The relationship of cigarette prices and no-smoking bylaws to the prevalence of smoking in Canada

Education-smoking gradient and upstream health policies: comparing Generation X with millennials

Purpose

Over the years, many upstream health policies have sought to reduce smoking across populations. While smoking has been substantially reduced, the effects of these policies on education-smoking gradient remain unclear. The present paper compares the education-smoking gradient among the Generation X and the millennials, who grew up with different types of upstream policies.

Design/methodology/approach

The study relies on regression analysis. The data are from the Canadian Tobacco, Alcohol and Drugs Survey of 2017, with the sample restricted to those born between 1965 and 1995.

Findings

At the zero-order, the education-smoking gradient has not significantly flattened from Generation X to millennials. And, accounting for the channels of impact of education on smoking does not substantially change this pattern.

Social implications

The implications for health inequalities associated with socioeconomic status, and tobacco consumption reduction policies, are discussed.

Originality/value

This paper is the first study of the kind using Canadian data.

Evidence-based policy making for health promotion to reduce the burden of non-communicable diseases in Moldova

The Republic of Moldova faces several concurrent health challenges most notably an increase in chronic non-communicable diseases, spiralling health care costs and widening health inequalities. To accelerate progress in their resolution there is a need for new and innovative health promotion and behaviour change communication interventions. The Ministry of Health, Labour and Social Protection in collaboration with the newly created National Agency for Public Health held a conference on the occasion of the Moldovan National Day of Health Promotion on 14th March 2018 in which national and invited international experts exchanged their views on (1) best practice examples of behaviour change interventions, health promotion activities and lessons learned from the UK and elsewhere; and (2) possible ways forward for Moldova to implement cost-effective and evidence-based intersectoral health promotion programmes. The experts provided recommendations on implementing behaviour change interventions to reduce and prevent obesity; on the creation of a favourable tobacco control environment to reduce smoking prevalence; and on how physical activity programme design can benefit from health psychology research. All these strategies could foster health promotion activities and ultimately contribute to improving the health outcomes of the Moldovan population.

The Economic Impact of Smoking and of Reducing Smoking Prevalence: Review of Evidence

BACKGROUND

Tobacco smoking is the cause of many preventable diseases and premature deaths in the UK and around the world. It poses enormous health- and non-health-related costs to the affected individuals, employers, and the society at large. The World Health Organization (WHO) estimates that, globally, smoking causes over US$500 billion in economic damage each year.

OBJECTIVES

This paper examines global and UK evidence on the economic impact of smoking prevalence and evaluates the effectiveness and cost effectiveness of smoking cessation measures.

STUDY SELECTION

SEARCH METHODS We used two major health care/economic research databases, namely PubMed and the National Institute for Health Research (NIHR) database that contains the British National Health Service (NHS) Economic Evaluation Database; Cochrane Library of systematic reviews in health care and health policy; and other health-care-related bibliographic sources. We also performed hand searching of relevant articles, health reports, and white papers issued by government bodies, international health organizations, and health intervention campaign agencies. SELECTION CRITERIA The paper includes cost-effectiveness studies from medical journals, health reports, and white papers published between 1992 and July 2014, but included only eight relevant studies before 1992. Most of the papers reviewed reported outcomes on smoking prevalence, as well as the direct and indirect costs of smoking and the costs and benefits of smoking cessation interventions. We excluded papers that merely described the effectiveness of an intervention without including economic or cost considerations. We also excluded papers that combine smoking cessation with the reduction in the risk of other diseases. DATA COLLECTION AND ANALYSIS The included studies were assessed against criteria indicated in the Cochrane Reviewers Handbook version 5.0.0. OUTCOMES ASSESSED IN THE REVIEWPrimary outcomes of the selected studies are smoking prevalence, direct and indirect costs of smoking, and the costs and benefits of smoking cessation interventions (eg, "cost per quitter", "cost per life year saved", "cost per quality-adjusted life year gained," "present value" or "net benefits" from smoking cessation, and "cost savings" from personal health care expenditure).

