>Magister Scientiae - MSc / Background: The explosion in the popularity and use of e- cigarettes over the last decade has raised concerns and incited intense discussions over their safety, efficacy and potential public health impact. Globally there is dramatic variation in the approach to regulation, with certain jurisdictions attempting to regulate e-cigarettes either as tobacco products, medicines, consumer products or poisons whilst others have banned their use and sale. The aim of this study was to review the e-cigarette regulatory strategies adopted by the World Health Organisation, Australia, European Union and United States in an attempt to identify feasible approaches to the regulation of e-cigarettes in South Africa within the context of existing institutional regulatory frameworks. Methods: The principles of an explorative comprehensive literature-based review using a thematic qualitative approach were employed. The primary method of data collection was documentation, collected and selected using document review and analysis. Results: The strategies between jurisdictions studied vary significantly in their approach to e-cigarette regulation with each equally facing challenges and massive criticism. The South African approach to the medicalisation of e-cigarettes when evaluated against the WHO FCTC regulatory objectives was found to be ineffective and warrants a change in strategy. Within the existing medicine and tobacco product regulatory frameworks, SA has the option to regulate e-cigarettes as: (1) medicine; (2) tobacco products; or (3) an amalgam of the two approaches. Conclusion: The most expeditious way for SA to regulate e-cigarettes immediately, in the absence of robust scientific data would be to implement a hybrid approach - regulation as a medicine when marketed for therapeutic use and as tobacco products when used recreationally.

The most commonly attributed causes of failure of smoking cessation are non-adherence to treatment, experiencing severe nicotine withdrawal symptoms and post-cessation weight gain. However, there is a lack of information regarding these factors among smokers who attempt to quit in low-income country settings. The main objective of this study was to identify predictors of: 1) adherence to cessation treatment; 2) severity of withdrawal symptoms: and 3) post-cessation changes in body mass index among 269 smokers who attempted to quit in a randomized smoking cessation trial in a low-income country setting (Aleppo, Syria). All participants received behavioral counseling and were randomized to receive either 6 weeks of nicotine or placebo patch and were followed for one year. Findings from logistic regression showed that lower adherence to cessation treatment was associated with higher daily smoking, greater withdrawal symptoms, waterpipe use, being on placebo patch and the perception of receiving placebo patch. Generalized estimating equation (GEE) analyses indicated that throughout the study, lower total withdrawal score was associated with greater education, older age of smoking initiation, higher confidence in ability to quit, higher adherence to patch, lower nicotine dependence, lower reported depression, waterpipe use and the perception of receiving nicotine patches rather than placebo. Further, smoking abstainers gained 1.8 BMI units (approximately 4.8kg) greater than non-abstainers over one year post quitting. In addition, greater BMI was associated with being female, smoking to control weight and having previously failed to quit due to weight gain. In conclusion, nicotine dependence, waterpipe use and expectancies regarding cessation treatment are important factors that influence adherence to cessation treatment and severity of nicotine withdrawal symptoms. Moreover, targeted interventions that take into consideration the prevailing local and cultural influences on diet and levels of physical activity are recommended especially for females and smokers with weight concerns prior to quitting. Collectively, these findings will help in conducting future tailored effective cessation programs in Syria and other low-income countries with similar levels of developments and tobacco use patterns.

The Diploma Thesis deals with the regulation of the tobacco market. The first part is dedicated to the theoretical view on regulation. It describes the historical development of the different points of view on regulation within economic schools, then it characterizes different types of market failure and within those it shows possible solutions in form of regulatory measures. The second part of the diploma thesis deals with tobacco and tobacco products market. In this chapter the current situation on the market is analyzed and some trends are derived, the chapter also deals with the largest producers of tobacco products nowadays. The last chapter deals with current tobacco control legislation. The Framework Convention on Tobacco Control and current European tobacco control legislation are looked at in detail and there is a comparison conducted of the level of tobacco market regulation in different parts of the world. The last part of the thesis delivers the evaluation of the level to which the current tobacco regulation is in line with the economic theory of regulation.

Bottom-up processes, starting at the local government level, are valuable for more-stringent tobacco control measures. The existence of industry-backed state-level tobacco control preemption in states has impeded policy progress within the state and localities/communities. A national public health goal under Healthy People 2020 is to eliminate state-level preemption across the United States. This study explored individual-level perceptions of the impact of state-level preemption in Appalachian Tennessee—a high-smoking, low-income region. During 2015–2016, a community-engagement project to develop a Population Health Improvement Plan (PHIP) involving over 200 stakeholders and 90 organizations was conducted in Appalachian Tennessee to identify policies/programs to address tobacco use. Using a multifaceted framework approach that focused on prevention, protection, and cessation, interviews and meeting discussions were audio-recorded and transcribed. Content analysis using NVivo 11 was conducted to generate themes. Although the central focus of the PHIP was not preemption, the issue emerged naturally in the discussions as a major concern among participants. Cultural and normative factors in Appalachian Tennessee were identified as key rationales for participants’ aversion to state preemption. Thus, repealing preemption would facilitate culturally tailored and region-specific policies/programs to the high tobacco use among Appalachian Tennessee communities where statewide/nationwide policies/programs have not had the intended impacts.

