What public health strategies are needed to reduce smoking initiation?

Parental smoking, rejection of parental smoking, and smoking susceptibility and behaviors in Hong Kong adolescents

INTRODUCTION

We explored the role of rejection of parental smoking in the association between parental smoking and smoking in adolescents.

METHODS

In 2010-11 cross-sectional survey, 61,810 Hong Kong secondary school students (mean age 14.6 years, 50.5% boys) reported their smoking (never, not susceptible; never, susceptible; ever, not current; current), paternal and maternal smoking, and whether they accepted paternal and maternal smoking (acceptance/rejection). We used multinomial logistic regression to estimate the odds ratios (ORs) and 95% confidence intervals (CIs) of students' smoking in relation to acceptance and rejection of parental smoking, compared with no parental smoking.

RESULTS

The OR (95% CI) of "never, susceptible", "ever, not current", and "current", compared with "never, not susceptible", in relation to acceptance of paternal smoking was 1.81 (1.67-1.96), 2.46 (2.25-2.69), and 2.79 (2.51-3.10), respectively. The corresponding ORs for rejection were 0.70 (0.64-0.76), 1.23 (1.13-1.35), and 0.47 (0.40-0.56). The OR (95% CI) of "never, susceptible", "ever, not current", and "current", compared with "never, not susceptible", in relation to acceptance of maternal smoking was 2.05 (1.80-2.33), 2.57 (2.29-2.88), and 6.33 (5.39-7.44), respectively. The corresponding ORs for rejection were 0.85 (0.69-1.05), 1.59 (1.39-1.81), and 2.14 (1.71-2.68). No overlapping was observed between the 95% CIs for acceptance and rejection of paternal or maternal smoking.

CONCLUSIONS

While adolescent smoking was associated with parental smoking, especially in those who accepted parental smoking, the association was attenuated or reversed in those who rejected parental smoking.

Inequities in coverage of smokefree outdoor space policies within the United States: school grounds and playgrounds

Background

Previous studies have found extensive geographic and demographic differences in tobacco use. These differences have been found to be reduced by effective public policies, including banning smoking in public spaces. Smokefree outdoor spaces reduce secondhand smoke exposure and de-normalize smoking.

Methods

After previously publishing a study of smokefree indoor and outdoor space policies, it was brought to the authors’ attention that the dataset used in analyses was incomplete (Lowrie et al., BMC Public Health 17:456, 2017). The current manuscript is a corrected version. Here, we include analyses for outdoor space policies. We evaluated regional and demographic differences in the proportion of the population (both adult and child) covered by smokefree outdoor space policies for school grounds and playgrounds enacted in the United States prior to 2014.

Results

Children had a low level of protection in playgrounds and schools (8% covered nationwide in both settings). Significant differences in coverage were found by ethnicity, region, income, and education (p < 0.001). The odds of having a smokefree playgrounds policy was lower for jurisdictions with higher proportions of poor households, households with no high school diploma, whites and the Alaska/Hawaii region. Increased ethnic heterogeneity was found to be a significant predictor of increased odds of having a smokefree playgrounds policy, meaning that diversity is protective, with differential effect by region (p < 0.001) – which may relate to urbanicity.

Conclusions

Disparities in smokefree outdoor space policies have potential to exacerbate existing health inequities. A national increase in smokefree outdoor space policies to protect children in playgrounds and schools is a crucial intervention to reduce such inequities.

Inequalities in health and health risk factors in the Southern African Development Community: evidence from World Health Surveys

Background

Socioeconomic inequalities in health have been documented in many countries including those in the Southern African Development Community (SADC). However, a comprehensive assessment of health inequalities and inequalities in the distribution of health risk factors is scarce. This study specifically investigates inequalities both in poor self-assessed health (SAH) and in the distribution of selected risk factors of ill-health among the adult populations in six SADC countries.

Methods

Data come from the 2002/04 World Health Survey (WHS) using six SADC countries (Malawi, Mauritius, South Africa, Swaziland, Zambia and Zimbabwe) where the WHS was conducted. Poor SAH is reporting bad or very bad health status. Risk factors such as smoking, heavy drinking, low fruit and vegetable consumption and physical inactivity were considered. Other environmental factors were also considered. Socioeconomic status was assessed using household expenditures. Standardised and normalised concentration indices (CIs) were used to assess socioeconomic inequalities. A positive (negative) concentration index means a pro-rich (pro-poor) distribution where the variable is reported more among the rich (poor).

Results

Generally, a pro-poor socioeconomic inequality exists in poor SAH in the six countries. However, this is only significant for South Africa (CI = − 0.0573; p < 0.05), and marginally significant for Zambia (CI = − 0.0341; P < 0.1) and Zimbabwe (CI = − 0.0357; p < 0.1). Smoking and inadequate fruit and vegetable consumption were significantly concentrated among the poor. Similarly, the use of biomass energy, unimproved water and sanitation were significantly concentrated among the poor. However, inequalities in heavy drinking and physical inactivity are mixed. Overall, a positive relationship exists between inequalities in ill-health and inequalities in risk factors of ill-health.

Conclusion

There is a need for concerted efforts to tackle the significant socioeconomic inequalities in ill-health and health risk factors in the region. Because some of the determinants of ill-health lie outside the health sector, inter-sectoral action is required.

Older African American Homeless-Experienced Smokers' Attitudes Toward Tobacco Control Policies-Results from the HOPE HOME Study

PURPOSE

To examine attitudes toward tobacco control policies among older African American homeless-experienced smokers.

APPROACH

A qualitative study.

SETTING

Oakland, California.

PARTICIPANTS

Twenty-two African American older homeless-experienced smokers who were part of a longitudinal study on health and health-related outcomes (Health Outcomes of People Experiencing Homelessness in Older Middle Age Study).

METHOD

We conducted in-depth, semistructured interviews with each participant to explore beliefs and attitudes toward tobacco use and cessation, barriers to smoking cessation, and attitudes toward current tobacco control strategies including raising cigarette prices, smoke-free policies, and graphic warning labels. We used a grounded theory approach to analyze the transcripts.

RESULTS

Community social norms supportive of cigarette smoking and co-use of tobacco with other illicit substances were strong motivators of initiation and maintenance of tobacco use. Self-reported barriers to cessation included nicotine dependence, the experience of being homeless, fatalistic attitudes toward smoking cessation, substance use, and exposure to tobacco industry marketing. While participants were cognizant of current tobacco control policies and interventions for cessation, they felt that they were not specific enough for African Americans experiencing homelessness. Participants expressed strong support for strategies that de-normalized tobacco use and advertised the harmful effects of tobacco.

CONCLUSION

Older African American homeless-experienced smokers face significant barriers to smoking cessation. Interventions that advertise the harmful effects of tobacco may be effective in stimulating smoking cessation among this population.

The Short-term Effects of ASPIRA: A Web-based, Multimedia Smoking Prevention Program for Adolescents in Romania: A Cluster Randomized Trial

INTRODUCTION

Although web-based, multimedia smoking prevention programs have been tested in several high-income countries, their efficacy in Central and Eastern Europe is unknown. The aim of this trial was to assess the short-term effects of ASPIRA, among Romanian and Hungarian speaking ninth graders in Tirgu Mures, Romania. ASPIRA is the Romanian acronym for the translated and adapted version of ASPIRE, "A Smoking Prevention Interactive Experience," an evidence-based smoking prevention program originally developed to prevent tobacco use among high school students in the United States.

METHODS

Sixteen high schools in Tirgu Mures, Romania were randomized to receive five weekly sessions of the ASPIRA web-based, multimedia program or to a control condition. Socio-demographic data, psychosocial characteristics, and smoking behavior were collected from students at baseline and at 6 months. A hierarchical logistic regression analysis was conducted to test the efficacy of the intervention on smoking initiation and current smoking among 1369 students.

