Associations between tobacco control policy awareness, social acceptability of smoking and smoking cessation. Findings from the International Tobacco Control (ITC) Europe Surveys

A Qualitative Study of Barriers and Motivators to Prevent Secondhand Smoke Exposure Among Pregnant Women and Children in Egypt: Identifying Appropriate Approaches for Change

INTRODUCTION

The prevalence of daily secondhand smoke (SHS) exposure among pregnant nonsmoking women and children in Egypt is estimated to be about 50% and 55%, respectively. This study aimed to explore barriers to preventing SHS exposure among pregnant women/children and smoking in the home in Egypt.

AIMS AND METHODS

Six focus group discussions with pregnant women or mothers of children residing in urban-rural areas (n = 61) were conducted. Data were managed and analyzed using the Framework Method.

RESULTS

Sixty-one participants aged 18-49 were recruited. They reported being never smokers and SHS exposure for themselves and their children was mainly at home. Pregnant women or mothers had some general knowledge of the dangers of SHS, but their knowledge appeared incomplete. The most commonly reported barriers to preventing SHS exposure/adopting a smoke-free home or workplace were social acceptance of smoking and SHS exposure, masculinity and gender norms of accepting smoking among men as a normative behavior, fear among women of damaging a relationship with family or even divorce, women resigning themselves to SHS exposure, and doctors not being supportive of smoking cessation. The majority of interviewees' families were reported to allow smoking anywhere in the home. Others implemented some measures to prevent SHS; however, these tended to be inconsistently implemented.

CONCLUSIONS

Changing the norm of accepting smoking among men as a normative behavior within Egyptian society and better enforcement of smoke-free policies, will help to protect pregnant women and children from SHS.

IMPLICATIONS

This study suggests promising approaches to support the promotion of smoke-free homes and the prevention of SHS exposure among pregnant women and children in public places in Egypt. Better enforcement of smoke-free policies is needed. Healthcare professionals should support smoking cessation services in primary health centers. SHS policy, practice, and research should focus on husbands/fathers as they are the main source of SHS. There is a need for denormalization of SHS exposure in Egyptian society.

Youth Smoking Behavior and Policy Attitudes: A Study of High-School Students in the Maldives

Background

Tobacco use significantly impacts health and economic sectors. In the Maldives, 4 out of 10 men smoke daily, despite anti-tobacco policies. The Maldives Global Youth Tobacco Survey (GYTS) shows fluctuating cigarette smoking prevalence among secondary school students: 6.9% (2004), 3.8% (2007), 4.3% (2011), and 4.7% (2019). No studies have investigated smoking prevalence and attitudes toward anti-smoking policies among higher-secondary students in Addu City. This study examines smoking habits, susceptibility, and attitudes toward anti-smoking regulations to support policy development.

Methods

We conducted an observational cross-sectional study using a self-administered survey based on the GYTS and the Canadian Student Tobacco, Alcohol and Drugs Survey (CSTADS), involving 335 high school students in Addu City. Variables included sociodemographic factors, ever-smokers, current smokers, age at first cigarette, smoking dependency, use of other tobacco products, smoking susceptibility, willingness to quit, and reasons to quit or not smoke. Results with p-values < 0.05 were statistically significant.

Results

22.8% of the students had tried smoking, with 4.74% currently smoking, predominantly males. Additionally, 32.2% had tried e-cigarettes. Smoking susceptibility was 44.2%. Seven students showed smoking dependency, with a significant gender difference (75.4% boys vs 33.3% girls, p < 0.05). Among smokers, 20% wanted to quit, and 70% cited cost as a deterrent. Only 20% of smokers supported a total ban on smoking in media compared to 49.8% of non-smokers (p = 0.03). Non-smokers significantly supported anti-smoking measures (73% vs 12.5% of smokers).

Conclusion

Cigarette smoking among high school students in Addu is below the national average, but the high number of ever-smokers and interest in smoking and e-cigarettes suggest potential future increases. Policymakers should enact stronger legislation, enforce age restrictions, raise tobacco taxes, and implement comprehensive smoking cessation programs to address tobacco use effectively.

Re-assessing the social climate of physical (in)activity in Canada

Social-ecological models suggest that a strategy for increasing population physical activity participation is to reconstruct the "social climate" through changing social norms and beliefs about physical activity (PA). In this study, we assessed whether the PA social climate in Canada has changed over a five-year period after controlling for sociodemographic factors and PA levels. Replicating a survey administered in 2018, a sample of adults in Canada (n = 2,507) completed an online survey assessing social climate dimensions, including but not limited to descriptive and injunctive norms. Descriptive statistics were calculated, and binary logistic regressions were conducted to assess the associations of sociodemographic factors and year of the survey with social climate dimensions. Results suggest some social climate constructs are trending in a positive direction between 2018 and 2023. Physical inactivity was considered a serious public health concern by 49% of respondents, second to unhealthy diets (52%). Compared to those who participated in the 2018 survey, participants in 2023 were less likely to see others walking or wheeling in their neighbourhood (OR = 1.58, 95% CI: 1.41, 1.78), but more likely to see people exercising (OR = 0.82, 95% CI: 0.73, 0.92) and kids playing in their neighbourhood (OR = 0.75, 95% CI: 0.66, 0.85). No changes were reported between 2018 and 2023 in individuals' perceptions of whether physical inactivity is due to individual versus external factors (OR = 0.99, 95% CI: 0.87, 1.13). The findings of this work indicate a modest positive shift in some measured components of the social climate surrounding PA although attributing causes for these changes remain speculative.

Quality of service and commitment to tobacco dependence treatment for individuals living with mental disorders in France: A pilot study

BACKGROUND

There are remarkably high smoking rates in patients living with mental disorders (PLWMD), and the absence of a specific treatment policy for smoking cessation for these patients worldwide. The present study aimed to (i) investigate the quality of service and commitment to tobacco dependence treatment, and (ii) produce high-quality French versions of the Index of Tobacco Treatment Quality (ITTQ) and Tobacco Treatment Commitment Scale (TTCS).

