Impact of laws restricting the sale of tobacco to minors on adolescent smoking and perceived obtainability of cigarettes: an intervention-control pre-post study of 19 European Union countries

Correlation between tobacco control policies and the smoking behaviors of European adolescents from 2005 to 2019

Despite legislative efforts, tobacco smoking prevalence among European adolescents remains high and heterogeneous between countries. While tobacco control policies, often assessed using Tobacco Control Scale (TCS), have been studied in adults, their influence on preventing adolescent smoking initiation remains unknown. This ecological study investigates the correlation between tobacco control policies implementation and adolescents smoking behavior across 25 European countries. Correlation analyses were conducted using TCS scores from 2005 to 2016, and 2007 to 2019 data from the European School Survey Project on Alcohol and Other Drugs. Total TCS scores inversely correlated with adolescents' smoking prevalence, as did the prohibition of tobacco advertising. The effect of prices increases have progressively faded, as bans on smoking in public spaces. Information campaigns are poorly implemented, and treatments for addiction do not show effect on adolescents. Besides further raises in cigarette prices, policies should target the smoking social perception to curb adolescent tobacco use.

What is the Relationship Between Raising the Minimum Legal Sales Age of Tobacco Above 20 and Cigarette Smoking? A Systematic Review

INTRODUCTION

There is considerable interest in raising the age of sale of tobacco above the conventional age of 18 years. We systematically reviewed whether raising the minimum legal sales age of tobacco (MLSA) to 20 or above is associated with a reduced prevalence of smoking compared to an MLSA set at 18 or below.

AIMS AND METHODS

Following a preregistered protocol on PROSPERO (ref: CRD42022347604), six databases of peer-reviewed journals were searched from January 2015 to April 2024. Backward and forward reference searching was conducted. Included studies assessed the association between MLSAs ≥20 with cigarette smoking or cigarette sales for those aged 11-20 years. Assessments on e-cigarettes were excluded. Pairs of reviewers independently extracted study data. We used ROBINS-I to assess the risk of bias and GRADE to assess the quality of evidence. Findings were also synthesized narratively.

RESULTS

Twenty-three studies were reviewed and 34 estimates of association were extracted. All extracted studies related to Tobacco 21 laws in the United States. Moderate quality evidence was found for reduced cigarette sales, moderate quality evidence was found for reduced current smoking for 18-20-year-olds, and low-quality evidence was found for reduced current smoking for 11-17-year-olds. The positive association was stronger for those with lower education. Study bias was variable.

CONCLUSIONS

There is moderate quality evidence that Tobacco 21 can reduce overall cigarette sales and current cigarette smoking amongst those aged 18-20 years. It has the potential to reduce health inequalities. Research in settings other than the United States is required.

IMPLICATIONS

This systematic review on raising the minimum legal sale age of tobacco to 20 or above demonstrates there is moderate quality evidence that such laws reduce cigarette sales and moderate quality evidence they reduce smoking prevalence amongst those aged 18-20 years compared to a minimum legal sale age of 18 years or below. The research highlights potential benefits in reducing health inequalities, especially for individuals from lower educational backgrounds. Studies are limited to the United States, highlighting a need for more global research to assess the impact of these policies in other settings.

Regulatory Strategies for Preventing and Reducing Nicotine Vaping Among Youth: A Systematic Review

INTRODUCTION

Many jurisdictions have implemented different regulatory strategies to reduce vaping among youth. The objective of this systematic review is to synthesize the evidence of the effectiveness of different regulatory strategies for preventing and reducing nicotine vaping among youth.

METHODS

Five electronic databases were searched from January 1, 2004 to July 17, 2022 for primary studies examining state/provincial or national regulations targeting vaping among youth (aged 12-21 years) in high-income countries. The primary outcome was vaping prevalence. Included studies were qualitatively synthesized through systematic review.

