Heterogeneous trend in smoking prevalence by sex and age group following the implementation of a national smoke-free law

Trend in the incidence of hepatitis A in mainland China from 2004 to 2017: a joinpoint regression analysis

Background

China has experienced a continuous decreasing trend in the incidence of hepatitis A in recent years. Temporal trend analyses are helpful in exploring the reasons for the changing trend. Thus, this study aims to analyse the incidence trend of viral hepatitis A by region and age group in mainland China from 2004 to 2017 to evaluate the effectiveness of prevention and control measures.

Methods

Data on hepatitis A and population information were collected and analysed with a joinpoint regression model. Annual percentage changes (APCs) and average annual percentage changes (AAPCs) were estimated for the whole country and for each region and age group.

Results

From 2004 to 2017, the seasonality and periodicity of hepatitis A case numbers were obvious before 2008 but gradually diminished from 2008 to 2011 and disappeared from 2012–2017. The national incidence of hepatitis A (AAPC =  − 12.1%) and the incidence rates for regions and age groups showed decreasing trends, with differences in the joinpoints and segments. Regarding regions, the hepatitis A incidence in the western region was always the highest among all regions, while a nonsignificant rebound was observed in the northeastern region from 2011 to 2017 (APC = 14.2%). Regarding age groups, the hepatitis A incidence showed the fastest decrease among children (AAPC =  − 15.3%) and the slowest decrease among elderly individuals (AAPC =  − 6.6%). Among all segments, the hepatitis A incidence among children had the largest APC value in 2007–2017, at − 20.4%.

Conclusion

The national annual incidence of hepatitis A continually declined from 2004 to 2017 and the gaps in hepatitis A incidence rates across different regions and age groups were greatly narrowed. Comprehensive hepatitis A prevention and control strategies, including the use of routine vaccination during childhood in mainland China, especially the implementation of the national Expanded Program on Immunization (EPI) in 2008, resulted in substantial progress from 2004 to 2017. However, gaps remain. Regular monitoring and analysis of hepatitis A epidemic data and prompt adjustment of hepatitis A prevention and control strategies focusing on children, elderly individuals and those living in certain regions are recommended.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

IMPLICATIONS

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

Social inequalities in tobacco-attributable mortality in Spain. The intersection between age, sex and educational level

INTRODUCTION

First study of social inequalities in tobacco-attributable mortality (TAM) in Spain considering the joint influence of sex, age, and education (intersectional perspective).

METHODS

Data on all deaths due to cancer, cardiometabolic and respiratory diseases among people aged ≥35 years in 2016 were obtained from the Spanish Statistical Office. TAM was calculated based on sex-, age- and education-specific smoking prevalence, and on sex-, age- and disease-specific relative risks of death for former and current smokers vs lifetime non-smokers. As inequality measures, the relative index of inequality (RII) and the slope index of inequality (SII) were calculated using Poisson regression. The RII is interpreted as the relative risk of mortality between the lowest and the highest educational level, and the SII as the absolute difference in mortality.

RESULTS

The crude TAM rate was 55 and 334 per 100,000 in women and men, respectively. Half of these deaths occurred among people with the lowest educational level (27% of the population). The RII for total mortality was 0.39 (95%CI: 0.35-0.42) in women and 1.61 (95%CI: 1.55-1.67) in men. The SII was -41 and 111 deaths per 100,000, respectively. Less-educated women aged <55 years and men (all ages) showed an increased mortality risk; nonetheless, less educated women aged ≥55 had a reduced risk.

CONCLUSIONS

TAM is inversely associated with educational level in men and younger women, and directly associated with education in older women. This could be explained by different smoking patterns. Appropriate tobacco control policies should aim to reduce social inequalities in TAM.

The limits of single-group interrupted time series analysis in assessing the impact of smoke-free laws on short-term mortality

BACKGROUND

Decreases in circulatory/respiratory morbimortality after the January-2006 Spanish partial smoke-free law have been found using designs without control groups, such as single-group interrupted time series (ITS), which are prone to biases. The aim was to reassess the law's impact on mortality using ITS designs with robustness checks.

