Decline in smoking prevalence--New York City, 2002-2006

In 2002, after a decade with no decrease in smoking prevalence, New York City began implementation of a five-point tobacco-control program consisting of increased taxation in 2002, establishment of smoke-free workplaces in 2003, public and health-care--provider education, cessation services, and rigorous evaluation, including annual cross-sectional, citywide telephone surveys using the same measures as CDC's state-based Behavioral Risk Factor Surveillance System (BRFSS). During 2002-2004, estimated adult smoking prevalence decreased from 21.5% to 18.4%, representing nearly 200,000 fewer smokers. However, in 2005, no change in adult smoking prevalence occurred, either among New York City residents overall or among demographic subpopulations. In 2006, to further reduce smoking in New York City, the New York City Department of Health and Mental Hygiene (DOHMH) implemented an extensive, television-based anti-tobacco media campaign using graphic imagery of the health effects of smoking; the campaign aired simultaneously with a large New York state anti-tobacco media campaign. This report describes the two campaigns and analyzes citywide survey data before and after the campaigns. In 2006, during the first year of the media campaigns, adult smoking prevalence decreased significantly among men (11.6% decrease) and among Hispanics (15.2% decrease). These findings confirm the importance of comprehensive tobacco-control programs and suggest that this intensive, broad-based media campaign has reduced smoking prevalence among certain subgroups.     

Purchasing patterns and smoking behaviors after a large tobacco tax increase: a study of Chinese Americans living in New York City

OBJECTIVES: Tobacco taxes are one of the most effective policy interventions to reduce tobacco use. Tax avoidance, however, lessens the public health benefits of higher-priced cigarettes. Few studies examine responses to cigarette tax policies, particularly among high-risk minority populations. This study examined the prevalence and correlates of tax avoidance and changes in smoking behaviors among Chinese American smokers in New York City after a large tax increase. METHODS: We conducted a cross-sectional study with data for 614 male smokers from in-person and telephone interviews using a comprehensive household-based survey of 2,537 adults aged 18-74 years. Interviews were conducted in multiple Chinese dialects. RESULTS: A total of 54.7% of respondents reported engaging in at least one low- or no-tax strategy after the New York City and New York State tax increases. The more common strategies for tax avoidance were purchasing cigarettes from a private supplier/importer and purchasing duty free/overseas. Higher consumption, younger age, and number of years in the U.S. were consistently associated with engaging in tax avoidance. Younger and heavier continuing smokers were less likely to make a change in smoking behavior in response to the tax increase. Despite high levels of tax avoidance and varying prices, nearly half of continuing smokers made a positive change in smoking behavior after the tax increase. CONCLUSIONS: Expanded legislation and enforcement must be directed toward minimizing the availability of legal and illegal low- or no-tax cigarette outlets. Public education and cessation assistance customized for the Chinese American community is key to maximizing the effectiveness of tobacco tax policies in this population.     

The economic impact of early life environmental tobacco smoke exposure: early intervention for developmental delay

BACKGROUND AND OBJECTIVES: Early-life exposure to environmental tobacco smoke (ETS) can result in developmental delay as well as childhood asthma and increased risk of cancer. The high cost of childhood asthma related to ETS exposure has been widely recognized; however, the economic impact of ETS-related developmental delay has been less well understood. METHODS AND RESULTS: The Columbia Center for Children's Environmental Health (CCCEH) has reported adverse effects of prenatal ETS exposure on child development in a cohort of minority women and children in New York City (odds ratio of developmental delay = 2.36; 95% confidence interval 1.22-4.58). Using the environmentally attributable fraction (EAF) approach, we estimated the annual cost of one aspect of ETS-related developmental delay: Early Intervention Services. The estimated cost of these services per year due to ETS exposure is > Dollars 50 million per year for New York City Medicaid births and Dollars 99 million per year for all New York City births. CONCLUSION: The high annual cost of just one aspect of developmental delay due to prenatal exposure to ETS provides further impetus for increased prevention efforts such as educational programs to promote smoke-free homes, additional cigarette taxes, and subsidizing of smoking cessation programs.     

