Local restaurant smoking regulations and the adolescent smoking initiation process: results of a multilevel contextual analysis among Massachusetts youth

The contribution of Dutch municipalities to stimulate smoke-free outdoor sports clubs: a qualitative study

Local governments may play a key role in making outdoor sports clubs smoke free. This study aims to assess the activities, motives, challenges and strategies of Dutch municipalities regarding stimulating outdoor sports clubs to become smoke free. Semi-structured interviews were conducted with 19 policy officers of different municipalities in the Netherlands. The included municipalities varied in terms of region, population size and degree of urbanization. Data were analyzed using content analysis. Municipalities stimulated sports clubs to become smoke free by providing information and support and, to a lesser extent, by using financial incentives. Motives of municipalities varied from facilitating a healthy living environment for youth, responding to denormalization of smoking and aligning with goals formulated in national prevention policy. Policy officers faced several challenges, including limited capacity and funds, a reluctance to interfere with sports clubs and little support within the municipal organization. These challenges were addressed by employing various strategies such as embedding smoke-free sports in a broader preventive policy, setting a good example by creating outdoor smoke-free areas around municipal buildings, and collaborating with stakeholders in the municipality to join forces in realizing smoke-free sports clubs. Municipalities demonstrated evident motivation to contribute to a smoke-free sports environment. Currently, most municipalities fulfil an informative and supportive role, while some municipalities still explore their role and position in relation to supporting sports clubs to become smoke free. Other municipalities have established, according to them, effective strategies.

Diffusion of smoke-free policies at outdoor sports clubs in the Netherlands

BACKGROUND

Although outdoor smoke-free policies (SFPs) at sports clubs represent an important new area of tobacco control, the majority of sports clubs are not smoke free. This study aims to assess diffusion patterns of outdoor SFPs at sports clubs in the Netherlands.

METHODS

Using a retrospective, registry-based design, an inventory was made of football, field hockey, tennis and korfball clubs that became smoke free between 2016 and 2020. We determined the type of sports, number of members and proportion of youth members. The degree of urbanisation and density of smoke-free sports clubs were measured at the municipality level. The association between sports clubs' characteristics, degree of urbanisation and SFP adoption was analysed using multilevel regression analysis. Horizontal diffusion was tested by analysing the association between the density and annual incidence of smoke-free sports clubs.

RESULTS

Since 2016, the number of sports clubs with an outdoor SFP increased from 0.3% to 26.4%. Field hockey and korfball clubs and clubs with many (youth) members were more likely to be smoke-free. SFPs spread from the most urbanised to less urbanised municipalities, which could mostly be attributed to sports clubs' characteristics. A higher density of smoke-free sports clubs within municipalities was associated with an increased incidence of new SFPs in the following year.

CONCLUSION

Outdoor SFPs at sports clubs in the Netherlands diffused across horizontal and hierarchical lines. National strategies for smoke-free sports should monitor clubs that are more likely to stay behind, such as football and tennis clubs, smaller clubs and clubs in less urbanised areas.

The impact of smoke-free policies on smoking at outdoor sports clubs: a qualitative study

OBJECTIVES

Smoking may still occur at sports clubs with an outdoor smoke-free policy (SFP). This study aims to map the occurrence of smoking at various sports clubs in the Netherlands and to understand why smoking occurs at some clubs but not at others.

STUDY DESIGN

This was a qualitative design in the form of semistructured interviews.

METHODS

Semistructured interviews (n = 34) were held online with smoking and non-smoking members of 17 Dutch outdoor sports clubs (in field hockey, korfball, football, and tennis) with an outdoor SFP. Data were analyzed using content analysis.

RESULTS

We identified four situations where smoking still occurred: (1) directly at the entrance, (2) at some distance from the entrance, (3) in particular places on the premises, and (4) in various places or on occasions when alcohol is consumed. Smoking directly at the entrance was most often perceived as a bothersome situation that was difficult to avoid. The occurrence of these situations differed per sports club depending on the scope of the SFP (the comprehensiveness of the SFP and the presence or absence of a smoking area) and factors influencing policy compliance (physical characteristics of the sports club's premises, the presence or absence of children, and several enforcement difficulties).

CONCLUSION

In some sports clubs, smoking remained common on the premises despite an outdoor SFP. Exposure to second-hand smoke might be reduced by formulating a comprehensive SFP, improving policy compliance also in situations where children are absent, and organizing the enforcement of the policy.

Influence of Personal, Environmental, and Community Factors on Cigarette Smoking in Adolescents: A Population-Based Study from Taiwan

Understanding the factors that influence cigarette smoking among adolescents is critical. We identified personal, community, and environmental factors associated with current cigarette smoking among adolescents. This population-based cross-sectional analysis study was conducted using the 2012 Taiwan Global Youth Tobacco Survey and the sociodemographic statistics of the city or county from Taiwan’s Ministry of the Interior. A total of 27,524 participants (age: 12–18-years) was included. The associated factors were identified through logistic regression. A path analysis was performed to examine the pathway from the associated factors to current cigarette smoking. According to this analysis, the following factors were prominently and positively associated with adolescent cigarette smoking: one personal factor (pocket money), five environmental factors (home secondhand smoke (SHS) exposure, smoker friends, outside SHS exposure, school SHS exposure, and smoker parents), and two community factors (free cigarettes from tobacco companies and indigenous population). By contrast, five personal factors (feeling less comfortable smoking at social occasions, feeling indifferent about smoking or not smoking at social occasions, female sex, feeling that quitting is difficult, and feeling that quitting after having smoked is harmful to health) and one environmental factor (school antismoking education) had negative effects. Thus, comprehensive interventions promoting the perception of harm caused by smoking and interrupting access to cigarettes through social networks can reduce cigarette smoking in adolescents.

A longitudinal analysis of smoke-free laws and smoking initiation disparities among young adults in the United States

BACKGROUND AND AIMS

Tobacco control policies may differentially impact smoking initiation among socio-demographic groups. We measured longitudinal associations between exposure to smoke-free laws in grade 12 (modal age 18 years) and patterns of smoking initiation in the United States.

DESIGN

Prospective longitudinal analysis.

SETTING AND PARTICIPANTS

We used data on US young adults sampled at modal age 18 years from the Monitoring the Future Survey. Baseline data were collected between 2000 and 2017, with the last year of follow-up in 2018. The sample number varied by outcome and time-point, ranging from 7314 to 17 702.

MEASUREMENTS

Smoke-free law coverage in work-places and hospitality venues (restaurants/bars) was measured as the percentage of the county population covered by each type of law. We examined associations with any past 30-day smoking initiation and daily smoking initiation at modal ages 19/20, 21/22 and 23/24, using Poisson regression and calculating average marginal effects. We explored effect modification by sex, race/ethnicity and parental education by testing the significance of interaction terms.

FINDINGS

Work-place law coverage at modal age 18 was associated with a lower probability of daily smoking initiation at modal ages 21/22 [-2.4 percentage points (p.p.); 95% confidence interval (CI) = -3.9, -0.9] and 23/24 (-2.0 p.p.; 95% CI = -3.9, -0.2). Hospitality law coverage was associated with a lower probability of daily smoking initiation at modal ages 19/20 (-1.6 p.p.; 95% CI = -2.8, -0.4), 21/22 (-2.3 p.p.; 95% CI = -3.7, -0.9) and 23/24 (-1.8 p.p.; 95% CI = -3.6, -0.0). Findings were inconclusive with regard to associations with any past 30-day smoking initiation and with regard to effect modification, after adjusting for multiple testing.