RESULTS

Never-smoker students in the intervention arm were 35% less likely to report smoking initiation 6 months after the baseline assessment (OR = 0.65, 95%CI: 0.44-0.97). Reduced smoking initiation was observed most notably among students who were exposed to at least 75% of the ASPIRA program. There was no statistically significant effect of the intervention on current tobacco use (OR = 0.80, 95%CI: 0.44-1.46).

CONCLUSIONS

ASPIRA, an adapted version of the evidence-based, multimedia ASPIRE program that was originally developed and tested in the United States may decrease smoking initiation among multi-ethnic adolescents in Central and Eastern Europe.

IMPLICATIONS

(1). Web-based, multimedia smoking prevention programs may be effective tools to prevent smoking initiation among multi-ethnic adolescent communities in Central and Eastern Europe. (2). The degree of exposure is critical, only high exposure to the multimedia smoking prevention program is associated with reduced smoking initiation.

Adolescence and Later Life Disease Burden: Quantifying the Contribution of Adolescent Tobacco Initiation From Longitudinal Cohorts

PURPOSE

Adolescence is a time of initiation of behaviors leading to noncommunicable diseases (NCDs). We use tobacco to illustrate a novel method for assessing the contribution of adolescence to later burden.

METHODS

Data on initiation of regular smoking during adolescence (10-19 years) and current adult smoking were obtained from the 1958 British Birth Cohort, the U.S. National Longitudinal Study of Adolescent Health (Add Health), the Pelotas 1982 Birth Cohort, and the Victorian Adolescent Health Cohort Study. We estimated an "adolescent attributable fraction" (AAF) by calculating the proportion of persisting adult daily smoking initiated < age 20 years. We used findings to estimate AAFs for >155 countries using contemporary surveillance data.

RESULTS

In the 1958 British Birth Cohort, 81.6% of daily smokers at age 50 years initiated < age 20 years, with a risk ratio of 6.1 for adult smoking related to adolescent initiation. The adjusted AAF was 69.1. Proportions of smokers initiating <20 years, risk ratio, and AAFs were 83.3%, 7.0%, and 70.4% for Add Health; 75.5%, 3.7%, and 50.2% in Victorian Adolescent Health Cohort Study; and 70.9%, 5.8%, and 56.9% in Pelotas males and 89.9%, 6.4%, and 75.9% in females. Initiation <16 years resulted in the highest AAFs. Estimated AAFs globally ranged from 35% in China to 76% in Argentina.

CONCLUSIONS

The contribution of adolescent smoking initiation to adult smoking burden is high, suggesting a need to formulate and implement effective actions to reduce smoking initiation in adolescents. Similar trends in other NCD risks suggest that adolescents will be central to future efforts to control NCDs.

Assessing app quality through expert peer review: a case study from the gray matters study

Health apps focused on inciting behavior change are becoming increasingly popular. Nevertheless, many lack underlying evidence base, scientific credibility and have limited clinical effectiveness. It is therefore important that apps are well-informed, scientifically credible, peer reviewed and evidence based. This paper presents the use of the Mobile App Rating Scale (MARS) to assess the quality of the Grey Matters app, a cross platform app to deliver health education material and track behavior change across multi-domains with the aim of reducing the risk of developing Alzheimer's disease. The Gray Matters app shows promising results following reviews from 5 Expert raters, achieving a mean overall MARS score of 4.45 ± 0.14. Future work will involve undertaking of a detailed content analysis of behavior change apps to identify common themes and features which may lead to the successful facilitation of sustained behavior change.

Historical declines and disparities in cigarette coupon saving among adolescents in the United States, 1997-2013

Exposure to cigarette coupons is associated with smoking initiation and likelihood of cigarette purchase among adolescents. Some adolescents who are exposed to cigarette coupons take a step further by choosing to save or collect these coupons, a further risk factor for cigarette smoking. This study examines historical trends and disparities in cigarette coupon saving among adolescents in the United States from 1997 to 2013. National samples of 10th and 12th grade students (n=129,111) were obtained from Monitoring the Future surveys in 1997-2013. Prevalence of lifetime and current cigarette coupon saving was estimated in each year in the overall adolescent population, and in race/ethnicity, parent education level, sex, and urban/rural subgroups. Prevalence of lifetime and current cigarette coupon saving was then estimated in each year based on smoking status. Prevalence of cigarette coupon saving has decreased dramatically among adolescents; only 1.2% reported currently saving coupons in 2013. However, disparities in cigarette coupon saving remain with prevalence higher among rural, White, and low parental education level students. Adolescent smokers continue to save coupons at high rates; 21.2% had ever saved coupons and 6.9% currently saved coupons as of 2013. Despite overall declines in adolescent cigarette coupon saving, existing sociodemographic disparities and the considerably high prevalence of coupon saving among adolescent smokers suggest that cigarette coupons remain a threat to smoking prevention among youth. Additional research is needed to further elucidate longitudinal associations between cigarette coupon saving and smoking initiation and maintenance among adolescents.

Poor quality of life in Australian men: Cross-sectional associations with obesity, mobility, lifestyle and psychiatric symptoms

OBJECTIVES

Despite their public health importance, little is known about associations between modifiable lifestyles, quality of life (QOL), and psychiatric symptoms in men. We investigated relationships between QOL, obesity, mobility and lifestyle in Australian men, including whether associations were mediated by anxiety and depression.

STUDY DESIGN

A cross-sectional study of 893 men (aged 24-92 yrs) participating in the Geelong Osteoporosis Study: an age-stratified, population-based sample of men randomly recruited from the Barwon Statistical Division (BSD), in south-eastern Australia.

MAIN OUTCOME MEASURES

Using a validated tool, QOL was measured in the domains of physical health, psychological health, social relationships and the environment. Anxiety and depression were ascertained using the Hospital Anxiety and Depressive Scale. Models were adjusted for age, clinical measures of obesity and mobility, and self-reported lifestyles, with adjustment made for anxiety and depression.

RESULTS

Associations were observed between low mobility and lower psychological-related QOL (OR 0.70, 95%CI 0.53-0.93), and for smoking and low mobility with lower environment-related QOL (OR 0.48, 95%CI 0.27-0.84; OR 0.67, 95%CI 0.50-0.90, respectively). Age, anxiety and depression were independently associated with QOL in each domain.

CONCLUSIONS

Independent of age, anxiety and depression, smoking and low mobility showed particularly strong effects on the likelihood of men reporting a lower satisfaction with their QOL. This information will inform the design of effective and equitable health policies, the allocation of resources toward unmet needs, and the development of strategic health-related plans.

Inequities in coverage of smokefree space policies within the United States

BACKGROUND

Previous studies have found extensive geographic and demographic differences in tobacco use. These differences have been found to be reduced by effective public policies, including banning smoking in public spaces. Smokefree indoor and outdoor spaces reduce secondhand smoke exposure and denormalize smoking.

METHODS

We evaluated regional and demographic differences in the proportion of the population covered by smokefree policies enacted in the United States prior to 2014, for both adults and children.

RESULTS

Significant differences in coverage were found by ethnicity, region, income, and education (p < 0.001). Smokefree policy coverage was lower for jurisdictions with higher proportions of poor households, households with no high school diploma and the Southeast region. Increased ethnic heterogeneity was found to be a significant predictor of coverage in indoor "public spaces generally", meaning that diversity is protective, with differential effect by region (p = 0.004) - which may relate to urbanicity. Children had a low level of protection in playgrounds and schools (~10% covered nationwide) - these spaces were found to be covered at lower rates than indoor spaces.

CONCLUSIONS

Disparities in smokefree space policies have potential to exacerbate existing health inequities. A national increase in smokefree policies to protect children in playgrounds and schools is a crucial intervention to reduce such inequities.

Stress, Socializing, and Other Motivations for Smoking Among the Lesbian, Gay, Bisexual, Transgender, and Queer Community in New York City

PURPOSE

This study contributes to the emerging literature on lesbian, gay, bisexual, transgendered, and queer (LGBTQ) health disparities and tobacco use by examining the motivations for smoking among the New York City (NYC) LGBTQ population.

