Denormalization, smoke-free air policy, and tobacco use among young adults

Comprehensive vaping bans are associated with lower odds of initiation into electronic nicotine delivery systems use among young people

BACKGROUND AND AIMS

E-cigarette and other electronic nicotine delivery systems (ENDS) use has grown considerably over the past decade, with notable increases among young people. US state policy contexts for ENDS and tobacco may shape initiation into ENDS use among adolescents as they age into early adulthood. We aimed to determine whether state-level comprehensive vaping ban policies reduce the odds of youth initiation into ENDS use, net of additional state-level ENDS and tobacco policies, as well as the youth's cigarette smoking status.

DESIGN

Longitudinal data from the Population Assessment of Tobacco and Health study were merged with a state-year database on tobacco and ENDS policies. Multivariable discrete-time event history models of ENDS initiation were estimated.

SETTING

United States.

PARTICIPANTS

Twenty thousand twelve youth assessed over six waves from 2013 to 2019 (n = 53 974 observations).

MEASUREMENT

We examined comprehensive indoor vaping bans (i.e. 100% vape-free workplaces, restaurants and bars) as a key factor in initiation into ENDS use (i.e. first instance of vaping) from age 13 to 22.

FINDINGS

Among young people, residing in a state with a comprehensive vaping ban was associated with 18% lower odds of ENDS initiation (odds ratio = 0.82; 95% confidence interval =[0.71, 0.94]), even after controlling for other state ENDS and tobacco policies, the youth's cigarette smoking and socio-demographic background and state-level covariates.

CONCLUSIONS

In the United States, state-level vaping bans (i.e. 100% vape-free workplaces, restaurants and bars) are associated with reduced odds of youth initiation into electronic nicotine delivery systems use.

The crossroads of work and home: linkages between smoke-free policies at work and household environments

BACKGROUND

Tobacco use causes over eight million global deaths annually, with seven million directly attributed to tobacco use and 1.2 million to second hand smoke (SHS). Smoke-free environments are crucial to counter SHS. Although India banned smoking in public places in 2008, SHS exposure remains high. Studies have noted that limiting smoking in workplaces, restaurants, etc., helps to reduce overall smoking and reduce SHS exposure. Under this background, the study explores the linkages between smoke-free workplaces and living in smoke-free homes in India.

METHODS

The two rounds of the GATS India (2009-10 and 2016-17) have been used for the study. The study focuses on male tobacco smokers working indoors or outdoors or both indoors and outdoors. The sample for the study was 2,969 for GATS 1 and 2,801 for GATS 2. Dependent variables include living in a smoke-free home, while the independent variables were adherence to a smoke-free office policy and socio-demographic variables. The two rounds of the GATS data were pooled for analysis. Statistical analysis involves bivariate and multivariate analysis.

RESULTS

Findings reveal that 41% of respondents worked in smoke-free workplaces in GATS 2. Nationally, smoke-free homes increased from 35% in 2009-2010 to 44% in 2016-17. Individuals with smoke-free workplaces were more likely to have smoke-free homes. The Southern region consistently exhibited the highest proportion of smoke-free homes. Urban areas and higher education correlated with increased smoke-free homes. Logistic regression analysis confirmed that workplace smoke-free status is a significant predictor of smoke-free homes. In GATS 2, respondents aged 30 years and above were less likely to have smoke-free homes, while education and Southern region residence positively influenced smoke-free homes.

CONCLUSIONS

The correlation between smoke-free workplaces and smoke-free homes is linked to stringent workplace no-smoking policies, potentially deterring individuals from smoking at home. Opportunities exist for the expansion and stringent implementation of the smoke-free policies among Indian working adults, leveraging the workplace as a key setting for evidence-based tobacco control. The study highlights positive trends in India's smoke-free homes, crediting workplace policies. Effective policies, education, and regional strategies can advance smoke-free homes, stressing the pivotal role of workplace policies and advocating broader implementation.

A drink equals how many cigarettes? Equating mortality risks from alcohol and tobacco use in Canada

Objective

To quantify and communicate risk equivalencies for alcohol-and tobacco-attributable mortality by comparing per standard drinks consumed to per number of cigarettes smoked in Canada.

Methods

Alcohol-and tobacco-attributable premature deaths (≤75 years of age) and years of life lost (YLL) were estimated using a lifetime risk modeling approach. Alcohol-attributable death statistics were obtained from the 2023 Canadian Guidance on Alcohol and Health data source. Tobacco-attributable death statistics were derived from the Mortality Population Risk Tool (MPoRT) model.

Results

The risk of alcohol use on premature death and YLL increased non-linearly with the number of drinks consumed, while the risk for tobacco use on these two measures increased linearly with the number of cigarettes smoked. Males who consumed 5 drinks/day-a standard drink contains 13.45 grams of alcohol in Canada-had an equivalent risk as smoking 4.9 cigarettes/day (when modeling for premature death) and 5.1 cigarettes/day (when modeling for YLL). Females who consumed 5 drinks/day experienced an equivalent risk as smoking 4.2 cigarettes/day for premature deaths and YLL. At all levels of alcohol consumption females and males who consumed <5 drinks/day have less risks from consuming a standard drink than from smoking a cigarette. For males who consumed 5 drinks/day, the increased risks of death from per drink consumed and per cigarette smoked were equal.

Conclusion

Risk equivalencies comparing alcohol use to tobacco use could help people who drink improve their knowledge and understanding of the mortality risks associated with increased number of drinks consumed per day.

Quasi-experimental study on the impact of local smoke-free policies on smoking among Indonesian adults: Evidence from repeated national health surveys

BACKGROUND

Smoke-free policies (SFPs) have been effective in reducing smoking prevalence, but evidence remains limited for low- and middle-income countries. Due to decentralized governance in Indonesia, SFPs are adopted in different ways in different locations. This study aims to assess the impact of local smoke-free policies (SFPs) on current smoking among Indonesian adults.