CONCLUSIONS

Exposure to smoke-free laws at age 18 appears to be prospectively associated with reduced daily smoking initiation 1-6 years later.

Smoke-Free Laws and Disparities in Youth Smoking in the U.S., 2001-2018

INTRODUCTION

This study examines whether smoke-free laws are differentially associated with youth smoking outcomes by parental education, race/ethnicity, sex, and college plans in a U.S.

METHODS

This study assessed the relationships between smoke-free laws in workplaces and hospitality venues (restaurants/bars) and past 30-day smoking participation, first cigarette initiation, and daily smoking initiation within a repeated cross-sectional sample of 8th, 10th, and 12th graders from the Monitoring the Future study. Data were collected between 2001 and 2018 and were analyzed in 2020-2021. Grade-stratified Poisson models were used to calculate prevalence ratios and average marginal effects, incorporating interaction terms to examine differential associations across groups.

RESULTS

Hospitality smoke-free laws were significantly associated with lower probabilities of smoking participation in all grades as well as with first cigarette and daily smoking initiation in 8th and 10th grade. Workplace smoke-free laws were associated with lower probabilities of smoking participation among 10th and 12th graders as well as with first cigarette and daily smoking initiation among 10th graders. Average marginal effects ranged from -0.4 percentage points (hospitality laws and daily smoking initiation in 8th and 10th grades) to -2.2 percentage points (workplace laws and smoking participation in 10th grade). Associations between smoke-free laws and a lower probability of smoking participation were most pronounced among students who definitely planned to attend college. Other instances of effect modification suggested more pronounced associations for students who were female and from high-SES households; however, relationships varied by grade.

CONCLUSIONS

Smoke-free laws were associated with reduced smoking among youth; however, associations varied by grade, sex, parental education, and college plans.

Exposure to Secondhand Smoke: Inconsistency between Self-Response and Urine Cotinine Biomarker Based on Korean National Data during 2009-2018

This study aimed to estimate the secondhand smoke (SHS) exposure using urinary cotinine (UCo) to prove that the SHS exposure could not be properly assessed by self-reporting (SR). In total, 28,574 nonsmokers aged >19 years were selected from the Korean National Health and Nutrition Examination Survey data (2009-2018). First, changes in the annual concentration of UCo were analyzed, and the annual SHS exposure rates were measured based on SR and UCo from 2009 to 2018. Then, the average UCo concentration and UCo-measured SHS exposure rate were confirmed according to the subjects' characteristics. Finally, factors associated with the UCo-measured SHS exposure rate were identified based on multiple regression analysis. The findings showed that the annual UCo concentrations and self-reported SHS exposure rates dropped significantly over the past decade. In contrast, the UCo-measured SHS exposure rate indicated that >80% of nonsmokers are still exposed to SHS. Moreover, we found vulnerable groups using UCo-measured SHS exposure rate. In particular, the self-reported SHS exposure at home and in workplaces and house type was highly associated with SHS exposure. Thus, these findings indicate that the actual SHS exposure could not be properly assessed by SR and should be verified using a biomarker, such as UCo. Considering that even a short-term exposure can be harmful to health, the goal of the policy should be to keep cotinine concentration as low as possible.

The dynamics of the smoking wage penalty

Cigarette smokers earn significantly less than nonsmokers, but the magnitude of the smoking wage gap and the pathways by which it originates are unclear. Proposed mechanisms often focus on spot differences in employee productivity or employer preferences, neglecting the dynamic nature of human capital development and addiction. In this paper, we formulate a dynamic model of young workers as they transition from schooling to the labor market, a period in which the lifetime trajectory of wages is being developed. We estimate the model with data from the National Longitudinal Survey of Youth, 1997 Cohort, and we simulate the model under counterfactual scenarios that isolate the contemporaneous effects of smoking from dynamic differences in human capital accumulation and occupational selection. Results from our preferred model, which accounts for unobserved heterogeneity in the joint determination of smoking, human capital, labor supply, and wages, suggest that continued heavy smoking in young adulthood results in a wage penalty at age 30 of 15.9% and 15.2% for women and men, respectively. These differences are much smaller than the raw difference in means in wages at age 30. We show that the contemporaneous effect of heavy smoking net of any life-cycle effects explains 62.9% of the female smoking wage gap but only 20.4% of the male smoking wage gap.

Association between smoke-free legislation in hospitality venues and smoking behavior of young people: a systematic review

INTRODUCTION

While evaluations of indoor smoke-free legislation have demonstrated major public health benefits among adults, their impact on smoking behavior of young people remains unclear. Therefore, we performed a systematic review of the association between smoke-free legislation in hospitality venues and smoking behavior of young people.

METHODS

A systematic search was conducted in PubMed, Scopus, and Embase in June 2020. We searched for studies that assessed the association of any form of smoke-free legislation in any hospitality venue (e.g. bar, restaurant) with a smoking behavior outcome (e.g. initiation, current smoking) among young people (aged 10-24 years).

RESULTS

Our search yielded 572 articles of which 31 were screened based on full-text and 9 were included in the analysis. All studies were published between 2005 and 2016. The majority of studies used a quasi-experimental design. Four studies evaluated smoke-free legislation in hospitality venues specifically. Two studies reported that comprehensive, but not weaker, smoke-free legislation decrease progression to established smoking. Two other studies provided mixed results on which level of comprehensiveness of legislation would be effective, and which smoking outcomes would be affected. Five studies evaluated legislation that also included other workplaces. Out of these five studies, three studies found significant decreases in current smoking, smoking frequency, and/or smoking quantity, while two other studies did not.

CONCLUSION

Most studies found that smoke-free legislation in hospitality venues is associated with a decrease in smoking behavior among young people. Their results indicate the need for comprehensive smoke-free legislation without exemptions.

IMPLICATIONS

This is the first systematic review to provide insight in the relationship between smoke-free legislation in hospitality venues and smoking behavior of young people. Our findings show that there is a need for comprehensive smoke-free legislation without exemptions (such as designated smoking areas).

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

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.

Adolescent Tobacco Exposure in 31 Latin American Cities before and after the Framework Convention for Tobacco Control

Our objective was to describe the prevalence and changes in tobacco use and tobacco control policies in Latin American countries and cities before and after ratification of the 2003 Framework Convention on Tobacco Control (FCTC). Country-level tobacco policy data came from reports on the global tobacco epidemic (World Health Organization, 2007-2014). Global Youth Tobacco Survey data, 2000-2011, came from six countries (Argentina, Brazil, Chile, Colombia, Mexico, Peru), 31 cities and 132,065 students. Pre- and post-FCTC prevalence and relative changes were estimated. All countries showed improvements in tobacco control policies but Mexico and Peru showed the smallest improvements. In general, adolescents reduced their tobacco use, reported less exposure to smoking at home, more tobacco education, and more retailer refusals to sell them cigarettes. Adolescents reported smaller reductions in secondhand smoke exposure outside the home and no change in exposure to tobacco media/promotions. Pre-FCTC prevalence and relative changes during the post-FCTC period were more heterogeneous across cities than across countries. Despite overall improvements in tobacco policies and the decline in exposure to tobacco, policies related to media/promotions and secondhand smoke need strengthening. There was wide variation in adolescent exposure to tobacco between cities (within countries), which suggested major heterogeneity of policy implementation at the local level.

