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

How do people who smoke perceive a tobacco retail outlet reduction policy in Aotearoa New Zealand? A qualitative analysis

BACKGROUND

Aotearoa New Zealand plans to greatly reduce tobacco retail outlets, which are concentrated in areas of higher deprivation and perpetuate health inequities caused by smoking and borne particularly by Māori. However, we lack in-depth analyses of how this measure could affect people who smoke.

METHODS

We undertook in-depth interviews with 24 adults from two urban areas who smoke. We used a novel interactive mapping approach to examine participants' current retail outlets and their views on a scenario where very few outlets would sell tobacco. To inform policy implementation, we probed participants' anticipated responses and explored the measure's wider implications, including unintended impacts. We used qualitative description to interpret the data.

RESULTS

Most participants anticipated accommodating the changes easily, by using alternative outlets or bulk-purchasing tobacco; however, they felt others would face access problems and increased costs, and greater stress. They thought the policy would spur quit attempts, reduce relapse among people who had quit and protect young people from smoking uptake, and expected more people to switch to alternative nicotine products. However, most foresaw unintended social outcomes, such as increased crime and reduced viability of local businesses.

CONCLUSIONS

Many participants hoped to become smoke-free and thought retail reduction measures would prompt quit attempts and reduce relapse. Adopting a holistic well-being perspective, such as those developed by Māori, could address concerns about unintended adverse outcomes and provide comprehensive support to people who smoke as they adjust to a fundamental change in tobacco availability.

Going 'Super Value' in New Zealand: cigarette pricing strategies during a period of sustained annual excise tax increases

BACKGROUND

Between 2010 and 2020, the New Zealand (NZ) Government increased tobacco excise tax by inflation plus 10% each year. We reviewed market structure changes and examined whether NZ tobacco companies shifted excise tax increases to maintain the affordability of lower priced cigarette brands.

METHODS

We cluster-analysed market data that tobacco companies supply to the NZ Ministry of Health, created four price partitions and examined the size and share of these over time. For each partition, we analysed cigarette brand numbers and market share, calculated the volume-weighted real stick price for each year and compared this price across different price partitions. We calculated the net real retail price (price before tax) for each price partition and compared these prices before and after plain packaging took effect.

RESULTS

The number and market share of Super Value and Budget brands increased, while those of Everyday and Premium brands decreased. Differences between the price of Premium and Super Value brands increased, as did the net retail price difference for these partitions. Following plain packaging's implementation, Super Value brand numbers more than doubled; contrary to industry predictions, the price difference between these and higher priced brands did not narrow.

CONCLUSIONS

Between 2010 and 2020, NZ tobacco companies introduced more Super Value cigarette brands and shifted excise tax increases to reduce the impact these had on low-priced brands. Setting a minimum retail price for cigarettes could curtail tobacco companies' ability to undermine tobacco taxation policies designed to reduce smoking.

Mapping alcohol and tobacco tax policy interventions to inform health and economic impact analyses: A United Kingdom based qualitative framework analysis

BACKGROUND

Alcohol and tobacco have different policy regimes and there is little understanding of how changes to policy on each commodity might combine to affect the same outcomes or to affect people who both drink and smoke. The aim of this study was to deepen understanding of the policy objectives of UK alcohol and tobacco tax options being considered at the time of the interviews with a set of UK policy participants in 2018, and the factors affecting the implementation and outcomes of the policy options discussed.

METHODS

Ten tax policy experts were recruited from government arms-length organisations and advocacy groups in England and Scotland (4 alcohol, 4 tobacco, 2 alcohol and tobacco). Alcohol and tobacco experts were interviewed together in pairs and asked to discuss alcohol and tobacco tax policy objectives, options, and the mechanisms of effect. Interviews were semi-structured, supported by a briefing document and topic guide, audio-recorded, transcribed and then analysed deductively using framework analysis.

