The role of public policies in reducing smoking prevalence and deaths caused by smoking in Arizona: results from the Arizona tobacco policy simulation model.

Arizona was one of the first few states to implement a comprehensive tobacco control program. The effect of that program is examined using a computer-simulation model (SimSmoke) developed for the purposes of evaluation, planning, and justifying policies. This approach assesses the impact to date of tobacco control policies on smoking prevalence and generates predictions about the effects of tobacco control policies on past and future smoking prevalence and associated future premature mortality. SimSmoke estimates indicate that tobacco control policies reduced smoking rates in Arizona by about 20 percent over the period 1993-2002. A previous CDC study obtains similar effects, but does not net out the effects of individual policies. SimSmoke attributes much of the reduction, about 61 percent, to price increases and attributes 38 percent of the overall effect to media policies, leaving only a small percentage of the smoking reductions attributed to quitlines, youth access policies, and the weak clean air laws. Tobacco control policies implemented as comprehensive strategies have significantly affected smoking rates in Arizona, which leads to large reductions in deaths attributable to smoking. It will be important to maintain these efforts over time to reduce or keep smoking prevalence down and to minimize smoking-attributable deaths.     

The role of public policies in reducing smoking prevalence and deaths: the Argentina Tobacco Policy Simulation Model.

OBJECTIVES: To compare tobacco control policies independently and as a package through a simulation model to project smoking prevalence and associated future premature mortality in Argentina beginning in 2001. METHODS: A simulation model of tobacco control policies known as SimSmoke was modified using data for Argentina on population, fertility and mortality, smoking prevalence, and tobacco control policies in effect between 2001 and 2004. We used the Argentina Tobacco Policy Simulation model (ATPSM) to consider the effect on smoking prevalence of changes in taxes and prices, clean air laws, media campaigns, cessation programs, and youth access policies on smoking initiation and cessation rates. Smoking prevalence and relative risks of smoking were used to estimate smoking-attributable mortality. The ATPSM was used to project smoking prevalence and smoking-attributable deaths during the period 2001-2034. RESULTS: The largest reductions in smoking prevalence and premature mortality were predicted for a comprehensive tobacco control policy package, but relative reductions of as much as 30% were also predicted for large tax increases. Adding a media campaign along with programs to publicize and enforce clean air laws, advertising bans, and youth access laws would further reduce smoking rates by up to 45% by the year 2034, and would save almost 16 000 lives per year. CONCLUSIONS: Tobacco control policies can substantially reduce smoking rates, which can save many lives. Without such policies, deaths from smoking, and associated medical costs, will increase. The ATPSM is expected to provide guidance in filling the most important information gaps pertinent to both modeling and policy-making in Argentina, e.g., the lack of data on initiation and cessation rates, and the need for studies on the impact of policies. Similar models might be developed for other Latin American countries.     

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 role of public policies in reducing smoking and deaths caused by smoking in Vietnam: results from the Vietnam tobacco policy simulation model

A simulation model is developed for Vietnam to project smoking prevalence and associated premature mortality. The model examines independently and as a package the effects of five types of tobacco control policies: tax increases, clean air laws, mass media campaigns, advertising bans, and youth access policies. Predictions suggest that the largest reductions in smoking rates will result from implementing a comprehensive tobacco control policy package. Significant inroads may be achieved through tax increases. A media campaign along with programs to publicize and enforce clean air laws, advertising bans and youth access laws would further reduce smoking rates. Tobacco control policies have the potential to make large dents in smoking rates, which in turn could lead to many lives saved. In the absence of these measures, deaths from smoking will increase. The model also helps to identify information gaps pertinent both to modeling and policy-making.     