Location and duration of secondhand smoke exposure among Minnesota Nonsmokers, 2018

In 2007 Minnesota passed into law a comprehensive ban on indoor smoking of tobacco products in public places including bars, restaurants, and workplaces. Despite reductions in smoking prevalence in the past 12 years, people are still exposed to secondhand smoke (SHS). It remains important to understand where and how long nonsmokers face exposure to SHS.

The 2018 Minnesota Adult Tobacco Survey was analyzed to examine self-reported SHS exposure among nonsmoking adults. We report prevalence and 95 percent confidence intervals of SHS exposure overall, by specific locations, and by demographics. Length of exposure to SHS was summarized in median minutes.

Overall, 30 percent of nonsmokers reported exposure in the past seven days. A total of 1382 participants indicated a location of exposure. The most common locations other than one’s own home or car included building entrances (18.7 [16.2–21.1] percent), somewhere else outdoors (17.7 [15.1–20.3] percent), and restaurant/bar patios (12.8 [10.5–15.0] percent). Exposure was more likely to be reported by young adults (44.6 percent) and males (33.7 percent). The locations with the longest duration of SHS exposure in the prior seven days were a gambling venue (117.2 [72.2–162.2] minutes), another person’s home (26.1 [15.4–36.8] minutes), and a bus stop (10.8 [4.7–16.9] minutes).

Monitoring nonsmokers’ self-reported exposure to SHS remains important as a way to measure the impact and compliance with smoke-free policies. Additional information on the location and duration of exposure can be used programmatically to address high levels of exposure and consider additional policies or strategies.

"Look at Me, I Plan to Quit Smoking": Bayesian Hierarchical Analysis of Adolescent Smokers' Intention to Quit Smoking

The tobacco epidemic is one of the most prominent public health threats the world has ever faced. Public health policy that seeks to limit the problem may have to target not only the price of tobacco but also the initiation stage in a smoker’s life—the adolescent stage. Most research on teen smoking focuses on initiation and other stories. Moreover, what determines the desire to quit smoking among teens is not well understood, even though planning to quit smoking is an important stage toward successful cessation. This research contributes to healthcare literature by using Bayesian hierarchical techniques, estimated using Hamiltonian Monte Carlo (HMC) and its extension, the No-U-Turn Sampler (NUTS), to empirically identify what drives the intention to quit smoking among teen smokers in Zambia. Results suggest that, among the junior secondary school-going adolescent smokers in Zambia, about 63% have plans to quit smoking. We find socio-demographic characteristics and several tobacco-smoking-related factors as salient drivers of adolescent smokers’ plans to quit smoking. For policymaking, we recommend that school-going teen smokers should have access to smoking cessation aids to help them quit smoking. Most importantly, increased awareness of dangers of smoking, advice by health professionals, stringent public policies on smoking, as well as parental guidance could be useful to help adolescent smokers realize their quitting plans.

Use of Heated Tobacco Products within Indoor Spaces: Findings from the 2018 ITC Japan Survey

Although heated tobacco products (HTPs) have become increasingly popular in Japan, little is known about whether these emerging tobacco products are being used within indoor public spaces. Nationally representative data were obtained prior to implementation of a comprehensive smoke-free law in Japan as part of Wave 1 of the International Tobacco Control Japan Survey (February-March 2018). We estimated the weighted prevalence of HTP use within indoor public spaces among tobacco users and compared these to estimates for combustible cigarettes (CCs). Overall, 15.6% of current tobacco users in Japan declared that they used HTPs within indoor public spaces. Any HTP use within indoor public spaces was significantly lower than any CC use (80.1% vs. 96.7%). Dual HTP + CC users reported using CCs more frequently than using HTPs within indoor public spaces (97.7% vs. 76.0%). In conclusion, HTP use is less common than CC use within indoor public spaces. Findings of this study can inform the development of targeted smoke-free policies to benefit public health.

Clean indoor air laws, cigarette excise taxes, and smoking: Results from the current population survey-tobacco use supplement, 2003-2011

There was an increase in the number and coverage of state and local clean indoor air laws in the US during the past fifteen years. These laws coincided with increases in federal, state, and local cigarette excise taxes. In light of these changes, the objective of this study was to examine the association between clean indoor air laws, cigarette excise taxes and smoking patterns between 2003 and 2011. Using data on 62,165 adult participants in the 2003 and 2010/2011 Current Population Survey-Tobacco Use Supplement who reported smoking cigarettes in the past year, we examined the association of state and county workplace, bar, and restaurant clean indoor air laws and cigarette excise taxes with quitting and current every-day smoking. Between 2003 and 2011, quitting increased and daily smoking among those who continued to smoke decreased significantly. Participants living in states and counties with higher excise taxes and more comprehensive clean indoor air laws had a higher likelihood of quitting and lower likelihood of everyday smoking. Based on the assumption of no uncontrolled confounding, changes in taxes and laws accounted for 64.8% of the increase in smoking cessation and all of the reduction in everyday smoking. Implementation of state and county-level clean indoor air laws and cigarette taxes appears to have achieved the intended goal of encouraging smokers to either quit or reduce their frequency of smoking.

Where Do People Vape? Insights from Twitter Data

Background: Emerging evidence suggests that exposure to secondhand and thirdhand aerosol from electronic cigarettes may have serious health risks including respiratory and cardiovascular diseases. Social media data can help identify common locations referenced in vaping-related discussions and offer clues about where individuals vape. These insights can strengthen current tobacco regulations and prioritize new policies to improve public health. This study identified commonly referenced locations in vaping-related discussions on Twitter in 2018. Methods: Vaping-related posts to Twitter were obtained from 1 January 2018 to 31 December 2018. Rule-based classifiers categorized each Twitter post into 11 location-related categories (social venues, living spaces, stores, modes of transportation, schools, workplaces, healthcare offices, eateries, correctional facilities, religious institutions, and miscellaneous) using a data dictionary of location-related keywords (n = 290,816). Results: The most prevalent category was social venues (17.9%), followed by living spaces (16.7%), stores (15.9%), modes of transportation (15.5%), schools (14.9%), and workplaces (11.9%). Other categories pertained to: healthcare offices (2.0%), eateries (1.2%), correctional facilities (0.7%), and religious institutions (0.4%). Conclusion: This study suggests that locations related to socialization venues may be priority areas for future surveillance and enforcement of smoke-free air policies. Similarly, development and enforcement of similar policies at workplaces, schools and multi-unit housing may curb exposure to secondhand and thirdhand aerosol among the public.

Implementing smoke-free policies in low- and middle-income countries: A brief review and research agenda

INTRODUCTION

Some low- and middle-income countries (LMICs) struggle to implement smoke-free policies. We sought to review the academic and gray literature, and propose a research agenda to improve implementation of smoke-free policies and make them more effective in LMICs.