METHODS

A comprehensive cohort of people aged ≥25 in each calendar-year of 2002-2007, living in 13 of 18 Spanish regions, was followed up between 01/2002 and 12/2007. The law included a smoking ban in indoor public and workplaces, allowing exceptions in catering, hospitality and leisure venues, and other interventions. Post-law changes in monthly coronary/respiratory mortality were estimated using segmented regression, adjusting for relevant covariates, including seasonality, extreme temperatures, influenza incidence and air pollution. The validity of results was assessed using control outcomes, hypothetical law dates, and non-equivalent control groups, analysing their results as difference-in-differences (DID) designs.

RESULTS

Significant immediate post-law decreases in coronary, respiratory and non-tobacco-related mortality were observed among people aged ≥70. A significant immediate post-law decrease in respiratory mortality (-12.7%) was also observed among people age 25-69, although this was neutralized by a subsequent upward trend before 1.5 years. More favourable post-law changes in coronary/respiratory mortality among the target (people aged 25-69) than control groups (people aged ≥70 or women aged ≥80) were not identified in DID designs. Establishing hypothetical law dates, immediate decreases began in February/March 2005 with maxima between April and July 2005.

CONCLUSIONS

After robustness checks, the results do not support a clear positive impact of the 2006 Spanish smoke-free law on short-term coronary/respiratory mortality. The favourable immediate changes observed pre- and post-law could derive mainly from the harvesting effect of the January-2005 cold wave. This highlights the risks of assessing the impact of health interventions using both morbimortality outcomes and designs without a control group and adequate robustness checks.

Effect of the comprehensive smoke-free law on time trends in smoking behaviour in primary healthcare patients in Spain: a longitudinal observational study

OBJECTIVE

This study aimed to analyse the impact of comprehensive smoke-free legislation (SFL) on the prevalence and incidence of adult smoking in primary healthcare (PHC) patients from three Spanish regions, overall and stratified by sex.

DESIGN

Longitudinal observational study conducted between 2008 and 2013.

SETTING

66 PHC teams in Catalonia, Navarre and the Balearic Islands (Spain).

PARTICIPANTS

Population over 15 years of age assigned to PHC teams.

PRIMARY AND SECONDARY OUTCOMES MEASURES

Quarterly age-standardised prevalence of non-smoker, smoker and ex-smoker and incidence of new smoker, new ex-smoker and ex-smoker relapse rates were estimated with data retrieved from PHC electronic health records. Joinpoint analysis was used to analyse the trends of age-standardised prevalence and incidence rates. Trends were expressed as annual percentage change and average annual percent change.

RESULTS

The overall standardised smoker prevalence rate showed a significant downward trend (higher in men than women) and the overall standardised ex-smoker prevalence rate showed a significant increased trend (higher in women than men) in the three regions. Standardised smoker and ex-smoker prevalence rates were higher for men than women in all regions. With regard to overall trends of incidence rates, new smokers decreased significantly in Catalonia and Navarre and similarly in men and women, new ex-smokers decreased significantly and more in men in Catalonia and the Balearic Islands, and ex-smoker relapse increased in Catalonia (particularly in women) and decreased in Navarre.

CONCLUSIONS

Trends in smoking behaviour in PHC patients remain unchanged after the implementation of comprehensive SFL. The impact of the comprehensive SFL might have been lessened by the effect of the preceding partial SFL.

Examples of sex/gender sensitivity in epidemiological research: results of an evaluation of original articles published in JECH 2006-2014

BACKGROUND

During the last decades, sex and gender biases have been identified in various areas of biomedical and public health research, leading to compromised validity of research findings. As a response, methodological requirements were developed but these are rarely translated into research practice. The aim of this study is to provide good practice examples of sex/gender sensitive health research.