METHODS

ITTQ and TTCS were used to assess French mental health professionals (n = 80). Both scales were translated from their original language following standard procedures (i.e. forward translation). Descriptive analysis for total score, each factor and item were calculated for the entire sample, followed by subgroup analysis by gender, and role of the practitioner.

RESULTS

Nurses presented higher levels of both treatment commitment and treatment quality in their mental health care units, compared to psychiatrists, and residents. Overall, counseling offering was low and there was a perception that it is unfair to take tobacco away from PLWMD. In the other hand, there were high levels of smoking assessment and perceptions that nicotine dependence should be included in drug treatment programs.

CONCLUSIONS

There is a gap in tobacco treatment implementation for French PLWMD. The present pilot study alerts about the problem, and should stimulate larger studies validating such measures for wide use with French-speaking mental health professionals. French nurses presented higher levels of both treatment commitment and quality, and could be in a leadership position for such implementation. Encouraging the implementation of tobacco counseling within conventional mental health treatment is critical to improve cessation rates among this population. There is a potential for the sustainability of tobacco treatment interventions since the levels of commitment observed here were higher than in previous studies conducted abroad.

Examining pathways between family or peer factors and smoking cessation in a nationally representative US sample of adults with mental health conditions who smoke: a structural equation analysis

Background

Supportive family or peer behaviors positively impact smoking cessation in people with mental health problems who smoke. However, the limited understanding of the pathways through which family or peer factors impact quitting limits the development of effective support interventions. This study examined pathways through which family or peer views on tobacco use, family or peer smoking status, and rules against smoking in the home influenced quitting in adults with mental health problems who smoke.

Methods

We used data from the Population Assessment of Tobacco and Health Study, a national longitudinal survey. Baseline data were collected in 2015, and follow-up data in 2016. We included adults’ current smokers who had experienced two or more mental health symptoms in the past year (unweighted n = 4201). Structural equation modeling was used to test the relationships between family and peer factors, mediating factors, and smoking cessation.

Results

We found that having family or peers with negative views on tobacco use had a positive indirect effect on smoking cessation, mediated through the individual’s intention to quit (regression coefficient: 0.19) and the use of evidence-based approaches during their past year quit attempt (regression coefficient: 0.32). Having rules against smoking in the home (regression coefficient: 0.33) and having non-smoking family members or peers (regression coefficient: 0.11) had a positive indirect effect on smoking cessation, mediated through smoking behaviors (regression coefficient: 0.36). All paths were statistically significant (p <  0.01). The model explained 20% of the variability in smoking outcomes.

Conclusion

Family or peer-based cessation interventions that systematically increase intentions to quit and monitor smoking behavior may be able to assess the efficacy of family and peer support on quitting in people with mental health problems who smoke.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-13979-z.

Awareness of tobacco control policies and anti-tobacco attitudes and behaviors among school personnel

INTRODUCTION

Adolescent smoking is a serious public health concern, and the role of personnel in reducing students’tobacco use has been proven. Anti-tobacco policies are strong factors for tobacco control but most are newly implemented in China. This study aimed to examine the awareness of anti-tobacco policies among school personnel in a southern city of China, and assess its influence on personnel’s anti-tobacco attitudes and behaviors towards students.

METHODS

An online cross-sectional study was conducted between September 2017 and January 2018 in schools of Shanghai, China. A total of 3194 subjects from 33 schools were selected by a two-stage stratified cluster randomized sampling design. Prevalence of anti-tobacco policy awareness is presented. Crude (ORs) and adjusted odds ratios (AORs) and their 95% confidence intervals (CIs) were estimated to assess the association between policy awareness and anti-tobacco attitudes or behaviors.

RESULTS

In all, 22.4% of surveyed participants knew four or five polices presented in the survey and 13.0% of personnel knew none of these policies. Most of the participants fully support prohibiting indoor (94.6%) and outdoor (86.3%) smoking in public places, bans on tobacco advertising (90.9%), and printing warning pictures on cigarette boxes (89.5%). Less than half of the personnel had taken action to stop students from smoking (45.7%), encourage students to quit smoking (42.4%) or participated in relevant educational activities held by schools (37.4%) in the previous year. The school personnel’s anti-tobacco attitudes (AOR=1.28; 95% CI: 1.21–1.36) and behaviors (AOR=1.10; 95% CI: 1.03–1.17) were strengthened with increasing level of policy awareness.

CONCLUSIONS

The involvement of school personnel can be an important part of intervention to improve anti-tobacco campaigns on campus. The study calls for the implementation of projects or activities to improve anti-tobacco policy awareness in the school environment as part of school tobacco control strategy.

Youth susceptibility to tobacco use in the Gulf Cooperation Council Countries, 2001–2018

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Analysis of the susceptibility to initiating tobacco use identifies youth at higher risk of initiating tobacco.

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Susceptibility to initiate tobacco use in increased in the United Arab Emirates while decreased in Bahrain and Qatar.

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FCTC may have an independent impact on initiating tobacco use among youth.

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The study helps policymakers identify impactful policies and prioritize resources accordingly.