RESULTS

The systematic review included 30 studies. There was insufficient evidence to recommend age restrictions (n=16), restrictions on location of use (n=1), and mixed/combined regulations (n=3). Flavor bans (n=4), sales licenses (n=2), and taxation (n=2) were generally shown to be associated with decreased rates of youth vaping. Warning labels (n=2) were associated with a decreased desire to initiate vaping. Included studies had moderate-to-serious risks of bias.

DISCUSSION

Although several regulatory interventions have been shown to be effective at reducing vaping among youth, evidence is insufficient to recommend a specific type of regulation. Regulatory authorities could implement various regulations targeting the price, accessibility, and desirability (i.e., flavors and packaging) of E-cigarettes.

A Novel Methodological Approach to Measure Linear Trends in Health Inequalities: Proof of Concept With Adolescent Smoking in Europe

We describe a new method for presenting and interpreting linear trends in health inequalities, and present a proof-of-concept analysis of inequalities in smoking among adolescents in Europe. We estimated the regression line of the assumed linear relationship between smoking prevalence in low- and high-socioeconomic status (SES) youth over time. Using simulation, we constructed a 95% confidence interval (CI) for the smoking prevalence in low-SES youth for when this would be 0% in high-SES youth, and we calculated the likelihood of eradicating smoking inequality (<5% for both low and high SES). This method was applied to data on adolescents aged 15-16 years (n = 250,326) from 23 European countries, derived from the 2003-2015 European Survey Project on Alcohol and Other Drugs. Smoking prevalence decreased more slowly among low- than among high-SES adolescents. The estimated smoking prevalence was 9.4% (95% CI: 6.1, 12.7) for boys and 5.4% (95% CI: 1.4, 9.2) for girls with low SES when 0% with high SES. The likelihood of eradicating smoking inequality was <1% for boys and 37% for girls. We conclude that this novel methodological approach to trends in health inequalities is feasible in practice. Applying it to trends in smoking inequalities among adolescents in Europe, we found that Europe is currently not on track to eradicate youth smoking across SES groups.

Minimum legal age laws and perceived access to cigarettes, e-cigarettes, and other substances among youth in Canada, England, and the United States: 2017-2021

BACKGROUND

Minimum legal age (MLA) restrictions are a core policy to reduce youth use of tobacco, e-cigarettes, and other substances. We examined trends in perceived ease of access to tobacco and other substances across three countries with differing MLA policies, including the United States (US), which increased the federal MLA for tobacco products from 18 to 21 in 2019.

METHODS

Repeat cross-sectional data were analyzed from seven waves of the International Tobacco Control (ITC) Youth Tobacco and Vaping Survey conducted between 2017 and 2021. Online surveys were conducted with non-probability samples of 91,647 youth aged 16-19 in Canada, England, and the US. Regression models were used to examine differences in perceived ease of accessing each of 7 substances (analyzed as "very easy" or "fairly easy" versus else), and differences between countries and over time (including before and after any MLA changes) for cigarettes, e-cigarettes, cannabis, and alcohol; additional models examined sub-national variation in MLA.

RESULTS

Perceived access varied by substance and across countries: in August/September 2021, perceived ease of accessing cigarettes and e-cigarettes was greater in Canada where MLA was 18-19 (61.7% cigarettes, 66.4% e-cigarettes) and England where MLA was 18 (66.9%, 69.6%), compared to the US where MLA was 21 (48.0%, 60.9%; p < 0.001 for all). Perceived ease of accessing cannabis was greatest in Canada (53.3%), followed by the US (44.1%) and England (34.0%; p < 0.001 for all). Following the federal MLA increase for tobacco products in the US, perceived ease of access decreased significantly for cigarettes (65.1% in 2019Aug to 59.7% in 2020Feb; aOR=0.80 (95%CI=0.71-0.89)) and e-cigarettes (72.4% in 2019Aug to 69.4% in 2020Feb; aOR=0.87 (95%CI=0.77-0.98)).

CONCLUSIONS

Higher MLA was strongly associated with fewer youth perceiving easy access to substances: perceived access varied between countries with differing MLA, as well as within-country before and after changes to MLA.