METHODS

Data from national health surveys conducted in 515 districts and 34 provinces in 2007, 2013, and 2018, involving 1,599,517 adults, were analyzed. A multilevel logistic regression analysis was performed, considering variables such as survey year, SFP adoption in 2007, SFP between 2007 and 2013, SFP between 2013 and 2018, socio-demographic factors, and district characteristics.

RESULTS

Moderate (OR:0.94, 95%CI:0.91-0.97) and strong (OR:0.95, 95%CI:0.0.92-0.98) district-level SFPs between 2013 and 2018 were associated with decreased odds of current smoking, compared to no district-level SFP adoption. Similar results were observed for moderate (OR:0.91, 95%CI:0.86-0.96) and strong (OR:0.89, 95%CI:0.85-0.94) district-level SFPs between 2007 and 2013, compared to no district-level SFP. Compared to provinces without SFPs, individuals living in provinces with moderate SFPs between 2007 and 2013 had lower odds of current smoking (OR:0.67; 95% CI:0.63-0.71), while those in districts with moderate SFPs between 2013 and 2018 had higher odds (OR: 1.08, 95% CI: 1.05-1.11).

CONCLUSIONS

Local SFPs demonstrated a potential in reducing smoking persistence in Indonesia, particularly at the district level. However, the impact of province-level SFPs differed. Tailored SFPs and district-province strategies, focusing on synchronizing the top-down SFP implementation in the Indonesia's decentralized systems, are critical for lowering smoking rates.

Social Ecological Influences on Nicotine/Tobacco Use Among Gender-Varying and Gender-Stable Adolescents and Adults in the USA

BACKGROUND AND PURPOSE

Our study examined individual-, interpersonal-, community-, and policy-level associations with nicotine/tobacco use among gender-varying and gender-stable U.S. individuals.

METHODS

Data from Waves 2-4 (2014/15-2016/18) of the Population Assessment of Tobacco and Health (n = 33,197 U.S. adolescents and adults aged ≥14 years) and state-level gender minority policy data were used. Using multivariable logistic regression, the odds of past-30-day nicotine/tobacco use at W4 were estimated as a function of gender stability/variability, psychological distress, number of tobacco products used by family/friends, anti-tobacco marketing exposure, and change in gender minority-related policies from 2015 to 2017.

RESULTS

Gender-varying individuals had higher odds of nicotine/tobacco use compared with gender-stable individuals (AOR range = 1.7-2.3, p < .01). In the overall sample, positive change in gender minority policy protections (tallied from medium to high) was associated with lower odds of any nicotine/tobacco, other tobacco, and poly-tobacco use (AOR = 0.8, p < .05) compared to states with no change in their negative policies. Anti-tobacco marketing exposure was associated with lower odds of any tobacco, cigarette, e-cigarette, and poly-tobacco use compared with those who had no anti-tobacco marketing exposure (AOR = 0.9, p < .05). Higher psychological distress (AOR range = 1.7-2.4, p < .001) and an increasing number of tobacco products used by family/friends (AOR range = 1.1-1.3, p < .001) were associated with increased odds of nicotine/tobacco use.

CONCLUSIONS

Multilevel prevention and intervention strategies are needed to reduce the risk of nicotine/tobacco use among gender-varying and gender-stable individuals.

A mixed-methods evaluation of the indoor and outdoor smoking ban in dining venues in Armenia: Early successes and challenges

INTRODUCTION

Since March 2022, Armenia introduced a comprehensive smoking ban on all types of tobacco products in indoor and outdoor areas of hospitality venues. We aimed to rapidly appraise the implementation of the ban in the dining areas of the capital Yerevan and explore any differences in compliance and enforcement patterns between indoor and outdoor areas of the venues.

METHODS

We used a mixed-methods approach through quantitative air quality monitoring, qualitative observations, and in-depth interviews (IDIs). We visited one venue in each remote district of the city and more venues from the central districts that have a much higher density of dining areas. Overall, we made 24 measurements of PM2.5 particles, 24 unobtrusive observations in the 19 visited venues, and 11 IDIs with six visitors and five workers. We used Stata13 for the analysis of numerical data and completed direct deductive content analysis of the textual data.

RESULTS

Active tobacco use was observed in 12 out of 24 venues (50.0%) with more cases of smoking in outdoor areas (10 out of 12; 83.3%). No warning by workers or no reports to the police were observed. We detected elevated levels of PM2.5 particles in indoor and outdoor areas. The IDIs revealed predominantly negative attitudes towards the outdoor ban and the lack of awareness of and readiness to engage in the enforcement measures. The lack of enforcement by the owners and the respective bodies was mentioned as a contributor to continued violations of the ban. The change in the dynamic and the characteristics of the visitors, cleaner air, and less unpleasant work were mentioned as important positive aftermaths of the ban.

CONCLUSIONS

The Government of Armenia should enhance the monitoring and enforcement activities and organize tailored awareness-raising campaigns to inform the general public and the hospitality industry of the health and social implications of the ban.

A decade beyond the economic recession: A study of health-related lifestyles in urban and rural Spain (2006-2017)

The 2008 economic recession may have affected health-related indicators differently depending on the living environment. We analyze health-related indicators in Spain using data from four Spanish health surveys (2006, 2011, 2014, and 2017, 95 924 individuals aged ≥16 years). In 2006-2011, physical activity decreased among men and women, while in 2006-2017, physical activity only decreased among urban women. Daily vegetable intake, except in rural women, increased in 2006-2011 but decreased in 2006-2017 in all groups. Smoking decreased among urban women in 2006-2011 and 2006-2014 but only decreased among men, and even increased among rural women, in 2006-2017. In 2006-2017, obesity increased among men and urban women, good self-rated health status increased in all groups and flu vaccination declined. Blood pressure and cholesterol control decreased in urban women in 2006-2011 but increased in 2006-2017 in all groups, as well as mammographic and cytological control. Our findings highlight the differential impact of the economic recession on health-related lifestyles according to sex and place of residence, underscoring the need for targeted health policies to address evolving health disparities over time.