METHODS

We reviewed 10 databases for variations of (‘implementation’ /‘enforcement’ /‘compliance’) and (‘smoke-free’ /‘ban’ /‘restriction’) and (‘tobacco’ /‘smoking’). We also reviewed cited sources and the gray literature including non-governmental organization reports.

We included articles that described problems that arose, attempted solutions, lessons learned, and research questions posed regarding smoke-free policy implementation in LMICs. We excluded studies of high-income countries, institution-level implementation, voluntary smoke-free policies, smoke-free homes, and outdoor smoke-free policies.

RESULTS

The academic literature review led to 4931 unique articles, reduced to 1541 after title screening, 331 after abstract screening, and 101 after full-text review. The citation and gray literature review led to an additional 179 publications of which 67 met the inclusion criteria. In total we retained 168 sources. We conducted a narrative review and synthesis of the literature, extracting key themes and noting research gaps.

CONCLUSIONS

We find that progress is urgently needed in five categories: identifying the critical lessons learned for effective implementation, evaluating different enforcement approaches, learning how to rejuvenate stalled smoke-free policies, learning how to increase ground-level will to enforce policies, and developing a conceptual framework that explains implementation. Investigation into these topics can improve implementation of smoke-free policies in LMICs.

Workplace Smoke-Free Policies and Cessation Programs Among U.S. Working Adults

INTRODUCTION

Workplace tobacco control interventions reduce smoking and secondhand smoke exposure among U.S. workers. Data on smoke-free workplace policy coverage and cessation programs by industry and occupation are limited. This study assessed smoke-free workplace policies and employer-offered cessation programs among U.S. workers, by industry and occupation.

METHODS

Data from the 2014-2015 Tobacco Use Supplement to the Current Population Survey, a random sample of the civilian, non-institutionalized population, were analyzed in 2018. Self-reported smoke-free policy coverage and employer-offered cessation programs were assessed among working adults aged ≥18 years, overall and by occupation and industry. Respondents were considered to have a 100% smoke-free policy if they indicated smoking was not permitted in any indoor areas of their workplace, and to have a cessation program if their employer offered any stop-smoking program within the past year.

RESULTS

Overall, 80.3% of indoor workers reported having smoke-free policies at their workplace and 27.2% had cessation programs. Smoke-free policy coverage was highest among workers in the education services (90.6%) industry and lowest among workers in agriculture, forestry, fishing, and hunting industry (64.1%). Employer-offered cessation programs were significantly higher among workers reporting 100% smoke-free workplace policies (30.9%) than those with partial/no policies (23.3%) and were significantly higher among indoor workers (29.2%) than outdoor workers (15.0%).

CONCLUSIONS

Among U.S. workers, 100% smoke-free policy and cessation program coverage varies by industry and occupation. Lower smoke-free policy coverage and higher tobacco use in certain industry and occupation groups suggests opportunities for workplace tobacco control interventions to reduce tobacco use and secondhand smoke exposure.

[Autonomy and heteronomy, a necessary alliance to address smoking cessation. Views of professionals and patients]

OBJECTIVE

To explore the perception of professionals and patients with regard to ethical issues involved in addressing the habit of smoking in primary care consultations.

METHOD

A qualitative study was designed, consisting of 12 semi-structured interviews with professionals, 7 interviews with patients and 2 focus groups with 6 professionals and 7 primary care patients (a total of 32 participants). An intentional sampling was conducted, including profiles of professionals and patients of both sexes, different ages and experience in relation to smoking. A content analysis was performed with an inductive analytical approach from data to the creation of theoretical categories.

RESULTS

Four main categories were identified: 1) ethical issues related to the responsibility of the professional when treating patients who smoke; 2) issues related to attitude to patients who smoke; 3) issues related to fair and equitable distribution of resources and to the role of the different levels of government in relation to the control of smoking; and 4) issues related to smokers' autonomy regarding their habit and smoking cessation.

CONCLUSIONS

An alliance is needed between the ethics that support the autonomy of patients who smoke and the regulation of tobacco consumption. This approach should be included in clinical training programmes dealing with tobacco use, dependence and cessation.

E-cigarette use and quantity of cigarette smoking among adolescent cigarette smokers: A finite mixture model analysis

BACKGROUND

E-cigarette use is popular among adolescents and youth, but its long-term public health implications remain largely unknown. Much of the literature has focused on understanding the relationship between e-cigarette use and youth cigarette initiation. However, very little is known about e-cigarette use and cigarette quantity among those who continue to smoke cigarettes. The objective of the present study was to examine the association between current e-cigarette use and quantity of cigarette smoking.

METHODS

Cross-sectional data on current smokers were drawn from the 2014-2015 Canadian Student Tobacco, Alcohol and Drugs Survey among high school students (n = 1411). A finite mixture model (FMM) was employed to account for unobserved heterogeneity due to clusters of finite sub-populations.

RESULTS

Current e-cigarette users reported smoking more conventional cigarettes in the past week compared to non-e-cigarette users (t [1409] = 4.7998; p < 0.001 in unadjusted analysis). Results from a finite mixture regression showed that current e-cigarette use was significantly associated with the number of cigarettes smoked in the past week, but only among light smokers (IRR = 1.40; CI = 1.05-1.85). However, additional analyses found that the association between e-cigarette use and quantity of cigarette smoked varied by individual smoking pattern. An FMM with a group or class modelling using individual smoking pattern showed a weaker association between e-cigarette use and quantity of cigarette smoking.

CONCLUSION

Findings of this study suggest that the significant association between e-cigarette use and quantity of cigarette smoking may be driven by patterns of use among experimental or beginner smokers.

Electronic Cigarettes: Their Constituents and Potential Links to Asthma

PURPOSE OF REVIEW

Vaping is gaining popularity in the USA, particularly among teens and young adults. While e-cigs are commonly represented as safer alternatives to tobacco cigarettes, little is known regarding the health effects of their short- or long-term use, especially in individuals with pre-existing respiratory diseases such as asthma. Flavored e-cig liquids (e-liquids) and e-cig aerosols contain airway irritants and toxicants that have been implicated in the pathogenesis and worsening of lung diseases. In this review, we will summarize existing data on potential health effects of components present in e-cig aerosols, such as propylene glycol, vegetable glycerin, nicotine, and flavorings, and discuss their relevance in the context of asthma.

