Publications by authors named "Stanton A Glantz"

288 Publications

Associations between smoking trajectories, smoke-free laws and cigarette taxes in a longitudinal sample of youth and young adults.

PLoS One 2021 11;16(2):e0246321. Epub 2021 Feb 11.

Center for Tobacco Control Research and Education, University of California San Francisco, San Francisco, California, United States of America.

Cigarette smoking patterns vary within the population, with some individuals remaining never smokers, some remaining occasional users, and others progressing to daily use or quitting. There is little research on how population-level tobacco control policy interventions affect individuals within different smoking trajectories. We identified associations between tobacco control policy interventions and changes across different smoking trajectories among adolescents and young adults. Using 15 annual waves of data drawn from the National Longitudinal Survey of Youth 1997 (NLSY97), we applied a group-based trajectory model to identify associations between days smoked per month, comprehensive smoke-free laws, cigarette tax rates, and known socio-demographic risk factors for membership in different smoking trajectories. Comprehensive smoke-free laws were associated with reduced risk of initiation and reductions in days smoked per month for all trajectories other than occasional users. Higher tax rates were associated with reduced risk of initiation and days smoked for all trajectories other than established users. Overall, population-based tobacco control policies, particularly comprehensive smoke-free laws, were associated with reduced smoking. Tobacco taxes primarily reduced risk of initiation and use among never smokers, experimenters, and quitters, consistent with previous research suggesting that tobacco manufacturers lower prices after tax increases to reduce the cost of continued smoking for established users. These results provide support for expanding smoke-free laws and establishing a minimum tobacco floor price, which could improve public health by reducing the risk of initiation as well as use among occasional and established smokers.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0246321PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7877665PMC
February 2021

How to combat efforts to overturn bans on electronic nicotine delivery systems: lessons from tobacco industry efforts during the 1980s to open closed cigarette markets in Thailand.

BMJ Glob Health 2021 Jan;6(1)

Center for Tobacco Control Research and Education, University of California San Francisco, San Francisco, California, USA.

Until 1990, it was illegal for transnational tobacco companies (TTCs) to sell cigarettes in Thailand. We reviewed and analysed internal tobacco industry documents relevant to the Thai market during the 1980s. TTCs' attempts to access the Thai cigarette market during the 1980s concentrated on political lobbying, advertising and promotion of the foreign brands that were illegal to sell in Thailand at the time. They sought to take advantage of the Thai Tobacco Monopoly's (TTM) inefficiency to propose licencing agreements and joint ventures with TTM and took advantages of unclear regulations about cigarette marketing to promote their products through advertising and sponsorship activities. After their initial efforts failed, they successfully lobbied the US to impose trade sanctions to liberalise Thailand's market. Similar to the situation for cigarettes in the 1980s, since 2017, Philip Morris International has worked in parallel with a pro-e-cigarette group to pressure Thailand's government to allow sales of electronic nicotine delivery systems (ENDS; including e-cigarettes and heated tobacco products), knowing the products were illegal under Thai law. Health advocates and government authorities should be aware of past TTCs' tactics for cigarettes and anticipate that TTCs will attempt to use international trade law to force markets open for ENDS if their domestic efforts fail.
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http://dx.doi.org/10.1136/bmjgh-2020-004288DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7843299PMC
January 2021

Defeating JUUL's Effort to Rewrite San Francisco's E-Cigarette Regulations.

Am J Public Health 2021 03 21;111(3):457-464. Epub 2021 Jan 21.

Neiloy Sircar is a postdoctoral fellow at the Center for Tobacco Control Research and Education at the University of California San Francisco. S. A. Glantz was professor of medicine at the Center for Tobacco Control Research and Education and Institute for Health Policy Studies at the University of California San Francisco until he recently retired.

In 2019, San Francisco, California, prohibited the sale of electronic cigarettes lacking US Food and Drug Administration authorization. JUUL then promoted a ballot initiative (Proposition C) to replace San Francisco's e-cigarette legislation with legislation JUUL wrote that required future legislation to be approved by the voters. JUUL promoted Proposition C as a way to reduce youth e-cigarette use while allowing adult choice.Health groups argued that JUUL's measure could nullify San Francisco's prohibition on selling flavored tobacco products. Health groups benefitted from having an established campaign network that recently defended the flavor ban. They successfully framed Proposition C as a tobacco industry ploy to undo San Francisco's e-cigarette regulations, particularly the prohibition on selling flavored tobacco products. JUUL ended its campaign on September 30, 2019, and the measure failed on election day, with 82% voting against it.Lessons learned from the campaign include the importance of framing an industry initiative as a threat to local public health lawmaking and the potential for the e-cigarette issue to attract parents as new leaders and engage a powerful constituency to support tobacco control measures.
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http://dx.doi.org/10.2105/AJPH.2020.305993DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7893333PMC
March 2021

Tobacco imagery in entertainment media: evolution of tobacco-free movies and television programmes rules in India.

BMJ Glob Health 2021 Jan;6(1)

Center for Tobacco Control Research and Education, University of California San Francisco, San Francisco, California, USA

Introduction: Tobacco imagery in films and television increased in India after it ended conventional tobacco advertising in 2004. The Ministry of Health and Family Welfare (MoHFW) introduced rules to eliminate this tobacco imagery in 2005 which took effect in amended form in 2012. This study presents the enablers and barriers in development and implementation of the regulations to curb tobacco imagery in films and television in India.

Method: We reviewed legislation, evolving regulations, parliamentary questions, judicial decisions, Bollywood trade publications and relevant news articles from 2003 to 2019 and interviewed key informants.

