Effects of tobacco taxation and pricing on smoking behavior in high risk populations: a knowledge synthesis

A population-based comparison of European and North American sinonasal cancer survival

OBJECTIVE

Sinonasal cancers (SNC) are rare, thus limiting previous prognostic studies on a multinational level. The aim of this study is to utilize two population-based datasets to compare prognoses for SNC between the United States (US) and Europe.

METHODS

The European Cancer Registry (EUROCARE) database and the United States National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) database were searched to identify survival of patients diagnosed with SNC between 1990 and 2007. Relative survival (RS) data were stratified by age group, gender, geographic location, and diagnostic time period.

RESULTS

12,541 SNC cases were identified in EUROCARE, while SEER identified 4,312. Males comprised the majority in Europe (62.3%) and the US (58.3%). Most patients were over 55 years in Europe (77.0%) and the US (69.5%). Age over 75 was a statistically significant poor prognostic indicator for 5-year RS in the US (48.2%; 95% CI=[43.9, 52.4]) and Europe (38.5%; [34.7, 42.7]). Female gender imparted a favorable 5-year RS in all regions except in Central Europe. By region, the US had the highest 5-year RS (58.8%; [56.4, 61.1]) and Eastern Europe had the lowest 5-year RS (37.1%; [34.0, 40.6]). The aggregate European 5-year RS was 48.1% [46.4, 49.8].

CONCLUSION

SNC in Europe and the US most commonly affects males and individuals over the age of 55 years. Male gender and age over 75 are poor prognostic factors at 5 years. Five-year RS in the US is higher than the 5-year European aggregate RS.

Tobacco industry strategies undermine government tax policy: evidence from commercial data

OBJECTIVE

Taxation equitably reduces smoking, the leading cause of health inequalities. The tobacco industry (TI) can, however, undermine the public health gains realised from tobacco taxation through its pricing strategies. This study aims to examine contemporary TI pricing strategies in the UK and implications for tobacco tax policy.

DESIGN

Review of commercial literature and longitudinal analysis of tobacco sales and price data.

SETTING

A high-income country with comprehensive tobacco control policies and high tobacco taxes (UK).

PARTICIPANTS

2009 to 2015 Nielsen Scantrak electronic point of sale systems data.

MAIN OUTCOME MEASURES

Tobacco segmentation; monthly prices, sales volumes of and net revenue from roll-your-own (RYO) and factory-made (FM) cigarettes by segment; use of price-marking and pack sizes.

RESULTS

The literature review and sales data concurred that both RYO and FM cigarettes were segmented by price. Despite regular tax increases, average real prices for the cheapest FM and RYO segments remained steady from 2013 while volumes grew. Low prices were maintained through reductions in the size of packs and price-marking. Each year, at the point the budget is implemented, the TI drops its revenue by up to 18 pence per pack, absorbing the tax increases (undershifting). Undershifting is most marked for the cheapest segments.

CONCLUSIONS

The TI currently uses a variety of strategies to keep tobacco cheap. The implementation of standardised packaging will prevent small pack sizes and price-marking but further changes in tax policy are needed to minimise the TI's attempts to prevent sudden price increases.

Behavioral change in response to a statewide tobacco tax increase and differences across socioeconomic status

BACKGROUND

Tobacco use is a leading behavioral risk factor for morbidity and mortality, and the tobacco epidemic disproportionately affects low-socioeconomic status (SES) populations. Taxation is effective for reducing cigarette use, and it is an effective population-based policy for reducing SES-related tobacco disparities. However, progress in implementing cigarette excise taxes has stalled across the United States, and there is a dearth of research on the full spectrum of behavioral shifts that result from taxes, particularly among low-SES populations. This project documents the impact of Minnesota's $1.75 cigarette tax increase implemented in 2013.

METHODS

Data come from the 2014 Minnesota Adult Tobacco Survey. Descriptive analyses and Latent Class Analysis (LCA) were used to provide a typology of the tax impact.

RESULTS

From the LCA, six classes were identified, and 42% of respondents were classified as reporting action-oriented behavioral change related to the tax-8% reported sustained smoking abstinence. We found differential behavior change across levels of SES. Low-SES and medium/high-SES individuals were equally likely to report complete tobacco cessation, but the prevalence of daily smokers who reported action-oriented behavior without sustained cessation was nearly double for low-SES individuals.

CONCLUSIONS

Smokers report a range of behavioral changes in response to cigarette taxes, with differences across SES. The majority of smokers, and particularly low-SES smokers, report behavioral steps toward quitting or achieving sustained tobacco cessation in response to cigarette taxes. Complementary population-based programs geared toward assisting individuals, especially low-SES individuals, to achieve continuous tobacco cessation could increase the reach and effectiveness of cigarette taxes.

Association between smoking and alcohol-related behaviours: a time-series analysis of population trends in England

AIMS

This paper estimates how far monthly changes in prevalence of cigarette smoking, motivation to quit and attempts to stop smoking have been associated with changes in prevalence of high-risk drinking, and motivation and attempts to reduce alcohol consumption in England.

DESIGN

Data were used from the Alcohol and Smoking Toolkit Studies between April 2014 and June 2016. These involve monthly household face-to-face surveys of representative samples of ~1700 adults in England.

MEASUREMENTS

Autoregressive Integrated Moving Average with Exogeneous Input (ARIMAX) modelling was used to assess the association over time between monthly prevalence of (a) smoking and high-risk drinking; (b) high motivation to quit smoking and high motivation to reduce alcohol consumption; and (c) attempts to quit smoking and attempts to reduce alcohol consumption.

FINDINGS

Mean smoking prevalence over the study period was 18.6% and high-risk drinking prevalence was 13.0%. A decrease of 1% of the series mean smoking prevalence was associated with a reduction of 0.185% of the mean prevalence of high-risk drinking 2 months later [95% confidence interval (CI) = 0.033 to 0.337, P = 0.017]. A statistically significant association was not found between prevalence of high motivation to quit smoking and high motivation to reduce alcohol consumption (β = 0.324, 95% CI = -0.371 to 1.019, P = 0.360) or prevalence of attempts to quit smoking and attempts to reduce alcohol consumption (β = -0.026, 95% CI = -1.348 to 1.296, P = 0.969).

CONCLUSION

Between 2014 and 2016, monthly changes in prevalence of smoking in England were associated positively with prevalence of high-risk drinking. There was no significant association between motivation to stop and motivation to reduce alcohol consumption, or attempts to quit smoking and attempts to reduce alcohol consumption.

Effective tobacco control measures: agreement among medical students

Objective:

To determine the level of agreement with effective tobacco control measures recommended by the World Health Organization and to assess the attitudes toward, knowledge of, and beliefs regarding smoking among third-year medical students at University of São Paulo School of Medicine, located in the city of São Paulo, Brazil.

Methods:

Between 2008 and 2012, all third-year medical students were invited to complete a self-administered questionnaire based on the Global Health Professionals Student Survey and its additional modules.

Results:

The study sample comprised 556 students. The level of agreement with the World Health Organization recommendations was high, except for the components "received smoking cessation training" and "raising taxes is effective to reduce the prevalence of smoking". Most of the students reported that they agree with banning tobacco product sales to minors (95%), believe that physicians are role models to their patients (84%), and believe that they should advise their patients to quit cigarette smoking (96%) and using other tobacco products (94%). Regarding smoking cessation methods, most of the students were found to know more about nicotine replacement therapy than about non-nicotine therapies (93% vs. 53%). Only 37% of the respondents were aware of the importance of educational antismoking materials, and only 31% reported that they believe in the effectiveness of encouraging their patients, during medical visits. In our sample, the prevalence of current cigarette smoking was 5.23%; however, 43.82% of the respondents reported having experimented with water-pipe tobacco smoking.

Conclusions:

Our results revealed the need to emphasize to third-year medical students the importance of raising the prices of and taxes on tobacco products. We also need to make students aware of the dangers of experimenting with tobacco products other than cigarettes, particularly water-pipe tobacco smoking.