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.

Drawing on Adolescent Psychology to Achieve Tobacco-Free Generations

Background: In 2021, the European Union called for creation of a “tobacco-free generation.” We consider the means to this end. The persistence of youthful noncompliance with current minimum age laws (leading to widespread subsequent addiction, morbidity and mortality) raises questions whether such laws are truly aligned with adolescent psychology.

Evidence: The ubiquity of minimum-age laws limits direct evidence of their effectiveness, so we seek indirect evidence. Qualitative findings originally intended for tobacco manufacturers indicate counterproductive aspects of minimum-age laws. Further evidence about adolescent reactions is provided by a recent review and meta-analysis of greater youth defiance of under-age laws than whole-of-life laws in the domain of motorcycle helmets.

Policy Options and Recommendations: As an alternative to minimum-age laws, we consider the Tobacco-Free Generation proposal (TFG), which phases out sales on an age cohort basis and has recently gained prominence.

Conclusion: The Tobacco-Free Generation proposal (TFG) seems well aligned with adolescent psychology, and is therefore especially worthy of attention. It has recently been introduced or endorsed by a number of jurisdictions, both local and national.

Combustible tobacco age-of-sale laws: an opportunity?

This editorial argues for the benefits of raising age-of-sale laws for combustible tobacco only, such as through a Combustible 21 law that would prohibit the sale of combustible tobacco to individuals under 21 years of age but leave open the opportunity to legally purchase e-cigarettes and smokeless tobacco products.

Who would be targeted by increasing the legal age of sale of cigarettes from 18 to 21? A cross-sectional study exploring the number and characteristics of smokers in England

AIMS

To establish the number of smokers in England who would be targeted by increasing the age of sale of cigarettes from 18 to 21 years and to assess the smoking and socio-demographic profile of those smokers.

DESIGN AND SETTING

Nationally representative cross-sectional survey of adults in England conducted between January 2009 and July 2019.

PARTICIPANTS

A total of 219 720 adults.

MEASUREMENTS

All participants reported their current smoking status and socio-demographic characteristics (i.e. age, gender, home ownership, social grade and ethnicity). Smokers reported motivation to quit, urges to smoke and the Heaviness of Smoking Index (HIS). Weighted prevalence statistics were calculated. Multinomial regression and logistic regression were used to assess differences in smoking characteristics among smokers and socio-demographic characteristics relative to non-smokers.

FINDINGS

The prevalence of smoking between January 2009 and July 2019 was highest among those aged 21-30. In 2019, 15.6% [95% confidence interval (CI) = 12.8-18.8%] of 18-20-year-olds reported smoking, which is estimated to represent 364 000 individuals in England. Relative to smokers aged 18-20, older smokers (aged 21+) had a higher motivation to quit smoking [odds ratios (ORs) = 1.40-1.45 range] and higher nicotine dependency as measured by urges to smoke (ORs = 1.06-1.24 range) and HSI (ORs = 1.05-2.85 range). Compared with non-smokers aged 18-20, smokers in this age group had lower odds of being female (OR = 0.89) and higher odds of being of white ethnicity (OR = 2.78) and from social grades C1-E (lower social grades) compared with AB (higher social grades) (OR = 1.19-1.83 range).

CONCLUSION

Increasing the age of sale of cigarettes to 21 years in England would currently target approximately 364 000 lower dependent smokers from more disadvantaged backgrounds aged 18-20, who have less motivation to quit.

Support for Minimum Legal Sales Age Laws Set to Age 21 Across Australia, Canada, England, and United States: Findings From the 2018 ITC Four Country Smoking and Vaping Survey

INTRODUCTION

Although the United States has seen a rapid increase in tobacco minimum legal sales age (MLSA) laws set to age 21, there is wide variation across high-income countries and less is known about policy support outside of the United States. We examined the prevalence of support for tobacco MLSA 21 laws as well as associations by sociodemographic, smoking, and household characteristics among current and former adult smokers.