MAIN RESULTS

The main findings of this study are as follows: The costs of smoking can be classified into direct, indirect, and intangible costs. About 15% of the aggregate health care expenditure in high-income countries can be attributed to smoking. In the US, the proportion of health care expenditure attributable to smoking ranges between 6% and 18% across different states. In the UK, the direct costs of smoking to the NHS have been estimated at between £2.7 billion and £5.2 billion, which is equivalent to around 5% of the total NHS budget each year. The economic burden of smoking estimated in terms of GDP reveals that smoking accounts for approximately 0.7% of China's GDP and approximately 1% of US GDP. As part of the indirect (non-health-related) costs of smoking, the total productivity losses caused by smoking each year in the US have been estimated at US$151 billion.The costs of smoking notwithstanding, it produces some potential economic benefits. The economic activities generated from the production and consumption of tobacco provides economic stimulus. It also produces huge tax revenues for most governments, especially in high-income countries, as well as employment in the tobacco industry. Income from the tobacco industry accounts for up to 7.4% of centrally collected government revenue in China. Smoking also yields cost savings in pension payments from the premature death of smokers.Smoking cessation measures could range from pharmacological treatment interventions to policy-based measures, community-based interventions, telecoms, media, and technology (TMT)-based interventions, school-based interventions, and workplace interventions.The cost per life year saved from the use of pharmacological treatment interventions ranged between US$128 and US$1,450 and up to US$4,400 per quality-adjusted life years (QALYs) saved. The use of pharmacotherapies such as varenicline, NRT, and Bupropion, when combined with GP counseling or other behavioral treatment interventions (such as proactive telephone counseling and Web-based delivery), is both clinically effective and cost effective to primary health care providers.Price-based policy measures such as increase in tobacco taxes are unarguably the most effective means of reducing the consumption of tobacco. A 10% tax-induced cigarette price increase anywhere in the world reduces smoking prevalence by between 4% and 8%. Net public benefits from tobacco tax, however, remain positive only when tax rates are between 42.9% and 91.1%. The cost effectiveness ratio of implementing non-price-based smoking cessation legislations (such as smoking restrictions in work places, public places, bans on tobacco advertisement, and raising the legal age of smokers) range from US$2 to US$112 per life year gained (LYG) while reducing smoking prevalence by up to 30%-82% in the long term (over a 50-year period).Smoking cessation classes are known to be most effective among community-based measures, as they could lead to a quit rate of up to 35%, but they usually incur higher costs than other measures such as self-help quit-smoking kits. On average, community pharmacist-based smoking cessation programs yield cost savings to the health system of between US$500 and US$614 per LYG.Advertising media, telecommunications, and other technology-based interventions (such as TV, radio, print, telephone, the Internet, PC, and other electronic media) usually have positive synergistic effects in reducing smoking prevalence especially when combined to deliver smoking cessation messages and counseling support. However, the outcomes on the cost effectiveness of TMT-based measures have been inconsistent, and this made it difficult to attribute results to specific media. The differences in reported cost effectiveness may be partly attributed to varying methodological approaches including varying parametric inputs, differences in national contexts, differences in advertising campaigns tested on different media, and disparate levels of resourcing between campaigns. Due to its universal reach and low implementation costs, online campaign appears to be substantially more cost effective than other media, though it may not be as effective in reducing smoking prevalence.School-based smoking prevalence programs tend to reduce short-term smoking prevalence by between 30% and 70%. Total intervention costs could range from US$16,400 to US$580,000 depending on the scale and scope of intervention. The cost effectiveness of school-based programs show that one could expect a saving of approximately between US$2,000 and US$20,000 per QALY saved due to averted smoking after 2-4 years of follow-up.Workplace-based interventions could represent a sound economic investment to both employers and the society at large, achieving a benefit-cost ratio of up to 8.75 and generating 12-month employer cost savings of between $150 and $540 per nonsmoking employee. Implementing smoke-free workplaces would also produce myriads of new quitters and reduce the amount of cigarette consumption, leading to cost savings in direct medical costs to primary health care providers. Workplace interventions are, however, likely to yield far greater economic benefits over the long term, as reduced prevalence will lead to a healthier and more productive workforce.

CONCLUSIONS

We conclude that the direct costs and externalities to society of smoking far outweigh any benefits that might be accruable at least when considered from the perspective of socially desirable outcomes (ie, in terms of a healthy population and a productive workforce). There are enormous differences in the application and economic measurement of smoking cessation measures across various types of interventions, methodologies, countries, economic settings, and health care systems, and these may have affected the comparability of the results of the studies reviewed. However, on the balance of probabilities, most of the cessation measures reviewed have not only proved effective but also cost effective in delivering the much desired cost savings and net gains to individuals and primary health care providers.

