Differential effects of cigarette price changes on adult smoking behaviours

Follow the money: a closer look at US tobacco industry marketing expenditures

INTRODUCTION

While much of the concern with tobacco industry marketing has focused on direct media advertising, a less explored form of marketing strategy is to discount prices. Price discounting is important because it keeps the purchase price low and can undermine the impact of tax increases.

METHODS

We examine annual US marketing expenditures from 1975 to 2019 by the largest cigarette and smokeless tobacco companies as reported to the Federal Trade Commission. We consider three categories: direct advertising, promotional allowances and price discounting. In addition to considering trends in these expenditures, we examine how price discounting expenditures relate to changes in product prices and excise taxes.

RESULTS

US direct advertising expenditures for cigarettes fell from 80% of total industry marketing expenditures in 1975 to less than 3% in 2019, while falling from 39% in 1985 to 6% in 2019 for smokeless tobacco. Price discounting expenditures for cigarettes became prominent after the Master Settlement Agreement and related tax increases in 2002. By 2019, 87% of cigarette marketing expenditures were for price discounts and 7% for promotional allowances. Smokeless marketing expenditures were similar: 72% for price promotions and 13% for promotional allowances. Price discounting increased with prices and taxes until reaching their currently high levels.

CONCLUSIONS

Between 1975 and 2019, direct advertising dramatically fell while price discounting and promotional expenditures increased. Local, state and federal policies are needed that apply non-tax mechanisms to increase tobacco prices and restrict industry contracts to offset industry marketing strategies. Further study is needed to better understand industry decisions about marketing expenditures.

Motivations to Change Smoking Behaviors Between 2007 and 2019 in Australia: A Repeated Cross-sectional Study

INTRODUCTION

In 2010, Australian tobacco excise (administered federally) increased by 25%, and by 12.5% annually from 2013 to 2020, with additional increases on roll-your-own (RYO) tobacco between 2017 and 2020. We estimated past year changes in smoking behavior among Australian adults who smoked (daily and non-daily) in the past year, and the association between consumer characteristics and stated motivations to change/attempt to change smoking behavior between 2007 and 2019.

METHODS

Logistic regression analysis of combined data from national representative triennial cross-sectional surveys in Australia (N = 22 977).

RESULTS

The main motivation cited for changing smoking behavior switched from health-related from 2007 to 2010 to cost-related from 2013 to 2019. Among those who quit between one and 12 months ago, living in a lower socioeconomic area (odds ratio (OR) = 1.61, 95% CI = 1.18% to -2.18%), was associated with reporting the cost of smoking motivated them to quit. Among those who reduced their smoking, smoking daily and >20 cigarettes/day vs. non-daily smoking (OR = 2.11, 95% CI = 1.60% to 2.78%), having high/very high psychological distress (OR = 1.33, 95% CI = 1.12% to 1.59%), and alcohol consumption (ORdaily drinking = 1.38, 95% CI = 1.05% to 1.81%) was associated with cost as a motivation. Exclusive (OR = 0.65, 95% CI = 0.53% to 0.80%) and non-exclusive (OR = 0.77, 95% CI = 0.65% to 0.91%) RYO use was associated with being less likely to report the cost of tobacco as motivation for cutting down.

CONCLUSIONS

The cost of smoking became the most cited motivator to change smoking behavior (eg, quitting and cutting down), particularly for those who lived in low socioeconomic areas, smoked more cigarettes per day, drank alcohol, and had high/very high psychological distress.

IMPLICATIONS

A change in the main federal tobacco control intervention implemented in Australia from mass-media campaigns to tobacco tax increases has likely led to cost, rather than health, being the main motivation cited for changing smoking behavior in Australia since 2013. Further monitoring is needed to ensure the harmonization in tax rates for RYO and factory-made cigarettes has effectively reduced the price difference between these products because the lower cost of RYO may have reduced the effectiveness of tax increases as a motivator to change smoking behavior.

Tobacco Couponing: A Systematic Review of Exposures and Effects on Tobacco Initiation and Cessation

INTRODUCTION

Tobacco couponing continues to be part of contemporary tobacco marketing in the United States. We performed a systematic review of the evidence of tobacco product coupon receipt and redemption to inform regulation.

AIMS AND METHODS

We searched EMBASE OVID and Medline databases for observational (cross-sectional and longitudinal) studies that examined the prevalence of tobacco coupon receipt and coupon redemption across different subpopulations, as well as studies of the association between coupon receipt and redemption with tobacco initiation and cessation at follow-up. We extracted unadjusted and adjusted odds ratios for the associations between coupon exposure (receipt, redemption) and tobacco use outcomes (initiation, cessation) and assessed each studies' potential risk of bias.