APPROACH

We used grounded theory and blended methods from 3 grounded theorists-Strauss, Corbin, and Charmaz-for data collection, coding, and analysis.

SETTING

NYC has extensive legislation to prevent smoking; however, the current smoking prevalence of homosexuals is double that of heterosexuals.

PARTICIPANTS

Study participants were leaders from 23 NYC LGBTQ organizations. Leaders were chosen to establish a relationship with community and to ensure cultural sensitivity. Eligibility criteria required holding a leadership position in an organization serving the NYC LGBTQ community.

METHODS

Interviews were transcribed verbatim and uploaded into Dedoose for analysis. An initial code list was developed from the interview guide. Key themes were identified as the themes with the most number of quotes.

RESULTS

Three key themes emerged from our interviews: image, socializing, and stress. Smoking was reported to be a socialization aid and a maladaptive coping technique for stress arising from interactions of conflicting identities.

CONCLUSION

Future smoking cessation interventions among the LGBTQ community should equip smokers with healthy coping mechanisms that address the stressors that arise from the intersections of smokers' many identities.

Prevalence and risk factors of electronic cigarette use among adolescents: Data from four Swedish municipalities

Aims

To assess the prevalence rates and risk factors of electronic cigarette (e-cigarette) use, with special focus on e-cigarettes containing nicotine, among grade 9 students (aged 15–16 years) in four different municipalities in Sweden.

Methods

A cross-sectional sample of 665 adolescents was collected in April 2014. The data was analysed using binary logistic regression analysis.

Results

The results show that 26% of adolescents in this study have smoked e-cigarettes (have ever used), while 19% have smoked e-cigarettes with nicotine or do not know whether or not they contained nicotine. The strongest risk factor for ever having used e-cigarettes (any type or with nicotine) was smoking conventional cigarettes. Having tried cigarettes and having tried snus, as well as using or having used alcohol and having smoked a water pipe were also statistically significant risk factors for ever use of any type of e-cigarettes but not for use of e-cigarettes with nicotine. There was no gender difference.

Conclusions

Our result show that the use of e-cigarettes tends to cluster with the use of other substances, such as other tobacco products and alcohol. As a relatively large share of the participating adolescents, more than a fourth, had smoked e-cigarettes, this rather new phenomenon requires monitoring as a part of the tobacco control.

Multilevel analysis of school anti-smoking education and current cigarette use among South African students

INTRODUCTION

South Africa (SA) implemented the Global Youth Tobacco Survey (GYTS) four times between 1999 and 2011. Data from the four surveys indicated that downward trends in cigarette use among students may have stalled. Understanding the effect of school anti-smoking education on current smoking among students within schools and variability across schools may provide important insights into policies aimed at preventing or reducing tobacco use among students. The objective was to assess the student- and school-level effects of students' exposure to school anti-smoking education on current cigarette use among the study population using the most recent wave of GYTS data in SA (2011).

METHODS

An analytic sample of students 13-15 years of age was selected (n=3,068) from the SA GYTS 2011. A taxonomy of two-level logistic regression models was fit to assess the relationship of various tobacco use, control, and exposure predictor variables on current cigarette smoking among the study population.

RESULTS

At the student-level in the full model, secondhand smoke (SHS) exposure, peer smoking, and ownership of a promotional item were significantly associated with higher risk of current smoking. At the school-level in the full model, average exposure to peer smoking was associated with significant increases in the prevalence of current cigarette use, while average family anti-smoking education was significantly associated with decreases in the outcome variable. School anti-smoking education was not a statistically significant predictor at the student- or school-levels.

CONCLUSION

in this study, exposure to school anti-smoking education had no association with current cigarette smoking among the study population. Consistent with previous studies, having peers that smoked was highly associated with a student being a current smoker. Interestingly, at the school-level in the multilevel analysis, schools with higher rates of average family anti-smoking education had lower prevalence of current smoking. This finding has potential implications for tobacco control in SA, particularly if the school-level, family-centered protective effect can be operationalized as a prevention tool in the country's tobacco control program.

Tobacco use patterns, knowledge, attitudes towards tobacco and availability of tobacco control training among school personnel from a rural area in Poland

Background

Tobacco-free school environment as well as non-smoking teachers and school personnel provide positive role models for children and young people. In Poland, smoking should be banned in colleges, schools, educational establishments and educational care facilities. However, for the existing law to be effective, awareness of all people in school curriculum and enforcement of the law are crucial. The aim of the study was to evaluate tobacco use patterns, knowledge and attitudes towards tobacco as well as availability of tobacco control training among school personnel in a rural area in Poland. Moreover, compliance with tobacco control policies and their enforcement were assessed.

Methods

The study was carried out in Piotrkowski district between November 2014 and May 2015 in accordance with the Global School Personnel Survey (GSPS) methodology. Sixty schools participated in the survey (92% of the schools from the region) with involvement of 1044 teachers and 500 non-teaching staff (the response rate – 83.1%). The multivariate linear regression analyses were applied to study factors linked to the need for anti-tobacco training dedicated to the youth and teachers’ knowledge as well as activities to educate the students about tobacco use and its prevention.

Results

About 24% of the school personnel were current and 9% were ex-smokers. Significantly more teachers than the non-teaching staff indicated that the schools had a policy prohibiting tobacco use among students. In addition, 6% of the study participants indicated everyday violations of the tobacco control policy by the school personnel. More than 80% of the teaching personnel indicated the need for training dedicated to the youth to prevent their tobacco use. In the multivariate linear regression model, longer duration of working experience predicted higher levels of knowledge and more activities performed to teach the youth about tobacco use and its prevention. The smokers comparing to the non–smokers perceived the need for anti- tobacco training among the youth less strongly.

Conclusions

In order to make it possible for the inhabitants of Piotrkowski district to work and learn in tobacco smoke free environment there is an urgent need for taking actions aiming at increasing effectiveness of enforcing applicable tobacco control regulations in educational units. The necessity for systematic training dedicated to the youth to prevent their tobacco use, including accurate preparation of teachers, also needs to be highlighted.

Electronic supplementary material

The online version of this article (doi:10.1186/s12971-016-0110-y) contains supplementary material, which is available to authorized users.

The Empowering Role of Mobile Apps in Behavior Change Interventions: The Gray Matters Randomized Controlled Trial

BACKGROUND

Health education and behavior change programs targeting specific risk factors have demonstrated their effectiveness in reducing the development of future diseases. Alzheimer disease (AD) shares many of the same risk factors, most of which can be addressed via behavior change. It is therefore theorized that a behavior change intervention targeting these risk factors would likely result in favorable rates of AD prevention.

OBJECTIVE

The objective of this study was to reduce the future risk of developing AD, while in the short term promoting vascular health, through behavior change.

METHODS

The study was an interventional randomized controlled trial consisting of subjects who were randomly assigned into either treatment (n=102) or control group (n=42). Outcome measures included various blood-based biomarkers, anthropometric measures, and behaviors related to AD risk. The treatment group was provided with a bespoke "Gray Matters" mobile phone app designed to encourage and facilitate behavior change. The app presented evidence-based educational material relating to AD risk and prevention strategies, facilitated self-reporting of behaviors across 6 behavioral domains, and presented feedback on the user's performance, calculated from reported behaviors against recommended guidelines.

RESULTS

This paper explores the rationale for a mobile phone-led intervention and details the app's effect on behavior change and subsequent clinical outcomes. Via the app, the average participant submitted 7.3 (SD 3.2) behavioral logs/day (n=122,719). Analysis of these logs against primary outcome measures revealed that participants who improved their high-density lipoprotein cholesterol levels during the study duration answered a statistically significant higher number of questions per day (mean 8.30, SD 2.29) than those with no improvement (mean 6.52, SD 3.612), t97.74=-3.051, P=.003. Participants who decreased their body mass index (BMI) performed significantly better in attaining their recommended daily goals (mean 56.21 SD 30.4%) than those who increased their BMI (mean 40.12 SD 29.1%), t80 = -2.449, P=.017. In total, 69.2% (n=18) of those who achieved a mean performance percentage of 60% or higher, across all domains, reduced their BMI during the study, whereas 60.7% (n=34) who did not, increased their BMI. One-way analysis of variance of systolic blood pressure category changes showed a significant correlation between reported efforts to reduce stress and category change as a whole, P=.035. An exit survey highlighted that respondents (n=83) reported that the app motivated them to perform physical activity (85.4%) and make healthier food choices (87.5%).