Results: Based on the WHO reports and civil society demands, the MoHFW issued a complete ban on tobacco imagery in movies and television programmes in 2005. The Ministry of Information and Broadcasting (MoIB) joined the film industry in opposing the rules. A filmmaker challenged the rules in court, which ruled that they violated constitutional freedoms. On appeal by MoHFW, the Supreme Court allowed the rules to take effect. Continuing opposition by MoIB and the film industry weakened the rules and delayed implementation until 2012. As of 2020, rather than a ban, all films with tobacco imagery require strong editorial justification, 100 s of antitobacco messages produced by the MoHFW, and a static health warning at the bottom of screen during tobacco imagery display. In 2015, less than 48% of movies had tobacco imagery compared with 89% in 2005.

Conclusions: Although, not a ban, MoHFW, supported by local advocates and WHO, issued regulations that resulted in a substantial drop in on-screen tobacco imagery and increased exposure to antitobacco messages. India's experience informs WHO Framework Convention on Tobacco Control parties as they develop and implement policies to curb tobacco imagery in entertainment media.
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http://dx.doi.org/10.1136/bmjgh-2020-003639DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7786799PMC
January 2021

E-Cigarette Use and Adult Cigarette Smoking Cessation: A Meta-Analysis.

Am J Public Health 2021 02 22;111(2):230-246. Epub 2020 Dec 22.

Richard J. Wang and Sudhamayi Bhadriraju were initially postdoctoral fellows in the Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of California San Francisco; Richard J. Wang subsequently joined the faculty as an assistant professor of medicine, and Sudhamayi Bhadriraju joined the pulmonary medicine staff at the Kaiser Permanente Medical Center, Redwood City, CA. Stanton A. Glantz was professor of medicine and director of the Center for Tobacco Control Research and Education at the University of California San Francisco.

To determine the association between e-cigarette use and smoking cessation. We searched PubMed, Web of Science Core Collection, and EMBASE and computed the association of e-cigarette use with quitting cigarettes using random effects meta-analyses. We identified 64 papers (55 observational studies and 9 randomized clinical trials [RCTs]). In observational studies of all adult smokers (odds ratio [OR] = 0.947; 95% confidence interval [CI] = 0.772, 1.160) and smokers motivated to quit smoking (OR = 0.851; 95% CI = 0.684, 1.057), e-cigarette consumer product use was not associated with quitting. Daily e-cigarette use was associated with more quitting (OR = 1.529; 95% CI = 1.158, 2.019) and less-than-daily use was associated with less quitting (OR = 0.514; 95% CI = 0.402, 0.665). The RCTs that compared quitting among smokers who were provided e-cigarettes to smokers with conventional therapy found e-cigarette use was associated with more quitting (relative risk = 1.555; 95% CI = 1.173, 2.061). As consumer products, in observational studies, e-cigarettes were not associated with increased smoking cessation in the adult population. In RCTs, provision of free e-cigarettes as a therapeutic intervention was associated with increased smoking cessation. E-cigarettes should not be approved as consumer products but may warrant consideration as a prescription therapy.
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http://dx.doi.org/10.2105/AJPH.2020.305999DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7811087PMC
February 2021

Effects of e-cigarette use on cigarette smoking among U.S. youth, 2004-2018.

Prev Med 2021 01 30;142:106316. Epub 2020 Nov 30.

Center for Tobacco Control Research and Education, University of California, San Francisco, United States; Department of Medicine, University of California, San Francisco, United States.

Objective: To determine if the declining trend in U.S. youth cigarette smoking changed after e-cigarettes were introduced, and if youth e-cigarette users would have been likely to smoke cigarettes based on psychosocial and demographic predictors of smoking.

Methods: An interrupted time series analysis was used for cross-sectional data from the 2004 to 2018 National Youth Tobacco Surveys (NYTS) to assess changes in cigarette and e-cigarette use over time. A multivariable logistic regression model used 2004-2009 NYTS data on psychosocial risk factors to predict individual-level cigarette smoking risk from 2011 to 2018. Model-predicted and actual cigarette smoking behavior were compared.

Results: The decline in current cigarette smoking slowed in 2014 (-0.75 [95% CI: -0.81, -0.68] to -0.26 [95% CI: -0.40, -0.12] percentage points per year). The decline in ever cigarette smoking accelerated after 2012 (-1.45 [95% CI: -1.59, -1.31] to -1.71 [95% CI: -1.75, -1.66]). Ever and current combined cigarette and/or e-cigarette use declined during 2011-2013 and increased during 2013-2014 with no significant change during 2014-2018 for either variable. The psychosocial model estimated that 69.0% of current cigarette smokers and 9.3% of current e-cigarette users (who did not smoke cigarettes) would smoke cigarettes in 2018.

Conclusions: The introduction of e-cigarettes was followed by a slowing decline in current cigarette smoking, a stall in combined cigarette and e-cigarette use, and an accelerated decline in ever cigarette smoking. Traditional psychosocial risk factors for cigarette smoking suggest that e-cigarette users do not fit the traditional risk profile of cigarette smokers.
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http://dx.doi.org/10.1016/j.ypmed.2020.106316DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7796895PMC
January 2021

Association between tobacco control policies and hospital admissions for acute myocardial infarction in Thailand, 2006-2017: A time series analysis.

PLoS One 2020 2;15(12):e0242570. Epub 2020 Dec 2.

Center for Tobacco Control Research and Education, Department of Medicine, University of California San Francisco, San Francisco, California, United State of America.

Introduction: Studies in many countries have documented reductions of acute myocardial infarction (AMI) hospitalizations with smokefree policies. However, evidence on the association of cigarette tax with AMI events is unclear. There have been no studies of the associations between these two policies and AMI hospitalizations in Thailand.