METHODS

In this cross-sectional analysis, we used the 2018 International Tobacco Control Four Country Smoking and Vaping Survey to examine support for MLSA 21 laws among 12 904 respondents from Australia, Canada, England, and United States.

RESULTS

Support for raising the legal age of purchasing cigarettes/tobacco to 21 ranged from 62.2% in the United States to 70.8% in Canada. Endorsement also varied by age, such that 40.6% of 18-20 years old supported the policy compared with 69.3% of those aged ≥60 years. In the adjusted regression model, there was also higher support among respondents who were female than male, non-white than white, those who did not allow smoking in the household than those that did, and those who had children in the household than those that did not. There were no differences by household income, education, or smoking status.

CONCLUSIONS

Most current and former smokers, including a sizable minority of those aged ≤20 years, support raising the legal age of purchasing cigarettes/tobacco to 21.

IMPLICATIONS

There was strong support for MLSA 21 laws among smokers and former smokers across Australia, Canada, England, and the United States, providing evidence for the increasing public support of the passage of these laws beyond the United States.

Youth Access to Cigarettes Across Seven European Countries: A Mixed-Methods Study

Background

Despite widespread age-of-sale restrictions on tobacco, adolescents continue to obtain cigarettes and experiment with smoking. This mixed-methods study aimed to understand how European adolescents access cigarettes and how the policy context may influence this process, using a realist evaluation approach. This is the first study to assess access to cigarettes across various European contexts.

Methods

A survey of 4104 students was combined with qualitative data from focus groups among 319 adolescents aged 14–19 across seven European countries. Data were synthesized to explore mechanisms via which young people obtain cigarettes despite age-of-sale restrictions.

Results

While purchasing cigarettes from supermarkets was widely regarded as difficult, many participants purchased cigarettes from noncompliant retailers (often in smaller shops or cafes). Other contra-mechanisms included circumventing age checks, proxy purchases, and/or social sources. Dominant forms of access differed across the seven contexts, with direct purchases more common where perceived enforcement was low (eg, Belgium) and proxy purchases more important where perceived enforcement of age-of-sale laws was high (eg, Finland). The effectiveness of age-of-sale restrictions in reducing youth access appears to be influenced by a range of contextual factors including retailer compliance, the availability of vending machines, and the specific minimum age-of-sale.

Conclusions

Our findings illustrate the relevance of programme theory in understanding the contra-mechanisms that undermine the effectiveness of age-of-sale laws in discouraging youth smoking. Young people’s access to cigarettes could be further limited by addressing these contra-mechanisms, including an increase in the legal sales age (particularly in Belgium), banning vending machines, and strengthening enforcement.

Implications

Despite widespread implementation of age-of-sale laws, a substantial proportion of minors continue to access cigarettes. Young people use a number of contra-mechanisms to circumvent age-of-sale restrictions. These include accessing cigarettes via social sources, proxy sales or by circumventing age checks. Our findings show that in contexts where perceived enforcement of age-of-sale restrictions is high, young people are more reliant on irregular forms of access such as proxy sales. Young people’s access to cigarettes may be further reduced by policy interventions that address these contra-mechanisms—for example, banning vending machines, strengthening enforcement of age-of-sale laws, and increasing the minimum age-of-sale.

Ten-year changes in the psychosocial well-being, psychopathology, substance use, suicidality, bullying, and sense of coherence of 18-year-old males: a Finnish population-based time-trend study

