New Zealand's tobacco control programme 1985-1998

Incidence, trends, and survival of oropharyngeal squamous cell cancer in Aotearoa New Zealand, 2006-2020

BACKGROUND

An increasing trend of oropharyngeal cancer (OPC) has been reported in several countries with different demographic characteristics, and often attributed to increases in human papillomavirus (HPV) infection. The survival of patients with OPC has steadily improved, especially for those with positive HPV status. This study assessed the incidence, trends, and survival of OPC in Aotearoa New Zealand (NZ) by age at diagnosis, sex and ethnicity.

METHODS

The study included all 2109 patients resident in NZ with a primary diagnosis of oropharyngeal squamous cell carcinoma from 2006 to 2020, identified from the National Cancer Registry. We assessed age-standardised incidence rate (ASR), annual percent change (APC) and overall and relative survival rates.

RESULTS

The average annual incidence of OPC was 2.2 per 100,000 population. There was a steady increase of 4.9% per year over 15 years. Although the incidence rates were higher in males over the study period, the overall rate of increase was similar in males (4.9%) and in females (4.3%). The incidence was highest in the 50-69-year group (8.8/100,000 population). This age group had an incidence that increased by 7.5% per year to 2018, and then declined. The main increase in rates was seen between the birth cohort of 1946-50 and that of 1956-60. The increase in incidence was seen in Māori and Pākehā/European populations, but no increase was seen in Pacific or Asian populations. The 5-year overall relative survival rate improved from 69% in 2006-13 to 78% in 2014-20. Survival rates were lower in older patients, females, and Māori patients.

CONCLUSION

This study confirmed a substantial increase in OPC incidence in NZ, with some evidence to suggest a recent slowing in this increase. Māori and Pākehā/European had the highest incidence, while Pacific and Asian populations showed the lowest rates and no increase over the study period. Survival rates have improved over time, but remained lower in some demographic groups.

Peptic ulcer disease among dyspeptic patients at endoscopy unit, University of Gondar hospital, Northwest Ethiopia

Background

Dyspepsia is a common complaint in upper gastrointestinal disorders. It is described as predominant epigastric pain lasting for at least one month. Globally, peptic ulcer disease occurs in 3.5–32% of patients with dyspepsia. Helicobacter pylori (H. pylori) infection and non-steroidal anti-inflammatory drugs/aspirin use are the widely known risk factors for peptic ulcer disease. There was no recent document on H. pylori infection rate among patients with peptic ulcer disease in Ethiopia. This study aimed to determine magnitude and associated factors of peptic ulcer disease among dyspeptic patients in Northwest Ethiopia.

Methods

An institutional-based cross sectional study was conducted at the University of Gondar hospital, Northwest Ethiopia. A convenience sampling method was used to recruit 218 study subjects. A pre-designed semi-structured questionnaire was used to extract clinical information. Olympus flexible fiber-optic endoscope (Olympus, GIF-E 600, Olympus Corp., Hamburg, Germany) was used to confirm the presence of peptic ulcer disease. Diagnosis of active H. pylori infection was made using the fecal H. pylori Antigen 25 T Card Test (Anamol Lab., Pvt. Ltd., Palghar, India). The Data were entered into EPI Info version 4.6.0.2, and then exported to SPSS version 20 for analysis. Explanatory variables associated with peptic ulcer disease were analyzed by applying logistic regression model. P value < 0.05 was used to declare significant association.

Result

A total of 218 dyspeptic patients who underwent upper gastrointestinal endoscopic evaluations were included in the study. The mean (+ SD) age of patients was 42 ± 16.4 years. Forty nine percent (95% CI 42.4–56.2) of dyspeptic patients had active H. pylori infection. Peptic ulcer disease was diagnosed in 35% (95% CI 31.4–39.2) of patients with dyspepsia. H. pylori infection (AOR = 6.298, 95% CI 2.965–13.378, P value <  0.001) and NSAIDs/ASA use (AOR = 6.252, 95% CI 2.925–13.362, P value <  0.001) were identified as risk factors for peptic ulcer disease.

Conclusion

Medical treatment of peptic ulcer disease should target treatment of H. pylori infection and cautious use of non-steroidal anti-inflammatory drugs/aspirin.

Cigarette consumption estimates for 71 countries from 1970 to 2015: systematic collection of comparable data to facilitate quasi-experimental evaluations of national and global tobacco control interventions

OBJECTIVES

To collect, appraise, select, and report the best available national estimates of cigarette consumption since 1970.

DESIGN

Systematic collection of comparable data.

SETTING AND POPULATION

71 of 214 countries for which searches for national cigarette consumption data were conducted, representing over 95% of global cigarette consumption and 85% of the world's population.

MAIN OUTCOME MEASURES

Validated cigarette consumption data covering 1970-2015 were identified for 71 countries. Data quality appraisal was conducted by two research team members in duplicate, with greatest weight given to official government sources. All data were standardised into units of cigarettes consumed per year in each country, a detailed accounting of data quality and sourcing was prepared, and all collected data and metadata were made freely available in an open access dataset.