Objetivo:

Determinar o grau de concordância com medidas eficazes de controle do tabaco recomendadas pela Organização Mundial da Saúde e avaliar as atitudes, o conhecimento e as crenças a respeito do tabagismo em alunos do terceiro ano de medicina da Faculdade de Medicina da Universidade de São Paulo, em São Paulo (SP).

Métodos:

Entre 2008 e 2012, todos os alunos do terceiro ano de medicina foram convidados a preencher um questionário autoaplicável baseado na Global Health Professions Student Survey e em seus módulos adicionais.

Resultados:

A amostra consistiu em 556 estudantes. O grau de concordância com as recomendações da Organização Mundial da Saúde foi alto, à exceção de "receberam treinamento a respeito de cessação do tabagismo" e "aumentar os impostos é uma medida eficaz para reduzir a prevalência do tabagismo". A maioria dos estudantes relatou que concorda com a proibição da venda de produtos do tabaco a menores de idade (95%), acredita que os médicos são modelos de comportamento para seus pacientes (84%) e acredita que deveriam aconselhar seus pacientes a parar de fumar cigarros (96%) e de usar outros produtos do tabaco (94%). No tocante aos métodos de cessação do tabagismo, observamos que a maioria dos estudantes sabe mais sobre terapia de reposição da nicotina do que sobre terapias não nicotínicas (93% vs. 53%). Apenas 37% dos participantes estavam cientes da importância de material educacional antitabagismo, e apenas 31% relataram que acreditam na eficácia de incentivar seus pacientes, durante as consultas médicas, a parar de fumar. Em nossa amostra, a prevalência de tabagismo atual foi de 5,23%; entretanto, 43,82% dos participantes relataram ter experimentado fumar tabaco com um narguilé.

Conclusões:

Nossos resultados revelaram a necessidade de deixar claro para os alunos do terceiro ano de medicina o quão importante é aumentar os preços e impostos dos produtos do tabaco. É também preciso conscientizar os alunos dos perigos de experimentar outros produtos do tabaco que não os cigarros, particularmente o narguilé.

Costo por años de vida perdidos: una propuesta para estimar el impuesto al tabaco

Objetivos Determinar y justificar la carga impositiva de los cigarrillos, con base en los años de vida que se pierden por su consumo.Métodos Mediante revisión de literatura se estimó la reducción promedio de la expectativa de vida de un fumador. Se aplicó a cada año perdido el valor empleado en estudios de costo-efectividad, de tres veces el PIB per cápita (COP 16 613.951 de 2015, equivalentes a USD 6 056, aplicando tasa de 1 USD=2 743 COP). A partir de los años de consumo promedio, y de los paquetes que consume en ese lapso, se estimó el impuesto que debería tener cada paquete para que, con un interés de 3 % anual, el fumador al fallecer reuniera el valor correspondiente a los años que pierde.Resultados Dada una reducción promedio de esperanza de vida de seis años, cada fumador debería contribuirle al sistema de salud COP 299 051 115 (USD 109 008). Si en promedio consume 166 paquetes de cigarrillos anuales, durante 50 años, debería reunir COP 2.659 648 (USD 969) cada año, y cada paquete debería tener un impuesto de COP 16 022 (USD 5,84).Conclusiones Si se acepta que el sistema de salud pague hasta tres PIB per cápita por cada año de vida por intervenciones en salud que aporten años, es razonable que aquellas intervenciones que quitan años de vida hagan también un aporte equivalente.

Evidence for a comprehensive approach to Aboriginal tobacco control to maintain the decline in smoking: an overview of reviews among Indigenous peoples

BACKGROUND

Tobacco smoking is a leading cause of disease and premature mortality among Aboriginal and Torres Strait Islander (Indigenous) Australians. While the daily smoking prevalence among Indigenous Australians has declined significantly from 49% in 2001, it remains about three times higher than that of non-Indigenous Australians (39 and 14%, respectively, for age ≥15 years in 2014-15). This overview of systematic reviews aimed to synthesise evidence about reducing tobacco consumption among Indigenous peoples using a comprehensive framework for Indigenous tobacco control in Australia comprised of the National Tobacco Strategy (NTS) and National Aboriginal and Torres Strait Islander Health Plan (NATSIHP) principles and priorities.

METHODS

MEDLINE, EMBASE, systematic review and Indigenous health databases were searched (2000 to Jan 2016) for reviews examining the effects of tobacco control interventions among Indigenous peoples. Two reviewers independently screened reviews, extracted data, and assessed review quality using Assessing the Methodological Quality of Systematic Reviews. Data were synthesised narratively by framework domain. Reporting followed the PRISMA statement.

RESULTS

Twenty-one reviews of varying quality were included. There was generally limited Indigenous-specific evidence of effective interventions for reducing smoking; however, many reviewers recommended multifaceted interventions which incorporate Indigenous leadership, partnership and engagement and cultural tailoring. Under the NTS priority areas, reviewers reported evidence for brief smoking cessation interventions and pharmacological support, mass media campaigns (on knowledge and attitudes) and reducing affordability and regulation of tobacco sales. Aspects of intervention implementation related to the NATSIHP domains were less well described and evidence was limited; however, reviewers suggested that cultural tailoring, holistic approaches and building workforce capacity were important strategies to address barriers. There was limited evidence regarding social media and mobile applications, for Indigenous youth, pregnant women and prisoners, and no evidence regarding interventions to protect communities from industry interference, the use of electronic cigarettes, interventions for people experiencing mental illness, juvenile justice, linguistic diversity or 'pubs, clubs and restaurants'.

CONCLUSIONS

There is limited Indigenous-specific evidence for most tobacco interventions. A 'comprehensive approach' incorporating NTS and NATSIHP Principles and Priorities of partnership and engagement, evidence from other settings, programme logic and responsive evaluation plans may improve intervention acceptability, effectiveness and implementation and mitigate risks of adapting tobacco evidence for Indigenous Australians.

The contribution of excise cigarette taxes on the decline in youth smoking in Canada during the time of the Federal Tobacco Control Strategy (2002-2012)

OBJECTIVES

To evaluate the impact of changes in cigarette taxes on smoking for youths aged 15-18 in Canada during the time of the Federal Tobacco Control Strategy (FTCS).

METHODS

We used a difference-in-differences framework and leveraged the variation in cigarette taxes across Canada and over time. We used regression models with province and year fixed effects, and individual-level and provincial-level covariates on 2002-2012 data from the Canadian Tobacco Use Monitoring Survey.

RESULTS

Tax increases generally did not affect smoking outcomes. Each increase of CAD $1.00 (adjusted to year 2000 dollars) in excise cigarette taxes per package of 20 was associated with a 0.2 percentage point (95% CI: -1.8; 2.2) change in smoking prevalence, and a change of 0.3 in mean cigarettes smoked in the past week (95% CI: -1.2; 1.8).

CONCLUSION

From 2002 to 2012, smoking prevalence and mean smoking frequency were in steady decline among youths in Canada. This decline, however, was evident even among provinces with stable or decreasing cigarette tax levels. Tobacco taxes have mostly increased since the 1980s, and so, tax levels were already quite high by the launch of the FTCS. Province fixed effects and common temporal changes accounted for 83.7% of the variation in smoking prevalence. We derived similar results for smoking frequency. The cumulative tax increase during our study period was at least $1.00 for only three provinces. Thus, our findings suggest that factors driving down tobacco use among youths in all provinces appear to outweigh any impact of small tax increases at already high tax levels.