Making It Harder to Smoke and Easier to Quit: The Effect of 10 Years of Tobacco Control in New York City

In 2002, New York City implemented a comprehensive tobacco control plan that discouraged smoking through excise taxes and smoke-free air laws and facilitated quitting through population-wide cessation services and hard-hitting media campaigns.Following the implementation of these activities through a well-funded and politically supported program, the adult smoking rate declined by 28% from 2002 to 2012, and the youth smoking rate declined by 52% from 2001 to 2011.These improvements indicate that local jurisdictions can have a significant positive effect on tobacco control.An estimated one third of smokers will die of a smoking-related illness, losing, on average, 14 years of life.1 In New York City, New York, in 2006, it was estimated that more than 7000 adults died from smoking-related illnesses, with these deaths accounting for approximately 14% of all adult deaths—or one in seven.2In 2002, tobacco control became a major priority of the New York City Health Department. At that time, a pack of cigarettes cost about $5.20, and smoking in bars, restaurants with fewer than 35 seats, and separate areas of workplaces was permitted. The adult smoking prevalence averaged 22% and showed no sign of change over the 10 preceding years.3To address tobacco use, the health department implemented a “Five Point Plan” in 2002, making it harder to smoke and easier to quit. This population-based tobacco control strategy consisted of

1. an increase in the price of cigarettes,
2. comprehensive smoke-free air legislation,
3. access to cessation medications,
4. mass media messages on the health consequences of smoking and secondhand smoke exposure, and
5. evaluation of key interventions.

     

State-specific prevalence of cigarette smoking and smokeless tobacco use among adults --- United States, 2009

The health consequences of cigarette smoking and smokeless tobacco use both have been well documented, including increased risk for lung, throat, oral, and other types of cancers. To assess state-specific current cigarette smoking and smokeless tobacco use among adults, CDC analyzed data from the 2009 Behavioral Risk Factor Surveillance System (BRFSS). This report summarizes the results of that analysis, which indicated wide variation in self-reported cigarette smoking prevalence (range: 6.4% [U.S. Virgin Islands (USVI)] to 25.6% [Kentucky and West Virginia]) and smokeless tobacco use (range: 0.8% [USVI] to 9.1% [Wyoming]). For 15 of the states, Puerto Rico, and Guam, smoking prevalence was significantly higher among men than among women. The prevalence of smokeless tobacco use was higher among men than women in all states and territories. Smokeless tobacco use was highest among persons aged 18--24 years and those with a high school education or less. From 0.9% (Puerto Rico) to 13.7% (Wyoming) of current smokers reported also using smokeless tobacco. Clinicians should identify all tobacco use in their patients and advise those who use any tobacco product to quit. The World Health Organization (WHO) recommends implementing this approach in combination with other measures, including raising excise taxes on tobacco and strengthening smoke-free policies to prevent tobacco-related deaths.     

Use of pharmacy data to evaluate smoking regulations' impact on sales of nicotine replacement therapies in New York City

OBJECTIVES: Recently, New York City and New York State increased cigarette excise taxes and New York City implemented a smoke-free workplace law. To assess the impact of these policies on smoking cessation in New York City, we examined over-the-counter sales of nicotine replacement therapy (NRT) products. METHODS: Pharmacy sales data were collected in real time as part of nontraditional surveillance activities. We used Poisson generalized estimating equations to analyze the effect of smoking-related policies on pharmacy-specific weekly sales of nicotine patches and gum. We assessed effect modification by pharmacy location. RESULTS: We observed increases in NRT product sales during the weeks of the cigarette tax increases and the smoke-free workplace law. Pharmacies in low-income areas generally had larger and more persistent increases in response to tax increases than those in higher-income areas. CONCLUSIONS: Real-time monitoring of existing nontraditional surveillance data, such as pharmacy sales of NRT products, can help assess the effects of public policies on cessation attempts. Cigarette tax increases and smoke-free workplace regulations were associated with increased smoking cessation attempts in New York City, particularly in low-income areas.     