RESULTS

Cigarette consumption fell in most countries over the past three decades but trends in country specific consumption were highly variable. For example, China consumed 2.5 million metric tonnes (MMT) of cigarettes in 2013, more than Russia (0.36 MMT), the United States (0.28 MMT), Indonesia (0.28 MMT), Japan (0.20 MMT), and the next 35 highest consuming countries combined. The US and Japan achieved reductions of more than 0.1 MMT from a decade earlier, whereas Russian consumption plateaued, and Chinese and Indonesian consumption increased by 0.75 MMT and 0.1 MMT, respectively. These data generally concord with modelled country level data from the Institute for Health Metrics and Evaluation and have the additional advantage of not smoothing year-over-year discontinuities that are necessary for robust quasi-experimental impact evaluations.

CONCLUSIONS

Before this study, publicly available data on cigarette consumption have been limited; they have been inappropriate for quasi-experimental impact evaluations (modelled data), held privately by companies (proprietary data), or widely dispersed across many national statistical agencies and research organisations (disaggregated data). This new dataset confirms that cigarette consumption has decreased in most countries over the past three decades, but that secular country specific consumption trends are highly variable. The findings underscore the need for more robust processes in data reporting, ideally built into international legal instruments or other mandated processes. To monitor the impact of the WHO Framework Convention on Tobacco Control and other tobacco control interventions, data on national tobacco production, trade, and sales should be routinely collected and openly reported.

Proximate determinants of tuberculosis in Indigenous peoples worldwide: a systematic review

BACKGROUND

Indigenous peoples worldwide carry a disproportionate tuberculosis burden. There is an increasing awareness of the effect of social determinants and proximate determinants such as alcohol use, overcrowding, type 1 and type 2 diabetes, substance misuse, HIV, food insecurity and malnutrition, and smoking on the burden of tuberculosis. We aimed to understand the potential contribution of such determinants to tuberculosis in Indigenous peoples and to document steps taken to address them.

METHODS

We did a systematic review using seven databases (MEDLINE, Embase, CINAHL, Global Health, BIOSIS Previews, Web of Science, and the Cochrane Library). We identified English language articles published from Jan 1, 1980, to Dec 20, 2017, reporting the prevalence of proximate determinants of tuberculosis and preventive programmes targeting these determinants in Indigenous communities worldwide. We included any randomised controlled trials, controlled studies, cohort studies, cross-sectional studies, case reports, and qualitative research. Exclusion criteria were articles in languages other than English, full text not available, population was not Indigenous, focused exclusively on children or older people, and studies that focused on pharmacological interventions.

FINDINGS

Of 34 255 articles identified, 475 were eligible for inclusion. Most studies confirmed a higher prevalence of proximate determinants in Indigenous communities than in the general population. Diabetes was more frequent in Indigenous communities within high-income countries versus in low-income countries. The prevalence of alcohol use was generally similar to that among non-Indigenous groups, although patterns of drinking often differed. Smoking prevalence and smokeless tobacco consumption were commonly higher in Indigenous groups than in non-Indigenous groups. Food insecurity was highly prevalent in most Indigenous communities evaluated. Substance use was more frequent in Indigenous inhabitants of high-income countries than of low-income countries, with wide variation across Indigenous communities. The literature pertaining to HIV, crowding, and housing conditions among Indigenous peoples was too scant to draw firm conclusions. Preventive programmes that are culturally appropriate targeting these determinants appear feasible, although their effectiveness is largely unproven.

INTERPRETATION

Indigenous peoples were generally reported to have a higher prevalence of several proximate determinants of tuberculosis than non-Indigenous peoples, with wide variation across Indigenous communities. These findings emphasise the need for community-led, culturally appropriate strategies to address smoking, food insecurity, and diabetes in Indigenous populations as important public health goals in their own right, and also to reduce the burden of tuberculosis.

FUNDING

Canadian Institutes of Health Research.

Mass media interventions for smoking cessation in adults

BACKGROUND

Mass media tobacco control campaigns can reach large numbers of people. Much of the literature is focused on the effects of tobacco control advertising on young people, but there are also a number of evaluations of campaigns targeting adult smokers, which show mixed results. Campaigns may be local, regional or national, and may be combined with other components of a comprehensive tobacco control policy.

OBJECTIVES

To assess the effectiveness of mass media interventions in reducing smoking among adults.

SEARCH METHODS

The Cochrane Tobacco Addiction Group search strategy was combined with additional searches for any studies that referred to tobacco/smoking cessation, mass media and adults. We also searched the Cochrane Central Register of Controlled Trials (CENTRAL) and a number of electronic databases. The last search was carried out in November 2016.