RECENT FINDINGS

Recent survey data indicate that adolescents with asthma had a higher prevalence of current e-cig use (12.4%) compared to their non-asthmatics peers (10.2%) and conveyed positive beliefs about tobacco products, especially e-cigs. Similarly, a study conducted among high school students from Ontario, Canada, indicated a greater likelihood of e-cig use in asthmatics as compared to their non-asthmatic peers. Availability of different flavorings is often cited as the main reason among youth/adolescents for trying e-cigs or switching from cigarettes to e-cigs. Occupational inhalation of some common food-safe flavoring agents is reported to cause occupational asthma and worsen asthmatic symptoms. Moreover, workplace inhalation exposures to the flavoring agent diacetyl have caused irreversible obstructive airway disease in healthy workers. Additionally, recent studies report that thermal decomposition of propylene glycol (PG) and vegetable glycerin (VG), the base constituents of e-liquids, produces reactive carbonyls, including acrolein, formaldehyde, and acetaldehyde, which have known respiratory toxicities. Furthermore, recent nicotine studies in rodents reveal that prenatal nicotine exposures lead to epigenetic reprogramming in the offspring, abnormal lung development, and multigenerational transmission of asthmatic-like symptoms. Comparisons of the toxicity and health effects of e-cigs and conventional cigarettes often focus on toxicants known to be present in cigarette smoke (CS) (i.e., formaldehyde, nitrosamines, etc.), as well as smoking-associated clinical endpoints, such as cancer, bronchitis, and chronic obstructive pulmonary disease (COPD). However, this approach disregards potential toxicity of components unique to flavored e-cigs, such as PG, VG, and the many different flavoring chemicals, which likely induce respiratory effects not usually observed in cigarette smokers.

Ever-Use and Curiosity About Cigarettes, Cigars, Smokeless Tobacco, and Electronic Cigarettes Among US Middle and High School Students, 2012-2014

Introduction

Among young people, curiosity about tobacco products is a primary reason for tobacco experimentation and is a risk factor for future use. We examined whether curiosity about and ever-use of tobacco products among US middle and high school students changed from 2012 to 2014.

Methods

Data came from the 2012 and 2014 National Youth Tobacco Surveys, nationally representative surveys of US students in grades 6 through 12. For cigarettes, cigars, smokeless tobacco, and e-cigarettes (2014 only), students were classified as ever-users or never-users of each product. Among never-users, curiosity about using each product was assessed by asking participants if they had “definitely,” “probably,” “probably not,” or “definitely not” been curious about using the product.

Results

From 2012 to 2014, there were declines in ever-use of cigarettes (26% to 22%; P = .005) and cigars (21% to 18%; P = .003) overall and among students who were Hispanic (cigarettes, P = .001; cigars, P = .001) or black (cigarettes, P = .004; cigars, P = .01). The proportion of never-users reporting they were “definitely not” curious increased for cigarettes (51% to 54%; P = .01) and cigars (60% to 63%; P = .03). Ever-use and curiosity about smokeless tobacco did not change significantly from 2012 to 2014. In 2014, the proportion of young people who were “definitely” or “probably” curious never-users of each product was as follows: cigarettes, 11.4%; e-cigarettes, 10.8%; cigars, 10.3%; and smokeless tobacco, 4.4%.

Conclusion

The proportion of US students who are never users and are not curious about cigarettes and cigars increased. However, many young people remain curious about tobacco products, including e-cigarettes. Understanding factors driving curiosity can inform tobacco use prevention for youth.

The influence of the social environment on youth smoking status

OBJECTIVE

Youth smoking is complex with multilevel influences. While much is known about certain levels of influence on youth smoking, the lack of focus on institutional influences is notable. This study evaluated the effects of ambient smoking attitudes and behaviors in schools on individual youth smoking.

METHOD

Data from the 2012 Florida Youth Tobacco Survey (n=67,460) were analyzed. Multinomial logistic regression was used to investigate individual and aggregated school-level factors that were associated with a youth being classified as a "susceptible nonsmoker" (SN) or "current smoker" (CS) relative to a "non-susceptible nonsmoker" (NN).

RESULTS

The aggregated percentage of regular smokers at a school, ambient school level positive smoking perceptions, and the standardized difference between individual and school-level positive smoking perceptions were statistically significant in the fully adjusted model. We also found an increased risk of being a SN relative to a NN for Hispanic youth. Moreover, our approach to modeling institutional-level factors raised the pseudo r-squared from 0.05 to 0.14.

CONCLUSION

These findings suggest the importance of ambient smoking attitudes and behaviors on youth smoking. Prevention efforts affecting ambient smoking attitudes may be beneficial.

Perceived Harm of Secondhand Electronic Cigarette Vapors and Policy Support to Restrict Public Vaping: Results From a National Survey of US Adults

INTRODUCTION

There is ongoing debate over banning electronic cigarette (e-cigarette) use (vaping) in public places. Many people perceive secondhand e-cigarette vapors (SHV) to be relatively harmless, which may affect their support for policies to restrict vaping in public places. Given that awareness of secondhand cigarette smoke risks predicts public support for clean air policies, we hypothesized that greater perceived harm of SHV to personal health would be associated with stronger support for vaping restrictions.

METHODS

Data from 1449 US adults in a national online panel was collected from October to December 2013. Using multiple regressions, we predict a three-item scale of support for e-cigarette restricting policies in restaurants, bars/casinos/clubs, and parks using a two-item scale measuring concern and perceptions of harm to personal health from breathing SHV. Analyses adjusted for demographic covariates, smoking status and e-cigarette use, and were weighted to represent the US adult population.

RESULTS

Overall, respondents considered SHV exposure to be moderately harmful to their health and tended to favor restricting vaping in public places. Perceived harm of SHV to personal health was associated with support for vaping restrictions in public spaces (unstandardized regression coefficient, B = 0.18, 95% CI = 0.16, 0.20). Current smokers (vs. nonsmokers), those who ever tried e-cigarettes (vs. never), those who directly observed others vaping, and those with some college education (vs. high school or less) demonstrated less support for such policies.

IMPLICATIONS

This study shows that support for banning vaping in public spaces in the United States is positively associated with perceived health harms of SHV exposure. The findings suggest that continued monitoring of public perception of SHV harm and the accuracy of e-cigarette marketing claims about reduced harm would be needed to guide clean air policy decisions. With the emergence of new scientific evidence of the potential effects of SHV exposure, these results will serve as an important baseline of public perceptions and opinion during a time when such evidence was particularly limited.

Secondhand smoke emission levels in waterpipe cafes in Doha, Qatar

BACKGROUND

Exposure to the emissions of a tobacco waterpipe is associated with increased health risks among its users as well as those exposed to its secondhand smoke. Waterpipe use is an emerging concern to the tobacco control community, particularly among countries of the Eastern Mediterranean Region. In 2002, Qatar adopted legislation that prohibited cigarette smoking inside public venues, but exempted tobacco waterpipe smoking. To inform the development and enforcement of effective policy, the impact of cigarette and waterpipe use on indoor air quality was monitored in waterpipe cafes in Doha, Qatar.

METHODS

Particulate matter (PM2.5) levels were measured inside and outside of a sample of 40 waterpipe cafes and 16 smoke-free venues in Doha, Qatar between July and October 2012. In addition, the number of waterpipes being smoked and the number of cigarette smokers were counted within each venue. Non-paired and paired sample t tests were used to assess differences in mean PM2.5 measurements between venue type (waterpipe vs smoke-free) and environment (indoor vs outdoor).

RESULTS

The mean PM2.5 level inside waterpipe venues (476 μg/m(3)) was significantly higher than the mean PM2.5 level inside smoke-free venues (17 μg/m(3); p<0.001), and significantly higher than the mean PM2.5 level found immediately outside waterpipe venues (35 μg/m(3); p<0.001). In smoke-free venues, the outside mean PM2.5 level (30 μg/m(3)) did not differ significantly from the mean PM2.5 inside levels inside these venues (p=0.121).