METHODS

We conducted a systematic search of research articles published in JECH between 2006 and 2014. An instrument was constructed to evaluate sex/gender sensitivity in four stages of the research process (background, study design, statistical analysis, discussion).

RESULTS

In total, 37 articles covering diverse topics were included. Thereof, 22 were evaluated as good practice example in at least one stage; two articles achieved highest ratings across all stages. Good examples of the background referred to available knowledge on sex/gender differences and sex/gender informed theoretical frameworks. Related to the study design, good examples calculated sample sizes to be able to detect sex/gender differences, selected sex/gender sensitive outcome/exposure indicators, or chose different cut-off values for male and female participants. Good examples of statistical analyses used interaction terms with sex/gender or different shapes of the estimated relationship for men and women. Examples of good discussions interpreted their findings related to social and biological explanatory models or questioned the statistical methods used to detect sex/gender differences.

CONCLUSIONS

The identified good practice examples may inspire researchers to critically reflect on the relevance of sex/gender issues of their studies and help them to translate methodological recommendations of sex/gender sensitivity into research practice.

Has Childhood Smoking Reduced Following Smoke-Free Public Places Legislation? A Segmented Regression Analysis of Cross-Sectional UK School-Based Surveys

INTRODUCTION

Smoke-free legislation has been a great success for tobacco control but its impact on smoking uptake remains under-explored. We investigated if trends in smoking uptake amongst adolescents differed before and after the introduction of smoke-free legislation in the United Kingdom.

METHODS

Prevalence estimates for regular smoking were obtained from representative school-based surveys for the four countries of the United Kingdom. Post-intervention status was represented using a dummy variable and to allow for a change in trend, the number of years since implementation was included. To estimate the association between smoke-free legislation and adolescent smoking, the percentage of regular smokers was modeled using linear regression adjusted for trends over time and country. All models were stratified by age (13 and 15 years) and sex.

RESULTS

For 15-year-old girls, the implementation of smoke-free legislation in the United Kingdom was associated with a 4.3% reduction in the prevalence of regular smoking (P = .029). In addition, regular smoking fell by an additional 1.5% per annum post-legislation in this group (P = .005). Among 13-year-old girls, there was a reduction of 2.8% in regular smoking (P = .051), with no evidence of a change in trend post-legislation. Smaller and nonsignificant reductions in regular smoking were observed for 15- and 13-year-old boys (P = .175 and P = .113, respectively).

CONCLUSIONS

Smoke-free legislation may help reduce smoking uptake amongst teenagers, with stronger evidence for an association seen in females. Further research that analyses longitudinal data across more countries is required.

IMPLICATIONS

Previous research has established that smoke-free legislation has led to many improvements in population health, including reductions in heart attack, stroke, and asthma. However, the impacts of smoke-free legislation on the rates of smoking amongst children have been less investigated. Analysis of repeated cross-sectional surveys across the four countries of the United Kingdom shows smoke-free legislation may be associated with a reduction in regular smoking among school-aged children. If this association is causal, comprehensive smoke-free legislation could help prevent future generations from taking up smoking.

Legislative smoking bans for reducing harms from secondhand smoke exposure, smoking prevalence and tobacco consumption

BACKGROUND

Smoking bans have been implemented in a variety of settings, as well as being part of policy in many jurisdictions to protect the public and employees from the harmful effects of secondhand smoke (SHS). They also offer the potential to influence social norms and the smoking behaviour of those populations they affect. Since the first version of this review in 2010, more countries have introduced national smoking legislation banning indoor smoking.

OBJECTIVES

To assess the effects of legislative smoking bans on (1) morbidity and mortality from exposure to secondhand smoke, and (2) smoking prevalence and tobacco consumption.

SEARCH METHODS

We searched the Cochrane Tobacco Addiction Group Specialised Register, MEDLINE, EMBASE, PsycINFO, CINAHL and reference lists of included studies. We also checked websites of various organisations. Date of most recent search; February 2015.

