Tobacco smoke exposure in public places and workplaces after smoke-free policy implementation: a longitudinal analysis of smoker cohorts in Mexico and Uruguay

To use or not to use electronic cigarettes? Reasons for use, stopping use and their behavioural sequelae among Mexicans who smoke

INTRODUCTION

Reasons for using and stopping the use of e-cigarettes and their associations with transitions in nicotine product use are relatively unknown in countries with e-cigarette bans, such as Mexico.

METHODS

Data comes from an open cohort of people who smoke in Mexico, surveyed every 4 months from November 2018 to November 2021. Those who smoked and used e-cigarettes at time t (n=904 individuals, 1653 observations) were categorised at 4-month follow-up (t+1): (1) continued 'dual use', (2) exclusive smoking, (3) exclusive use of e-cigarettes or neither product. For people who formerly used e-cigarettes at time t (n=332 individuals, 372 observations), follow-up categories were: (1) continued exclusive smoking; (2) re-initiated e-cigarette use. Multinomial and logistic models regressed follow-up status (ref=status at time t) on reasons for using or stopping e-cigarette use, respectively, at time t, adjusting for covariates.

RESULTS

The most prevalent reasons for current e-cigarette use were 'they were less harmful to others' (40.5%) and 'enjoyable' (39.0%). Those who reported using e-cigarettes because they were less harmful to others (Adjusted Relative Risk Ratio (ARRR)=0.67), more enjoyable (ARRR=0.52), could help them to quit smoking (ARRR=0.65), or to control weight (ARRR=0.46) were less likely to return to exclusively smoking. Among people who formerly used e-cigarettes, lack of satisfaction was the primary reason for stopping e-cigarette use (32%) and those who reported this were less likely to start using e-cigarettes again at follow-up (Adjusted Odds Ratio (AOR)=0.58).

CONCLUSIONS

Specific reasons for using and stopping e-cigarettes predict changes in smoking and e-cigarette use, and targeting these beliefs could promote desired behaviour changes.

The potential impact of removing a ban on electronic nicotine delivery systems using the Mexico smoking and vaping model (SAVM)

Objective

To develop the Mexico Smoking and Vaping Model (Mexico SAVM) to estimate cigarette and electronic nicotine delivery systems (ENDS) prevalence and the public health impact of legalizing ENDS use.

Methods

SAVM, a cohort-based discrete-time simulation model, compares two scenarios. The ENDS-Restricted Scenario estimates smoking prevalence and associated mortality outcomes under the current policy of an ENDS ban, using Mexico-specific population projections, death rates, life expectancy, and smoking and e-cigarette prevalence. The ENDS-Unrestricted Scenario projects smoking and vaping prevalence under a hypothetical scenario where ENDS use is allowed. The impact of legalizing ENDS use is estimated as the difference in smoking- and vaping-attributable deaths (SVADs) and life-years lost (LYLs) between the ENDS-Restricted and Unrestricted scenarios.

Results

Compared to a national ENDS ban, The Mexico SAVM projects that legalizing ENDS use could decrease smoking prevalence by 40.1% in males and 30.9% in females by 2049 compared to continuing the national ENDS ban. This reduction in prevalence would save 2.9 (2.5 males and 0.4 females) million life-years and avert almost 106 (91.0 males and 15.5 females) thousand deaths between 2025 and 2049. Public health gains decline by 43% to 59,748 SVADs averted when the switching rate is reduced by half and by 24.3% (92,806 SVADs averted) with a 25% ENDS risk level from that of cigarettes but increased by 24.3% (121,375 SVADs averted) with the 5% ENDS risk.

Conclusions

Mexico SAVM suggests that greater access to ENDS and a more permissive ENDS regulation, simultaneous with strong cigarette policies, would reduce smoking prevalence and decrease smoking-related mortality. The unanticipated effects of an ENDS ban merit closer scrutiny, with further consideration of how specific ENDS restrictions may maximize public health benefits.