RESULTS

Alcohol and tobacco tax policy share objectives of health improvement and there is a common set of policy options: increasing duty rates, duty escalators, multi-rate tax structures, industry levies and the hypothecation of tax revenue for investment in societal benefits. However, participants agreed that the harms caused by alcohol and tobacco and their industries are viewed differently, and that this influences the impacts that are prioritised in tax policymaking. Working-out how alcohol and tobacco taxes could work synergistically to reduce health inequalities was seen as desirable. Participants also highlighted the importance of avoiding the combined effects of price increases on alcohol and tobacco widening economic inequalities.

CONCLUSIONS

Impact analyses should consider the combined effects of alcohol and tobacco tax policies on health and economic inequalities, and how the effects of changes to the tax on each commodity might trade-off.

Examining attitudes toward a proposed sugar-sweetened beverage tax among urban Indigenous adults: a qualitative study using a decolonizing lens

BACKGROUND

Sugar-sweetened beverage taxation has been proposed as a public health policy to reduce consumption, and compared with other ethnic or racialized groups in Canada, off-reserve Indigenous populations consume sugar-sweetened beverages at higher frequencies and quantities. We sought to explore the acceptability and anticipated outcomes of a tax on sugar-sweetened beverages among Indigenous adults residing in an inner-city Canadian neighbourhood.

METHODS

Using a community-based participatory research approach, we conducted semistructured interviews (November 2019-August 2020) with urban Indigenous adults using purposive sampling. Interviews were audio-recorded, transcribed verbatim and analyzed using theoretical thematic analysis.

RESULTS

All 20 participants (10 female, 8 male and 2 two-spirit) consumed sugar-sweetened beverages on a regular, daily basis at the time of the interview or at some point in their lives. Most participants were opposed to and concerned about the prospect of sugar-sweetened beverage taxation owing to 3 interconnected themes: government is not trustworthy, taxes are ineffective and lead to inequitable outcomes, and Indigenous self-determination is critical. Participants discussed government's mismanagement of previous taxes and lack of prioritization of their community's specific needs. Most participants anticipated that Indigenous people in their community would continue to consume sugar-sweetened beverages, but that a tax would result in fewer resources for other necessities, including foods deemed healthy.

INTERPRETATION

Low support for the tax among urban Indigenous people is characterized by distrust regarding the tax, policy-makers and its perceived effectiveness. Findings underscore the importance of self-determination in informing health policies that are equitable and nonstigmatizing.

Smokers' strategies to reduce tobacco spending: self-reported use and differences across subgroups. Findings from the International Tobacco Control (ITC) Netherlands Survey

BACKGROUND

The cost of tobacco is one of the most reported reasons for smoking cessation. Rather than quitting, smokers can use also strategies to reduce tobacco expenditure while continuing smoking, such as smoking less or using price-minimising strategies. The Netherlands announced to increase the price of a pack cigarettes from seven (2018) to ten euros (2023), to reduce tobacco prevalence and consumption. This study explores the self-reported strategies to reduce tobacco spending among Dutch smokers, and whether this differed per age, income, and education. Additionally, we analysed among quitters in these subgroups whether price played a role in their decision to quit.

METHODS

Cross-sectional survey data from the International Tobacco Control (ITC) Netherlands Wave 2 (September-November 2020, N = 1915) was used. Strategies to reduce spending among smokers (N = 1790) were: reducing consumption, bulk buying, switching to cheaper products or buying from low-taxed sources. These were collapsed into: reducing consumption (solely or in combination with other behaviours), solely price-minimising behaviours (such as buying cheaper brands), or no strategies to reduce spending. Associations between strategies and characteristics were analysed through multinomial and binary logistic regression models. Second, we explored which subgroups were more likely to report that price played a role in their decision to quit among quitters (N = 125).

RESULTS

The majority of smokers used strategies to reduce tobacco spending: 35.6% reduced consumption and 19.3% used solely price-minimising strategies. 82.1% of quitters reported that price played a role in their decision to quit. Low-income individuals were more likely to report price as a reason for quitting and reduce consumption, but also to buy cheaper products. Highly nicotine dependent smokers were more likely to use price-minimising behaviours, and less likely to reduce consumption.