We studied Finnish 18-year-old males attending obligatory military call-up assessments in 1999 (n = 2340) and 2009 (n = 4309) on time-trend changes in psychosocial well-being, psychopathology, substance use, suicidality, bullying, and sense of coherence. Subjects filled in questionnaires, including the Young Adult Self-Report (YASR) for psychopathology and the Orientation to Life Questionnaire (SOC-13) for sense of coherence. The prevalence of minor mental health problems in the last 6 months decreased from 22.3% in 1999 to 18.6% in 2009 (OR 0.8, 95% CI 0.7-0.9), whereas severe mental health problems remained stable. Suicidal thoughts decreased from 5.7 to 3.7% (OR 0.6, 95% CI 0.5-0.8). The use of illicit drugs decreased from 6.0 to 4.7% (OR 0.8, 95% CI 0.6-0.95), but being drunk at least once a week increased from 10.3 to 13.4% (OR 1.3, 95% CI 1.0-1.5). Attention problems increased in YASR syndrome domains (mean score 2.9 vs 3.2, p < 0.001) and so did somatic complains (mean score 1.7 vs 1.9, p = 0.005). The SOC-13 scores remained stable. The percentage of males who had studied during the past 6 months increased from 91.4 to 93.4% (OR 1.3, 95% CI 1.1-1.6), while being employed decreased from 64.9 to 49.4% (OR 0.5, 95% CI 0.5-0.6). The positive findings included reductions in the prevalence of suicidal thoughts and the use of illicit drugs, but being drunk at least once a week increased. Self-reported somatic problems and attention problems increased. Despite changes in society and family structures, there were only minor overall changes in psychopathology.

The Tobacco Control Scale as a research tool to measure country-level tobacco control policy implementation

INTRODUCTION

The Tobacco Control Scale (TCS) was designed for advocacy purposes but has also been used as a research tool. In the present study, we characterized TCS use, its limitations and strengths, and critically assessed its use as a research instrument.

METHODS

We conducted an extensive search of the biomedical databases PubMed and Web of Science for the keyword ‘tobacco control scale’ in all fields. The search was limited to studies published in the period March 2006 to December 2019. Out of 69 hits, 32 studies met the inclusion criteria. Two reviewers independently extracted information from each publication regarding their general characteristics, publication and research aspects, and the characteristics of the use of the TCS.

RESULTS

We found that researchers have used the TCS as a tool to monitor tobacco control policies mainly in cross-sectional observational studies with ecological and multilevel designs directed to advocacy and the promotion of further research. Different outcomes, such as smoking prevalence and quit ratios, have been associated with tobacco control policy scores. The main reported limitations of the TCS were a low variance across countries and a failure to express enforcement and to incorporate the most recent legislation.

CONCLUSIONS

The TCS has been commonly used to assess differences in outcomes according to tobacco control policies. However, there are still areas for improvement in its use in research regarding the lack of comparability of TCS scores across time. The lessons that have been learned should be used to adapt and expand the TCS overseas.

Never-smoking adolescents' perceived accessibility of cigarettes following an increase in the tobacco age-of-sale from 16 to 18: A quasi-experimental study of two cities in the Netherlands and Belgium

BACKGROUND

The Netherlands increased the tobacco age-of-sale from 16 to 18 in 2014, paired with mass-media campaigns. We evaluated changes in perceived accessibility of cigarettes between 2013 and 2016 among adolescent never-smokers in the Netherlands compared with Belgium, where the age-of-sale remained 16 and no campaigns were conducted.

METHODS

Repeated cross-sectional surveys were conducted in 2013 and 2016 among 4112 13-17-year-olds at a total of 22 schools in Amersfoort (the Netherlands) and Namur (Belgium). Multilevel Poisson regression quantified changes over time in prevalence of easy perceived accessibility to cigarettes (i.e., thinking it would be fairly/very easy to get cigarettes). Interaction terms were used to test whether changes differed between the Netherlands and Belgium. Analyses were stratified by age (13-15 and 16-17 years), sex (male and female), family smoking (0 and ≥1 smoking family members), and friend smoking (no and at least some smoking friends).

RESULTS

Perceived accessibility to cigarettes decreased in the Netherlands (Prevalence Ratio (PR): 0.82; 95% CI: 0.72-0.93) and Belgium (PR: 0.78; 95% CI: 0.70-0.87), to a similar extent (PR interaction: 1.04; 95% CI: 0.90-1.21). Results by sex, age, and family/friend smoking were similar to those for the total population; there were no significant differences in the decrease in perceived access over time between the Netherlands and Belgium within each of these subgroups.