Achievements, challenges, priorities and needs to address the current tobacco epidemic in Latin America

Most Latin American countries have signed and ratified the FCTC, although implementation has been uneven. Countries across the region were relatively quick to adopt mandatory smoke-free workplace policies, but regional progress in other areas has been slower. In taxation, for example, Uruguay and Brazil have made considerable progress while Paraguay and Bolivia have relatively weak policies. More recently, the region is grappling with challenges regulating novel tobacco and nicotine products. Market share for flavor capsule cigarettes in Latin America is the highest in the world; electronic cigarettes and heated tobacco products are, for the most part, dissimilarly regulated; and uptake of these emerging products by adolescents and young adults is on the rise. In examining the needs and challenges in the region, we conclude that the adoption of a strong regulatory framework based on the FCTC and its Protocols is needed to accelerate a positive public health impact. In particular, countries in the region need more consistent progress in implementing FCTC provisions while strengthening regulation of flavored tobacco products, electronic cigarettes and heated tobacco products. Failing to do so threatens to undermine the progress Latin America has made in tobacco use prevention and control.

Better air but not for all? Changes in second-hand smoke exposure at workplaces in 29 European countries over 10 years

BACKGROUND

As the largest study of its kind to date, this article aims to describe the scope, trends over time, socio-demographic risk groups and the association with different progressive regulations relating to workplace second-hand smoke (SHS) exposure in 29 European countries during a period of high regulatory action.

METHODS

Three waves of the European Working Conditions Surveys (2005, 2010 and 2015) were evaluated, including a total of 95 718 workers. The samples are representative for all employed residents of the 29 countries included. All interviews were conducted face-to-face at respondents' homes (computer-assisted personal interviews). SHS exposure among the overall working population of 29 countries-including smokers-was examined. Workplace regimes were grouped corresponding to the sub-scale 'workplace' as used in the Tobacco Control Scale.

RESULTS

Between 2005 and 2015, SHS exposure in the European countries declined from around 19.0% (95% CI 16.1-22.0) to 9.9% (8.3-11.5). High SHS-exposure was reported by workers with the lowest level of education [11.5% (9.7-13.2)], among high-skilled manual labourers [14.3% (12.1-16.4)] and among those without a standard employment contract [11.2% (9.3-13.1)]. The highest exposure was reported by workers in the food service industry [19.7% (16.8-22.6)]. Countries with less workplace-related smoking prevention regulations were found to have the highest overall levels of exposure.

CONCLUSION

This multinational series of cross-sectional surveys on the trends in passive smoking in the workplace have shown that countries with more comprehensive workplace smoking bans overall report lower levels of SHS exposure among their work force as compared with slow progressing countries.

Smoke-Free Air Interventions in Seven Latin American Countries: Health and Financial Impact to Inform Evidence-Based Policy Implementation

INTRODUCTION

Disease burden due to tobacco smoking in Latin America remains very high. The objective of this study was to evaluate the potential impact of implementing smoke-free air interventions on health and cost outcomes in Argentina, Bolivia, Brazil, Chile, Colombia, Mexico, and Peru, using a mathematical model.

AIMS AND METHODS

We built a probabilistic Monte Carlo microsimulation model, considering natural history, direct health system costs, and quality of life impairment associated with main tobacco-related diseases. We followed individuals in hypothetical cohorts and calculated health outcomes on an annual basis to obtain aggregated 10-year population health outcomes (deaths and events) and costs. To populate the model, we completed an overview and systematic review of the literature. Also, we calibrated the model comparing the predicted disease-specific mortality rates with those coming from local national statistics.

RESULTS

With current policies, for the next 10 years, a total of 137 121 deaths and 917 210 events could be averted, adding 3.84 million years of healthy life and saving USD 9.2 billion in these seven countries. If countries fully implemented smoke-free air strategies, it would be possible to avert nearly 180 000 premature deaths and 1.2 million events, adding 5 million healthy years of life and saving USD 13.1 billion in direct healthcare.

CONCLUSIONS

Implementing the smoke-free air strategy would substantially reduce deaths, diseases, and health care costs attributed to smoking. Latin American countries should not delay the full implementation of this strategy.

IMPLICATIONS

Tobacco smoking is the single most preventable and premature mortality cause in the world. The Framework Convention on Tobacco Control, supported by the World Health Organization, introduced a package of evidence-based measures for tobacco control. This study adds quality evidence on the potential health effects and savings of implementing smoke-free air policies in countries representing almost 80% of the Latin America and the Caribbean population.

The impact of local smoke-free policies on smoking behaviour among adults in Indonesia: a quasi-experimental national study

AIMS

To investigate to what extent the adoption of local smoke-free policies (SFPs) in Indonesia in 2007-13 was associated with changes in adult smoking behaviour.

DESIGN

A quasi-experimental study.

SETTING

Indonesia, 2007 and 2013.