Mexico SimSmoke: how changes in tobacco control policies would impact smoking prevalence and smoking attributable deaths in Mexico

We examined the effect of tobacco control policies in Mexico on smoking prevalence and smoking-related deaths using the Mexico SimSmoke model. The model is based on the previously developed SimSmoke simulation model of tobacco control policy, and uses population size, smoking rates and tobacco control policy data for Mexico. It assesses, individually, and in combination, the effect of six tobacco control policies on smoking prevalence and smoking-related deaths. Policies included: cigarette excise taxes, smoke-free laws, anti-smoking public education campaigns, marketing restrictions, access to tobacco cessation treatments and enforcement against tobacco sales youth. The model estimates that, if Mexico were to adopt strong tobacco control policies compared to current policy levels, smoking prevalence could be reduced by 30% in the next decade and by 50% by 2053; an additional 470,000 smoking-related premature deaths could be averted over the next 40 years. The greatest impact on smoking and smoking-related deaths would be achieved by raising excise taxes on cigarettes from 55% to at least 70% of the retail price, followed by strong youth access enforcement and access to cessation treatments. Implementing tobacco control policies in Mexico could reduce smoking prevalence by 50%, and prevent 470,000 smoking-related deaths by 2053.     

The Intended and Unintended Consequences of a Legal Measure to Cut the Flow of Illegal Cigarettes Into New York City: The Case of the South Bronx

Objectives. We examined the impact of a change in New York tax law on the numbers of untaxed cigarettes bootlegged from Native American reservations and resold in the South Bronx.Methods. Discarded cigarette packs were systematically collected in 30 randomized South Bronx census tracks before and after the amended tax law went into effect in 2011. Also, administrative data were gathered on the number of taxed cigarettes sold in New York State, including sales to Native American reservations.Results. Before the tax amendment, 42% of discarded cigarette packs collected in the South Bronx had no tax stamp. After the tax law went into effect, the percentage of cigarette packs without tax stamps declined to 6.2%. Simultaneously, the percentage of packs with out-of-state tax stamps rose from 18.3% to 66.3%. The percentage of packs with a combined New York State and New York City tax stamp did not change after the tax amendment.Conclusions. After the tax amendment, the supply of contraband cigarettes appears to have quickly shifted from one lower-priced jurisdiction to another without a change in the overall prevalence of contraband cigarettes.In June 2010, as part of an emergency budget measure, New York State raised its cigarette tax from $2.75 to $4.35 per pack and, in an effort to prevent smokers from circumventing state cigarette taxes, amended its tax law so that Native American reservations would no longer be able to sell untaxed cigarettes to non–tribal members. Since the 1980s, Native American reservations within New York State have imported billions of premium brand cigarettes, reselling them directly to smokers or to bootleggers who in turn supplied a thriving black market, particularly in New York City. This constituted a considerable challenge to smoking cessation policies that relied on high cigarette taxes as an economic disincentive for smokers. After a legal battle between several Native American tribes and the governor of New York, the tax amendment went into effect in June 2011.Our goal was to assess the effects of this tax amendment on the illegal cigarette market in economically disadvantaged neighborhoods in New York City, taking the South Bronx as an example. Specifically, we examined whether the measure has been successful in cutting off the supply of untaxed cigarettes from Native American reservations and whether it resulted in a reduction in the overall prevalence of illegal cigarettes, thus preventing a displacement to other sources of illegal cigarettes in response to increased cigarette taxes.     