Tobacco Policy and ENDS Policy Influences on Adolescent Vaping Across the U.S. States

INTRODUCTION

Although the use of tobacco has declined among youth, ENDS has the potential to disrupt or reverse these trends. Policies for tobacco and ENDS may have an impact on adolescent ENDS use. The impacts of state-level policies were examined for both tobacco and ENDS indoor use bans, excise taxes, and age-of-purchase laws on past-month adolescent ENDS use from 2013 to 2019.

METHODS

This study used cohort data from the Population Assessment of Tobacco and Health study and policy data from the Americans for Nonsmokers' Rights Foundation repository-3 policies for ENDS and 2 policies for tobacco products. Policies included comprehensive indoor vaping/smoking bans, purchase-age restrictions, and excise taxes. Hybrid panel models were estimated in 2022 using data merged from the 2 longitudinal sources on past-month vaping. The analytic sample (observations=26,008) included adolescents aged 12-17 years, yielding a total of 72,684 observations.

RESULTS

The odds of adolescent ENDS use were 21.4% lower when the state had an ENDS purchase-age restriction and 55.0% lower when the state had a comprehensive tobacco smoking ban than in the years when the state did not have the ban.

CONCLUSIONS

During a period of significant growth in ENDS use among U.S. youth, ENDS purchase-age restrictions and smoking bans reduced the odds of past-month vaping among adolescents. Wider implementation of policies may help intervene in youth vaping.

Exploring the Potential for Smoke-Free Laws to Reduce Smoking Disparities by Sexual Orientation in the USA

BACKGROUND

We examined associations between smoke-free laws and smoking outcomes in a nationally representative sample of US adults, including exploring whether these associations differed for heterosexual and sexual minority (SM) adults.

METHODS

We constructed county-level variables representing the percent of the population covered by state-, county-, or city-level smoke-free laws in workplaces and hospitality venues. We combined this information with restricted individual-level adult data with masked county identifiers from the National Health Interview Survey (NHIS), 2013-2018. We used modified Poisson regression to explore associations between each type of smoke-free law and the prevalence ratio (PR) of current smoking, and we used linear regression to explore associations with smoking intensity (mean cigarettes per day). We assessed interactions between smoke-free laws and SM status on the additive scale to determine whether associations were different for SM and heterosexual adults.

RESULTS

In adjusted models without interaction terms, smoke-free laws in hospitality venues were associated with lower prevalence of current smoking (PR = 0.93, 95% confidence interval (CI) = 0.89, 0.98). Both types of smoke-free laws were associated with lower mean cigarettes per day (workplace law change in mean =  - 0.50, 95% CI =  - 0.89, - 0.12; hospitality law change in mean =  - 0.72, 95% CI =  - 1.14,-0.30). We did not observe any statistically significant interactions by SM status, though statistical power was limited.

CONCLUSIONS

We did not find evidence that smoke-free laws were differentially associated with smoking outcomes for heterosexual and SM adults. Additional studies are needed to further explore the potential for tobacco control policies to address the elevated risk of smoking in SM communities.

Dénormalisation du tabac et de son industrie par la société civile : mise en œuvre et évaluation de la campagne « Pouvoir de vivre » par l’ACT – Alliance contre le tabac

This article examines the "denormalization" approach, which has gradually gained ground in the field of tobacco control. This process encompasses a wide range of practices and aims to renew tobacco control by extending its scope beyond the usual individual and health considerations; it also considers smoking as a societal problem. This contribution illustrates the implementation of this approach, as embodied in France by the Alliance Contre le Tabac denormalization program launched in 2019, through campaigns addressing a diverse range of themes. The latest campaign, carried out in January 2023, demonstrates that smoking also exacerbates the social and economic difficulties of the most disadvantaged members of society. Its presentation illustrates the deployment of such a campaign, the methodology used, the tools mobilized, and the results obtained by carrying out a post-test.

The toxic gift: reciprocity and social capital in cigarette exchange in China

The widespread exchange of tobacco cigarettes as a gift in some societies normalises the symbolic desirability of tobacco products and promotes smoking. Little is known about how and why people exchange toxic substances as gifts. This study argues two key factors involved in social exchange processes - reciprocity and social capital - can explain gift cigarette circulation. We conducted a multistage survey among household heads from China and measured the quantity and monetary values of outgoing and incoming gift cigarettes circulated by each household and measured social capital in three dimensions: collective participation, social ties, and trust. Ordinary Least Square regressions showed that reciprocity is strongly and significantly associated with both the value and quantity of gift cigarettes. All three dimensions of social capital are varyingly associated with gifting cigarettes. Income and higher classes are also associated with greater quantity and value of received cigarettes. This study broadens the phenomenon of gifting cigarettes to the more universal patterns of reciprocity and social capital, wherein better social capital and socioeconomic position ironically lead to a higher risk of tobacco use and endanger health. We suggest policymakers target the endemic social need for gift exchange in China's informal economy.

Tobacco Consumption and Mental Health in the Canary Islands: A Quantitative Analysis

Although the detrimental health effects of tobacco, there has been scant research into determining comprehensive profiles to characterize individuals with a higher risk of smoking. This paper identifies such profiles and probabilistically quantifies the effects of certain traits on the decision to smoke in the Canary Islands. This characterization is approached from a broad and novel point of view for the region studied, given that the analysis not only studies sociodemographic characteristics, lifestyle and health, but also incorporates mental health. The results show that suffering from some type of psychopathology leads to a higher probability of tobacco consumption. Moreover, just as the promotion of a healthy lifestyle has a direct impact on tobacco consumption, the implementation of public policies that reduce the risks of suffering from a mental illness could also reduce the prevalence of smoking in the region and contribute to the design of more effective prevention strategies.