The Gulf Cooperation Council (GCC) countries – Bahrain, Kuwait, Oman, Qatar, Saudi Arabia, and the United Arab Emirates (UAE) – ratified the Framework Convention on Tobacco Control (FCTC) in 2006. Yet, GCC countries predict a slight reduction in tobacco use compared to the Eastern Mediterranean region’s significant downward trend. The purpose of this study was to examine changes in self-reported intention to initiating tobacco use (susceptibility) among youth over time in five GCC countries and the relationship between susceptibility and key FCTC provisions. Complex sample logistic regression analyses were conducted using data from the 2001 to 2018 Global Youth Tobacco Survey (n = 349,878 adolescents). Since the ratification of FCTC in GCC countries, susceptibility to initiate tobacco use significantly decreased in Bahrain and Qatar while it increased in UAE (P < 0.001). Exposure to smoking in public places increased the odds of susceptibility to tobacco use in Bahrain (AOR = 1.6, 95% CI = [1.2–2.2), Kuwait (AOR = 1.6, 95% CI = [1.2–2.0]), Qatar (AOR = 1.9, 95% CI = [1.4–2.6]), and UAE (AOR = 2.1, 95% CI = [1.6–2.7]). Susceptibility to tobacco use was significantly associated with exposure to tobacco imagery in media in the UAE (AOR = 1.7, 95% CI = [1.2–2.3]) and with tobacco industry activities like promotion in Bahrain (AOR = 2.8, 95% CI = [1.9–4.2]) and Kuwait (AOR = 2.2, 95% CI = [1.5–3.1]). In conclusion, the impact of FCTC provisions on tobacco use differs across countries. Findings suggested that the implementation of tobacco control policies may independently influence the initiation of tobacco use.

Compliance with the smoke-free public places legislation in Nepal: A cross-sectional study from Biratnagar Metropolitan City

Background

Smoke-free legislation banning tobacco smoking in public places was implemented across Nepal in 2014 with the ambition to reduce the impact of second-hand smoking. As part of a comprehensive policy package on tobacco control, the implementation of the legislation has seen a marked reduction in tobacco consumption. Yet there remains uncertainty about the level of compliance with smoke-free public places.

Objectives

This study assesses the compliance with smoke-free laws in public places and the factors associated with active smoking in public places in Biratnagar Metropolitan City, Nepal.

Methods

A cross-sectional study was conducted in the Biratnagar metropolitan city in Province 1 of Nepal from July to December 2019. A total of 725 public places within the metropolitan city were surveyed using a structured survey tool. Active smoking was the primary outcome of the study which was defined as smoking by any person during the data collection time at the designated public place.

Results

The overall compliance with smoke-free legislation was 56.4%. The highest compliance (75.0%) was observed in Government office buildings. The lowest compliance was observed in eateries, entertainment, and shopping venues (26.3%). There was a statistically significant association between active smoking and the presence of ‘no smoking’ notices appended at the entrance and the odds of active smoking in eateries, entertainment, hospitality, shopping venues, transportations and transits was higher compared to education and health care institutions. None of the ‘no smoking’ notices displayed fully adhered to the contents as prescribed by the law.

Conclusion

As more than half of the public places complied with the requirements of the legislation, there was satisfactory overall compliance with the smoke-free public places law in this study. The public venues (eateries, shopping venues and transportations) that are more frequently visited and have a high turnover of the public have lower compliance with the legislation. The content of the message in the ‘no smoking’ notices needs close attention to adhere to the legal requirements.

Do Longitudinal Trends in Tobacco 21-Related Media Coverage Correlate with Policy Support? an Exploratory Analysis Using Supervised and Unsupervised Machine Learning Methods

Media coverage can impact support for health policies and, ultimately, compliance with those policies. Prior research found consistent, high support for Tobacco 21 policies, which raise the minimum legal age of tobacco purchase to 21, among adults and nonsmoking youth. However, a recent study found support (i.e., agreement with the statement: "The legal age to buy tobacco cigarettes should be increased from 18 to 21") among 13-20-year-old smokers increased from 2014 until mid-2016 and then declined steadily through mid-2017. To assess whether media coverage could be related to young smokers' changing support, we conducted an exploratory content analysis to identify texts about Tobacco 21 in a large corpus of tobacco texts (N = 135,691) published in four popular media sources from 2014 to 2017. For this content analysis, we developed a novel methodological approach that combined supervised and unsupervised machine learning methods and could be useful in other areas of communication research. We found that the prevalence of Tobacco 21 media coverage and Tobacco 21 support among young smokers exhibited similar temporal patterns for much of the study period. These findings highlight the need for continued research into the effects of media coverage on Tobacco 21 support among young smokers, a group that must comply with Tobacco 21 policies in order to ensure maximum effectiveness. This research is of particular utility following the 2019 passage of a federal Tobacco 21 regulation, as the public health impact of this regulation could be limited by low public support, and thus low rates of policy compliance.

Effect of smoke-free policies in outdoor areas and private places on children's tobacco smoke exposure and respiratory health: a systematic review and meta-analysis

BACKGROUND

Smoke-free policies in outdoor areas and semi-private and private places (eg, cars) might reduce the health harms caused by tobacco smoke exposure (TSE). We aimed to investigate the effect of smoke-free policies covering outdoor areas or semi-private and private places on TSE and respiratory health in children, to inform policy.

METHODS

In this systematic review and meta-analysis, we searched 13 electronic databases from date of inception to Jan 29, 2021, for published studies that assessed the effects of smoke-free policies in outdoor areas or semi-private or private places on TSE, respiratory health outcomes, or both, in children. Non-randomised and randomised trials, interrupted time series, and controlled before-after studies, without restrictions to the observational period, publication date, or language, were eligible for the main analysis. Two reviewers independently extracted data, including adjusted test statistics from each study using a prespecified form, and assessed risk of bias for effect estimates from each study using the Risk of Bias in Non-Randomised Studies of Interventions tool. Primary outcomes were TSE in places covered by the policy, unplanned hospital attendance for wheezing or asthma, and unplanned hospital attendance for respiratory tract infections, in children younger than 17 years. Random-effects meta-analyses were done when at least two studies evaluated policies that regulated smoking in similar places and reported on the same outcome. This study is registered with PROSPERO, CRD42020190563.

