What we know: Comprehensive age of sale restrictions on tobacco products with enforcement measures have been shown to be effective. These restrictions have been associated with lower smoking initiation and adverse transition among low socioeconomic status adolescent girls (Brown et al., 2014a) as well as decreases in underage sales (O'Connell and Kephart, 2020). Efficacy of these restrictions is dependent on retailer compliance and can have limited impact as they are only enforceable at the point of sale and do not affect young people getting tobacco products and/or vapes outside of the retail settings (O'Connell and Kephart, 2020).

Examples of implementation: California (USA) raised the age of sale for tobacco from 18 to 21 years old and seven months post-implementation, a cited evaluation found that among retailers, there was almost universal awareness (98.6%) and high levels of support (60.6%); in contrast, there was less awareness of the policy among young adults (18-24 years old) (approx. 66%) (see Zhang et al., 2018 in O'Connell and Kephart, 2020). In this study, most young adults (60%) thought age restricts would decrease youth tobacco use, though those using vapes were less likely to share this belief (see Zhang et al., 2018 in O'Connell and Kephart, 2020). Overall there was a decrease in underage sales in California after the implementation of their T21 law, but for some retailers (tobacco-only shops and vape shops), there was a greater likelihood of selling electronic smoking devices to youth, compared sales made by convenience stores that sell gas (see Zhang et al., 2018 in O'Connell and Kephart, 2020).

Types of identified restrictions: restricting tobacco retail outlets per density of population; requiring minimum distances between tobacco retailers; banning tobacco retail outlets in certain facilities or within a minimum distance from specific facilities.

What we know: There is strong evidence that higher outlet density of tobacco retailers and greater availability of tobacco is associated with youth initiation and expertimentation with tobacco, but less conclusive evidence indicates whether this trend is also true for vaping products and youth initiation and use (O'Connell and Kephart, 2020). Banning tobacco sales within pharmacies has been proven to reduce tobacco sales density and smoking prevalence (Alebshehy et al., 2023). Restrictions to establish a minimum required distance between tobacco retailers can decrease outlet density, which can have positive equity impact considering the known tendency for greater outlet density in lower socioeconomic areas (Alebshehy et al., 2023). A cited study based in the US indicated that creation of a minimum allowable distance of 500 feet between tobacco outlets could reduce tobacco retailers’ density by 22.1% and a restriction of sales of tobacco products within 1,000 feet of schools could reduce retailer density by 17.8% Alebshehy et al., 2023). Another cited study that was based in New Zealand indicated that banning tobacco retail outlets with 2km of schools as well as restricting tobacco sales to only 50% of liquour stores could each lower smoking prevalence compared to no intervention (Alebshehy et al., 2023).

Examples of implementation: Alebshehy et al., (2023) identified several examples of policies targeting tobacco outlet density and locations. Within Italy, two relevant policies exist, with one that restricts one tobacco shop per 1,500 inhabitants for municipalities with no more than 10,0000 inhabitants and another that requires a minimum distance between two tobacco sellers as per inhabitants' density, which is 200m in cities with 100,000+ inhabitants, 250m in cities with 30,000+ inhabitants and 300m for cities up to 30,000 inhabitants (Alebshehy et al., 2023). In California (USA), there is minimum distance of 200ft between a new and existing tobacco retailer and 500ft in unincorporated parts of the city, and more stringently in the city of San Francisco, there is a minimum distance of 500ft between tobacco retail outlets (Alebshehy et al., 2023).

Types of identified labelling requirements: child-resistant packaging and craftmanship to prevent leakage; warning labels for tobacco and/or nicotine containing products.

What we know: Multi-component tobacco control policy action involving increased tobacco taxes, clean indoor air laws, advertisment bans and labelling is highly cost-effective (Singh et al., 2018). Heath warnings on tobacco products have been shown to be effective for reducing adult smoking and are one of the recommended action areas within the World Health Organization's Framework Convention on Tobacco Control (Brown et al., 2014b). Less is known about the impacts of packaging and warning labels on non-tobacco, nicotine-containing products like vapes, but one cited study suggest that text warnings with illustrative elements on vaping products appeared more effect than text-only warnings among US young adults (see Sontag et al., 2019 in O'Connell and Kephart, 2020).

Examples of implementation: According to O'Connell and Kephart, (2020), ther are 33 states with packaging laws around tobacco and/or related products, with some also requiring child-resistant packaging and craftmanship to prevent leakages for vaping products.

What we know: Matthes et al., (2023) identified five types of counterstrategy activities against tobacco industry interference: exposing harmful industry practices and false claims, accessing political decision-makers, generating and using scientific evidence, use of legal tools (e.g., filing complaints) and mobilising coalitions of potential supporters. Effective examples of counterstrategies were characterised by increased public awareness of tobacco industry wrongdoing, generated community support for tobacco control measures and greater pressure on political and legal desicion-makers (Matthes et al., 2023).

Examples of implementation: : Matthes et al., (2023) reports on several case examples of national and local level displays of counterstrategy activities to tackle tobacco industry interference include four papers where legal actions / filing complaints were successful. One cited examples from the US involved filing complaints to the Federal Communications Commission against ten of the largest radio and televisions stations in Oregon to enforce their complaince with existing regulations to identify the tobacco industry as a sponsor of anti-tobacco legislation advertisements ('No on 44') every time they were broadcasted (see Goldman and Glantz 1999 in Matthes et al., 2023).

Types of identified target populations: racial/ethnic minorities, low socioeconomic status (SES) population, women of reproductive age and pregnant women; urban/rural areas; military or veterans; sexual minorities (LGBT+); those with mental health disorders.

What we know: Anti-tobacco campaigns and mass media campaigns targeted at specific vulnerable populations appeared to have mixed effects on reducing smoking initiation, cessation and/or prevalence (Wilson et al., 2012; Brown et al., 2014a). Evidence of impact for mass media campaigns was more consistent among youths than adults, with cited studies reporting reductions of 20%-40% likelihood of smoking initation (Wilson et al., 2012). Findings from behavioural research indicate that different types of messaging are more effective among adults and youths, with campaigns featuring graphic depictions of health consequences more likely to impact adults (to stop smoking) and campaigns focusing on tobacco industry manipulation and deception more is likely to persuade youth (to not begin smoking) (Wilson et al., 2012). Messaging that frames smoking as an adult choice, which is a common tobacco industry tactic, has been shown to be ineffetive and potentially increase youth tobacco use (Wilson et al., 2012).

Example of implementation: Brown et al., (2014a) discuss the US-based 'Truth Initiative' countermarketing campaign to prevent smoking among at-risk youth. A cited evaluation of the campaign showed inconsistent effects on campaign awareness and receptivity among 12-17 year olds as well as mixed equity impacts (Brown et al., 2014a).