CONCLUSION

This study found approximately the same rate of decline between 2013 and 2016 in adolescent never-smokers' perceived access to cigarettes in the Netherlands as in Belgium. This implies that we did not find clear evidence for an effect of the 2014 increase in legal age of tobacco sales from 16 to 18 years in the Netherlands.

Long-term evaluation of the rise in legal age-of-sale of cigarettes from 16 to 18 in England: a trend analysis

OBJECTIVE

To assess the long-term impact of the increase in age-of-sale of cigarettes from 16 to 18 in England in October 2007.

METHODS

Data were collected between November 2006 and September 2018 on 252,601 participants taking part in a nationally representative survey of adults aged 16+ in England, the Smoking Toolkit Study (STS). We assessed the impact of the introduction of the increase in age-of-sale on prevalence of ever smoking, current smoking, and quit attempts, among 16-17 year olds compared with 18-24 year olds.

RESULTS

Following the increase in age-of-sale, there was a declining trend in ever smoking that was greater among 16-17 year olds than 18-24 year olds (OR 0.990 versus OR 0.993; p = 0.019). Data on current smoking were insensitive to detect a difference between the age groups in a step-level change or change in trend following the increase in age-of-sale (Bayes factors (BFs) 0.75 and 2.10). Data on quit attempts were also insensitive to detect a change in trend (BF 0.71), and despite a greater step-level decline among those aged 16-17 (OR 0.311 versus OR 0.547, p = 0.025), quit attempts remained higher among those aged 16-17. Secondary analysis indicated that post-policy change, trends in current and ever smoking were linear for 16-17 year olds but quadratic for 18-24 year olds (slowing decline).

CONCLUSION

There is some evidence from an assessment of long-term trends in the Smoking Toolkit Study that the increase in legal age-of-sale of cigarettes in England was associated with a greater long-term decline in ever smoking among those aged 16-17 compared with those aged 18-24.

Youth smoking and anti-smoking policies in North Dakota: a system dynamics simulation study

BACKGROUND

The current study utilizes system dynamics to model the determinants of youth smoking and simulate effects of anti-smoking policies in the context of North Dakota, a state with one of the lowest cigarette tax rates in the USA.

METHODS

An explanatory model was built to replicate historical trends in the youth smoking rate. Three different policies were simulated: 1) an increase in cigarette excise taxes; 2) increased funding for CDC-recommended comprehensive tobacco control programs; and 3) enforcement of increased retailer compliance with age restrictions on cigarette sales.

RESULTS

The explanatory model successfully replicated historical trends in adolescent smoking behavior in North Dakota from 1992 to 2014. The policy model showed that increasing taxes to $2.20 per pack starting in 2015 was the most effective of the three policies, producing a 32.6% reduction in youth smoking rate by 2032. Other policies reduced smoking by a much lesser degree (7.0 and 3.2% for comprehensive tobacco control program funding and retailer compliance, respectively). The effects of each policy were additive.

CONCLUSIONS

System dynamics modeling suggests that increasing cigarette excise taxes are particularly effective at reducing adolescent smoking rates. More generally, system dynamics offers an important complement to conventional analysis of observational data.

Impact of the WHO FCTC over the first decade: a global evidence review prepared for the Impact Assessment Expert Group

OBJECTIVE

To present findings of a narrative review on the implementation and effectiveness of 17 Articles of the WHO Framework Convention on Tobacco Control (FCTC) during the Treaty's first decade.

DATA SOURCES

Published reports on global FCTC implementation; searches of four databases through June 2016; hand-search of publications/online resources; tobacco control experts.

STUDY SELECTION

WHO Convention Secretariat global progress reports (2010, 2012, 2014); 2015 WHO report on the global tobacco epidemic; studies of social, behavioural, health, economic and/or environmental impacts of FCTC policies.