The impact of tobacco control programs on adult smoking

Objectives. We examined whether state tobacco control programs are effective in reducing the prevalence of adult smoking.Methods. We used state survey data on smoking from 1985 to 2003 in a quasi-experimental design to examine the association between cumulative state antitobacco program expenditures and changes in adult smoking prevalence, after we controlled for confounding.Results. From 1985 to 2003, national adult smoking prevalence declined from 29.5% to 18.6% (P<.001). Increases in state per capita tobacco control program expenditures were independently associated with declines in prevalence. Program expenditures were more effective in reducing smoking prevalence among adults aged 25 or older than for adults aged 18 to 24 years, whereas cigarette prices had a stronger effect on adults aged 18 to 24 years. If, starting in 1995, all states had funded their tobacco control programs at the minimum or optimal levels recommended by the Centers for Disease Control and Prevention, there would have been 2.2 million to 7.1 million fewer smokers by 2003.Conclusions. State tobacco control program expenditures are independently associated with overall reductions in adult smoking prevalence.Recent data from the Centers for Disease Control and Prevention (CDC) showed that adult smoking remained constant at 20.8% from 2004 to 2005 after years of steady decline.1 The CDC study cited a 27% decline in funding for tobacco control programs from 2002 through 2006 and smaller annual increases in cigarette prices in recent years as 2 possible explanations for stalled smoking rates. Our study is a systematic assessment of the association between adult smoking, funding for state tobacco control programs, and state cigarette excise taxes.In 1989, California began the first comprehensive statewide tobacco control program in the United States after passage of a state ballot measure that raised cigarette excise taxes by $0.25.2 Comprehensive programs include interventions such as mass media campaigns, increased cigarette excise taxes, telephone quit lines, reduced out-of-pocket costs for smoking cessation treatment, health care provider assistance for cessation, and restrictions on secondhand smoke in public places.3^–6 Subsequently, other states, including Massachusetts in 1992, Arizona in 1995, and Florida in 1998, began similar large-scale state tobacco control programs.3 Multistate tobacco control interventions with substantial financial support began in the 1990s, with assistance from US government programs (e.g., the CDC’s Initiatives to Mobilize for the Prevention and Control of Tobacco Use [IMPACT] and the National Cancer Institute’s Americans Stop Smoking Intervention Study [ASSIST]) and other national programs.3Some states also committed resources from other sources, such as revenue from the 1998 Master Settlement Agreement (MSA) between the 4 largest tobacco companies in the United States and 46 US states.7 The MSA imposes restrictions on the advertising, promotion, and marketing or packaging of cigarettes, including a ban on tobacco advertising that targets people younger than 18, and requires the tobacco companies to pay $246 billion over 25 years to the states. The MSA also established a foundation that became the American Legacy Foundation.Extensive research has shown that state tobacco control programs, combined with other efforts, such as the American Legacy Foundation’s national truth campaign, have been effective in reducing adolescent tobacco use.3^,8^,9 Following a large increase in adolescent smoking during the mid-1990s, there has been an unprecedented decline, with the national prevalence among high school students dropping from 36.4% in 1997 to 21.9% in 2003.10In marked contrast, there has been little research into the effects of state programs on the prevalence of adult smoking, which is unfortunate given that smoking cessation confers substantial health benefits to adults.3^,11^,12 To date, findings from California, Massachusetts, and Arizona suggest that state tobacco control programs have had some effect on adults.13^–16 From 1988 through 1999, the prevalence of adult smoking in California declined from 22.8% to 17.1%, compared with an overall national decline from 28.1% to 23.5% (a relative percentage decline of 25% in California and 16% elsewhere).13^,14 From 1992 through 1999, the relative percentage decline in adult smoking was 8% in Massachusetts compared with 6% nationwide.14^,15 Findings from Arizona from 1996 to 1999 suggest a greater effect: the relative percentage decline was 21% compared with 8% nationwide.16 In addition, per capita cigarette sales—a proxy for cigarette consumption—have declined faster in Arizona, California, Massachusetts, and Oregon (where another large-scale program began in 1997) than in the rest of the United States since the programs’ implementation.17 The ASSIST evaluation showed that smoking prevalence decreased more in ASSIST states than in non-ASSIST states by the end of an 8-year intervention; by contrast, the evaluation found no difference in per capita cigarette consumption.6^,18These few state-specific studies on the prevalence of adult smoking had important limitations. First, state-specific findings may not be generalizable. Second, none of the studies considered the key role of cigarette price increases on prevalence (i.e., through higher cigarette excise taxes, which have consistently been shown to reduce cigarette consumption and prevalence)3 or controlled for other state characteristics, such as demographic changes or secular trends. Third, the studies did not assess the potential effects of programs on adults of different ages. Although the ASSIST evaluation provides a more comprehensive view of state tobacco control programs, it failed to control for baseline differences in state-level demographics and policy variables between ASSIST and non-ASSIST states. Finally, none of the studies considered the possible long-term effects of tobacco control programs on adult smoking.In 1999, the CDC published Best Practices for Comprehensive Tobacco Control Programs,19 which provided states with guidelines and recommendations for 9 tobacco control program activities (e.g., community programs, counter-marketing, cessation), along with minimum and optimum funding levels for each specific activity. On the basis of this document, in fiscal year 2006, states should have allocated $6.47 per capita minimum and $17.14 optimally to tobacco control programs (i.e., the $5.98 and $15.85, respectively, recommended in the 1999 CDC document, adjusted for inflation).We used data on state tobacco control program expenditures and periodic surveys of adult smoking prevalence conducted by the US Census Bureau from 1985 to 2003 to answer the following questions: (1) After control for potentially confounding factors (e.g., cigarette excise taxes), were increases in state tobacco control program expenditures independently associated with declines in adult smoking prevalence, and did effects differ by age group? (2) What would have been the predicted effect of state tobacco control program expenditures on adult smoking prevalence if all states had met CDC-recommended minimum or optimum per capita funding levels from 1995 to 2003?     