RESULTS

Twenty-seven studies met the criteria for inclusion. Of 60 observations extracted, 37 measured coupon receipt, nine measured coupon redemption, eight assessed tobacco use initiation, and six assessed cessation. Tobacco product coupon receipt and redemption tended to be more prevalent among younger adults, women, lower education individuals, members of sexual and gender minorities, and more frequent tobacco users. Coupon receipt at baseline was associated with greater initiation. Coupon receipt and redemption at baseline were associated with lower cessation at follow-up among tobacco users. Results in high-quality studies did not generally differ from all studies.

CONCLUSIONS

Tobacco product coupon receipt and redemption are often more prevalent among price-sensitive subpopulations. Most concerning, our results suggest coupon receipt may be associated with higher tobacco initiation and lower tobacco cessation. Couponing thereby increases the toll of tobacco use and could prove to be a viable public health policy intervention point.

IMPLICATIONS

A systematic review was conducted of the scientific literature about the receipt, redemption, and effects on tobacco initiation and cessation of tobacco product couponing. This review found that tobacco coupons are more often received by price-sensitive persons and these coupons serve to increase tobacco initiation and decrease tobacco cessation. Policy efforts to address these consequences may help curb tobacco's harms and address health inequities.

Trends in Cigarette Marketing Expenditures, 1975-2019: An Analysis of Federal Trade Commission Cigarette Reports

INTRODUCTION

With tightened regulations on cigarette marketing and decreased smoking, the major tobacco companies quickly shifted their marketing expenditures in recent decades to maintain profits. We investigated cigarette marketing expenditures in the United States from 1975 through 2019 to examine the trends in cigarette marketing expenditures over the past 45 years.

AIMS AND METHODS

Cigarette marketing expenditure data were obtained from the Federal Trade Commission (FTC) cigarette reports, 1975-2019. Based on individual expenditure categories included in the FTC reports, we created seven aggregate categories for marketing expenditures: Retail; Print; Out of home; Free tobacco products and gifts; Sports, public entertainment, and sponsorships; Telephone and digital; and Other. Dollar amounts and percentages by category were examined to assess trends in marketing expenditures.

RESULTS

Cigarette marketing expenditures increased since 1975 and peaked in 2003 at $21.1 billion (adjusted dollars); afterward, they declined dramatically until 2010 and remained stable at around $9 billion through 2019. While all other expenditures decreased, retail expenditures increased, comprising more than 50% of expenditures in 1988 and reaching about 98% in 2019. In the retail category, tobacco companies spent the most on promotional allowances, coupons, and retail-value-added bonuses between 1988 and 2003, after which price discounts dominated retail spending.

CONCLUSIONS

Overall, cigarette marketing expenditures peaked in 2003 and retail first became the leading category in 1988. Tobacco companies adapted their marketing strategies in retail and allocated most of their retail spending on price discounts since 2003 to lower cigarette prices.

IMPLICATIONS

The major US tobacco companies directed the bulk of their vast spending on the retail environment since 1988. Moreover, they have dramatically shifted their marketing strategies within the retail category from cigarette advertising before 2003 to customer-directed price discounts since then. This shift may imply a change in focus from recruiting new smokers to retaining current smokers, in response to tax increases and government regulations. Accordingly, restrictions on price-related promotions in retail and nontax strategies should be implemented to counter tobacco companies' marketing efforts in retail.

Current Cigarette Smoking Is Associated With a High Seizure Frequency and Anxiety Symptoms in People With Epilepsy

Purpose

This study aims to answer the following questions: how many people with epilepsy (PWE) have cigarette smoking habits? Which demographic or clinical characteristics are associated with cigarette smoking? Is cigarette smoking related to depressive and anxiety symptoms in PWE?

Methods

A total of 524 PWE were included in the final analysis. Demographic and clinical data were gathered and recorded. Smoking status was identified. The associations of smoking status with the clinical features of epilepsy and depressive and anxiety symptoms were evaluated by logistic regression models.

Results

The overall prevalence of cigarette smoking was 23.5% (123 PWE) in this sample. In the multivariate logistic regression model, men (adjusted OR = 10.414, 95% CI: 5.552–19.535, P < 0.001), high seizure frequency (adjusted OR = 1.474, 95% CI: 1.043–2.084, P = 0.028), and anxiety symptoms (adjusted OR = 2.473, 95% CI: 1.483–4.112, P = 0.001) were shown to have independent associations with cigarette smoking in PWE.