PARTICIPANTS

A total of 1 052 611 > 25-year-old adults. Data were derived from the 2007 and 2013 Indonesian national health survey.

MEASUREMENTS

For both years, provincial and district SFPs were identified from government documents in 497 districts in 33 provinces. Multi-level logistic regression analysis assessed the association of adoption of provincial and district SFPs between 2007 and 2013 with smoking continuation (among ever-smokers), current smoking and high smoking intensity (among current smokers). We controlled for survey year, SFP in 2007, socio-demographics and district characteristics.

FINDINGS

Provincial SFP exposure was associated with lower odds of smoking continuation [strong SFP versus no SFP: odds ratio (OR) = 0.71, 95% confidence interval (CI) = 0.66-0.76] and smoking intensity (strong SFP: OR= 0.91, 95% CI = 0.86-0.97), but also with higher odds of current smoking (strong SFP versus no SFP: OR = 1.08; 95% CI = 1.04-1.12). District SFP exposure was associated with higher odds of smoking continuation (strong SFP versus no SFP: OR = 1.07, 95% CI = 1.01-1.14) and current smoking (strong SFP versus no SFP: OR = 1.09, 95% CI = 1.05-1.14), but with lower odds of smoking intensity (moderately strong SFP versus no SFP: OR = 0.95, 95% CI = 0.91-0.99).

CONCLUSIONS

There may be an association between the adoption of local smoke-free policies in Indonesia and decreased adult smoking intensity. However, the evidence is inconsistent, which may reflect problems with policy implementation and enforcement.

Smoking trends in Mexico, 2002-2016: before and after the ratification of the WHO's Framework Convention on Tobacco Control

INTRODUCTION

Mexico was the first Latin American country to ratify the Framework Convention on Tobacco Control (FCTC) in 2004, after which it implemented some key FCTC policies (e.g., taxes, smoke-free, pictorial warnings and ad bans). This study assessed trends in the prevalence of current, daily and non-daily smoking in Mexico before and after the implementation of key FCTC policies.

METHODS

Data were analysed from two comparable, nationally representative surveys (i.e., the National Survey on Addictions 2002, 2011 and 2016, and the Global Adult Tobacco Survey 2009 and 2015). The pooled sample comprised 100 302 persons aged 15-65 years. Changes in the prevalence of current, daily and non-daily smoking were assessed.

RESULTS

From 2002 to 2016, the prevalence of current smoking fell 11% in relative terms (from 21.5% to 19.0%). The decrease was registered between 2002 and 2009, and after that, a slight increase was observed (from 16.5% in 2009 to 19% in 2016). The prevalence of daily smoking decreased by about 50% between 2002 and 2016 (from 13.5% to 7.0%) with most of the decrease occurring by 2009. Conversely, the prevalence of non-daily smoking increased by 35% between 2009 and 2016 (from 8.8% to 11.9%).

CONCLUSIONS

Full implementation of the FCTC is necessary to further reduce smoking. Specific interventions may be needed to target non-daily smokers, who now comprise more than half of current smokers in Mexico.

Changes in adolescent smoking with implementation of local smoke-free policies in Indonesia: Quasi-experimental repeat cross-sectional analysis of national surveys of 2007 and 2013

BACKGROUND

Banning smoking from public places may prevent adolescent smoking, but there is little evidence on impact of smoke-free policies (SFPs) from low and middle-income countries. This study assessed to what extent the adoption of local SPFs in Indonesia between 2007 and 2013 associated with adolescent smoking.

METHODS

Data on 239,170 adolescents (12-17 years old) were derived from the 2007 and 2013 national health surveys in 497 districts and 33 provinces. This study compared 2013 survey respondents living in districts/provinces that adopted SFPs between 2007 and 2013, with 2007 respondents and 2013 respondents in districts/provinces that did not adopt policies. Multilevel logistic regression analysis assessed whether SFP was associated with daily and non-daily smoking. We controlled for survey year, SFP in 2007, socio-demographics, and district characteristics.

RESULTS

Strong district SFPs was significantly associated with lower odds of daily smoking (OR:0.81, 95 %CI:0.69-0.97), but non-significantly with non-daily smoking (OR:0.89, 95 %CI:0.76-1.05). Strong provincial SFPs was not associated with daily smoking (OR:1.02, 95 %CI:0.84-1.25), but was associated with higher odds of non-daily smoking (OR:1.22, 95 %CI:0.99-1.51). Moderately strong SFPs did not consistently show associations in the same direction. For example, moderately strong provincial SFP was associated with higher odds of daily smoking (OR:1.27, 95 %CI:1.11-1.46) and lower odds of non-daily smoking (OR:0.82, 95 %CI:0.72-0.93).