CONCLUSIONS

Elevated levels of particulate pollution were found in waterpipe cafes in Doha, Qatar, potentially endangering the health of employees and patrons. To protect the public from the dangers of secondhand tobacco smoke, and to change social norms around tobacco use, smoke-free policies that apply to all forms of combusted tobacco products, including the waterpipe, are needed.

Association of Smoke-Free Laws With Lower Percentages of New and Current Smokers Among Adolescents and Young Adults: An 11-Year Longitudinal Study

IMPORTANCE

Smoke-free laws are associated with a lower prevalence of smoking.

OBJECTIVE

To quantify the effect of 100% smoke-free laws on the smoking behavior of adolescents and young adults in a longitudinal analysis.

DESIGN, SETTING, AND PARTICIPANTS

Pooled logistic regression and zero-inflated negative binomial regression analysis of participants in the National Longitudinal Survey of Youth 1997 (data from 1997 to 2007), with complete data on initiation of smoking (n = 4098) and number of days respondents reported smoking in the past 30 days (n = 3913).

EXPOSURES

Laws for 100% smoke-free workplaces, laws for 100% smoke-free bars, and state cigarette taxes.

MAIN OUTCOMES AND MEASURES

Smoking initiation (first report of smoking cigarette), current (for 30 days) smoking, and number of days respondents reported smoking in the past 30 days among current smokers.

RESULTS

Laws for 100% smoke-free workplaces, but not bars, were associated with significantly lower odds of initiating smoking (odds ratio, 0.66 [95% CI, 0.44-0.99]). Laws for 100% smoke-free bars were associated with lower odds of being a current smoker (odds ratio, 0.80 [95% CI, 0.71-0.90]) and fewer days of smoking (incidence rate ratio, 0.85 [95% CI, 0.80-0.90]) among current smokers. Taxes were associated with a lower percentage of new smokers but not current smokers among adolescents and young adults. The effect of smoke-free workplace laws on smoking initiation is equivalent to a $1.57 (in 2007 dollars) tax increase. Smoke-free bar laws are associated with lower rates of current smoking, as well as a decrease in the number of days reported smoking among current smokers.

CONCLUSIONS AND RELEVANCE

Smoke-free laws are an important tobacco control tool. They not only protect bystanders from secondhand smoke but also contribute to less smoking among adolescents and young adults.

Perspectives on Smoking Initiation and Maintenance: A Qualitative Exploration among Singapore Youth

Studies among adolescents have shown that several important interpersonal, intrapersonal and environmental factors are associated with smoking behaviour. The current qualitative research project aimed to explore the determinants of smoking initiation and maintenance, from a youth perspective, among young people who smoked, living in a multi-ethnic Asian country. Focus group discussions (FGDs) were conducted with youths in Singapore in youth-friendly and accessible locations. Young people, from a variety of social contexts-varying on age, gender, ethnicity and educational level, were included in the study. All FGDs were conducted in English and participants were recruited using a mix of network and purposive sampling. All FGDs were audio recorded and transcribed verbatim. The data were analyzed using qualitative content analysis, allowing themes to emerge from the data with the goal of answering the research question. Ninety-one youth smokers (54 males, 37 females), aged between 14 to 29 years, participated in the study. The majority were males (59%) and of Chinese ethnicity (52%). Participants identified multiple personal, social, and familial influences on young adults' smoking behaviors. Peer and family influences, as well as risk minimization, played a key role in smoking initiation and maintenance. While young people were aware of policies that restricted smoking, these did not directly affect their decision to start smoking. The theory of triadic influence provided a promising theoretical framework to understand smoking initiation and maintenance in a sample of young adult smokers from a multi-ethnic Asian country. It also provides actionable information for initiatives to prevent smoking in young people, which includes their perspectives and emphasizes an inclusive approach without stigmatizing those who smoke.

A controlled community-based trial to promote smoke-free policy in rural communities

PURPOSE

Rural, tobacco-growing areas are disproportionately affected by tobacco use, secondhand smoke, and weak tobacco control policies. The purpose was to test the effects of a stage-specific, tailored policy-focused intervention on readiness for smoke-free policy, and policy outcomes in rural underserved communities.

METHODS

A controlled community-based trial including 37 rural counties. Data were collected annually with community advocates (n = 330) and elected officials (n = 158) in 19 intervention counties and 18 comparison counties over 5 years (average response rate = 68%). Intervention communities received policy development strategies from community advisors tailored to their stage of readiness and designed to build capacity, build demand, and translate and disseminate science. Policy outcomes were tracked over 5 years.

FINDINGS

Communities receiving the stage-specific, tailored intervention had higher overall community readiness scores and better policy outcomes than the comparison counties, controlling for county-level smoking rate, population size, and education. Nearly one-third of the intervention counties adopted smoke-free laws covering restaurants, bars, and all workplaces compared to none of the comparison counties.

CONCLUSIONS

The stage-specific, tailored policy-focused intervention acted as a value-added resource to local smoke-free campaigns by promoting readiness for policy, as well as actual policy change in rural communities. Although actual policy change and percent covered by the policies were modest, these areas need additional resources and efforts to build capacity, build demand, and translate and disseminate science in order to accelerate smoke-free policy change and reduce the enormous toll from tobacco in these high-risk communities.

Exposure to electronic cigarette television advertisements among youth and young adults

BACKGROUND AND OBJECTIVE

Currently, the US Food and Drug Administration does not regulate electronic cigarette (e-cigarette) marketing unless it is advertised as a smoking cessation aid. To date, the extent to which youth and young adults are exposed to e-cigarette television advertisements is unknown. The objective of this study was to analyze trends in youth and young adult exposure to e-cigarette television advertisements in the United States.

METHODS

Nielsen data on television household audiences' exposure to e-cigarette advertising across US markets were examined by calendar quarter, year, and sponsor.

RESULTS

Youth exposure to television e-cigarette advertisements, measured by target rating points, increased 256% from 2011 to 2013. Young adult exposure increased 321% over the same period. More than 76% of all youth e-cigarette advertising exposure occurred on cable networks and was driven primarily by an advertising campaign for 1 e-cigarette brand.

CONCLUSIONS

E-cigarette companies currently advertise their products to a broad audience that includes 24 million youth. The dramatic increase in youth and young adult television exposure between 2011 and 2013 was driven primarily by a large advertising campaign on national cable networks. In the absence of evidence-based public health messaging, the current e-cigarette television advertising may be promoting beliefs and behaviors that pose harm to the public health. If current trends in e-cigarette television advertising continue, awareness and use of e-cigarettes are likely to increase among youth and young adults.

The changing public image of smoking in the United States: 1964-2014

Tobacco use behaviors in the U.S. have changed significantly over the past century. After a steep increase in cigarette use rates over the first half of the 20th century, adult smoking prevalence rates started declining from their peak reached in 1964. Improved understanding of the health risks of smoking has been aided by the U.S. Surgeon General's Reports, issued on a nearly annual basis starting in 1964. Among the many forces driving down smoking prevalence were the recognition of tobacco use as an addiction and cause of cancer, along with concerns about the ill effects of breathing secondhand smoke. These factors contributed to the declining social acceptance of smoking, especially with the advent of legal restrictions on smoking in public spaces, mass media counter-marketing campaigns, and higher taxes on cigarettes. This article reviews some of the forces that have helped change the public image of smoking, focusing on the 50 years since the 1964 Surgeon General's Report on smoking and health.