Conclusion

Our findings suggested that the overall prevalence of cigarette smoking was 23.5% in adults with epilepsy, which is slightly lower than that (26.6%) in general adults in China. In the present study, cigarette smoking was associated with men, high seizure frequency, and anxiety symptoms in PWE. Further prospective clinical studies with larger sample sizes are required to confirm our findings.

Cigarettes smoked among daily and non-daily smokers following CVS Health's tobacco-free pharmacy policy

INTRODUCTION

In September 2014, CVS Health ceased tobacco sales in all of its 7700 pharmacies nationwide. We investigate the impact of the CVS policy on the number of cigarettes smoked per day among metropolitan daily and non-daily smokers, who may respond to the availability of smoking cues in different manners.

METHODS

Data are from the US Census Bureau Tobacco Use Supplement to the Current Population Survey 2014-2015 and the Blue Cross and Blue Shield Institute Community Health Management Hub. Adjusted difference-in-difference (DID) regressions assess changes in the number of cigarettes smoked per day among daily smokers (n=10 759) and non-daily smokers (n=3055), modelling core-based statistical area (CBSA) level CVS pharmacy market share continuously. To assess whether the policy had non-linear effects across the distribution of CVS market share, we also examine market share using tertiles.

RESULTS

CVS's tobacco-free pharmacy policy was associated with a significant reduction in the number of cigarettes smoked by non-daily smokers in the continuous DID (rate ratio=0.985, p=0.022), with a larger reduction observed among non-daily smokers in CBSAs in the highest third of CVS market share compared with those living in CBSAs with no CVS presence (rate ratio=0.706, p=0.027). The policy, however, was not significantly associated with differential changes in the number of cigarettes by daily smokers.

CONCLUSION

The removal of tobacco products from CVS pharmacies was associated with a reduction in the number of cigarettes smoked per day among non-daily smokers in metropolitan CBSAs, particularly those in which CVS had a large pharmacy market share.

One-year changes in sugar-sweetened beverage consumers' purchases following implementation of a beverage tax: a longitudinal quasi-experiment

BACKGROUND

Few longitudinal studies examine the response to beverage taxes, especially among regular sugar-sweetened beverage (SSB) consumers.

OBJECTIVE

This study aimed to examine changes in objectively measured beverage purchases associated with the Philadelphia beverage tax on sugar-sweetened and artificially sweetened beverages.

METHODS

A longitudinal quasi-experiment was conducted with adult sugar-sweetened beverage (SSB) consumers in Philadelphia (n = 306) and Baltimore (n = 297; a nontaxed comparison city). From 2016 to 2017 participants submitted all food and beverage receipts during a 2-wk period at: baseline (pretax) and 3, 6, and 12 mo posttax (91.0% retention; data analyzed in 2019). Linear mixed effects models were used to assess the difference-in-differences in total purchased ounces (fl oz) of taxed beverages in a 2-wk period in Philadelphia compared with Baltimore. Secondary analyses: 1) excluded weeks that contained major holidays at baseline and 12 mo (42% of measured weeks at baseline and 12 mo) because policy implementation timing necessitated data collection during holidays when SSB demand may be more inelastic, and 2) aggregated posttax time points to address serial correlation and low power.

RESULTS

There were no statistically significant changes in purchased ounces of taxed beverages in Philadelphia compared with Baltimore in the primary analysis. After excluding holiday purchasing, the tax was associated with statistically significant reductions of taxed beverage purchases at 3 and 6 mo (-157.1 ounces, 95% CI: -310.1, -4.1 and -175.1 ounces, 95% CI: -328.0, -22.3, respectively) but not 12 mo. Analyses aggregating all 6 wk of posttax time points showed statistically significant reductions (-203.7 ounces, 95% CI: -399.6, -7.8).

CONCLUSIONS

A sweetened beverage tax was not associated with reduced taxed beverage purchases among SSB consumers 12 mo posttax in the full sample. Both secondary analyses excluding holiday purchasing or aggregating posttax time periods found reductions in taxed beverage purchases ranging from -4.9 to -12.5 ounces per day. Larger longitudinal studies are needed to further understand tax effects.

The Experimental Tobacco Marketplace: Demand and Substitutability as a Function of Cigarette Taxes and e-Liquid Subsidies

INTRODUCTION

The experimental tobacco marketplace (ETM) approximates real-world situations by estimating the effects of several, concurrently available products and policies on budgeted purchasing. Although the effects of increasing cigarette price on potentially less harmful substitutability are well documented, the effects of other, nuanced pricing policies remain speculative. This study used the ETM as a tool to assess the effects of two pricing policies, conventional cigarette taxation and e-liquid subsidization, on demand and substitutability.