CONCLUSIONS

The majority reported using strategies to reduce spending or that price played a role in their decision to quit. Reducing consumption was the most reported strategy. Low-income smokers were more likely to reportedly reduce consumption, buy cheaper products, or quit. Price policies have the potential to reduce socioeconomic inequalities in smoking. To discourage price-minimising behaviours, such as switching to cheaper products, reducing price differences between products should be prioritized.

Measuring public opinion and acceptability of prevention policies: an integrative review and narrative synthesis of methods

Acceptability of and public support for prevention are an important part of facilitating policy implementation. This review aims to identify, summarize and synthesize the methods and study designs used to measure and understand public opinion, community attitudes and acceptability of strategies to prevent chronic noncommunicable disease (NCDs) in order to allow for examination of imbalances in methodological approaches and gaps in content areas. We searched four scientific databases (CINAHL, Embase, Ovid/MEDLINE and Scopus) for peer-reviewed, English-language studies published between January 2011 and March 2020 in high-income, democratic countries across North America, Europe and the Asia–Pacific region. Studies were included if they focused on opinions, attitudes and acceptability of primary prevention strategies and interventions addressing the key NCD risk factors of alcohol use, unhealthy diet, overweight/obesity, tobacco use and smoking, and physical inactivity. A total of 293 studies were included. Two thirds of studies (n = 194, 66%) used quantitative methods such as cross-sectional studies involving surveys of representative (n = 129, 44%) or convenience (n = 42, 14%) samples. A smaller number of studies used qualitative methods (n = 60, 20%) such as focus groups (n = 21, 7%) and interviews (n = 21, 7%). Thirty-nine studies (13%) used mixed methods such as content analysis of news media (n = 17, 6%). Tobacco control remains the dominant topic of public opinion literature about prevention (n = 124, 42%). Few studies looked solely at physical inactivity (n = 17, 6%). The results of this review suggest that public opinion and acceptability of prevention in the peer-reviewed literature is investigated primarily through cross-sectional surveys. Qualitative and mixed methods may provide more nuanced insights which can be used to facilitate policy implementation of more upstream strategies and policies to prevent NCDs.

New Zealand Smokers' Perceptions of Tobacco Endgame Measures: A Qualitative Analysis

INTRODUCTION

New Zealand's equity-focused endgame goal (Smokefree 2025) aims to reduce smoking prevalence to minimal levels (ie, <5%) in all population groups by 2025. Inadequate progress has stimulated discussion of innovative measures to reduce prevalence; because few studies have explored how marginalized groups perceive these measures, we addressed this knowledge gap.

AIMS AND METHODS

In November and December 2020, we conducted 20 in-depth interviews with people who smoked daily, were aged between 21 and 53, earned less than the median income (NZD33 900), and had marginal or inadequate income sufficiency. We explored participants' smoking history and used an elicitation exercise to probe their views on smokefree policies, including potential endgame measures. We used qualitative descriptive analysis and reflexive thematic analysis to interpret the data.

RESULTS

Participants favored increasing personal support to quit and reducing nicotine levels in cigarettes, but generally opposed tobacco excise tax increases and paying people to quit. While many privileged their right to "choose," some recognized that stronger policies could restore the loss of agency addiction caused. Participants felt smoking's powerful addictiveness remained poorly understood, and called for smoking to be recognized and treated as an addiction.

CONCLUSIONS

Several participants supported intensifying existing measures or introducing new measures. However, their use of tobacco industry rhetoric to frame smoking as a choice they had made could inadvertently reinforce the stigma they experienced. Reframing cigarettes as an addictive product engineered by a deceptive industry, may make it easier for participants to access the expanded support and compassion they sought.

IMPLICATIONS

Policy measures, such as reducing the nicotine level in cigarettes, could support endgame goals; however, greater public understanding of addiction is needed to reduce stigma, support self-efficacy, and foster smoking cessation. Industry denormalization campaigns could challenge views of smoking as a personal choice, decrease self-blame among people who smoke, and present endgame goals as likely to enhance agency.