CONCLUSION

We did not detect a consistent short-term effect of district and province-level smoke-free policies on adolescent smoking in Indonesia. Weak implementation and poor compliance may compromise effectiveness, which would call for improvement of SFP implementation in Indonesia.

Implementing smoke-free policies in low- and middle-income countries: A brief review and research agenda

INTRODUCTION

Some low- and middle-income countries (LMICs) struggle to implement smoke-free policies. We sought to review the academic and gray literature, and propose a research agenda to improve implementation of smoke-free policies and make them more effective in LMICs.

METHODS

We reviewed 10 databases for variations of (‘implementation’ /‘enforcement’ /‘compliance’) and (‘smoke-free’ /‘ban’ /‘restriction’) and (‘tobacco’ /‘smoking’). We also reviewed cited sources and the gray literature including non-governmental organization reports.

We included articles that described problems that arose, attempted solutions, lessons learned, and research questions posed regarding smoke-free policy implementation in LMICs. We excluded studies of high-income countries, institution-level implementation, voluntary smoke-free policies, smoke-free homes, and outdoor smoke-free policies.

RESULTS

The academic literature review led to 4931 unique articles, reduced to 1541 after title screening, 331 after abstract screening, and 101 after full-text review. The citation and gray literature review led to an additional 179 publications of which 67 met the inclusion criteria. In total we retained 168 sources. We conducted a narrative review and synthesis of the literature, extracting key themes and noting research gaps.

CONCLUSIONS

We find that progress is urgently needed in five categories: identifying the critical lessons learned for effective implementation, evaluating different enforcement approaches, learning how to rejuvenate stalled smoke-free policies, learning how to increase ground-level will to enforce policies, and developing a conceptual framework that explains implementation. Investigation into these topics can improve implementation of smoke-free policies in LMICs.

A Mobile Smoking Cessation Intervention for Mexico (Vive sin Tabaco... ¡Decídete!): Single-Arm Pilot Study

BACKGROUND

Of the 14.3 million Mexicans who smoke, only a minority take advantage of evidence-based approaches to smoking cessation. Mobile health interventions have the potential to increase the reach of effective cessation interventions in Mexico.

OBJECTIVE

This study aimed to assess the feasibility and acceptability of an innovative, personalized, and interactive smoking cessation mobile intervention developed for Mexican smokers.

METHODS

We recruited 40 Mexican smokers to participate in Vive sin Tabaco... ¡Decídete!, a smoking cessation program that uses a tablet-based decision support software to drive a 12-week text messaging smoking cessation program and pharmacotherapy support. Outcome measures included participant text messaging interactivity with the program, participant satisfaction, and 12-week verified abstinence using urinary cotinine testing or exhaled carbon monoxide.

RESULTS

Average age of the participants was 36 years (SD 10.7), and they were primarily male (65%, 26/40) with at least an undergraduate degree (62%, 25/40). Most participants (95%, 38/40) smoked daily and were interested in quitting in the next 7 days. As an indicator of participant interactivity, participants sent an average of 21 text messages during the 12-week intervention (SD 17.62). Of the 843 messages that participants sent to the program, only 96 messages (11.3%, 96/843) used keywords. At 12 weeks, 40% (16/40) of participants were biochemically verified (87%, 35/40, follow-up rate). The majority of participants (85%, 30/35) reported being very satisfied or extremely satisfied with the program.

CONCLUSIONS

The Vive sin Tabaco... ¡Decídete! smoking cessation mobile intervention was accepted by participants, generated high satisfaction and high text messaging interactivity, and resulted in a noteworthy cessation rate at the end of treatment. This intervention is a promising strategy for smoking cessation in Mexico. Additional testing as a formal randomized clinical trial appears warranted.

Implementation of 100% smoke-free law in Uganda: a qualitative study exploring civil society's perspective

BACKGROUND

In 2016, Uganda became one of few sub-Saharan African countries to implement comprehensive national smoke-free legislation. Since the World Health Organisation recommends Civil Society Organisation's (CSO) involvement to support compliance with smoke-free laws, we explored CSOs' perceptions of law implementation in Kampala, Uganda, and the challenges and opportunities for achieving compliance. Since hospitality workers tend to have the greatest level of exposure to second-hand smoke, we focussed on implementation in respect to hospitality venues (bars/pubs and restaurants).