CONCLUSIONS

In this study, the ubiquitous nature of the mobile phone excelled as a delivery platform for the intervention, enabling the dissemination of educational intervention material while simultaneously monitoring and encouraging positive behavior change, resulting in desirable clinical effects. Sustained effort to maintain the achieved behaviors is expected to mitigate future AD risk.

TRIAL REGISTRATION

ClinicalTrails.gov NCT02290912; https://clinicaltrials.gov/ct2/show/NCT02290912 (Archived by WebCite at http://www.webcitation.org/6ictUEwnm).

Is preference for mHealth intervention delivery platform associated with delivery platform familiarity?

BACKGROUND

The aim of this paper was to ascertain whether greater familiarity with a smartphone or tablet was associated with participants' preferred mobile delivery modality for eHealth interventions.

METHODS

Data from 1865 people who participated in the Australian Health and Social Science panel study were included into two multinomial logistic regression analyses in which preference for smartphone and tablet delivery for general or personalised eHealth interventions were regressed onto device familiarity and the covariates of sex, age and education.

RESULTS

People were more likely to prefer both general and personalised eHealth interventions presented on tablets if they reported high or moderate tablet familiarity (compared to low familiarity) and people were more likely to prefer both general and personalised eHealth interventions presented on smartphones if they reported high or moderate smartphone familiarity, were younger, and had university education (compared to completing high school or less).

CONCLUSION

People prefer receiving eHealth interventions on the mobile devices they are most familiar with. These findings have important implications that should be considered when developing eHealth interventions, and demonstrates that eHealth interventions should be delivered using multiple platforms simultaneously to optimally cater for as many people as possible.

The Effect of Comparatively-Framed versus Similarity-Framed E-Cigarette and Snus Print Ads on Young Adults' Ad and Product Perceptions

OBJECTIVES

This study examined the effects of comparative-framing [C-F; ads highlighting differences between the advertised product and conventional cigarettes and/or smokeless tobacco products] versus similarity-framing (S-F; ads highlighting congruence with conventional cigarettes and/or smokeless tobacco products) in e-cigarette and snus ads on young adult smokers' and non-smokers' ad- and product-related perceptions.

METHODS

One thousand fifty one (1,051) young adults (18-24 years; 76% women; 50% smokers) from existing consumer panels were recruited in a within-subjects quasi-experiment. Each participant viewed 4 online advertisements, varied by tobacco product type (e-cigarette or snus) and ad framing (C-F or S-F). The dependent measures for this study were ad-related (ad perceptions, ad credibility) and product-related perceptions (absolute and comparative risk perceptions, product appeal, and product use intentions).

RESULTS

Former and current smokers rated C-F ads as more persuasive than S-F ads, as evidenced by favorable ad perceptions and high product use intentions. Former and current smokers also rated e-cigarette ads with more favorable ad perceptions, low absolute and comparative risk perceptions, high product appeal, and high product use intentions as compared to snus ads. However, the effect sizes of the significant differences are less than.2, indicating small magnitude of difference between the study variables.

CONCLUSIONS

Unless FDA regulates e-cig and snus advertising, there is a potential of decreasing risk perceptions and increasing use of e-cigs among young adults. Further research on implicit/explicit comparative claims in e-cigarettes and snus advertisements that encourage risk misperceptions is recommended.

Impact of alcohol and alcohol mixed with energy drinks on non-medical prescription stimulant use in a nationally representative sample of 12th-grade students

BACKGROUND AND OBJECTIVES

Approximately 30% of high school students use energy drinks. Alcohol use and alcohol mixed with energy drink use (AmED) is associated with risky behavior, including non-medical prescription stimulant use. We assessed alcohol-only, AmED and non-medical prescription stimulant use among 12th grade students in the U.S. using a nationally representative secondary data from the 2012 Monitoring the Future Study.

METHODS

Wilcoxon-Mann-Whitney tests and logistic regression analyses were used to determine differences in non-medical prescription stimulant use by students who used alcohol-only versus AmED and to identify covariates of non-medical prescription stimulant use. Pearson-product moment coefficients were used to determine strength of variable relationships.

RESULTS

Significant differences were found in frequency of Ritalin (p < .001, Cohen's d = .23) and Adderall (p < .001, Cohen's d = .32) use between alcohol-only students and AmED students. Greater frequency of AmED use was also associated with greater frequency of Ritalin use (r = .293, p < .001) and Adderall use (r = .353, p < .001). Males (b = .138, OR = 1.148) were more likely to use prescription stimulants non-medically than females.

DISCUSSION AND CONCLUSIONS

This study highlights the need to better understand influences on non-medical prescription stimulant, energy drink and AmED use, as the combined effects of stimulants contained in energy drinks and the depressant effects of alcohol appear to be associated with increased non-medical prescription stimulant use.

SCIENTIFIC SIGNIFICANCE

Research on the influential factors related to energy drinks, alcohol, and non-medical prescription stimulants will help practitioners to more appropriately design prevention and intervention strategies addressing these high-risk behaviors. (Am J Addict 2016;25:378-384).

Consensus statement on assessment of waterpipe smoking in epidemiological studies

Numerous epidemiological accounts suggest that waterpipe smoking (aka hookah, shisha, narghile) has become a global phenomenon, especially among youth. The alarming spread of waterpipe and accumulating evidence of its addictive and harmful effects represent a new threat in the global fight to limit tobacco-related morbidity and mortality. In response to waterpipe's alarming trends, major public health and tobacco control organisations have started or are considering systematic collection of data about waterpipe smoking to monitor its trends and assess its harmful effects in different societies. Such plans require coordination and agreement on epidemiological measurement tools that reflect the uniqueness of this tobacco use method, and at the same time allow comparison of waterpipe trends across time and place, and with other tobacco use methods. We started a decade ago our work to develop standardised measures and definitions for the assessment of waterpipe smoking in epidemiological studies. In this communication, we try to expand and update these assessment tools in light of our increased knowledge and understanding of waterpipe use patterns, its context and marketing, as well as the need for evidence-guided policies and regulations to curb its spread. We have assembled for this purpose a group of leading waterpipe researchers worldwide, and worked through an iterative process to develop the suggested instruments and definitions based on what we know currently about the waterpipe epidemic. While the suggested measures are by no means comprehensive, we hope that they can provide the building blocks for standard and comparable surveillance of waterpipe smoking globally.

Index of tobacco control sustainability (ITCS): a tool to measure the sustainability of national tobacco control programmes

Objective

To produce a tool to assess and guide sustainability of national tobacco control programmes.

Method

A two-stage process adapting the Delphi and Nominal group techniques. A series of indicators of tobacco control sustainability were identified in grantee/country advisor reports to The International Union Against Tuberculosis and Lung Disease under the Bloomberg Initiative to Reduce Tobacco Control (2007–2015). Focus groups and key informant interviews in seven low and middle-income countries (52 government and civil society participants) provided consensus ratings of the indicators’ relative importance. Data were reviewed and the indicators were accorded relative weightings to produce the ‘Index of Tobacco Control Sustainability’ (ITCS).

Results

All 31 indicators were considered ‘Critical’ or ‘Important’ by the great majority of participants. There was consensus that a tool to measure progress towards tobacco control sustainability was important. The most critical indicators related to financial policies and allocations, a national law, a dedicated national tobacco control unit and civil society tobacco control network, a national policy against tobacco industry ‘Corporate Social Responsibility’ (CSR), national mortality and morbidity data, and national policy evaluation mechanisms.