Quantifying the effect of changes in state-level adult smoking rates on youth smoking

OBJECTIVE

Quantify the degree to which changes in state-level adult smoking prevalence subsequently influence youth smoking prevalence.

DESIGN

Analysis of data from the Tobacco Use Supplement to the Current Population Survey (TUS-CPS) collected from 1995 to 2006 and the National Youth Tobacco Survey (NYTS) collected from 1999 to 2006.

SETTING AND PARTICIPANTS

Adults 25 years or older who completed the TUS-CPS and youth in middle and high school who completed the NYTS.

MAIN OUTCOME MEASURES

Current smoking among middle and high school students as a function of the change in state-level adult smoking, controlling for individual-level sociodemographic characteristics and state-level tobacco control policy variables.

RESULTS

Among middle school students, declines in state-level adult smoking rates are associated with lower odds of current smoking (P < .05), and each doubling of the decline in adult smoking rates is associated with a 6.0% decrease in youth smoking. Among high school students, declines in state-level adult smoking rates are not associated with current smoking. Higher cigarette prices were associated with lower odds of smoking among middle and high school students. Greater population coverage by smoke-free air laws and greater funding for tobacco control programs were associated with lower odds of current smoking among high school students but not middle school students. Compliance with youth access laws was not associated with middle or high school smoking.

CONCLUSION

By quantifying the effect of changes in state-level adult smoking rates on youth smoking, this study enhances the precision with which the tobacco control community can assess the return on investment for adult-focused tobacco control programs.

Association between local indoor smoking ordinances in Massachusetts and cigarette smoking during pregnancy: a multilevel analysis

OBJECTIVE

To estimate the association between local clean indoor air ordinances and prenatal maternal smoking across 351 municipalities in Massachusetts before the 2004 statewide ban and to test the effect of time since ordinance adoption on the association.

METHODS

The authors linked 2002 birth certificate data of women who gave birth in the state and reported a Massachusetts residence (n=67,584) to a database of indoor smoking ordinances in all municipalities. Multilevel regression models accounting for individual- and municipality-level variables estimate the associations between the presence of local smoking ordinances, strength of the ordinances, time since ordinance adoption and prenatal smoking.

RESULTS

Compared with those living in municipalities with no ordinances, women living in municipalities with a smoking ordinance had lower odds of prenatal smoking (OR=0.72, CI=0.53 to 0.98). No effect was found for 100% smoke-free ordinances. For the analyses testing the effect of time, pregnant women living in municipalities with ordinances enacted >2 years were less likely to smoke than those in municipalities with more recent (<1 year) ordinances.

CONCLUSIONS

Preventing smoking among women of reproductive age is a public health priority. This study suggests that indoor smoking ordinances were associated with lower prenatal smoking prevalence and the favourable effect increased over time. Findings highlight the public health benefit of tobacco control policies.

A comprehensive examination of the influence of state tobacco control programs and policies on youth smoking

OBJECTIVES

We examined the influence of tobacco control policies (tobacco control program expenditures, smoke-free air laws, youth access law compliance, and cigarette prices) on youth smoking outcomes (smoking susceptibility, past-year initiation, current smoking, and established smoking).

METHODS

We combined data from the 2002 to 2008 National Surveys on Drug Use and Health with state and municipality population data from the US Census Bureau to assess the associations between state tobacco control policy variables and youth smoking outcomes, focusing on youths aged 12 to 17 years. We also examined the influence of policy variables on youth access when these variables were held at 2002 levels.

RESULTS

Per capita funding for state tobacco control programs was negatively associated with all 4 smoking outcomes. Smoke-free air laws were negatively associated with all outcomes except past-year initiation, and cigarette prices were associated only with current smoking. We found no association between these outcomes and retailer compliance with youth access laws.

CONCLUSIONS

Smoke-free air laws and state tobacco control programs are effective strategies for curbing youth smoking.

Effects of smoke-free laws on alcohol-related car crashes in California and New York: time series analyses from 1982 to 2008

We examined effects of New York and California's statewide smoke-free restaurant and bar policies on alcohol-related car crash fatalities. We used an interrupted time-series design from 1982 to 2008, with 312 monthly observations, to examine the effect of each state's law on single-vehicle-nighttime crashes and crashes involving a driver with a blood alcohol concentration of 0.08 grams per deciliter or greater. Implementation of New York and California's statewide smoke-free policies was not associated with alcohol-related car crash fatalities. Additionally, analyses showed no effect of New York's smoke-free policy on alcohol-related car crash fatalities in communities along the Pennsylvania-New York border. Statewide smoke-free restaurant and bar laws do not appear to affect rates of alcohol-related car crashes.

Minnesota's comprehensive statewide smokefree law: short-term effects on young adults

BACKGROUND

Young adults have the highest rate of smoking among any age group.

PURPOSE

The purpose of this study is to assess the short-term effects of Minnesota's comprehensive statewide smokefree law on young adult smoking perceptions and behavior.

METHODS

Telephone surveys were conducted before and up to 18 months after Minnesota's statewide smokefree law went into effect on October 1, 2007 (data analyzed 2010-2011). Participants included young adults from a population-based cohort in Minnesota (n=1458) and from five other upper Midwest states that serve as a comparison (n=248). Differences in perceptions and smoking behavior were examined between Minnesota participants who lived with and without a local smokefree law prior to Minnesota's statewide law, and participants who lived in the comparison states.

RESULTS

The majority of youth in Minnesota were aware of the smoking restrictions in restaurants and bars following the law. After implementation of the law, Minnesota participants who previously lived without a local law (versus comparison) were more likely to perceive fewer adult and peer smokers and less likely to report leaving social events early because it was too smoky. No changes in smoking behaviors were observed before and after the law. Minnesota participants, however, who lived without a prior law (versus participants with a prior law) were more likely to attribute a quit attempt after the law to smoking restrictions in restaurant and bars.

CONCLUSIONS

Results suggest that Minnesota's law has changed perceptions of the tobacco environment. Longer-term follow-up may be needed to observe changes in smoking behavior.

The impact of state preemption of local smoking restrictions on public health protections and changes in social norms

INTRODUCTION

Preemption is a legislative or judicial arrangement in which a higher level of government precludes lower levels of government from exercising authority over a topic. In the area of smoke-free policy, preemption typically takes the form of a state law that prevents communities from adopting local smoking restrictions.

BACKGROUND

A broad consensus exists among tobacco control practitioners that preemption adversely impacts tobacco control efforts. This paper examines the effect of state provisions preempting local smoking restrictions in enclosed public places and workplaces.

METHODS

Multiple data sources were used to assess the impact of state preemptive laws on the proportion of indoor workers covered by smoke-free workplace policies and public support for smoke-free policies. We controlled for potential confounding variables.

RESULTS

State preemptive laws were associated with fewer local ordinances restricting smoking, a reduced level of worker protection from secondhand smoke, and reduced support for smoke-free policies among current smokers.