METHODS

During sampling periods, participants were provided 2-day samples of 24 mg/mL e-liquid, after which ETM purchase sessions occurred. Across two ETM sessions, conventional cigarettes were taxed or e-liquid was subsidized in combination with increasing cigarette price. The other four available products were always price constant and not taxed or subsidized.

RESULTS

E-liquid functioned as a substitute for conventional cigarettes across all conditions. Increasing cigarette taxation and e-liquid subsidization increased the number of participants for which e-liquid functioned as a substitute. Cigarette taxation decreased cigarette demand, by decreasing demand intensity, and marginally increased the initial intensity of e-liquid substitution, but did not affect the functions' slopes (substitutability). E-liquid subsidization resulted in large increases in the initial intensity of e-liquid substitution, but did not affect e-liquid substitutability nor cigarette demand.

IMPLICATIONS

24 mg/mL e-cigarette e-liquid was the only product to significantly substitute for cigarettes in at least one condition throughout the experiment; it functioned as a significant substitute throughout all four tax and all four subsidy conditions. Increasing cigarette taxes decreased cigarette demand through decreases in demand intensity but did not affect e-cigarette substitution. Increasing e-liquid subsidies increased e-liquid initial intensity of substitution but did not affect cigarette demand.

CONCLUSIONS

This study extended research on the behavioral economics of conventional cigarette demand and e-liquid substitutability in a complex marketplace. The results suggest that the most efficacious method to decrease conventional cigarette purchasing and increase e-liquid purchasing may involve greatly increasing cigarette taxes while also increasing the value of e-liquid through potentially less harmful product subsidization or differential taxation.

Effects of an 80% cigarette price increase on quit attempts, successful quitting and smoking intensity among Korean adult smokers: results from nationally representative longitudinal panel data

OBJECTIVES

South Korea implemented an unprecedented cigarette tax increase in 2015, raising its cigarette price by 80%. This study evaluated the extent to which the 2015 cigarette tax increase affected Korean adult smokers in terms of quit attempts, successful quitting and smoking intensity.

METHODS

Data were drawn from a nationally representative longitudinal study, the Korean Welfare Panel Study (waves 9-12, 2014-2017). Korean adults who smoked before the 2015 cigarette tax increase comprised the sample (n=2114). We used the multiple logistic regressions to examine factors of quit attempts and successful quitting and the generalised estimating equations to estimate changes in smoking intensity among continued smokers.

RESULTS

After the cigarette tax increase, 60.9% (n=1334) of baseline smokers attempted to quit and 34.7% of the attempters succeeded in quitting. The smokers aged ≥ 65 years and light smokers both attempted more (p<0.01) and succeeded more (p<0.05) in quitting than smokers aged 35-44 years and heavy smokers, respectively. The successful quitting was not significantly associated with income levels. Depressive symptoms, first cigarette use before age 19 and smoking a pack or more a day at baseline were associated with failures in quitting. Smoking intensity among continued smokers decreased after the cigarette tax increase (p<0.001), but such a decrease was not observed in light smokers, young smokers and high-income smokers.

CONCLUSION

The current study findings imply that the Korean government may consider implementing periodic increases in cigarette tax which should reflect the rate of inflation and income growth. Smoking cessation programmes need to address depressive symptoms.

Receipt of direct tobacco mail/email coupons and coupon redemption: Demographic and socioeconomic disparities among adult smokers in the United States

A key marketing strategy used by tobacco companies to lower tobacco product prices is the distribution of tobacco coupons via direct marketing channels such as mail or email. We analyzed data on adult smokers from Wave 1 of the Population Assessment of Tobacco and Health (PATH) Study (n = 10,994) to examine the prevalence and correlates of coupon receipt via both channels, and associations with cigarette coupon redemption. Overall, 22% and 32% of smokers received tobacco coupons via email and mail, respectively, and 22% redeemed cigarette coupons. White, 25-44 year old, female, sexual minority, and more nicotine dependent smokers were more likely to receive coupons via both channels and to redeem coupons, as were smokers with mid-levels education (GED to associate degree) and those unable to pay important bills (OR _{email receipt} = 1.37, 95% CI 1.22-1.54; OR _{mail receipt} = 1.38, 95% CI 1.24-1.55; and OR _{coupon redemption} = 1.44, 95% CI 1.26-1.64). Smokers who received coupons via mail only or via both channels, had three times (OR = 2.97, 95% CI 2.31-3.83) and five times (OR = 4.56, 95% CI 3.61-5.76) higher odds to redeem cigarette coupons compared to those who received them via email only. Major demographic and socioeconomic disparities exist in receipt and redemption of direct email\mail tobacco coupons among US smokers. Cigarette coupons received via direct mail are more likely to be redeemed than coupons received via email. Restrictions on tobacco coupon redemption, implemented jointly with increasing access to affordable cessation resources, may incentivize smokers vulnerable to tobacco marketing tactics to quit.

