Teenage smoking behaviour following a high-school smoking ban in Chile: interrupted time-series analysis

How Dangerous? Substance Use Risk Perceptions in Chilean Preadolescents

Early substance use initiation among children represents a significant risk to public health. Research suggests that early positive perceptions and cognitions of elementary students toward substance use may predict later use during adolescence. Studies among adolescent populations have shown an inverse relationship between substance use and risk perceptions. To gain insight into alcohol, tobacco, and marijuana risk perceptions prior to adolescence, we analyzed data from the Chilean Early Childhood Longitudinal Survey (ELPI). In a sample of 5,278 families (mean age of preadolescents 10.63 years, SD = .64; 50.5% males), our findings showed that an important proportion of Chilean 10 years old did not perceive occasional tobacco, alcohol, or marijuana use to be high-risk activities. However, the majority of respondents did consider daily substance use to be a high-risk activity, with some variation across substances. Overall, older preadolescents were more likely to consider substance use to be less risky compared to their slightly younger counterparts. Our analysis also demonstrated that past month substances use by caregivers were all found to be predictive of low-medium risk perceptions among preadolescents surveyed, while conversely, caregivers' negative reactions to finding out their child had used a substance decreased the likelihood of holding low-medium risk perceptions. Individuals from single-parent households were less likely to consider substance use as being high-risk compared to their peers. Preadolescents with caregivers reporting higher average incomes were also more likely to hold lower risk perceptions of occasional substance use. Implications for public policies to prevent substance use in the pre-adolescent population are discussed.

A systematic review and network meta-analysis of population-level interventions to tackle smoking behaviour

This preregistered systematic review and meta-analysis (PROSPERO: CRD 42022311392) aimed to synthesize the effectiveness of all available population-level tobacco policies on smoking behaviour. Our search across 5 databases and leading organizational websites resulted in 9,925 records, with 476 studies meeting our inclusion criteria. In our narrative summary and both pairwise and network meta-analyses, we identified anti-smoking campaigns, health warnings and tax increases as the most effective tobacco policies for promoting smoking cessation. Flavour bans and free/discounted nicotine replacement therapy also showed statistically significant positive effects on quit rates. The network meta-analysis results further indicated that smoking bans, anti-tobacco campaigns and tax increases effectively reduced smoking prevalence. In addition, flavour bans significantly reduced e-cigarette consumption. Both the narrative summary and the meta-analyses revealed that smoking bans, tax increases and anti-tobacco campaigns were associated with reductions in tobacco consumption and sales. On the basis of the available evidence, anti-tobacco campaigns, smoking bans, health warnings and tax increases are probably the most effective policies for curbing smoking behaviour.

Changes in parental smoking behavior and children's health status in Chile

Studies on parental smoking behavior have mostly been conducted for developed countries and show that current parental smoking is negatively associated with children's current health. Using four waves of a Chilean longitudinal survey (Encuesta de Protección Social), we estimate probit and ordinary least squares models relating parents' self-report of their children's current health status to several covariates, including current parental smoking status and change (transitions) in parental smoking status across the waves of the survey. The data were collected in the years 2004, 2006, 2009, and 2015. The working sample includes 25,052 observations. The study revealed that parents' self-report of their children's current health status is strongly associated with current and past parental smoking status. Parents who smoke have an increased 11.17% probability of reporting that their children are in fair, poor, or very poor health status, when compared to non-smoking parents. The effect is stronger if the smoker is the mother, and it is exacerbated if she is less educated or unemployed/inactive. In addition, quitting smoking has a significant positive effect on children's reported health status, which is greater if the mother quits smoking. Cessation among mothers who are unemployed or inactive is also associated with a more positive assessment of their children's health status. The findings suggest that cessation programs may have health benefits not only for smoking parents, but also for their children. Improving coverage or establishing a national cessation program may have important present and future effects on population health and well-being.

Evaluation of the Implementation of a 25-Year Outdoor School Ground Smoking Ban: A Qualitative Interview Study With Implications for Prevention Practise

Introduction: Tobacco use, often initiated in younger ages, is a serious health challenge worldwide. In Sweden, smoking has been prohibited on school grounds since 1994. Municipal environmental and health inspectors control the compliance of the ban. Nevertheless, the enforcement and maintenance of the ban are inadequate. The aim of the current study was to identify facilitators, barriers, and the potential for improved implementation of a 25-year outdoor school ground smoking ban in upper secondary schools.

Materials and Methods: A process evaluation was conducted using semi-structured interviews with principals in upper secondary schools, local environmental and health inspectors, and local politicians (n = 30) in Stockholm County, with purposive sampling for informant recruitment. A qualitative content analysis of the transcribed interviews was performed.

Results: Three main categories and 10 subcategories were generated from the interviews, revealing facilitators, barriers, and the potential for improvement of the implementation of the ban. A prominent facilitator of the ban was informed and engaged principals and inspectors. Prominent barriers were conflicting goals governing the schools, which reduce staffs' motivation to maintain the ban, unclear school ground boundaries, and lack of resources. Potential for improvement was found in a new tobacco act with an extended ban on smoking at school entrances, extended support for schools and staff to strictly enforce the ban, and a continued denormalisation of smoking in society.

Conclusion: To achieve effective implementation of outdoor school ground smoking bans in upper secondary schools, authorities need to address conflicts between different goals governing the schools and give necessary support to the staff to strictly enforce the ban. Policies on smoke-free working hours in the municipalities along with tobacco restrictive policies in the surrounding society may increase the possibility to maintain the smoking ban in upper secondary school grounds.

The association between flavor capsule cigarette use and sociodemographic variables: Evidence from Chile

Purpose

The objective of this article is to examine the factors associated with smoking of flavor capsule cigarettes in Chile, where the popularity of these products has increased dramatically, a trend increasingly observed across the world.

