Environmental determinants of smoking behaviors: The role of policy and environmental interventions in preventing smoking initiation and supporting cessation

Assessing client and staff beliefs and attitudes to inform tobacco-free campus policy implementation at substance use disorder treatment centers

INTRODUCTION

US patients with behavioral health conditions have smoking rates two to three times higher than the general population. Tobacco-free environments at substance use disorder (SUD) facilities can positively impact patient's outcomes as well as the health of staff, but client perceptions to the contrary can slow adoption. This study assessed client and staff beliefs, attitudes, and knowledge regarding the implementation of a tobacco-free campus policy at McLeod Addictive Disease Center, a full-service SUD treatment facility based in Charlotte, North Carolina.

METHODS

During the height of the 2020 COVID-19 pandemic, the research team conducted a mixed-methods study at the McLeod Center lasting from May to November 2020. Using convenience sampling, the team conducted two staff surveys that were administered online (n=134; n=28) and virtual interviews of clients (n=38) to assess beliefs, attitudes and knowledge of tobacco use and the tobacco-free campus planned for 2021.

RESULTS

Many staff identified as current or former smokers (n=57); some expressed the belief that the policy will positively impact clients' SUD recovery (n=12). Encouragingly, clients expressed positive feelings associated with the policy (n=16) and reported interest in receiving tobacco cessation treatment (n=25).

CONCLUSIONS

Staff are interested in helping clients quit tobacco use. Most of the interviewed clients, however, believed that utilizing tobacco products while receiving treatment for their dependence on another substance, would improve their success. The McLeod Center was one of the first community-based SUD treatment facilities in North Carolina to transition to a 100% tobacco-free campus in 2021. This research and results serve as a blueprint for other facilities making similar policy changes.

Future nicotine use preferences of current cigarette smokers: Findings from the 2020 International Tobacco Control Four Country Smoking and Vaping Survey

INTRODUCTION

Consumer preferences should be important factors that are considered when developing health policies and interventions. This paper examines the prevalence of, and factors associated with, consumer preferences regarding smoking behaviour 1 to 2 years in the future.

METHODS

At least weekly cigarette smokers in the 2020 wave of the International Tobacco Control Four Country Smoking and Vaping Survey (USA, Canada, England and Australia) (N = 8642) were asked if they preferred to continue to smoke or to quit with or without an alternative nicotine product (ANP) over the next 1-2 years.

RESULTS

Country-specific weighted data showed 21.5% preferred to continue smoking and 8.0% were uncertain, leaving 70.6% preferring to quit: 13.7% using an ANP and 56.9% completely quitting nicotine. Apart from interest in quitting, the main predictors of preferring to quit were history of vaping, being aged 55 and over, smoking weekly, worrying about smoking harms, regretting starting and believing vaping is less harmful relative to smoking. Among those preferring to quit, preferring to use ANPs in future was very strongly associated with current vaping (especially daily), being younger, living in England, reporting strong urges to smoke, believing vaping is much less harmful than smoking, and not strongly regretting starting to smoke, and not wanting to quit.

DISCUSSION AND CONCLUSIONS

A significant minority of smokers preferred not to quit, at least in the next year or two. Both interest in quitting and preference for ANPs over complete cessation were associated with similar covariates, including interest in vaping.

State of the literature discussing smoke-free policies globally: A narrative review

Despite the success of the Framework Convention on Tobacco Control (FCTC), most jurisdictions in the world do not have policies that create 100% smoke-free environments in indoor workplaces, indoor public places, public transport, or other public places. We conducted a narrative review of articles that discuss smoke-free policies and describe the state of the current literature. A search of peer-reviewed and gray literature, published between 1 January 2004 and 30 April 2022, was conducted using PubMed and EMBASE databases. We classified articles based on the location of the policy discussed (WHO region, World Bank income classification) and the environment that was being made smoke-free. Insights related to policy development and implementation, as well as compliance and enforcement, were also identified. The search identified 4469 unique citations; 134 articles met the criteria for inclusion and underwent data extraction by two independent coders. The sample included articles published in or about jurisdictions in each WHO region, in high- and low- and mediumincome countries, and articles that discussed policies regulating smoke-free indoor workplaces, indoor public places, public transport, outdoor/quasi-outdoor environments, and other (unspecified) public places. Some important insights from the literature related to smoke-free policy implementation included tobacco industry interference, the important role of civil society, and the need for effective communication, education, and leadership. Enforcement officials' awareness and training, stakeholders' attitudes and beliefs, and understanding social norms were identified as relevant determinants of effective smoke-free policies. There continue to be challenges for implementing smoke-free policies in jurisdictions throughout the globe, in high- and low- and middle-income countries. The literature includes insights to support 100% smoke-free policies in each environment that must be made smoke-free as per the FCTC.