ADHD, Lifestyles and Comorbidities: A Call for an Holistic Perspective - from Medical to Societal Intervening Factors

The review examines Attention Deficit Hyperactivity Disorder (ADHD in its Child and Adult form) and its various presentations (Hyperactive Impulsive, Inattentive, and Combined) with a particular focus on environmental (incl. social factors), lifestyles and comorbidities. It is argued that ADHD is best understood in a holistic and interactive context and a vast empirical literature is presented to illustrate the point: Environmental factors include stress in general as well as exposure to toxins (phthalates, bisphenol A). Social factors are illustrated by effects of social deprivation and seduction to unhealthy lifestyles. Maternal lifestyle during pregnancy is pointed out (particularly her exposure to nicotine, alcohol, caffeine, and drugs, even seemingly benign medications like acetaminophen), which all tend to be related to ADHD. Family environment is discussed with respect to protective effect of (mainly authoritative and autocratic) parenting styles. Societal factors include mainly economic and political issues: income inequality and poverty (low SES is an ADHD risk factor) and a growing moral dilemma between a humanistic effort to globally spread the knowledge of ADHD and the medicalization and commercialization of the disorder. The second part of the review is devoted to ADHD related lifestyles and resulting comorbidities (e.g., food addiction and obesity, substance abuse, electronic media dependencies and conduct and personality disorders). Although ADHD is a neurodevelopmental disorder, its assessment and treatment are also linked to environmental, behavioral and social factors and their interactions.

Oral Cancer Awareness Among Dental Patients in Omdurman, Sudan: a cross-sectional Study

Background

Oral cancer is a preventable disease. Its occurrence is mostly due to lifestyle. In Sudan, the use of smokeless tobacco (Toombak) has long been linked to oral cancer. Knowledge of the signs and symptoms of oral cancer may well aid in early diagnosis and treatment. This is bound to result in increasing survival rates, as well as reducing the oral cancer burden on the society. This study aimed to assess oral cancer awareness regarding knowledge of signs, symptoms, risk factors and sources of the information. Furthermore, it attempts to evaluate attitudes towards oral cancer screening and any previous experience of screening, amongst dental patients attending University of Science and Technology (UST) Dental Teaching Hospital. Omdurman, Sudan.

Methods

A hospital based cross-sectional study, interviewer-administered questionnaire was conducted amongst 500 adult patients attending the UST Dental Hospital during 2015.

Results

A total of 57.7% (286) of the individuals demonstrated good knowledge of signs and symptoms, whereas 49% (139) expressed good knowledge of risk factors of oral cancer. For the majority of the individuals 66.1% (290), the most common source of information about oral cancer was from the media, while 33.9% individuals (149), obtained knowledge from direct contact of health workers. The overwhelming majority, 93.2% (466) never screened for oral cancer despite their positive attitude towards it 66.4% (332). Knowledge of risk factors associated significantly with those reported positive attitude towards oral cancer screening and those reported direct contact with health workers as a source of information, (p ≤ 0.001). Moreover, females and those living in urban districts scores higher than their counterpart in knowledge of risk factor of oral cancer. In addition, those employed 58.6% (280) and 62.8% (164) with correct believes about oral cancer showed significant association with positive knowledge of signs and symptoms (p ≤ 0.05).

Conclusions

Awareness levels, knowledge of risk factors and identifying early signs and symptoms of oral cancer necessitate the need for more structured preventive programs using media. Dentists and health workers should do more because they have a pivotal role in early diagnosis by performing oral cancer screening, raising levels of knowledge and in rectifying misconceptions about oral cancer. This would entail a reduction in high rates of morbidity and mortality associated with oral cancer.

Electronic supplementary material

The online version of this article (doi:10.1186/s12903-017-0351-z) contains supplementary material, which is available to authorized users.

Exploring Impacts of Taxes and Hospitality Bans on Cigarette Prices and Smoking Prevalence Using a Large Dataset of Cigarette Prices at Stores 2001-2011, USA

In the USA, little is known about local variation in retail cigarette prices; price variation explained by taxes, bans, and area-level socio-demographics, and whether taxes and hospitality bans have synergistic effects on smoking prevalence. Cigarette prices 2001–2011 from chain supermarkets and drug stores (n = 2973) were linked to state taxes (n = 41), state and county bar/restaurant smoking bans, and census block group socio-demographics. Hierarchical models explored effects of taxes and bans on retail cigarette prices as well as county smoking prevalence (daily, non-daily). There was wide variation in store-level cigarette prices in part due to differences in state excise taxes. Excise taxes were only partially passed onto consumers (after adjustment, $1 tax associated with $0.90 increase in price, p < 0.0001) and the pass-through was slightly higher in areas that had bans but did not differ by area-level socio-demographics. Bans were associated with a slight increase in cigarette price (after adjustment, $0.09 per-pack, p < 0.0001). Taxes and bans were associated with reduction in smoking prevalence and taxes had a stronger association when combined with bans, suggesting a synergistic effect. Given wide variation in store-level prices, and uneven state/county implementation of taxes and bans, more federal policies should be considered.

Self-Reported Reasons for Smoking: Predicting Abstinence and Implications for Smoking Cessation Treatments Among Those With a Psychotic Disorder

OBJECTIVES

People living with a psychotic illness have higher rates of cigarette smoking and face unique barriers to quitting compared to the general population. We examined whether self-reported reasons for smoking are useful predictors of successful quit attempts among people with psychosis.

METHODS

As part of a randomized controlled trial addressing smoking and cardiovascular disease risk behaviors among people with psychosis, self-reported reasons for smoking were assessed at baseline (n = 235), 15 weeks (n = 151), and 12 months (n = 139). Three factors from the Reasons for Smoking Questionnaire (Coping, Physiological, and Stimulation/Activation) were entered into a model to predict short- and long-term abstinence. The relationship between these factors and mental health symptoms were also assessed.

RESULTS

Participants scoring higher on the Stimulation/Activation factor (control of weight, enjoyment, concentration, and "peps me up") at baseline were just less than half as likely to be abstinent at 15 weeks. Female participants were five times more likely to abstinent at 15 weeks, and those with a higher global functioning at baseline were 5% more likely to be abstinent. There was a positive correlation between changes over time in the Stimulation/Activation factor from baseline to 12-month follow-up and the Brief Psychiatric Rating Scale total score at 12-month follow-up. This indicates that increasingly higher endorsement of the factor was associated with more psychological symptoms. There was also a negative correlation between the change over time in the Stimulation/Activation factor and global functioning at 12 months, indicating that increasingly higher endorsement of the factor led to lower global assessment of functioning.

CONCLUSIONS

The Stimulation/Activation factor may be particularly important to assess and address among smokers with psychosis. It is recommended that further research use the Reasons for Smoking Questionnaire among smokers with psychosis as a clinical tool to identify specific quit barriers. Further research into why females have higher smoking cessation rates in the short term and relapse prevention interventions seem worthy of further investigation.

A qualitative analysis of low income smokers' responses to tobacco excise tax increases

BACKGROUND

While increasing the excise tax applied to tobacco products reduces consumption and smoking prevalence, it may also cause hardship among smokers who do not quit. We explored how smokers living on a low income respond to increasing tobacco excise taxes.

METHODS

Using a social justice perspective, we explored the increasing costs of tobacco with a sample of 27 adult smokers who live below the poverty line (i.e., with an income less than 60% of the median New Zealand income). Face-to-face interviews were conducted in Dunedin, New Zealand, a city with marked income differences, and were undertaken shortly after a further tobacco excise tax increase. The interview guide explored participants' smoking practices, their perceptions of excise tax as a strategy to reduce smoking prevalence, and the strategies they used to manage their tobacco needs.

RESULTS

We identified three key themes: depriving the poor; tobacco as a precious commodity, and desperation. While many participants described smoking as a pleasure or coping mechanism, they also saw it as a burden that they struggled to manage. Despite trying to quit, most had failed to become smokefree and felt victimised by a punitive policy system that coerced change without supporting it. They managed financial pressure by reducing their tobacco consumption but also used increasingly desperate measures, including recycling waste tobacco; participants reported feeling demeaned by measures they saw as their only option.

CONCLUSION

Providing intensive cessation support for lower income smokers could avoid further alienating a group already experiencing considerable disadvantage.