METHODS

In August 2016, three months after law implementation, we invited key Kampala-based CSOs to participate in face-to-face semi-structured interviews. Interviews probed participants' perceptions about law implementation, barriers impeding compliance, opportunities to enhance compliance, and the role of CSOs in supporting law implementation. Interviews were recorded and transcribed. Qualitative content analysis was conducted using the interview transcripts.

RESULTS

Fourteen individuals, comprising mainly senior managers from CSOs, participated and reported poor compliance with the smoke-free law in hospitality venues. Respondents noted that contributing factors included low awareness of the law amongst the general public and hospitality staff, limited implementation activities due to scarce resources and lack of coordinated enforcement. Opportunities for improving compliance included capacity building for enforcement agency staff, routine monitoring, rigorous enactment of penalties, and education about the smoke-free law aimed at hospitality venue staff and the general public. Allegations of tobacco industry misinformation were said to have undermined compliance. Civil Society Organisations saw their role as supporting law implementation through education, stakeholder engagement, and evidence-based advocacy.

CONCLUSIONS

This study suggests that the process of smoke-free law implementation in Uganda has not aligned with World Health Organisation (WHO) guidelines for implementing smoke-free laws, and highlights that low-income countries may need additional support to enable them to effectively plan for policy implementation and resist industry interference.

A percepção do cumprimento das leis antifumo em bares e restaurantes em três cidades brasileiras: dados do ITC-Brasil

Resumo: O tabagismo passivo causa sérios e mortais efeitos à saúde. Desde 1996, o Brasil vem avançando na implementação da legislação antifumo em locais públicos fechados. Este artigo busca avaliar a percepção do cumprimento da legislação antifumo nas cidades de Porto Alegre (Rio Grande do Sul), Rio de Janeiro e São Paulo, com base nos resultados da pesquisa ITC-Brasil (International Tobacco Control Policy Evaluation Project). Os resultados desta pesquisa mostraram uma redução significativa da proporção de pessoas que notaram indivíduos fumando em restaurantes e bares entre 2009 e 2013 nas três cidades pesquisadas. Paralelamente, houve um aumento da proporção de fumantes que referiram ter fumado na área externa desses estabelecimentos. Tais resultados provavelmente refletem uma implementação exitosa das leis antifumo. Vale ressaltar que ao diminuir a exposição ao fumo passivo, aumentamos ainda mais a desnormalização do tabagismo na população em geral, podendo assim diminuir sua iniciação e aumentar a cessação de fumar.

Adherence to the Tobacco Control Act, 2007: presence of a workplace policy on tobacco use in bars and restaurants in Nairobi, Kenya

INTRODUCTION

Despite extensive knowledge about effective tobacco control interventions, the prevalence of tobacco use in many middle- and low-income countries continues to rise. In these countries, public appreciation of levels of protection provided by laws and regulations on tobacco use and exposure to tobacco smoke is limited. After ratification of the Framework Convention on Tobacco Control, Kenya enacted the Tobacco Control Act, 2007, banning smoking in public places except in designated smoking areas.

OBJECTIVE

To assess adherence to the Tobacco Control Act, 2007 by determining the presence of a workplace policy on tobacco use in bars and restaurants.

METHODS

A survey of 176 liquor licensed bars and restaurants in Nairobi County was carried out. Their managers were asked about the presence of a workplace policy governing smoking of tobacco, and observations made on provisions that determine adherence to the Tobacco Control Act, 2007.

RESULTS

Smoking took place in almost all bars and restaurants (150 (85%)). Half the establishments (86 (49%)) had a workplace policy governing tobacco use among employees, although a difference between bars (11 (23%)) and restaurants (75 (58%)) was recorded (p<0.001). Establishments at which managers had lower levels of education were less likely to have a workplace policy (p<0.001) and less likely to have 'no smoking' signs and designated smoking areas (p<0.005).

CONCLUSIONS AND RECOMMENDATIONS

Kenya's implementation of the Tobacco Control Act, 2007 does not provide sufficient protection of patrons and workers in bars and restaurants. It is important to sensitise hospitality workers to the dangers of tobacco smoke. Bar and restaurants managers should have a minimum post-secondary education level. The Tobacco Control Act, 2007 requires strengthening to ensure that bars and restaurants have a smoke-free environment.