Latinx Individuals Who Smoke Daily with and without a Probable Anxiety Disorder: Differences in Smoking Behavior and Beliefs about Abstinence

There is a well-established relation between anxiety psychopathology and smoking in the general population. However, little work focuses on Latinx/Hispanic (hereafter Latinx) persons who smoke from this comorbidity perspective. The present investigation aimed to explore differences among English-speaking Latinx adults who live in the United States (US) and smoke cigarettes with and without a probable anxiety disorder in terms of cigarette dependence, perceived barriers for quitting, severity of problems when quitting, and smoking abstinence expectancies. The sample included 338 adult Latinx daily cigarette smokers (Mage = 35.53 years; SD = 8.65; age range 18-61; 37.3% female) who identified as Latinx and were recruited nationally throughout the US. Results indicated that among Latinx persons who smoke, those with a probable anxiety disorder (compared to those without) were more likely to demonstrate higher levels of cigarette dependence, severity of problems when trying to quit, perceived barriers for quitting, and negative abstinence expectancies after adjusting for key variables linked to smoking and anxiety (e.g., hazardous drinking, education). The current findings are the first to document probable anxiety disorder status as a clinically relevant factor for a wide range of smoking variables and beliefs about abstinence among Latinx persons who smoke.

Spotlight on tobacco guidance: NICE public health guidance update

The updated NICE guidelines on tobacco recommend cost-effective and evidence-based interventions to prevent smoking initiation and promote smoking cessation across the life course. E-cigarettes are a cost-effective adjunct to support smoking cessation in adults, but their long-term effects are yet to be fully understood. Concerted efforts from healthcare and public health providers are required to reach underserved groups and hence address stark and longstanding inequalities in smoking prevalence and associated ill health in England.

Guest Support for Outdoor Smoke-Free Policies within a Homeless Shelter

Roughly 70-80% of adults experiencing homelessness smoke cigarettes. Smoke-free living/workplace policies are an empirically-supported tobacco control intervention. However, homeless shelters may be reluctant to implement smoke-free policies due to fears of it discouraging current/potential shelter guests from taking refuge there. The current study was meant to characterize guest support for on-property smoke-free policies within a homeless shelter with an extant indoor tobacco use ban amongst never smokers, former smokers, and current smokers to provide data on this point. Participants comprised a convenience sample of adult guests of a homeless shelter in Texas (N = 394, 28.2% women; 10.2% former; and 75.9% current smokers). Participant sociodemographics, smoking status, behavioral health diagnoses, and support for two versions of an on-property outdoor courtyard smoke-free policy (one partial, one complete) were assessed. Data were collected in two waves in a repeated cross-sectional design. Overall, 64.0% of participants supported a partial, and 32.0% a full smoking ban. Logistic regressions, controlling for wave of data collection, age, sex, and any additional significant predictors from a semi-adjusted model, examined associations between participant characteristics and policy support. Older participants (OR = 1.024, CI_0.95 = 1.005-1.044), non-veterans (OR = 2.523, CI_0.95 = 1.156-5.506), former smokers (OR = 2.730, CI_0.95 = 1.191-6.258), and those without severe mental illness (OR = 1.731, CI_0.95 = 1.061-2.824) had significantly greater odds of supporting a partial smoking ban. Relative to current smokers, never smokers (OR = 3.902, CI_0.95 = 2.133-7.137) and former smokers (OR = 8.257, CI_0.95 = 3.951-17.258) had significantly greater odds of supporting a complete smoking ban. The implementation of smoke-free living/workplace policies in homeless shelters may enjoy more support from guests-specifically, non-smokers-than anticipated by shelter administrators. Aside from reducing ambient smoke exposure for never and former smokers, these policies can help to reduce ubiquitous smoking cues for those who may want to quit, are undergoing a quit attempt, or are trying to maintain abstinence. Interventionists might partner with shelter guests, particularly smokers, to inform the roll-out of such policies for maximal acceptance and adoption.