Exploring indigenous perspectives on tobacco tax: how some Māori families are responding in Aotearoa New Zealand

OBJECTIVE

High smoking prevalence rates, combined with a steep tax on tobacco and lower household income, mean that 5% of Māori (indigenous) whānau (family unit) expenditure in New Zealand is on tobacco. This paper outlines whānau perceptions of, and behavioural responses to, increasing tobacco tax.

METHODS

This qualitative study was informed by the Kaupapa Māori theory and used a simplified interpretive phenomenological analysis thematic hybrid methodology. A semistructured, open-ended interview guide was designed and used in one-off focus group interviews.

SETTING AND PARTICIPANTS

Interviews were separately conducted with each of 15 whānau units. A total of 72 participants, most of whom were smokers, took part in the interviews carried out in two geographical regions: one rural/provincial and one urban.

RESULTS

Whānau were concerned about the rising cost of tobacco. However, this concern had not generally translated into quit attempts. Whānau had instead developed innovative tobacco-related practices. Working collectively within their whānau, they were able to continue to smoke, although in a modified fashion, despite the rising costs of tobacco. Whānau thereby resisted the intended outcome of the government's tobacco tax which is to reduce rates of smoking prevalence.

CONCLUSION

In the face of significant government disinvestment in New Zealand tobacco control over the last 10 years, hypothecated taxes should be used to scale up Māori-specific cessation and uptake prevention programmes, supporting authentic Māori partnerships for endgame solutions including restricting the availability and appeal of tobacco.

The effect of price on cigarette consumption, distribution, and sale in Tehran: a qualitative study

Background

Appropriate increases in tobacco taxes and prices are an essential component of comprehensive tobacco control strategies. This study investigates factors related to the use, sale, and distribution of cigarettes in Iran, focusing on the relationship between cigarette price and its consumption.

Methods

This interview-based qualitative study was conducted among 20 participants, including cigarette smokers, retail shop owners, large-scale distributors, and an expert in tobacco control research.

Results

Seven themes were extracted from participant interviews, including the type and price of cigarette, the best time to sell cigarettes, profits from the sale of cigarette, affordability, rise in cigarette price and smokers’ reaction to it, lobbying and black-market sales of cigarettes, and the sale and distribution of cigarettes across the country. Although the price of cigarettes in Iran has shown some increases in the past decade, the timing of these increases are not predictable and the limited amount of these increases has not reduced the use of cigarettes. Following a price increase, consumers are more likely to switch from buying packets to single cigarettes, or buy a less expensive brand, then to quit. Moreover, increases in prices may encourage smokers and sellers to buy a large number of cigarettes and store them for a rainy day. Another adverse effect may be increased smuggling of illicit cigarettes to balance the pressure caused by rising prices.

Conclusions

Our findings highlight two important aspects concerning cigarette pricing in Iran. First is the change in the type of purchase from the whole box of cigarettes to the single stick cigarette or swapping to less expensive cigarettes. Second, increase in cigarette price (either through taxing or regular increases) could be offset by flooding smuggled cigarettes into the market. Therefore, in addition to raising cigarette prices, reducing cigarette consumption rates in Iran requires the development and effective implementation of regulatory policies to control cigarette smuggling, reduce purchasing, and subsequently curb the use of this leading cause of premature morbidity and mortality.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-11733-5.

New Zealand roll-your-own smokers' reaction to novel roll-your-own tobacco packaging warning labels

INTRODUCTION

Although roll-your-own (RYO) loose tobacco is increasingly popular among smokers, no jurisdictions have used RYO-specific pictorial warning labels (PWL) on tobacco packaging. We explored how New Zealand RYO smokers, a population with over 10 years of exposure to PWLs, reacted to RYO-specific warnings featuring novel themes.

METHODS

We conducted an online survey of 785 RYO smokers in March 2019. Eligible participants were smokers aged 18-70 years who smoked predominantly RYO cigarettes. Participants randomly viewed two of eight RYO-specific PWLs featuring themes of health information (mouth and throat cancer), suffering (male and female), toxins, material hardship, cost, family transmission of smoking and harm to pets and answered items assessing negative emotions and perceived effectiveness.

