Background Hardcore smoking behaviours and test of hardening are seldom reported from low-and-middle-income countries (LMICs). We report country-wise changes in smoking behaviors between two sequential surveys and explored ecologically the relationship between MPOWER scores and smoking behaviors including hardcore smoking. Methods We analysed sequential Global Adult Tobacco Survey (GATS) data done at least at five years interval in 10 countries namely India, Bangladesh, China, Mexico, Philippines, Russia, Turkey, Ukraine, Uruguay, and Vietnam. We estimated weighted prevalence rates of smoking behaviors namely current smoking (both daily and non-daily), prevalence of hardcore smoking (HCS) among current smokers (HCSs%) and entire surveyed population (HCSp%), quit ratios (QR), and the number of cigarettes smoked per day (CPD). We calculated absolute and relative (%) change of rates between two surveys in each country. Using aggregate data, we correlated relative change in current smoking prevalence with relative change in HCSs% and HCSp% as well explored the relationship of MPOWER score with relative change in smoking behaviors using Spearman’ rank correlation test. Results Overall daily smoking has declined in all ten countries lead by a 23% decline in Russia. In India, Bangladesh, and Philippines HCSs% decreased as the smoking rate decreased while HCSs% increase in Turkey (66%), Vietnam (33%) and Ukraine (15%). In most countries, CPD ranged from 15 - 20 sticks except in Mexico (7.8), and India (10.4) where CPD declined by 18% and 22% respectively. MPOWER scores were moderately and significantly correlated with HCSs% in both sexes (r=0.578, p=0.023) and HCSp% (r= 0.489, p=0.057) and among women both HCSs% (r=0.667, p=0.009) and HCSp% (r=0.533, p=0.037) were significantly correlated with MPOWER scores. Conclusion With declining smoking prevalence, HCS had also decreased and quit rates improved. Ecologically, a positive linear relationship between changes in smoking and HCS is a possible evidence against ‘hardening’. Continued monitoring of the changes in quitting and hardcore smoking behaviours is required to plan cessation services.

Background We report the country-level prevalence of awareness about and electronic cigarette use, and ‘dual use’ and its associations with age, sex, and country income,e and e-cigarette regulatory status. Methods We analyzed the most recent Global Youth Tobacco Surveys done on nationally representative samples of school-going youth aged 13–15 years in 75 countries. The weighted prevalence of ‘awareness’ (heard about e-cigarettes), ‘ever use’ (even tried a few puffs), ‘current use’ (during the last 30 days), and ‘dual-use’ (e-cigarette use and cigarette smoking during the last 30 days) were estimated. Results Awareness was > 80% in 13 countries mostly from Europe, Poland being the highest at 95.8% (95% CI94.8- 96.6). In seven countries, 30–50% of the youth had ever used an e-cigarette, Italy was the highest at 55.1% (95%CI 51 − 3,58.9). In 30 countries, current e-cigarette use was > 10%, highest of 35.1% (95%CI 32.4–38.0) in Guam. Awareness and use were highest in the European region (74.6% and 34.5%) and HIC (83.6% and 39.4%). Youth from HIC and countries having restrictive e-cigarette regulations had 1.1 times (aOR 1.03, 95% CI 1.03, 1.24) and 1.8 times (aOR 1.81, 95% CI 1.63, 2.01) higher odds of being current e-cigarette users. Youth in countries with the most restrictive e-cigarette regulations had 0.6 times lower odds of being current e-cigarette users (aOR 0.64, 95% CI 0.56, 0.72). Conclusion Awareness and e-cigarette use varied by sex, country income level, and region. Continued global surveillance of youth e-cigarette use to assist in the formulation of e-cigarette regulatory policy. Implications Awareness and use of e-cigarettes including dual-use were higher among boys, in countries in Europe and America regions, and those with higher income and restrictive policies, whereas lower in most restrictive policies. Higher awareness strongly correlated with a trial and current use of e-cigarettes. E-cigarette marketing should be restricted, and continued surveillance of e-cigarette use is needed. Most restrictive policies such as the ban on e-cigarettes appear to reduce e-cigarette use among the youth.

