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April 17th, 2015:

World Medical Association supports growing moves for plain tobacco packaging

The World Medical Association has supported the increasing number of countries planning to introduce plain packaging of tobacco products, including Australia and France. This week it joined the Norwegian Medical Association in supporting proposals to introduce plain packaging in Norway.

The WMA, in Oslo this week for its 200th Council meeting, was responding to a public consultation by the Norwegian Ministry of Health and Care Services suggesting that all tobacco products sold in Norway should have standardized packaging. The goal is to prevent tobacco use among children and young people. The consultation also discusses the possibility of stopping the influence of the tobacco industry on tobacco policy.

Dr. Xavier Deau, President of the WMA, said: ‘The WMA strongly supports this proposal for plain packaging. Four years ago we called on all national governments to follow the example of the Australian Government in introducing plain packaging to break the brand recognition and smoking cycle. We also deplored the legal moves being taken by the tobacco industry to oppose this.

Now we have evidence from Australia that plain packaging does lead to a reduction in the take up of cigarettes and tobacco.’

WMA policy declares that cigarettes are a serious threat to the life and health of individuals who use them and a considerable cost to the health care services of every country. It says that those who smoke predominantly start to do so while adolescents and that there is a proven link between brand recognition and likelihood of starting to smoke. And it adds that brand recognition is strongly linked to cigarette packaging and that plain packaging reduces the impact of branding, promotion and marketing of cigarettes.

Dr. Hege Gjessing, President of the Norwegian Medical association, said: ‘I welcome the WMA’s support. Tobacco is a serious threat to people’s health. The Norwegian Medical Association has a long history of supporting restrictions on tobacco. We supported the ban on tobacco advertising in 1973, and then we supported the ban on smoking in aeroplanes and the ban on smoking in restaurants.’

Tobacco Use Among Middle and High School Students — United States, 2011–2014

Tobacco use and addiction most often begin during youth and young adulthood (1,2). Youth use of tobacco in any form is unsafe (1). To determine the prevalence and trends of current (past 30-day) use of nine tobacco products (cigarettes, cigars, smokeless tobacco, e-cigarettes, hookahs, tobacco pipes, snus, dissolvable tobacco, and bidis) among U.S. middle (grades 6–8) and high school (grades 9–12) students, CDC and the Food and Drug Administration (FDA) analyzed data from the 2011–2014 National Youth Tobacco Surveys (NYTS). In 2014, e-cigarettes were the most commonly used tobacco product among middle (3.9%) and high (13.4%) school students. Between 2011 and 2014, statistically significant increases were observed among these students for current use of both e-cigarettes and hookahs (p<0.05), while decreases were observed for current use of more traditional products, such as cigarettes and cigars, resulting in no change in overall tobacco use. Consequently, 4.6 million middle and high school students continue to be exposed to harmful tobacco product constituents, including nicotine. Nicotine exposure during adolescence, a critical window for brain development, might have lasting adverse consequences for brain development (1), causes addiction (3), and might lead to sustained tobacco use. For this reason, comprehensive and sustained strategies are needed to prevent and reduce the use of all tobacco products among youths in the United States.

NYTS is a cross-sectional, school-based, self-administered, pencil-and-paper questionnaire administered to U.S. middle and high school students. Information is collected on tobacco control outcome indicators to monitor the impact of comprehensive tobacco control policies and strategies (4) and inform FDA’s regulatory actions (5). A three-stage cluster sampling procedure was used to generate a nationally representative sample of U.S. students who attend public and private schools in grades 6–12. This report includes data from 4 years of NYTS (2011–2014), using an updated definition of current tobacco use that excludes kreteks (sometimes referred to as clove cigarettes).* Of 258 schools selected for the 2014 NYTS, 207 (80.2%) participated, with a sample of 22,007 (91.4%) among 24,084 eligible students; the overall response rate was 73.3%. Sample sizes and overall response rates for 2011, 2012, and 2013 were 18,866 (72.7%), 24,658 (73.6%), and 18,406 (67.8%), respectively. Participants were asked about current (past 30-day) use of cigarettes, cigars (defined as cigars, cigarillos, or little cigars), smokeless tobacco (defined as chewing tobacco, snuff, or dip), e-cigarettes,† hookahs,§ tobacco pipes (pipes),¶ snus, dissolvable tobacco (dissolvables), and bidis. Current use for each product was defined as using a product on ≥1 day during the past 30 days. Tobacco use was categorized as “any tobacco product use,” defined as use of one or more tobacco products and “≥2 tobacco product use,” defined as use of two or more tobacco products. Data were weighted to account for the complex survey design and adjusted for nonresponse; national prevalence estimates with 95% confidence intervals and population estimates rounded down to the nearest 10,000 were computed. Estimates for current use in 2014 are presented for any tobacco use, use of ≥2 tobacco products, and use of each tobacco product, by selected demographics for each school level (high and middle). Orthogonal polynomials were used with logistic regression analysis to examine trends from 2011 to 2014 in any tobacco use, use of ≥2 tobacco products, and use of each tobacco product by school level, controlling for grade, race/ethnicity, and sex and simultaneously assessing for linear and nonlinear trends.** A p-value <0.05 was considered statistically significant. SAS-Callable SUDAAN was used for analysis.