"Tobacco denormalization at home": the contribution of the smoking ban in enclosed workplaces in Brazil

Estimates suggest that exposure to environmental tobacco smoke is related to 1.2 million deaths per year worldwide. Synergy between various anti-smoking legislative and educational measures is essential to stimulate cessation and prevent initiation. This article aimed to explore how legislative protection from exposure to environmental tobacco smoke in enclosed workplaces in Brazil, whose strengthening occurred in a phased manner between 1996 and 2014, possibly contributed to the protection from passive smoking at home. We evaluated, via generalized linear models, the absolute and relative differences in the proportion of individuals living in smoke-free homes between those exposed and not exposed to passive smoking in enclosed workplaces, both crude and adjusted by sociodemographic and smoking behavior variables, and stratified by non-smokers and smokers. Data from three national surveys conducted in 2008, 2013, and 2019 were used. Regardless of smoking status and year when the data were analyzed, individuals who were employed in smoke-free workplaces were more likely to live in smoke-free homes than smokers who were employed in workplaces that allowed smoking. Adjusted absolute difference increased from +5.5% in 2008 to +10.5% in 2013 among non-smokers, and from +7.1% in 2013 to 15.6% in 2019 among smokers (p-values for additive interaction ≤ 0.05). Strengthening the Brazilian smoke-free legislation was likely associated with a reduction in passive smoking at home, which, therefore, may also reduce the burden of mortality, morbidity, and costs for society related to smoking.

A longitudinal analysis of smoke-free laws and smoking initiation disparities among young adults in the United States

BACKGROUND AND AIMS

Tobacco control policies may differentially impact smoking initiation among socio-demographic groups. We measured longitudinal associations between exposure to smoke-free laws in grade 12 (modal age 18 years) and patterns of smoking initiation in the United States.

DESIGN

Prospective longitudinal analysis.

SETTING AND PARTICIPANTS

We used data on US young adults sampled at modal age 18 years from the Monitoring the Future Survey. Baseline data were collected between 2000 and 2017, with the last year of follow-up in 2018. The sample number varied by outcome and time-point, ranging from 7314 to 17 702.

MEASUREMENTS

Smoke-free law coverage in work-places and hospitality venues (restaurants/bars) was measured as the percentage of the county population covered by each type of law. We examined associations with any past 30-day smoking initiation and daily smoking initiation at modal ages 19/20, 21/22 and 23/24, using Poisson regression and calculating average marginal effects. We explored effect modification by sex, race/ethnicity and parental education by testing the significance of interaction terms.

FINDINGS

Work-place law coverage at modal age 18 was associated with a lower probability of daily smoking initiation at modal ages 21/22 [-2.4 percentage points (p.p.); 95% confidence interval (CI) = -3.9, -0.9] and 23/24 (-2.0 p.p.; 95% CI = -3.9, -0.2). Hospitality law coverage was associated with a lower probability of daily smoking initiation at modal ages 19/20 (-1.6 p.p.; 95% CI = -2.8, -0.4), 21/22 (-2.3 p.p.; 95% CI = -3.7, -0.9) and 23/24 (-1.8 p.p.; 95% CI = -3.6, -0.0). Findings were inconclusive with regard to associations with any past 30-day smoking initiation and with regard to effect modification, after adjusting for multiple testing.

CONCLUSIONS

Exposure to smoke-free laws at age 18 appears to be prospectively associated with reduced daily smoking initiation 1-6 years later.

A qualitative assessment of the perceptions and attitudes towards commercial tobacco policies and education among tribal communities in California

Background: California has the largest American Indian and Alaska Native (AIAN) population in the United States and faces several commercial tobacco related disparities. This study assessed current interest, readiness, and knowledge regarding commercial tobacco control policies in California Tribal communities.Objectives: A community readiness assessment was conducted in California Tribal communities to understand commercial tobacco policies that included: Tobacco 21 (California State, and now federal, law restricting commercial tobacco sales to age 21 and over), tobacco tax, smoke-free worksites on Tribal lands, smoke-free households, and smoke-free indoor and outdoor areas in multi-unit housing.Methods: Twelve Tribal communities participated in focus groups and interviews between 2016-2019. Content analysis was utilized to code and data were analyzed using ATLAS.ti software.Results: A total of 165 community members participated (65% female), with most expressing support for unwritten, community-based "small p" policies, (e.g., placing signage to create a smoke-free perimeter). However, there was little to no support for "big P" policies (e.g., written ordinances on smoke-free casinos, smoke-free housing). Support for tobacco product taxation varied. The importance of Tribal sovereignty and the need for tobacco prevention and cessation programs for youth were two additional topics that emerged.Conclusions: Participants supported Tribal policies and wished for outsiders to respect Tribal sovereignty in this regard. Communities are currently working to raise awareness about the dangers associated with commercial tobacco use and would benefit from the responsiveness of future funders to these requests.

Further Consideration of the Impact of Tobacco Control Policies on Young Adult Smoking in Light of the Liberalization of Cannabis Policies

INTRODUCTION

Changing patterns of cannabis consumption related to the liberalization of cannabis policies may have a countervailing effect on tobacco use. We analyzed whether cannabis policies have tempered the effects of tobacco control policies as well as the extent to which they were associated with young adult cigarette smoking.

AIMS AND METHODS

Combining data on tobacco and cannabis policies at the state, county, and city levels with the nationally-representative geocoded National Longitudinal Survey of Youth 1997 and Census data, we use multilevel regression and fixed effect analyses to examine the impact of cannabis policies on any past 30-day cigarette smoking, frequency of smoking, and past 30-day near-daily smoking among young adults while accounting for community and individual covariates.

RESULTS

Tobacco control policies, including significant effects of comprehensive smoking bans, total vending machine restrictions, single cigarette sale restrictions, and advertising restrictions, remain robust in reducing young adult smoking, net of cannabis policy liberalization, including the legal status of possession, penalties for sale, and medical cannabis. Cannabis policies do not directly affect young adult smoking patterns in an adverse way.

CONCLUSIONS

This paper provides evidence that the liberalization of cannabis laws has not adversely affected the efficacy of tobacco control efforts.

IMPLICATIONS

While the effects of tobacco control policies on smoking are well-established, little research has considered how the liberalization of cannabis policies may affect these relationships, which is important given the co-use of these substances. This paper provides evidence that the liberalization of cannabis laws has not adversely affected tobacco control efforts.