RESULTS

Compared to a reference health information PWL (most similar in content and tone to New Zealand's existing PWLs), only a male suffering PWL elicited both significantly stronger negative emotion and higher perceived effectiveness. No themes performed significantly worse than the health information PWL, suggesting any of the themes could be at least as effective as existing health warnings among New Zealand RYO smokers. The individual-level factors consistently associated with negative emotion and perceived effectiveness were age, desire to quit smoking, believing quitting could reduce risk of serious disease, a quit attempt within the previous 6 months and ever-planning to quit.

CONCLUSION

Our findings suggest that, in the New Zealand context, a PWL emphasising male suffering could be a useful starting point for assessing RYO-specific PWLs compared to general smoking warnings.

Exploring attitudes toward taxation of sugar-sweetened beverages in rural Michigan

BACKGROUND

While policies to address "obesity" have existed for decades, they have commonly focused on behavioral interventions. More recently, the taxation of sugar-sweetened beverages is gaining traction globally. This study sought to explore individuals' attitudes and beliefs about sugar-sweetened beverages being taxed in a rural Michigan setting.

METHODS

This qualitative study was conducted using critical policy analysis. Data were collected in 25 semi-structured, audio-recorded interviews with adult Michiganders. Following data collection, transcripts were coded into themes using NVivo software.

RESULTS

Four themes emerged in participants' perspectives regarding sugar-sweetened beverages being taxed: resistance, unfamiliarity, tax effects, and need for education. While some participants were unfamiliar with sugar-sweetened beverage taxes, many viewed taxation as a "slippery slope" of government intervention, which invoked feelings of mistrust. In addition, participants predicted a sugar-sweetened beverage tax would be ineffective at reducing intake, particularly among regular consumers, who were frequently perceived as mostly low income and/or of higher weight.

CONCLUSIONS

Further research is needed to explore perceptions of sugar-sweetened beverage taxes in different geographic areas in the USA to examine how perceptions vary. Policymakers should be aware of the potential implications of this health policy with respect to government trust and stigma towards lower income and higher-weight individuals.

Changes in Tobacco Use During the 2020 COVID-19 Lockdown in New Zealand

Introduction

New Zealand’s response to the COVID-19 pandemic was one of the most restrictive lockdowns of any country, inevitably causing stress for many people. Because situations that increase stress and anxiety are associated with higher smoking prevalence, we examined self-reported smoking before and during the lockdown, and analyzed factors associated with reported changes in cigarette consumption.

Aims and Methods

We conducted an online panel survey of a demographically representative sample of 2010 adult New Zealanders during the COVID-19 lockdown; the final, weighted sample included 261 daily smokers and 71 weekly smokers. We measured psychological distress and anxiety, as well as situational factors, tobacco consumption, and demographic attributes.

Results

Nearly half of daily smokers reported smoking more during than before the lockdown, on average, an increase of six cigarettes a day; increased daily cigarette consumption was associated with loneliness and isolation. Most weekly smokers reported either that their smoking during the lockdown had not changed or had slightly reduced.

Conclusions

Smoking cessation services need to anticipate that unexpected disruptions, such as pandemic lockdowns, may be associated with increased daily tobacco consumption, and that this increase may be sustained after lockdown. While public health responses to pandemics predictably focus on immediate and obvious consequences, interventions to support recent quitters and those making quit attempts should also form a key component of pandemic planning.

Implications

As governments introduce unprecedented measures to manage COVID-19, they need also to consider other public health risks, such as increased smoking among current smokers or relapse among recent quitters. Evidence that loneliness was associated with increased smoking during a lockdown suggests a need for cessation out-reach strategies that promote and support smoke-free practices.

Tool to assess appeal-aversion response to graphic warning labels on cigarette packs among US smokers

INTRODUCTION

Graphic warning labels on cigarette packaging are mandated in 118 countries and are under consideration in the USA. We propose an appeal-aversion assessment tool to help regulators choose among graphic packaging options.