Prevalence and sociodemographic determinants of tobacco use among adults in Pakistan: findings of a nationwide survey conducted in 2012

Background

Smoking is one of the leading causes of preventable mortality. The World Health Organization recommends that countries should monitor tobacco use regularly. In Pakistan, the last national study on smoking in the general population was conducted in 2002 to 2003.

Methods

We conducted a cross-sectional survey of a nationally representative sample of men and women living in rural and urban areas of four main provinces of Pakistan from March through April 2012. Face-to-face in-house interviews were undertaken using a pre-tested structured questionnaire that asked about smoking and other forms of tobacco use. Multistage stratified random area probability sampling was used. To determine the national prevalence of tobacco use, the sample was weighted to correspond to rural–urban population proportions in each of the four provinces as in the 1998 census conducted by Pakistan’s Population Census Organization. Associations between sociodemographic variables and tobacco use were investigated using multivariable robust regression.

Results

Out of 2,644 respondents (1,354 men and 1,290 women), 354 men and 4 women reported being current cigarette smokers. The weighted prevalence of current cigarette smoking was 15.2% (95% confidence interval [CI]; 11.2, 19.3) overall, 26.6% (95% CI: 19.1, 34.1) among males, and 0.4% (95% CI: -0.2, 1.0) among females. Among females, 1.8% (95% CI: 0.4, 3.1) used any smoked tobacco and 4.6% (95% CI: 1.8, 7.4) used any smokeless tobacco daily or on some days of the week. Among males, odds of current cigarette smoking decreased with increasing level of education (OR?=?0.75; 95% CI: 0.68, 0.84) and increased with having a father who used tobacco (OR?=?2.11; 95% CI: 1.39, 3.22) after adjusting for other sociodemographic characteristics. Lower household income was associated with current cigarette smoking among rural males only (odds ratio [OR]?=?0.67; 95% CI: 0.48, 0.92 per category increase in monthly household income).

Conclusion

A large proportion of males smoked cigarettes. Cigarette use was negligible among females, but they used other forms of tobacco. Low education was a determinant of cigarette smoking among males irrespective of socioeconomic status and area of residence. Tobacco control campaigns should target uneducated and rural poor men and monitor all forms of tobacco used by the population.

