Youth tobacco control: reconciling theory and empirical evidence

Youth smoking is an important target for public policy. The implicit assumption behind targeting youth is that policies that reduce youth smoking initiation will reduce lifetime smoking propensities. This assumption has never been tested empirically. I use data from the National Longitudinal Survey of Youth (NLSY) to follow the smoking pattern of one cohort of teenagers. I examine how smoking rates in youth and young adulthood are affected by the taxes individuals faced at age 14. In panel data analysis, I find that the effects of taxes at age 14 are considerably attenuated by adulthood. I find some evidence suggesting that this result is a consequence of delayed smoking initiation that is correlated with taxes. These results suggest that reducing smoking among teens through tax policy may not be sufficient to substantially reduce smoking in adulthood.     

The dawn of a smoke-free leisure industry in The Nederlands

From the 1st of July 2008 the Dutch smoking ban for public spaces will be extended to hotels, restaurants and bars. The ban is a result of a 2003 Health Council report in which it was concluded that the annual incidence of deaths due to passive smoking is considerable. Based on these numbers, smoking in public spaces is prohibited since 2004. In a society where smoking in public spaces is prohibited, the harm of passive smoking will decrease. In this issue of The Nederlands Tijdschrit voor Geneeskunde (Dutch Journal of Medicine) a number of articles are dedicated to the subject of smoking.     

Population health and the hardcore smoker: Geoffrey Rose revisited

The "hardening hypothesis" suggests that as smoking prevalence decreases, lighter smokers will quit first, leaving more "hardcore" smokers in the population. At a population level, however, the weight of evidence suggests that no hardening is occurring. By understanding the lessons from Geoffrey Rose's model of population-level risk factor change, we argue that the hardening of the smoking population is not inevitable. The Rose model predicts that the effect of policy interventions, and changes in social norms, can shift the population-level risk distribution for continuing to be a smoker, making it more likely that all smokers will quit. This analysis also suggests that further reductions in smoking prevalence will not come without further changes in the underlying--and largely cultural--root causes of smoking in a population.     

Tobacco consumption in New Zealand: why did it fall?

OBJECTIVE: To estimate the relative contributions of trends in smoking prevalence and trends in smoking intensity (average number of cigarettes smoked per day) to the observed decline in per capita tobacco consumption in New Zealand from 1984 to 2004. METHOD: Tobacco consumption and smoking prevalence time series data were sourced from Statistics New Zealand and the ACNielsen Omnibus Survey respectively and checked for accuracy against other sources. The contribution of changes in smoking prevalence to the observed decline in tobacco consumption was estimated by counterfactual modelling. The corresponding contribution of trends in smoking intensity was then calculated by difference. RESULTS: Changes in smoking prevalence accounted for 48% of the decline in per capita tobacco consumption from 1984-89 and for 39% thereafter. Correspondingly, changes in smoking intensity accounted for 52% of the consumption decline during the first five years of the study period and 61% thereafter (i.e. from 1990 to 2004). DISCUSSION: Understanding the relative contributions of trends in smoking prevalence and smoking intensity to the observed decline in per capita tobacco consumption is important, because the relationship between smoking intensity and health effects is non-linear. Our results indicate that the dramatic fall in tobacco consumption in New Zealand over the past 30 years will not be accompanied by an equivalent reduction in tobacco-attributable morbidity and mortality. Furthermore, our findings raise doubts as to how much longer tobacco consumption will continue to decline, given that smoking intensity is already low. The key message for the tobacco control program is to re-focus on helping smokers to quit and stay quit.     