Implementation of tobacco control measures in the Gulf Cooperation Council countries, 2008-2020

BACKGROUND

The World Health Organization (WHO) Framework Convention on Tobacco Control (FCTC) was developed to assist nations in reducing the demand and supply of tobacco. As of 2020, 182 nations joined the FCTC, agreeing to implement the recommended tobacco control measures. The Gulf Cooperation Council (GCC) countries, including Bahrain, Kuwait, Oman, Qatar, Saudi Arabia, and United Arab Emirates (UAE) ratified the WHO FCTC by August 2006. Given the unique political, cultural, and religious context - and known tobacco industry efforts to influence tobacco use- in these nations, a careful examination of the translation of FCTC measures into policy is needed. This study aimed to assess the implementation of FCTC tobacco control measures at the national level within the six GCC countries.

METHOD

We collected and coded the FCTC measures that were implemented in the GCC countries. We examined trends and variations of the implementation between 2008 and 2020.

RESULTS

GCC countries implemented most FCTC measures targeting the demand for and supply of tobacco, with some variation among countries. Bahrain and Qatar were more comprehensively implementing FCTC measures while Kuwait and Oman implemented the least number of the FCTC measures. Implementing measures related to tobacco prices and eliminating the illicit tobacco trade has slowly progressed in GCC countries. All GCC countries entirely banned smoking in workplaces while three countries implemented a partial ban in restaurants. Only Oman has restrictions on tobacco ads shown in media. There is progress in implementing FCTC measures related to tobacco packaging, cessation, and sale to minors in most GCC countries.

CONCLUSIONS

Given the influence of the tobacco industry in the Gulf region, the findings suggest a need for ongoing surveillance to monitor the proliferation of tobacco control measures and evaluate their effectiveness. Efforts required to address tobacco use should correspond to the unique political and cultural background of the GCC countries.

Cigarette Smoking and Its Financial Burden among Iranian Households: Evidence from Household Income and Expenditures Survey

Background: The financial burden of cigarette smoking on households’ budget is not well documented in Iran. We aimed to identify the determinants of cigarette consumption and its financial burden among households in Iran.

Study design: A cross-sectional study.

Methods: A total of 39,864 Iranian’s households from 31 provinces were included in the analysis. Data on sociodemographic and socioeconomic characteristics (age, sex, household size, education level, employment status, income and wealth index), living area, number of cigarettes smoked and cigarette expenditures for households were extracted from the 2016 Household Income and Expenditures Survey (HIES). Tobit model was used to identify the determinants of cigarette smoking frequency and expenditures among Iranian households.

Results: The average number of cigarettes smoked and cigarettes expenditures by all household members was 85.25 cigarettes and US$ 2.64 per month. Living in urban areas, wealth index of households, household income, household size and low educational attainment of household members were positively associated with frequency and expenditures of cigarette smoking. Results also indicated increasing patterns in the number of cigarettes smoked and cigarettes expenditures from east to west of the country. East Azerbaijan, Hamadan, Markazi and Chaharmahal va Bakhtiari provinces had higher cigarette smoking frequency and expenditures in Iran.

Conclusions: Tobacco control interventions in Iran should focus more on households living in urban areas and low-educated households. As the frequency of cigarette smoking was higher in the western region of Iran, comprehensive tobacco control policies should be adopted in western provinces.