Methods

A representative poll of 851 smokers in Metropolitan Santiago de Chile, which comprises 40% of the country's total population, was implemented in mid-2017. Smokers were given a questionnaire that collected socio-demographic information and information on smoking patterns. Four discrete-choice models were estimated on the decision to smoke flavor capsule cigarettes to better understand the statistical relationships between traits of smokers and the consumption of flavor capsule cigarettes.

Results

The results of these models show that each year less in a smoker’s age increases the likelihood of preferring flavor capsule cigarettes by, on average, between 0.8 and 0.9 percentage points. If the smoker is a woman, the likelihood of preferring flavor capsule cigarettes increases between 13.4 and 13.5 percentage points. Results also reveal a positive relationship between the price paid and the consumption of flavor capsule cigarettes, indicating that these cigarettes tend to be more expensive. There is no statistical relationship between participation in the labor market and smoking these products.

Conclusions

Chile has the world’s highest prevalence of flavor capsule cigarette smoking, which is concentrated among young people (25 years and younger) and females. No relationship between socioeconomic status and use of these products is found, though there are indications that such relationship may exist, as they were at the time of study 14% more expensive, on average, than conventional non-flavored cigarettes. As in most countries, the tobacco industry appears to be deliberately promoting these products with the goal of halting or slowing the decline in cigarette consumption in Chile. Thus, to reduce cigarette consumption (especially among youth), restricting or forbidding cigarette flavorings of all types, including flavor capsules, would be an effective strategy.

Association of Tobacco Control Policies With Youth Smoking Onset in Chile

IMPORTANCE

Tobacco smoking is still responsible for more than 6 million preventable deaths annually, most of which occur in low- and middle-income countries. South American countries, Chile in particular, endure some of the highest cigarette smoking prevalence rates globally. Despite the lack of any meaningful increases in cigarette taxes (the most effective tobacco control measure) between 1999 and 2014, cigarette prices in Chile increased sharply almost entirely driven by British American Tobacco (BAT).

OBJECTIVE

To examine the associations between cigarette prices and nonprice tobacco control policies targeted at youth introduced in 2006 (Law 20105) and smoking onset among Chilean youths.

DESIGN, SETTING, AND PARTICIPANTS

This study used data from 8 waves of a large national school survey of urban communities in Chile conducted between October and December in 2001, 2003, 2015, 2007, 2009, 2011, 2013, and 2015 and discrete-time hazard models. Data analysis was performed from May 2017 to January 2019.

EXPOSURES

Prices, advertising, and retail restrictions.

MAIN OUTCOMES AND MEASURES

Smoking onset (the transition between never smoking and smoking) in youth.

RESULTS

In this study of 181 624 survey respondents in 8751 Chilean secondary schools, higher prices (own-price elasticity [percentage change in quantity demanded in response to a 1% change in price], -0.40; 95% CI, -0.45 to -0.36) and the tobacco control policies enacted in 2006 (hazard ratio, 0.83; 95% CI, 0.81-0.85) were associated with lower hazards of starting smoking. The study found that an increase in real prices of 58.6% and the introduction of Law 20105 were associated with similar lower hazards of starting smoking (hazard ratio, 0.83; 95% CI, 0.81-0.85); in comparison, between 1999 and 2017, inflation-adjusted cigarette prices increased by 206%.

CONCLUSIONS AND RELEVANCE

The findings suggest that higher prices initiated by BAT and the tobacco control policies enacted by the Ministry of Health in 2006 were associated with lower hazards of starting smoking in Chilean youth. Large cigarette tax increases may be a strategy that can be used to help reduce smoking among youths in Chile.

The use of controls in interrupted time series studies of public health interventions

Interrupted time series analysis differs from most other intervention study designs in that it involves a before-after comparison within a single population, rather than a comparison with a control group. This has the advantage that selection bias and confounding due to between-group differences are limited. However, the basic interrupted time series design cannot exclude confounding due to co-interventions or other events occurring around the time of the intervention. One approach to minimizse potential confounding from such simultaneous events is to add a control series so that there is both a before-after comparison and an intervention-control group comparison. A range of different types of controls can be used with interrupted time series designs, each of which has associated strengths and limitations. Researchers undertaking controlled interrupted time series studies should carefully consider a priori what confounding events may exist and whether different controls can exclude these or if they could introduce new sources of bias to the study. A prudent approach to the design, analysis and interpretation of controlled interrupted time series studies is required to ensure that valid information on the effectiveness of health interventions can be ascertained.

Relationship between smoking and health and education spending in Chile

Objective

To estimate the degree to which tobacco consumption is associated with spending on a set of goods and services in Chile, especially health and education, for the total population as well as for specific subgroups.

Methods

A seemingly unrelated regression equation system was used to estimate the statistical relationship between having tobacco expenditures and the budget share allocated to other items for the total population and for specific subgroups in Chile (eg, households within the bottom/top 33% by total expenditures). The use of household-level data allows for the control of a number of sociodemographic characteristics. The nationally representative 2012 Chilean Household Expenditure Survey was used for the analysis.

Results

Tobacco consumption is associated with lower budget shares allocated to healthcare, education and housing expenses, especially for poorer households. In the case of health, not consuming tobacco is related to higher health expenditures: up to 32% for the total population. Similarly, in the case of education, not consuming tobacco is statistically related to higher education expenditures: up to 16% for the total population. For all groups, tobacco consumption is also related to a significantly higher budget share allocated to alcoholic beverages.

Conclusions

The strong significant statistical relationship found between tobacco consumption and resources allocated to healthcare and education consumption may be indicative of the existence of a crowding out effect of tobacco. This effect, in turn, may increase the burden that the rest of society must bear for the increased healthcare that they require because of tobacco consumption.