FINDINGS

We identified 5745 records and assessed 204 full-text articles for eligibility, of which 11 studies met the inclusion criteria and were included in the qualitative synthesis. Of these studies, seven fit prespecified robustness criteria as recommended by the Cochrane Effective Practice and Organization of Care group, assessing smoke-free cars (n=5), schools (n=1), and a comprehensive policy covering multiple areas (n=1). Risk of bias was low in three studies, moderate in three, and critical in one. In the meta-analysis of ten effect estimates from four studies, smoke-free car policies were associated with an immediate TSE reduction in cars (risk ratio 0·69, 95% CI 0·55-0·87; 161 466 participants); heterogeneity was substantial (I² 80·7%; p<0·0001). One additional study reported a gradual TSE decrease in cars annually. Individual studies found TSE reductions on school grounds, following a smoke-free school policy, and in hospital attendances for respiratory tract infection, following a comprehensive smoke-free policy.

INTERPRETATION

Smoke-free car policies are associated with reductions in reported child TSE in cars, which could translate into respiratory health benefits. Few additional studies assessed the effect of policies regulating smoking in outdoor areas and semi-private and private places on children's TSE or health outcomes. On the basis of these findings, governments should consider including private cars in comprehensive smoke-free policies to protect child health.

FUNDING

Dutch Heart Foundation, Lung Foundation Netherlands, Dutch Cancer Society, Dutch Diabetes Research Foundation, Netherlands Thrombosis Foundation, and Health Data Research UK.

Evaluating the impact of introducing standardized packaging with larger health-warning labels in England: findings from adult smokers within the EUREST-PLUS ITC Europe Surveys

BACKGROUND

The European (EU) Tobacco Product Directive (TPD) was implemented in May 2016 to regulate the design and labelling of cigarettes and roll-your-own tobacco. At the same time, the UK introduced standardized packaging measures, whereas Germany, Greece, Hungary, Poland, Romania and Spain did not. This study examines the impact of introducing standardized packaging in England using a quasi-experimental design.

METHODS

Data from adult smokers in Waves 1 (2016; N=9547) and 2 (2018; N=9724) from the International Tobacco Control Policy Evaluation surveys (England) and EUREST-PLUS surveys (Germany, Greece, Hungary, Poland, Romania and Spain) were used. Generalized estimating equations were used to estimate changes in pack/brand appeal, salience of health-warning labels (HWLs) and perceived relative harm of different brands in England (where larger HWLs and standardized packaging were implemented), vs. each EU country (where only larger HWLs were implemented).

RESULTS

There was an increase in the percentage of respondents from Germany, Hungary and Poland reporting they did not like the look of the pack (4.7%, 9.6%, and 14.2%, respectively), but the largest increase was in England (41.0%). Moreover, there was a statistically significant increase in the salience of HWLs in Hungary, Poland and Romania (17.0%, 13.9%, and 15.3%, respectively), but the largest increase was in England (27.6%). Few differences were observed in cross-country comparisons of the perceived relative harm of different brands.

CONCLUSIONS

Findings suggest that standardized packaging reduces pack appeal and enhances the salience of HWLs over and above the effects of larger HWLs. Findings provide additional evidence and support for incorporating standardized packaging into the EU TPD.

Are anti-smoking social norms associated with tobacco control mass media campaigns, tax and policy changes? Findings from an Australian serial cross-sectional population study of smokers

BACKGROUND

Anti-smoking social norms are associated with subsequent quitting behaviours. We examined if exposure to tobacco control advertisements and policy changes predict subjective (perceived disapproval of smoking among close family and friends) and internalised injunctive norms (embarrassed about telling others you are a smoker).

METHODS

A serial cross-sectional population survey of Australian adult smokers (n=6649; 2012 to 2015). Logistic regression analyses examined associations of social norms with exposure to different types of tobacco control advertisements, tax increases and other tobacco control policies, adjusting for key demographic, smoking and media exposure covariates. Interaction analyses examined differences by age and socioeconomic status (SES).

RESULTS

Greater past month exposure to predominantly fear-evoking advertisements was associated with increased odds of perceiving disapproval (per 1000 gross rating points: adjusted OR (AOR) 2.69, 95% CI: 1.34 to 5.39), while exposure to advertisements evoking multiple negative emotions (fear, guilt, sadness) reduced perceived disapproval (AOR 0.61, 95% CI: 0.42 to 0.87). Increased perceived disapproval was also associated with anticipation (AOR 1.38, 95% CI: 1.02 to 1.88), and implementation of a series of annual 12.5% tobacco tax rises (AOR 1.41, 95% CI: 1.03 to 1.94). Associations were consistent across age and SES. There were no associations nor subgroup interactions between advertisement exposure or policy changes and feeling embarrassed about telling others you are a smoker.

CONCLUSION

Smokers' perceptions of family and friends' disapproval of their smoking was more common after exposure to fear-evoking tobacco control campaigns and after large tobacco tax increases were announced and implemented.

A comparison of self-reported to cotinine-detected smoking status among adults in Georgia

BACKGROUND

Self-reported measures of tobacco use may have limited validity, particularly among some populations. This study aims to validate self-reported smoking measures among Georgian adults participating in the 2016 STEPS survey using cotinine biomarker measurements, and to explore potential differences according to sociodemographic characteristics. Additionally, this paper examines how the estimated prevalence of smoking in the population varies according to measurement type.

METHODS

Using the WHO standardized STEPS methodology, adults self-reported their smoking status. In a later stage of the survey, a subset of participants provided a urine sample, which was tested for cotinine. Using each participant's objective cotinine measurement and their self-reported smoking status, we calculated the sensitivity, specificity and positive predictive value of self-reported smoking. Next, we calculated the estimated prevalence of smokers according to the type of measurement.