Methods: We used negative binomial time series analyses of AMI hospitalizations (ICD-10 codes I21.0-I21.9), stratified by sex and age groups, from October 2006 to September 2017 to determine whether there was a change in AMI hospitalizations as a result of the changes in cigarette prices and the implementation of a 100% smokefree law.

Results: Cigarette price increases were associated with a significant 4.7% drop in AMI hospitalizations among adults younger than 45 (incidence rate ratio [IRR], 0.953; 95% confidence interval [CI], 0.914-0.993; p = 0.021). Implementation of the 100% smokefree law was followed by a significant 13.1% drop in AMI hospitalizations among adults younger than 45 (IRR, 0.869; 95% CI, 0.801-0.993; P = 0.001). There were not significant associations in older age groups.

Conclusions: The Thai cigarette tax policy and the smokefree law were associated with reduced AMI hospitalizations among younger adults. To improve effectiveness of the policies, taxes should be high enough to increase cigarette price above inflation rates, making cigarettes less likely to be purchased; smokefree laws should be strictly enforced.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0242570PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7710088PMC
January 2021

The Theoretical Problems Do Not Materially Affect the Results of Our Meta-analysis of Smoking and Covid-19 Disease Progression.

Nicotine Tob Res 2020 Nov 27. Epub 2020 Nov 27.

Center for Tobacco Control Research and Education, Department of Medicine, University of California San Francisco, San Francisco, CA, U.S.A.

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http://dx.doi.org/10.1093/ntr/ntaa250DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7717386PMC
November 2020

Smoking is associated with worse outcomes of COVID-19 particularly among younger adults: A systematic review and meta-analysis.

medRxiv 2020 Sep 23. Epub 2020 Sep 23.

Background: Smoking impairs lung immune functions and damages upper airways, increasing risks of contracting and severity of infectious diseases.

Methods: We searched PubMed and Embase for studies published from January 1-May 25, 2020. We included studies reporting smoking behavior of COVID-19 patients and progression of disease, including death. We used a random effects meta-analysis and used meta-regression and lowess regressions to examine relationships in the data.

Results: We identified 47 peer-reviewed papers with a total of 31,871 COVID-19 patients, 5,759 (18.1%) experienced disease progression and 5,734 (18.0%) with a history of smoking. Among smokers, 29.2% experienced disease progression, compared with 21.1% of non-smokers. The meta-analysis confirmed an association between smoking and COVID-19 progression (OR 1.56, 95% CI 1.32-1.83, p=0.001). Smoking was associated with increased risk of death from COVID-19 (OR 1.19, 95% CI 1.05-1.34, p=0.007). We found no significant difference (p=0.432) between the effects of smoking on COVID-19 disease progression between adjusted and unadjusted analyses, suggesting that smoking is an independent risk factor for COVID-19 disease progression. We also found the risk of having COVID-19 progression among younger adults (p=0.023), with the effect most pronounced among people under about 45 years old.

Conclusions: Smoking is an independent risk for having severe progression of COVID-19, including mortality. The effects seem to be higher among young people. Smoking prevention and cessation should remain a priority for the public, physicians, and public health professionals during the COVID-19 pandemic.
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http://dx.doi.org/10.1101/2020.09.22.20199802DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7523170PMC
September 2020

The proper approach to assessing the impact of the fact that e-cigarettes were not available before 2007.

Addiction 2020 11 13;115(11):2180-2182. Epub 2020 Aug 13.

Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, CA, USA.

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http://dx.doi.org/10.1111/add.15103DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7949485PMC
November 2020

Smoking is Associated with COVID-19 Progression: A Meta-Analysis.

medRxiv 2020 Apr 16. Epub 2020 Apr 16.

Objective: To determine the association between smoking and progression of COVID-19.

Design: A meta-analysis of 12 published papers.

Data Source: PubMed database was searched on April 6, 2020. Eligibility criteria and data analysis: We included studies reporting smoking behavior of COVID-19 patients and progression of disease. Search terms included smoking, smoker*, characteristics, risk factors, outcomes, and COVID-19, COVID, coronavirus, sar cov-2, sar cov 2. There were no language limitations. One author extracted information for each study, screened the abstract or the full text, with questions resolved through discussion among both authors. A random effects meta-analysis was applied.

Main Outcome Measures: The study outcome was progression of COVID-19 among people who already had the disease.

Results: We identified 12 papers with a total of 9,025 COVID-19 patients, 878 (9.7%) with severe disease and 495 with a history of smoking (5.5%). The meta-analysis showed a significant association between smoking and progression of COVID-19 (OR 2.25, 95% CI 1.49-3.39, p=0.001). Limitations in the 12 papers suggest that the actual risk of smoking may be higher.

Conclusions: Smoking is a risk factor for progression of COVID-19, with smokers having higher odds of COVID-19 progression than never smokers. Physicians and public health professionals should collect data on smoking as part of clinical management and add smoking cessation to the list of practices to blunt the COVID-19 pandemic.
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http://dx.doi.org/10.1101/2020.04.13.20063669DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7277001PMC
April 2020

Public Health and Medicine's Need to Respond to Cannabis Commercialization in the United States: A Commentary.

J Psychoactive Drugs 2020 Sep-Oct;52(4):377-382. Epub 2020 May 19.

Center for Tobacco Control Research and Education, Philip R. Lee Institute for Health Policy Studies, Department of Medicine, University of California, San Francisco , San Francisco, California, USA.