Smoke-Free Laws and Disparities in Youth Smoking in the U.S., 2001-2018

INTRODUCTION

This study examines whether smoke-free laws are differentially associated with youth smoking outcomes by parental education, race/ethnicity, sex, and college plans in a U.S.

METHODS

This study assessed the relationships between smoke-free laws in workplaces and hospitality venues (restaurants/bars) and past 30-day smoking participation, first cigarette initiation, and daily smoking initiation within a repeated cross-sectional sample of 8th, 10th, and 12th graders from the Monitoring the Future study. Data were collected between 2001 and 2018 and were analyzed in 2020-2021. Grade-stratified Poisson models were used to calculate prevalence ratios and average marginal effects, incorporating interaction terms to examine differential associations across groups.

RESULTS

Hospitality smoke-free laws were significantly associated with lower probabilities of smoking participation in all grades as well as with first cigarette and daily smoking initiation in 8th and 10th grade. Workplace smoke-free laws were associated with lower probabilities of smoking participation among 10th and 12th graders as well as with first cigarette and daily smoking initiation among 10th graders. Average marginal effects ranged from -0.4 percentage points (hospitality laws and daily smoking initiation in 8th and 10th grades) to -2.2 percentage points (workplace laws and smoking participation in 10th grade). Associations between smoke-free laws and a lower probability of smoking participation were most pronounced among students who definitely planned to attend college. Other instances of effect modification suggested more pronounced associations for students who were female and from high-SES households; however, relationships varied by grade.

CONCLUSIONS

Smoke-free laws were associated with reduced smoking among youth; however, associations varied by grade, sex, parental education, and college plans.

Support of the Implementation of a Whistleblowing System for Smoke-Free Environments: A Mixed Methods Approach

Enforcement of a smoke-free policy is of vital concern in support of the health of smokers and bystanders. Indonesia has issued a smoke-free law, but implementation and enforcement lie with the regional and municipal governments. In a survey of 225 respondents recruited via schools, knowledge about the health effects of smoking and the smoke-free regulation, as well as attitudes towards and commitment and support of the enforcement of the smoke-free regulation in the Kendari City through an electronic whistleblowing system was examined. Furthermore, the participants were asked about the smoking status and smoking behavior. About half of the respondents were students (teenagers), the other half—their parents. Male respondents were strongly overrepresented (85%). Only 18% of the respondents declared to be smokers, mostly adults and males. Both the smokers and the non-smokers supported the smoke-free law and its enforcement through a whistleblowing system. Representatives of the local government were interviewed and participated in focus group discussions. In general, they also exhibited strong support of an electronic enforcement tool. However, issues of efficiency, costs, and responsibility must still be resolved. Nevertheless, an electronic whistleblowing system has the potential to further the health and livelihoods in a community like the Kendari City.

Key Informant Perspectives on Somali Adolescent Tobacco Use: Contextualizing Influences and Prevention Opportunities

INTRODUCTION

Somali American adolescent tobacco use has increased over the past decade amid a high prevalence of tobacco use among Somali American adults. While established adolescent tobacco use determinants may apply for Somali youth, a deeper understanding of these influences is imperative to the development of effective prevention strategies for this population. This study aimed to identify risk and protective factors influencing Somali American adolescent tobacco use decision making and potential family and community roles in tobacco prevention.

METHOD

We conducted 15 semistructured, in-depth interviews with 12 Somali and 3 non-Somali professionals serving Minnesotan metropolitan Somali communities in clinical, educational, religious, and other community organizations. Grounded Theory informed our data collection and analysis.

RESULTS

Key informants cited three major influences on Somali adolescent tobacco use: evolving norms and increasing exposure to tobacco products in the United States, low risks perception, especially for waterpipes, and conflicting interpretations of faith. Informants highlighted the important roles of families in Somali youth tobacco prevention while acknowledging areas where families would benefit from greater support. Proposed sources of support included faith communities and nonparental, ethnically similar adult mentors. Informants acknowledged challenges to addressing youth tobacco prevention in clinics and underscored the importance of youth involvement in developing prevention strategies.

CONCLUSIONS

Our results indicate Somali adolescent tobacco prevention efforts should address the evolving tobacco use exposures and norms, low risk perceptions, and clarify faith messaging. Effective strategies may include strengthening family-based tobacco prevention approaches that also engage faith and other community leaders along with youth themselves.

Community- and individual-level risk factors of past month e-cigarette use among adolescents in France

PURPOSE

Studies of adolescent e-cigarette use infrequently consider how environmental effects impact use. Adolescent e-cigarette use in France is also understudied, yet an important contrast since e-cigarette use rarely precedes conventional tobacco use and daily tobacco use is common. We examine whether there is significant variation in e-cigarette use across the geographic unit of départements (n = 95), and whether community factors explain these differences and individual-level probabilities of e-cigarette use.

METHODS

The ESCAPAD survey is a cross-sectional, nationally representative survey collected at a day of civic and military information mandatory for French 17-year-olds. We use the 2014 (n = 22,023) and 2017 (n = 39,115) surveys and geographic information from Eurostat and INSEE. Multilevel, multiple logistic regression models examine any and daily past month e-cigarette use.

RESULTS

We find significant département-level variation in both outcomes, with a considerable proportion of this variation explained by département-level factors. Net of numerous significant individual-level covariates, département-level unemployment (OR = 1.049, p < .05), poverty (OR=0.975, p < .05), age structure (OR=0.720, p < .01), and population growth (OR=0.987 p < .01) were associated with any past month use. The département-level percentage of adolescents using conventional tobacco daily was associated with individual-level any (OR=1.029, p < .001) and daily (OR=1.033, p < .01) e-cigarette use. Predicted probabilities demonstrate that département-level and individual-level tobacco use together were associated with e-cigarette use.

CONCLUSIONS

Researchers should incorporate community effects into studies of e-cigarette use. Particularly, the tobacco use environment contributes to risk of e-cigarette use. For policymakers, resources may be mobilized to address local socioeconomic, demographic, and tobacco use patterns to potentially affect adolescent e-cigarette use.

