The impact of tobacco control policies on smoking initiation in eleven European countries

Understanding the mechanisms of change in social norms around tobacco use: A systematic review and meta-analysis of interventions

BACKGROUND AND AIMS

Tobacco use spreads through social networks influencing social norms around tobacco use. However, the social norms scholarship is extremely diverse and occasionally conflicting, complicating efforts to understand how best to leverage social norms to reduce tobacco use. This study systematically reviewed and meta-analyzed this vast terrain by focusing on social norms measurement and mechanism, and intervention effectiveness and modality aimed at changing social norms around tobacco use and actual tobacco use.

METHODS

We searched Scopus, PubMed, PsycInfo, Clinicaltrials.gov, ProQuest Dissertations, the Cochrane Trial Registry, as well as the websites of the Society for Research on Nicotine and Tobacco, the Open Science Framework, medrXiv and the Truth Initiative for experimental and quasi-experimental evaluation studies of interventions designed to shift tobacco use. We included studies written in English from inception to 30 May 2024. We only included studies which noted social norms or social influence as part of the intervention design or set of measured variables. We excluded studies with only one time point, without an intervention being evaluated and those not published in English. Study screening followed the PRISMA 2020 guidelines, and was conducted by at least two independent reviewers who resolved discrepancies through discussion and consensus. All included studies were analyzed in a narrative synthesis, and those providing sufficient statistics for tobacco and social norms outcomes were included in meta-analyses, which were performed separately for tobacco outcomes and social norms outcomes. Study outcomes were transformed into a standardized mean difference (Hedges' g) and several meta-regressions were fit to explore sources of heterogeneity using a robust variance estimation specification to handle effect size dependency.

RESULTS

A total of 95 studies met inclusion criteria for the narrative synthesis, 200 effect sizes from 86 studies were included in the tobacco outcomes meta-analysis, and 66 effect sizes from 29 studies were included in the social norms outcomes meta-analysis. Nearly 90% of included studies were conducted in high-income settings, with the remainder conducted in middle-income settings. No studies were conducted in Latin America or on the African continent. Social norms change interventions had a statistically significant effect on reducing tobacco use and pro-tobacco social normative perceptions [g = 0.233, 95% confidence interval (CI) = 0.166, 0.301, P < 0.001 and g = 0.292, 95% CI = 0.090, 0.494, P = 0.007, respectively]. Interventions were commonly conducted among schoolchildren in classrooms through multicomponent education sessions, often coupled with regular 'booster' sessions over time. Among adult populations, motivational interviewing and other counselling approaches were used in some cases, and few interventions leveraged digital technologies to change social norms.

CONCLUSIONS

Social norms change interventions appear to be effective for reducing tobacco use and pro-tobacco social normative perceptions. In particular, leveraging role models appears to be the most effective social norms change mechanisms for tobacco control.

Cancer situation in China: an analysis based on the global epidemiological data released in 2024

BACKGROUND

Cancer remains a major cause of mortality and a significant economic burden in China. Exploring the disparities in cancer patterns and control strategies between China and developed countries may offer valuable insights for policy formulation and enhance cancer management efforts. This study examined the incidence, mortality, and disability-adjusted life year (DALY) burden of cancer in China, and compared these metrics with those observed in the United States (US) and the United Kingdom (UK).

METHODS

Data on cancer incidence, mortality, and DALYs for China, the US, and the UK were sourced from the GLOBOCAN 2022 online database and the Global Burden of Disease 2021 study (GBD 2021). We utilized Joinpoint regression models to analyze trends in cancer incidence and mortality across these countries, calculating annual percent changes (APCs) and determining the optimal joinpoints.