Cannabis legalization has resulted in rapid commercialization, making this new market increasingly attractive to tobacco, alcohol and beverage, agricultural, and pharmaceutical multinational corporations, who are well positioned to capitalize on the synergy between cannabis and their products. The fact that cannabis remains a Schedule I drug under the Controlled Substances Act is inhibiting research, which consequently prevents evidence-based regulation of modern, more potent, engineered cannabis products and their use. Without a research exemption for legitimate studies of commercially available products, cannabis' Schedule I classification makes it very difficult to conduct medical and scientific research to inform policymaking and regulation. As corporate commercialization looms large, public health organizations need to engage the issue of rapid commercialization of cannabis products and press for evidence-based policies based on public health best practices.
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http://dx.doi.org/10.1080/02791072.2020.1761040DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7674246PMC
May 2020

Smoking Is Associated With COVID-19 Progression: A Meta-analysis.

Nicotine Tob Res 2020 08;22(9):1653-1656

Center for Tobacco Control Research and Education, Department of Medicine, University of California, San Francisco, San Francisco, CA.

Introduction: Smoking depresses pulmonary immune function and is a risk factor contracting other infectious diseases and more serious outcomes among people who become infected. This paper presents a meta-analysis of the association between smoking and progression of the infectious disease COVID-19.

Methods: PubMed was searched on April 28, 2020, with search terms "smoking", "smoker*", "characteristics", "risk factors", "outcomes", and "COVID-19", "COVID", "coronavirus", "sar cov-2", "sar cov 2". Studies reporting smoking behavior of COVID-19 patients and progression of disease were selected for the final analysis. The study outcome was progression of COVID-19 among people who already had the disease. A random effects meta-analysis was applied.

Results: We identified 19 peer-reviewed papers with a total of 11,590 COVID-19 patients, 2,133 (18.4%) with severe disease and 731 (6.3%) with a history of smoking. A total of 218 patients with a history of smoking (29.8%) experienced disease progression, compared with 17.6% of non-smoking patients. The meta-analysis showed a significant association between smoking and progression of COVID-19 (OR 1.91, 95% confidence interval [CI] 1.42-2.59, p = 0.001). Limitations in the 19 papers suggest that the actual risk of smoking may be higher.

Conclusions: Smoking is a risk factor for progression of COVID-19, with smokers having higher odds of COVID-19 progression than never smokers.

Implications: Physicians and public health professionals should collect data on smoking as part of clinical management and add smoking cessation to the list of practices to blunt the COVID-19 pandemic.
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http://dx.doi.org/10.1093/ntr/ntaa082DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7239135PMC
August 2020

Predictive validation and forecasts of short-term changes in healthcare expenditure associated with changes in smoking behavior in the United States.

PLoS One 2020 16;15(1):e0227493. Epub 2020 Jan 16.

Center for Tobacco Control Research and Education, University of California San Francisco, San Francisco, California, United States of America.

Objectives: Out-of-sample forecasts are used to evaluate the predictive adequacy of a previously published national model of the relationship between smoking behavior and real per capita health care expenditure using state level aggregate data. In the previously published analysis, the elasticities between changes in state adult current smoking prevalence and mean cigarette consumption per adult current smoker and healthcare expenditures were 0.118 and 0.108 This new analysis provides evidence that the model forecasts out-of-sample well.

Methods: Out-of-sample predictive performance was used to find the best specification of trend variables and the best model to bridge a break in survey data used in the analysis. Monte-Carlo simulation was used to calculate forecast intervals for the effect of changes in smoking behavior on expected real per capita healthcare expenditures.

Results: The model specification produced good-out-of-sample forecasts and stable recursive regression parameter estimates spanning the break in survey methodology. In 2014, a 1% relative reduction in adult current smoking prevalence and mean cigarette consumption per adult current smoker decreased real per capita healthcare expenditure by 0.104% and 0.113% the following year, respectively (elasticity). A permanent relative reduction of 5% reduces expected real per capita healthcare expenditures $99 (95% CI $44, $154) in the next year and $31.5 billion for the entire US (in 2014 dollars), holding other factors constant. The reductions accumulate linearly for at least five years following annual permanent decreases of 5% each year. Given the limitations of time series modelling in a relatively short time series, the effect of changes in smoking behavior may occur over several years, even though the model contains only one lag for the explanatory variables.

Conclusion: Reductions in smoking produce substantial savings in real per capita healthcare expenditure in short to medium term. A 5% relative drop in smoking prevalence (about a 0.87% reduction in absolute prevalence) combined with a 5% drop in consumption per remaining smoker (about 16 packs/year) would be followed by a $31.5 billion reduction in healthcare expenditure (in 2014 dollars).
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0227493PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6964879PMC
April 2020

Transferring Racial/Ethnic Marketing Strategies From Tobacco to Food Corporations: Philip Morris and Kraft General Foods.

Am J Public Health 2020 03 16;110(3):329-336. Epub 2020 Jan 16.

All of the authors are with the Philip R. Lee Institute for Health Policy Studies, School of Medicine, University of California San Francisco (UCSF), San Francisco.

To investigate the transfer of marketing knowledge and infrastructure for targeting racial/ethnic minorities from the tobacco to the food and beverage industry in the United States. We analyzed internal industry documents between April 2018 and April 2019 from the University of California San Francisco Truth Tobacco Industry Documents Library, triangulated with other sources. In the 1980s, Philip Morris Companies purchased General Foods and Kraft Foods and created Kraft General Foods. Through centralized marketing initiatives, Philip Morris Companies directly transferred expertise, personnel, and resources from its tobacco to its food subsidiaries, creating a racial/ethnic minority-targeted food and beverage marketing program modeled on its successful cigarette program. When Philip Morris Companies sold Kraft General Foods in 2007, Kraft General Foods had a "fully integrated" minority marketing program that combined target marketing with racial/ethnic events promotion, racial/ethnic media outreach, and corporate donations to racial/ethnic leadership groups, making it a food industry leader. The tobacco industry directly transferred racial/ethnic minority marketing knowledge and infrastructure to food and beverage companies. Given the substantial growth of food and beverage corporations, their targeting of vulnerable populations, and obesity-related disparities, public policy and community action is needed to address corporate target marketing.
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http://dx.doi.org/10.2105/AJPH.2019.305482DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7002936PMC
March 2020

The Association Between Secondhand Smoke Exposure and Survival for Patients With Heart Failure.