Adolescents' beliefs, attitudes and social norms with regard to smoking and sports: a qualitative study

OBJECTIVES

The aim of this study is to explore the beliefs, attitudes and social norms of Dutch adolescents with regard to smoking and sports. In addition, we examine whether there are differences between adolescents at sports clubs with versus without an outdoor smoke-free policy (SFP).

DESIGN

Qualitative design in the form of focus group interviews.

SETTING

Focus group interviews (n=27) were conducted at 16 sports clubs in the Netherlands. Soccer, tennis, field hockey and korfball clubs were included. Focus group discussions were transcribed verbatim and analysed thematically using MAXQDA.

PARTICIPANTS

180 adolescents aged 13-18 years old were included in the study. All participants signed an informed consent form. For participants younger than 16 years, parental consent was required.

RESULTS

With respect to smoking in relation to sports, participants had mostly negative beliefs (ie, smoking has a negative effect on health and sports performance), attitudes (ie, sports and smoking are activities that do not fit together; at sports clubs smoking is not appropriate), and social norms (ie, it is not normal to smoke at sports clubs). The same beliefs, attitudes and social norms were expressed by participants at both sports clubs with and without an outdoor SFP. However, argumentation against smoking was more detailed and more consistent among participants at sports clubs with an outdoor SFP.

CONCLUSION

Adolescents have negative beliefs, attitudes and social norms with regard to smoking in relationship to sports. Outdoor SFP at sports clubs might reinforce these negative associations. These findings point to the potential importance of sports in the prevention of adolescent smoking.

Smoke-Free Laws and Disparities in Secondhand Smoke Exposure Among Nonsmoking Adults in the United States, 1999-2014

INTRODUCTION

Little is known about the relationship between smoke-free laws and persistent disparities in secondhand smoke (SHS) exposure among nonsmoking adults in the United States.

AIMS AND METHODS

We constructed time-varying smoke-free law measures representing whether or not at least 50% of each US county's population was covered by smoke-free laws in workplaces and hospitality venues (restaurants/bars). We merged these data with restricted data on cotinine-derived SHS exposure among nonsmokers from the National Health and Nutrition Examination Survey, 1999-2014 (N = 25 444). Using logistic regression, we estimated associations between smoke-free law coverage and SHS exposure among all nonsmokers, and within age strata (25-39, 40-59, 60+). We explored differential associations by gender, race/ethnicity, education, and poverty-income ratio (PIR) by testing the significance of interactions terms for the full sample and within age strata.

RESULTS

In adjusted models, hospitality coverage was associated with lower odds of SHS exposure in the full sample (odds ratio [OR] = 0.62; 95% confidence interval [CI] = 0.51-0.76), and within each age group, with ORs ranging from 0.58 (ages 25-39) to 0.67 (ages 60+). Workplace coverage was associated with lower SHS exposure only among younger adults (OR = 0.81; 95% CI = 0.65-0.99). Within the full sample and among adults ages 40-59, hospitality laws were associated with narrowing SHS exposure differentials between males and females. Among adults ages 40-59, workplace laws were associated with narrowing exposure differentials between males and females, but worsening exposure disparities by PIR.

CONCLUSIONS

Smoke-free laws may reduce SHS exposure among adult nonsmokers, but may be insufficient to improve disparities in SHS exposure.

IMPLICATIONS

In a repeated cross-sectional sample of adult nonsmokers, smoke-free laws in hospitality venues were consistently associated with lower odds of SHS exposure and appeared to narrow exposure differentials between males and females. Associations between workplace smoke-free laws and SHS exposure were variable by age. Among adults ages 40-59, workplace laws were associated with narrowing exposure differentials between males and females while exacerbating exposure differentials by PIR. Differential patterns of association highlight the need to examine the impacts of tobacco control policies on downstream health equity.

Exposure to new smoking environments and individual-level cigarette smoking behavior: Insights from exogenous assignment of military personnel

Despite overall declines in cigarette smoking prevalence in the United States (U.S.) in the past several decades, smoking rates remain highly variable across geographic areas. Past work suggests that smoking norms and exposure to other smokers in one's social environment may correlate with smoking risk and cessation, but little is known about how exposure to other smokers in one's community is causally linked to smoking behavior - in part due to endogeneity and inability to randomly assign individuals to different 'smoking environments.' The goal of this study was to evaluate how exposure to localities with high population-level smoking prevalence affects individual-level cigarette smoking behaviors, including quitting. The study addresses key limitations in the literature by leveraging a unique natural experiment: the plausibly exogenous compulsory assignment of military personnel to installations. Logistic and multivariate regressions estimated cross-sectional associations between smoking/quitting behaviors and our proxy for social environments for smoking, county-level smoking prevalence (CSP). Across 563 U.S. counties, CSP ranged from 3.8 to 37.9%. Among the full sample, a 10 percentage point increase in CSP was associated with an 11% greater likelihood of smoking. In subgroup analyses, young adults, women, those without children in the household, and risk/sensation-seekers were more likely to smoke and less likely to quit when exposed to counties with higher CSP. Relocation to areas with high population-level smoking prevalence may increase likelihood of smoking and impede quitting, and may disparately affect some population subgroups. Findings provide novel evidence that community smoking environments affect adult smoking risk and underscore a need for sustained, targeted efforts to reduce smoking in areas where prevalence remains high.

A public health approach to gambling regulation: countering powerful influences

Often portrayed as a harmless leisure activity in the UK, gambling is being increasingly recognised as a public health concern. However, a gambling policy system that explicitly tackles public health concerns and confronts the dependencies and conflicts of interest that undermine the public good is absent in the UK. Although there is a window of opportunity to change the gambling policy system, with the UK Government's launch of a review of the Gambling Act 2005, the adoption of a comprehensive and meaningful public health approach is not guaranteed. Too often, government policy has employed discourses that align more closely with those of the gambling industry than with those of the individuals, families, and communities affected by the harms of gambling. In view of the well described commercial determinants of health and corporate behaviour, an immense effort will be needed to shift the gambling discourse to protect public health. In this Viewpoint, we seek to advance this agenda by identifying elements that need challenging and stimulating debate.