In 2014, a total of 24.6% of high school students reported current use of a tobacco product, including 12.7% who reported current use of ≥2 tobacco products. Among all high school students, e-cigarettes (13.4%) were the most common tobacco products used, followed by hookahs (9.4%), cigarettes (9.2%), cigars (8.2%), smokeless tobacco (5.5%), snus (1.9%), pipes (1.5%), bidis (0.9%), and dissolvables (0.6%) (Table). Among high school non-Hispanic whites, Hispanics,†† and persons of non-Hispanic other races, e-cigarettes were the most used product, whereas among non-Hispanic blacks, cigars were used most commonly. Current use of any tobacco and ≥2 tobacco products among middle school students was 7.7% and 3.1%, respectively. E-cigarettes (3.9%) were the tobacco product used most commonly by middle school students, followed by hookahs (2.5%), cigarettes (2.5%), cigars (1.9%), smokeless tobacco (1.6%), pipes (0.6%), bidis (0.5%), snus (0.5%), and dissolvables (0.3%).

From 2011 to 2014, statistically significant nonlinear increases were observed among high school students for current e-cigarette (1.5% to 13.4%) and hookah (4.1% to 9.4%) use (Figure 1). Statistically significant linear decreases were observed for current cigarette (15.8% to 9.2%) and snus (2.9% to 1.9%) use. Statistically significant nonlinear decreases were observed for current cigar (11.6% to 8.2%), pipe (4.0% to 1.5%), and bidi (2.0% to 0.9%) use. Current use of any tobacco product (24.2% to 24.6%) and use of ≥2 tobacco products (12.5% to 12.7%) did not change significantly from 2011 to 2014. Among middle school students, similar trends were observed during 2011–2014 (Figure 2). A statistically significant linear decrease was observed only in middle school students currently using ≥2 tobacco products (3.8% to 3.1%).

In 2014, an estimated 4.6 million middle and high school students currently used any tobacco product, of which an estimated 2.2 million students currently used ≥2 tobacco products. Of current tobacco users, 2.4 million used e-cigarettes and 1.6 million used hookahs. The largest increase in current e-cigarette use occurred from 2013 to 2014. Current e-cigarette use tripled from 2013 (660,000 [4.5%]) to 2014 (2 million [13.4%]) among high school students (Figure 1); and among middle school students, prevalence increased by a similar magnitude, from 1.1% (120,000) to 3.9% (450,000) (Figure 2). From 2013 to 2014, substantial increases also were observed for current hookah use, with prevalence almost doubling for high school students from 5.2% (770,000) to 9.4% (1.3 million) and for middle school students from 1.1% (120,000) to 2.5% (280,000) over this period.


From 2011 to 2014, substantial increases were observed in current e-cigarette and hookah use among middle and high school students, resulting in an overall estimated total of 2.4 million e-cigarette youth users and an estimated 1.6 million hookah youth users in 2014. Statistically significant decreases occurred in the use of cigarettes, cigars, tobacco pipes, bidis, and snus. The increases in current use of e-cigarettes and hookahs offset the decreases in current use of other tobacco products, resulting in no change in overall current tobacco use among middle and high school students. In 2014, one in four high school students and one in 13 middle school students used one or more tobacco products in the last 30 days. In 2014, for the first time in NYTS, current e-cigarette use surpassed current use of every other tobacco product, including cigarettes.