Exposure to smoking on patios and quitting: a population representative longitudinal cohort study

OBJECTIVES

Smoke-free policies not only reduce harm to non-smokers, they may also reduce harm to smokers by decreasing the number of cigarettes smoked and increasing the likelihood of a successful quit attempt. However, little is known about the impact of exposure to smoking on patios on smoking behaviour.

DESIGN AND PARTICIPANTS

Smokers from the Ontario Tobacco Survey, a longitudinal population representative cohort of smokers (2005-2011). There were 3460 current smokers who had completed one to six follow-ups and were asked at each follow-up whether or not they had been exposed to smoking on patios in the month.

MAIN OUTCOME MEASURES

Generalised estimating equations and survival analysis were used to examine the association between exposure to patio smoking and smoking behaviour changes (making a quit attempt and time to relapse after a quit attempt), controlling for potential confounders.

RESULTS

Smokers who were exposed to smoking on patios (adjusted incident rate ratio (aIRR) = 0.89; 95% CI 0.81 to 0.97) or had been to a patio (aIRR = 0.86; 95% CI 0.74 to 0.99) were less likely to have made a quit attempt than smokers who had not visited a patio. Smokers who were exposed to smoking on patios were more likely to relapse (adjusted HR=2.40; 95% CI 1.07 to 5.40)) after making a quit attempt than those who visited a patio but were not exposed to smoking.

CONCLUSIONS

Exposure to smoking on patios of a bar or restaurant is associated with a lower likelihood of success in a quit attempt. Instituting smoke-free patio regulations may help smokers avoid relapse after quitting.

Effects of a workplace-smoking ban in combination with tax increases on smoking in the Dutch population

INTRODUCTION

In the Netherlands, between 2003 and 2005, 3 tobacco control measures were implemented: a workplace-smoking ban and 2 tax increases on tobacco products. This study explores how the combination of measures influences the smoking behavior of the general population divided into subpopulations with and without paid work (all aged 16-65 years).

METHODS

Data from the Dutch Continuous Survey of Smoking Habits were used. The total sample consisted of 32,014 respondents (27,150 with paid work and 4,864 without paid work) aged 16-65 years. Analyses were done by linear and logistic regression, controlling for relevant factors.

RESULTS

For respondents with paid work, the combination of a smoking ban and 2 tax increases led to a decrease in the number of cigarettes per day and in the prevalence of daily smoking. For respondents without paid work, there was no significant effect on any of the outcome parameters. In both groups, there was no evidence that the effect of the measures on smoking was moderated by the respondent's gender, age, or level of education.

CONCLUSIONS

The combination of policy measures has influenced the smoking behavior of respondents with paid work in a positive way. Compared with most other studies, the effect of the workplace-smoking ban alone is smaller. However, the effect of the combined interventions is higher than the that of tax increases in other studies. Among respondents without paid work who were exposed to tax increases only, no significant effects were found.

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

BACKGROUND

Smoking bans have been implemented in a variety of settings, as well as being part of policy in many jurisdictions to protect the public and employees from the harmful effects of secondhand smoke (SHS). They also offer the potential to influence social norms and smoking behaviour of those populations they affect.

OBJECTIVES

To assess the extent to which legislation-based smoking bans or restrictions reduce exposure to SHS, help people who smoke to reduce tobacco consumption or lower smoking prevalence and affect the health of those in areas which have a ban or restriction in place.

SEARCH STRATEGY

We searched the Cochrane Tobacco Addiction Group Specialised Register, MEDLINE, EMBASE, PsycINFO, CINAHL, Conference Paper Index, and reference lists and bibliographies of included studies. We also checked websites of various organisations. Date of most recent search; July 1st 2009.

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

Characteristics and content of the interventions, participants, outcomes and methods of the included studies were extracted by one author and checked by a second. Because of heterogeneity in the design and content of the studies, we did not attempt a meta-analysis. We evaluated the studies using qualitative narrative synthesis.