Conclusions

The 31 indicators were agreed to be ‘critical’ or ‘important’ factors for tobacco control sustainability. The Index comprises the weighted indicators as a tool to identify aspects of national tobacco control programmes requiring further development to augment their sustainability and to measure and compare progress over time. The next step is to apply the ITCS and produce tobacco control sustainability assessments.

Socioeconomic Disparities in Age of Initiation and Ever Tobacco Smoking: Findings from Romania

AIM

Smoking initiation is considered the fundamental behaviour that determines the future health burden of tobacco smoking in a society. The aim of the study was to evaluate the socio-demographic factors associated with initiation of regular smoking among adults.

METHODS

The data source was the 2011 Global Adult Tobacco Survey Romania (GATS), which is a cross-sectional, nationally representative study. Multivariate logistic regression model was applied for relevant analysis.

RESULTS

Among males, the regular smoking initiation rate was significantly higher compared to females (52.4% vs. 18.5%; p<0.001). Mean age of smoking initiation was lower in men compared to women (18.4±4.8 vs. 21.5±6.8; p<0.001). Age in men, awareness of environmental tobacco smoke consequences and place of living for women as well as educational attainment and employment status in both genders were associated with ever regular smoking. Moreover, cohabitation with a smoker was associated with greater odds for initiating smoking among both genders.

CONCLUSIONS

GATS revealed a significant but diverse role of socioeconomic factors in initiation of regular smoking among adult Romanians.

Multiple Levels of Influence That Impact Youth Tobacco Use

OBJECTIVE

Multiple levels of influence interplay to impact youth tobacco use. We work towards understanding important policy and environmental strategies that are associated with youth tobacco use behaviors.

METHODS

We utilized data from participants of the Monitoring the Future (MTF) study and linked national data from multiple sources to assess correlates of youth tobacco use behaviors across individual, family, school, community, and state-level policy influences.

RESULTS

Higher cigarette prices had the strongest association with youth tobacco use behaviors. Demographic and socio-economic characteristics at the individual, familial, and community/school-levels were associated with youth tobacco use behaviors.

CONCLUSIONS

In the present study, we confirm that higher cigarette prices could help to reduce youth tobacco use behaviors. Several states are still lagging behind in terms of their low cigarette tax and they should enact tax policies to reduce youth tobacco use.

Perceptions of the solarium ban in Australia: 'Fake it, don't bake it'

ISSUE ADDRESSED

The causal link between ultraviolet radiation from solarium use and skin cancer is well established. In 2012 and 2013, state governments across Australia announced plans to ban commercial solarium use from 31 December 2014. The present study examined the responses of solarium and non-solarium users to the ban on commercial solariums in Australia.

METHODS

Participants (n = 488; 388 females, 100 males; mean age = 26.02, s.d. = 9.95) completed an online questionnaire during the summer prior to the ban relating to solarium usage and their opinions about the ban.

RESULTS

Overall, 49% (n = 237) of participants were aware of the impending ban; 17% (n = 83) had used a solarium at some point in their life. The response to the solarium ban was positive; however, some current solarium users intended post-ban to use privately owned sunbeds and or spend a greater amount of time sun-tanning.

CONCLUSIONS

These findings indicate a high level of public support for the solarium ban, which has removed a risky source of ultraviolet radiation in Australia. SO WHAT? Further steps are now needed to monitor the tanning behaviours of previous solarium users post-ban and their access to private sunbed use and other potentially dangerous methods of tanning (e.g. tanning injections).

[Tobacco consumption and its relationship to the level of regular physical activity and physical fitness in adolescents from the region of Murcia (Spain)]

This study looks at the relationship between tobacco consumption and the physical activity and fitness levels of adolescents. In a sample of 533 adolescents, both a questionnaire to obtain information regarding tobacco consumption and the International Physical Activity Questionnaire for information on physical activity were implemented; a battery of tests to assess physical fitness were also applied. Tobacco consumption was significantly higher in females (32.5%) than in males (25.7%). Levels of physical activity in both males and females were significantly associated with tobacco consumption (p<0.0005). Moreover, subjects who consumed tobacco showed lower overall averages in physical fitness tests than those who did not (4.26 vs. 5.77 in males and 4.54 vs. 6.71 in females). Tobacco consumption is therefore shown to be related to lower levels of physical activity and physical fitness in adolescents.

Health knowledge and smokeless tobacco quit attempts and intentions among married women in rural Bangladesh: Cross-sectional survey

INTRODUCTION AND AIMS

The aim of this study was to investigate health knowledge, attitudes and smokeless tobacco quit attempts and intentions among married women in rural Bangladesh.

DESIGN AND METHODS

A cross-sectional survey was conducted using an interviewer administered, pretested, semistructured questionnaire. All 8082 women living in the Jhaudi and Ghotmajhee local government areas, aged ≥18 years with at least one pregnancy in their lifetime, were invited to participate. Questions covered smokeless tobacco consumption (STC), knowledge regarding its health effects, users' quit attempts and intentions and sociodemographic characteristics.

RESULTS

Eight thousand seventy-four women completed the survey (response rate 99.9%). Almost half (45%) of current consumers thought STC was good for their health and many ascribed medicinal values to it, for example 25% thought STC reduced stomach aches. A quarter had previously tried to quit and 10% intended to quit. After adjusting for potential confounders, inaccurate knowledge of STC health consequences was associated with being older [adjusted odds ratio (aOR) = 2.71, 95% confidence interval (CI) 1.99-3.50], less educated (aOR = 2.18, 95% CI 1.66-2.85), Muslim (aOR = 17.0, 95% CI 12.0-23.9) and unemployed (aOR = 29.7, 95% CI: 25.2-35.1). Having less education (aOR = 2.52, 95% CI 0.98-6.45) and being unemployed (aOR = 1.52, 95% CI 1.03-2.23) were associated with the intention to quit.

DISCUSSION AND CONCLUSIONS

Large gaps exist in rural Bangladeshi women's understanding of the adverse health effects of STC. Health awareness campaigns should highlight the consequences of STC. Routine screening and cessation advice should be provided in primary healthcare and smokeless tobacco control strategies should be implemented. [Hossain MS, Kypri K, Rahman B, Akter S, Milton AH. Health knowledge and smokeless tobacco quit attempts and intentions among married women in rural Bangladesh: Cross-sectional survey. Drug Alcohol Rev 2016;35:514-522].

Assessing tobacco marketing receptivity among youth: integrating point of sale marketing, cigarette package branding and branded merchandise

BACKGROUND

As countries prohibit tobacco marketing through traditional channels, marketing at point of sale (PoS) and through tobacco packaging is increasingly important for promoting tobacco consumption.

OBJECTIVES

Assess the validity of a novel marketing receptivity index that considers frequency of PoS exposures, tobacco brand recall and ownership of branded merchandise.

METHODS

Data come from a cross-sectional survey of 3172 secondary school students in Argentina. Questions assessed frequency of going to stores where tobacco is often sold; cued recall of brand names for 3 cigarette packages with brand name removed and ownership of branded merchandise. A four-level marketing receptivity index was derived: low PoS exposure only; high PoS exposure or recall of 1 brand; recall of 2 or more brands; and ownership of branded merchandise. Indicators of marketing receptivity and smoking involvement were regressed on the index, including in adjusted models that controlled for sociodemographics, social influences and sensation seeking.

FINDINGS

Among never-smokers, the index had independent positive associations with smoking susceptibility (ie, adjusted OR (AOR)_2v1=1.66; AOR_3v1=1.64; AOR_4v1=2.95), willingness to try a specific brand (ie, AOR_2v1=1.45; AOR_3v1=2.38; AOR_4v1=2.20) and positive smoking expectancies (ie, B_{adj 2v1}=0.09; B_{adj 3v1}=0.18; B_{adj 4v1}=0.34). A more marked dose-response independent association was found with current smoking behaviour (ie, AOR_2v1=2.47; AOR_3v1=3.16; AOR_4v1=3.62).