Tobacco Policies in Louisiana: Recommendations for Future Tobacco Control Investment from SimSmoke,a Policy Simulation Model

Despite the presence of tobacco control policies, Louisiana continues to experience a high smoking burden and elevated smoking-attributable deaths. The SimSmoke model provides projections of these health outcomes in the face of existing and expanded (simulated) tobacco control polices. The SimSmoke model utilizes population data, smoking rates, and various tobacco control policy measures from Louisiana to predict smoking prevalence and smoking-attributable deaths. The model begins in 1993 and estimates are projected through 2054. The model is validated against existing Louisiana smoking prevalence data. The most powerful individual policy measure for reducing smoking prevalence is cigarette excise tax. However, a comprehensive cessation treatment policy is predicted to save the most lives. A combination of tobacco control policies provides the greatest reduction in smoking prevalence and smoking-attributable deaths. The existing Louisiana excise tax ranks as one of the lowest in the country and the legislature is against further increases. Alternative policy measures aimed at lowering prevalence and attributable deaths are: cessation treatments, comprehensive smoke-free policies, and limiting youth access. These three policies have a substantial effect on smoking prevalence and attributable deaths and are likely to encounter more favor in the Louisiana legislature than increasing the state excise tax.     

The role of public policies in reducing smoking prevalence in California: results from the California tobacco policy simulation model

Tobacco control policies are examined utilizing a simulation model for California, the state with the longest running comprehensive program. We assess the impact of the California Tobacco Control Program (CTCP) and surrounding price changes on smoking prevalence and smoking-attributable deaths. Modeling begins in 1988 and progresses chronologically to 2004, and considers four types of policies (taxes, mass media, clean air laws, and youth access policies) independently and as a package. The model is validated against existing smoking prevalence estimates. The difference in trends between predicted smoking rates from the model and other commonly used estimates of smoking prevalence for the overall period were generally small. The model also predicted some important changes in trend, which occurred with changes in policy. The California SimSmoke model estimates that tobacco control policies reduced smoking rates in California by an additional 25% relative to the level that they would have been if policies were kept at their 1988 level. By 2004, the model attributes 59% of the reduction to price increases, 28% of the overall effect to media policies, 11% to clean air laws, and only a small percent to youth access policies. The model estimates that over 5000 lives will be saved in the year 2010 alone as a result of the CTCP and industry-initiated price increases, and that over 50,000 lives were saved over the period 1988-2010. Tobacco control policies implemented as comprehensive tobacco control strategies have significantly impacted smoking rates. Further tax increases should lead to additional lives saved, and additional policies may result in further impacts on smoking rates, and consequently on smoking-attributable health outcomes in the population.     

Epidemiology of smoking in Ukraine, 2000.

BACKGROUND: A clear, up-to-date picture of smoking prevalence and its determinants is needed to inform the development of an effective tobacco control policy in Ukraine, particularly given the way in which the tobacco industry has targeted post-Soviet countries since transition. METHODS: A nationally representative household survey was undertaken in Ukraine in February 2000. RESULTS: Data were available on 1,590 individuals (response rate 72%). Fifty-seven percent of men and 10% of women were current smokers and an additional 21 and 7%, respectively, were ex-smokers. Smoking behavior has changed considerably over successive generations, with an increase in the proportion of women smoking and a reduction in the mean age at first smoking. Factors associated with smoking include young age, urban residence (among women), and material hardship, particularly unemployment. Involvement in social networks appears to reduce the probability of smoking. Smoking commonly occurs in public places and smokers differ from nonsmokers in their health beliefs about smoking. CONCLUSIONS: Levels of smoking among men are already high and among young women are increasing rapidly. Unless an effective tobacco policy response is developed to address the issues identified, tobacco will continue to make an increasingly large contribution to premature morbidity and mortality in Ukraine.     

Smoking prevalence and smoking attributable mortality in Italy, 2010

Objective

To provide updated information on smoking prevalence and attributable mortality in Italy.

Method

A representative survey on smoking was conducted in 2010 on a sample of 3020 Italian adults (1453 men and 1567 women). We used SAMMEC software to update smoking attributable mortality in Italy.