Modeling the impacts of policy measures on resident's PM2.5 reduction behavior: an agent-based simulation analysis

With the rapid economic growth of China, the increasingly serious environmental problems of haze pollution have become a large concern. Urban resident's PM2.5 reduction behavior contributes significantly to Chinese haze pollution control. Resident-level policy measures are beneficial for encouraging residents to engage in PM2.5 reduction behaviors. The current research aims to explore the long-term intervention effects of three types of policies (i.e., command and control policies, economic incentive policies and education-guided policies) on resident's PM2.5 reduction intention and actual behavior. Based on the agent-based modeling and simulation approach, a resident's PM2.5 reduction behavioral simulation model is developed, and data adopted from a questionnaire survey are analyzed. The simulation results show that resident's PM2.5 reduction intention is motivated by the interactions among resident agents, and it eventually stabilizes at a higher level (from 4.11 to 4.48). Moreover, the effects of the three types of policy measures on PM2.5 reduction behavior vary depending on the specific scenarios. With respect to single-policy scenarios, these policies all enhance the actual resident's PM2.5 reduction behavior over the long term. The effects of command and control policies (M = 3.42) and education-guided policies (M = 3.44) are much better than those of the economic incentive policies (M = 3.15). Regarding policy combination scenarios, a combination of economic incentive policies and education-guided policies (M_II = 4.15) has a remarkable promotional effect over others for encouraging residents to conduct PM2.5 reduction behaviors. Based on the results, implications and suggestions for improving current resident-level PM2.5 reduction policies and encouraging resident's PM2.5 reduction behavior are provided.

The global burden of urinary bladder cancer: an update

Bladder cancer is among the top ten most common cancer types in the world, with approximately 550,000 new cases annually. The highest burden of bladder cancer is currently falling on most developed communities across the globe. But with an anticipated shift in world demographics with growing and aging populations mainly on the African continent, and important shifts in exposure to different risk factors across the world, this is likely to change over the next decades. In this review, we provide an overview of the current incidence, mortality, prevalence, survival, risk factors and costs of bladder cancer worldwide.

Awareness, attitudes, and beliefs about music-induced hearing loss: Towards the development of a health communication strategy to promote safe listening

OBJECTIVE

Worldwide, 1.1 billion young people are at risk of developing hearing loss due to unsafe listening. The World Health Organization plans a global health campaign to promote behavior change. In an effort to develop effective evidence-based interventions, this study identifies modifiable factors that influence listening habits.

METHODS

Online survey among 1019 individuals aged 18-35. The questionnaire was based on theories of behavior change.

RESULTS

Individuals not contemplating change showed a lack of knowledge, tended not to feel particularly at risk, and did not see the benefits of preventive measures. Conversely, those considering a change perceived more barriers (e.g., lack of information on how to act,). Self-efficacy was shown to play an ambivalent role.

CONCLUSION

Four factors that can be influenced by a health communication intervention were identified: risk perception, perceived safe listening level due to a lack of symptoms, knowledge, and perceived benefits and barriers, in particular perceived loss of pleasure.

PRACTICE IMPLICATIONS

The first aspects can be influenced through health communication interventions. Influencing the perceived loss of pleasure additionally requires an analysis of competing pressures. To support and not exceedingly burden the individual, we further suggest to address environmental aspects (e.g., policies).

Customers' Perceptions of Compliance with a Tobacco Control Law in Restaurants in Hanoi, Vietnam: A Cross-Sectional Study

The Tobacco Harm Prevention Law has been promulgated in 2012 in Vietnam, prohibiting smoking in public places such as restaurants except for designated smoking areas. However, currently, evidence about Vietnamese customers’ and restaurants’ compliance with the Law is constrained. This study aimed to explore customers’ perceptions; attitudes and practices towards the compliance with tobacco control regulations in the restaurants in Hanoi, Vietnam. A cross-sectional study was performed in October 2015 with 1746 customers in 176 communes in Hanoi, Vietnam. Data about customers’ perceptions on how restaurants comply with the smoking control law and whether customers smoking actively or experienced SHS in restaurants in the last 30 days were collected. Multivariable mixed effects logistic regression model was used to determine the factors related to smoking in the restaurant. Most customers were aware of the law on Tobacco Harm Prevention (79%; n = 1320) and regulations that prohibited smoking in restaurants (78.4%; n = 1137). While 75.8% (n = 1285) of customers perceived that they did not see or rarely saw no-smoking signs, 17.7% (n = 481) of customers reported that they frequently saw direct marketing of tobacco in visited restaurants. About one-fourth of customers witnessed that the staff reminded customers not to smoke inside restaurants (28.8%; n = 313), and 65% (n = 1135) sometimes or always were exposed to secondhand smoke in their visited restaurants. People who were female (OR = 0.02, 95% CI = 0.01⁻0.05) were less likely to report their smoking in the restaurant than their counterparts. Those having higher age (OR = 1.03; 95% CI = 1.01⁻1.06), high school education (OR = 2.14, 95% CI = 1.07⁻4.26), being office workers (OR = 3.24, 95% CI = 1.33⁻7.92) or unemployed (OR = 4.45; 95% CI = 1.09⁻18.15) had a higher likelihood of reporting to be restaurant smokers than those having lower high education or students, respectively. This study highlighted a low level of perceived compliance with the smoke-free law in Vietnamese restaurants. Improving the monitoring systems for the enforcement of the smoking law in restaurants should be prioritized; restaurant owners should implement 100% smoke-free environments as following the best practice towards the tobacco control law along with educational campaigns to promote the awareness of restaurant owners and customers about the tobacco control law.