CONCLUSIONS

The marketing receptivity index was associated with important variation in smoking-related perceptions, intentions and behaviour among Argentine adolescents. Future research should determine the predictive validity and generalisability of this measure to other contexts, including the explanatory power gained by integrating cigarette package brand recognition tasks.

Portion, package or tableware size for changing selection and consumption of food, alcohol and tobacco

BACKGROUND

Overeating and harmful alcohol and tobacco use have been linked to the aetiology of various non-communicable diseases, which are among the leading global causes of morbidity and premature mortality. As people are repeatedly exposed to varying sizes and shapes of food, alcohol and tobacco products in environments such as shops, restaurants, bars and homes, this has stimulated public health policy interest in product size and shape as potential targets for intervention.

OBJECTIVES

1) To assess the effects of interventions involving exposure to different sizes or sets of physical dimensions of a portion, package, individual unit or item of tableware on unregulated selection or consumption of food, alcohol or tobacco products in adults and children.2) To assess the extent to which these effects may be modified by study, intervention and participant characteristics.

SEARCH METHODS

We searched CENTRAL, MEDLINE, EMBASE, PsycINFO, eight other published or grey literature databases, trial registries and key websites up to November 2012, followed by citation searches and contacts with study authors. This original search identified eligible studies published up to July 2013, which are fully incorporated into the review. We conducted an updated search up to 30 January 2015 but further eligible studies are not yet fully incorporated due to their minimal potential to change the conclusions.

SELECTION CRITERIA

Randomised controlled trials with between-subjects (parallel-group) or within-subjects (cross-over) designs, conducted in laboratory or field settings, in adults or children. Eligible studies compared at least two groups of participants, each exposed to a different size or shape of a portion of a food (including non-alcoholic beverages), alcohol or tobacco product, its package or individual unit size, or of an item of tableware used to consume it, and included a measure of unregulated selection or consumption of food, alcohol or tobacco.

DATA COLLECTION AND ANALYSIS

We applied standard Cochrane methods to select eligible studies for inclusion and to collect data and assess risk of bias. We calculated study-level effect sizes as standardised mean differences (SMDs) between comparison groups, measured as quantities selected or consumed. We combined these results using random-effects meta-analysis models to estimate summary effect sizes (SMDs with 95% confidence intervals (CIs)) for each outcome for size and shape comparisons. We rated the overall quality of evidence using the GRADE system. Finally, we used meta-regression analysis to investigate statistical associations between summary effect sizes and variant study, intervention or participant characteristics.

MAIN RESULTS

The current version of this review includes 72 studies, published between 1978 and July 2013, assessed as being at overall unclear or high risk of bias with respect to selection and consumption outcomes. Ninety-six per cent of included studies (69/72) manipulated food products and 4% (3/72) manipulated cigarettes. No included studies manipulated alcohol products. Forty-nine per cent (35/72) manipulated portion size, 14% (10/72) package size and 21% (15/72) tableware size or shape. More studies investigated effects among adults (76% (55/72)) than children and all studies were conducted in high-income countries - predominantly in the USA (81% (58/72)). Sources of funding were reported for the majority of studies, with no evidence of funding by agencies with possible commercial interests in their results.A meta-analysis of 86 independent comparisons from 58 studies (6603 participants) found a small to moderate effect of portion, package, individual unit or tableware size on consumption of food (SMD 0.38, 95% CI 0.29 to 0.46), providing moderate quality evidence that exposure to larger sizes increased quantities of food consumed among children (SMD 0.21, 95% CI 0.10 to 0.31) and adults (SMD 0.46, 95% CI 0.40 to 0.52). The size of this effect suggests that, if sustained reductions in exposure to larger-sized food portions, packages and tableware could be achieved across the whole diet, this could reduce average daily energy consumed from food by between 144 and 228 kcal (8.5% to 13.5% from a baseline of 1689 kcal) among UK children and adults. A meta-analysis of six independent comparisons from three studies (108 participants) found low quality evidence for no difference in the effect of cigarette length on consumption (SMD 0.25, 95% CI -0.14 to 0.65).One included study (50 participants) estimated a large effect on consumption of exposure to differently shaped tableware (SMD 1.17, 95% CI 0.57 to 1.78), rated as very low quality evidence that exposure to shorter, wider bottles (versus taller, narrower bottles) increased quantities of water consumed by young adult participants.A meta-analysis of 13 independent comparisons from 10 studies (1164 participants) found a small to moderate effect of portion or tableware size on selection of food (SMD 0.42, 95% CI 0.24 to 0.59), rated as moderate quality evidence that exposure to larger sizes increased the quantities of food people selected for subsequent consumption. This effect was present among adults (SMD 0.55, 95% CI 0.35 to 0.75) but not children (SMD 0.14, 95% CI -0.06 to 0.34).In addition, a meta-analysis of three independent comparisons from three studies (232 participants) found a very large effect of exposure to differently shaped tableware on selection of non-alcoholic beverages (SMD 1.47, 95% CI 0.52 to 2.43), rated as low quality evidence that exposure to shorter, wider (versus taller, narrower) glasses or bottles increased the quantities selected for subsequent consumption among adults (SMD 2.31, 95% CI 1.79 to 2.83) and children (SMD 1.03, 95% CI 0.41 to 1.65).

AUTHORS' CONCLUSIONS

This review found that people consistently consume more food and drink when offered larger-sized portions, packages or tableware than when offered smaller-sized versions. This suggests that policies and practices that successfully reduce the size, availability and appeal of larger-sized portions, packages, individual units and tableware can contribute to meaningful reductions in the quantities of food (including non-alcoholic beverages) people select and consume in the immediate and short term. However, it is uncertain whether reducing portions at the smaller end of the size range can be as effective in reducing food consumption as reductions at the larger end of the range. We are unable to highlight clear implications for tobacco or alcohol policy due to identified gaps in the current evidence base.

Learning to drink: How Chinese adolescents make decisions about the consumption (or not) of alcohol

BACKGROUND

The aim of the study was to provide in-depth understanding of how Chinese adolescents learn to drink and how they make decisions about the consumption (or not) of alcohol. This study explored the ways in which social and cultural factors shape the drinking trajectories of Chinese underage young people.

METHODS

The study used a qualitative design to collect and analyse the data. We recruited adolescents aged between 14 and 17 from a range of secondary schools in Hong Kong. Focus group interviews were undertaken with 22 groups encompassing 111 participants. A thematic analysis based upon grounded theory was performed using NVivo 10.

RESULTS

The traditional Chinese drinking culture, characterised by the coming together of friends and relatives for celebrations, signifies the Chinese adolescents' first alcohol experiment. The adolescents' motivations for drinking essentially reflect the value placed upon alcohol within the Chinese culture - promoting conviviality, sociability and camaraderie. Whereas a sense of commonality encouraged alcohol use among them, there was little indication that drinkers and non-drinkers separately clustered around friendship networks. A high degree of self-regulation was exercised when drinking and this emerged as an acceptable social norm amongst young drinkers within social and cultural contexts. Most respondents saw underage drinking as an entirely normal and accepted part of social lives provided that it is kept under control.

CONCLUSIONS

This study sheds light on the Chinese adolescents' own understandings and interpretations of their drinking. Our findings suggest that interventions aimed to curtail underage drinking need to reflect social and cultural contexts within which alcohol comes into play and importantly, consider social environments that are conducive to underage drinking.

Trends and timing of cigarette smoking uptake among US young adults: survival analysis using annual national cohorts from 1976 to 2005

AIMS

To measure changes over time in cigarette smoking uptake prevalence and timing during young adulthood (ages 19-26 years), and associations between time-invariant/-varying characteristics and uptake prevalence/timing.

DESIGN

Discrete-time survival modeling of data collected from United States high school seniors (modal age 17/18) enrolled in successive graduating classes from 1976 to 2005 and participating in four follow-up surveys (to modal age 25/26).