Descriptive epidemiology of lung cancer and current status of tobacco control measures in Central and South America

RATIONALE AND OBJECTIVE

Lung cancer is the most commonly diagnosed cancer and the leading cause of cancer death in the world. In Central and South America lung cancer is now one of most frequent cancers and the leading cause of cancer-related death in both sexes. We describe patterns and trends in lung cancer incidence and mortality in Central and South America and give a brief overview of the current status of tobacco control measures based on the most recent MPOWER report.

METHODS

We obtained regional and national-level incidence data from 48 population-based cancer registries in 13 countries and cancer deaths from the WHO mortality database for 18 countries. We estimated world population age-standardized incidence and mortality rates per 100,000 person-years. Incidence of lung cancer by histological subtype were only available from high-quality population-based cancer registries for the period 2003-2007.

RESULTS

The highest incidence and mortality rates in the region were seen among males in Argentina, Cuba, Chile and Uruguay. Adenocarcinoma was the most frequent histological type overall, though squamous carcinoma was more frequent in Antofagasta-Chile and Villa Clara-Cuba. Smoke-free policies and warnings are widely implemented tobacco control measures; cessation is offered but the costs are not covered by health systems in the majority of countries.

CONCLUSION

The high burden of lung cancer in the region highlights the need to improve long term information and strengthen current tobacco control policies including aggressive taxing measures and supporting smoking cessation in order to achieve the targeted reductions in smoking prevalence.

Compliance to the smoke-free law in Guatemala 5-years after implementation

BACKGROUND

Smoke-free environments decrease smoking prevalence and consequently the incidence of heart disease and lung cancer. Due to issues related to poor enforcement, scant data is currently available from low/middle income countries on the long-term compliance to smoke-free laws. In 2006, high levels of secondhand smoke (SHS) were found in bars and restaurants in Guatemala City. Six months after a smoking ban was implemented in 2009, levels significantly decreased. However, in 2010, poor law compliance was observed. Therefore, we sought to assess long-term compliance to the ban using SHS measurements.

METHODS

In 2014 we assessed SHS exposure using airborne nicotine monitors in bars (n = 9) and restaurants (n = 12) for 7 days using the same protocol as in 2006 and in 2009. Nicotine was measured using gas-chromatography (μg/m(3)) and compared to levels pre- (2006) and post-ban (2009). Employees responded to a survey about SHS exposure, perceived economic impact of the ban and customers' electronic cigarette use. In addition, we estimated the fines that could have been collected for each law infringement.

RESULTS

Most (71 %) venues still have a smoking section, violating the law. The percentage of samples with detectable nicotine concentrations was 100, 85 and 43 % in 2006, 2009 and 2014, respectively. In bars, median (25(th) and 75(th) percentiles) nicotine concentrations were 4.58 μg/m(3) (1.71, 6.45) in 2006, 0.28 (0.17, 0.66) in 2009, and 0.59 (0.01, 1.45) in 2014. In restaurants, the corresponding medians were 0.58 μg/m(3) (0.44, 0.71), 0.04 (0.01, 0.11), and 0.01 (0.01, 0.09). Support for the law continues to be high (88 %) among bar and restaurant employees. Most employees report no economic impact of the law and that a high proportion of customers (78 %) use e-cigarettes. A total of US$50,012 could have been collected in fines.

CONCLUSIONS

Long-term compliance to the smoking ban in Guatemala is decreasing. Additional research that evaluates the determinants of non-compliance is needed and could also contribute to improve enforcement and implementation of the smoke-free law in Guatemala.

Adolescents' smoking experiences, family structure, parental smoking and socio-economic status in Ciudad Juárez, Mexico

BACKGROUND

Cigarette smoking is the leading cause of preventable death worldwide. Tobacco use and secondhand-tobacco smoke (SHS) exposure are classified as a pediatric disease. In Mexico, the prevalence of smoking has decreased among adults but paradoxically increased among adolescents, particularly among young females. This study was designed to determine the association between adolescents' smoking experiences (smoking behaviors and second hand smoke [SHS] exposure), family structure, parental smoking and socio-economic status (SES) in Ciudad Juárez, Mexico.

METHODS

This is a cross-sectional, population-based study. Data was collected from sixth-grade students (N = 506) attending school in Ciudad Juárez, Mexico. Descriptive analyses were conducted. The relationship between key outcome variables (adolescents smoking and SHS exposure) and independent variables (family structure, parental smoking, and SES level) were examined. Adjusted odds ratios were calculated. Multiple logistic regression analysis was performed while controlling for possible confounders (i.e. gender and age).