METHODS

After familiarisation with different cigarette packaging, adult daily smokers (n=338) from San Diego, California, USA completed a discrete choice appeal-aversion purchasing task and provided information on nicotine dependence and sociodemographics (2017-2019). The conjoint analysis estimated the importance and price utility for product attributes (ie, packaging, price, tobacco origin and quitline number). The price premiums that smokers would be willing to pay to avoid purchasing graphic packaging were calculated.

RESULTS

Among purchase determinants, the price was the most important attribute (65.5%), followed by packaging design (27.1%). Compared with blank packaging without marketing, branded industry packs had appeal valuations (US$0.54; 95% CI: US$0.44 to US$0.65), whereas graphic warning packs had aversion valuations that varied with the salience of the image (blindness=-US$2.53, 95% CI: -US$2.76 to -US$2.31; teeth damage=-US$2.90, 95% CI: -US$3.17 to -US$2.63; and gangrenous foot=-US$3.70, 95% CI: -US$4.01 to -US$3.39). The aversion was such that 46.2% of participants were willing to pay a 50+% premium over their current cigarette price to have their branded packs rather than a graphic pack. These appeal-aversion valuations were moderated by sex, income and nicotine dependence (p<0.05).

CONCLUSIONS

Smokers indicated a willingness to pay substantial premiums to avoid purchasing graphic packaging. Results suggest that mandating graphic warnings on US cigarette packs would induce price aversion and may deter cigarette purchasing. Price valuations from this appeal-aversion tool could be useful for regulators to differentiate between graphic warning labels.

Retailers' perspectives on selling tobacco in a low-income San Francisco neighbourhood after California's $2 tobacco tax increase

BACKGROUND

California's tobacco tax increased by $2.00 per pack in 2017. Although such increases are among the most effective tobacco control strategies, little is known about their impact from the perspective of corner store owners in low-income neighbourhoods with high concentrations of tobacco outlets.

METHODS

We interviewed 38 corner store owners and managers in San Francisco's Tenderloin, the district with the city's highest tobacco outlet density, 60-90 days following implementation of the tax increase. Questions focused on perceptions of the impact of the higher tobacco tax on their revenues, customers and tobacco company promotions. We used qualitative content analysis to identify, compare and reconcile key themes.

RESULTS

Most retailers reported a decline in cigarette sales, with customers buying fewer cigarettes, switching to cheaper brands or other products like marijuana, or trying to quit smoking. Retailers described challenges associated with running a small business and selling tobacco and concerns about selling a product that is 'bad' for customers' health. Contrary to expectation, tobacco companies appeared to be offering few product promotions in this neighbourhood.

CONCLUSIONS

Small, independent retailers' concerns, about selling tobacco and about the health and well-being of customers, suggest that such retailers may be important allies in tobacco control efforts,particularly those focused on the point-of-sale.

The Relationship Between Neighborhood Disorder and Barriers to Cessation in a Sample of Impoverished Inner-City Smokers in Baltimore, Maryland, United States

Introduction

Economic disparities in rates of smoking have been well documented in many countries. These disparities exist on an individual and geographic or neighborhood level. This cross-sectional study examined the relationship between neighborhood physical and social disorder and barriers to smoking cessation among an impoverished urban sample.

Methods

A sample of current smokers were recruited through street outreach, posted advertisements, and word of mouth from impoverished neighborhoods in Baltimore, Maryland, USA for a study of psychosocial factors and smoking behaviors. Neighborhood disorder was assessed with a 10-item scale from the Block Environmental Inventory and barriers to cessation with a 9-item scale.

Results

In the multiple logistic regression model, perceived stress (aOR = 1.60, 95% CI = 1.32 to 1.95), neighborhood disorder (aOR= 1.34, 95% CI = 1.11 to 1.63), and level of nicotine dependence (aOR = 1.97), 95% CI = 1.62 to 2.40) were all strongly associated with barriers to cessation.