Health Warnings, Smoking Rules, and Smoking Status: A Cross-National Comparison of Turkey and the United States

OBJECTIVES

This study aimed to compare the prevalence of smoking status (i.e., current, former and never) between the United States and Turkey in terms of age and gender, and examine how smoking rules and health warnings are associated with smoking status within and between the two countries.

METHODS

The study used data from the 2012-2013 National Adult Tobacco Survey (U.S. sample, N = 60,196) and the 2012 Global Adult Tobacco Survey (Turkey sample, N = 9,581). SAS PROC SURVEYLOGISTIC with a weighted variable was used to examine the associations between demographics (age, gender and education), smoking rules, health warnings, and smoking status within and between the two countries.

RESULTS

There was an 18% current smoking prevalence among U.S. sample, compared to 27% of the Turkey sample. The U.S. sample had a higher rate of former smoking compared to the Turkey sample (25% vs. 22%). In both countries, being older and male gender predicted former smoking while being younger and female gender predicted never smoking. Having seen a health warning, and not allowing smoking in the vehicle and home positively predicted former and never smoking status. Higher education predicted both smoking statuses in the U.S. only.

CONCLUSIONS

It is important to work with partners particularly in low- and middle-income countries (e.g., Turkey) to combat the global tobacco epidemic. In both counties, cessation endeavors should emphasize a comprehensive understanding of smoking status in terms of smoking rules in personal spaces and health warnings.

Installation Tobacco Control Programs in the U.S. Military

Tobacco use prevalence is unacceptably high in the U.S. military, and the Department of Defense and service branches have implemented tobacco control policies and cessation programs. To explore aspects of programs regarded as exemplary by their services, we visited four installations, nominated by their service's health promotion leaders, and conducted interviews, observations, and focus groups. Installations included Naval Hospital Guam, Tripler Army Medical Center, MacDill Air Force Base, and the Naval Hospital at Marine Corps Air Ground Combat Center Twentynine Palms. The tobacco control managers (TCMs) at the programs studied were all civilian employees, highly motivated and enthusiastic, and had remained in their positions for approximately a decade. Other commonalities included support from command, a "culture" of health, and location in warm climates. Programs varied in their involvement in establishing designated tobacco use areas, and length and requirement of attending cessation classes; however, no evaluation of cessation programs is currently underway. TCMs should be more engaged in policy discussions for the larger installations they serve. A strong policy framework and command support for TCMs will be necessary to achieve the goal of a tobacco-free military.

Second and Thirdhand Smoke Exposure, Attitudes and Protective Practices: Results from a Survey of Hispanic Residents in Multi-unit Housing

Secondhand and third hand smoke (SHS, THS) exposure is prevalent in multi-unit housing (MUH). Minorities and low-income MUH residents are disproportionally exposed to SHS and THS compared to other populations. This study describes the characteristics, attitudes, knowledge, and behaviors related to SHS, THS and marijuana smoke exposure (MSHS) of a sample of Hispanic tenants in randomly selected MUH units in eastern metro Los Angeles (n = 402). Although most participants (97%) banned smoking inside their homes, 80% reported infiltration of SHS inside their apartments within the last year. Most (85%) favored a complete ban on smoking in apartment buildings. Twenty-eight percent did not know that marijuana (MSHS) smoke exposure is also harmful to their health. Knowledge scores were higher among Spanish-speakers (p < 0.05). Given the interpersonal barriers to advocating for change, widespread policy and communication interventions are also necessary to protect Hispanic MUH residents' rights to clean air in their living space.