     

The impact of tobacco control policies on disparities in children's secondhand smoke exposure: a comparison of methods

To examine the impact of cigarette excise taxes and smoke-free legislation on tobacco use among households with school-age children and adolescents as well as disparities in children's secondhand smoke exposure. We compare the results from models using causal inference techniques to those from cross-sectional models. We linked families of 6-17-year-olds from the 2003 (N = 67,607) and 2007 (N = 62,768) contacts of the National Survey of Children's Health with state-level cigarette excise taxes and smoke-free legislation total score (0 [none]-32 [very strong]) in 2001 and 2005. Parents reported whether anyone in the household used tobacco products. In adjusted causal inference models every $1.00 increase in cigarette excise tax between 2001 and 2005 was associated with a 4 percentage point decrease in household tobacco use between 2003 and 2007 (p = 0.008); however, there was no effect of smoke-free legislation on household tobacco use. Significant interactions revealed that cigarette tax increases were only associated with reductions in household tobacco use for parents of white children and, separately, lower income households. In contrast, in adjusted cross-sectional models, a higher smoke-free legislation total score was associated with a lower prevalence of household tobacco use. Stronger cigarette excise taxes decrease tobacco use among households with school-age children and adolescents, but smoke-free legislation at the state level does not change parental smoking. Since cross-sectional models cannot assess the direction of causality, evaluations should employ causal inference methods to help inform policy decisions to reduce disparities in adult smoking and, ultimately, protect children from secondhand smoke.     

Who supports tobacco excise taxes? Factors associated with towns' and individuals' support in Massachusetts.

OBJECTIVES: The authors examined factors related to public support for cigarette taxes: smoking behavior, attitudes about other tobacco control policies, and sociodemographic factors. METHODS: The authors regressed referendum voting outcomes on sociodemographic characteristics of Massachusetts' 351 towns. Logistic regressions on the surveys of Massachusetts adults (N = 14,000+) showed support for hypothetical tax increases to be related to respondents' smoking status, support for other tobacco control policies, and sociodemographic characteristics. RESULTS: Average educational attainment, probably acting as a proxy for nonsmoking prevalence, strongly predicted town-level support for Massachusetts' 1992 cigarette tax referendum. Survey respondents' support for hypothetical further increases was strongest if tax proceeds were earmarked for tobacco control or health purposes and if the individual was a nonsmoker and favored other tobacco control policies. For an earmarked tax, support was stronger among younger persons, females, persons with higher education, racial/ethnic minorities, and smokers with children. CONCLUSIONS: The high nationwide proportion of nonsmokers means that tobacco tax proposals can obtain strong voter support, but only if tax revenues are clearly earmarked for tobacco control and similar uses. Individual- and town-level characteristics can identify likely concentrations of support. Because attitudes toward tobacco control are only partly linked to smoking status, education campaigns may make a difference.     

Current cigarette smoking prevalence among working adults--United States, 2004-2010

Cigarette smoking is among the most important modifiable risk factors for adverse health outcomes and a major cause of morbidity and mortality. Current cigarette smoking prevalence among all adults aged ≥18 years has decreased 42.4% since 1965, but declines in current smoking prevalence have slowed during the past 5 years (declining from 20.9% in 2005 to 19.3% in 2010) and did not meet the Healthy People 2010 (HP2010) objective to reduce cigarette smoking among adults to ≤12%. Targeted workplace tobacco control interventions have been effective in reducing smoking prevalence and exposure to secondhand smoke; therefore, CDC analyzed National Health Interview Survey (NHIS) data for 2004-2010 to describe current cigarette smoking prevalence among currently working U.S. adults by industry and occupation. This report describes the results of that analysis, which found that, overall, age-adjusted cigarette smoking prevalence among working adults was 19.6% and was highest among those with less than a high school education (28.4%), those with no health insurance (28.6%), those living below the federal poverty level (27.7%), and those aged 18-24 years (23.8%). Substantial differences in smoking prevalence were observed across industry and occupation groups. By industry, age-adjusted cigarette smoking prevalence among working adults ranged from 9.7% in education services to 30.0% in mining; by occupation group, prevalence ranged from 8.7% in education, training, and library to 31.4% in construction and extraction. Although some progress has been made in reducing smoking prevalence among working adults, additional effective employer interventions need to be implemented, including health insurance coverage for cessation treatments, easily accessible help for those who want to quit, and smoke-free workplace policies.     