RESULTS

In 2022, China recorded around 4,824,703 new cancer cases and 2,574,176 cancer-related deaths, contributing to 71,037,170 DALYs. China exhibited a lower cancer incidence rate compared to the US and the UK. Although cancer-related mortality in China is slightly lower than that in the UK, it is significantly higher than that in the US. Additionally, China experienced significantly higher DALY rates compared to both the US and UK. The cancer landscape in China was also undergoing significant changes, with a rapid rise in the incidence and burden of lung, colorectal, breast, cervical, and prostate cancers. Meanwhile, the incidence and burden of stomach cancer continued to decline. Although the incidence of liver and esophageal cancers was decreasing, the burden of liver cancer was increasing, while the burden of esophageal cancer remained largely unchanged.

CONCLUSIONS

The cancer profile of China is shifting from that of a developing country to one more typical of a developed country. The ongoing population aging and the rise in unhealthy lifestyles are expected to further escalate the cancer burden in China. Consequently, it is crucial for Chinese authorities to revise the national cancer control program, drawing on successful strategies from developed countries, while also accounting for the regional diversity in cancer types across China.

A systematic review and network meta-analysis of population-level interventions to tackle smoking behaviour

This preregistered systematic review and meta-analysis (PROSPERO: CRD 42022311392) aimed to synthesize the effectiveness of all available population-level tobacco policies on smoking behaviour. Our search across 5 databases and leading organizational websites resulted in 9,925 records, with 476 studies meeting our inclusion criteria. In our narrative summary and both pairwise and network meta-analyses, we identified anti-smoking campaigns, health warnings and tax increases as the most effective tobacco policies for promoting smoking cessation. Flavour bans and free/discounted nicotine replacement therapy also showed statistically significant positive effects on quit rates. The network meta-analysis results further indicated that smoking bans, anti-tobacco campaigns and tax increases effectively reduced smoking prevalence. In addition, flavour bans significantly reduced e-cigarette consumption. Both the narrative summary and the meta-analyses revealed that smoking bans, tax increases and anti-tobacco campaigns were associated with reductions in tobacco consumption and sales. On the basis of the available evidence, anti-tobacco campaigns, smoking bans, health warnings and tax increases are probably the most effective policies for curbing smoking behaviour.

Impact of cigarette price and tobacco control policies on youth smoking experimentation in Albania

BACKGROUND

Albania has one of the highest smoking prevalence in Europe especially among the youth. There is a lack of evidence in Albania, as well as in most of Eastern Europe and middle-income countries, regarding the effect of price on smoking experimentation.

OBJECTIVE

The study aims to assess the effect of price and tobacco control policies on youth smoking experimentation in Albania.

METHODS

We used microdata from the Global Youth Tobacco Survey in Albania for 2004, 2009, 2015 and 2020. We constructed a pseudo-longitudinal dataset and estimated a split-population model to assess the hazard of smoking experimentation.

RESULTS

Price is a significant predictor of smoking experimentation among teenagers in Albania for both males and females (p<0.001). Being male increases the odds for smoking experimentation by more than 50% as compared with females (p<0.001), whereas females appear to be more price sensitive. Peer and parent smoking are also important determinants for smoking experimentation. Introducing penalties for smokers and legal entities violating smoke-free policies implemented in 2014 is also associated with a lower hazard of smoking experimentation.

CONCLUSION

Price is a significant predictor of smoking experimentation among teenagers in Albania for both males and females. A combination of increasing taxes and strengthening the rule of law to control tobacco use in public spaces, in addition to public awareness campaigns targeting both youth and smoking parents, could help to significantly reduce the probability of smoking experimentation.

A Health Economics Inquiry into Regulatory Constraints on the European Tobacco Market

Despite the implementation of significant measures by European countries in recent years, smoking rates in Europe remain persistently high. The European Commission is currently undertaking a comprehensive review of its tobacco regulations. This article aims to address critical inquiries that arise during the amendment of the regulatory framework. We evaluate the effectiveness of existing tobacco control methods and observe a diminishing impact on promoting smoking cessation. Additionally, we explore how individuals of varying genders respond to the regulatory environment. We propose a comprehensive and evidence-based framework for implementing a taxation system in response to the proliferation of emerging products, including e-cigarettes and heated tobacco. This system is designed to align effectively with health policy objectives, providing a strategic approach to curbing tobacco use and promoting public health.