Update on Performance in Tobacco Control: A Longitudinal Analysis of the Impact of Tobacco Control Policy and the US Adult Smoking Rate, 2011-2013

CONTEXT

Tobacco use remains the leading cause of preventable death in the United States. States and municipalities have instituted a variety of tobacco control measures (TCMs) to address the significant impact tobacco use has on population health. The American Lung Association annually grades state performance of tobacco control using the State of Tobacco Control grading framework.

OBJECTIVE

To gain an updated understanding of how recent efforts in tobacco control have impacted tobacco use across the United States, using yearly State of Tobacco Control TCM assessments.

DESIGN

The independent TCM variables of smoke-free air score, cessation score, excise tax, and percentage of recommended funding were selected from the American Lung Association State of Tobacco Control reports. Predictors of adult smoking rates were determined by a mixed-effects model.

SETTING/PARTICIPANTS

The 50 US states and District of Columbia.

MAIN OUTCOME MEASURE

Adult smoking rate in each state from 2011 to 2013.

RESULTS

The average adult smoking rate decreased significantly from 2011 to 2013 (21.3% [SD: 3.5] to 19.3% [SD: 3.5], P = .016). All forms of TCMs varied widely in implementation levels across states. Excise taxes (β = -.812, P = .006) and smoke-free air regulations (β = -.057, P = .008) were significant, negative predictors of adult smoking. Cessation services (β = .015, P = .46) did not have a measurable effect on adult smoking.

CONCLUSION

Tobacco control measures with the strongest influence on adult smoking include the state excise tax and state smoke-free air regulations. The lack of robust funding for tobacco cessation services across the majority of US states highlights an important shortfall in current tobacco control policy.

Assessing contraband tobacco in two jurisdictions: a direct collection of cigarette butts

Background

The sale of contraband tobacco allows for tobacco tax evasion, which can undermine the effectiveness of tobacco tax policies in reducing the number of smokers. Estimates of the proportion of contraband vary widely as do the methods used to measure the proportion of contraband being smoked. The purpose of this study is to determine the proportion of contraband use in two different jurisdictions.

Methods

A cross-sectional direct collection of cigarette butts was conducted in Peel and Brantford, Ontario, Canada in 2013 and 2014, respectively. Cigarette butts were collected from a variety of locations within both regions. Cigarette butts were assessed and classified into one of the following categories: contraband, legal Canadian, legal Native, International, unknown, and discards.

Results

The overall proportion of contraband cigarettes in Peel was 5.3 %, ranging from 2.8 to 8.6 % by location. In Brantford, the proportion of contraband was 33.0 %, with a range from 32.8 to 33.1 % by location.

Conclusions

The direct collection of cigarette butts was determined to be a feasible method for a local public health unit in determining the proportion of contraband cigarettes. This approach showed that Brantford has a higher proportion of contraband consumption compared to Peel, which may be due to geographic location and proximity to the United States (US)-Canada border and Native Reserves. More research is needed to confirm this geographic association with other jurisdictions.

The impact of an increase in excise tax on the retail price of tobacco in New Zealand

BACKGROUND

In 2010, the New Zealand (NZ) government introduced an annual 10% tobacco excise tax increase. We examined retailers' adherence to recommended retail prices (RRP), and whether the RRP included the full tax increase.

METHODS

We collected price data on three British American Tobacco (BAT) factory-made cigarette brands, (premium, mainstream, and budget), and one roll-your-own tobacco brand before and after the 2014 tax increase from a sample of tobacco retailers. We examined price increases in each tobacco brand and compared these with the RRP. The extent to which the excise tax increases had been included in the RRP since 2010 was estimated using data sourced from the Ministry of Health and NZ Customs.

FINDINGS

The median increase in price from before to after the tax change was only 3% for the budget brand (461 retailers). This contrasted with the median of 8% for the premium brand (448 retailers), and 11% for both mainstream and roll-your-own brands (471 and 464 retailers, respectively). While many retail outlets made changes according to the RRP set by BAT, several did not comply. Our analyses suggest BAT may be undershifting excise tax on the budget brand, and overshifting tax on brands in other price partitions.

CONCLUSIONS

Tobacco companies do not appear to be increasing the RRPs of budget brands in line with tobacco excise tax increases. The increasing price differential between budget brands, and mainstream and premium brands may undermine cessation and impede realisation of New Zealand's Smokefree 2025 goal.

Price-Minimizing Behaviors in a Cohort of Smokers before and after a Cigarette Tax Increase

Cigarette tax increases result in a reduced demand for cigarettes and increased efforts by smokers to reduce their cost of smoking. Less is known about how smokers think about their expenditures for cigarettes and the possible mechanisms that underlie price-minimizing behaviors. In-depth longitudinal interviews were conducted with Minnesota smokers to explore the factors that influence smokers’ decisions one month prior to a $1.75 cigarette tax increase and again one and three months after the increase. A total of 42 were sampled with 35 completed interviews at all three time points, resulting in 106 interviews across all participants at all time points. A qualitative descriptive approach examined smoking and buying habits, as well as reasons behind these decisions. A hierarchy of ways to save money on cigarettes included saving the most money by changing to roll your own pipe tobacco, changing to a cheaper brand, cutting down or quitting, changing to cigarillos, and buying online. Using coupons, shopping around, buying by the carton, changing the style of cigarette, and stocking up prior to the tax increase were described as less effective. Five factors emerged as impacting smokers’ efforts to save money on cigarettes after the tax: brand loyalty, frugality, addiction, stress, and acclimation.

Changes in Cigarette Smoking Behavior Among US Young Workers From 2005 to 2010: The Role of Occupation

INTRODUCTION

Young adult workers (18-24 years) in the United States have been identified as a high-risk group for smoking. This study compares changes in smoking behavior by occupational class among this group between 2005 and 2010.

METHODS

Data were pooled from the Tobacco Supplement in the 2005 and 2010 National Health Interview Survey. All respondents 18-24 years who reported that they were employed during the two surveys were selected (n = 1880 in 2005; and n = 1531 in 2010). Weighted percentages and 95% confidence interval were reported. Logistic regression analyses were performed to compare smoking behavior between occupational groups (white-collar, blue-collar, and service) and between years (2005-2010), and to examine correlates of smoking, successful quit attempt, and heavy smoking.

RESULTS

Smoking prevalence and daily smoking declined in 2010 in white-collar. Smoking prevalence and intensity decreased while age of smoking initiation increased in blue-collar workers. Young workers were more likely to smoke in 2005 than 2010. Service and blue-collar workers were more likely to smoke than white-collar workers. Older young adults, whites, individuals with a high school/or less education, those without health insurance were more likely to smoke. White workers and individuals with a high school/or less education were more likely to be heavy smokers.

CONCLUSIONS

White-collar workers have benefited the most from tobacco control efforts. Although improvements were seen in smoking behavior among blue-collar workers, smoking prevalence remained the highest in this group. Smoking behavior among service workers did not change. Young service workers and blue-collar are priority populations for workplace tobacco control efforts.

IMPLICATIONS

The current study examines changes in smoking behavior among young adult workers (18-24 years) by occupational class (white-collar, blue-collar, and service workers) between 2005 and 2010. Data were pooled from the Tobacco Supplement in the 2005 and 2010 National Health Interview Survey. Smoking prevalence and daily smoking declined significantly in white-collar workers. No change in smoking behavior was observed among service workers. Positive changes in smoking behavior were observed among blue-collar workers, but smoking prevalence remained the highest in this group. Blue-collar and service workers are priority groups for future workplace tobacco control efforts.

Tanning bed use and melanoma: Establishing risk and improving prevention interventions

PURPOSE

Exposure to ultraviolet radiation (UVR) from indoor tanning devices is thought to cause melanoma and other negative health consequences. Despite these findings, the practice of indoor tanning in the United States remains prevalent. In this paper we aim to present a clear discussion of the relationship between indoor tanning and melanoma risk, and to identify potential strategies for effective melanoma prevention by addressing indoor tanning device use.