Smoker perceptions of health warnings on cigarette packaging and cigarette sticks: A four-country study

INTRODUCTION

Innovations in tobacco control interventions are required to ensure continued reductions in global tobacco use, and to minimise attributable morbidity and mortality. We therefore aimed to investigate the perceived effectiveness of current cigarette packaging warnings and the potential effectiveness of cigarette-stick warnings across four countries.

METHODS

An online survey was distributed to adult smokers in Australia, Canada, the United Kingdom, and the United States. Participants rated (using a 5-point Likert scale) and commented on the effectiveness of current cigarette packaging warnings and text warnings on eight cigarette sticks that prompted smokers to quit. Ratings were analysed using proportional odds logistic regression, and comments were analysed using content analysis.

RESULTS

Participants (N=678, mean age=44.3 years) from all four countries perceived cigarette packaging warnings as being minimally effective in prompting smokers to quit, citing desensitisation and irrelevance of the warnings, with US participants particularly critical of the text-only warnings. Compared to packaging warnings, the cigarette-stick warnings describing the financial costs of smoking and the effect of smoking on others, were the highest rated in all four countries (OR=3.42, 95% CI: 2.75–4.25, p<0.001 and OR=2.85, 95% CI: 2.29–3.55, p<0.001, respectively) and cited as strong messages to reduce smoking. Half of the participants either ‘agreed’ or ‘strongly agreed’ to the use of cigarette-stick warnings.

CONCLUSIONS

The findings of this study suggest that cigarette packaging warnings may experience a loss of effectiveness over time, eventually resulting in minimal impact on smoker behaviour. Health and non-health focused warnings and messages on individual cigarette sticks represent a novel and potentially effective method for reducing tobacco use. This would complement tobacco control interventions currently employed, resulting in public health benefits.

Did high sugar-sweetened beverage purchasers respond differently to the excise tax on sugar-sweetened beverages in Mexico?

OBJECTIVE

To estimate changes in taxed and untaxed beverages by volume of beverage purchased after a sugar-sweetened beverage (SSB) tax was introduced in 2014 in Mexico.

DESIGN

We used household purchase data from January 2012 to December 2015. We first classified the sample into four groups based on pre-tax purchases of beverages: (i) higher purchases of taxed beverages and lower purchases of untaxed beverages (HTLU-unhealthier); (ii) higher purchases of both types of beverages (HTHU); (iii) lower purchases of taxed and untaxed beverages (LTLU); and (iv) lower purchases of taxed beverages and higher purchases of untaxed beverages (LTHU-healthier). Next, we estimated differences in purchases after the tax was implemented for each group compared with a counterfactual based on pre-tax trends using a fixed-effects model.

SETTING

Areas with more than 50 000 residents in Mexico.ParticipantsHouseholds (n 6089).

RESULTS

The HTLU-unhealthier and HTHU groups had the largest absolute and relative reductions in taxed beverages and increased their purchases of untaxed beverages. Households with lower purchases of untaxed beverages (HTLU-unhealthier and LTLU) had the largest absolute and relative increases in untaxed beverages. We also found that among households with higher purchases of taxed beverages, the group with lowest socio-economic status had the greatest reduction in purchases of taxed beverages.

CONCLUSIONS

Evidence associating the SSB tax with larger reductions among high purchasers of taxed beverages prior to the tax is relevant, as higher SSB purchasers have a greater risk of obesity, diabetes and other cardiometabolic outcomes.

Have higher cigarette taxes in the United States discouraged smoking? A review of data from 1999-2013

INTRODUCTION

Cigarette smoking continues to be a leading cause of preventable morbidity and premature death in the United States. This study examined the impact of federal and state cigarette excise taxes on adult smoking between 1999 and 2013.

METHODS

Data came from the National Health Interview Survey, Behavioural Risk Factor Surveillance System and Tax Burden on Tobacco. Analyses were done from 1999-2013, 2002-6 and 2009-13. Associations between cigarette taxes, prices and smoking were examined in several states based on cigarette tax: Missouri and Virginia (low tax), Florida, Nebraska and Nevada (median tax) and New York and Rhode Island (high tax).

RESULTS

Smoking declined nationally from 22.8% (1999) to 19.0% (2013) with rates falling from 25.7% to 20.5% in men and 21.5% to 15.3% in women. Annual cigarette consumption (in millions) declined from 432,758 to 280,534 and per capita consumption from 1,621 cigarettes (1999) to 894 cigarettes (2013). Smoking declined across age, gender, race/ethnicity, education and poverty level in 2009-13 compared to 2002-6 with large reductions in states with higher cigarette taxes. Negative correlations between cigarette tax and smoking, and positive correlations between cigarette tax and price, were seen.