Smoking practices in New York City: The use of a population-based survey to guide policy-making and programming

To inform New York City’s (NYC’s) tobacco control program, we identified the neighborhoods with the highest smoking rates, estimated the burden of second-band smoke exposure, assessed the early response to state taxation, and examined cessation practices. We used a stratified random design to conduct a digit-dialed telephone survey in 2002 among 9,674 New York City adults. Our main outcome measures included prevalence of cigarette smoking, exposure to second-hand smoke, the response of smokers to state tax increases, and cessation practices. Even after controlling for sociodemographic factors (age, racelethnicity, income, education, marital status, employment status, and foreign-born status) smoking rates were highest in Central Harlem and in the South Bronx. Sixteen percent of nonsmokers reported frequent exposure to second-hand smoke at home or in a workplace. Among smokers with a child with asthma, only 33% reported having a no-smoking policy in their homes. More than one fifth of smokers reported reducing the number of cigarettes they smoked in response to the state tax increase. Of current smokers who tried to quit, 65% used no cessation aid. These data were used to inform New York City’s smoke-free legislation, taxation, public education, and a free nicotine patch give-away program. In conclusion, large, local surveys can provide essential data to effectively advocate for, plan, implement, and evaluate a comprehensive tobacco control program. Dr. Mostashari (the guarantor) made substantial contributions to the conception, design, and supervision of this paper, the analysis and interpretation of data, the drafting of the paper, critical revisions of the paper for important intellectual content, and the acquisition of data and funding for this research. Dr. Kerker made substantial contributions to the analysis and interpretation of data, the drafting of the paper and critical revisions of the paper for important intellectual content. Ms. Hajat made substantial contributions to the acquisition of data and critical revisions of the paper for important intellectual content. Dr. Miller made substantial contributions to the conception of this paper and critical revisions of the paper for important intellectual content. Dr. Frieden made substantial contributions to the conception, design, and supervision of this paper and critical revisions of the paper for important intellectual content.     

Tobacco control in the Czech Republic

Main points of tobacco control measures in the country are mentioned: smoking prevalence among population and health professionals (both about one third), smoking cessation availability (about 70 smoking cessation clinics), education of health professionals, both pre- and post-gradual, public-oriented actions, advertising, tobacco prices, legislation, cigarette consumption, mortality.     

Changes in Smoking Prevalence and Number of Cigarettes Smoked Per Day Following the Implementation of a Comprehensive Tobacco Control Plan in New York City

The New York City (NYC) Health Department has implemented a comprehensive tobacco control plan since 2002, and there was a 27% decline in adult smoking prevalence in NYC from 2002 to 2008. There are conflicting reports in the literature on whether residual smoker populations have a larger or smaller share of “hardcore” smokers. Changes in daily consumption and daily and nondaily smoking prevalence, common components used to define hardcore smokers, were evaluated in the context of the smoking prevalence decline. Using the NYC Community Health Survey, an annual random digit dial, cross-sectional survey that samples approximately 10,000 adults, the prevalence of current heavy daily, light daily, and nondaily smokers among NYC adults was compared between 2002 and 2008. A five-level categorical cigarettes per day (CPD) variable was also used to compare the population of smokers between the 2 years. From 2002 to 2008, significant declines were seen in the prevalence of daily smoking, heavy daily smoking, and nondaily smoking. Among daily smokers, there is also evidence of population declines in all but the lowest smoking category (one to five CPD). The mean CPD among daily smokers declined significantly, from 14.6 to 12.5. After an overall decline in smoking since 2002, the remaining smokers may be less nicotine dependent, based on changes in daily consumption and daily and nondaily smoking prevalence. These findings suggest the need to increase media and cessation efforts targeted towards lighter smokers.     