J Card Fail 2020 Sep 9;26(9):745-750. Epub 2020 Jan 9.

Division of Cardiology, Department of Medicine, School of Medicine, University of California San Francisco, San Francisco, California. Electronic address:

Background: The effect of secondhand tobacco smoke (SHS) exposure on patients with heart failure (HF) is uncertain. We investigated the association of mortality with SHS exposure for patients with HF.

Methods: Nonsmokers with clinical HF were enrolled from 2003 to 2008 in a single-center longitudinal cohort study. The effect of SHS exposure determined by high-sensitivity urinary cotinine on mortality was estimated by multivariable proportional hazards modeling.

Results: Mortality was assessed after median 4.3 years. Of 202 patients, enrollment urinary cotinine levels were below the limit of detection for 106 (52%) considered unexposed to SHS. The median detectable cotinine was 0.47 ng/mL (interquartile range: [0.28, 1.28]). Participants were 41% female, 65 ± 17 years old, and 57% white race. Elevated cotinine was associated with increased mortality after multivariate adjustment: hazard ratio (HR) per 1 ng/mL increase in urinary cotinine: 1.15, 95% confidence interval (CI): 1.08-1.23, P < .001. Higher age (HR per 5-year increase: 1.32, 95% CI: 1.22-1.43, P < .001), male sex (HR vs female: 1.52, 95% CI: 1.02-2.28, P = .040), and New York Heart Association class (HR for class III vs I: 2.91, 95% CI: 1.71-4.99, P < .001) were also associated with mortality.

Conclusions: SHS exposure is associated with a dose-dependent increase in mortality for patients with HF.
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http://dx.doi.org/10.1016/j.cardfail.2019.12.008DOI Listing
September 2020

Net Effect of Young Adult Dual Combusted Cigarette and E-Cigarette Users' Anticipated Responses to Hypothetical E-Cigarette Marketing Restrictions.

Authors:
Stanton A Glantz

Subst Use Misuse 2020 6;55(6):1028-1030. Epub 2020 Jan 6.

Center for Tobacco Control Research and Education, University of California San Francisco, San Francisco, California, USA.

Dual use of e-cigarettes and cigarettes is common among young adults. Earlier research has used an internet panel to assess anticipated effects of eliminating nicotine, flavors (except menthol), and customizable e-cigarettes on predicted changes in e-cigarette and cigarette consumption. This earlier analysis showed that all these policies were predicted to lower e-cigarette consumption and increase cigarette consumption among these dual users. The earlier analysis, did not, however, estimate the effect of these policies considering both lowered and increased consumption. We computed the net effects of these policies as the difference between people predicting quitting or using cigarettes less and those predicting that they would use them more. The same calculations were done for e-cigarettes. Significance testing was done with -tests. As expected, the net effect of all three policies was to significantly lower e-cigarette consumption. The net effect was to also lower cigarette consumption for eliminating nicotine and flavors in e-cigarettes, with no significant net effect of eliminating modifiable e-cigarettes. Eliminating nicotine and flavors from e-cigarettes is predicted to lower cigarette as well as e-cigarette consumption.
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http://dx.doi.org/10.1080/10826084.2019.1710209DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7166138PMC
January 2020

Association of E-Cigarette Use With Respiratory Disease Among Adults: A Longitudinal Analysis.

Am J Prev Med 2020 02 16;58(2):182-190. Epub 2019 Dec 16.

Center for Tobacco Control Research and Education, University of California, San Francisco, San Francisco, California; Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, San Francisco, California; Department of Medicine (Cardiology), University of California, San Francisco, San Francisco, California; Cardiovascular Research Institute, University of California, San Francisco, San Francisco, California; Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, San Francisco, California. Electronic address:

Introduction: E-cigarettes deliver an aerosol of nicotine by heating a liquid and are promoted as an alternative to combustible tobacco. This study determines the longitudinal associations between e-cigarette use and respiratory disease controlling for combustible tobacco use.

Methods: This was a longitudinal analysis of the adult Population Assessment of Tobacco and Health Waves 1, 2, and 3. Multivariable logistic regression was performed to determine the associations between e-cigarette use and respiratory disease, controlling for combustible tobacco smoking, demographic, and clinical variables. Data were collected in 2013-2016 and analyzed in 2018-2019.

Results: Among people who did not report respiratory disease (chronic obstructive pulmonary disease, chronic bronchitis, emphysema, or asthma) at Wave 1, the longitudinal analysis revealed statistically significant associations between former e-cigarette use (AOR=1.31, 95% CI=1.07, 1.60) and current e-cigarette use (AOR=1.29, 95% CI=1.03, 1.61) at Wave 1 and having incident respiratory disease at Waves 2 or 3, controlling for combustible tobacco smoking, demographic, and clinical variables. Current combustible tobacco smoking (AOR=2.56, 95% CI=1.92, 3.41) was also significantly associated with having respiratory disease at Waves 2 or 3. Odds of developing respiratory disease for a current dual user (e-cigarette and all combustible tobacco) were 3.30 compared with a never smoker who never used e-cigarettes. Analysis controlling for cigarette smoking alone yielded similar results.

Conclusions: Use of e-cigarettes is an independent risk factor for respiratory disease in addition to combustible tobacco smoking. Dual use, the most common use pattern, is riskier than using either product alone.
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http://dx.doi.org/10.1016/j.amepre.2019.07.028DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6981012PMC
February 2020

The Grassroots of Grass: Cannabis Legalization Ballot Initiative Campaign Contributions and Outcomes, 2004-2016.