RESULTS

The overall prevalence of ever/lifetime smoking and SHS exposure at home was 29.6 and 41.1 %, respectively. Results of the logistic regression analysis show that being a member of a non-intact family [(OR = 2.20; 95 % CI = 1.21-3.90) and (OR = 2.45; 95 % CI = 1.19-4.10) respectively], having parents who smoke [(OR = 4.41; 95 % CI = 2.15-5.46) and (OR = 4.95; 95 % CI = 2.25-7.12) respectively], and living in low SES setting [(OR = 1.73; 95 % CI = 1.43-3.30) and (OR = 1.99; 95 % CI = 1.16-4.00) respectively] are significantly associated with ever smoking and SHS exposure at home among sixth grade students.

CONCLUSIONS

The findings of our study show that tobacco use and SHS exposure are strongly associated with adolescents living in low SES, non-intact households that have parents that smoke. To be effective, tobacco strategies specifically tailored for this particularly vulnerable group of adolescents would require a comprehensive, multi-faceted approach centered on prevention, cessation and protection.

Mexico SimSmoke: how changes in tobacco control policies would impact smoking prevalence and smoking attributable deaths in Mexico

We examined the effect of tobacco control policies in Mexico on smoking prevalence and smoking-related deaths using the Mexico SimSmoke model. The model is based on the previously developed SimSmoke simulation model of tobacco control policy, and uses population size, smoking rates and tobacco control policy data for Mexico. It assesses, individually, and in combination, the effect of six tobacco control policies on smoking prevalence and smoking-related deaths. Policies included: cigarette excise taxes, smoke-free laws, anti-smoking public education campaigns, marketing restrictions, access to tobacco cessation treatments and enforcement against tobacco sales youth. The model estimates that, if Mexico were to adopt strong tobacco control policies compared to current policy levels, smoking prevalence could be reduced by 30% in the next decade and by 50% by 2053; an additional 470,000 smoking-related premature deaths could be averted over the next 40 years. The greatest impact on smoking and smoking-related deaths would be achieved by raising excise taxes on cigarettes from 55% to at least 70% of the retail price, followed by strong youth access enforcement and access to cessation treatments. Implementing tobacco control policies in Mexico could reduce smoking prevalence by 50%, and prevent 470,000 smoking-related deaths by 2053.

The impact of neighbourhood violence and social cohesion on smoking behaviours among a cohort of smokers in Mexico

BACKGROUND

Recent increases in violent crime may impact a variety of health outcomes in Mexico. We examined relationships between neighbourhood-level violence and smoking behaviours in a cohort of Mexican smokers from 2011 to 2012, and whether neighbourhood-level social cohesion modified these relationships.

METHODS

Data were analysed from adult smokers and recent ex-smokers who participated in waves 5 and 6 of the International Tobacco Control Mexico survey. Self-reported neighbourhood violence and social cohesion were asked of wave 6 survey participants (n=2129 current and former smokers, n=150 neighbourhoods). Neighbourhood-level averages for violence and social cohesion (ranges 4-14 and 10-25, respectively) were assigned to individuals. We used generalised estimating equations to determine associations between neighbourhood indicators and individual-level smoking intensity, quit behaviours and relapse.

RESULTS

Higher neighbourhood violence was associated with higher smoking intensity (risk ratio (RR)=1.17, 95% CI 1.02 to 1.33), and fewer quit attempts (RR=0.72, 95% CI 0.61 to 0.85). Neighbourhood violence was not associated with successful quitting or relapse. Higher neighbourhood social cohesion was associated with more quit attempts and more successful quitting. Neighbourhood social cohesion modified the association between neighbourhood violence and smoking intensity: in neighbourhoods with higher social cohesion, as violence increased, smoking intensity decreased and in neighbourhoods with lower social cohesion, as violence increased, so did smoking intensity.

CONCLUSIONS

In the context of recent increased violence in Mexico, smokers living in neighbourhoods with more violence may smoke more cigarettes per day and make fewer quit attempts than their counterparts in less violent neighbourhoods. Neighbourhood social cohesion may buffer the impact of violence on smoking intensity.

