Smoke From Multiple Sources, Thirdhand Smoke and Respiratory Symptoms in Hong Kong Adolescents

Lok Tung Leung, BSc Sai Yin Ho, PhD Man Ping Wang, PhD Tai Hing Lam, MD



Reports on involuntary tobacco smoke exposure in children have focused mostly on secondhand smoke (SHS) from smoking inside the home. We studied the separate and combined prevalence of SHS exposure from multiple sources and thirdhand smoke (THS) and the associations with respiratory symptoms in Hong Kong adolescents.


In 2010–2011, 61 810 Secondary 1 (US Grade 7) to seven students reported their smoking status, respiratory symptoms, and exposure to four sources of tobacco smoke in the past 7 days. Weighted prevalence of exposure was calculated. Associations with respiratory symptoms were analyzed in 50 762 never smokers using logistic regression.


Tobacco smoke exposure at home was 23.2% considering SHS exposure from inside the home, but increased to 33.2% including SHS from neighbors and 36.2% further including THS. Including SHS outside home (55.3%), 63.3% of adolescents were exposed to SHS anywhere or THS at home. In never smokers, SHS from each source and THS at home were linearly associated with respiratory symptoms. Exposure to more sources yielded stronger associations with respiratory symptoms (p for trend<.001).

The adjusted odds ratios (95% CI) were 1.04 (0.97–1.11), 1.12 (1.03–1.22), 1.40 (1.26–1.56) and 1.99 (1.74–2.28) for 1, 2, 3, and 4 sources, respectively.


Although Hong Kong’s smoking prevalence is among the lowest in the developed world, over 60% of its adolescents were involuntarily exposed to tobacco smoke from one or more sources with a linear association with respiratory symptoms in never smokers. More stringent policies are needed to protect adolescents from tobacco smoke.


In a high-density urban setting, involuntary exposure to tobacco smoke in adolescents can be much higher than the smoking prevalence of the general population, especially if SHS exposure from multiple sources and THS are also considered. Such exposures have important health implications as demonstrated by their linear associations with respiratory symptoms. Tobacco control measures effective in reducing smoking prevalence may have little effect in reducing adolescent exposure to tobacco smoke, especially in the private home, in which other public health strategies are urgently needed.

Tobacco firms at each other’s throats

Tobacco firm Carnilinx has laid corruption charges against rival British American Tobacco for allegedly spying on the competition with the help of Sars.

Low-cost tobacco producer Carnilinx has declared war on its competitor British American Tobacco (BAT), laying corruption charges against the latter’s directors and various government agencies officials related to the SA Revenue Service’s (Sars’) Illicit Tobacco Task Team, which has been accused of using illicit practices to spy on key players in South Africa’s tobacco industry.

“Evidence has been collated of instances which point to various practices by certain role players in the tobacco industry that speak to unfair treatment of some by the state, preferential treatment in other cases, and various anti-competitive practices,” the tobacco giant said in a statement.

This is the latest in a string of spats with BAT and the Fair-Trade Independent Tobacco Association (Fita). Last year, Carnilinx launched a court application against Walter citing BAT South Africa (Batsa) as a respondent, which appears to have died in the water.

The 16 respondents named in the complaint include Sars officials Piet Swart and Danie le Roux, as well as the woman at the centre of the spying allegations in the local tobacco industry, Belinda Walter. The Hawks are also named.

Walter is the former head of Fita, which represented smaller tobacco firms in disputes with tax authorities.

She has also represented Carnilinx, whose head Adriano Mazzotti was being investigated for tax evasion by Sars investigator Johann van Loggerenberg.

Batsa corporate affairs manager Mandlakazi Sigcawu told The Citizen that the company had hired law firm Norton Rose Fulbright to conduct an independent investigation into the allegations.

“The allegations in question are not new and have been propagated through various social media channels.

We wish to assure our suppliers‚ customers, shareholders and government that we take this matter extremely seriously and will not in any way‚ shape or form tolerate unlawful behaviour,” she said.

In 2014, it emerged BAT had paid Walter to feed them information, supposedly concerning the illicit tobacco trade in South Africa. Carlininx was also a client of Walter’s at the time.

At the time, Carlilinx director Kyle Phillips detailed in an affidavit that Walters had unlawfully fed information about the manufacturer to BAT. The company accused BAT of using this information for commercial advantage rather than fighting crime in the tobacco industry, as they had claimed.

Walter, in her replying affidavit, alleged her former client was not the “victim” it made itself out to be and that it had used a separate entity to spy on fellow Fita members to “rat out” its competitors to Sars.

In its latest action, Carnilinx called on state officials implicated in the charges to be removed from matters where they were required to deal directly with the manufacturer and other local tobacco manufacturers, pending the outcome of these criminal investigations.