Bar Atmospherics and Smoking: A Qualitative Analysis of New Zealand Young Adult Smokers

INTRODUCTION

Smoking among young adults is often associated with social contexts and alcohol use. Although many countries, including New Zealand, have prohibited smoking inside licensed premises, outdoor areas have enabled smoking and alcohol co-use to persist. We examined whether and how outdoor bar areas facilitate and normalize young adult smoking and explored potential policy implications.

METHODS

We conducted in-depth interviews with 22 young adults who had recently smoked in a New Zealand bar or nightclub and investigated how physical design attributes (atmospherics) influenced experiences of smoking in outside bar settings. We used qualitative description to identify recurring accounts of the outdoor bar environment and thematic analysis to explore how participants experienced the bar in relation to smoking.

RESULTS

Participants valued outdoor smoking areas that were comfortable and relaxing, and saw attributes such as seating, tables, heating, protection from inclement weather, and minimal crowding, as important. We identified four themes; these explained how participants used smoking to gain respite and make social connections, showed how bar settings enabled them to manage smoking's stigma, and identified potential policy measures that would decouple smoking and alcohol co-use.

CONCLUSIONS

Evidence bar environments facilitate and normalize smoking among young adults questions whether smokefree policies should be expanded to include all bar areas. Introducing more comprehensive smokefree outdoor policies could reduce the influence of design attributes that foster smoking while also reframing smoking as outside normal social practice.

IMPLICATIONS

Bar environments contain many stimuli that cue and reinforce smoking and integrate smoking into social experiences. Expanding smokefree bar settings to include outdoor areas would reduce exposure to these stimuli, decrease opportunities for casual smoking, help maintain young people's smokefree status, and support longer-term goals of sustained reductions in smoking prevalence.

Intergenerational Coresidential Patterns by Young Adult's and Their Mother's Mental Health and Substance Use

Intergenerational coresidence is at a 30-year high. Studies find that economic, familial, and demographic factors shape the likelihood of this arrangement. We use NLSY79 and NLSY79YA data (2000-2014; N = 3,092) to examine how the mental health and substance use of both adult children and their mothers matter for coresidential biographies, estimating risks of moving out of and returning to their mothers' households. Adult children who drink, smoke, or have more depressive symptoms, or whose mothers drink or smoke, are more likely to leave their mother's household; adult children with more depressive symptoms and who smoke are more likely to return. Our findings show that children's and mothers' health are key determinants of coresidential patterns, suggesting that it is not just family arrangements that impact health but health that impacts family arrangements. As intergenerational coresidence increases, researchers should continue to look beyond economic, familial, and demographic determinants of coresidence to health dynamics.

Social capital and peer influence of tobacco consumption: a cross-sectional study among household heads in rural Uttar Pradesh, India

OBJECTIVE

Having the world's second-largest tobacco-consuming population, tobacco control is a priority agenda of the Indian Government. Yet, there is no evidence of how peer influence and nature of social relationships-defined as social capital-affect tobacco use. This study aimed to explore the role of social capital and peer influence on tobacco consumption among household heads in rural Uttar Pradesh (UP), India.

DESIGN AND SETTING

This study was embedded within the baseline evaluation of Project Samuday. A cross-sectional multistage cluster survey was implemented in six census blocks of Hardoi and Sitapur districts of UP from June to August 2017. Self-reported tobacco consumption status of randomly selected 6218 household heads (≥18 years; men vs women=5312 vs 906) was assessed from 346 rural communities. Peer influence of tobacco use was measured by the non-self cluster proportion of tobacco consumption among respondents. Community engagement, social support, trust and social cohesion were separately measured as unique facets of social capital both at individual and community levels using the Shortened Adapted Social Capital Assessment Tool in India (SASCAT-I). The explanatory power of covariates was assessed using gender-stratified generalised estimating equations (GEE) with robust-variance estimator.

RESULT

Tobacco consumption patterns were starkly different for men and women (71% vs 14%). The peer influence only affected men (adjusted odds ratio (AOR)=1.10, 95% CI: 1.05 to 1.16, p<0.01), whereas women were more likely to consume tobacco if they were more engaged with community organisations (AOR=1.33, 95% CI=1.07 to 1.66, p<0.01).

CONCLUSION

Gender alters the way social engagement affects tobacco use in rural India. Countering peer influence on Indian men should be prioritised as a tobacco control strategy. Moreover, as gender mainstreaming is a critical egalitarian agenda in India, further research is needed to understand how social engagement affects tobacco consumption behaviours among women.

Smoking in apartment buildings - Spatiality, meanings and understandings

Increased higher density urban living may exacerbate exposure to environmental tobacco smoke. Using a social practices lens, this research explored the locations, experiences and governance of smoking in apartment buildings in Melbourne, Australia, through semi-structured interviews in high-rise buildings ranging from subsidised housing to luxury apartments. Tacit rules on acceptable locations, building rules and smoke alarms in public areas consigned smoking to balconies and building entrances. The perceived health threat from second hand smoke and mental stress due to invasion of olfactory and visual privacy undermined the full enjoyment of the home environment. Interventions may benefit from targeting the link between smoking and balconies.

Cancer Prevention in Low-Resource Countries: An Overview of the Opportunity

Rising trends in the incidence of cancer in low- and middle-income countries (LMICs) add to the existing challenges with communicable and noncommunicable diseases. While breast and colorectal cancer incidence rates are increasing in LMICs, the incidence of cervical cancer shows a mixed trend, with rising incidence rates in China and sub-Saharan Africa and declining trends in the Indian subcontinent and South America. The increasing frequencies of unhealthy lifestyles, notably less physical activity, obesity, tobacco use, and alcohol consumption are causing a threat to health care in LMICs. Also, poorly developed health systems tend to have inadequate resources to implement early detection and adequate basic treatment. Inequalities in social determinants of health, lack of awareness of cancer and preventive care, lack of efficient referral pathways and patient navigation, and nonexistent or inadequate health care funding can lead to advanced disease presentation at diagnosis. This article provides an overview of opportunities to address cancer control in LMICs, with a focus on tobacco control, vaccination for cervical cancer, novel tools to assist with early detection, and screening for breast and other cancers.