Predictors of quitting smoking behavior: evidence from Pakistan

This study attempts to identify factors that significantly encourage the cessation of smoking in the context of Pakistan. The study distributes a modified questionnaire among 421 respondents (current as well as former smokers) in the capital city of Pakistan, Islamabad. The binary regression method was employed to data for analyzing predictors of making quit attempts and successful smoking cessation. The result indicates that respondents having strong intentions to quit, high socioeconomic status, low nicotine dependency, and past quit attempts, and those having no-smoking friends, are more likely to quit cigarette smoking successfully. On the other hand, factors like social pressure to quit smoking, religious information against smoking, intention to quit smoking, and public regulation on smoking are more likely to encourage smokers to make quit attempts. The study calls for community and school-wide smoking cessation campaigns involving officials, peers and parents, religious leaders, and other influential individuals to inform people about the dangers of smoking. In addition, religious leaders should be encouraged to issue rulings against smoking especially during "Friday Prayer." Furthermore, the government should pronounce more strict and comprehensive regulations on smoking by properly monitoring its implementation to encourage cessation of cigarette smoking.

Trends in age of tobacco use initiation over time in Bangladesh, India and Pakistan: analysis of cross-sectional nationally representative surveys

OBJECTIVE

Tobacco use begins at an early age and typically leads to a long-term addiction. The age of initiation for tobacco use is not well studied in South Asia, where 22% of tobacco smokers and 81% of smokeless tobacco (SLT) users reside.

METHODS

Data from the nationally representative Global Adult Tobacco Surveys in India, Bangladesh and Pakistan were analysed to examine patterns of initiation among smokers and smokeless tobacco users.

RESULTS

Data on 94 651 individuals were analysed, of which 13 396 reported were ever daily smokers and 17 684 were ever SLT users. The proportion of individuals initiating tobacco use before the age of 15 years has increased over time. The rates of SLT initiation among those aged 15-24 years increased markedly in Bangladesh (by 7.8%) and Pakistan (by 37.7%) between 1983 and 1999-2000. Among males, the increase in SLT initiation was higher in individuals aged below 15 years compared with other age groups in India and Bangladesh. Smoking initiation among females aged below 15 years has also significantly increased in India over time. Compared with the initiation of tobacco smoking before the age of 15 years, a greater increase in the proportion of SLT users was observed in urban areas.

CONCLUSION

Our findings indicate that the proportion of youth initiating tobacco (both smoking and smokeless) before the age of 15 years has increased over time in all three countries. Moreover, variations in age at initiation for different types of tobacco products across countries, and by rurality, were noticeable. Younger youths (aged up to 15 years) should therefore be a priority population for tobacco control interventions. Strategies such as raising the legal age of tobacco sale and use to 21 years, and, other measures under WHO Framework Convention on Tobacco Control (FCTC), may prevent underage use and avert lifelong addiction to tobacco products.

Beyond MPOWER: a systematic review of population-level factors that affect European tobacco smoking rates

BACKGROUND

Population-level factors within and beyond the scope of the World Health Organization's (WHO) MPOWER policy package have significant impacts on smoking rates. However, no synthesis of the existing evidence exists. This systematic review identifies population-level factors that influence cigarette smoking rates in European countries.

METHODS

We searched the ProQuest database collection for original, peer-reviewed quantitative evaluations that investigated the effects of population-level exposures on smoking rates in European countries. Of the 3122 studies screened, 62 were ultimately included in the review. A standardized data extraction form was used to identify key characteristics of each study including publication year, years evaluated, countries studied, population characteristics, study design, data sources, analytic methods, exposure studied, relevant covariates and effects on tobacco smoking outcomes.