SELECTION CRITERIA

Controlled trials allocating communities, regions or states to intervention or control conditions; interrupted time series.Adults, 25 years or older, who regularly smoke cigarettes. Studies which cover all adults as defined in studies were included.Mass media are defined here as channels of communication such as television, radio, newspapers, billboards, posters, leaflets or booklets intended to reach large numbers of people, and which are not dependent on person-to-person contact. The purpose of the mass media campaign must be primarily to encourage smokers to quit. They could be carried out alone or in conjunction with tobacco control programmes.The primary outcome was change in smoking behaviour. This could be reported as changes in prevalence, changes in cigarette consumption, quit rates, or odds of being a smoker.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed all studies for inclusion criteria and for study quality (MB, LS, RTM). One author (MB) extracted data, and a second author (LS) checked them.Results were not pooled due to heterogeneity of the included studies and are presented narratively and in table form.

MAIN RESULTS

Eleven campaigns met the inclusion criteria for this review. Studies differed in design, settings, duration, content and intensity of intervention, length of follow-up, methods of evaluation and also in definitions and measures of smoking behaviour used. Among seven campaigns reporting smoking prevalence, significant decreases were observed in the California and Massachusetts statewide tobacco control campaigns compared with the rest of the USA. Some positive effects on prevalence in the whole population or in the subgroups were observed in three of the remaining seven studies. Three large-scale campaigns of the seven presenting results for tobacco consumption found statistically significant decreases. Among the eight studies presenting abstinence or quit rates, four showed some positive effect, although in one of them the effect was measured for quitting and cutting down combined. Among the three that did not show significant decreases, one demonstrated a significant intervention effect on smokers and ex-smokers combined.

AUTHORS' CONCLUSIONS

There is evidence that comprehensive tobacco control programmes which include mass media campaigns can be effective in changing smoking behaviour in adults, but the evidence comes from a heterogeneous group of studies of variable methodological quality. One state-wide tobacco control programme (Massachusetts) showed positive results up to eight years after the campaign. Another (California) showed positive results during the period of adequate funding and implementation and in final evaluation since the beginning of the programme. Six of nine studies carried out in communities or regions showed some positive effects on smoking behaviour and at least one significant change in smoking prevalence (Sydney). The intensity and duration of mass media campaigns may influence effectiveness, but length of follow-up and concurrent secular trends and events can make this difficult to quantify. No consistent relationship was observed between campaign effectiveness and age, education, ethnicity or gender.

Impacto de la política de control de tabaco en población adolescente en Uruguay

Objetivo. Analizar la evolución de la prevalencia del consumo de tabaco, comparando los datos obtenidos en la Encuesta Mundial de Tabaquismo en Jóvenes en sus ediciones 2007 y 2014. Material y métodos. Se compararon los datos de la Encuesta Mundial de Tabaquismo en Jóvenes 2007 y 2014. También se analizaron las medidas de control de tabaco adoptadas en el periodo considerado. Resultados. Los datos muestran un descenso en el consumo de cigarrillos a 30 días en población de 13 a 15 años: de 20.2% en 2007 a 8.2% en 2014. No se encontraron diferencias significativas entre los sexos. La susceptibilidad de convertirse en fumador en el próximo año se redujo de 25.8% en 2007 a 16.6% en 2014. Conclusiones. La implementación, en forma simultánea, de medidas contenidas en el Convenio Marco de la OMS para el Control del Tabaco es una estrategia eficaz para alcanzar los objetivos de reducción de la prevalencia del consumo.

Lung cancer epidemiology: contemporary and future challenges worldwide

Over the last century, lung cancer from the rarest of diseases became the biggest cancer killer of men worldwide and in some parts of the world also of women (North America, East Asia, Northern Europe, Australia and New Zealand). In 2012 over 1.6 million of people died due to lung cancer. The cause-effect relationship between tobacco smoking and lung cancer occurrence has been proven in many studies, both ecological and clinical. In global perspective one can see the increasing tobacco consumption trend followed by ascending trends of lung cancer mortality, especially in developing countries. In some more developed countries, where the tobacco epidemics was on the rise since the beginning of the 20th century and peaked in its mid, in male population lung cancer incidence trend reversed or leveled off. Despite predicted further decline of incidence rates, the absolute number of deaths will continue to grow in these countries. In the remaining parts of the world the tobacco epidemics is still evolving what brings rapid increase of the number of new lung cancer cases and deaths. Number of lung cancer deaths worldwide is expected to grow up to 3 million until 2035. The figures will double both in men (from 1.1 million in 2012 to 2.1 million in 2035) and women (from 0.5 million in 2012 to 0.9 million in 2035) and the two-fold difference between sexes will persist. The most rapid increase is expected in Africa region (AFRO) and East Mediterranean region (EMRO). The increase of the absolute number of lung cancer deaths in more developed countries is caused mostly by population aging and in less developed countries predominantly by the evolving tobacco epidemic.