J Health Polit Policy Law 2020 02;45(1):73-109

University of California, San Francisco.

Context: As of November 2018, medical cannabis was legal in 33 US states and recreational cannabis in 10, mostly enacted via ballot initiative.

Methods: We identified 32 cannabis legalization initiatives from 2004 to 2016 and obtained campaign contribution and state political and demographic data. After exploratory analyses of 15 potential independent variables, we quantified effects of 4 factors (initiative year, voter turnout, population born before 1946, advocate funding advantage) on voter support and likelihood of passage.

Findings: A small number of campaign contributors dominated both sides of the issue, with little involvement by health advocates. Time and turnout, not money, were the factors most associated with electoral outcomes, consistent with increases in public opinion favoring cannabis legalization over time. Year, turnout, and population age were associated with voter support, while year, turnout, and advocate funding advantage were associated with likelihood of passage. When adjusting for an anomalous result, initiative year was the only variable that remained significantly associated with odds of passage, with a 1-year increase in initiative date associated with 2.02 times higher odds of passage (p < .01).

Conclusion: These results underscore the importance of health advocate participation in developing cannabis legalization frameworks.
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http://dx.doi.org/10.1215/03616878-7893579DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6980940PMC
February 2020

Tobacco Use in Top-Grossing Movies - United States, 2010-2018.

MMWR Morb Mortal Wkly Rep 2019 Nov 1;68(43):974-978. Epub 2019 Nov 1.

The Surgeon General has concluded that there is a causal relationship between depictions of smoking in movies and initiation of smoking among young persons (1). Youths heavily exposed to onscreen smoking imagery are more likely to begin smoking than are those with minimal exposure (1,2). To assess tobacco-use imagery in top-grossing youth-rated movies (General Audiences [G], Parental Guidance [PG], and Parents Strongly Cautioned [PG-13]),* 2010-2018 data from the Breathe California Sacramento Region and University of California-San Francisco's Onscreen Tobacco Database were analyzed. The percentage of all top-grossing movies with tobacco incidents remained stable from 2010 (45%) to 2018 (46%), including youth-rated movies (31% both years). However, total tobacco incidents increased 57% from 2010 to 2018, with a 120% increase in PG-13 movies. Tobacco incidents in PG-13 fictional movies declined 57% from 511 in 2010 to an all-time low of 221 in 2018. Although the number of PG-13 fictional movies with tobacco incidents declined 40% during 2010-2018, the number of PG-13 biographical dramas with tobacco incidents increased 233%. In 2018, biographical dramas accounted for most tobacco incidents, including 82% of incidents in PG-13 movies; 73% of characters who used tobacco in these biographical dramas were fictional. Continued efforts could help reduce tobacco incidents in top-grossing movies, particularly in PG-13 biographical dramas, to help prevent youth smoking initiation.
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http://dx.doi.org/10.15585/mmwr.mm6843a4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6822812PMC
November 2019

Adding Data From 2015 Strengthens the Association Between E-Cigarette Use and Myocardial Infarction.

Am J Prev Med 2019 10;57(4):569-571

Department of Medicine, Cardiovascular Research Institute, Philip R. Lee Institute for Health Policy Studies, Center for Tobacco Control Research and Education, University of California, San Francisco, San Francisco, California.

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http://dx.doi.org/10.1016/j.amepre.2019.03.008DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6759047PMC
October 2019

Uneven Access to Smoke-Free Laws and Policies and Its Effect on Health Equity in the United States: 2000-2019.

Am J Public Health 2019 11 19;109(11):1568-1575. Epub 2019 Sep 19.

Amy Y. Hafez and Stanton A. Glantz are with the Center for Tobacco Control Research and Education, University of California, San Francisco. Mariaelena Gonzalez is with the School of Social Sciences, Humanities & Arts, University of California, Merced. Margarete C. Kulik is with the Fay W. Boozman College of Public Health, University of Arkansas for Medical Sciences, Little Rock. Maya Vijayaraghavan is with the Zuckerberg San Francisco General Hospital and the Center for Tobacco Control Research and Education, University of California, San Francisco.

Tobacco control measures have played an important role in the reduction of the cigarette smoking prevalence among US adults.However, although overall smoking prevalence has declined, it remains high among many subpopulations that are disproportionately burdened by tobacco use, resulting in tobacco-related health disparities. Slow diffusion of smoke-free laws to rural regions, particularly in the South and Southeast, and uneven adoption of voluntary policies in single-family homes and multiunit housing are key policy variables associated with the disproportionate burden of tobacco-related health disparities in these subpopulations.Developing policies that expand the reach of comprehensive smoke-free laws not only will facilitate the decline in smoking prevalence among subpopulations disproportionately burdened by tobacco use but will also decrease exposure to secondhand smoke and further reduce tobacco-caused health disparities in the United States.
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http://dx.doi.org/10.2105/AJPH.2019.305289DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6775904PMC
November 2019

In defense of sugar: a critical analysis of rhetorical strategies used in The Sugar Association's award-winning 1976 public relations campaign.

BMC Public Health 2019 Aug 22;19(1):1150. Epub 2019 Aug 22.

Department of Clinical Pharmacy, University of California, San Francisco, San Francisco, CA, USA.

Background: In 1976, the U.S. Sugar Association (SA), a globally networked trade organization representing the cane and beet sugar industry, won the Public Relations Society of America's (PRSA) Silver Anvil Award for a crisis communication campaign. Their campaign successfully limited the diffusion of sugar restriction policies to control obesity, heart disease, diabetes, and dental caries, and marked the beginning of the modern-day SA. The sugar industry continues to resist measures to reduce sugar consumption, therefore understanding and addressing industry opposition is crucial to achieving global targets to reduce non-communicable disease.