RESULTS

One hundred and fifty-five population-level exposures were extracted from the 62 studies included in the review, 99 of which were related to WHO MPOWER measures. An additional 56 exposures fell into eight policy realms: economic crises, education policy, macro-economic factors, non-MPOWER tobacco regulations, population welfare, public policy, sales to minors and unemployment rates. About one-half of the MPOWER exposures affected smoking rates (55/99) and did so in an overwhelmingly positive way (55/55). Over three-quarters of the non-MPOWER exposures were associated with statistically significant changes in smoking outcomes (43/56), with about two-thirds of these exposures leading to a decrease in smoking (29/43).

CONCLUSIONS

Population-level factors that fall outside of the WHO's MPOWER measures are an understudied research area. The impacts of these factors on tobacco control should be considered by policymakers.

Return on investment of Canadian tobacco control policies implemented between 2001 and 2016

OBJECTIVES

To determine the return on investment (ROI) associated with tobacco control policies implemented between 2001 and 2016 in Canada.

METHODS

Canadian expenditures on tobacco policies were collected from government sources. The economic benefits considered in our analyses (decrease in healthcare costs, productivity costs and monetised life years lost, as well as tax revenues) were based on the changes in smoking prevalence and attributable deaths derived from the SimSmoke simulation model for the period 2001-2016. The net economic benefit (monetised benefits minus expenditures) and ROI associated with these policies were determined from the government and societal perspectives. Sensitivity analyses were conducted to check the robustness of the result. Costs were expressed in 2019 Canadian dollars.

RESULTS

The total of provincial and federal expenditures associated with the implementation of tobacco control policies in Canada from 2001 through 2016 was estimated at $2.4 billion. Total economic benefits from these policies during that time were calculated at $49.2 billion from the government perspective and at $54.2 billion from the societal perspective. The corresponding ROIs were $19.8 and $21.9 for every dollar invested. Sensitivity analyses yielded ROI values ranging from $16.3 to $28.3 for every dollar invested depending on the analyses and perspective.

CONCLUSIONS

This analysis has found that the costs to implement the Canadian tobacco policies between 2001 and 2016 were far outweighed by the monetised value associated with the benefits of these policies, making a powerful case for the investment in tobacco control policies.

E-cigarette use and conventional cigarette smoking among European students: findings from the 2019 ESPAD survey

BACKGROUND AND AIMS

Representative data on e-cigarette use among European adolescents are scant. This study reports current vaping and tobacco smoking individual and country-specific correlates among European students.

DESIGN

Cross-sectional survey: 2019 European School Survey Project on Alcohol and Other Drugs (ESPAD) collecting data on risk behaviours on a representative sample of 16-year-old students.

SETTING

A total of 35 European countries, 25-30 with Tobacco Control Scale (TCS) and TCS components PARTICIPANTS: A total of 99 648 students (49.1% males) turning 16 years in the survey year.

MEASUREMENTS

Data on current cigarette and e-cigarette use were gathered through a self-administered questionnaire which also collected socio-demographics and individual and family characteristics. ESPAD data were integrated with country-level data on TCS and selected TCS parameters to assess their association with the prevalence of current cigarette and e-cigarette use.

FINDINGS

Of the 99 648 participating students, 12.4% were current e-cigarette users, from 5.5% in Serbia to 41.4% in Monaco; 19.3% current smokers, from 5.1% in Iceland to 32.4% in Italy. Compared with non-users, current e-cigarette users less frequently came from an average well-off family [odds ratio (OR) = 0.85, 95% confidence interval (CI) = 0.80-0.90] and lived in countries with higher cigarette prices (OR = 0.71, 95% CI = 0.50-0.99), restrictive measures on tobacco advertising and promotion (OR = 0.79, 95% CI = 0.63-0.99) and intermediate implementation of tobacco control measures (OR = 0.57, 95% CI = 0.38-0.85). Current vapers were more frequently life ever smokers (OR = 7.31, 95% CI = 6.47-8.25), were early smokers (OR = 4.35, 95% CI = 3.66-5.17), males (OR = 1.61, 95% CI = 1.55-1.67), from non-traditional families (OR = 1.43, 95% CI = 1.34-1.53), with relatively low parental education (OR = 1.15, 95% CI = 1.10-1.20). Compared with non-smokers, current smokers had similar family characteristics to vapers, and were less likely to live in countries with higher cigarette prices (OR = 0.70, 95% CI = 0.49-0.99) and higher spending on public anti-tobacco media campaigns (OR = 0.23, 95% CI = 0.10-0.50).