DATA EXTRACTION

Progress in the implementation of 17 FCTC Articles was categorised (higher/intermediate/lower) by consensus. 128 studies were independently selected by multiple authors in consultation with experts.

DATA SYNTHESIS

Implementation was highest for smoke-free laws, health warnings and education campaigns, youth access laws, and reporting/information exchange, and lowest for measures to counter industry interference, regulate tobacco product contents, promote alternative livelihoods and protect health/environment. Price/tax increases, comprehensive smoking and marketing bans, health warnings, and cessation treatment are associated with decreased tobacco consumption/health risks and increased quitting. Mass media campaigns and youth access laws prevent smoking initiation, decrease prevalence and promote cessation. There were few studies on the effectiveness of policies in several domains, including measures to prevent industry interference and regulate tobacco product contents.

CONCLUSIONS

The FCTC has increased the implementation of measures across several policy domains, and these implementations have resulted in measurable impacts on tobacco consumption, prevalence and other outcomes. However, FCTC implementation must be accelerated, and Parties need to meet all their Treaty obligations and consider measures that exceed minimum requirements.

Time trends of Finnish adolescents' mental health and use of alcohol and cigarettes from 1998 to 2014

This study reports time-trend changes in self-reported mental health problems, smoking, and alcohol habits among Finnish adolescents over a 16-year period using three cross-sectional studies with similar designs, methodologies, and geographical recruitment areas. There were 4508 participants with a mean age of 14.4 years (range 13-18) in 1998 (n = 1449), 2008 (n = 1560), and 2014 (n = 1499). The information they provided on their mental health was measured with the Strengths and Difficulties Questionnaire and they were also asked questions about their alcohol and smoking habits. The findings showed that from 1998 to 2014 females reported less hyperactivity and conduct problems and males reported fewer peer problems and better prosocial skills. The only mental health problem that showed a significant increase was emotional symptoms among females. Smoking and alcohol use consistently decreased in males and females during the 16-year period. Our findings suggest that overall adolescent's self-reported mental health problems were either stable or falling, indicating increased well-being. The decreased smoking indicates that anti-smoking campaigns have been successfully changing teenagers' attitudes towards smoking. The important finding is that self-reported emotional symptoms had increased in females. This may indicate an increase or earlier onset of affective disorders.

Impact of removing point-of-sale tobacco displays on smoking behaviour among adolescents in Europe: a quasi-experimental study

BACKGROUND

An increasing number of European countries implemented a point-of-sale (PoS) display ban on tobacco products. This study assessed the association between PoS display bans in Europe and adolescent smoking and perceived accessibility of tobacco, 2-6 years after PoS display ban implementation.

METHODS

In a quasi-experimental design, we compared individuals in countries that did and countries that did not implement a PoS display ban, before and after implementation. We used repeated cross-sectional data of 174 878 15-year-old and 16-year-old adolescents from 25 countries from the 2007, 2011 and 2015 European Survey Project on Alcohol and Other Drugs surveys. Multilevel logistic regression models examined smoking behaviour (regular smoking vs other) and perceived access (easy vs difficult) as a function of display ban implementation and controlled for survey year, gender, parental education and implementation of other tobacco control policies. Interaction with gender was tested.

RESULTS

The implementation of a PoS display ban was associated with a 15% larger drop in the odds of regular smoking (OR 0.85, 95% CI 0.79 to 0.91), but was not significantly associated with perceived accessibility of tobacco (OR 0.97, 95% CI 0.892 to 1.03). Associations were similar in males and females (cross-level interactions of gender with display ban were not statistically significant for either outcome).

CONCLUSION

The implementation of PoS display bans in Europe was associated with a stronger decrease in regular smoking among adolescents. This decrease does not appear to be driven by a decreasing accessibility of tobacco, but might be caused by further de-normalisation of tobacco as a result of PoS display bans.

Impacts of Canada's minimum age for tobacco sales (MATS) laws on youth smoking behaviour, 2000-2014

BACKGROUND

Recently, the US Institute of Medicine has proposed that raising the minimum age for tobacco purchasing/sales to 21 years would likely lead to reductions in smoking behavior among young people. Surprisingly few studies, however, have assessed the potential impacts of minimum-age tobacco restrictions on youth smoking.