Australian smokers' support for plain or standardised packs before and after implementation: findings from the ITC Four Country Survey

BACKGROUND

Plain packaging (PP) for tobacco products was fully implemented in Australia on 1 December 2012 along with larger graphic health warnings. Using longitudinal data from the Australian arm of the ITC Four Country Survey, we examined attitudes to the new packs before and after implementation, predictors of attitudinal change, and the relationship between support and quitting activity.

METHODS

A population-based cohort study design, with some cross-sectional analyses. Surveys of Australian smokers assessed attitudes to PP at four time points prior to implementation (from 2007 to 2012) and one post-implementation wave collected (early/mid-2013).

RESULTS

Trend analysis showed a slight rise in opposition to PP among smokers in the waves leading up to their implementation, but no change in support. Support for PP increased significantly after implementation (28.2% pre vs 49% post), such that post-PP more smokers were supportive than opposed (49% vs 34.7%). Multivariate analysis showed support either before or after implementation was predicted by belief in greater adverse health impacts of smoking, desire to quit and lower addiction. Among those not supportive before implementation, having no clear opinion about PP (versus being opposed) prior to the changes also predicted support post-implementation. Support for PP was prospectively associated with higher levels of quitting activity.

CONCLUSIONS

Since implementation of PP along with larger warnings, support among Australian smokers has increased. Support is related to lower addiction, stronger beliefs in the negative health impacts of smoking, and higher levels of quitting activity.

The support for smoke free policy and how it is influenced by tolerance to smoking - experience of a developing country

This cross sectional survey was conducted to determine the support in making Penang UNESCO World Heritage Site (GTWHS) smoke free and to determine the influence of tolerance towards smoking on this support. This is the first phase in making Penang, Malaysia a smoke free state. A multistage sampling process was done to select a sample of respondents to represent the population of GTWHS. Attitude towards smoking was assessed using tolerance as a proxy. A total of 3,268 members of the community participated in the survey. A big majority (n = 2969; 90.9%) of the respondents supported the initiative. Support was lowest among the owners and residents/tenants, higher age groups, the Chinese, men, respondents who had poor knowledge of the places gazetted as smoke free, and respondents with poor knowledge of the health effects on smokers and on passive smokers. The odds (both adjusted and unadjusted) of not supporting the initiative was high among those tolerant to smoking in public areas. Tolerance towards smoking was associated with 80.3% risk of non-support in the respondents who were tolerant to smoking and a 57.2% risk in the population. Health promotion and education concerning the harm of tobacco smoke in Malaysia, which has mainly targeted smokers, must change. Health education concerning the risks of second hand smoke must also be given to non-smokers and efforts should be made to denormalize smoking.

Neighbourhood deprivation and smoking and quit behaviour among smokers in Mexico: findings from the ITC Mexico Survey

BACKGROUND

In high-income countries (HICs), higher neighbourhood socioeconomic deprivation is associated with higher levels of smoking. Few studies in low-income and middle-income countries (LMICs) have investigated the role of the neighbourhood environment on smoking behaviour.

OBJECTIVE

To determine whether neighbourhood socioeconomic deprivation is related to smoking intensity, quit attempts, quit success and smoking relapse among a cohort of smokers in Mexico from 2010 to 2012.

METHODS

Data were analysed from adult smokers and recent ex-smokers who participated in waves 4-6 of the International Tobacco Control (ITC) Mexico Survey. Data were linked to the Mexican government's composite index of neighbourhood socioeconomic deprivation, which is based on 2010 Mexican Census data. We used generalised estimating equations to determine associations between neighbourhood deprivation and individual smoking behaviours.

FINDINGS

Contrary to past findings in HICs, higher neighbourhood socioeconomic deprivation was associated with lower smoking intensity. Quit attempts showed a U-shaped pattern whereby smokers living in high/very high deprivation neighbourhoods and smokers living in very low deprivation neighbourhoods were more likely to make a quit attempt than smokers living in other neighbourhoods. We did not find significant differences in neighbourhood deprivation on relapse or successful quitting, with the possible exception of people living in medium-deprivation neighbourhoods having a higher likelihood of successful quitting than people living in very low deprivation neighbourhoods (p=0.06).

CONCLUSIONS

Neighbourhood socioeconomic environments in Mexico appear to operate in an opposing manner to those in HICs. Further research should investigate whether rapid implementation of strong tobacco control policies in LMICs, as occurred in Mexico during the follow-up period, avoids the concentration of tobacco-related disparities among socioeconomically disadvantaged groups.