CONCLUSIONS

E-cigarette use among European adolescents is associated with weaker tobacco control measures, particularly on tobacco price, advertising and promotion. Besides preventing tobacco smoking, the adoption of governmental tobacco control policies in European countries also seems to contribute to the prevention of vaping among adolescents.

Tobacco Consumption and Mental Health in the Canary Islands: A Quantitative Analysis

Although the detrimental health effects of tobacco, there has been scant research into determining comprehensive profiles to characterize individuals with a higher risk of smoking. This paper identifies such profiles and probabilistically quantifies the effects of certain traits on the decision to smoke in the Canary Islands. This characterization is approached from a broad and novel point of view for the region studied, given that the analysis not only studies sociodemographic characteristics, lifestyle and health, but also incorporates mental health. The results show that suffering from some type of psychopathology leads to a higher probability of tobacco consumption. Moreover, just as the promotion of a healthy lifestyle has a direct impact on tobacco consumption, the implementation of public policies that reduce the risks of suffering from a mental illness could also reduce the prevalence of smoking in the region and contribute to the design of more effective prevention strategies.

Understanding long-term trends in smoking in England, 1972-2019: an age-period-cohort approach

BACKGROUND AND AIMS

Smoking prevalence has been falling in England for more than 50 years, but remains a prevalent and major public health problem. This study used an age-period-cohort (APC) approach to measure lifecycle, historical and generational patterns of individual smoking behaviour.

DESIGN

APC analysis of repeated cross-sectional smoking prevalence data obtained from three nationally representative surveys.

SETTING

England (1972-2019).

PARTICIPANTS

Individuals aged 18-90 years.

MEASUREMENTS

We studied relative odds of current smoking in relation to age in single years from 18 to 90, 24 groups of 2-year survey periods (1972-73 to 2018-19) and 20 groups of 5-year birth cohorts (1907-11 to 1997-2001). Age and period rates were studied for two groups of birth cohorts: those aged 18-25 years and those aged over 25 years.

FINDINGS

Relative to age 18, the odds of current smoking increased with age until approximately age 25 [odds ratio (OR) = 1.48, 95% confidence interval (CI) = 1.41-1.56] and then decreased progressively to age 90 (OR = 0.06, 95% CI = 0.04-0.08). They also decreased almost linearly with period relative to 1972-73 (for 2018-19: OR = 0.30, 95% CI = 0.26-0.34) and with birth cohort relative to 1902-06, with the largest decreased observed for birth cohort 1992-96 (OR = 0.44, 95% CI = 0.35-0.46) and 1997-2001 (OR = 0.35, 95% CI = 0.74-0.88). Smoking declined in the 18-25 age group by an average of 7% over successive 2-year periods and by an average of 5% in those aged over 25.

CONCLUSIONS

Smoking in England appears to have declined over recent decades mainly as a result of reduced smoking uptake before age 25, and to a lesser extent to smoking cessation after age 25.