MAIN RESULTS

There were 50 studies included in this review. Thirty-one studies reported exposure to secondhand smoke (SHS) with 19 studies measuring it using biomarkers. There was consistent evidence that smoking bans reduced exposure to SHS in workplaces, restaurants, pubs and in public places. There was a greater reduction in exposure to SHS in hospitality workers compared to the general population. We failed to detect any difference in self-reported exposure to SHS in cars. There was no change in either the prevalence or duration of reported exposure to SHS in the home as a result of implementing legislative bans. Twenty-three studies reported measures of active smoking, often as a co-variable rather than an end-point in itself, with no consistent evidence of a reduction in smoking prevalence attributable to the ban. Total tobacco consumption was reduced in studies where prevalence declined. Twenty-five studies reported health indicators as an outcome. Self-reported respiratory and sensory symptoms were measured in 12 studies, with lung function measured in five of them. There was consistent evidence of a reduction in hospital admissions for cardiac events as well as an improvement in some health indicators after the ban.

AUTHORS' CONCLUSIONS

Introduction of a legislative smoking ban does lead to a reduction in exposure to passive smoking. Hospitality workers experienced a greater reduction in exposure to SHS after implementing the ban compared to the general population. There is limited evidence about the impact on active smoking but the trend is downwards. There is some evidence of an improvement in health outcomes. The strongest evidence is the reduction seen in admissions for acute coronary syndrome. There is an increase in support for and compliance with smoking bans after the legislation.

Smokefree policies to reduce tobacco use. A systematic review

In 2001, a systematic review for the Guide to Community Preventive Services identified strong evidence of effectiveness of smoking bans and restrictions in reducing exposure to environmental (secondhand) tobacco smoke. As follow-up to that earlier review, the focus here was on the evidence on effectiveness of smokefree policies in reducing tobacco use. Smokefree policies implemented by worksites or communities prohibit smoking in workplaces and designated public areas. The conceptual approach was modified for this review; an updated search for evidence was conducted; and the available evidence was evaluated. Published articles that met quality criteria and evaluated changes in tobacco-use prevalence or cessation were included in the review. A total of 57 studies were identified in the period 1976 through June 2005 that met criteria to be candidates for review; of these, 37 met study design and quality of execution criteria to qualify for final assessment. Twenty-one studies measured absolute differences in tobacco-use prevalence with a median effect of -3.4 percentage points (interquartile interval: -6.3 to -1.4 percentage points). Eleven studies measured differences in tobacco-use cessation among tobacco users exposed to a smokefree policy compared with tobacco users not exposed to a smokefree policy. The median absolute change was an increase in cessation of 6.4 percentage points (interquartile interval: 1.3 to 7.9 percentage points). The qualifying studies provided sufficient evidence that smokefree policies reduce tobacco use among workers when implemented in worksites or by communities. Finally, a systematic economic review identified four studies that, overall, demonstrated economic benefits from a smokefree workplace policy. Additional research is needed to more fully evaluate the total economic effects of these policies.

Individual, social-normative, and policy predictors of smoking cessation: a multilevel longitudinal analysis

OBJECTIVES

We assessed the prospective impact of individual, social-normative, and policy predictors of quit attempts and smoking cessation among Massachusetts adults.

METHODS

We interviewed a representative sample of current and recent smokers in Massachusetts by telephone in 2001 through 2002 and then again twice at 2-year intervals. The unit of analysis was the 2-year transition from wave 1 to wave 2 and from wave 2 to wave 3. Predictors of quit attempts and abstinence of longer than 3 months were analyzed using multilevel analysis. Predictors included individual, social-normative, and policy factors.

RESULTS

Multivariate analyses of 2-year transitions showed that perceptions of strong antismoking town norms were predictive of abstinence (odds ratio = 2.06; P < .01). Household smoking bans were the only policy associated with abstinence, but smoking bans at one's worksite were significant predictors of quit attempts.

CONCLUSIONS

Although previous research showed a strong relation between local policy and norms, we found no observable, prospective impact of local policy on smoking cessation over 2 years. Our findings provide clear support for the importance of strong antismoking social norms as a facilitator of smoking cessation.