Sister chromatid exchange, (SCE), High-Frequency Cells (HFCs) and SCE distribution patterns in peripheral blood lymphocytes of Spanish adult smokers compared to non-smokers

According to the International Agency for Research on Cancer, smoking tobacco is a major cause of cancer in humans. It causes about half of all male cancer deaths and an ever increasing number of cancer deaths in females. The aim of this study was to establish whether cigarette smoking increases sister chromatid exchanges (SCEs) in peripheral blood lymphocytes in two Spanish population groups; light and heavy smokers. The mean number of High-Frequency Cells (HFCs) was determined and, the SCE distribution pattern among the chromosomes was analysed represented by a ratio described below. A local sample of 101 adult smokers (n=48) and non-smokers (n=53), aged from 18 to 49 years, was studied using SCE levels in peripheral lymphocytes. Heavy smoking (≥ 10 cigarettes per day) increased significantly the SCE frequency and the HFC parameters. Neither age nor sex significantly influenced the frequencies in the groups studied.

Mass media interventions for smoking cessation in adults

BACKGROUND

Mass media tobacco control campaigns can reach large numbers of people. Much of the literature is focused on the effects of tobacco control advertising on young people, but there are also a number of evaluations of campaigns targeting adult smokers, which show mixed results. Campaigns may be local, regional or national, and may be combined with other components of a comprehensive tobacco control policy.

OBJECTIVES

To assess the effectiveness of mass media interventions in reducing smoking among adults.

SEARCH METHODS

The Cochrane Tobacco Addiction Group search strategy was combined with additional searches for any studies that referred to tobacco/smoking cessation, mass media and adults. We also searched the Cochrane Register of Controlled Trials (CENTRAL) and a number of electronic databases. The last search was carried out in February 2013.

SELECTION CRITERIA

Controlled trials allocating communities, regions or states to intervention or control conditions; interrupted time series. Adults, 25 years or older, who regularly smoke cigarettes. Studies which cover all adults as defined in studies were included. Mass media are defined here as channels of communication such as television, radio, newspapers, billboards, posters, leaflets or booklets intended to reach large numbers of people, and which are not dependent on person-to-person contact. The purpose of the mass media campaign must be primarily to encourage smokers to quit. They could be carried out alone or in conjunction with tobacco control programmes. The primary outcome was change in smoking behaviour. This could be reported as changes in prevalence, changes in cigarette consumption, quit rates, odds of being a smoker.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed all studies for inclusion criteria and for study quality. One author (MB) extracted data, and a second author (LS) checked them.Results were not pooled due to heterogeneity of the included studies and are presented narratively and in table form.

MAIN RESULTS

Eleven campaigns met the inclusion criteria for this review. Studies differed in design, settings, duration, content and intensity of intervention, length of follow-up, methods of evaluation and also in definitions and measures of smoking behaviour used. Among nine campaigns reporting smoking prevalence, significant decreases were observed in the California and Massachusetts statewide tobacco control campaigns compared with the rest of the USA. Some positive effects on prevalence in the whole population or in the subgroups were observed in three of the remaining seven studies. Three large-scale campaigns of the seven presenting results for tobacco consumption found statistically significant decreases. Among the seven studies presenting abstinence or quit rates, four showed some positive effect, although in one of them the effect was measured for quitting and cutting down combined. Among the three that did not show significant decreases, one demonstrated a significant intervention effect on smokers and ex-smokers combined.

AUTHORS' CONCLUSIONS

There is evidence that comprehensive tobacco control programmes which include mass media campaigns can be effective in changing smoking behaviour in adults, but the evidence comes from a heterogeneous group of studies of variable methodological quality. One state-wide tobacco control programme (Massachusetts) showed positive results up to eight years after the campaign. Another (California) showed positive results during the period of adequate funding and implementation and in final evaluation since the beginning of the programme. Six of nine studies carried out in communities or regions showed some positive effects on smoking behaviour and at least one significant change in smoking prevalence (Sydney). The intensity and duration of mass media campaigns may influence effectiveness, but length of follow-up and concurrent secular trends and events can make this difficult to quantify. No consistent relationship was observed between campaign effectiveness and age, education, ethnicity or gender.

Interventions for smoking cessation in Indigenous populations

BACKGROUND

Tobacco use in Indigenous populations (people who have inhabited a country for thousands of years) is often double that of the non-Indigenous population. A disproportionate burden of substance-related morbidity and mortality exists as a result.

OBJECTIVES

To evaluate the effectiveness of smoking cessation interventions in Indigenous populations and to summarise these approaches for future cessation programmes and research.

SEARCH METHODS

The Cochrane Tobacco Addiction Group Specialised Register of Trials was searched (April 2011), with additional searches of MEDLINE (May 2011). Online clinical trial databases and publication references were also searched for potential studies.

SELECTION CRITERIA

We included randomized and non-randomized controlled trials for smoking cessation interventions in Indigenous populations. Interventions could include pharmacotherapies, cognitive and behavioural therapies, alternative therapies, public policy and combination therapies. No attempts were made to re-define Indigenous status for the purpose of including a study in this review.

DATA COLLECTION AND ANALYSIS

Data pertaining to methodology, participants, interventions and outcomes were extracted by one reviewer and checked by a second, whilst methodological quality was extracted independently by two reviewers. Studies were assessed by qualitative narrative synthesis and where possible meta-analysis. The review process was examined by an Indigenous (Aboriginal) Australian for applicability, acceptability and content.