RESULTS

Results indicated high sensitivity (83.37%, 95% CI: 76.79-88.37%) among males and relatively low sensitivity (38.60% CI: 29.23-48.90%) among females. According to self-report, the prevalence of smokers was 26.44% (23.61-29.48%), while according to cotinine detection, the prevalence of smokers was 32.27% (29.16-35.55%). Among all subgroups, the self-reported prevalence of smoking was significantly lower than the cotinine-detected prevalence.

CONCLUSIONS

To the best of our knowledge, this is the first time that the validity of the STEPS self-reported tobacco indicator has been tested. Self-reported measures of smoking status may lead to an under-estimation of smoking prevalence among Georgian adults, especially women. These findings suggest that integration of biochemical measures of smoking into tobacco use studies may be an important investment.

Implementation of smoke-free law in Denpasar Bali: Between compliance and social norms of smoking

Background: Since 2013, City of Denpasar government has adopted a smoke-free law. Implementation of the law faces several obstacles, partly due to the high social acceptability of smoking in the city, where cigarette and smoking has been deeply engrained within social life and become part of hospitality. This study aims to assess the smoke-free law compliance and to explore the social norms that may affect the compliance. Design and Methods: The study was a mix of cross-sectional compliance survey and qualitative exploration conducted in Denpasar in 2019. Survey included 538 samples, which were selected using stratified random sampling and a walking protocol. The qualitative data was collected through in-depth interviews and Focus Group Discussion (FGD) in four sub-districts of Denpasar. Results: Of the 538 venues, 32.9% complied with the seven compliance indicators. The university has the highest compliance (83.3%), while public places including worship places have a low compliance. The three most common violations were the absence of no-smoking signage (58.6%), provision of ashtray (17.5%), and smell of tobacco smoke (15.8%). The poor compliance was related to the lack of awareness of the regulation, and the fact that smoking is highly acceptable and part of the culture. The informants highlighted the essential role of public figures and potency of local policy as social disapproval of smoking. Conclusions: Compliance to the smoke-free law in Denpasar remains low, continuous education, socialization and improved supervision are crucial. Meanwhile, social and cultural acceptance of smoking is considered as an essential factor that hampers the implementation of the smoke free law.

The role of social norms in the relationship between anti-smoking advertising campaigns and smoking cessation: a scoping review

A systematic scoping review of anti-smoking mass media campaign literature provided opportunity to explore how social normative theories and constructs are used to influence smoking cessation. Synthesis of findings was constrained by significant heterogeneity. Nevertheless, the results indicate that a broader conceptualization of social norm is worthy of further exploration. Perceptions of what others think and do contributed in multiple ways to the relationship between anti-smoking messaging and quitting outcomes. Furthermore, integrating research on social norms, social identity and communication may improve understanding of why quitting intentions are enhanced in some circumstances but reactance and counter-arguing responses corresponding to lower quitting intentions occur in others. Integrating a broader theoretical understanding of normative influences into campaign development and evaluation may prove useful in demonstrating the effectiveness of this approach in behaviour change campaigns.

A cross-sectional study of the relationship of proximal smoking environments and cessation history, plans, and self-efficacy among low-income smokers

Introduction

Proximal environments could facilitate smoking cessation among low-income smokers by making cessation appealing to strive for and tenable.

Aims

We sought to examine how home smoking rules and proximal environmental factors such as other household members' and peers' smoking behaviors and attitudes related to low-income smokers' past quit attempts, readiness, and self-efficacy to quit.

Methods

This analysis used data from Offering Proactive Treatment Intervention (OPT-IN) (randomized control trial of proactive tobacco cessation outreach) baseline survey, which was completed by 2,406 participants in 2011/12. We tested the associations between predictors (home smoking rules and proximal environmental factors) and outcomes (past-year quit attempts, readiness to quit, and quitting self-efficacy).

Results

Smokers who lived in homes with more restrictive household smoking rules, and/or reported having 'important others' who would be supportive of their quitting, were more likely to report having made a quit attempt in the past year, had greater readiness to quit, and greater self-efficacy related to quitting.

Conclusions

Adjustments to proximal environments, including strengthening household smoking rules, might encourage cessation even if other household members are smokers.

Anti-smoking social norms are associated with increased cessation behaviours among lower and higher socioeconomic status smokers: A population-based cohort study

BACKGROUND

Social denormalisation of smoking can provide an environment that helps smokers to quit. This study examined which of three measures of anti-smoking social norms have the greatest influence on quitting-related cognitions and behaviours, and if this influence differs according to socioeconomic status (SES).

METHODS

The Victorian Tracking Survey measured social norms among 1,348 (n(weighted) = 1,373) Australian adult smokers (aged 18-59) between 2012 and 2014, who were followed-up one week later. Weighted logistic regression analyses examined prospective associations of baseline subjective (family and friends' disapproval of smoking), injunctive (feeling embarrassed about being a smoker) and descriptive norms (living with someone who tried to quit in the past 12 months), with quitting-related cognitions and behaviours at follow-up. Data were weighted to account for telephony status (landline or mobile phone), sex and age. Analyses were adjusted for demographic characteristics, addiction level, tobacco control policies and quitting-related outcomes measured at baseline. Differences in associations between lower and higher SES smokers (based on educational attainment and area-based disadvantage) were examined through interaction terms and stratified analyses.

RESULTS

Sixty-four percent of participants (n(weighted) = 872) perceived disapproval from family and friends, 31% (n(weighted) = 419) felt embarrassed to be a smoker, and 11% (n(weighted) = 155) lived with a recent quitter. All three norms were associated with having set a firm date to quit in the next month and with engaging in smoking limiting behaviours. Embarrassment was also associated with an increased likelihood of talking about quitting and with making a quit attempt. Associations were mostly comparable for lower and higher SES smokers, with no significant negative rebound effects overall or among subgroups.

CONCLUSIONS

These findings indicate close others' disapproval and feelings of embarrassment most strongly motivate smokers to try to quit. If tobacco control policies or media campaigns further denormalise smoking, there should be no reason for concern that such denormalisation undermines cessation behaviours.