State-level tobacco control policies and youth smoking cessation measures

ObjectiveResearch on the effects of state-level tobacco control policies targeted at youth has been mixed, with little on the effects of these policies and youth smoking cessation. This study explored the association between state-level tobacco control policies and youth smoking cessation behaviors from 1991 to 2006.MethodsThe study design was a population-based, nested survey of students within states. Study participants were 8th, 10th, and 12th graders who reported smoking “regularly in the past” or “regularly now” from the Monitoring the Future study. Main cessation outcome measures were: any quit attempt; want to quit; non-continuation of smoking; and discontinuation of smoking.ResultsResults showed that cigarette price was positively associated with a majority of cessation-related measures among high school smokers. Strength of sales to minors’ laws was also associated with adolescent non-continuation of smoking among 10th and 12th graders.ConclusionsFindings suggest that increasing cigarette price can encourage cessation-related behaviors among high school smokers. Evidence-based policy, such as tax increases on tobacco products, should be included as an important part of comprehensive tobacco control policy, which can have a positive effect on decreasing smoking prevalence and increasing smoking cessation among youth.     

Sociocultural determinants of tobacco use among Cambodian Americans

The objectives of this study included the following: obtaining qualitative information on tobacco use among Cambodian Americans, identifying cultural factors that influence tobacco use and acquiring information for the development of effective smoking prevention and cessation strategies. Data were collected by using demographic and behavioral questionnaires and focus group interviews. A total of 14 focus group interviews that covered cultural practices associated with smoking were administered. Statistical analyses included univariate frequency distributions and cross-tabulations. The subjects (n = 119) were Cambodian American volunteers who participated in social services programs offered by a community service organization. All subjects were 18 years of age or older and resided in the city of Long Beach. The principal outcomes measured were cigarette smoking and tobacco use. Other variables included reasons for smoking, traditional uses of tobacco, stress factors related to smoking and the perceived health effects of smoking. Predisposing, reinforcing and enabling factors associated with tobacco-use behaviors included peer group influences, smoking adopted as a coping method, tobacco used for medicinal purposes and smoking practiced within cultural traditions. The frequency of smoking was four times higher among males than among females. Smokers (n = 29) in comparison with non-smokers (n = 90) tended to be men (79% versus 33%), not married (68% versus 49%) and unemployed (79% versus 54%), and had attained somewhat lower levels of education. The role of cultural factors needs to be considered when designing appropriate smoking cessation strategies for Cambodian Americans.     

Co-occurrence and clustering of tobacco use and obesity in New Zealand: cross-sectional analysis

Objective: To describe the co‐occurrence and clustering/aversion of tobacco use and obesity in New Zealand. Method: Data were sourced from the 2002/03 New Zealand Health Survey, a nationally representative household survey that included measured body mass index (BMI) and self‐reported smoking status. The association of cigarette smoking, obesity, and the combination of these risk factors with socio‐demographic variables was analysed by multiple logistic regression. Clustering/aversion (defined as observed prevalence of [smoking + obesity] > or < expected prevalence, where expected prevalence = prevalence of [smoking] x prevalence of [obesity] > was also estimated. Results: The joint prevalence of smoking plus obesity in the adult population (15+ years) was 4.5%. However, this was 10% for Maori and 8.5% for deprivation quintile 5. Adjusting for relevant covariates, Maori were twice as likely to have both risk factors as non‐Maori. A smooth deprivation gradient was found, with deprivation quintile 1 (least deprived) only one‐fifth as likely to have both risk factors as quintile 5 (most deprived). There was no evidence of clustering, and aversion (negative clustering) was demonstrated only for middle‐aged adults and for Maori. Discussion: Since smoking cessation is associated with weight gain, substantial aversion might have been expected across all subgroups, yet this was not found. The most likely explanations are that the extent of weight gain associated with smoking cessation has been overestimated or is often not sustained. Even so, health promotion and clinical interventions need to take the dually exposed population into account, addressing not only the unhealthy behaviours themselves but also the social context in which dual exposure occurs.