SELECTION CRITERIA

We considered studies that reported legislative smoking bans affecting populations. The minimum standard was having an indoor smoking ban explicitly in the study and a minimum of six months follow-up for measures of smoking behaviour. Our search included a broad range of research designs including: randomized controlled trials, quasi-experimental studies (i.e. non-randomized controlled studies), controlled before-and-after studies, interrupted time series as defined by the Cochrane Effective Practice and Organisation of Care Group, and uncontrolled pre- and post-ban data.

DATA COLLECTION AND ANALYSIS

One author extracted characteristics and content of the interventions, participants, outcomes and methods of the included studies and a second author checked the details. We extracted health and smoking behaviour outcomes. We did not attempt a meta-analysis due to the heterogeneity in design and content of the studies included. We evaluated the studies using qualitative narrative synthesis.

MAIN RESULTS

There are 77 studies included in this updated review. We retained 12 studies from the original review and identified 65 new studies. Evidence from 21 countries is provided in this update, an increase of eight countries from the original review. The nature of the intervention precludes randomized controlled trials. Thirty-six studies used an interrupted time series study design, 23 studies use a controlled before-and-after design and 18 studies are before-and-after studies with no control group; six of these studies use a cohort design. Seventy-two studies reported health outcomes, including cardiovascular (44), respiratory (21), and perinatal outcomes (7). Eleven studies reported national mortality rates for smoking-related diseases. A number of the studies report multiple health outcomes. There is consistent evidence of a positive impact of national smoking bans on improving cardiovascular health outcomes, and reducing mortality for associated smoking-related illnesses. Effects on respiratory and perinatal health were less consistent. We found 24 studies evaluating the impact of national smoke-free legislation on smoking behaviour. Evidence of an impact of legislative bans on smoking prevalence and tobacco consumption is inconsistent, with some studies not detecting additional long-term change in existing trends in prevalence.

AUTHORS' CONCLUSIONS

Since the first version of this review was published, the current evidence provides more robust support for the previous conclusions that the introduction of a legislative smoking ban does lead to improved health outcomes through reduction in SHS for countries and their populations. The clearest evidence is observed in reduced admissions for acute coronary syndrome. There is evidence of reduced mortality from smoking-related illnesses at a national level. There is inconsistent evidence of an impact on respiratory and perinatal health outcomes, and on smoking prevalence and tobacco consumption.

Assessing the effects of the Spanish partial smoking ban on cardiovascular and respiratory diseases: methodological issues

OBJECTIVE

Recent research has assessed the impact of tobacco laws on cardiovascular and respiratory morbidity. In this study, we also examined whether the association between the implementation of the 2005 Spanish smoking ban and hospital admissions for cardiovascular and respiratory diseases varies according to the adjustment for potential confounders.

DESIGN

Ecological time series analysis.

SETTING

Residents of Madrid and Barcelona cities (Spain).

OUTCOME

Data on daily emergency room admissions for acute myocardial infarction, cerebrovascular disease, chronic obstructive pulmonary disease (COPD), and asthma derived from the 2003-2006 Spanish hospital admissions registry.

METHODS

Changes in admission rates between 2006 and the 2003-2005 period were estimated using additive Poisson models allowing for overdispersion adjusted for secular trend in admission, seasonality, day of the week, temperature, number of flu and acute respiratory infection cases, pollution levels, tobacco consumption prevalence and, for asthma cases, pollen count.

RESULTS

In Madrid, fully adjusted models failed to detect significant changes in hospital admission rates for any disease during the study period. In Barcelona, however, hospital admissions decreased by 10.2% (95% CI 3.8% to 16.1%) for cerebrovascular diseases and by 16.0% (95% CI 7.0% to 24.1%) for COPD. Substantial changes in effect estimates were observed on adjustment for linear or quadratic trend. Effect estimates for asthma-related admissions varied substantially when adjusting for pollen count in Madrid, and for seasonality and tobacco consumption in Barcelona.