Assessing the social climate of physical (in)activity in Canada

BACKGROUND

Ecological models suggest that a strategy for increasing physical activity participation within a population is to reconstruct the "social climate". This can be accomplished through 1) changing norms and beliefs, 2) providing direct support for modifying environments, and 3) implementing policies to encourage physical activity. Nevertheless, surveillance efforts have paid limited attention to empirical assessment of social climate. This study responds to this gap by assessing the social climate of physical activity in Canada.

METHODS

A representative sample of Canadian adults (n = 2519, male/female = 50.3%/49.7%, Mage = 49.1 ± 16.3 years) completed an online survey asking them to assess social climate dimensions including social norms of physical (in)activity, perceptions of who causes physical inactivity and who is responsible for solving physical inactivity, and support for physical activity-related policy. Descriptive statistics (frequencies) were calculated. Multinomial logistic regressions were constructed to identify whether demographic variables and physical activity participation associated with social climate dimensions.

RESULTS

Physical inactivity was considered a serious public health concern by 55% of the respondents; similar to unhealthy diets (58%) and tobacco use (57%). Thirty-nine percent of the respondents reported that they often see other people exercising. Twenty-eight percent of the sample believed that society disapproves of physical inactivity. The majority of respondents (63%) viewed the cause of physical inactivity as both an individual responsibility and other factors beyond an individuals' control. Sixty-seven percent of respondents reported physical inactivity as being both a private matter and a public health matter. Strong support existed for environmental-, individual-, and economic-level policies but much less for legislative approaches. The social climate indicators were associated with respondents' level of physical activity participation and demographic variables in expected directions.

CONCLUSION

This study is the first known attempt to assess social climate at a national level, addressing an important gap in knowledge related to advocating for, and implementing population-level physical activity interventions. Future tracking will be needed to identify any temporal (in)stability of these constructs over time and to explore the relationship between physical activity participation and indicators of the national social climate of physical activity.

Cigarette tax rates, behavioral disengagement, and quit ratios among daily smokers

Cigarette taxation is an economics-based policy associated with increased population-level quit ratios. However, the estimated effects of tax increase on smoking behavior vary substantially, underscoring the need to identify moderating variables. We examined whether behavioral disengagement - the tendency to abandon goals when experiencing stress - modified the association between cigarette taxes and daily smoking behavior. We connected state-level cigarette tax rate data with individual-level behavioral data, including a national sample of 725 US adults who smoked daily at baseline and reported follow-up data approximately 10 years later, and 376 who were resampled a third time after another 10 years. Analyses involved multilevel logistic regression (with time as a nested variable and anonymized state codes as a grouping variable), where current smoking status (dichotomous) was regressed on behavioral disengagement, state-level cigarette tax at baseline and current time, and the interaction between disengagement and current tax. Consistent with hypotheses, tax rate interacted with disengagement (OR=0.95, 95% CI=0.90,0.99, p=.0255): Among those one SD above the mean for disengagement, tax rate was unassociated with quit ratio (OR=0.99, 95% CI=0.85,1.16, p=.6975). However, among those one SD below the mean, tax rate was significantly associated with higher quit ratio (OR=1.22, 95% CI=1.04,1.43, p=.0163). Our data suggest the possibility that cigarette taxes may be more effective in facilitating cessation among smokers low in behavioral disengagement or when accompanied by interventions that reduce stress or maintain goal pursuit. Identifying psychological moderators of policy effectiveness holds promise for improving policy design and targeting.

Awareness About Anti-Smoking Related Laws and Legislation Among General Population in Slums of Delhi, India

Introduction

Almost 40% of Delhi's population lives in slums and is vulnerable to tobacco use. It is therefore important to assess their opinion and ensure compliance to antismoking legislation. The present study was undertaken to assess the awareness of the general public residing in slums in Delhi regarding the smoke-free initiative of 2009, 3 years after intensive implementation.

Methods

It was a cross-sectional study conducted among participants selected by cluster sampling from the slums in six districts of Delhi using a pretested semistructured questionnaire. A total of 708 slum dwellers were interviewed.

Results

Out of the total, only 16.1% (n = 114) of the participants had heard of The Cigarettes and Other Tobacco Products (Prohibition of Advertisement and Regulation of Trade and Commerce, Production, Supply and Distribution) Act, 2003 (COTPA), though, they were aware about some of the provisions of the COTPA. Majority (n = 529; 74.7%) perceived the smoke-free zones as the places where smoking forms of tobacco are banned. Regarding the awareness about the places designated as smoke-free zones, 82.1% (n = 581) of the respondents named educational institutions. About 61% of the people interviewed reported to have seen people smoking at public places on the day of interview while only 21.5% reported to have seen any one getting punished for smoking.

Conclusions

Awareness about COTPA was low. The study respondents perceived that no action was being taken against persons acting in violation of the law. Thus, there is a need for stricter implementation of COTPA and increased spreading of awareness among the general public.

Implications

While awareness about antismoking legislation among general population (particularly slums) has been studied world over, this has not been the case in India. The study depicts opinion of one of the susceptible populations regarding tobacco control legislation, which has hitherto not been studied in the Indian context. This study has an important implication as it highlights the need for stringent enforcement of antismoking legislation for tobacco control.