MAIN RESULTS

Four studies met all of the eligibility criteria for inclusion within the review. Two used combination therapies consisting of a pharmacotherapy combined with cognitive and behavioural therapies, whilst the remaining two used cognitive and behavioural therapy through counselling, one via text message support and the other delivered via clinic doctors trained in smoking cessation techniques. Smoking cessation data were pooled across all studies producing a statistically and clinically significant effect in favour of the intervention (risk ratio 1.43, 95%CI 1.03 to 1.98, p=0.032), however following sensitivity analysis a statistically non-significant but clinically significant effect was observed in favour of the intervention (risk ratio 1.33, 95%CI 0.95 to 1.85, p=NS) .

AUTHORS' CONCLUSIONS

A significant health disparity exists, whereby Indigenous populations, a minority, are over-represented in the burden of smoking-related morbidity and mortality. This review highlights the paucity of evidence available to evaluate the effectiveness of smoking cessation interventions, despite the known success of these interventions in non-Indigenous populations. Due to this lack of published investigations, the external validity of this review is limited, as is the ability to draw reliable conclusions from the results. The limited but available evidence reported does indicate that smoking cessation interventions specifically targeted at Indigenous populations can produce smoking abstinence. However this evidence base is not strong with a small number of methodologically sound trials investigating these interventions. More rigorous trials are now required to assist in bridging the gap between tobacco related health disparities in Indigenous and non-Indigenous populations.

Mass media interventions for smoking cessation in adults

BACKGROUND

Mass media tobacco control campaigns can reach large numbers of people. Much of the literature is focused on the effects of tobacco control advertising on young people, but there are also a number of evaluations of campaigns targeting adult smokers, which show mixed results. Campaigns may be local, regional or national, and may be combined with other components of a comprehensive tobacco control policy.

OBJECTIVES

To assess the effectiveness of mass media interventions in reducing smoking among adults.

SEARCH STRATEGY

The Cochrane Tobacco Addiction Group search strategy was combined with additional searches for any studies that referred to tobacco/smoking cessation, mass media and adults. We also searched the Cochrane Register of Controlled Trials (CENTRAL) and a number of electronic databases. The last search was carried out in March 2007.

SELECTION CRITERIA

Controlled trials allocating communities, regions or states to intervention or control conditions; interrupted time series.Adults, 25 years or older, who regularly smoke cigarettes. Studies which cover all adults as defined in studies were included. Mass media are defined here as channels of communication such as television, radio, newspapers, billboards, posters, leaflets or booklets intended to reach large numbers of people, and which are not dependent on person-to-person contact. The purpose of the mass media campaign must be primarily to encourage smokers to quit. They could be carried out alone or in conjunction with tobacco control programmes.The primary outcome was change in smoking behaviour. This could be reported as changes in prevalence, changes in cigarette consumption, quit rates, odds of being a smoker.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed all studies for inclusion criteria and for study quality. One author (MB) extracted data, and a second author (LS) checked them.Results were not pooled due to heterogeneity of included studies and are presented narratively and in table form.

MAIN RESULTS

Eleven campaigns met the inclusion criteria for this review. Studies differed in design, settings, duration, content and intensity of intervention, length of follow up, methods of evaluation and also in definitions and measures of smoking behaviour used. Among nine campaigns reporting smoking prevalence, significant decreases were observed in the California and Massachusetts statewide tobacco control campaigns compared with the rest of the USA. Some positive effects on prevalence in the whole population or in the subgroups were observed in three of the remaining seven studies. Three large-scale campaigns of the seven presenting results for tobacco consumption found statistically significant decreases. Among the seven studies presenting abstinence or quit rates, four showed some positive effect, although in one of them the effect was measured for quitting and cutting down combined. Among the three that did not show significant decreases, one demonstrated a significant intervention effect on smokers and ex-smokers combined.

AUTHORS' CONCLUSIONS

There is evidence that comprehensive tobacco control programmes which include mass media campaigns can be effective in changing smoking behaviour in adults, but the evidence comes from a heterogeneous group of studies of variable methodological quality. One state-wide tobacco control programme (Massachusetts) showed positive results up to eight years after the campaign, while another (California) showed positive results only during the period of adequate funding and implementation. Six of nine studies carried out in communities or regions showed some positive effects on smoking behaviour and at least one significant change in smoking prevalence (Sydney). The intensity and duration of mass media campaigns may influence effectiveness, but length of follow up and concurrent secular trends and events can make this difficult to quantify. No consistent relationship was observed between campaign effectiveness and age, education, ethnicity or gender.

Could mainstream anti-smoking programs increase inequalities in tobacco use? New Zealand data from 1981-96

OBJECTIVE

To examine changes in the socio-economic and ethnic distribution of smoking in the New Zealand population from 1981 to 1996, and to consider the implication of these data for policies aimed at reducing tobacco consumption.