Conclusion

The results of this study suggest that neighborhood disorder may lead to barriers to cessation among low-income populations. The findings also indicate that tobacco control interventions should examine and address social and physical aspects of impoverished neighborhoods.

Implications

In many countries, tobacco control programs and policies have been less effective among low-income populations as compared to more affluent populations. Little is known about how neighborhood factors influence smoking cessation. This study examined the relationship between neighborhood disorder and barriers to cessation among a low-income population. We recruited a convenience sample of hard-to-reach cigarette smokers from low-income neighborhoods. Even after controlling for level of nicotine dependence and stress, neighborhood disorder was found to be associated with barriers to cessation. The findings suggest the important role of neighborhood disorder as a barrier to smoking cessation.

Roll-your-own cigarette use and smoking cessation behaviour: a cross-sectional population study in England

OBJECTIVES

Roll-your-own (RYO) cigarettes have become popular in the UK and reduce the cost of smoking, potentially mitigating the impact of tax increases on quitting. We examined whether RYO cigarette use was associated with reduced motivation to quit smoking, incidence of quit attempts and quit success.

DESIGN

Cross-sectional survey.

SETTING

England.

PARTICIPANTS

38 590 adults who reported currently smoking or having stopped within the past 12 months.

MAIN OUTCOME MEASURES

Motivation to quit smoking, quit attempt in the last year, motives for quitting and quit success were regressed onto RYO cigarette use, adjusting for sociodemographic variables and level of cigarette addiction. Mediation by weekly spending on smoking was tested.

RESULTS

Compared with manufactured cigarette smokers, RYO smokers had lower odds of high motivation to quit (OR=0.77, 95% CI 0.73 to 0.81) or having made a quit attempt (OR=0.87, 95% CI 0.84 to 0.91). Among those who had attempted to quit smoking, quit success did not differ by cigarette type (OR=1.00, 95% CI 0.89 to 1.12), but RYO smokers were less likely to report cost of smoking as a motive to quit (OR=0.68, 95% CI 0.61 to 0.74). Spending on smoking mediated the association between RYO use and quit attempts (β=-0.02, SE=0.003, 95% CI -0.03 to -0.02).

CONCLUSIONS

In England, compared with smokers of manufactured cigarettes, RYO cigarette smokers appear to have lower motivation to quit and lower incidence of quit attempts but similar success of quit attempts. The lower cost of RYO smoking appears to mediate the lower incidence of quit attempts among RYO users.

Social influences on health-related behaviour clustering during adulthood in two British birth cohort studies

Building upon evidence linking socio-economic position (SEP) in childhood and adulthood with health-related behaviours (HRB) in adulthood, we examined how pre-adolescent SEP predicted membership of three HRB clusters: "Risky", "Moderate Smokers" and "Mainstream" (the latter pattern consisting of more beneficial HRBs), that were detected in our previous work. Data were taken from two British cohorts (born in 1958 and 1970) in pre-adolescence (age 11 and 10, respectively) and adulthood (age 33 and 34). SEP constructs in pre-adolescence and adulthood were derived through Confirmatory Factor Analysis. Conceptualised paths from pre-adolescent SEP to HRB cluster membership via adult SEP in our path models were tested for statistical significance separately by gender and cohort. Adult SEP mediated the path between pre-adolescent SEP and adult HRB clusters. More disadvantaged SEP in pre-adolescence predicted more disadvantaged SEP in adulthood which was associated with membership of the "Risky" and "Moderate Smokers" clusters compared to the "Mainstream" cluster. For example, large positive indirect effects between pre-adolescent SEP and adult HRB via adult SEP were present (coefficient 1958 Women = 0.39; 1970 Women = 0.36, 1958 Men = 0.51; 1970 Men = 0.39; p < 0.01) when comparing "Risky" and "Mainstream" cluster membership. Amongst men we found a small significant direct association (p < 0.001) between pre-adolescent SEP and HRB cluster membership. Our findings suggest that associations between adult SEP and HRBs are not likely to be pre-determined by earlier social circumstances, providing optimism for interventions relevant to reducing social gradients in HRBs. Observing consistent findings across the cohorts implies the social patterning of adult lifestyles may persist across time.