Social Norms Change and Tobacco Use: A Protocol for a Systematic Review and Meta-Analysis of Interventions

Tobacco use kills more than eight million individuals each year, and results in substantial economic and human capital loss across nations. While effective supply-side solutions to tobacco control exist, these approaches are less effective at promoting cessation among heavy smokers, and less feasible to implement in countries with weaker tobacco control policy environments. Thus, effective demand-side solutions are needed. Shifting social norms around tobacco use is one such promising approach. To this end, a systematic review and meta-analysis of social norms intervention studies to influence tobacco use will be conducted following PRISMA 2020 guidance. Tobacco intervention studies with at least two time points that explicitly mention social norms or social influence as part of an intervention or set of measured variables will be included. Literature sources will comprise PubMed, Scopus, PsycInfo, and the Cochrane Trial Registry, as well as several grey literature sources. Two reviewers will independently screen studies, and risk of bias will be assessed using the Cochrane Risk of Bias 2 and ROBINS-I tools. The primary outcomes will be change in tobacco use and change in social norms. A random-effects meta-analysis will be conducted for both outcomes. Sources of heterogeneity will be explored using meta-regression with key covariates. Non-reporting biases will be explored using funnel plots. PROSPERO: CRD42021251535.

Cancer incidence, mortality, and burden in China: a time-trend analysis and comparison with the United States and United Kingdom based on the global epidemiological data released in 2020

BACKGROUND

Cancer is one of the leading causes of death and a main economic burden in China. Investigating the differences in cancer patterns and control strategies between China and developed countries could provide reference for policy planning and contribute to improving cancer control measures. In this study, we reviewed the rates and trends of cancer incidence and mortality and disability-adjusted life year (DALY) burden in China, and compared them with those in the United States (US) and the United Kingdom (UK).

METHODS

Cancer incidence, mortality, and DALY data for China, US and UK were obtained from the GLOBOCAN 2020 online database, Global Burden of Disease (GBD) 2019 study, and Cancer Incidence in Five Continents plus database (CI5 plus). Trends of cancer incidence and mortality in China, US, and UK were analyzed using Joinpoint regression models to calculate annual percent changes (APCs) and identify the best-fitting joinpoints.

RESULTS

An estimated 4,568,754 newly diagnosed cancer cases and 3,002,899 cancer deaths occurred in China in 2020. Additionally, cancers resulted in 67,340,309 DALYs in China. Compared to the US and UK, China had lower cancer incidence but higher cancer mortality and DALY rates. Furthermore, the cancer spectrum of China was changing, with a rapid increase incidence and burden of lung, breast, colorectal, and prostate cancer in addition to a high incidence and heavy burden of liver, stomach, esophageal, and cervical cancer.

CONCLUSIONS

The cancer spectrum of China is changing from a developing country to a developed country. Population aging and increase of unhealthy lifestyles would continue to increase the cancer burden of China. Therefore, the Chinese authorities should adjust the national cancer control program with reference to the practices of cancer control which have been well-established in the developed countries, and taking consideration of the diversity of cancer types by of different regions in China at the same time.

Impact of tobacco control interventions on smoking initiation, cessation, and prevalence: a systematic review

This article investigates the effects of tobacco control policies on smoking initiation, cessation and prevalence by examining the papers published in the last 5 years. Twenty-one articles have been selected by two authors and sorted by four types of tobacco control: tobacco prices, anti-smoking campaigns for young people, mass media intervention and public smoking bans. Price/tax increase has deterrent effect on smoking initiation but does not promote smoking cessation; intervention on young people could reduce the smoking initiation if carried out at an early age and if acted on social skills and with peer-led approach, as opposed to restraining measures which hare generally easily circumvented by young people. The mass media campaigns showed positive effect on attempts to quit among smokers if carried forward over time and by involving multiple communication channels (TV, internet, radio). The bans in public have little effect on smoking cessation but could improve the overall well-being of non-smokers. Heterogeneous results have been described by different studies probably because of different research methodologies, cultural aspects and the really effective implementation of the rules for each country. In conclusion, comprehensive tobacco control interventions to reduce smoking prevalence and modify the smoking behavior are recommended. Moreover, the use of e-cigarettes and heat-not-burn (HnB) products, as possible helping tool for smoke cessation, currently remains controversial.