These findings are subject to at least three limitations. First, data were collected only from youths who attended either public or private schools and might not be generalizable to all middle and high school-aged youth. Second, current tobacco use was estimated by including students who reported using at least one of the nine tobacco products asked in the survey but might have had missing responses to any of the other eight tobacco products; missing responses were considered as nonuse, which might have resulted in underestimated results. Finally, changes between 2013 and 2014 in the wording and placement of questions about the use of e-cigarettes, hookahs, and tobacco pipes might have had an impact on reported use of these products. Despite these limitations, overall prevalence estimates are similar to the findings of other nationally representative youth surveys (6,7).

Tobacco prevention and control strategies, including increasing tobacco product prices, adopting comprehensive smoke-free laws, and implementation of national public education media campaigns, might have influenced the reduction of cigarette smoking in youths (2). However, the lack of decline in overall tobacco use from 2011 to 2014 is concerning and indicates that an estimated 4.6 million youths continue to be exposed to harmful constituents, including nicotine, present in tobacco products (Table). Youth use of tobacco in any form, whether it be combustible, noncombustible, or electronic, is unsafe (1); regardless of mode of delivery, nicotine exposure during adolescence, a critical time for brain development, might have lasting adverse consequences for brain development (1), causes addiction (3), and might lead to sustained use of tobacco products. Rapid changes in use of traditional and emerging tobacco products among youths underscore the importance of enhanced surveillance of all tobacco use.

Sustained efforts to implement proven tobacco control policies and strategies are necessary to prevent youth use of all tobacco products. In April 2014, FDA issued a proposed rule to deem all products made or derived from tobacco subject to FDA jurisdiction, and the agency is reviewing public comments on the proposed rule (8). Regulation of the manufacturing, distribution, and marketing of tobacco products coupled with full implementation of comprehensive tobacco control and prevention strategies at CDC-recommended funding levels could reduce youth tobacco use and initiation (1,2,9). Because use of emerging tobacco products (e-cigarettes and hookahs) is increasing among middle and high school students, it is critical that comprehensive tobacco control and prevention strategies for youths should address all tobacco products and not just cigarettes.

Hong Kong Customs to work with Guangdong counterparts to crack down on cigarette smuggling

A consignment of illegal cigarettes seized by Hong Kong customs earlier this year. Photo: ISD

A consignment of illegal cigarettes seized by Hong Kong customs earlier this year. Photo: ISD

Hong Kong Customs will seek help from their mainland counterparts to investigate a cross-border syndicate after making their biggest seizure of smuggled cigarettes this year.

The HK$4.9 million haul of untaxed cigarettes was discovered hidden in two shipping containers which arrived from Guangdong by sea on Thursday.

“The containers were declared to have carried electronic parts and LED lights but its shipper is not involved in such business. This aroused our officers’ suspicions,” Superintendent Cecilia Yeung Kai-fei, deputy head of the Customs’ revenue and general investigation bureau, said.

The two containers were taken to a Customs cargo examination plant in Tuen Mun for inspection.

Under an X-ray examination, suspicious images were found at the back of the containers. A total 122 boxes of illicit cigarettes were uncovered after the two containers were opened for inspection. No one was arrested.

“Our investigation indicates that consignment was for local consumption,” Yeung said.

She said it was the fourth major seizure of contraband cigarettes this year but “this is the biggest”.

“We believe there is a cross-border syndicate behind the shipment because it involved such large quantity of illicit cigarettes,” she said.

“We will ask our Guangdong counterparts for help in our follow-up investigation.”

In the previous three cases detected in the first quarter of this year, in total 2.4 million cigarettes, worth about HK$6.3 million, were smuggled into Hong Kong from the mainland by land or by sea.

“Syndicates use different methods of smuggling in an attempt to evade our detection,” Yeung said, adding that the latest seizure showed the effectiveness of enforcement strategy.

She said Hong Kong Customs would continue to carry out stringent enforcement actions against such illegal activities.

Last year, customs officers confiscated 14 millions of illicit cigarettes worth HK$37.8 million in seven major seizures.

Under the import and export ordinance, smuggling is a serious offence that carries a maximum penalty of a HK$2 million fine and seven years of imprisonment.

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