Results

In 2010, 21.7% of Italians (23.9% of men and 19.7% of women) described themselves as current smokers. Smoking prevalence was higher in men than in women in all age groups, except for the middle-aged population (45-64 years; 25.6% in men and 25.9% in women). Age-standardized smoking prevalence was higher in men than in women among less educated subjects and in southern Italy. No substantial difference was observed either in educated subjects or in northern and central Italy. Overall, 71,445 deaths in Italy (52,707 men and 18,738 women, 12.5% of total mortality) are attributable to smoking.

Conclusion

The overall smoking prevalence of 21.7% in 2010 is the lowest registered over the last 50 years. Since 1998, smoking related deaths declined by almost 15%. Given that Italy has now reached the final stage of the tobacco epidemic, anti-smoking strategies should focus on support for smoking cessation.     

Smoking trends in Italy from 1950 to 2000

STUDY OBJECTIVE: To assess how the prevalence of smokers in Italy from 1950 to 2000 has changed, in parallel with law development and the growing attention towards smoking prevention. DESIGN, SETTING, AND PARTICIPANTS: Historical data on smoking trends have been obtained using data collected in 2000 by the National Institute of Statistics. A correction coefficient is proposed to overcome the bias of differential mortality reported in other papers. The sample is made up of 102 261 people aged 15-69 years. MAIN RESULTS: A general downward trend is seen; there is a more pronounced decrease starting from 1975 to 1980. In both sexes the peak prevalence tends to decrease according to the birth cohort because of the earlier age in which they gave up. A partial exception to the decline of tobacco use in recent years may be made for the 15-19 year-old age group, which has remained stable since 1990. CONCLUSIONS: Although a comprehensive community programme against tobacco was not developed, the different prevention actions implemented in Italy have contributed to a change in attitude and behaviour. The effect of tobacco control strategies implemented in Italy until now is more evident in relation to the breaking of the smoking habit, which happens at an increasingly younger age, although it is not clear how much it is able to prevent people from starting smoking.     

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.     

State-specific prevalence of current cigarette smoking among adults and secondhand smoke rules and policies in homes and workplaces--United States, 2005

Smoking causes premature death and disease in children and adults who do not smoke but are exposed to secondhand smoke (SHS). To assess the state-specific prevalence of current smoking among adults in the United States and the proportions of adults who report having smoke-free home rules and smoke-free policies in their workplace, CDC analyzed data from the 2005 Behavioral Risk Factor Surveillance System (BRFSS). This report summarizes the results of that analysis, which indicated a threefold difference (from lowest to highest) in self-reported cigarette smoking prevalence in 50 states, the District of Columbia (DC), Puerto Rico (PR), and the U.S. Virgin Islands (USVI) (range: 8.3%-28.7%). Wide variations also were observed in USVI and the 14 states that assessed prevalence of smoke-free home rules (from 63.6% [Kentucky] to 82.9% [Arizona]) and smoke-free workplace policies (from 54.8% [Nevada] to 85.8% [West Virginia]). Evidence-based, comprehensive tobacco prevention and control programs that focus on decreasing smoking initiation, increasing smoking cessation, and establishing smoke-free workplaces, homes, and other venues should be continued and expanded to reduce smoking prevalence, exposure of nonsmokers to SHS, and smoking-related morbidity and mortality.     

Impact of tobacco control policies and mass media campaigns on monthly adult smoking prevalence