Smoke-free spaces over time: a policy diffusion study of bylaw development in Alberta and Ontario, Canada

Policy diffusion is a process whereby political bodies 'learn' policy solutions to public health problems by imitating policy from similar jurisdictions. This suggests that diffusion is a critical element in the policy development process, and that its role must be recognised in any examination of policy development. Yet, to date, no systematic work on the diffusion of smoke-free spaces bylaws has been reported. We examined the diffusion of municipal smoke-free bylaws over a 30-year period in the provinces of Alberta and Ontario, Canada, to begin to address this gap and to determine whether spatial patterns could be identified to help explain the nature of policy development. Bylaw adoption and change were analysed within local, regional, and provincial contexts. Geographical models of hierarchical and expansion diffusion in conjunction with the diffusion of innovations framework conceptually guided the analyses. Study findings contribute to a broader understanding of how and why health policies diffuse across time and place. Policy development can be a powerful mechanism for creating environments that support healthy decisions; hence, an understanding of policy diffusion is critical for those interested in policy interventions aimed at improving population health in any jurisdiction.

Treatment of tobacco dependence: integrating recent progress into practice

Tobacco use is one of the leading preventable causes of death in developed countries. Adoption of approaches that have demonstrated efficacy to improve the treatment of tobacco dependence are critical to reduce the health consequences of tobacco use. We summarize the latest epidemiologic data on tobacco use, the mechanisms that underlie tobacco dependence, and advances in pharmacotherapy and nonpharmacologic interventions available for the treatment of tobacco dependence. Specifically, we discuss the use of nicotine replacement therapy, bupropion and varenicline in primary care settings.

Effect of smoking regulations in local restaurants on smokers' anti-smoking attitudes and quitting behaviours

OBJECTIVE

To examine the effect of smoking regulations in local restaurants on anti-smoking attitudes and quitting behaviours among adult smokers.

DESIGN

Hierarchical linear modelling (HLM) was used to assess the relationship between baseline strength of town-level restaurant smoking regulation and follow-up (1) perceptions of the social acceptability of smoking and (2) quitting behaviours.

SETTING

Each of the 351 Massachusetts towns was classified as having strong (complete smoking ban) or weak (all other and no smoking restrictions) restaurant smoking regulations.

SUBJECTS

1712 adult smokers of Massachusetts aged > or = 18 years at baseline who were interviewed via random-digit-dial telephone survey in 2001-2 and followed up 2 years later.

MAIN OUTCOME MEASURES

Perceived social acceptability of smoking in restaurants and bars, and making a quit attempt and quitting smoking.

RESULTS

Among adult smokers who had made a quit attempt at baseline, living in a town with a strong regulation was associated with a threefold increase in the odds of making a quit attempt at follow-up (OR = 3.12; 95% CI 1.51 to 6.44). Regulation was found to have no effect on cessation at follow-up. A notable, although marginal, effect of regulation was observed for perceiving smoking in bars as socially unacceptable only among smokers who reported at baseline that smoking in bars was socially unacceptable.

CONCLUSIONS

Although local restaurant smoking regulations did not increase smoking cessation rates, they did increase the likelihood of making a quit attempt among smokers who had previously tried to quit, and seem to reinforce anti-social smoking norms among smokers who already viewed smoking in bars as socially unacceptable.

Relationships between community characteristics and municipal smoke-free bylaw status and strength

BACKGROUND

Municipal smoke-free spaces bylaws are a common population-level intervention to address the prominent health risks associated with exposure to second-hand smoke. In Canada, bylaw prevalence is increasing, but inequities in level of protection across communities remain as bylaws vary from place to place. Little is known about the role of place in this policy disparity. To address this gap, this study examined associations between community characteristics and municipal smoke-free spaces policy outcomes to elucidate how ecological conditions are associated with bylaw status and strength.

METHOD

Smoke-free public place and workplace bylaws were obtained from all municipalities with a population of >or=5000 in the provinces of Alberta (N=78) and Ontario (N=245), Canada. Bylaws were assigned a strength score (ranging 0-100) rating the degree of bylaw comprehensiveness, restrictiveness and enforcement provisions. These data were then linked to socio-demographic data from the Canadian Census (1996) and the Canadian Community Health Survey Cycle 1.1 (2000/2001). Logistic and multiple linear regression analyses were used to develop models for municipal bylaw status and strength using community factors including: socio-demographics, municipality type, health region smoking rates, and provincial tobacco control environment.