SETTING

The longitudinal component of the Monitoring the Future study.

PARTICIPANTS

A total of 10 758 individuals reporting no life-time smoking when first surveyed as high school seniors.

MEASUREMENTS

Smoking uptake (any, experimental, occasional and regular); socio-demographic variables; marital, college and work status; time spent socializing.

FINDINGS

The percentage of young adults moving from non-smoker to experimental smoking [slope estimate 0.11, standard error (SE) = 0.04, P = 0.005] or occasional smoking (slope estimate 0.17, SE = 0.03, P < 0.001) increased significantly across graduating classes; the percentage moving from non-smoker to regular smoker remained stable. All forms of smoking uptake were most likely to occur at age 19/20, but uptake prevalence at older ages increased over time [e.g. cohort year predicting occasional uptake at modal age 25/26 adjusted hazard odds ratio (AHOR) = 1.05, P = 0.002]. Time-invariant/-varying characteristics had unique associations with the timing of various forms of smoking uptake (e.g. at modal age 21/22, currently attending college increased occasional uptake risk (AHOR = 2.11, P < 0.001) but decreased regular uptake risk (AHOR = 0.69, P = 0.026).

CONCLUSIONS

Young adult occasional and experimental smoking uptake increased in the United States for non-smoking high school seniors graduating from 1976 to 2005. Smoking uptake for these cohorts remained most likely to occur at age 19/20, but prevalence of uptake at older ages increased.

The relation between cigarette price and hand-rolling tobacco consumption in the UK: an ecological study

OBJECTIVES

Cigarette price increases reduce smoking prevalence but as a tobacco control policy are undermined by the availability of lower cost alternatives such as hand-rolling tobacco. The aim of this descriptive study is to explore time trends in the price of manufactured cigarettes and hand-rolling tobacco, and in the numbers of people who smoke these products, over recent years in the UK.

SETTINGS AND PARTICIPANTS

UK.

OUTCOME MEASURES

Trends in the most popular price category (MPPC) data for cigarettes and hand-rolling tobacco from 1983 to 2012 adjusted for inflation using the Retail Price Index, and trends in smoking prevalence and the proportion of smokers using hand-rolling tobacco from 1974 to 2010.

RESULTS

After adjustment for inflation, there was an increase in prices of manufactured cigarettes and hand-rolling tobacco between 1983 and 2012. Between 1974 and 2010, the prevalence of smoking fell from 45% to 20%, and the estimated total number of smokers from 25.3 to 12.4 million. However the number of people smoking hand-rolling tobacco increased from 1.4 to 3.2 million, and MPPC cigarette price was strongly correlated with number of people smoking hand-rolling tobacco.

CONCLUSIONS

Although the ecological study design precludes conclusions on causality, the association between increases in manufactured cigarette price and the number of people smoking hand-rolling tobacco suggests that the lower cost of smoking hand-rolling tobacco encourages downtrading when cigarette prices rise. The magnitude of this association indicates that the lower cost of hand-rolling tobacco seriously undermines the use of price as a tobacco control measure.

Gender equality and smoking: a theory-driven approach to smoking gender differences in Spain

BACKGROUND

The intersection between gender and class can aid in understanding gender differences in smoking.

AIM

To analyse how changes in gender inequality relate to differences in smoking prevalence by gender, education and birth cohort in Spain over the past five decades (1960-2010).

METHODS

The Gender Inequality Index (GII) was calculated in 5-year intervals from 1960 to 2010. GII ranges from 0 to 1 (1=highest inequality) and encompasses three dimensions: reproductive health, empowerment and labour market. Estimates of female and male smoking prevalence were reconstructed from representative National Health Surveys and stratified by birth cohort and level of education. We calculated female-to-male smoking ratios from 1960 to 2010 stratified by education and birth cohort.

RESULTS

Gender inequality in Spain decreased from 0.65 to 0.09 over the past 50 years. This rapid decline was inversely correlated (r=-0.99) to a rising female-to-male smoking ratio. The youngest birth cohort of the study (born 1980-1990) and women with high education levels had similar smoking prevalences compared with men. Women with high levels of education were also the first to show a reduction in smoking prevalence, compared with less educated women.

CONCLUSIONS

Gender inequality fell significantly in Spain over the past 50 years. This process was accompanied by converging trends in smoking prevalence for men and women. Smoking prevalence patterns varied greatly by birth cohort and education levels. Countries in earlier stages of the tobacco epidemic should consider gender-sensitive tobacco control measures and policies.

The Reinforcing Effects of Nicotine in Humans and Nonhuman Primates: A Review of Intravenous Self-Administration Evidence and Future Directions for Research

INTRODUCTION

Cigarette smoking is largely driven by the reinforcing properties of nicotine. Intravenous (IV) self-administration procedures are the gold standard for investigating the reinforcing effects of psychoactive drugs. The goal of this review was to examine the results of published investigations of the reinforcing effects of nicotine measured using IV self-administration procedures in humans and nonhuman primates.

RESULTS

The body of literature using nonhuman primate subjects indicates nicotine functions as a positive reinforcer when available for self-administration via IV catheters. However, it can also be difficult to establish IV nicotine self-administration in nonhuman primates and sometimes supplemental strategies have been required (e.g., priming injections or food deprivation) before subjects acquire the behavior. Although the body of literature using human subjects is limited, the evidence indicates nicotine functions as a reinforcer via the IV route of administration in adult cigarette smokers. Rates of nicotine self-injection can be variable across subjects and responding is sometimes inconsistent across sessions in both humans and nonhuman primates.

CONCLUSIONS

The Family Smoking Prevention and Tobacco Control Act, enacted in 2009, gave the Food and Drug Administration regulatory authority over the manufacture, marketing, and distribution of tobacco products. Research examining the threshold reinforcing doses for initiation and maintenance of nicotine self-administration, comparisons of the reinforcing effects of nicotine in adolescent versus adult subjects, investigations of gender differences in the reinforcing effects of nicotine, and studies of the abuse liability of non-nicotine tobacco product constituents and their ability to alter the reinforcing effects of nicotine will inform potential tobacco regulatory actions.

Towards a comprehensive global approach to prevention and control of NCDs

BACKGROUND

The "25×25" strategy to tackle the global challenge of non-communicable diseases takes a traditional approach, concentrating on a few diseases and their immediate risk factors.

DISCUSSION

We propose elements of a comprehensive strategy to address NCDs that takes account of the evolving social, economic, environmental and health care contexts, while developing mechanisms to respond effectively to local patterns of disease. Principles that underpin the comprehensive strategy include: (a) a balance between measures that address health at the individual and population level; (b) the need to identify evidence-based feasible and effective approaches tailored to low and middle income countries rather than exporting questionable strategies developed in high income countries; (c) developing primary health care as a universal framework to support prevention and treatment; (d) ensuring the ability to respond in real time to the complex adaptive behaviours of the global food, tobacco, alcohol and transport industries; (e) integrating evidence-based, cost-effective, and affordable approaches within the post-2015 sustainable development agenda; (f) determination of a set of priorities based on the NCD burden within each country, taking account of what it can afford, including the level of available development assistance; and (g) change from a universal "one-size fits all" approach of relatively simple prevention oriented approaches to more comprehensive multi-sectoral and development-oriented approaches which address both health systems and the determinants of NCD risk factors.

SUMMARY

The 25×25 is approach is absolutely necessary but insufficient to tackle the the NCD disease burden of mortality and morbidity. A more comprehensive approach is recommended.

Smoking cessation

Cigarette smoking is a major preventable cause of morbidity and mortality. It is the major risk factor for chronic obstructive pulmonary disease in the developed world. Smoking is a chronic relapsing disease. Optimal treatment includes nonpharmacologic support, together with pharmacotherapy. All clinicians should be comfortable with the use of nicotine replacement therapy, bupropion, and varenicline. Second-line therapies can be used by those familiar with their use. Effective use of these medications requires their integration into an effective management plan, which is likely to be a long-term undertaking, involving several cycles of remission and relapse.