DISCUSSION

State preemptive laws have several effects that could impede progress in secondhand smoke protections and broader tobacco control efforts. Conclusion. Practitioners and advocates working on other public health issues should familiarize themselves with the benefits of local policy making and the potential impact of preemption.

Multilevel predictors of smoking initiation among adolescents: findings from the Minnesota Adolescent Community Cohort (MACC) study

OBJECTIVE

To understand how factors at multiple levels of influence impact adolescent smoking initiation.

METHOD

Data from the Minnesota Adolescent Community Cohort, a population-based cohort, were analyzed. Adolescents were recruited from randomly selected geopolitical units (GPUs) in Minnesota at ages 12 to 13 (n=1953), and were surveyed every six months (2000-2006) until 18. The association between baseline social factors and smoking initiation was analyzed using logistic regression. Linear regression was used to analyze predictors and age of initiation among smokers (n=603).

RESULTS

Higher proportion of 15-16 year-olds who smoke at the area-level (GPU) was associated with younger initiation (15.47 vs 15.87, p<.05). Higher proportion of the population employed and higher median household income were associated with older initiation (15.90 vs. 15.56 p<.05). Parent education, living with parents or siblings who smoke, living in homes that allow smoking, and having friends who smoke at baseline were associated with smoking initiation or younger initiation (p<.05). Participants whose parents had less than a high school education were 1.6 times more likely than those with college educated parents to have smoked at least a whole cigarette (CI=1.06, 2.26).

CONCLUSION

Factors at multiple levels of influence effect adolescent smoking initiation. Smoking by older age peers and lower SES predicts earlier smoking.

Ohio Appalachian residents' views on smoke-free laws and cigarette warning labels

INTRODUCTION

Smoke-free laws and the addition of graphic warning labels to cigarette packages represent public health policies that can potentially reduce smoking and smoking-related disease. The attitudes and beliefs relating to these policies were examined among residents of Ohio Appalachia, a mostly rural region with high smoking prevalence among its residents.

METHODS

Focus groups were conducted with participants from Ohio Appalachia during the summer of 2007. Groups included healthcare providers (n=37), community leaders (n=31), parents (n=19), and young adult women aged 18-26 years (n=27).

RESULTS

Most participants were female (94%), non-Hispanic White (94%), and married (65%). Participants believed that most non-smokers supported Ohio's enforced statewide comprehensive smoke-free law that began in 2007, while some smokers opposed the law due to a perceived infringement of their rights. They also reported that most residents and local businesses were abiding by and enforcing the law. Participants supported the addition of graphic warning labels to cigarette packages in the USA. They believed that such warning labels could help deter adolescents and adult non-smokers from smoking initiation, particularly if the negative aesthetic effects of smoking were emphasized. However, they felt the labels would be less effective among current smokers and older individuals living in their communities.

CONCLUSIONS

Participants generally held positive views about both the smoke-free law and the addition of graphic warning labels to cigarette packages in the USA. These tobacco-related public health policies are promising strategies for potentially reducing smoking and its associated diseases among residents living in Appalachia. Additional research is needed to further examine support for these policies among more diverse Appalachian populations.

The potential of smoking cessation programmes and a smoking ban in public places: Comparing gain in life expectancy and cost effectiveness

Background: Interventions aimed at reducing the number of smokers are generally believed to be cost effective. However as the cost of the interventions should be paid up front whereas the gains in life years only appear in the future – the budgetary consequences might be a barrier to implementing such interventions. Aims: The aim of the present paper was to assess the long-term cost effectiveness as well as the short-term (10 years) budget consequences of cessation programmes and a smoking ban in enclosed public places. Methods: We develop a population-based Markov model capable of analyzing both interventions and assess long-term costs effectiveness as well as short-term budgetary consequences and outcome gains. The smoking cessation programme model was based on data from the Danish National Smoking Cessation Database (SCDB), while the model of the smoking ban was based on effect estimates found in the literature. Results: On a population level the effect of a smoking ban has the largest potential compared with the effect of smoking cessation programmes. Our results suggest that smoking cessation programmes are cost saving and generate life-years, whereas the costs per life-year gained by a smoking ban are 40,645 to 64,462 DKK (100 DKK = €13.4). These results are conservative as they do not include the healthcare cost saving related to reduced passive smoking. Conclusions: Our results indicate that smoking cessation programmes and a smoking ban in enclosed public places both in the short term and the long term are cost-effective strategies compared with the status quo.

The effect of a smoke-free campus policy on college students' smoking behaviors and attitudes

OBJECTIVE

To evaluate the impact of a smoke-free campus policy on college students' smoking behaviors and attitudes.

METHODS

The current study utilized repeated cross-sectional surveys with a nested 4-wave longitudinal cohort design. Data were collected from undergraduate students at two large matched public universities in Indiana before and after one of the campuses went smoke-free in January 2008. Baseline data were collected in fall 2007 (n=3266) and follow-up data were collected in fall 2009 (n=3207). In addition, volunteers provided longitudinal follow-up data at four different time points.

RESULTS

In the cross-sectional analyses, students exposed to the smoke-free campus policy demonstrated significant favorable changes in smoking behavior (16.5% to 12.8%, p<0.001), perceptions of peer tobacco use (73.6% to 66.8%, p<0.001), and smoking norms (45.5% to 40.4%, p<0.001) compared to students on the control campus. In the longitudinal analyses, students exposed to the smoke-free campus policy demonstrated these changes plus significant favorable changes in attitudes toward regulation of tobacco (83.2% to 89.9%, p<0.01).

CONCLUSIONS

The implementation of a smoke-free campus policy may be an effective intervention for reducing tobacco use among college students.

What impact have tobacco control policies, cigarette price and tobacco control programme funding had on Australian adolescents' smoking? Findings over a 15-year period

AIMS

To assess the impact of tobacco control policies relating to youth access, clean indoor air and tobacco advertising at point-of-sale and outdoors, in addition to cigarette price and per capita tobacco control spending, on adolescent smoking prevalence.

DESIGN

Repeated cross-sectional surveys. Logistic regression analyses examined association between policies and smoking prevalence.

SETTING

Australia, 1990-2005.

PARTICIPANTS

A nationally representative sample of secondary students (aged 12-17 years) participating in a triennial survey (sample size per survey range: 20 560 to 27 480).

MEASUREMENTS

Students' report of past-month smoking. In each jurisdiction, extent of implementation of the three policies for the year of the survey was determined. For each survey year, national per capita tobacco control spending was determined and jurisdiction-specific 12-month change in cigarette price obtained.

FINDINGS

Extent of implementation of the three policy areas varied between states and over the survey years. Multivariate analyses that adjusted for demographic factors, year and all tobacco control variables showed that 12-month cigarette price increases [odds ratio (OR): 0.98, 95% confidence interval (CI): 0.97-0.99], greater per capita tobacco control spending (OR: 0.99, 95% CI: 0.98-0.99) and stronger implementation of clean indoor air policies (OR: 0.93, 95% CI: 0.92-0.94) were associated with reduced smoking prevalence.

CONCLUSIONS

Adult-directed, population-based tobacco control policies such as clean indoor air laws and increased prices of cigarettes, implemented as part of a well-funded comprehensive tobacco control programme are associated with lower adolescent smoking.