CONCLUSIONS

Higher cigarette taxes appear to have had a negative impact on smoking in the US. Our data suggest that states with higher cigarette taxes have lower smoking rates than states with lower taxes. Tax measures are however implemented as part of a comprehensive tobacco control package and further research is needed to assess the relative contribution of cigarette tax on smoking reductions in the states examined.

Bayesian Analysis of the Association between Family-Level Factors and Siblings' Dental Caries

We conducted a Bayesian analysis of the association between family-level socioeconomic status and smoking and the prevalence of dental caries among siblings (children from infant to 14 y) among children living in rural and urban Northern Appalachia using data from the Center for Oral Health Research in Appalachia (COHRA). The observed proportion of siblings sharing caries was significantly different from predicted assuming siblings' caries status was independent. Using a Bayesian hierarchical model, we found the inclusion of a household factor significantly improved the goodness of fit. Other findings showed an inverse association between parental education and siblings' caries and a positive association between households with smokers and siblings' caries. Our study strengthens existing evidence suggesting that increased parental education and decreased parental cigarette smoking are associated with reduced childhood caries in the household. Our results also demonstrate the value of a Bayesian approach, which allows us to include household as a random effect, thereby providing more accurate estimates than obtained using generalized linear mixed models.

The neurobiological and behavioral overlaps of nicotine and food addiction

Both cigarette smoking and obesity are significant public health concerns and are associated with increased risk of early mortality. It is well established that the mesolimbic dopamine pathway is an important component of the reward system within the brain and is implicated in the development of addiction. Indeed, nicotine and highly palatable foods are capable of altering dopamine release within this system, engendering addictive like responses in susceptible individuals. Although additional research is warranted, findings from animal and human literature have elucidated many of neuroadaptions that occur from exposure to nicotine and highly palatable foods, leading to a greater understanding of the underlying mechanisms contributing to these aberrant behaviors. In this review we present the findings taken from preclinical and clinical literature of the known effects of exposure to nicotine and highly palatable foods on the reward related circuitry within the brain. Further, we compare the neurobiological and behavioral overlaps between nicotine, highly palatable foods and obesity. Lastly, we examine the stigma associated with smoking, obesity and food addiction, and the consequences stigma has on the overall health and wellbeing of an individual.

Effects of State-Level Tobacco Environment on Cigarette Smoking are Stronger Among Those With Individual-Level Risk Factors

INTRODUCTION

To better understand the impact of the state-level tobacco environment (eg, tobacco control policies, attitudes towards smoking) on cigarette smoking, we examined whether the relationship of state tobacco environments to smoking is modified by individual-level vulnerability factors.

METHODS

In a nationally representative sample of US adults (N = 34 638), past-year smoking and heavy smoking were examined. State-level tobacco environment was defined by tobacco-related control policies and attitudes, ranging from permissive to restrictive; individual vulnerability was defined by childhood maltreatment and/or parental substance problems. Additive interaction tested differences in state-level tobacco environment effects on smoking and heavy smoking by individual-level vulnerability.

RESULTS

Significant interactions (P values < .01) indicated that the state tobacco environment had the strongest relationship to smoking outcomes among individuals with greatest individual vulnerability. For example, among respondents with childhood maltreatment and parental substance problems, those in states with permissive tobacco environments had 13.3% greater prevalence of smoking than those in restrictive states. Among respondents with neither individual-level risk factor, those in permissive states had 2.8% greater prevalence than those in restrictive states (interaction P value = .0002).

CONCLUSIONS

Further restricting states' smoking environments could help reduce the prevalence of smoking and heavy smoking, particularly among those at increased individual risk in the general population.

IMPLICATIONS

This study shows that the protective effect of restrictive state-level tobacco environments on smoking or heavy smoking was stronger among those especially vulnerable due to individual-level risk factors (parental substance problems, childhood maltreatment). Thus, public health campaigns to influence attitudes towards smoking or legislation to strengthen tobacco control could have a broad effect, particularly impacting those with vulnerability to smoking, which may help decrease smoking prevalence and reduce the massive public health burden of tobacco-related morbidity and mortality.

Tobacco prevention policies in west-African countries and their effects on smoking prevalence

BACKGROUND

The WHO Framework Convention on Tobacco Control was shown to effectively lower smoking prevalence in in high income countries, however knowledge for low and middle income settings is sparse. The objective of this study was to describe WHO MPOWER policy measures in thirteen West-African countries and to investigate their correlation with smoking prevalence.