BASIC PROCEDURES

We reviewed relevant literature on the risks of indoor tanning, current indoor tanning legislation, and trends in indoor tanning and melanoma incidence. Study was conducted at the University of Southern California, Los Angeles, CA between the years of 2014 and 2015.

MAIN FINDINGS

Our findings reaffirm the relationship between indoor tanning and melanoma risk, and suggest a widespread public misunderstanding of the negative effects of indoor tanning.

PRINCIPAL CONCLUSIONS

This review argues for an aggressive initiative to reduce indoor tanning in the United States, to design prevention efforts tailored towards specific high risk groups, and the need to better inform the public of the risks of indoor tanning.

Relationship between e-cigarette point of sale recall and e-cigarette use in secondary school children: a cross-sectional study

BACKGROUND

There has been a rapid increase in the retail availability of e-cigarettes in the UK and elsewhere. It is known that exposure to cigarette point-of-sale (POS) displays influences smoking behaviour and intentions in young people. However, there is as yet no evidence regarding the relationship between e-cigarette POS display exposure and e-cigarette use in young people.

METHODS

This cross sectional survey was conducted in four high schools in Scotland. A response rate of 87 % and a total sample of 3808 was achieved. Analysis was by logistic regression on e-cigarette outcomes with standard errors adjusted for clustering within schools. The logistic regression models were adjusted for recall of other e-cigarette adverts, smoking status, and demographic variables. Multiple chained imputation was employed to assess the consistency of the findings across different methods of handling missing data.

RESULTS

Adolescents who recalled seeing e-cigarettes in small shops were more likely to have tried an e-cigarette (OR 1.92 99 % CI 1.61 to 2.29). Adolescents who recalled seeing e-cigarettes for sale in small shops (OR 1.80 99 % CI 1.08 to 2.99) or supermarkets (OR 1.70 99 % CI 1.22 to 2.36) were more likely to intend to try them in the next 6 months.

CONCLUSIONS

This study has found a cross-sectional association between self-reported recall of e-cigarette POS displays and use of, and intention to use, e-cigarettes. The magnitude of this association is comparable to that between tobacco point of sale recall and intention to use traditional cigarettes in the same sample. Further longitudinal data is required to confirm a causal relationship between e-cigarette point of sale exposure and their use and future use by young people.

Prevention, early intervention, harm reduction, and treatment of substance use in young people

We did a systematic review of reviews with evidence on the effectiveness of prevention, early intervention, harm reduction, and treatment of problem use in young people for tobacco, alcohol, and illicit drugs (eg, cannabis, opioids, amphetamines, or cocaine). Taxation, public consumption bans, advertising restrictions, and minimum legal age are effective measures to reduce alcohol and tobacco use, but are not available to target illicit drugs. Interpretation of the available evidence for school-based prevention is affected by methodological issues; interventions that incorporate skills training are more likely to be effective than information provision-which is ineffective. Social norms and brief interventions to reduce substance use in young people do not have strong evidence of effectiveness. Roadside drug testing and interventions to reduce injection-related harms have a moderate-to-large effect, but additional research with young people is needed. Scarce availability of research on interventions for problematic substance use in young people indicates the need to test interventions that are effective with adults in young people. Existing evidence is from high-income countries, with uncertain applicability in other countries and cultures and in subpopulations differing in sex, age, and risk status. Concerted efforts are needed to increase the evidence base on interventions that aim to reduce the high burden of substance use in young people.

Country-level correlates of e-cigarette use in the European Union

OBJECTIVES

The aim of this study was to assess the relationship between the prevalence of e-cigarette use and country-level factors across 28 European countries.

METHODS

The study objectives were addressed in an ecological design in which both exposures and outcomes were measured at the country level. Data from the Eurobarometer Report, the Eurostat database and the WHO observatory were analyzed. Bivariate and multivariate analyses were performed considering the rates of current and ever smokers of e-cigarettes as dependent variables, and socio-economic factors, health status and policies against tobacco as independent variables.

RESULTS

Both the rate of current smokers and ever smokers of e-cigarette were positively associated to the offer of help to quit tobacco use (P < 0.01; P = 0.04) and to the raise of taxes on tobacco (P = 0.01; P = 0.01). The warn on dangers of tobacco negatively correlated with the rate of e-cigarette current smokers. The rate of current e-cigarette smokers correlated with the rate of current smokers and with national Gross Domestic Product, while the rate of ever e-cigarette smokers did not correlate with any socio-economic factor.

CONCLUSIONS

Our analysis suggests that both policy and non-policy factors are associated with the geographical variability seen in the prevalence of e-cigarette use. Policies against the consumption of conventional tobacco products may lead to an increase of e-cigarette smokers.

Impact of Canadian tobacco packaging policy on use of a toll-free quit-smoking line: an interrupted time-series analysis

BACKGROUND

A policy for new pictorial health warning labels on tobacco packaging was introduced by Health Canada in 2012. The labels included, for the first time, a prominently displayed toll-free number for a quit-smoking line. We used data from the Ontario provincial quitline to investigate the call volume and number of new callers receiving treatment in the months before and after the new policy was introduced.

METHODS

We used an interrupted time-series analysis to examine trends in the overall call volume and number of new callers receiving treatment (≥ 1 telephone counselling session) through Ontario's quitline (Smokers' Helpline) between January 2010 and December 2013. We analyzed data using Box-Jenkins autoregressive integrated moving-average models; we adjusted the models for a major campaign promoting the quitline, a seasonality (January) effect and tobacco pricing.

RESULTS

We found a relative increase of 160% in the average monthly call volume during the 7 months after the introduction of the new labels (870 calls per month at baseline and 1391 additional calls per month on average after the policy change; standard error [SE] 108.94, p < 0.001), and a sustained increase of 43% in subsequent months. We observed a relative increase of 174% in the number of new callers receiving treatment (153 new callers per month at baseline and 267 additional new callers per month after the policy change; SE 40.03, p < 0.001) and a sustained increase of 80% in subsequent months. The effect was significant even after controlling for a major promotion campaign and the January effect.

INTERPRETATION

We found a significant increase in the monthly overall call volume and number of new callers receiving treatment per month after the introduction of the new tobacco health warning labels, with a sustained increase in overall calls and new callers beyond the first 7 months. Our findings add to the body of evidence on the benefit of including a toll-free quitline number on tobacco packaging.

Cigarette smokers' classification of tobacco products

INTRODUCTION

Cigarette consumption has declined in the USA. However, cigar consumption has increased. This may be due in part to some cigarette smokers switching to filtered cigars as a less expensive substitute for cigarettes. Additionally, some cigarette smokers may perceive and consume little filtered cigars as cigarettes. The purpose of this study was to determine how cigarette smokers classify tobacco products when presented with photographs of those products.

METHODS

An online survey was conducted with a sample of 344 self-identified cigarette smokers. Respondents were presented with pictures of various types of tobacco products, both with and without packaging, and then asked to categorise them as either a cigarette, little cigar, cigarillo, cigar or machine-injected roll-your-own cigarette (RYO). Respondents were also asked about their tobacco use and purchasing behaviour.

RESULTS

Overall, respondents had difficulty distinguishing between cigarettes, little cigars, cigarillos and RYO. When presented with images of the products without packaging, 93% of respondents identified RYO as a cigarette, while 42% identified a little cigar as a cigarette. Additionally, respondents stated that they would consider purchasing little cigars as substitutes for cigarettes because of the price advantage.

CONCLUSIONS

The results of this survey suggest that when presented with photographs of tobacco products, large proportions of current smokers were unable to differentiate between cigarettes, little cigars, cigarillos, RYO and cigars. Findings have implications for existing public health efforts targeting cigarette smokers, and underscore the need to review current definitions of tobacco products and federal excise taxes on such products.