Stronger declines in youth alcohol consumption thanks to stronger integrated alcohol policies? A qualitative comparison of ten Dutch municipalities

Background

Little detailed evidence is available on how integrated policies could impact population health and under what conditions such policies could be realized. The aim of this study was to assess how youth alcohol consumption trends in the province of Noord-Brabant, The Netherlands, were related to the development and implementation of integrated policies.

Methods

In a retrospective multiple case study, alcohol policies of six municipalities with stronger declines in youth alcohol consumption between 2007 and 2011 (cases) were compared to four municipalities with weaker declines (controls). Information on the policy process in the same period was obtained through semi-structured in-depth interviews with policy advisors. Information on implemented interventions was extracted from policy documents and checked by the interviewees. Interviews were analyzed for thematic content.

Results

Only municipalities with stronger declines in alcohol consumption involved sectors other than public health and had started to implement interventions that use regulatory or enforcement strategies. Their involvement was facilitated by framing youth alcohol consumption as a safety rather than a health problem, whereby local media played a substantial role. Implementation of integrated policies was further facilitated by dedicated leadership and sufficient resources.

Conclusions

Reductions in youth alcohol consumption in Noord-Brabant were stronger when municipalities started to develop integrated policies. Results suggest that integrated policies framing a health problem as a broader societal problem could positively influence population health.

Age of smoking initiation among adolescents in Africa

OBJECTIVES

To estimate prevalence and identify correlates of age of smoking initiation among adolescents in Africa.

METHODS

Data (n = 16,519) were obtained from nationally representative Global Youth Tobacco Surveys in nine West African countries. Study outcome was adolescents' age of smoking initiation categorized into six groups: ≤7, 8 or 9, 10 or 11, 12 or 13, 14 or 15 and never-smoker. Explanatory variables included sex, parental or peer smoking behavior, exposure to tobacco industry promotions, and knowledge about smoking harm. Weighted multinomial logit models were conducted to determine correlates associated with adolescents' age of smoking initiation.

RESULTS

Age of smoking initiation was as early as ≤7 years; prevalence estimates ranged from 0.7 % in Ghana at 10 or 11 years age to 9.6 % in Cote d'Ivoire at 12 or 13 years age. Males, exposures to parental or peer smoking, and industry promotions were identified as significant correlates.

CONCLUSIONS

West African policymakers should adopt a preventive approach consistent with the World Health Organization Framework Convention on Tobacco Control to prevent an adolescent from initiating smoking and developing into future regular smokers.

Compliance with smoke-free legislation within public buildings: a cross-sectional study in Turkey

Objective

To investigate public compliance with legislation to prohibit smoking within public buildings and the extent of tobacco smoking in outdoor areas in Turkey.

Methods

Using a standardized observation protocol, we determined whether smoking occurred and whether ashtrays, cigarette butts and/or no-smoking signs were present in a random selection of 884 public venues in 12 cities in Turkey. We visited indoor and outdoor locations in bars/nightclubs, cafes, government buildings, hospitals, restaurants, schools, shopping malls, traditional coffee houses and universities. We used logistic regression models to determine the association between the presence of ashtrays or the absence of no-smoking signs and the presence of individuals smoking or cigarette butts.

Findings

Most venues had no-smoking signs (629/884). We observed at least one person smoking in 145 venues, most frequently observed in bars/nightclubs (63/79), hospital dining areas (18/79), traditional coffee houses (27/120) and government-building dining areas (5/23). For 538 venues, we observed outdoor smoking close to public buildings. The presence of ashtrays was positively associated with indoor smoking and cigarette butts, adjusted odds ratio, aOR: 315.9; 95% confidence interval, CI: 174.9–570.8 and aOR: 165.4; 95% CI: 98.0–279.1, respectively. No-smoking signs were negatively associated with the presence of cigarette butts, aOR: 0.5; 95% CI: 0.3–0.8.

Conclusion

Additional efforts are needed to improve the implementation of legislation prohibiting smoking in indoor public areas in Turkey, especially in areas in which we frequently observed people smoking. Possible interventions include removing all ashtrays from public places and increasing the number of no-smoking signs.