We report cessation behaviors, reasons for use of EC and HTP and association of their use with quit attempts and smoking intensity using Romania Global Adult Tobacco Survey 2018. Weighted estimates of EC and HTP by cigarette smoking (CS) status were assessed. ‘Quit attempts’, ‘intention to quit’, reasons for lack of intention to quit among current CS and reasons for current use of EC and HTP were estimated. Association of ‘ever use’ of EC and HTP with cigarette smoking intensity and quit attempts was explored using binary logistic regression. Of the total 4571 surveyed, 1243 (27.3%) were current CS, 300 (24.4%) made quit attempt in the past 12 months. Only 38 (12.5%) and 26 (8.6%) had used EC and HTP as an aid to quit. Among current CS, 512 (41.2%) had no intention to quit. Reasons for this were, ‘enjoy smoking’ (86.1%), ‘reduce stress’ (65.9%) and ‘staying alert’ (46.3%). Awareness and use of EC and HTP was significantly higher among current CS. ‘Dual use’ of EC and HTP with CS was manifolds higher than stand-alone use. Reasons for current use of EC and HTP were ‘enjoyment’, and ‘use in places where smoking was prohibited’.

Background Marketing and sales are unregulated in Malaysia. We systematically analyzed content displayed on e-cigarette retailer websites to identify marketing claims, promotional strategies, and product details. Methods We analyzed 30 Malaysia-based retailer websites. Data were extracted as the frequency of occurrence of marketing claims, presence of regulatory information, product types, and flavors of e-juice as per a predefined codebook based on published literature. We also extracted textual details published on the websites about marketing claims, and slogans. Results Most retailer websites provided contact information and physical store addresses (83%) but only half had ‘click through’ age verification (57%) that seldom needed any identification proof for age (3%). Marketing claims were related to health (47%), smoking cessation (37%), and modernity/trend (37%) and none had health warnings. Promotional strategies were discounts (80%). starter kits (57%) and email subscriptions (53%). Product types displayed were rechargeable (97%) and disposable (87%) devices and e-liquids (90%) of an array of flavors (> 100). Nicotine presence, its concentration, and “nicotine is an addictive chemical" were displayed in 93%, 53%, and 23% of websites respectively. Conclusion Surveillance of content displayed online on e-cigarette retailer websites and regulation of online marketing and sales are needed to prevent youth access and initiation.

Background The menopause Rating Scale (MRS) is an internationally used tool to measure menopause-related symptoms to date and is unavailable in the Bahasa Melayu language. We aimed to translate and validate the Bahasa Melayu version of the MRS. Methods Translation of the English version of MRS into Bahasa Melayu was done by a bilingual expert and back-translated. Bahasa Melayu MRS was reviewed by a panel to determine the face validity. A total of 321 women aged 40–60 years residing in Klang, Selangor, Malaysia were selected by stratified random sampling method in a house-to-house survey. The Bahasa Melayu MRS was self-administered. Reliability analyses, including test-retest reliability (on 30 women after a two-week interval) were conducted. To ascertain the construct validity, 11 items were analyzed using exploratory factor analyses to determine the factor structure. To further support the psychometric study, confirmatory factor analysis was conducted to evaluate the structural model fit of Bahasa Melayu MRS. Results A total of 294 (91.6%) completed the survey and their mean age was 50.9 years (SD = 6.3). An overall Cronbach’s alpha for MRS was 0.904. Cronbach’s alpha for psychosomatic, urogenital, and Somatovegetative subscales were 0.889, 0.846, and 0.776 respectively. The corrected item correlations were approximately 0.6 and inter-item correlations were between 0.3 and 0.9. Assumptions for exploratory factor analyses were not violated; Kaiser–Meier–Olkin test revealed a value of 0.883 and Bartlett’s test value of sphericity was statistically significant (χ2 = 2400.483 and p < 0.001). EFA identified three factors accounting for 51.4% of the variance. This study encountered straddling of items. EFA yielded all 4 psychological items in Factor 2. The items which are supposedly falling into Somatic-Vegetative and Urogenital domains are straddled in Factor 1. Two items (heart complications and bladder problems) are grouped in the 3rd Factor. Nevertheless, confirmatory factor analyses showed a good model fit, fitting well into the theoretical constructs. Conclusion The translated English version of the Menopause Rating Scale into the Bahasa Version showed excellent reliability, test-retest reliability, and construct validity. The instrument can be used to assess menopause-related symptoms among Malaysian women.