The Association of Exposure to Point-of-Sale Tobacco Marketing with Quit Attempt and Quit Success: Results from a Prospective Study of Smokers in the United States

The aim was to assess the association of exposure to point-of-sale (POS) tobacco marketing with quit attempt and quit success in a prospective study of smokers in the United States. Data were collected via telephone-interview on exposure to POS tobacco marketing, sociodemographic and smoking-related variables from 999 smokers in Omaha, Nebraska, in the United States. Exposure to POS tobacco marketing was measured by asking respondents three questions about noticing pack displays, advertisements, and promotions in their respective neighborhoods stores. These three variables were combined into a scale of exposure to POS tobacco marketing. About 68% of the respondents participated in a six-month follow-up phone interview and provided data on quit attempts and smoking cessation. At the six-month follow-up, 39.9% of respondents reported to have made a quit attempt, and 21.8% of those who made a quit attempt succeeded in quitting. Exposure to POS marketing at baseline was not associated with the probability of having made a quit attempt as reported at the six-month follow-up (p = 0.129). However, higher exposure to POS marketing was associated with a lower probability of quit success among smokers who reported to have attempted to quit smoking at six-month follow-up (p = 0.006). Exposure to POS tobacco marketing is associated with lower chances of successfully quitting smoking. Policies that reduce the amount of exposure to POS marketing might result in higher smoking cessation rates.

Who smokes in smoke-free public places in China? Findings from a 21 city survey

Efforts toward controlling secondhand smoke in public places have been made throughout China. However, in contrast to the western world, significant challenges remain for effectively implementing smoke-free regulations. This study explores individual and regional factors which influence smoking in smoke-free public places. Participants included 16 866 urban residents, who were identified through multi-stage sampling conducted in 21 Chinese cities. The reported smoking prevalence in smoke-free public places was 41.2%. Of those who smoked in smoke-free public places, 45.9% had been advised to stop smoking. Participants stated that no-smoking warnings/signs with 'please' in the statement had a better likelihood of gaining compliance and preventing smoking in public spaces. Multilevel logistic regression analysis showed that ethnicity, education, occupation, type of smoking, age of smoking initiation, smoking situation, stress, household smoking restrictions and city population were all associated with smoking in smoke-free public places. Interestingly local smoke-free regulations were not associated with smoking in public places. The findings underscore that efforts to restrict smoking in public places in China should emphasize strong enforcement, while simultaneously raising public awareness of the perils of second hand smoke.

Association of Cigarette Prices with the Prevalence of Smoking in Korean University Students: Analysis of Effects of the Tobacco Control Policy

BACKGROUND

Increased pricing of cigarettes might be one of the most effective approaches for reducing the prevalence of smoking. This study aimed to investigate the effects of increasing cigarette prices through taxation by a tobacco intervention policy on the changes in smoking prevalence in Korean university students.

MATERIALS AND METHODS

The participants in this study were 23,047 healthy university students aged 18-29 years from a health examination in 2011-2015. We investigated the adjusted prevalence of daily and occasional smoking before and after increasing cigarette prices through taxation.

RESULTS

The prevalence of occasional smoking was significantly decreased in 2015 from 2014 in both male (from 10.7% in 2014 to 5.4%) and female (from 3.6% to 1.1%) students, but the prevalence of daily smoking did not decrease significantly. The frequency of individuals who had attempted smoking cessation during the past year was significantly higher among occasional smokers in male students (90.2%) compared with daily smokers (64.9%). For female students, there were no differences in experience of smoking cessation, willingness for smoking cessation, or E-cigarette experience between daily and occasional smokers.

CONCLUSIONS

We found that a policy of increasing cigarette prices through taxation is associated with decreases in the prevalence of occasional smokers, who have relatively lower nicotine dependence compared with individuals who smoke daily. The results of our study suggest that social support and direct intervention for smoking cessation at the community level are needed for university students alongside the pricing policy.

Recall of anti-tobacco advertising and information, warning labels and news stories in a national sample of Aboriginal and Torres Strait Islander smokers

OBJECTIVES

To describe recall of anti-tobacco advertising (mainstream and targeted), pack warning labels, and news stories among a national sample of Aboriginal and Torres Strait Islander smokers, and to assess the association of these messages with attitudes that support quitting, including wanting to quit.

DESIGN, SETTING AND PARTICIPANTS

A quota sampling design was used to recruit participants from communities served by 34 Aboriginal community-controlled health services and one community in the Torres Strait. We surveyed 1643 Aboriginal and Torres Strait Islander smokers from April 2012 to October 2013.

MAIN OUTCOME MEASURES

Frequency of recall of advertising and information, warning labels and news stories; recall of targeted and local advertising; attitudes about smoking and wanting to quit.

RESULTS

More smokers recalled often noticing warning labels in the past month (65%) than recalled advertising and information (45%) or news stories (24%) in the past 6 months. When prompted, most (82%) recalled seeing a television advertisement. Just under half (48%) recalled advertising that featured an Aboriginal or Torres Strait Islander person or artwork (targeted advertising), and 16% recalled targeted advertising from their community (local advertising). Frequent recall of warning labels, news stories and advertising was associated with worry about health and wanting to quit, but only frequent advertising recall was associated with believing that society disapproves of smoking. The magnitude of association with relevant attitudes and wanting to quit increased for targeted and local advertising.

CONCLUSIONS

Strategies to tackle Aboriginal and Torres Strait Islander smoking should sustain high levels of exposure to anti-tobacco advertising, news stories and warning labels. More targeted and local information may be particularly effective to influence relevant beliefs and subsequently increase quitting.

Awareness and support for anti-tobacco policies among health professional students in Pakistan: findings from the Global Health Professional Students Survey, 2011

Background

Health professional (HP) students may have an important role in controlling future tobacco use of their patients, and public at large. It is important to understand their existing level of awareness and support for national anti-tobacco policies. We thus aim to explore Pakistani HP students’ existing attitudes towards national anti-tobacco policy and examine factors associated with lack of awareness, and support amongst them.

Methods

Secondary data analysis of the Global Health Professional Students Survey, Pakistan, 2011 was performed. Study population included 4,235 health professional students enrolled in third year of graduate level HP programs. The policy support metrics were developed using six questions from the survey. Univariate and multivariate analyses were conducted to analyze association between HP students’ awareness, and support for anti-tobacco policy (outcome variables), and various socio-demographic, attitudinal, and knowledge related factors. Descriptive statistics are reported as proportions, and results of logistic regression analysis were reported as odds ratios with 95% confidence interval.