Do consumers substitute opium for hashish? An economic analysis of simultaneous cannabinoid and opiate consumption in a legal regime

AIM

To analyze interrelationships in the consumption of opiates and cannabinoids in a legal regime and, specifically, whether consumers of opiates and cannabinoids treat them as substitutes for each other.

METHOD

Econometric dynamic panel data models for opium consumption are estimated using the generalized method of moments (GMM). A unique dataset containing information about opiate (opium) consumption from the Punjab province of British India for the years 1907-1918 is analyzed (n=252) as a function of its own price, the prices of two forms of cannabis (the leaf (bhang), and the resin (charas, or hashish)), and wage income. Cross-price elasticities are examined to reveal substitution or complementarity between opium and cannabis.

RESULTS

Opium is a substitute for charas (or hashish), with a cross price elasticity (βˆ3) of 0.14 (p<0.05), but not for bhang (cannabis leaves; cross price elasticity=0.00, p>0.10). Opium consumption (βˆ1=0.47 to 0.49, p<0.01) shows properties of habit persistence consistent with addiction. The consumption of opium is slightly responsive (inelastic) to changes in its own price (βˆ2=-0.34 to -0.35, p<0.05 to 0.01) and consumer wages (βˆ1=0.15, p<0.05).

CONCLUSION

Opium and hashish, a form of cannabis, are substitutes. In addition, opium consumption displays properties of habit persistence and slight price and wage income responsiveness (inelasticity) consistent with an addictive substance.

Implications of Risk Factors for Alzheimer's Disease in Canada's Indigenous Population

Background

Indigenous peoples in Canada have higher prevalence of modifiable risk factors for Alzheimer’s disease (AD). The relative importance of these risk factors on AD risk management is poorly understood.

Methods

Relative risks from literature and prevalence of risk factors from Statistics Canada or the First Nations Regional Health Survey were used to determine projected population attributable risk (PAR) associated with modifiable risk factors for AD (low education and vascular risk factors) among on- and off-reserve Indigenous and non-Indigenous people in Canada using the Levin formula.

Results

Physical inactivity had the highest PAR for AD among Indigenous and non-Indigenous peoples in Canada (32.5% [10.1%–51.1%] and 30.5% [9.2%–48.8%] respectively). The PAR for most modifiable risk factors was higher among Indigenous peoples in Canada, particularly among on-reserve groups. The greatest differences in PAR were for low educational attainment and smoking, which were approximately 10% higher among Indigenous peoples in Canada. The combined PAR for AD for all six modifiable risk factors was 79.6% among on-reserve Indigenous, 74.9% among off-reserve Indigenous, and 67.1% among non-Indigenous peoples in Canada. (All differences significant to p < .001.)

Conclusions

Modifiable risk factors are responsible for the most AD cases among Indigenous peoples in Canada. Further research is necessary to determine the prevalence of AD and the impact of risk factor modification among Indigenous peoples in Canada.

Overview of systematic reviews on the health-related effects of government tobacco control policies

BACKGROUND

Government interventions are critical to addressing the global tobacco epidemic, a major public health problem that continues to deepen. We systematically synthesize research evidence on the effectiveness of government tobacco control policies promoted by the Framework Convention on Tobacco Control (FCTC), supporting the implementation of this international treaty on the tenth anniversary of it entering into force.

METHODS

An overview of systematic reviews was prepared through systematic searches of five electronic databases, published up to March 2014. Additional reviews were retrieved from monthly updates until August 2014, consultations with tobacco control experts and a targeted search for reviews on mass media interventions. Reviews were assessed according to predefined inclusion criteria, and ratings of methodological quality were either extracted from source databases or independently scored.

RESULTS

Of 612 reviews retrieved, 45 reviews met the inclusion criteria and 14 more were identified from monthly updates, expert consultations and a targeted search, resulting in 59 included reviews summarizing over 1150 primary studies. The 38 strong and moderate quality reviews published since 2000 were prioritized in the qualitative synthesis. Protecting people from tobacco smoke was the most strongly supported government intervention, with smoke-free policies associated with decreased smoking behaviour, secondhand smoke exposure and adverse health outcomes. Raising taxes on tobacco products also consistently demonstrated reductions in smoking behaviour. Tobacco product packaging interventions and anti-tobacco mass media campaigns may decrease smoking behaviour, with the latter likely an important part of larger multicomponent programs. Financial interventions for smoking cessation are most effective when targeted at smokers to reduce the cost of cessation products, but incentivizing quitting may be effective as well. Although the findings for bans on tobacco advertising were inconclusive, other evidence suggests they remain an important intervention.

CONCLUSION

When designing and implementing tobacco control programs, governments should prioritize smoking bans and price increases of tobacco products followed by other interventions. Additional studies are needed on the various factors that can influence a policy's effectiveness and feasibility such as cost, local context, political barriers and implementation strategies.

The global burden of ischemic stroke: findings of the GBD 2010 study

This study sought to summarize the findings of the GBD 2010 (Global Burden of Diseases, Injuries, and Risk Factors) study for ischemic stroke (IS) and to report the impact of tobacco smoking on IS burden in specific countries. The GBD 2010 searched multiple databases to identify relevant studies published between 1990 and 2010. The GBD 2010 analytical tools were used to calculate region-specific IS incidence, mortality, mortality-to-incidence ratio, and disability-adjusted life years (DALY) lost, including 95% uncertainty intervals (UI). In 2010, there were approximately 11,569,000 incident IS events (63% in low- and middle-income countries [LMIC]), approximately 2,835,000 deaths from IS (57% in LMIC), and approximately 39,389,000 DALY lost due to IS (64% in LMIC). From 1990 to 2010, there was a significant increase in global IS burden in terms of absolute number of people with incident IS (37% increase), deaths from IS (21% increase), and DALY lost due to IS (18% increase). Age-standardized IS incidence, DALY lost, mortality, and mortality-to-incidence ratios in high-income countries declined by about 13% (95% UI: 6% to 18%), 34% (95% UI: 16% to 36%), and 37% (95% UI: 19% to 39%), 21% (95% UI: 10% to 27%), respectively. However, in LMIC there was a modest 6% increase in the age-standardized incidence of IS (95% UI: -7% to 18%) despite modest reductions in mortality rates, DALY lost, and mortality-to-incidence ratios. There was considerable variability among country-specific estimates within broad GBD regions. China, Russia, and India were ranked highest in both 1990 and 2010 for IS deaths attributable to tobacco consumption. Although age-standardized IS mortality rates have declined over the last 2 decades, the absolute global burden of IS is increasing, with the bulk of DALY lost in LMIC. Tobacco consumption is an important modifiable risk factor for IS, and in both 1990 and 2010, the top ranked countries for IS deaths that could be attributed to tobacco consumption were China, Russia, and India. Tobacco control policies that target both smoking initiation and smoking cessation can play an important role in the prevention of IS. In China, Russia, and India, even modest reductions in the number of current smokers could see millions of lives saved due to prevention of IS alone.

Behavioral Economics of Cigarette Purchase Tasks: Within-Subject Comparison of Real, Potentially Real, and Hypothetical Cigarettes

INTRODUCTION

Hypothetical rewards are commonly used in studies of laboratory-based tobacco demand. However, behavioral economic demand procedures require confirmation that the behavior elicited from real and hypothetical reward types are equivalent, and that results attained from these procedures are comparable to other accepted tasks, such as the hypothetical purchase task.

METHODS

Nineteen smokers were asked to purchase 1 week's worth of cigarettes that they would consume over the following week either at one price that incrementally increased across four weekly sessions ("real" sessions) or four prices in a single session ("potentially real" session), one of which was randomly chosen to be actualized. At each session, participants also completed a hypothetical cigarette purchase task. After each week, participants reported the number of cigarettes they actually smoked.