Adjusted tobacco legislation and accompanying actions for the benefit of future children of women smokers

Pregnant women are a population group of special interest as far as smoking is concerned. It is not only their own health but also that of their unborn children that is implicated. Consequently, achieving short-term abstention is relevant as well as long-term cessation. A paper published elsewhere in this issue provides empirical evidence on the smoking status of pregnant women and illustrates that currently one quarter of them smoke. For approximately 25% of pregnant women, their pregnancy is reason to stop smoking and for the majority this then results in lasting abstention. However, 11% of pregnant smokers keep on smoking throughout their pregnancy. These figures compare favourably with the 28% of pregnant women smokers in the Dutch population, but should nevertheless be reason for concern for the health of mother and child. One of the reasons for the high levels of smokers amongst pregnant women in the Dutch population could well be the waning political support for public health actions following tobacco legislation that came into effect in 2004. The effectiveness of smoking cessation can be enhanced by a combination of individual and public actions. For example, partners of smoking pregnant women should also be involved in quitting interventions. Moreover, the current and anxiously awaited proposal by the Minister of Health to impose a ban on smoking in the public domain of bars and restaurants will offer an ideal opportunity for promoting non-smoking on the part ofindividuals. Such a development will result in considerable health benefits for the unborn children of smoking, pregnant women.     

Racial and ethnic disparities in smoking prevalence in Israel and the United States: progress to date and prospects for the future

An article in this journal in 2016 demonstrated that smoking prevalence among Arab men in Israel is greater than among their Jewish counterparts born in Israel, while the reverse is true among Arab and Jewish Israeli women. This is reflected in lung cancer mortality rates. In the U.S., smoking prevalence in the mid-1960s was 20% higher in African American men than in white men, but has since decreased in both groups, and smoking prevalence in the two groups is now nearly identical. The black-white disparity in lung cancer mortality rates has been reduced by more than half as compared to its zenith in the early 1990s. The strategies employed to achieve these gains will continue to be important going forward, and successful strategies employed in Israel in addressing smoking in the male Arab population will be of increasing interest in the U.S. as its Arab population increases.     

Smoking and doctors: from 'therapeutic panacea' to 'tobacco use discouragement in the individual'

In The Netherlands smoking will be prohibited in bars, restaurants, pubs and enclosed public spaces on 1 July 2008, in accordance with European legislation. Smoking is already not allowed in most Dutch hospitals. Europeans have a long history of tobacco smoking, going back to the introduction of this habit by Columbus. For centuries tobacco was used as a medicine, and later as a recreational drug, especially after the introduction of the cigarette. There was no scientific understanding of the harmful effects of smoking until the 19th century, when nicotine was isolated and recognised as a poison. Despite the fact that health care professionals represent a valuable resource for tobacco control, doctors have generally shown a poor appreciation of their critical role in smoking control. A decreasing smoking prevalence in the general population however, will emphasize the function of physicians as role model.     

Cost-Effectiveness Analysis of the Not On Tobacco Program for Adolescent Smoking Cessation

Public health researchers and practitioners emphasize the need for effective, adoptable, and available youth smoking cessation interventions. Scarce resources demand that such interventions also be cost effective. This study describes a cost-effectiveness analysis (CEA) of the American Lung Association's Not On Tobacco (N-O-T) national and international teen smoking cessation program. N-O-T has been rigorously evaluated as an effective and adoptable program, and was recently found to be the most frequently-used teen smoking cessation program in the nation. N-O-T studies show intent-to-treat quit rates between 15% and 19%, among the highest reported in the literature. The current CEA resulted from a 2-year state-wide demonstration study in Florida, comparing the effectiveness of N-O-T with a 20-min brief intervention (BI). The CEA utilized a Markov transition model of decision analysis to explain stage progression of smoking cessation among participants from the age of 17 to 25 years. The Markov simulation predicted that out of a cohort of 100 N-O-T students, 10 will quit smoking and remain smoke-free at the age of 25 years and 14 will reduce smoking, resulting in 102.22 life years saved and a total of 20.11 years discounted life years (DLY) saved. Among BI youth, six will quit smoking and nine will reduce, indicating 64.31 life years saved and a total 12.65 DLY saved. The incremental DLY saved is 7.46 years. Results indicate that N-O-T is a very cost-effective option school-based smoking cessation, as cost effective as school-based primary tobacco prevention, and potentially more cost effective than adult tobacco use cessation.     