CONCLUSIONS

Our results confirm that the potential impact of a smoking ban must be adjusted for the underlying secular trend. In asthma-related admissions, pollen count, seasonality and tobacco consumption must be specified in the model. The substantial variability in effects detected between the two cities of Madrid and Barcelona lends strong support for a nationwide study to assess the overall effect of a smoking ban in Spain and identify the causes of the observed heterogeneity.

Cardiovascular Events Following Smoke-Free Legislations: An Updated Systematic Review and Meta-Analysis

BACKGROUND

Legislations banning smoking in indoor public places and workplaces are being implemented worldwide to protect the population from secondhand smoke exposure. Several studies have reported reductions in hospitalizations for acute coronary events following the enactment of smoke-free laws.

OBJECTIVE

We set out to conduct a systematic review and meta-analysis of epidemiologic studies examining how legislations that ban smoking in indoor public places impact the risk of acute coronary events.

METHODS

We searched MEDLINE, EMBASE, and relevant bibliographies including previous systematic reviews for studies that evaluated changes in acute coronary events, following implementation of smoke-free legislations. Studies were identified through December 2013. We pooled relative risk (RR) estimates for acute coronary events comparing post- vs. pre-legislation using inverse-variance weighted random-effects models.

RESULTS

Thirty-one studies providing estimates for 47 locations were included. The legislations were implemented between 1991 and 2010. Following the enactment of smoke-free legislations, there was a 12 % reduction in hospitalizations for acute coronary events (pooled RR: 0.88, 95 % CI: 0.85-0.90). Reductions were 14 % in locations that implemented comprehensive legislations compared to an 8 % reduction in locations that only had partial restrictions. In locations with reductions in smoking prevalence post-legislation above the mean (2.1 % reduction) there was a 14 % reduction in events compared to 10 % in locations below the mean. The RRs for acute coronary events associated with enacting smoke-free legislation were 0.87 vs. 0.89 in locations with smoking prevalence pre-legislation above and below the mean (23.1 %), and 0.87 vs. 0.89 in studies from the Americas vs. other regions.

CONCLUSION

The implementation of smoke-free legislations was related to reductions in acute coronary event hospitalizations in most populations evaluated. Benefits are greater in locations with comprehensive legislations and with greater reduction in smoking prevalence post-legislation. These cardiovascular benefits reinforce the urgent need to enact and enforce smoke-free legislations that protect all citizens around the world from exposure to tobacco smoke in public places.

Trends in inequalities in health, risk and preventive behaviour among the advanced-age population in Austria: 1983-2007

Background

Although a number of previous research studies have focused on the long-term analysis of the health and health behaviour of the elderly, there is still a shortage of information in relation to the long-term trends regarding health or risk and preventive behaviour in the elderly population taking into account gender differences and differences in educational level.

Methods

The database comprised subsamples of the Austrian Micro-Census, including individuals aged 65 years and older, for the years 1983, 1991, 1999, and subsamples of the ATHIS (Austrian Health Interview Survey) 2007. A trend analysis was conducted for four health-related variables with the year of the survey and education as predictors. The analysis was stratified by sex.

Results

We found a general trend towards better self-rated health, better preventive and less risk behaviour among the elderly, while the body mass index has been increasing over the years. There are indeed gender differences regarding the trend in smoking behaviour. While the prevalence of male smoking has been steadily decreasing, female smoking prevalence has not changed. At all points in time, individuals with higher education had significantly better self-rated health than those with lower education but the association between education and preventive behaviour significantly decreased over the years.

Conclusion

We agree with previous research in concluding that preventive action and health promotion should aim in particular to support older women and men with lower education.

Impact of the 2005 smoke-free policy in Italy on prevalence, cessation and intensity of smoking in the overall population and by educational group

AIMS

To estimate the immediate as well as the longer-term impact of the 2005 smoke-free law on smoking prevalence, cessation and intensity both in the overall population and separately by educational level.