OBJECTIVE

To estimate the impacts of Canadian minimum age for tobacco sales (MATS) laws on youth smoking behaviour.

DESIGN

A regression-discontinuity design, using seven merged cycles of the Canadian Community Health Survey, 2000-2014.

PARTICIPANTS

Survey respondents aged 14-22 years (n=98 320).

EXPOSURE

Current Canadian MATS laws are 18 years in Alberta, Saskatchewan, Manitoba, Quebec, the Yukon and Northwest Territories, and 19 years of age in the rest of the country.

MAIN OUTCOMES

Current, occasional and daily smoking status; smoking frequency and intensity; and average monthly cigarette consumption.

RESULTS

In comparison to age groups slightly younger than the MATS, those just older had significant and abrupt increases immediately after the MATS in the prevalence of current smokers (absolute increase: 2.71%; 95% CI 0.70% to 4.80%; P=0.009) and daily smokers (absolute increase: 2.43%; 95% CI 0.74% to 4.12%; P=0.005). Average past-month cigarette consumption within age groups increased immediately following the MATS by 18% (95% CI 3% to 39%; P=0.02). There was no evidence of significant increases in smoking intensity for daily or occasional smokers after release from MATS restrictions.

CONCLUSION

The study provides relevant evidence supporting the effectiveness of Canadian MATS laws for limiting smoking among tobacco-restricted youth.

Tobacco control environment: cross-sectional survey of policy implementation, social unacceptability, knowledge of tobacco health harms and relationship to quit ratio in 17 low-income, middle-income and high-income countries

OBJECTIVES

This study examines in a cross-sectional study 'the tobacco control environment' including tobacco policy implementation and its association with quit ratio.

SETTING

545 communities from 17 high-income, upper-middle, low-middle and low-income countries (HIC, UMIC, LMIC, LIC) involved in the Environmental Profile of a Community's Health (EPOCH) study from 2009 to 2014.

PARTICIPANTS

Community audits and surveys of adults (35-70 years, n=12 953).

PRIMARY AND SECONDARY OUTCOME MEASURES

Summary scores of tobacco policy implementation (cost and availability of cigarettes, tobacco advertising, antismoking signage), social unacceptability and knowledge were associated with quit ratios (former vs ever smokers) using multilevel logistic regression models.

RESULTS

Average tobacco control policy score was greater in communities from HIC. Overall 56.1% (306/545) of communities had >2 outlets selling cigarettes and in 28.6% (154/539) there was access to cheap cigarettes (<5cents/cigarette) (3.2% (3/93) in HIC, 0% UMIC, 52.6% (90/171) LMIC and 40.4% (61/151) in LIC). Effective bans (no tobacco advertisements) were in 63.0% (341/541) of communities (81.7% HIC, 52.8% UMIC, 65.1% LMIC and 57.6% LIC). In 70.4% (379/538) of communities, >80% of participants disapproved youth smoking (95.7% HIC, 57.6% UMIC, 76.3% LMIC and 58.9% LIC). The average knowledge score was >80% in 48.4% of communities (94.6% HIC, 53.6% UMIC, 31.8% LMIC and 35.1% LIC). Summary scores of policy implementation, social unacceptability and knowledge were positively and significantly associated with quit ratio and the associations varied by gender, for example, communities in the highest quintile of the combined scores had 5.0 times the quit ratio in men (Odds ratio (OR) 5·0, 95% CI 3.4 to 7.4) and 4.1 times the quit ratio in women (OR 4.1, 95% CI 2.4 to 7.1).

CONCLUSIONS

This study suggests that more focus is needed on ensuring the tobacco control policy is actually implemented, particularly in LMICs. The gender-related differences in associations of policy, social unacceptability and knowledge suggest that different strategies to promoting quitting may need to be implemented in men compared to women.