RESULTS

Demand was found to be equivalent under both the real and potentially real reward conditions but statistically different from the demand captured in the hypothetical purchase task. However, the amounts purchased at specific prices in the hypothetical purchase task were significantly correlated with the amount purchased at comparable prices in the other two tasks (except for the highest price examined in both tasks of $1.00 per cigarette). Number of cigarettes consumed that were obtained outside of the study was correlated with study cigarette price.

CONCLUSIONS

Combined, these results suggest that purchasing behavior during potentially real sessions (1) was not functionally different from real sessions, (2) imposes fewer costs to the experimenter, and (3) has high levels of both internal and external validity.

Stages of change of the readiness to quit smoking among a random sample of minority Arab male smokers in Israel

BACKGROUND

Despite advanced smoking prevention and cessation policies in many countries, the prevalence of cigarette smoking among indigenous and some ethnic minorities continues to be high. This study examined the stages of change (SOC) of the readiness to quit smoking among Arab men in Israel shortly after new regulations of free-of-charge smoking cessation workshops and subsidized medications were introduced through primary health care clinics.

METHODS

We conducted a countrywide study in Israel between 2012-2013. Participants, 735 current smokers; 18-64 years old; were recruited from a stratified random sample and interviewed face-to-face using a structured questionnaire in Arabic. We used ordered regression to examine the contribution of socio-economic position (SEP), health status, psychosocial attributes, smoking-related factors, and physician advice to the SOC of the readiness to quit smoking (pre-contemplation, contemplation and preparation).

RESULTS

Of the current smokers, 61.8% were at the pre-contemplation stage, 23.8% were at the contemplation stage, and only 14.4% were at the preparation stage. In the multinomial analysis, factors significantly (P < 0.05) contributing to contemplation stage compared to pre-contemplation stage included [odds ratio (OR), 95% confidence interval (CI)]: chronic morbidity [0.52, (0.31-0.88)], social support [1.35, (1.07-1.70)], duration of smoking for 11-21 years [1.94, (1.07-3.50)], three or more previous attempts to quit [2.27, (1.26-4.01)], knowledge about smoking hazards [1.75, (1.29-2.35)], positive attitudes toward smoking prevention [1.44, (1.14-1.82)], and physician advice to quit smoking [1.88, (1.19-2.97)]. The factors significantly (P < 0.05) contributing to preparation stage compared to pre-contemplation stage were [OR, (95 % CI)]: chronic morbidity [0.36, (0.20-0.67)], anxiety [1.07, (1.01-1.13)], social support [1.34, (1.01-1.78)], duration of smoking 5 years or less [2.93, (1.14-7.52)], three or more previous attempts to quit [3.16, (1.60-6.26)], knowledge about smoking hazards [1.57, (1.10-2.21)], and positive attitudes toward smoking prevention [1.34, (1.00-1.82)].

CONCLUSIONS

Most Arab men who currently smoke are in the pre-contemplation stage, indicating low readiness to quit smoking. New policies of free-of-charge smoking-cessation group sessions and subsidized medications introduced through primary health care clinics in Israel may be less effective among Arab men. For these policies to promote cessation more successfully, tailored interventions and campaigns may be needed to increase the readiness to quit smoking in this population, especially for those at the pre-contemplation stage.

Lifestyle Correlates of Female Snus Use and Smoking: A Large Population-Based Survey of Women in Norway

INTRODUCTION

While smoking in Norway has become less prevalent, snus use has increased, including among women. The aims of this study were to describe female snus use and its correlates, and to contrast patterns of snus use and smoking.

METHODS

In 2011-2012, data on tobacco use, age, education, alcohol consumption, sexual behaviors, and physical activity were collected from a population based sample of 13 756 Norwegian women aged 18-45 years, using a self-administered questionnaire.

RESULTS

Ever-use prevalence of snus ranged from 29.6% to 4.5% among those aged 18-19 years and 40-45 years, respectively. In contrast, the corresponding figures for smoking were 24.1% and 44.1%. Among snus users, 54.1% and 22.8% of 18-19 and 40 to 45-year-olds had never smoked, respectively. Debut age for snus use increased markedly with age, and was higher than debut age for smoking. Female snus use was positively associated with intermediate education, alcohol consumption, number of sexual partners, and hard physical activity. Smoking was also positively associated with alcohol consumption and number of sexual partners, but negatively associated with physical activity and education.

CONCLUSION

While most snus users among older women were former or current smokers, this was not the case among younger women. Low snus debut age and extensive snus use among younger women suggest that measures to reduce snus use should be targeted at young adolescents. The correlates of female snus use and smoking were not identical, and were similar to those previously documented for men.

Synthesizing Econometric Evidence: The Case of Demand Elasticity Estimates

Econometric estimates of the responsiveness of health-related consumer demand to higher prices are often key ingredients for risk policy analysis. We review the potential advantages and challenges of synthesizing econometric evidence on the price-responsiveness of consumer demand. We draw on examples of research on consumer demand for health-related goods, especially cigarettes. We argue that the overarching goal of research synthesis in this context is to provide policy-relevant evidence for broad-brush conclusions. We propose three main criteria to select among research synthesis methods. We discuss how in principle and in current practice synthesis of research on the price-elasticity of smoking meets our proposed criteria. Our analysis of current practice also contributes to academic research on the specific policy question of the effectiveness of higher cigarette prices to reduce smoking. Although we point out challenges and limitations, we believe more work on research synthesis in this area will be productive and important.

The relation between tobacco taxes and youth and young adult smoking: what happened following the 2009 U.S. federal tax increase on cigarettes?

BACKGROUND

On April 1, 2009, the federal government raised cigarette taxes from $0.39 to $1.01 per pack. This study examines the impact of this increase on a range of smoking behaviors among youth aged 12 to 17 and young adults aged 18 to 25.

METHODS

Data from the 2002-2011 National Survey on Drug Use and Health (NSDUH) were used to estimate the impact of the tax increase on five smoking outcomes: (1) past year smoking initiation, (2) past-month smoking, (3) past year smoking cessation, (4) number of days cigarettes were smoked during the past month, and (5) average number of cigarettes smoked per day. Each model included individual and state-level covariates and other tobacco control policies that coincided with the tax increase. We examined the impact overall and by race and gender.

RESULTS

The odds of smoking initiation decreased for youth after the tax increase (odds ratio (OR)=0.83, p<0.0001). The odds of past-month smoking also decreased (youth: OR=0.83, p<0.0001; young adults: OR=0.92, p<0.0001), but the odds of smoking cessation remained unchanged. Current smokers smoked on fewer days (youth: coefficient=-0.97, p=0.0001; young adults: coefficient=-0.84, p<0.0001) and smoked fewer cigarettes per day after the tax increase (youth: coefficient=-1.02, p=0.0011; young adults: coefficient=-0.92, p<0.0001).

CONCLUSIONS

The 2009 federal cigarette tax increase was associated with a substantial reduction in smoking among youths and young adults. The impact of the tax increase varied across male, female, white and black subpopulations.

The impact of prices and taxes on the use of tobacco products in Latin America and the Caribbean

We examined the impact of tobacco prices or taxes on tobacco use in Latin America and Caribbean countries. We searched MEDLINE, EconLit, LILACS, unpublished literature, 6 specialty journals, and reviewed references. We calculated pooled price elasticities using random-effects models. The 32 studies we examined found that cigarette prices have a negative and statistically significant effect on cigarette consumption. A change in price is associated with a less than proportional change in the quantity of cigarettes demanded. In most Latin American countries, own-price elasticity for cigarettes is likely below  -0.5  (pooled elasticities, short-run: -0.31; 95% confidence interval=-0.39, -0.24; long-run: -0.43; 95% CI=-0.51, -0.35). Tax increases effectively reduce cigarette use. Lack of studies using household- or individual-level data limits research's policy relevance.