Objectives. We sought to assess the impact of several tobacco control policies and televised antismoking advertising on adult smoking prevalence.Methods. We used a population survey in which smoking prevalence was measured each month from 1995 through 2006. Time-series analysis assessed the effect on smoking prevalence of televised antismoking advertising (with gross audience rating points [GRPs] per month), cigarette costliness, monthly sales of nicotine replacement therapy (NRT) and bupropion, and smoke-free restaurant laws.Results. Increases in cigarette costliness and exposure to tobacco control media campaigns significantly reduced smoking prevalence. We found a 0.3-percentage-point reduction in smoking prevalence by either exposing the population to televised antismoking ads an average of almost 4 times per month (390 GRPs) or by increasing the costliness of a pack of cigarettes by 0.03% of gross average weekly earnings. Monthly sales of NRT and bupropion, exposure to NRT advertising, and smoke-free restaurant laws had no detectable impact on smoking prevalence.Conclusions. Increases in the real price of cigarettes and tobacco control mass media campaigns broadcast at sufficient exposure levels and at regular intervals are critical for reducing population smoking prevalence.Population-wide interventions that can reduce adult smoking prevalence are important for curbing the pandemic of tobacco-related disease.1^–3 However, evaluating the effects of tobacco control policies and mass media interventions on populations is difficult.4^,5 Generally, there are few comparable control populations to which policy or media interventions are not delivered. Tobacco policies and media campaigns often co-occur, complicating assessment of the relative contribution of each. In addition, most studies in which smoking prevalence is the outcome measure rely on annual population surveys to track change over time, despite policy and media interventions being generally implemented throughout the year, and at differing strengths relative to the time of survey administration. Small or transient impacts on smoking prevalence are difficult to detect and may be underestimated.Over the past decade, the Australian population has been exposed to changes in several tobacco control policies, including changes in taxes on tobacco products resulting in increases in the real price of cigarettes, increasing availability of pharmaceutical smoking cessation products such as nicotine replacement therapies (NRT) and bupropion, and the introduction of smoke-free restaurant laws. In addition, there has been considerable variation in exposure to public health–sponsored mass media campaigns and pharmaceutical advertising for NRT. We have assessed the independent effect of each tobacco control policy and type of media campaign with a data series in which self-reported smoking prevalence was measured every month over a period of 11 years. This method has the advantage over annual population surveys of more closely matching the timing and extent of policy implementation and media exposure to smoking prevalence, and it has the ability to examine the pattern of change in prevalence, such as the lag time to a measurable impact and the duration of influence.     

Coronary heart disease deaths and decreased smoking prevalence in Massachusetts, 1993-2003

We used the previously validated IMPACT coronary heart disease (CHD) mortality model to estimate the CHD deaths attributable to reductions in smoking prevalence following the introduction of the Massachusetts Tobacco Control Program (MTCP) in 1993. A 29% and 31% decline in smoking prevalence and CHD mortality rates occurred, respectively (from 1993 to 2003). A total of 425 fewer CHD deaths, which generated approximately 3365 extra life-years, were attributable to decreased smoking prevalence. With these results in mind, a comprehensive tobacco control program should be sustained and supported.     

Prevalence and determinants of smoking in Belarus: A national household survey, 2000

A clear, up-to-date picture of smoking prevalence and its determinants is needed to inform the development of effective tobacco control policy in Belarus and other parts of the former Soviet Union. It is particularly important in view of the way the tobacco industry has targeted this region since transition. A nationally representative household survey designed to explore smoking behaviour and its determinants was undertaken in Belarus in April 2000. Data were available on 1090 individuals aged 18 years and over (response rate 53.4%). Respondents were similar demographically to the population of Belarus. Fifty three percent of men and 9% of women are current smokers and an additional 18% and 7% respectively are ex-smokers. Differences in smoking habits between successive generations were identified. These included a ninefold higher rate of ever-smoking amongst 18–29 years old women compared with those aged over 60 years (p < 0.0001) and a higher proportion of current smokers starting in childhood amongst those aged 18–29 years compared with older smokers (p = 0.0005). Smoking in public places, particularly the workplace where 65% smoke, is common. Smokers are more likely than non-smokers to have positive beliefs about the health impact of active and passive smoking (p < 0.0001). Amongst women the odds of smoking is 13 times higher in those living in large cities compared with those living in villages. In men, disadvantage and a positive attitude to the west appear to increase the likelihood of smoking. To date policy responses have been inadequate. Unless effective tobacco control policies are introduced, tobacco will continue to make an increasingly large contribution to premature morbidity and mortality in Belarus.     