Australia's $40 per pack cigarette tax plans: the need to consider equity

In May 2016, the Australian Government announced that it would implement annual increases in tobacco excise of 12.5% up to and including 2020, raising the cost of a pack of cigarettes to $A40. This increase will lead to Australia having one of the highest prices of cigarettes in the world. Increasing the cost of tobacco is considered by public health experts to be one of the most effective strategies to reduce tobacco use, and is generally well supported by the public. However, tobacco tax increases differentially impact various subgroups of the population. Based on a review of existing literature, this paper examines some of the potential (unintended) consequences of the tax to individual and family income; illicit trade; social stigma and opportunities for lobbying by the tobacco industry. In light of these considerations, we offer strategies that might be used by policymakers to mitigate potential harms. While this paper focuses on the impacts primarily on populations in Australia, the consequences and strategies offered may be useful to other countries implementing tobacco excise increases.

"I'm not strong enough; I'm not good enough. I can't do this, I'm failing"- A qualitative study of low-socioeconomic status smokers' experiences with accesssing cessation support and the role for alternative technology-based support

BACKGROUND

The social gradient in smoking rates persist with an overrepresentation of smoking and its associated harms concentrated within lower socioeconomic status (SES) populations. Low-SES smokers are motivated to quit but face multiple barriers when engaging a quit attempt. An understanding of the current treatment service model from the perspectives of treatment-seeking low-SES smokers is needed to inform the design of alternative smoking cessation support services tailored to the needs of low-SES populations. This qualitative study aimed to: i) explore low-SES smokers' recent quitting experiences; ii) assess factors that impact treatment engagement; and iii) determine the acceptability and feasibility of alternative approaches to smoking cessation.

METHOD

Low-SES participants (n = 24) previously enrolled in a smoking cessation RCT participated in either a semi-structured focus group or in-depth telephone interview. Data was obtained and analysed using thematic analysis from October 2015 to June 2016. Analysis was deductive from the interview guide and supplemented inductively.

RESULTS

Participants expressed feelings of guilt and shame around their smoking behaviour and experienced stigmatisation for their smoking. Guilt, shame, and stigmatisation negatively impacted treatment seeking behaviours with most avoiding current quit services. Costs of pharmacotherapy and treatment adherence were commonly cited barriers to treatment success. Electronic-cigarettes were perceived to be unsafe due to uncertainty on their legal status and regulatory restrictions. Technology-based text-messaging quit support was endorsed as a more favourable alternative compared to existing behavioural treatment services.

CONCLUSION

Stigmatisation was commonly endorsed and acted as an impediment to current treatment utilisation. Electronic-cigarettes may present a viable harm reduction alternative, but their likely uptake in socioeconomically disadvantaged groups in Australia is limited by smokers' uncertainty about their regulation and legality. Mobile phone based cessation support may provide an alternative to telephone counselling and overcome the stigmatisation low-SES smokers face while trying to quit.

Factors associated with smoking initiation among school-aged adolescents

Objective

To identify factors associated with smoking initiation in adolescent secondary school students.

Method

This is a cross-sectional study conducted in 2014 with 864 adolescents at a secondary school in southern Brazil. Data were collected using an instrument with sociodemographic questions, application of the Fagerström Nicotine Dependence Scale, and Beck Depression Inventory, and analysed using descriptive statistics, Fisher's Exact test, Chi-square test, Mann-Whitney's test, and the Poisson Regression test.

Results

Fifty-four of the adolescents started smoking, of which 35 continued smoking and exhibited high nicotine dependence. Smoking was associated with brown skin (p = 0.020), single-parent household (p = 0.006), a fair family relationship (p = 0.003), and drug users in the family (p = 0.04). A significantly higher prevalence ratio was detected for boys (p = 0.038), higher family income (p> 0.001), living with one family member (p> 0.001), and a fair family relationship (p> 0.001).

Conclusions

We identified factors associated with smoking initiation, revealing the importance of supporting health education strategies to change this reality.