“We expect of the state to investigate these complaints with the same vigour and allocation of resources as they appear to have directed against us in their multiple inspections, raids and criminal investigations over the past few years,” Carnilinx said in the statement.

In his response to the allegations, Van Loggerenberg emphatically denied “any allegations of impropriety attributed to me and a specific Sars unit as reflected in the complaint”.

While Sars sues Lackay for R12m, he wants R1.5m for being fired

Meanwhile, while President Jacob Zuma was fighting for the “state capture” report to disappear, judgment was reserved yesterday in the R12 million defamation suit at the Pretoria High Court by the South African Revenue Service (Sars) and its commissioner Tom Moyane against former spokesperson Adrian Lackay.

The dispute is over a letter he wrote to the chairperson of the Standing Committee on Finance, Yunus Carim, last year, regarding issues Lackay said he witnessed at his former employer under Sars commissioner Tom Moyane.

There was apparently a bid to have the letter tabled in Parliament, but Democratic Alliance MP Dion George publicised the letter after he accused Carim of not bringing it to the attention of the committee after receiving the letter from Lackay.

This comes as Lackay seeks R1.5 million in compensation for constructive dismissal in a case before the Commission for Conciliation, Mediation and Arbitration (CCMA) in which he accuses Sars and Moyane of leaving him no choice but to quit last year.

In his defence, Lackay said Sars, as an organ of state, “cannot be defamed at all” and that Moyane’s claim that he was defamed was “vague and meaningless”, and the level of damages he claims could not be quantified.

Sars and Moyane claim Lackay not only defamed them, but breached his oath of secrecy and the Tax Administration Act.

In his letter, Lackay, who was Sars spokesperson for 11 years, said that under Moyane’s leadership, he was forced to issue statements on behalf of his employer that contained “false and incorrect” information.

“My role as spokesperson, in particular with aspects contained herein, was diluted and eventually withdrawn in part by Sars and my duties were referred to the Sars Executive: Mr Luther Lebelo and other colleagues,” it said.

Nunavut smoking rates high, but tobacco law enforcement low

Five-year anti-smoking strategy set to expire, health minister planning assessment

Twelve years into implementation, no fines have been levied under Nunavut’s Tobacco Control Act for smoking within prohibited areas despite the territory remaining the highest per capita smoking jurisdiction in Canada.

That’s according to Health Minister George Hickes who responded to queries from South Baffin MLA David Joanasie on the implementation of the Tobacco Control Act during question period in Nunavut’s legislature Oct. 24.

“Can the minister clarify whether any contraventions to the Tobacco Control Act, specifically with respect to smoking within a prescribed radius, have ever been recorded and if any fines have ever been levied?” Joanasie asked.

“To my knowledge, there have currently been no fines levied for smoking within those parameters,” Hickes responded.

Across the territory, smoking is not permitted within three metres of a workplace or public place—or within 15 metres of a school—under the tobacco act.

In June, Iqaluit’s Qikiqtani General Hospital implemented a no smoking policy on its campus, designating two specific areas away from the main entrances to smoke.

According to a Canadian Community Health Survey from 2014, Nunavut’s smoking rate is the highest in Canada—at a whopping 62 per cent compared to the national average of 18.1 per cent, all tallied in 2013.

Hickes told MLAs that the Department of Health has been focusing on tobacco education and compliance programs targeting youth as well as consultations and marketing initiatives to reduce smoking.

Joanasie pressed the minister, asking if any inspectors have been appointed under the Tobacco Control Act and if not, who was enforcing the law.

“Currently, we have environmental health officers who are doing inspection of retailers,” Hickes responded.

Nunavut’s tobacco reduction action plan, tabled five years ago and entitled “Nunavut Tobacco Framework for Action, Tobacco Has No Place Here, or “Tuvvaakiqariaqanngilaq” in Inuktitut, expires later this year.

Joanasie asked Hickes if he would consider updating the act, in conjunction with drafting a new anti-smoking plan, by expanding the no-smoking radius around buildings and doorways and also areas under building intake vents.

Hickes thanked Joanasie for his suggestions, but said there is currently no plan to amend the Tobacco Control Act.

But Hickes added that his department is hoping to gather more data to evaluate the success of its various anti-smoking programs.

“We’re bringing in new software, upcoming, to be able to track usage and make more community-specific programs,” he said.

In 2013, Nunavut’s chief medical officer estimated Nunavummiut spent $43 million on tobacco products between 2011-12.

A current figure was not provided in the most recent tobacco control act annual report of 2014-15, but that number is likely to be higher due to tobacco tax increases passed on to retailers by the Government of Nunavut in 2012.