CONCLUSIONS

Study findings suggest that community characteristics play a key role in the status and strength of municipal smoke-free bylaws. As smoking bans continue to emerge world-wide under the Framework Convention on Tobacco Control, knowledge about conditions that promote policy success will be critical for those in need of immediate information to maximize policy-making in their own settings. Use of community profiles that consider socio-demographics along with broader contextual factors can aid decision-makers, public health advocates, and researchers in identifying similar jurisdictions with a successful smoke-free spaces policy and communicating with them about their policy-making experiences. Knowledge about the conditions associated with municipal policy-development may be translated to other jurisdictions where information is sparse, or evidence is newly emerging.

Smoking cessation guidelines: evidence-based recommendations of the French Health Products Safety Agency

Tobacco use is the leading preventable cause of death in developed countries. Millions of smokers are willing to stop, but few of them are able to do so. Clinicians should only use approaches that have demonstrated their efficacy in helping patients to stop smoking. This article summarizes the evidence-based major findings and clinical recommendations for the treatment of tobacco dependence of the French Health Products Safety Agency (AFSSAPS). Clinicians should enquire about the smoking status of each patient and provide information about health consequence of smoking and effective treatments available. These treatments include counseling (mainly individual or social support and behavioral and cognitive therapy) and pharmacological treatment with either nicotine replacement therapy (NRT) or bupropion LP. Pharmacological treatments should be used only for proven nicotine dependence, as assessed by the Fagerstrom test for Nicotine Dependence. The choice of pharmacologic treatment depends of the patient's preference and history and of the presence of contra-indications. The clinician should start with a single agent, but these treatments may be used in combination. Smoking behavior is a chronic problem that requires long-term management and follow-up. Access to intensive treatment combining pharmacological treatment and extensive behavioral and cognitive therapy should be available for highly dependent patients.

Relation between local restaurant smoking regulations and attitudes towards the prevalence and social acceptability of smoking: a study of youths and adults who eat out predominantly at restaurants in their town

OBJECTIVE

To examine the relation between strength of local restaurant smoking regulations and smoking related social norms among youths and adults.

DESIGN

We used generalised estimating equations logistic regression analysis to examine the relation between regulation strength and youths' and adults' perceptions of adult smoking prevalence and the social acceptability of smoking in their town, while controlling for baseline anti-smoking sentiment in the town.

SETTING

Each of the 351 Massachusetts towns were classified as having strong (complete smoking ban), medium (restriction of smoking to enclosed, separately ventilated areas), or weak (all others) restaurant smoking regulations.

SUBJECTS

1147 Massachusetts youths ages 12-17 years and 2116 adults who reported that they often or always eat out in their own town, drawn from a random digit dial survey.

MAIN OUTCOME MEASURES

Perceived adult smoking prevalence and perceived social acceptability of smoking in restaurants, in bars, or in general.

RESULTS

Compared to youths from towns with weak regulations, youths from towns with strong regulations were more likely to perceive lower adult smoking prevalence (odds ratio (OR) 1.71; 95% confidence interval (CI) 1.02 to 2.84) and social unacceptability of adult smoking (OR 2.00, 95% CI 1.29 to 3.08) in their town. Adults from towns with strong regulations were not more likely to perceive lower adult smoking prevalence, but had more than twice the odds of perceiving that smoking was unacceptable in restaurants (OR 2.19, 95% CI 1.58 to 3.02) or bars (OR 2.51, 95% CI 1.90 to 3.31).

CONCLUSIONS

Strong local restaurant smoking regulations are associated with favourable smoking related social norms among youths and adults.

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.

Gender and the social context of smoking behaviour

This paper examines the relative effect of both individual and societal factors that impinge directly on smoking behaviour of women and men. The societal factors are cigarettes price, tobacco control legislation, newspaper coverage of tobacco issues, overall economic factors, and social milieu characteristics. Three Canadian provinces are studied, from 1978 to 1995. A repeated cross-section design is used. Data are derived from national surveys and official documents. Results show that smoking occurs in social contexts within which the price of cigarettes appears to have a significant negative impact on the prevalence of smoking and the quantity of cigarettes smoked by men, but no effect on either the prevalence of smoking or the amount smoked by women. More comprehensive and restrictive no-smoking legislation and legislation on youth access to tobacco influence negatively the prevalence of smoking both for men and women. However, these laws do not have the same effects on the number of cigarettes smoked by women and men. Newspaper articles on the other hand, negatively influence smoking prevalence for women and men. As differences are observed in the responsiveness of men and women to tobacco control policies, policymakers and practitioners need to keep in mind that tobacco control policies have to be tailored to the broader context of the lives of women and men. Future work needs also to be done to clarify the interrelationships between social influences on smoking such as price, laws and media, and the relationships between these and intrapersonal and interpersonal factors, as well as other social and cultural factors.