METHODS

Cross-sectional data were taken from 4.7 million respondents to the 1981 and 1996 New Zealand Censuses and 4,619 participants in a 1989 national survey, aged 15 to 79 years. Smoking prevalence rates were calculated by socio-economic position and ethnicity.

RESULTS

Smoking prevalence fell in the period 1981-96 in every population group. However, socio-economic and ethnic differences in smoking increased in relative terms. Smoking prevalence ratios comparing the least advantaged with the most advantaged groups increased in men from 1.20 to 1.53 by income, 1.54 to 1.85 by education, and 1.49 to 1.67 by ethnicity. In women, prevalence ratios increased from 1.17 to 1.51 by income, 1.55 to 2.02 by education, and 1.85 to 2.20 by ethnicity. The greatest increase in socio-economic differences may have occurred during the 1980s, the period of greatest overall decline in total population smoking.

CONCLUSIONS

Socio-economic and ethnic disparities in New Zealanders' smoking patterns increased during the 1980s and '90s, a period of significant decline in overall smoking prevalence.

IMPLICATIONS

Public health programs aimed at reducing tobacco use should pay particular attention to disadvantaged, Indigenous and ethnic minority groups in order to avoid widening relative inequalities in smoking and smoking-related health outcomes.

Population level policy options for increasing the prevalence of smokefree homes

OBJECTIVE

To identify and evaluate the options for population level government policies to increase the prevalence of homes free of secondhand smoke.

METHODS

The literature was searched for population level policy options and evidence on them. Three criteria were used to evaluate the policy options: effectiveness, the reductions on inequalities in secondhand smoke exposure, and cost effectiveness. The setting was four developed, English speaking jurisdictions: Britain, USA, Australia, and New Zealand.

RESULTS

Evidence from all four countries shows some association between relatively comprehensive tobacco control programmes and lower prevalence levels of smoking in homes. The evidence of the effect of such programmes on inequalities in smokefree home prevalence is limited. No published evidence was found of the cost effectiveness of the programmes in achieving changes in smokefree homes. Within comprehensive programmes, there is some indirect evidence that some mass media campaigns could increase the prevalence of smokefree homes. Structural options that have potential to support smokefree homes include smokefree places legislation, and laws for the protection of children.

CONCLUSION

The available evidence to date suggests that comprehensive tobacco control programmes (to reduce the prevalence of smoking in the total population) are likely to be the most effective and sustainable option for increasing the prevalence of smokefree homes.

What are the effects of tobacco policies on vulnerable populations? A better practices review

BACKGROUND

While comprehensive tobacco policies have reduced the prevalence of smoking in Canada, some groups remain vulnerable to tobacco use and display high rates of smoking. This article reviews three types of tobacco policies--tax and price, smoking location restrictions and sales restrictions--and examines the consequences for Aboriginal people, youth and low-income people.

METHODS

A better practices review model was used to assess the strength of studies published between 1990 and 2004 that examined the effects of these tobacco policies on the three vulnerable populations of interest. A total of 72 studies were assessed and 42 judged medium or high strength. A gender-based and diversity analysis was applied to assess the differential impacts on females and males and/or diverse characteristics within these populations. Intended and unintended consequences were examined.

FINDINGS

Few studies assessed the potential or differential effects of tobacco policies on the three selected populations. In these, it was difficult to disentangle the effects of each policy in a comprehensive tobacco control environment, and there is need for improved indicators and greater attention to sex and gender analysis.

CONCLUSIONS

Research is required to measure the intended and unintended impacts of tobacco policies on populations vulnerable to tobacco use. There are problems in assessing these studies that could be resolved with more precise indicator development. An equity-based framework for assessing the effects of tobacco policies is needed that is conceptually linked to health determinants and inequities. The article concludes with a set of recommendations for research, evaluation, policy and ethics arising from this review.

Trends in Ethnic Disparities in Stroke Incidence in Auckland, New Zealand, During 1981 to 2003

Background and Purpose— Although geographical variations in stroke rates are well documented, limited data exist on temporal trends in ethnic-specific stroke incidence.

Methods— We assessed trends in ethnic-specific stroke rates using standard diagnostic criteria and community-wide surveillance procedures in Auckland, New Zealand (NZ) in 1981 to 1982, 1991 to 1992, and 2002 to 2003. Indirect and direct methods were used to adjust first-ever (incident) and total (attack) rates for changes in the structure of the population and reported with 95% CIs. Ethnicity was self-defined and categorized as “NZ/European,” “Maori,” “Pacific peoples,” and “Asian and other.”

Results— Stroke attack (19%; 95% CI, 11% to 26%) and incidence rates (19%; 95% CI, 12% to 24%) declined significantly in NZ/Europeans from 1981 to 1982 to 2002 to 2003. These rates remained high or increased in other ethnic groups, particularly for Pacific peoples in whom stroke attack rates increased by 66% (95% CI; 11% to 225%) over the periods. Some favorable downward trends in vascular risk factors, such as cigarette smoking, were counterbalanced by increasing age, body mass index, and diabetes in certain ethnic groups.