Trends in smoking behaviour between 1985 and 2000 in nine European countries by education

OBJECTIVE: To examine whether trends in smoking behaviour in Western Europe between 1985 and 2000 differed by education group. DESIGN: Data of smoking behaviour and education level were obtained from national cross sectional surveys conducted between 1985 and 2000 (a period characterised by intense tobacco control policies) and analysed for countries combined and each country separately. Annual trends in smoking prevalence and the quantity of cigarettes consumed by smokers were summarised for each education level. Education inequalities in smoking were examined at four time points. SETTING: Data were obtained from nine European countries: Norway, Sweden, Denmark, Finland, the United Kingdom, the Netherlands, Germany, Italy, and Spain. PARTICIPANTS: 451 386 non-institutionalised men and women 25-79 years old. MAIN OUTCOME MEASURES: Smoking status, daily quantity of cigarettes consumed by smokers. RESULTS: Combined country analyses showed greater declines in smoking and tobacco consumption among tertiary educated men and women compared with their less educated counterparts. In country specific analyses, elementary educated British men and women, and elementary educated Italian men showed greater declines in smoking than their more educated counterparts. Among Swedish, Finnish, Danish, German, Italian, and Spanish women, greater declines were seen among more educated groups. CONCLUSIONS: Widening education inequalities in smoking related diseases may be seen in several European countries in the future. More insight into effective strategies specifically targeting the smoking behaviour of low educated groups may be gained from examining the tobacco control policies of the UK and Italy over this period.     

The impact of school smoking policies and student perceptions of enforcement on school smoking prevalence and location of smoking

The purpose of this study was to comprehensively assess the impact of school tobacco policy intention, implementation and students' perceptions of policy enforcement on smoking rates and location of tobacco use during the school day. Data were obtained from all students in Grades 10-11 (n = 22,318) in 81 randomly selected schools from five Canadian provinces. Policy intention was assessed by coding written school tobacco policies. School administrators most familiar with the tobacco policy completed a survey to assess policy implementation. Results revealed policy intention and implementation subscales did not significantly predict school smoking prevalence but resulted in moderate prediction of tobacco use on school property (R(2) = 0.21-0.27). Students' perceptions of policy enforcement significantly predicted school smoking prevalence (R(2) = 0.36) and location of tobacco use (R(2) = 0.23-0.63). The research findings emphasize: (i) the need to consider both written policy intention and actual policy implementation and (ii) the existence of a policy is not effective in controlling tobacco use unless the policy is implemented and is perceived to be strongly enforced.     

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.     

Factors associated with Taiwanese junior high school personnel advising students to quit smoking

BACKGROUND: Most smokers in developing countries begin smoking before age 18, and smoking prevalence is rising among adolescents. School personnel represent a target group for tobacco‐control efforts because they interact daily with students, are role models for students, teach about tobacco‐use prevention in school curricula, and implement school tobacco‐control policies. The prevalence of teenage smoking has been examined in numerous studies, but few have focused on the influence of school personnel and the characteristics of school personnel who enforce school nonsmoking policy. The purpose of this study was to determine the factors associated with junior high school personnel advising students to quit smoking. METHODS: School personnel (N = 7129) were recruited by cluster sampling from 60 junior high schools in Taiwan; of these, 5280 voluntarily returned self‐administered, anonymous questionnaires (response rate = 74.06%) in 2004. RESULTS: Most personnel (70%) had advised students to quit smoking. School personnel who were older, male, responsible for teaching health, smokers, with positive attitude against tobacco, or with more knowledge of tobacco hazards were more likely to advise students to quit smoking. Personnel with more interest in and access to tobacco‐related materials were more likely to advise students to quit smoking. Personnel who had received tobacco‐prevention training were 2.41 times more likely to persuade students to quit smoking after adjusting for other factors. However, only half of the participants had ever had access to educational materials about tobacco use, and 8% had ever received training to prevent tobacco use. CONCLUSIONS: To reduce youth smoking prevalence, school tobacco‐control programs should support tobacco‐prevention training for school personnel.