Background: The tobacco industry has globalized and tobacco use continues to increase in low- and middle-income countries. Yet, the data and research to inform policy initiatives for addressing this phenomenon is sparse. This study aims to estimate the prevalence of adult tobacco use in 17 Sub-Saharan Africa (SSA) countries, and to identify key factors associated with adult tobacco consumption choices (smoked, smokeless tobacco and dual use) in Madagascar. Methods. We used Demographic Health Survey for estimating tobacco use prevalence among adults in SSA. A multinomial logistic regression model was used to identify key determinants of adult tobacco consumption choices in Madagascar. Results: While differences in tobacco use exist in SSA, Madagascar has exceptionally higher prevalence rates (48.9% of males; 10.3% of females). The regression analyses showed complexity of tobacco use in Madagascar and identified age, education, wealth, employment, marriage, religion and place of residence as factors significantly associated with the choice of tobacco use among males, while age, wealth, and employment were significantly associated with that of females. The effects, however, differ across the three choices of tobacco use compared to non-use. Conclusions: Tobacco use in Madagascar was higher than the other 16 SSA countries. Although the government continues to enact policies to address the problem, there is a need for effective implementation and enforcement. There is also the need for health education to modify social norms and denormalize tobacco use.

Background: The tobacco industry has globalized and tobacco use continues to increase in low- and middle-income countries. Yet, the data and research to inform policy initiatives for addressing this phenomenon is sparse. This study aims to estimate the prevalence of adult tobacco use in 17 Sub-Saharan Africa (SSA) countries, and to identify key factors associated with adult tobacco consumption choices (smoked, smokeless tobacco and dual use) in Madagascar. Methods. We used Demographic Health Survey for estimating tobacco use prevalence among adults in SSA. A multinomial logistic regression model was used to identify key determinants of adult tobacco consumption choices in Madagascar. Results: While differences in tobacco use exist in SSA, Madagascar has exceptionally higher prevalence rates (48.9% of males; 10.3% of females). The regression analyses showed complexity of tobacco use in Madagascar and identified age, education, wealth, employment, marriage, religion and place of residence as factors significantly associated with the choice of tobacco use among males, while age, wealth, and employment were significantly associated with that of females. The effects, however, differ across the three choices of tobacco use compared to non-use. Conclusions: Tobacco use in Madagascar was higher than the other 16 SSA countries. Although the government continues to enact policies to address the problem, there is a need for effective implementation and enforcement. There is also the need for health education to modify social norms and denormalize tobacco use.

The World Health Organization's Framework Convention on Tobacco Control (FCTC) is the first international public health treaty to address the global spread of tobacco products. Ethnographic research at the fourth meeting of the FCTC's Conference of the Parties in Uruguay highlights the role of the FCTC in recalibrating the relationship between international trade and investment agreements and those of global public health. Specifically, we chart the origins and development of the Punta del Este Declaration, tabled by Uruguay at the conference, to counter a legal request by Philip Morris International, the world's largest tobacco transnational, for arbitration by the International Centre for the Settlement of Investment Disputes over Uruguay's alleged violations of several international trade and investment treaties. We argue that medical anthropologists should give greater consideration to global health governance and diplomacy as a potential counterweight to the 'politics of resignation' associated with corporate capitalism.

The World Health Organization (WHO) Framework Convention for Tobacco Control (FCTC) has prompted major change in tobacco control globally. However, policy implementation has been uneven, making 'smoke free' outcomes possible in some countries, but not others. We identify the factors that would improve implementation. We describe an ideal type of 'comprehensive tobacco control regimes', where policy environments are conducive to the implementation of tobacco control measures designed to eradicate tobacco use. The ideal type requires that a country have certain policy processes: the department of health takes the policy lead; tobacco is 'framed' as a public health problem; public health groups are consulted at the expense of tobacco interests; socioeconomic conditions are conducive to policy change; and, the scientific evidence is 'set in stone' within governments. No country will meet all these criteria in the short term, and the gap between the ideal type and the current state is wide in many countries. However, the WHO experience provides a model for progress.

Campaigns against risk factors for non-communicable diseases (NCDs) caused by smoking and obesity have become increasingly common on multiple levels of government, from the local to the international. Non-governmental actors have cooperated with government bodies to make policies. By analysing the policies of the World Trade Organization, the World Health Organization, the European Union, and the United Kingdom and United States governments, we identify how the struggles between public health advocates and commercial interests reached the global level, and how the relatively successful fight to ‘denormalize’ tobacco consumption has become a model for anti-obesity advocates. It highlights three factors important in policy change: framing the policy problem, the policymaking environment and ‘windows of opportunity’—to analyse the struggle between ‘harm regulation’ and ‘neoprohibition’ approaches to an international obesity prevention regime.

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