METHODS

Age-standardized smoking prevalence data and policy measures were collected from various WHO reports. For analysis MPOWER measures from 2008 and 2010, were combined with prevalence data from 2009 and 2011. Multiple linear regression models were set up.

RESULTS

In West-Africa mean smoking prevalence was approximately 20% among males and approximately 3% among females. Policy measures were mostly at a middle or low level. Regression analysis showed that tobacco cessation programs, health warnings on cigarettes, and higher price of cigarettes were negatively correlated with smoking prevalence. Significant effects were observed for only one policy measure (tobacco cessation programs) and only within the male population where smoking prevalence is generally higher.

CONCLUSIONS

Tobacco control policies are enforced at relatively low levels in West-African countries. However, improving tobacco control policy implementation according to the WHO Framework Convention on Tobacco Control should assist in the reduction of smoking prevalence in African countries, thereby counteracting pro-smoking initiatives set forth by the tobacco industry.

The National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) Waves 1 and 2: review and summary of findings

PURPOSE

The NESARC, a "third-generation" psychiatric epidemiologic survey that integrated detailed measures of alcohol and drug use and problems has been the data source for over >850 publications. A comprehensive review of NESARC findings and their implications is lacking.

METHOD

NESARC was a survey of 43,093 participants that covered alcohol, drug and psychiatric disorders, risk factors, and consequences. Wave 1 of the NESARC was conducted in 2001-2002. Three years later, Wave 2 follow-up re-interviews were conducted with 34,653 of the original participants. Scopus and Pubmed were used to search for NESARC papers, which were sorted into topic areas and summarized.

RESULT

The most common disorders were alcohol and posttraumatic stress disorders, and major depression. Females had more internalizing disorders and males had more externalizing disorders, although the preponderance of males with alcohol disorders (the "gender gap") was less pronounced than it was in previous decades. A race/ethnic "paradox" (lower risk among disadvantaged minorities than whites) remains unexplained. Younger participants had higher risk for substance and personality disorders, but not unipolar depressive or anxiety disorders. Psychiatric comorbidity was extensive and often formed latent trans-diagnostic domains. Since 1991-1992, risk for marijuana and prescription drug disorders increased, while smoking decreased, although smoking decreases were less pronounced among those with comorbidity. A nexus of comorbidity, social support, and stress predicted transitions in diagnostic status between Waves 1 and 2. Childhood maltreatment predicted psychopathology. Alcohol and drug use disorders were seldom treated; attitudinal barriers (little perceived need, perceived alcoholism stigma, pessimism about efficacy) were more important in predicting non-treatment than financial barriers.

CONCLUSIONS

Understanding comorbidity and the effects of early stressors will require research incorporating biologic components, e.g., genetic variants and brain imaging. The lack of treatment for alcohol and drug disorders, predicted by attitudinal rather than financial variables, suggests an urgent need for public and professional education to reduce the stigma associated with these disorders and increase knowledge of treatment options.

Trends and socioeconomic differences in policy triggers for thinking about quitting smoking: Findings from the International Tobacco Control (ITC) Europe Surveys

INTRODUCTION

The aim of the current study is to investigate trends and socioeconomic differences in policy triggers for thinking about quitting in six European countries.

METHODS

Data were derived from all available survey waves of the International Tobacco Control (ITC) Europe Surveys (2003-2013). France conducted three survey waves (n=1420-1735), Germany three waves (n=515-1515), The Netherlands seven waves (n=1420-1668), Ireland three waves (n=582-1071), Scotland two waves (n=461-507), and the rest of the United Kingdom conducted seven survey waves (n=861-1737). Smokers were asked whether four different policies (cigarette price, smoking restrictions in public places, free or lower cost medication, and warning labels on cigarette packs) influenced them to think about quitting. Generalized Estimating Equation (GEE) models were estimated for each country.

RESULTS

Cigarette price was mentioned most often in all countries and across all waves as trigger for thinking about quitting. Mentioning cigarette price and warning labels increased after the implementation of price increases and warning labels in some countries, while mentioning smoking restrictions decreased after their implementation in four countries. All studied policy triggers were mentioned more often by smokers with low and/or moderate education and income than smokers with high education and income. The education and income differences did not change significantly over time for most policies and in most countries.

CONCLUSIONS

Tobacco control policies work as a trigger to increase thoughts about quitting, particularly in smokers with low education and low income and therefore have the potential to reduce health inequalities in smoking.

Concurrent access to nicotine and sucrose in rats

BACKGROUND

Animal models that allow concurrent access to drug and nondrug reinforcers provide unique insight into the etiology, maintenance, and treatment of drug use.