Conclusions— Divergent trends in ethnic-specific stroke incidence and attack rates, and of associated risk factors, have occurred in Auckland over recent decades. The findings provide mixed views as to the future burden of stroke in populations undergoing similar lifestyle and structural changes.

Implementation failures in the use of two New Zealand laws to control the tobacco industry: 1989-2005

BACKGROUND

We reviewed the implementation of New Zealand laws in relation to the activities of the tobacco industry and their allies. Material for two brief case studies was obtained from correspondence with official agencies, official information requests, internet searches (tobacco industry documents and official government sites), and interviews with 12 key informants.

RESULTS

The first case study identified four occasions over a period of 14 years where New Zealand Government agencies appeared to fail to enforce consumer protection law, although apparent breaches by the tobacco industry and their allies had occurred in relation to statements on the relative safety of secondhand smoke. The second case study examined responses to a legal requirement for the tobacco industry to provide information on tobacco additives. There was failure to enforce the law, and a failure of the political process for at least 13 years to clarify and strengthen the law. Relevant factors in both these cases of 'policy slippage' appear to have been financial and opportunity costs of taking legal action, political difficulties and the fragmented nature of government structures.

CONCLUSION

Considered together, these case studies suggest the need for governments to: (i) make better use of national consumer laws (with proper monitoring and enforcement) in relation to tobacco; and (ii) to strengthen international law and resources around tobacco-related consumer protection. A number of options for achieving these aims are available to governments.

The smoking–mortality association varies over time and by ethnicity in New Zealand

BACKGROUND

The strength of the smoking-mortality association may vary over time and by ethnic group.

METHODS

Cohort studies of 1.6 million (1981-84) and 1.9 million (1996-99) New Zealanders aged 25-74 years were formed by the linkage of census and mortality data. Comparing current smokers with never smokers, standardized rate ratios (RRs) and rate differences (RDs) were calculated for all-cause and ischaemic heart disease (IHD) mortality.

RESULTS

Between 1981-84 and 1996-99 the all-cause mortality RR increased from 1.59 (95% CI 1.53-1.66) to 2.05 (1.97-2.14) for men and from 1.49 (1.42-1.56) to 2.01 (1.91-2.12) for women. All-cause RRs were significantly greater among non-Ma-ori non-Pacific than Ma-ori: 2.22 (2.12-2.33) compared with 1.51 (1.35-1.69) in men and 2.20 (2.09-2.33) compared with 1.45 in women (1.27-1.66), respectively, in 1996-99. This RR heterogeneity remained after adjusting for socio-economic factors and was similar for IHD. The RDs demonstrated less heterogeneity. For example, in 1996-99 the RDs were 627 per 100,000 (452-802) for Ma-ori compared with 464 (427-502) for non-Ma-ori non-Pacific among men, and 368 (228-509) compared with 340 (311-370) among women.

CONCLUSIONS

In New Zealand the relative effect of smoking on mortality differs over time and by ethnicity. We expect that such heterogeneity exists in other countries where the background mortality rates vary over time or between social groups. Information on this heterogeneity, including ethnicity-specific data, is needed to accurately determine the mortality burden owing to tobacco. The size of the RR estimates should be interpreted in the context of absolute mortality and effect measures.

Adult tobacco use levels after intensive tobacco control measures: New York City, 2002-2003

OBJECTIVES

We sought to determine the impact of comprehensive tobacco control measures in New York City.

METHODS

In 2002, New York City implemented a tobacco control strategy of (1) increased cigarette excise taxes; (2) legal action that made virtually all work-places, including bars and restaurants, smoke free; (3) increased cessation services, including a large-scale free nicotine-patch program; (4) education; and (5) evaluation. The health department also began annual surveys on a broad array of health measures, including smoking.

RESULTS

From 2002 to 2003, smoking prevalence among New York City adults decreased by 11% (from 21.6% to 19.2%, approximately 140000 fewer smokers). Smoking declined among all age groups, race/ethnicities, and education levels; in both genders; among both US-born and foreign-born persons; and in all 5 boroughs. Increased taxation appeared to account for the largest proportion of the decrease; however, between 2002 and 2003 the proportion of cigarettes purchased outside New York City doubled, reducing the effective price increase by a third.

CONCLUSIONS

Concerted local action can sharply reduce smoking prevalence. However, further progress will require national action, particularly to increase cigarette taxes, reduce cigarette tax evasion, expand education and cessation services, and limit tobacco marketing.

Smoking prevalence, smoking-related lung diseases, and national tobacco control legislation

OBJECTIVES

To review statistics on smoking prevalence and to analyze whether the implementation of national tobacco control legislation had an association with the prevalence of smoking, and thereby, with the occurrence of smoking-related lung diseases.

DESIGN

Smoking prevalence rates (from 1960 to 2000), lung cancer incidence rates (from 1980 to 2000), and respiratory disease mortality rates (from 1980 to 1998) were obtained from Finnish national surveys and registers. Regression models with 20-year lag times for disease occurrence were applied in the statistical analysis.