Estimating price elasticities when there is smuggling: the sensitivity of smoking to price in Canada

A central parameter for evaluating tax policies is the price elasticity of demand for cigarettes. But in many countries this parameter is difficult to estimate reliably due to widespread smuggling, which significantly biases estimates using legal sales data. An excellent example is Canada, where widespread smuggling in the early 1990s, in response to large tax increases, biases upwards the response of legal cigarette sales to price. We surmount this problem through two approaches: excluding the provinces and years where smuggling was greatest; and using household level expenditure data on smoking. These two approaches yield a tightly estimated elasticity in the range of -0.45 to -0.47. We also show that the sensitivity of smoking to price is much larger among lower income Canadians. In the context of recent behavioral models of smoking, whereby higher taxes reduce unwanted smoking among price sensitive populations, this finding suggests that cigarette taxes may not be as regressive as previously suggested. Finally, we show that price increases on cigarettes do not increase, and may actually decrease, consumption of alcohol; as a result, smuggling of cigarettes may have raised consumption of alcohol as well.

The early 1990s cigarette price decrease and trends in youth smoking in Ontario

BACKGROUND

Youth are especially vulnerable to fluctuations in cigarette price, and both the smuggling increase during the early 1990s and the 1994 tax decrease made purchasing easier for youth. The purpose of this study is to examine the relation between these price decreases, and trends in smoking prevalence and amount smoked among Ontario youth.

METHODS

Data from the Ontario Student Drug Use Survey were analyzed for trend using: 1) polynomial regression, and 2) discontinuity regression with an "event time" of 1993 to capture effects of both pre-tax cut smuggling and the tax cut.

RESULTS

Overall, smoking prevalence decreased from 1977 to 1993, jumped upward at this time, and decreased after 1993. Among daily smokers, mean number of cigarettes smoked daily showed an increase followed by a decrease over the 24 years, and a negative quadratic trend. Trends for subgroups are also reported.

CONCLUSIONS

These findings suggest that the early 1990s cigarette price decrease may have played a role in increasing youth smoking in Ontario.

The early 1990s cigarette price decrease and trends in youth smoking in Ontario

BACKGROUND

Youth are especially vulnerable to fluctuations in cigarette price, and both the smuggling increase during the early 1990s and the 1994 tax decrease made purchasing easier for youth. The purpose of this study is to examine the relation between these price decreases, and trends in smoking prevalence and amount smoked among Ontario youth.

METHODS

Data from the Ontario Student Drug Use Survey were analyzed for trend using: 1) polynomial regression, and 2) discontinuity regression with an "event time" of 1993 to capture effects of both pre-tax cut smuggling and the tax cut.

RESULTS

Overall, smoking prevalence decreased from 1977 to 1993, jumped upward at this time, and decreased after 1993. Among daily smokers, mean number of cigarettes smoked daily showed an increase followed by a decrease over the 24 years, and a negative quadratic trend. Trends for subgroups are also reported.

CONCLUSIONS

These findings suggest that the early 1990s cigarette price decrease may have played a role in increasing youth smoking in Ontario.

Effect of smoke-free workplaces on smoking behaviour: systematic review

OBJECTIVE

To quantify the effects of smoke-free workplaces on smoking in employees and compare these effects to those achieved through tax increases.

DESIGN

Systematic review with a random effects meta-analysis.

STUDY SELECTION

26 studies on the effects of smoke-free workplaces.

SETTING

Workplaces in the United States, Australia, Canada, and Germany.

PARTICIPANTS

Employees in unrestricted and totally smoke-free workplaces.

MAIN OUTCOME MEASURES

Daily cigarette consumption (per smoker and per employee) and smoking prevalence.