Who kicks the habit and how they do it: socioeconomic differences across methods of quitting smoking in the USA

Although the prevalence of smoking has declined among US adults, an estimated 22.5% of the adult population (45.8 million adults) regularly smoked in 2002. Starting from this level, it will not be possible to achieve the Healthy People national health objectives of a reduction in the prevalence of smoking among adults to less than 12% by 2010 unless the rate of smoking cessation substantially rises from its current average of about 2.5%/year. To achieve that goal it is imperative that we better understand what factors are associated with successful quitting so that policies and resources can be better targeted. We describe the socioeconomic characteristics of smokers who attempt to and successfully quit and show how those characteristics differ across three methods they use in their cessation behavior. The results highlight socioeconomic differences across the methods smokers use and provide evidence that can be used to better target smoking cessation information and resources to smokers most likely to use particular methods. Better targeting is likely to lead to more quits. While it is unlikely that cessation rates can be raised by enough to achieve the reduction in national smoking prevalence that the Healthy People initiative has set, a better understanding of who chooses which method will move us closer to that goal.     

Determinants of smoking cessation among adolescents in South Africa

Data is required on the motivational determinants of smoking cessation among a multi-ethnic sample of adolescents in South Africa. The I-Change Model was used to explore the determinants of smoking cessation among a sample of 1267 Black African, Colored and White Grade 9-11 monthly smokers and former smokers in the Southern Cape-Karoo region. Across the ethnic groups, former smokers displayed a more positive attitude toward non-smoking, were surrounded by a social environment that was more supportive of non-smoking, displayed higher self-efficacy not to smoke in stressful, routine and social situations, and were more positive about their intention not to smoke in the next year. The I-Change Model can be used to address the cognitions of smoking in a multi-ethnic society like South Africa. However, some ethnic tailoring will be required. Black African students will benefit from a focus on attitudinal cognitions and cultural factors that motivate smoking. Colored students require the involvement of their social environment, while White students will benefit from the development of refusal skills in social situations.     

Protocol for the Smoking, Nicotine and Pregnancy (SNAP) trial: double-blind, placebo-randomised, controlled trial of nicotine replacement therapy in pregnancy

Background  

Smoking in pregnancy remains a public health challenge. Nicotine replacement therapy (NRT) is effective for smoking cessation in non-pregnant people, but because women metabolise nicotine and cotinine much faster in pregnancy, it is unclear whether this will be effective for smoking cessation in pregnancy. The NHS Health Technology Assessment Programme (HTA)-funded smoking, nicotine and pregnancy (SNAP) trial will investigate whether or not nicotine replacement therapy (NRT) is effective, cost-effective and safe when used for smoking cessation by pregnant women.     

The accuracy of teens' expectations of future smoking

BACKGROUND: Whether current and potential smokers recognize the full scope of smoking-related risks remains in dispute. This paper provides new evidence for one key group, teenagers, by assessing whether teens accurately assess the chances that they will be smoking in the future. Among current smokers, this is one measure of whether they understand the addictiveness of smoking. Among current nonsmokers, this provides evidence regarding the social environment in which teens decide whether to smoke. METHODS: A nationally representative sample of teens was asked to assess the chances that they would be smoking 1 year later. Mean expectations of future smoking were compared with the actual probabilities of smoking initiation or continuation over 1 year from comparable epidemiologic data. RESULTS: Among current smokers, the mean expectation of continued smoking in 1 year was significantly lower than the observed continuation rate (p <0.01). Among nonsmoking teens, the mean expectation of smoking initiation was significantly lower than the observed rate of initiation (p <0.02). Both types of underestimations were substantively large and consistent across the teenage years. CONCLUSIONS: Currently-smoking teens underestimate the chances that they will continue smoking--which is one measure of whether they understand the addictiveness of cigarettes--while currently-nonsmoking teens underestimate the chance that they will start to smoke, a measure of the social appeal of cigarettes. Tobacco control strategies should account for these misperceptions.     