DESIGN

Interrupted time-series analyses of 11 cross-sectional nationally representative surveys.

SETTING

Italy, 1999-2010.

PARTICIPANTS

Adults aged 20-64 years.

MEASUREMENTS

For each year we computed the prevalence of current smoking, the quit ratio and the mean number of cigarettes smoked per day. All measures were standardized by age. Segmented linear regression analyses were performed for each smoking variable separately by sex.

FINDINGS

Among males, smoking prevalence decreased by 2.6% (P = 0.002) and smoking cessation increased by 3.3% (P = 0.006) shortly after the ban, but both measures tended to return to pre-ban values in the following years. This occurred among both highly and low-educated males. Among low-educated females, the ban was followed by a 1.6% decrease (P = 0.120) in smoking prevalence and a 4.5% increase in quit ratios (P < 0.001). However, these favourable trends reversed over the following years. Among highly educated females, trends in smoking prevalence and cessation were not altered by the ban. Among both males and females, long-term trends in the daily number of cigarettes, which were already declining well before the implementation of the policy, changed to a minor extent.

CONCLUSION

The impact of the Italian smoke-free policy on smoking and inequalities in smoking was short-term. Smoke-free policies may not achieve the secondary effect of reducing smoking prevalence in the long term, and they may have limited effects on inequalities in smoking.

Two decades of inequalities in smoking prevalence, initiation and cessation in a southern European region: 1986-2007

BACKGROUND

The smoking epidemic is still progressing in southern Europe. We aimed to analyse the magnitude and trend of social inequalities in smoking prevalence, initiation and cessation in the Basque Country, a southern European region, from 1986 to 2007, determining the patterns by sex and age.

METHODS

This was a cross-sectional time trend study on the population aged >24 years using the Basque Country Health Surveys of 1986, 1992, 1997, 2002 and 2007. Age-adjusted prevalence of current and ever smoking and cessation were calculated, as were relative index of inequality and population-attributable risk by occupational social class and educational level. Relative risk of starting smoking was estimated using Cox proportional hazard regression models. Calculations were performed separately by sex and for two age groups (25-44 years and >44 years).

RESULTS

Men and young women in the Basque Country have evolved towards the last stage of the epidemic, with an increasing concentration of smoking in disadvantaged groups, by educational level, especially among the youngest population. In older women, smoking continues rising, especially among higher socio-economic groups, though differences between groups are diminishing. The role of initiation and cessation inequalities as determinants of smoking inequalities differed considerably by age and sex.

CONCLUSION

Inequalities in smoking prevalence widened from 1986 to 2007 in the Basque Country, especially among the youngest population. The changing pattern of these inequalities and the different roles of initiation and cessation dynamics need to be taken into account to improve the results of tobacco control policies and their effect on smoking inequalities.

The application of observational data in translational medicine: analyzing tobacco-use behaviors of adolescents

Background

Translational Medicine focuses on “bench to bedside”, converting experimental results into clinical use. The “bedside to bench” transition remains challenging, requiring clinicians to define true clinical need for laboratory study. In this study, we show how observational data (an eleven-year data survey program on adolescent smoking behaviours), can identify knowledge gaps and research questions leading directly to clinical implementation and improved health care. We studied gender-specific trends (2000–2010) in Italian students to evaluate the specific impact of various anti-smoking programs, including evaluation of perceptions of access to cigarettes and health risk.

Methods

The study used, ESPAD-Italia® (European School Survey Project on Alcohol and other Drugs), is a nationally representative sample of high-school students. The permutation test for joinpoint regression was used to calculate the annual percent change in smoking. Changes in smoking habits by age, perceived availability and risk over a 11-year period were tested using a gender-specific logistic model and a multinomial model.

Results

Gender-stratified analysis showed 1) decrease of lifetime prevalence, then stabilization (both genders); 2) decrease in last month and occasional use (both genders); 3) reduction of moderate use (females); 4) no significant change in moderate use (males) and in heavy use (both genders). Perceived availability positively associates with prevalence, while perceived risk negatively associates, but interact with different effects depending on smoking patterns. In addition, government implementation of public policies concerning access to tobacco products in this age group during this period presented a unique background to examine their specific impact on behaviours.