Smoking behavior among patients and staff: a snapshot from a major metropolitan hospital in Melbourne, Australia

Background

A cross-sectional study was conducted to provide a snapshot of smoking behavior among staff and patients at a major metropolitan hospital in Melbourne.

Methods

Patients and staff were surveyed using a questionnaire exploring demographics, nicotine dependence (Fagerstrom test), readiness to quit, and preference for smoking cessation options.

Results

A total of 1496 people were screened within 2 hours; 1,301 participated (1,100 staff, 199 patients). Mean age was 42 years, 68% were female. There were 113 (9%) current smokers and 326 (25%) ex-smokers. Seven percent of the staff were current smokers compared with 19% of the patients. The Fagerstrom test showed that 47% of patients who smoked were moderately nicotine dependent compared with 21% of staff. A third of the staff who smoked did not anticipate health problems related to smoking. Most patients (79%) who smoked disagreed that their current health problems were related to smoking. Although more than half of the current smokers preferred pharmacotherapy, one in two of them did not prefer behavior counseling; with consistent results among staff and patients. Multivariate analyses showed that patients were three times more likely (odds ratio 3.0, 95% confidence interval 1.9–4.7) to smoke than staff.

Conclusion

This study reports lower prevalence of smoking among hospital staff compared with national data. It also indicates an under-appreciation of health effects of smoking, and a preference not to use conventional methods of quitting.

Impact of a multi-level intervention to prevent secondhand smoke exposure in schoolchildren: a randomized cluster community trial

OBJECTIVE

To assess the effectiveness of a multi-level (individual, family, and school) school-based intervention to prevent the exposure to secondhand smoke (SHS) in a population of schoolchildren (12-14 years old).

METHOD

This was a community trial with cluster randomization of schools to an intervention and comparison group (ClinicalTrials.Gov identifier NCT01881607). The intervention targeted schoolchildren in Terrassa (Catalonia, Spain). We assessed SHS exposure in different settings and tobacco consumption by means of a questionnaire before and one year after the intervention.

RESULTS

We analyzed data from 1734 students with both baseline and follow-up data. The crude analysis showed that SHS exposure among students in the intervention group significantly decreased at school (-14.0%), at home (-19.9%), and on transportation (-21.8%). In the comparison group, SHS exposure significantly decreased only at home (-16.9%). After adjustment for potential confounders, the good accomplishment of the activities showed a possible trend towards a non-significant reduction in exposure at home, transportation, and leisure time.

CONCLUSION

While this school-based multi-level intervention had no overall effect in SHS exposure, the improvement of the activities focused on preventing SHS would be needed in order to achieve a significant decrease in the proportion of children exposed to SHS.

Impact of tobacco control policies on adolescent smoking: findings from the Global Youth Tobacco Survey in Taiwan

AIMS

To assess the impact of a set of comprehensive tobacco control policies implemented in Taiwan in 2009, including extensive smoke-free policy, advertisement ban, pictorial warning and price increase, on adolescent smoking prevalence.

DESIGN

Five waves of cross-sectional surveys.

SETTING

Taiwan, 2004-11.

PARTICIPANTS

Nationally representative sample of junior high schools aged 13-15 years, in a biennial survey, total sample size 101,100.

MEASURES

Core questionnaire of the Global Youth Tobacco Survey, including ever smoking, 30-day smoking and number of cigarettes smoked. The magnitude of prevalence change before and after the 2009 policy implementation was quantified by adjusted odds ratios estimated by piecewise logistic regression models.

FINDINGS

The 30-day smoking prevalence demonstrated an upward trend [odds ratio (OR) = 1.06, 95% confidence interval (CI) = 1.02-1.10] between 2004 and 2008. Significant decline in 30-day smoking prevalence after the 2009 law implementation was observed (OR = 0.84, 95% CI = 0.71-0.99). Those living in non-city areas demonstrated a greater magnitude of change. In addition to changes in prevalence, we observed some delay in the age starting smoking, reduction in smokers who smoke fewer than one cigarette per day, and decrease in smokers who did not buy cigarettes. The decline in smoking prevalence was contributed primarily by the reduction in experimenters.

CONCLUSION

The comprehensive tobacco control programme introduced in Taiwan in 2009 was associated with a reduction in adolescent smoking, particularly among those in earlier stages of smoking and those who resided in non-city areas.

Cultural and social influences on adolescent smoking dissipate by emerging adulthood among Hispanics in Southern California

The aim of the present study was to identify risk factors for smoking among Hispanic adolescents and determine whether these factors continued to influence smoking into emerging adulthood. Data were drawn from 932 Hispanics in the greater Los Angeles area who were surveyed in high school in 2007 and then again in emerging adulthood from 2010 to 2012. Logistic regression assessed the associations between predictors in adolescence and smoking in adolescence while an order one transition logistic model assessed predictors in adolescence and smoking in emerging adulthood. Adult and sibling smoking status, perceptions of smoking, perceived discrimination, and fatalism all influenced smoking in adolescence but not in emerging adulthood. Once Hispanics reach emerging adulthood different tactics to reduce smoking will be needed and are where future research should be directed.

Strategies to reduce indoor tanning: current research gaps and future opportunities for prevention

Exposure to ultraviolet radiation from indoor tanning device use is associated with an increased risk of skin cancer, including risk of malignant melanoma, and is an urgent public health problem. By reducing indoor tanning, future cases of skin cancer could be prevented, along with the associated morbidity, mortality, and healthcare costs. On August 20, 2012, the CDC hosted a meeting to discuss the current body of evidence on strategies to reduce indoor tanning as well as research gaps. Using the Action Model to Achieve Healthy People 2020 Overarching Goals as a framework, the current paper provides highlights on the topics that were discussed, including (1) the state of the evidence on strategies to reduce indoor tanning; (2) the tools necessary to effectively assess, monitor, and evaluate the short- and long-term impact of interventions designed to reduce indoor tanning; and (3) strategies to align efforts at the national, state, and local levels through transdisciplinary collaboration and coordination across multiple sectors. Although many challenges and barriers exist, a coordinated, multilevel, transdisciplinary approach has the potential to reduce indoor tanning and prevent future cases of skin cancer.

Starting to smoke: a qualitative study of the experiences of Australian indigenous youth

Background

Adult smoking has its roots in adolescence. If individuals do not initiate smoking during this period it is unlikely they ever will. In high income countries, smoking rates among Indigenous youth are disproportionately high. However, despite a wealth of literature in other populations, there is less evidence on the determinants of smoking initiation among Indigenous youth. The aim of this study was to explore the determinants of smoking among Australian Indigenous young people with a particular emphasis on the social and cultural processes that underlie tobacco use patterns among this group.

Methods

This project was undertaken in northern Australia. We undertook group interviews with 65 participants and individual in-depth interviews with 11 youth aged 13–20 years led by trained youth ‘peer researchers.’ We also used visual methods (photo-elicitation) with individual interviewees to investigate the social context in which young people do or do not smoke. Included in the sample were a smaller number of non-Indigenous youth to explore any significant differences between ethnic groups in determinants of early smoking experiences. The theory of triadic influence, an ecological model of health behaviour, was used as an organising theory for analysis.

Results

Family and peer influences play a central role in smoking uptake among Indigenous youth. Social influences to smoke are similar between Indigenous and non-Indigenous youth but are more pervasive (especially in the family domain) among Indigenous youth. While Indigenous youth report high levels of exposure to smoking role models and smoking socialisation practices among their family and social networks, this study provides some indication of a progressive denormalisation of smoking among some Indigenous youth.

Conclusions

Future initiatives aimed at preventing smoking uptake in this population need to focus on changing social normative beliefs around smoking, both at a population level and within young peoples’ immediate social environment. Such interventions could be effectively delivered in both the school and family environments. Specifically, health practitioners in contact with Indigenous families should be promoting smoke free homes and other anti-smoking socialisation behaviours.