吸烟对河南居民健康状况的影响

目的：了解吸烟对河南省居民健康状况的影响。方法：采用现况调查方法,1995年在河南省6个国家级疾病监测点进行,结果：吸烟人群和被动吸烟人群的总患病率均高于非吸烟人各,吸烟人群疾病模式与非吸烟人群不同,其中,吸烟者呼吸系统疾病极其显著高于非吸烟者,每天吸烟量大于14支者,其总患病率明显升高,结论：吸烟对本省居民健康和生命带来巨大威胁,应广泛开展健康教育。     

Smoking visibility,perceived acceptability,and frequency in various locations among youth and adults

OBJECTIVES: This study tests whether there is an association between high visibility of smoking, perceived acceptability of smoking, and where youth smoke. METHODS: Surveys of 9,762 students in grades 8-10 and 1,586 parents in 15 Minnesota communities asked about the frequency of and opinions of adult and youth smoking in various indoor and outdoor public places. Chi-square analysis and ANOVAs compared smokers and nonsmokers. RESULTS: More smoking than nonsmoking youth reported often seeing adults and teens smoking in all locations. Forty-two percent of students often noticed adults and 35% often noticed teens smoking outdoors, also the most frequent location where teens report smoking. Students perceived adult and teen smoking as more acceptable in restaurants, recreation centers, and outdoor gathering places. More student smokers than nonsmokers believe that smoking is acceptable for both adults and teens. Of the parent sample, 52% often observed adults and 36% often observed youth smoking outdoors. Nonsmoking parents observed adult and teen smoking more often than parents who smoke. CONCLUSIONS: The data support an association between the frequency that youth observe smoking in various locations and the perception that smoking is socially acceptable by smoking status. Policies that restrict smoking in various locations will reduce both visibility and perceived acceptability of smoking in those locations.     

The practice guideline 'Smoking cessation' from the Dutch College of General Practitioners; a response from the perspective of general practice

This article reviews the practice guideline from the Dutch College of General Practitioners on smoking cessation. General practitioners (GP) should strive after smoking cessation when patients consult and ask for support to stop smoking. Moreover, the practitioner should also show such initiative when patients present signs and symptoms related to smoking; in parents of children with asthma; and in pregnant women. The strength of general practice is its accessibility to the population: more than 60% of the population consults their GP at least once a year. However, it is important to realize that it is not always possible to raise the issue of smoking cessation, and in some consultations this might be inappropriate. The effectiveness of individual advice in smoking cessation is enhanced by public health campaigns, and it is expected that the smoking ban in Dutch bars and restaurants, that is to come into effect in July 2008, will support the role of GPs. A problem in the implementation of the practice guideline remains, however: medication and methods to support withdrawal symptoms are still not covered by health care insurers.     

Smoking in children: developing a social psychological strategy of deterrence.

Because smoking as an identifiable risk factor for several diseases, has not declined in adults and may be increasing in teen-agers and children, a social-psychological strategy to deter smoking in children is currently being implemented in the Houston (Texas) Independent School District. The study, developed by a group at the University of Houston Psychology Department, involves various sociological and psychological devices, such as modeling, identification, and attribution in conjunction with persuasive communication techniques—affect, specificity, and feedback.A pretest, post-test design is employed in a longitudinal study. An independent variable package, used in the pilot study involving seventh graders, includes four different videotapes presented to the subjects on four consecutive days. The role-played sequences in the tapes reflect how pressures by peers, parents, and media can precipitate smoking in children. The tape presentation is followed by focused discussion about coping with these pressures. The dependent variable package, in addition to various attitudinal and reported smoking behavior responses, employs a novel nicotine-in-saliva measure for more objective determination of whether or not a student is smoking. The long term longitudinal study will involve fifth- through 12th-graders. It is hoped that preventing children from starting to smoke will prove to be more effective than attempting to deal with already addicted smokers.     

The costs of smoking and the cost effectiveness of smoking-cessation programs

The impact of cigarette smoking on morbidity and mortality in this country is enormous. It is the cause of one out of every six deaths in the U.S., and is linked to conditions ranging from cardiovascular disease to cancer to low-birth weight. Economic analyses indicate that cessation of cigarette smoking will probably not lead to reduced health care expenditures in the general population because of increased health care utilization during those years of life saved as a result of cessation. However, when indirect costs (economic productivity) are taken into account, cessation of cigarette smoking appears to be cost saving. In addition, for particular subgroups (such as pregnant women and post-myocardial infarction patients), there may be health-care cost savings. Cost-effectiveness analyses of smoking cessation methods are reviewed. A relatively narrow range of smoking cessation methods has been evaluated for cost effectiveness. There is some evidence that cost-effective smoking cessation programs are tailored to the target population and consist of multiple interventions with reinforcement of the cessation techniques or messages. Equity considerations demand that smoking cessation programs not be chosen simply on the basis of their cost effectiveness because it is likely that certain groups (such as minorities or heavy smokers) will not be targeted. Some potentially efficacious smoking cessation methods such as bans on smoking in public places and excise taxes are not easily assessable using cost-effectiveness methodology.     