Conclusion

Large observational databases are a rich resource in support of translational research. From these observations, key clinically relevant issues can be identified and form the basis for further clinical studies. The ability to identify patterns of behaviour and gaps in available data translates into new experiments, but also impacts development of public policy and reveals patterns of clinical reality. The observed global decrease in use is countered by stabilization in number of heavy smokers. Increased cigarette cost has not reduced use. While perceived risk of smoking may prevent initial experimentation, how government policies impact the perception of risk is not easily quantifiable.

Tendência temporal de tabagismo em população urbana: um estudo de base populacional no Sul do Brasil

Avaliou-se a tendência temporal da prevalência de tabagismo conforme renda familiar, idade e sexo entre indivíduos com 20 anos ou mais residentes em Pelotas, Rio Grande do Sul, Brasil. Cinco inquéritos de base populacional utilizando-se de setores censitários foram realizados na cidade entre 2002-2010. Considerou-se tabagismo o consumo de um ou mais cigarros por dia há pelo menos um mês. A tendência temporal foi avaliada por meio do teste de qui-quadrado para tendência linear. Os cinco inquéritos realizados incluíram 15.136 indivíduos. Neste período, a prevalência total de tabagismo caiu de 28% (25,8-30,4) em 2002 para 21% (19,5-23,5) em 2010. Esta queda de 23% foi semelhante entre os sexos, mas muito diferente em relação à renda familiar. Quanto menor a renda familiar, maior a prevalência de tabagismo. Entre 2002-2010, a taxa de redução do tabagismo foi de 26% no menor quintil de renda e de 39% no maior. Apesar das reduções observadas, a prevalência de tabagismo ainda é elevada, indicando a necessidade de fortalecer medidas de controle voltadas principalmente aos indivíduos com menor renda.

Effect of smoke-free legislation on adult smoking behaviour in England in the 18 months following implementation

Background

Comprehensive smoke-free legislation covering all enclosed public places and workplaces was implemented in England on 1 July 2007. This study examines the impact of this legislation on smoking prevalence, number of cigarettes smoked and location of smoking, controlling for secular trends through the end of 2008.

Method and Findings

Repeat cross sectional survey using nationally representative data from the Health Survey for England (HSE). In total there are 54,333 respondents from 2003–2008. Logit and linear regression models were used to examine the effect of the legislation on smoking prevalence and the number of cigarettes smoked daily among continuing smokers which took the underlying trend into account. Our finding suggest that smoking prevalence (current smoker) decreased from 25% in 2003 to 21% in 2008 (AOR = 0.96 per year, 95% CI = 0.95–0.98, P<0.01) and the mean number of cigarettes consumed daily by smokers decreased from 14.1 in 2003 to 13.1 in 2008 (coefficient for time trend = −0.28±0.06 SE cig/day per year, P<0.01). After adjusting for these trends the introduction of smoke-free legislation was not associated with additional reductions in smoking prevalence (AOR = 1.02, 95% CI = 0.94–1.11, P = 0.596) or daily cigarette use in smokers (0.42±0.28 SE; P = 0.142). The percentage of respondents reporting smoking ‘at work’ and ‘inside pubs or bars’ decreased significantly from 14% to 2% (p<0.001) and from 34% to 2% (p<0.001), respectively, after the legislation. The percentage reporting smoking ‘inside restaurants, cafes, or canteens’ decreased significantly from 9% to 1% (p<0.001) and ‘inside their home’ decreased significantly from 65% to 55% (p<0.01).

Conclusion

There is widespread compliance with the smoke-free legislation in England, which has led to large drops in indoor smoking in all venues, including at home. Declines in smoking prevalence and consumption continued along existing trends; they did not accelerate during the 18 months immediately following implementation.