National Tobacco Control Policies from the Perspectives of Singapore Young Male Adults

Between 2016 and 2018, tobacco control legislation has undergone several amendments to further restrict tobacco use in Singapore. This study explored the attitudes toward these policy changes and the perceived effectiveness of legislations from the perspectives of young male adults in Singapore. Twenty-nine semi-structured telephone interviews were conducted among young male adults who have completed their National Service in 2017/18 and self-reported as a smoker at pre-enlistment screening. Young male smoker perspectives on Singapore tobacco policies including taxation, smoke-free environment, point-of-sale display ban on tobacco products, graphic health warnings, and raising the minimum legal age of smoking to 21, were evaluated. Participants held the view that cigarette pricing was a highly effective approach to control their smoking behavior because it has a direct impact on tobacco affordability, and they shared that the least effective approaches were point-of-sale display bans and graphic health warnings. Results demonstrate that participants were well aware of tobacco control policies in Singapore, but they did not always fully accept them or understand the rationale behind them. Tobacco control measures should be implemented along with public education to correct misperceptions and increase public support for tobacco control measures in Singapore.

Influence of Social Connections on Smoking Behavior across the Life Course

Although we know much about demographic patterns of smoking, we know less about people's explanations for when, how and why they avoid, develop, or alter smoking habits and how these explanations are linked to social connections across the life course. We analyze data from in-depth interviews with 60 adults aged 25-89 from a large southwestern U.S. city to consider how social connections shape smoking behavior across the life course. Respondents provided explanations for how and why they avoided, initiated, continued, and/or quit smoking. At various times, social connections were viewed as having both positive and negative influences on smoking behavior. Both people who never smoked and continuous smokers pointed to the importance of early life social connections in shaping decisions to smoke or not smoke, and viewed later connections (e.g., marriage, coworkers) as less important. People who quit smoking or relapsed tended to attribute their smoking behavior to social connections in adulthood rather than early life. People who changed their smoking behavior highlighted the importance of transitions as related to social connections, with more instability in social connections often discussed by relapsed smokers as a reason for instability in smoking status. A qualitative approach together with a life course perspective highlights the pivotal role of social connections in shaping trajectories of smoking behavior throughout the life course.

Moving Upstream: The Effect of Tobacco Clean Air Restrictions on Educational Inequalities in Smoking Among Young Adults

Education affords a range of direct and indirect benefits that promote longer and healthier lives and stratify health lifestyles. We use tobacco clean air policies to examine whether policies that apply universally-interventions that bypass individuals' unequal access and ability to employ flexible resources to avoid health hazards-have an effect on educational inequalities in health behaviors. We test theoretically informed but competing hypotheses that these policies either amplify or attenuate the association between education and smoking behavior. Our results provide evidence that interventions that move upstream to apply universally regardless of individual educational attainment-here, tobacco clean air policies-are particularly effective among young adults with the lowest levels of parental or individual educational attainment. These findings provide important evidence that upstream approaches may disrupt persistent educational inequalities in health behaviors. In doing so, they provide opportunities to intervene on behaviors in early adulthood that contribute to disparities in morbidity and mortality later in the life course. These findings also help assuage concerns that tobacco clean air policies increase educational inequalities in smoking by stigmatizing those with the fewest resources.

Attitudes of Korean smokers towards smoke-free public places: findings from the longitudinal ITC Korea Survey, 2005-2010

OBJECTIVE

Prior to December 2012, restaurants in South Korea were required to implement only partial smoking bans. This study documents the changes in Korean smokers' attitudes towards smoking bans between 2005 and 2010 and explores the effects of anti-smoking advertising as a correlate of support for total smoking bans in public places.

DESIGN

Longitudinal cohort study of Korean adult smokers.

SETTING

The data were derived from three waves (2005, 2008 and 2010) of the International Tobacco Control (ITC) Korea Survey.

PARTICIPANTS

The ITC Korea Survey respondents were a probability-based, nationally representative sample of Korean smokers aged 19 and older. The current analysis includes 995 smokers who participated in Wave 1 (2005), 1737 smokers who participated in Wave 2 (2008) and 1560 smokers who participated in Wave 3 (2010).

PRIMARY AND SECONDARY OUTCOME MEASURES

Changes in respondents' awareness of secondhand smoke (SHS) harm, attitudes towards smoking bans and personal rules for smoking in private homes and/or vehicles were analysed. Correlates of support for smoking bans in public places were examined using generalised estimating equation regression models.

RESULTS

More than 80% of Korean smokers are aware of the harms of SHS. The proportion of smokers who support smoke-free restaurants or smoke-free bars increased twofold between 2005 and 2010. Smokers who were aware of the dangers of SHS were more likely to support a total smoking ban in workplaces. Noticing anti-smoking advertising or information was not significantly associated with support for a total smoking ban in public places.

CONCLUSIONS

Korean smokers became more supportive of smoking bans in public places between 2005 and 2008. These results show that smokers' attitudes towards smoking bans can change with the implementation of smoke-free policies, even in a country that has a high prevalence of smokers.

"Don't smoke in public, you look like trash": An exploratory study about women's experiences of smoking-related stigmatisation and the connection to neighbourhood-level deprivation

In this exploratory qualitative study we used Goffman's theory of stigmatisation to examine how women experience smoking-related stigma in relation to neighbourhood-level deprivation. From an existing cohort, we recruited fifteen women who smoked. We found differences in the women's experiences and abilities to negotiate and avoid a stigmatised smoking identity based on neighbourhood-level deprivation. Women in high-deprivation neighbourhoods described limited access to such places and this restricted their abilities to 'pass' as non- or not-quite-smokers and avoid smoking-related stigmatisation. We discuss the implications of the findings in relation to social-spatial inequalities in health and public health policy.