RESULTS

Daily smoking prevalence among men decreased continuously from 58 to 28% in the period from 1960 to 2000. Between 1965 and 1971, male lung cancer incidence was still on the increase, but from 1971 it decreased from 80 to 32 per 100,000 men. The male respiratory disease mortality rate declined steeply during the study period. From 1960 to 1973, women's smoking prevalence increased from 12 to 20%. At the introduction of the tobacco control bill in 1975, the increase leveled off and female smoking prevalence slightly decreased, but then rose again after 1985 to remain at 20%. Lung cancer incidence among women increased throughout the study period, but the gradient of the curve lowered in the 1980s.

CONCLUSIONS

National legislative actions were found to be associated with a change in smoking prevalence among women from a linear rise to a plateau. The results of the present study showed a very strong association between reduced smoking prevalence and the occurrence of lung cancer.

The effects of tobacco control policies on smoking rates: a tobacco control scorecard

This article reviews studies of the effect of tobacco control policies on smoking rates with the aim of providing guidance on the importance of different policies. Based on past studies, we estimate the magnitude of effects of major tobacco control policies, how their effects depend on the manner in which the policies are implemented, the relationship between the different policies, and the barriers to implementation. The most successful campaigns have implemented a combination of tobacco control policies. Of those policies, substantial evidence indicates that higher taxes and clean air laws can have a large impact on smoking rates. Evidence also indicates that media campaigns when implemented with other policies are important. Research on greater access to treatment and telephone support hotlines indicates a strong potential to increase quit rates and may be important in affecting heavier smokers. Direct evidence on the effects of advertising bans and health warnings is mixed, but these policies appear to be important in some of the countries that have had success in reducing smoking rates. School education programs and limits on retail sales are not likely to have much impact if implemented alone, but may be more important when combined with other policies.

Sustaining dietary changes for preventing obesity and diabetes: lessons learned from the successes of other epidemic control programs

A degree of success has been achieved in controlling several epidemics of infectious and non-infectious causes of death in countries, such as, Australia and New Zealand. Using the epidemiological triad (host, vector, environment) as a model, the key components of the control of these epidemics have been identified and compared to the current status of interventions to prevent obesity and its main disease consequence, type 2 diabetes. Reductions in mortality from tobacco, cardiovascular diseases, road crashes, cervical cancer and sudden infant death syndrome have been achieved by addressing all corners of the triad. Similarly, prevention programs have minimized the mortality from HIV AIDS and melanoma mortality rates are no longer rising. The main lessons learned from these prevention programs that could be applied to the obesity/diabetes epidemic are: taking a more comprehensive approach by increasing the environmental (mainly policy-based) initiatives; increasing the 'dose' of interventions through greater investment in programs; exploring opportunities to further influence the energy density of manufactured foods (one of the main vectors for increased energy intake); developing and communicating specific, action messages; and developing a stronger advocacy voice so that there is greater professional, public and political support for action. Successes in the other epidemics have been achieved in the face of substantial barriers within individuals, society, the private sector and government. The barriers for preventing obesity/diabetes are no less formidable, but the strategies for surmounting them have been well tested in other epidemics.

The approach of comprehensive tobacco control in cancer prevention: elements and evidence

The aim of this overview is to present measures of comprehensive tobacco control (CTC) and recent evidence according to their efficacy. CTC includes eight measures: raising taxes, consumer regulations, information about tobacco products, advertisement and sponsoring, economic alternatives to the production of tobacco, programmes for the support of the motivation to stop smoking and maintain tobacco abstinence, including the change of attitudes and norms in the population to support non-smoking, financial and human resources of CTC, and quality assurance of CTC. These measures include single elements such as activities against smuggling, to be considered in conjunction with tax increases. Evidence, particularly from single US states, reveals the efficacy of CTC. As discussed, the literature shows that programmes have not yet included all single elements. This is due to individual, programme-related and external limiting factors. It is concluded that in spite of these, CTC programmes are effective in adults as well as minors. A dose-response relationship between CTC and reduction of smoker rates, the amount of tobacco consumption and tobacco-attributable mortality is probable.

Creating smoke-free environments in recreational settings

To facilitate the banning of tobacco industry sponsorship, Australian health promotion foundations were established to provide health sponsorship to sport, arts, and racing organizations. Health sponsorship dollars procure health sponsorship benefits such as naming rights, signage, personal endorsement of a (health) product by a performer or player, and structural controls such as smoke-free policies. Data are presented from surveys and observations of spectators attending events sponsored by the West Australian Health Promotion Foundation (Healthway) and surveys of Healthway-sponsored organizations and the community. The results demonstrate that by using health sponsorship, Healthway increased the prevalence of smoke-free policies in recreational settings, and there was growing support for these policies. There was evidence of good compliance with smoke-free policies, thus reducing exposure to environmental tobacco smoke. The introduction of smoke-free policies in recreational settings has involved working collaboratively with sectors outside of health, taking an incremental approach to change, and gaining the support of stakeholders by communicating evaluation results.