A Cross Sectional Study of Kretek Smoking in Indonesia as a Major Risk to Public Health

BACKGROUND

Tobacco smoking is a major cause of preventable disease and death worldwide. Kreteks are clove-flavored cigarettes made from a combination of tobacco and ground-clove mixed with a sauce, smoked widely in Indonesia. Because health and social consequences of kretek smoking are potentially as great as those of traditional cigarettes, this study examines the prevalence of kretek smoking in Indonesia and associated risk factors.

MATERIALS AND METHODS

The study used nationally representative Indonesia Global Adult Tobacco Survey data. Multiple logistic regression analysis was employed to identify correlates of kretek smoking.

RESULTS

One- third of Indonesian adults smoked tobacco of which about 90.0% smoked kreteks. Prevalence of kretek smoking among men (60.9%) was more than 25 times the rate among women (2.3%). Overall, the highest prevalence of kretek use was in the age group 45-54 years (36.5%), followed by 34-44 (35.1%), 25-34 (34.2 %), and 55-64 years (32.8%). By wealth index, prevalence of kreteks smoking among those in the middle index was almost 50% above the rate for the wealthiest group (36.4% vs 24.8% respectively). Logistic regression results showed that being male, being older, having less education, and being less wealthy were significant predictors of kretek smoking, while urban vs rural residence was not.

CONCLUSIONS

Kretek smoking is common in Indonesia and is entrenched in the sociocultural fabric of the country. However, potential consequences of kretek smoking, particularly as risks for noncommunicable diseases, underscore the importance of a comprehensive approach to tobacco control as outlined in the World Health Organization's MPOWER strategies.

Brand switching or reduced consumption? A study of how cigarette taxes affect tobacco consumption

We examined the influence of cigarette taxes on tobacco consumption, with an emphasis on smokers' choice between reducing cigarette consumption and switching brands. We constructed three scenario-based models to study the following two subjects: (1) the relationship between deciding whether to reduce one's cigarette consumption and to practice brand switching (simultaneous or sequential); (2) the key determinants that affect smokers' decisions in terms of their consumption and brand switching when facing higher taxes. We applied data collected from a survey in Taiwan, and the results indicated that both independent and two-stage decision-making models generated very similar conclusions. We also found that gender difference contributed to reduce cigarette consumption. In addition, this study indicated that high-income smokers were less likely to switch brands, whereas well-educated smokers were more likely to switch brands. Most importantly, we questioned the effectiveness of cigarette tax policy, as our results suggested that higher price did not necessarily reduce consumption. Indeed, data indicated that <24 % of smokers actually reduced their cigarette consumption after the tax on cigarettes increased.

A framework for evaluating the impact of obesity prevention strategies on socioeconomic inequalities in weight

We developed a theoretical framework to organize obesity prevention interventions by their likely impact on the socioeconomic gradient of weight. The degree to which an intervention involves individual agency versus structural change influences socioeconomic inequalities in weight. Agentic interventions, such as standalone social marketing, increase socioeconomic inequalities. Structural interventions, such as food procurement policies and restrictions on unhealthy foods in schools, show equal or greater benefit for lower socioeconomic groups. Many obesity prevention interventions belong to the agento-structural types of interventions, and account for the environment in which health behaviors occur, but they require a level of individual agency for behavioral change, including workplace design to encourage exercise and fiscal regulation of unhealthy foods or beverages. Obesity prevention interventions differ in their effectiveness across socioeconomic groups. Limiting further increases in socioeconomic inequalities in obesity requires implementation of structural interventions. Further empirical evaluation, especially of agento-structural type interventions, remains crucial.

Effects of state cigarette excise taxes and smoke-free air policies on state per capita alcohol consumption in the United States, 1980 to 2009

BACKGROUND

Increasing state cigarette excise taxes and strengthening smoke-free air (SFA) laws are known to reduce smoking prevalence. Some studies suggest that such policies may also reduce alcohol use, but results for cigarette taxes have been mixed, and associations with smoke-free air policies have been limited to some demographic subgroups. To shed further light on the potential secondary effects of tobacco control policy, we examined whether increases in cigarette taxes and strengthening of SFA laws were associated with reductions of per capita alcohol consumption and whether any reductions were specific to certain beverage types.

METHODS

State per capita alcohol consumption from 1980 to 2009 was modeled as a function of state price per pack of cigarettes and SFA policy scores while controlling for secular trends and salient state covariates. Both policy measures also accounted for local policies. Total alcohol, beer, wine, and spirits consumption per capita were modeled separately. For each type of beverage, we used a nested models approach to determine whether the 2 policies together were associated with reduced consumption.

RESULTS

For total alcohol consumption, and for beer or spirits (but not wine), one or both tobacco policies were associated with reductions in consumption. A 1% increase in cigarette price per pack was associated with a 0.083% decrease in per capita total alcohol consumption (95% confidence interval [CI] 0.0002 to 0.166, p = 0.0495), and a 1-point increase in SFA policy score, measured on a 6-point scale, was associated with a 1.1% decrease in per capita total alcohol consumption (95% CI 0.4 to 1.7, p = 0.001; p < 0.001 for the hypothesis that the 2 policies are jointly associated with reduced alcohol consumption).

CONCLUSIONS

The public health benefits of increasing cigarette taxes and smoke-free policies may go beyond the reduction of smoking and extend to alcohol consumption, specifically beer and spirits.

Conference report on tobacco taxes in Central America: current situation and opportunities to reduce prevalence and increase fiscal revenues

INTRODUCTION

As stated in Article 6 of Framework Convention on Tobacco Control (FCTC), increasing tobacco prices through higher taxes is one of the most effective interventions to reduce tobacco use and to encourage smokers to quit. The potential for tax increases on tobacco products in Central America is ample. We aim to synthesize the current tobacco taxes situation and highlight research needs to strengthen taxation.

BACKGROUND

In May 2012, a workshop was carried out with representatives from each Central American country to analyze the tobacco tax situation in each country and to identify key research gaps with experts in the field.

DISCUSSION

Tobacco taxes in Central America fall far short of the levels recommended by FCTC. Moreover, the legal framework is complex and creates barriers for higher taxes that require further research and political will. Top research priorities are an in-depth analysis of tobacco tax legislation, impact of tax and price policies, analysis of costs associated to health care of tobacco-related diseases and lost productivity, and the feasibility of approaches to increasing tobacco taxes in certain contexts. An additional area of research is the interrelationship between human rights and tobacco control.

CONCLUSION

Central American countries would benefit from increasing excise taxes on tobacco products. The lack of available data and research to counteract tobacco industry arguments are significant obstacles. Active leadership of civil society in support of the partnership of chronic disease interventions is vital in order to obtain tax increases on tobacco products.

Social norms in the development of adolescent substance use: a longitudinal analysis of the International Youth Development Study

Identifying specific aspects of peer social norms that influence adolescent substance use may assist international prevention efforts. This study examines two aggregated measures of social norms in the school setting and their predictive association with substance (alcohol, tobacco and marijuana) use 2 years later in a large cross-national population-based cohort of adolescents. The primary hypothesis is that in Grade 7 both "injunctive" school norms (where students associate substance use with "coolness") and "descriptive" norms (where student substance use is common) will predict Grade 9 substance use. Data come from the International Youth Development Study, including 2,248 students (51.2% female) in the US and Australia attending 121 schools in Grade 7. Independent variables included injunctive norms (aggregating measures of school-wide coolness ratings of each substance use) and descriptive norms (aggregating the prevalence of school substance use) in Grade 7. Dependent variables included binge drinking and current use of alcohol, tobacco and marijuana in Grade 9. Associations between each type of school-wide social norm and substance use behaviors in Grade 9 were tested using multilevel logistic regression, adjusting for covariates. In unadjusted models, both injunctive and descriptive norms each significantly predicted subsequent substance use. In fully adjusted models, injunctive norms were no longer significantly associated with Grade 9 use, but descriptive norms remained significantly associated with tobacco and marijuana use in the expected direction. The findings identify descriptive social norms in the school context as a particularly important area to address in adolescent substance use prevention efforts.