Results

Overall, among HP students, 10.8% (n = 391) were current smokers, and 26.7% (n = 965) of them were cigarette experimenters. Almost half, (46.1%, n = 1666) of the HP students did not have an awareness of the official policy banning tobacco use in their school buildings and clinics; and only one in ten (9.4%, n = 338) of them did not support anti-tobacco policies. Students were less likely to be aware if they had second hand exposure at home/work (OR = 0.73, 95% CI (0.57-0.92), p-value <0.01). Furthermore, students who were current smokers (OR = 0.21, 95% CI (0.08-0.56), or cigarette experimenters (OR = 0.42, 95% CI (0.26-0.70), p-value <0.01), were least likely to support anti-tobacco policies.

Conclusion

We found that HP students lack awareness of anti-tobacco policies; and were less likely to support such efforts if they were current smokers. These findings may help in understanding existing perceptions of the future care givers in Pakistan. Future anti-tobacco efforts and HP training programs may target the smoking HPs to enhance their full support in this regard.

Electronic supplementary material

The online version of this article (doi:10.1186/s13011-015-0001-x) contains supplementary material, which is available to authorized users.

The Impact of a City-Wide Indoor Smoking Ban on Smoking and Drinking Behaviors Across Emerging Adulthood

INTRODUCTION

Almost one-third of college students report recent cigarette use, primarily as "social smoking," and often in conjunction with alcohol use. While city-wide indoor smoking bans effectively reduce the number of social opportunities to smoke (eg, bars and music clubs), little is known about how these bans may impact the smoking behaviors of college students. Furthermore, nothing is known about how indoor smoking bans may impact students' drinking behaviors. The current study aims to determine the impact of a city-wide comprehensive indoor smoking ban on smoking and alcohol behaviors among a longitudinal sample of emerging adults.

METHODS

Data are from a 6-year longitudinal study (10 waves of data collection) that began the summer before college enrollment. Participants (N = 2244; 60% female) reported on their past 3-month smoking and drinking behaviors using Internet-based surveys at each wave. Piecewise linear growth modeling was used to determine how a city-wide comprehensive indoor smoking ban (implemented in the Fall of 2005 between Waves 4 and 5) impacted smoking frequency, cigarette quantity, drinking frequency, and number of binge drinking episodes.

RESULTS

Smoking and alcohol use increased from the summer before college through the semester before implementation of the city-wide smoking ban. While smoking frequency (P < .001) and cigarette quantity (P < .05) declined after the ban, drinking frequency increased (P < .001) and the number of binge drinking episodes remained stable.

CONCLUSIONS

Current findings suggest that comprehensive indoor smoking bans can influence the smoking behaviors of emerging adults, whereas trajectories of drinking are relatively unchanged.

The effect of tobacco control policy on smoking cessation in relation to gender, age and education in Lithuania, 1994-2010

BACKGROUND

This study aimed to evaluate the association between tobacco control policies and trends in smoking cessation according to gender, age and educational level in Lithuania in 1994-2010.

METHODS

The data were obtained from nine cross-sectional postal surveys conducted biennially within the framework of Finbalt Health Monitor project during 1994-2010. Each survey was based on a nationally representative random sample drawn from the National population register. The sample consisted of 3000 citizens aged 20-64 in 1994-2008 surveys and 4000 in the 2010 survey. In total, 17161 individuals participated in all surveys. The development of tobacco control policy in Lithuania was assessed using the Tobacco Control Scale (TCS). The association of the TCS scores with short-term and long-term quitting according to gender, age and education was examined using logistic regression analysis with control for secular trends.

RESULTS

Over the last two decades, a large improvement in the development of tobacco control policy has been achieved in Lithuania. At the same time, this progress was associated with the increase in smoking cessation. A significant increase in both short-term and long-term quit ratios was found among people aged 20-44. An increase by 10 points on the TCS was associated with 17% increase in the odds of short-term quitting and with 15% increase in the odds of long-term quitting. The association between tobacco control policies and long-term quitting was stronger among younger than older people. No differential effect of tobacco control policies on smoking cessation was found in relation to gender and educational level.

CONCLUSIONS

The improvement in Lithuanian tobacco control policies was associated with an increase in smoking cessation in long-term perspective. These policies have not only benefitted highly educated groups, but lower educated groups as well. Nonetheless, further development of comprehensive tobacco control policies is needed in order to decrease social inequalities in smoking cessation.

The support for smoke free policy and how it is influenced by tolerance to smoking - experience of a developing country

This cross sectional survey was conducted to determine the support in making Penang UNESCO World Heritage Site (GTWHS) smoke free and to determine the influence of tolerance towards smoking on this support. This is the first phase in making Penang, Malaysia a smoke free state. A multistage sampling process was done to select a sample of respondents to represent the population of GTWHS. Attitude towards smoking was assessed using tolerance as a proxy. A total of 3,268 members of the community participated in the survey. A big majority (n = 2969; 90.9%) of the respondents supported the initiative. Support was lowest among the owners and residents/tenants, higher age groups, the Chinese, men, respondents who had poor knowledge of the places gazetted as smoke free, and respondents with poor knowledge of the health effects on smokers and on passive smokers. The odds (both adjusted and unadjusted) of not supporting the initiative was high among those tolerant to smoking in public areas. Tolerance towards smoking was associated with 80.3% risk of non-support in the respondents who were tolerant to smoking and a 57.2% risk in the population. Health promotion and education concerning the harm of tobacco smoke in Malaysia, which has mainly targeted smokers, must change. Health education concerning the risks of second hand smoke must also be given to non-smokers and efforts should be made to denormalize smoking.