Methods: We critically analyze common crisis management rhetorical strategies used by SA to defend itself from perceived wrongdoing, and sugar from perceptions of harm using a thematic content analysis based on Hearit's Corporate Apologia theory. Data sources were internal SA documents related to the 1976 Silver Anvil Award in 1) PRSA records, 2) Great Western Sugar Company records, and 3) William Jefferson Darby Papers.

Results: SA, using prototypical apologia stances (counterattack, differentiation, apology, and corrective action) and rhetorical dissociation strategies (appearance/reality, opinion/knowledge, and act/essence) constructed a persuasive narrative to successfully defend sugar from a product safety crisis, and the sugar industry from a social legitimacy crisis. SA's overarching narrative was that restricting sugar, which it claimed was a valuable food that makes healthy foods more palatable, would cause harm and that claims to the contrary were made by opportunists, pseudoscientists, food-faddists, lay nutritionists or those who had been misled by them. SA's apologia does not meet criteria for truthfulness or sincerity.

Conclusion: Corporate apologia theory provides an accessible way of understanding sugar industry crisis communication strategies. It enables public health actors to recognize and predict industry corporate apologia in response to ongoing product safety and social legitimacy challenges. Industry counterarguments can be examined for truthfulness and sincerity (or the lack thereof), and explained to policymakers considering sugar restriction policies, and to the public, thereby decreasing the effectiveness of illegitimate industry communication efforts to oppose regulation and legislation.
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http://dx.doi.org/10.1186/s12889-019-7401-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6704551PMC
August 2019

Civic Engagement in California Cannabis Policy Development.

J Psychoactive Drugs 2019 Nov-Dec;51(5):391-399. Epub 2019 Jun 12.

Truth Initiative Distinguished Professor of Tobacco Control, Center for Tobacco Control Research and Education, Philip R. Lee Institute for Health Policy Studies, and Department of Medicine, University of California San Francisco.

During the regulatory drafting process, California considered allowing police officers to become licensed owners of cannabis businesses, an action that would have codified a conflict of interest (COI), allowing police to exert influence in two market strata, enforcement and licensure. Up until then, no state specifically excepted law enforcement from COI prohibitions, making California's proposed medical cannabis regulation unique. We performed two 50-state surveys and examined 298 public comments submitted to the Bureau of Cannabis Control during the initial medical cannabis rulemaking process in June 2017. After public comments, the Bureau withdrew this provision. However, that the exception was even considered is cause for concern in this new area of policy development. The progression from proposed medical cannabis rules to emergency rule adoption and now, into proposed final regulations, highlights the value of civic engagement with the rulemaking process. Jurisdictions should adopt bright-line COI rules within their cannabis codes that limit the relationships that law enforcement may have with the private cannabis markets.
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http://dx.doi.org/10.1080/02791072.2019.1627444DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6823132PMC
June 2020

Electronic Cigarette Use and Myocardial Infarction Among Adults in the US Population Assessment of Tobacco and Health.

J Am Heart Assoc 2019 06 5;8(12):e012317. Epub 2019 Jun 5.

1 Center for Tobacco Control Research and Education University of California, San Francisco San Francisco CA.

Background E-cigarettes are popular for smoking cessation and as an alternative to combustible cigarettes. We assess the association between e-cigarette use and having had a myocardial infarction ( MI ) and whether reverse causality can explain the observed cross-sectional association between e-cigarette use and MI . Methods and Results Cross-sectional analysis of the Population Assessment of Tobacco and Health Wave 1 for association between e-cigarette use and having had and MI . Longitudinal analysis of Population Assessment of Tobacco and Health Waves 1 and 2 for reverse causality analysis. Logistic regression was performed to determine the associations between e-cigarette initiation and MI , adjusting for cigarette smoking, demographic and clinical variables. Every-day (adjusted odds ratio, 2.25, 95% CI : 1.23-4.11) and some-day (1.99, 95% CI : 1.11-3.58) e-cigarette use were independently associated with increased odds of having had an MI with a significant dose-response ( P<0.0005). Odds ratio for daily dual use of both products was 6.64 compared with a never cigarette smoker who never used e-cigarettes. Having had a myocardial infarction at Wave 1 did not predict e-cigarette use at Wave 2 ( P>0.62), suggesting that reverse causality cannot explain the cross-sectional association between e-cigarette use and MI observed at Wave 1. Conclusions Some-day and every-day e-cigarette use are associated with increased risk of having had a myocardial infarction, adjusted for combustible cigarette smoking. Effect of e-cigarettes are similar as conventional cigarette and dual use of e-cigarettes and conventional cigarettes at the same time is risker than using either product alone.
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http://dx.doi.org/10.1161/JAHA.119.012317DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6645634PMC
June 2019

Tobacco Industry Promotions and Pricing After Tax Increases: An Analysis of Internal Industry Documents.

Nicotine Tob Res 2020 05;22(6):967-974

Department of Medicine, University of California, San Francisco, CA.

Background: Increasing tobacco taxes, and through them, prices, is an effective public health strategy to decrease tobacco use. The tobacco industry has developed multiple promotional strategies to undercut these effects; this study assessed promotions directed to wholesalers and retailers and manufacturer price changes that blunt the effects of tax and price increases.

Methods: We reviewed tobacco industry documents and contemporaneous research literature dated 1987 to 2016 to identify the nature, extent, and effectiveness of tobacco industry promotions and price changes used after state-level tobacco tax increases.