OBJECTIVES

We sought to develop and utilize a concurrent access procedure with nicotine and sucrose in rats.

METHODS

Pressing one lever delivered intravenous nicotine, and pressing another lever delivered sucrose pellets, with both reinforcers freely available throughout daily sessions.

RESULTS

Rats that had been pretrained with nicotine on some days and sucrose on other days responded on both levers when subsequently given concurrent access, but almost all responded at substantially higher rates on the sucrose lever. In contrast, rats pretrained exclusively with nicotine before being given concurrent access showed individual differences, with about half responding more on the nicotine lever. Treatment with the nicotinic receptor partial agonist varenicline selectively decreased nicotine self-administration. Food restriction and removal of the sucrose lever both increased nicotine self-administration.

CONCLUSIONS

The finding that rats continue to take nicotine when sucrose is concurrently available-and in many cases take it more frequently than sucrose-demonstrates that nicotine self-administration does not only occur in the absence of alternative reinforcement options. As a model of human nicotine use, concurrent access is more naturalistic and has higher face validity than procedures in which only one reinforcer is available or choosing one reinforcer precludes access to other reinforcers. As such, this procedure could be useful for evaluating therapeutic agents and improving our understanding of environmental conditions that promote or discourage nicotine use.

Motivations toward smoking cessation, reasons for relapse, and modes of quitting: results from a qualitative study among former and current smokers

BACKGROUND

Smoking cessation plays a crucial role in reducing preventable morbidity and mortality and is a recognized public-health-policy issue in many countries. Two of the most important factors that affect the efficacy of quitting smoking are motivation and the ability to cope with situations causing relapse.

AIM

The objective of the study reported here was to investigate former and current smokers' motivations for smoking cessation, reasons for relapse, and modes of quitting.

METHODS

We arranged four focus groups with 24 participants (twelve current and twelve former smokers) and eleven semi-structured interviews (five current and six former smokers) with a view to understanding and categorizing their opinions on motivations and the course and process of smoking cessation. The data were next analyzed using descriptive qualitative methods.

RESULTS

THREE MAIN THEMES WERE IDENTIFIED: (1) motivations to quit smoking, (2) reasons why smokers sometimes relapse, and (3) modes of quitting smoking. Within the first theme, the following six subthemes surfaced: (1) a smoking ban at home and at work due to other people's wishes and rules, (2) the high cost of cigarettes, (3) the unpleasant smell, (4) health concern, (5) pregnancy and breastfeeding, and (6) a variety of other factors. The second theme encompassed the following subthemes: (1) stress and the need to lessen it by smoking a cigarette, (2) the need to experience the pleasure connected with smoking, and (3) the smoking environment both at home and at work. Participants presented different smoking-cessation modes, but mainly they were unplanned attempts.

CONCLUSION

Two very important motivations for smoking cessation were a smoking ban at home and at work due to other people's wishes and rules, and the high cost of cigarettes. The most common smoking-cessation mode was a spontaneous decision to quit, caused by a particular trigger factor. Relapse causes encompassed, most notably: stress, lack of the pleasure previously obtained from smoking, and the smoking environment.

Probing the smoking-suicide association: do smoking policy interventions affect suicide risk?

INTRODUCTION

Smokers exhibit elevated risk for suicide, but it is unknown whether smoking interventions reduce suicide risk. We examined whether state-level policy interventions-increases in cigarette excise taxes and strengthening of smoke-free air laws-corresponded to a reduction in suicide risk during the 1990s and the early 2000s. We also examined whether the magnitude of such reductions correlated with individuals' predicted probability of smoking, which would be expected if the associations stemmed from changes in smoking behavior.

METHODS

We paired individual-level data on suicide deaths from the U.S. Multiple Cause of Death files, years 1990-2004, with living population data from the same period. These were linked with state data on cigarette excise taxes and smoke-free air policies. Utilizing a quasiexperimental analytical approach, we estimated the association between changes in policy and suicide risk. To examine whether associations correlated with individuals' probability of smoking, we used external survey data to derive a predicted probability of smoking function from demographic variables, which was then used to stratify the population by predicted smoking prevalence.

RESULTS

Cigarette excise taxes, smoke-free air policies, and an index combining the two policies all exhibited protective associations with suicide. The associations were strongest in segments of the population where predicted smoking prevalence was the highest and weaker in segments of the population where predicted smoking prevalence was the lowest, suggesting that the protective associations were related to changes in smoking behavior.

CONCLUSION

These results provide support for the proposition that population interventions for smoking could reduce risk for suicide.