What are the odds that smoking will kill you?

We calculated the long-term risks of death from smoking for individuals of various ages and smoking status in terms of the excess mortality contributed by smoking, over and above the baseline mortality from the same diseases caused by factors other than smoking using standard life table procedures. Since mortality data for specific smoking categories were available only from prospective studies in the late 1950s, we scaled these to the 1982 mortality levels. We assumed, for lung cancer, that the death rates for nonsmokers have not changed and, for other smoking-related diseases, that the risks of death for smokers relative to those for nonsmokers have not changed since the 1950s. Probabilities that result from alternative assumptions were also investigated and are presented. As many as one-third of heavy smokers age 35 will die before age 85 of diseases caused by their smoking. The probabilities of death from smoking when compared with other causes may be persuasive as public education tools. Their effective use for this purpose is affected not only by the deficiencies in the public's factual knowledge of the magnitude of the risks from smoking, but also by numerous apparent misconceptions relating to the interpretation of risk information. Risk data should be presented to the public in a manner that clarifies these misconceptions and facilitates their understanding of the overwhelming risk imposed by smoking.     

Long-term impact of smoking cessation on the incidence of coronary heart disease.

Using a simulation model of the US male population, we estimated the long-term impact that future smoking cessation programs would have on the distribution and occurrence of coronary heart disease in males ages 35-84. For interventions that reduce the number of smokers by 25 percent in 1990, the number of men free of coronary heart disease is projected to increase by 416,787 (0.7 percent) in 2015, and the age-standardized absolute incidence to decline by 2.3 percent. Incidence rates and absolute incidences are projected to fall in men under age 65, but absolute incidence would rise in men over age 65, in large part because of the increased number of men who were at risk for coronary heart disease because of a reduction in non-coronary smoking-related mortality. These trends were more marked for greater smoking reductions and were generally unaffected in a variety of analyses using alternative assumptions, which considered smoking as a risk factor in the elderly, a lag-time before benefits from smoking cessation were realized and secular declines in smoking prevalence. Subject to the assumptions of our model, we conclude that smoking reductions will markedly reduce coronary heart disease, especially in younger age groups, and that this benefit will be slightly offset by a small increase in absolute incidence in elderly men.     

Cultural context,older age and smoking in Scotland: qualitative interviews with older smokers with arterial disease

This paper explores how smoking among older smokers with a smoking-related illness is influenced by the wider cultural context of smoking. The paper draws upon a Scottish qualitative interview study to explore lifecourse changes in smoking-related beliefs and behaviours, in current smokers between the ages of 65 and 84 years with arterial disease. The respondents' understanding of smoking, as a socially acceptable behaviour of their youth, had undergone dramatic change over the course of their lives. While some respondents continued to associate their current smoking with their, albeit reduced, participation in social activities, others now smoked at home alone and associated smoking with increasing levels of isolation in their lives. Through an examination of how social attitudes may contribute to smoking as a solitary activity, the paper highlights the implications of cultural context for the adaptive strategies that older people use to cope with the circumstances and conditions of later life. The paper concludes that the wider cultural context of smoking is influential in shaping smoking as either an isolated 'home' activity, or as a 'social' activity for those whose opportunities to smoke in the private sphere are limited by disapproval of significant others. Within the social context, however, these 'social' smokers experience further constraints which shape and reduce their smoking behaviour. The data suggest that in order to be successful with this group of smokers, further research is needed to identify aspects of the lives of older people that sustain smoking in later life. These data will be necessary to develop appropriate health promotion measures to successfully target aspects of lives that support smoking in later life.