Results: Tobacco companies have created promotions to reduce the effectiveness of tobacco tax increases by encouraging established users to purchase tobacco in lower-tax jurisdictions and sometimes lowering manufacturer pricing to "undershift" smaller tax increases, so that tobacco prices increased by less than the amount of the tax.

Conclusions: Policymakers should address industry efforts to undercut an effective public health intervention through regulating minimum prices, limiting tobacco industry promotions, and by enacting tax increases that are large, immediate, and result in price increases.

Implications: Tobacco companies view excise tax increases on tobacco products as a critical business threat. To keep users from quitting or reducing tobacco use in response to tax increases, they have shifted manufacturer pricing and developed specific promotions that encourage customers to shop for lower-taxed products. Health authorities should address tobacco industry efforts to undercut the effects of taxes by regulating prices and promotions and passing large and immediate tax increases.
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http://dx.doi.org/10.1093/ntr/ntz068DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7249914PMC
May 2020

Estimation of 1-Year Changes in Medicaid Expenditures Associated With Reducing Cigarette Smoking Prevalence by 1.

Authors:
Stanton A Glantz

JAMA Netw Open 2019 04 5;2(4):e192307. Epub 2019 Apr 5.

Center for Tobacco Control Research and Education, Philip R. Lee Institute for Health Policy Studies, Department of Medicine, University of California, San Francisco.

Importance: Reducing smoking is associated with a reduction in health care costs, including in the short run. Medicaid recipients smoke at higher rates than the general population, which suggests that investments to reduce smoking in this population would reduce short-run Medicaid costs.

Objective: To estimate the short-run (1-year) change in health care expenditure associated with a 1% decrease in absolute smoking prevalence in all US states.

Design, Setting, And Participants: Economic evaluation based on state Medicaid expenditures and the elasticity between changes in smoking prevalence and health care costs. Data sources were the 2017 Behavioral Risk Factors Surveillance System, 2017 National Health Interview Survey, and Kaiser Family Foundation Total Medicaid Spending for fiscal year 2017. Analysis was conducted in 2018. Participants were all people receiving Medicaid in all US states and the District of Columbia.

Exposures: Cigarette smoking.

Main Outcomes And Measures: Short-run (1-year) change in health care costs.

Results: Reducing absolute smoking prevalence by 1% in each state was associated with substantial Medicaid savings the following year, totaling $2.6 billion (in 2017 dollars). Each state saved a median (interquartile range) of $25 million ($8 million to $35 million).

Conclusions And Relevance: Effective efforts to reducing smoking could be a cost-effective way to reduce Medicaid costs in the short run.
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http://dx.doi.org/10.1001/jamanetworkopen.2019.2307DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6481435PMC
April 2019

Exposure to household tobacco smoke and risk of cancer morbidity and mortality: Analysis of data from the Afghanistan Demographic and Health Survey 2015.

Prev Med 2019 06 30;123:217-224. Epub 2019 Mar 30.

Center for Tobacco Control Research and Education, University of California San Francisco, California, United States of America; Division of Hematology/Oncology, Department of Medicine, University of California San Francisco, California, United States of America; Division of Cardiology, Department of Medicine and Philip R Lee Institute for Health Policy Studies, University of California San Francisco, California, United States of America. Electronic address:

Active and secondhand tobacco exposures are major causes of cancer. Cancer prevention efforts are particularly relevant in resource-constrained settings in which significant barriers to early detection and cancer treatments contribute to poor outcomes. We assess the associations between exposure to household tobacco smoke and cancer morbidity and mortality. We used household data from Afghanistan Demographic and Health Survey, which was a national cross-sectional survey that applied a two-stage stratified random sampling technique in 2015 and 2016. We performed regression analysis to estimate associations between exposure to household tobacco smoke and cancer morbidity and mortality at the household level. Exposure to household tobacco smoke was significantly associated with household reports of a history of any cancer (Adjusted Odds Ratio (AOR): 1.90; 95% Confidence Interval (CI): 1.44, 2.51), breast cancer (1.59; 1.00, 2.55), lung cancer (2.88; 1.58, 5.27), and liver cancer (2.56; 1.10, 5.96), compared to households with no tobacco smoke exposure. These associations persisted after controlling for household location, wealth index, type of cooking fuel used in house, and location of food preparation. Households in a rural location experienced significantly higher mortality of any cancer (4.40; 95% CI: 1.57, 12.38), breast cancer (2.91; 1.02, 8.25), and liver cancer (3.91; 1.29, 11.89) vs. those in an urban location. Exposure to household tobacco smoke is a risk factor for cancer morbidity in Afghanistan. Strategies to implement comprehensive smoking cessation and smoke free housing policies are urgently needed as primary cancer prevention strategy in Afghanistan and comparable resource-constrained settings.
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http://dx.doi.org/10.1016/j.ypmed.2019.03.044DOI Listing
June 2019

The Evidence of Electronic Cigarette Risks Is Catching Up With Public Perception.

Authors:
Stanton A Glantz

JAMA Netw Open 2019 03 1;2(3):e191032. Epub 2019 Mar 1.

Center for Tobacco Control Research and Education, Department of Medicine, University of California, San Francisco.

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http://dx.doi.org/10.1001/jamanetworkopen.2019.1032DOI Listing
March 2019

The Association Between E-cigarette Use and Myocardial Infarction Is What One Would Expect Based on the Biological and Clinical Evidence.

Am J Prev Med 2019 04;56(4):627

Department of Medicine, Cardiovascular Research Institute, Philip R. Lee Institute for Health Policy Studies, Center for Tobacco Control Research and Education, University of California, San Francisco, San Francisco, California.

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http://dx.doi.org/10.1016/j.amepre.2018.11.006DOI Listing
April 2019