RESULTS

Totally smoke-free workplaces are associated with reductions in prevalence of smoking of 3.8% (95% confidence interval 2.8% to 4.7%) and 3.1 (2.4 to 3.8) fewer cigarettes smoked per day per continuing smoker. Combination of the effects of reduced prevalence and lower consumption per continuing smoker yields a mean reduction of 1.3 cigarettes per day per employee, which corresponds to a relative reduction of 29%. To achieve similar reductions the tax on a pack of cigarettes would have to increase from $0.76 to $3.05 (0.78 euro to 3.14 euro) in the United States and from 3.44 pounds sterling to 6.59 pounds sterling (5.32 euro to 10.20 euro) in the United Kingdom. If all workplaces became smoke-free, consumption per capita in the entire population would drop by 4.5% in the United States and 7.6% in the United Kingdom, costing the tobacco industry $1.7 billion and 310 million pounds sterling annually in lost sales. To achieve similar reductions tax per pack would have to increase to $1.11 and 4.26 pounds sterling.

CONCLUSIONS

Smoke-free workplaces not only protect non-smokers from the dangers of passive smoking, they also encourage smokers to quit or to reduce consumption.

Comprehensive tobacco control policies and the smoking behaviour of Canadian adults

OBJECTIVE

To examine the associations of cigarette prices, restrictions on public smoking, and health education with the odds of adult smoking and amount smoked daily.

DESIGN

Multi-level analysis of adult (age 25+) smoking patterns in Canada's National Population Health Survey, after adding administrative data on prices, bylaws, and health education according to the survey respondent's place of residence.

SETTING/SUBJECTS

Population based sample of Canadians age 25+ in households (n = 14 355).

OUTCOME MEASURES

Smoking status, amount consumed daily.

ANALYSIS

Logistic regression for smoking status, multiple regression for amount smoked, with controls for age, education, marital status; separate analyses for men and women.

RESULTS

Cigarette prices were positively associated with the odds of being a non-smoker and negatively with amount smoked, for adults of both sexes. Per capita health education expenditures were positively associated with the odds of being a non-smoker and negatively with amount smoked--for men but not women. The restrictiveness of municipal bylaws limiting public smoking was positively associated with the odds of being a non-smoker and negatively with amount smoked--for women but not men. These results are independent of age, education, and marital status.

CONCLUSIONS

To be effective, tobacco control must comprise a mix of strategies as men and women respond differently to health education and restrictions on public smoking; taxation, reflected in higher cigarette prices, is the only one of these measures related to smoking for both sexes. This model permits calculations of the level of increase in each measure that is required to reduce the prevalence of smoking by a specified amount.

Tobacco lobby political influence on US state legislatures in the 1990s

BACKGROUND

Throughout the 1990s the tobacco lobby was a potent political force in US state legislatures advancing its pro-tobacco agenda.

OBJECTIVE

To describe the market and political motivations of the tobacco lobby and the strategies they use to achieve these goals in US state legislatures.

DESIGN

This study is a content analysis and summary overview of recently released historical tobacco industry documents; tobacco related government documents; and recent state tobacco control policy reports.

RESULTS

In the 1990s, the tobacco lobby engaged in a comprehensive and aggressive political effort in state legislatures to sell tobacco with the least hindrance using lobbying, the media, public relations, front groups, industry allies, and contributions to legislators. These efforts included campaigns to neutralise clean indoor air legislation, minimise tax increases, and preserve the industry's freedom to advertise and sell tobacco. The tobacco lobby succeeded in increasing the number of states that enacted state pre-emption of stricter local tobacco control laws and prevented the passage of many state tobacco control policies. Public health advocates were able to prevent pre-emption and other pro-tobacco policies from being enacted in several states.

CONCLUSIONS

The tobacco lobby is a powerful presence in state legislatures. Because of the poor public image of the tobacco lobby, it seeks to wield this power quietly and behind the scenes. State and local health advocates, who often have high public credibility, can use this fact against the tobacco lobby by focusing public attention on the tobacco lobby's political influence and policy goals and expose links between the tobacco lobby and its legislative supporters.

Reviews of evidence regarding interventions to reduce tobacco use and exposure to environmental tobacco smoke

This report presents the results of systematic reviews of effectiveness, applicability, other effects, economic evaluations, and barriers to use of selected population-based interventions intended to reduce tobacco use and exposure to environmental tobacco smoke. The related systematic reviews are linked by a common conceptual approach. These reviews form the basis of recommendations by the Task Force on Community Preventive Services (TFCPS) regarding the use of these selected interventions. The TFCPS recommendations are presented on page 67 of this supplement.