Impact of UK Tobacco Control Policies on Inequalities in Youth Smoking Uptake: A Natural Experiment Study

Navigating the nexus between British Columbia's public consumption and decriminalization policies of illegal drugs

In January 2023, the province of British Columbia (BC) decriminalized the possession of certain illegal drugs for personal use. The province's primary intent was to reduce the stigma associated with drug use, as well as barriers for people who use drugs (PWUD) to access treatment and supports. However, less than ten months into the decriminalization policy, due to growing concerns about public safety voiced by municipal governments and communities, the provincial government made amendments to the policy to ban the public consumption of illicit drugs in additional locations, and subsequently introduced additional legislation, Bill 34, aimed at regulating public consumption of drugs in public spaces. Some communities have also implemented local bylaws similarly regulating public drug use. Bill 34 and local bylaws may serve as tools to promote community health and safety and minimize direct and indirect harms associated with public drug use. However, such legislation may re-criminalize PWUD and reinforce negative perceptions surrounding drug use, especially if these policies are not paired with strategies to expand the availability and accessibility of critical harm reduction and housing services. Without ample access to these services, limitations on public drug use can potentially displace individuals to areas where they are more likely to use alone, further exposing them to substance use-related harms, and undermining the goals of decriminalization. The potential effects of these restrictions may also disproportionately impact marginalized populations. As of April 2024, Bill 34 remains on hold. Moving forward, it will be important to monitor this bill, as well as other public consumption bylaws and legislation, and their impact on BC's overall decriminalization initiative. Decision-makers are urged to increase engagement with PWUD and relevant stakeholders in the design and implementation of policies pertaining to public consumption to ensure that they effectively address the evolving needs and realities of PWUD, and align with decriminalization goals.

The global magnitude and temporal trend of rheumatoid arthritis burden attributable to smoking from 1990 to 2019

OBJECTIVES

The relationship between smoking and RA has been confirmed. Most nations have ratified the Framework Convention on Tobacco Control. However, there are considerable regional differences in how effectively tobacco control measures were implemented. This study was carried out to estimate the spatiotemporal trends of smoking-related RA burdens.

METHODS

Data were available from the Global Burden of Disease Study 2019 and were analysed by age, sex, year and region. Joinpoint regression analysis was applied to the analysis of temporal trends in the RA burden resulting from smoking over 30 years.

RESULTS

From 1990 to 2019, the number of global RA cases increased each year. The age-standardized prevalence, death and disability-adjusted life-year (DALY) rates also increased. However, there was a wave in the changing trend of the age-standardized death rate, with the lowest point in 2012 and the highest point in 1990. Smoking, in particular, was responsible for 11.9% of total RA deaths and 12.8% of total DALYs in 1990 but only 8.5% of total RA deaths and 9.6% of total DALYs in 2019. A greater burden from smoking exposure was borne by men, older adults and people living in high-middle and high sociodemographic index (SDI) countries and regions. Moreover, the UK demonstrated the highest reduction in age-standardized death and DALY rates over the three decades.

CONCLUSION

There were reductions in the age-standardized burdens of RA caused by smoking worldwide. Nevertheless, this continues to be an issue in some areas, and efforts to reduce smoking should be made to lessen this growing burden.

Impacts of EU Tobacco Products Directive regulations on use of e-cigarettes in adolescents in Great Britain: a natural experiment evaluation

Background

E-cigarettes are a popular smoking-cessation tool. Although less harmful than tobacco, use of e-cigarettes by non-smokers should be prevented. There is concern about the use of e-cigarettes by young people and that e-cigarettes may renormalise smoking. In May 2016, Tobacco Products Directive regulations aimed to reduce e-cigarettes' appeal to young people.

Aims

To examine the effects of the Tobacco Products Directive regulations on young people's use of e-cigarettes, and the role of e-cigarettes in renormalising smoking.

Design

A mixed-method natural experimental evaluation combining secondary analyses of survey data, with process evaluation, including interviews with young people, policy stakeholders, retailers and trading standards observers, and observations of retail settings.

Settings

Wales, Scotland and England.

Participants

Survey participants were aged 13-15 years, living in England, Scotland or Wales and participated in routinely conducted surveys from 1998 to 2019. Process evaluation participants included 14- to 15-year-olds in England, Scotland and Wales, policy stakeholders, trading standards offices and retailers.

Intervention

Regulation of e-cigarettes, including bans on cross-border advertising, health warnings and restrictions on product strength.

Comparison group

Interrupted time series design, with baseline trends as the comparator.

Main outcome measures

The primary outcome was ever e-cigarette use. Secondary outcomes included regular use, ever and regular smoking, smoking attitudes, alcohol and cannabis use.

Data capture and analysis

Our primary statistical analysis used data from Wales, including 91,687 young people from the 2013-19 Health Behaviour in School-aged Children and School Health Research Network surveys. In Scotland, we used the Scottish Schools Adolescent Lifestyle and Substance Use Survey and in England we used the Smoking Drinking and Drug Use surveys. The process evaluation included interviews with 73 young people in 2017 and 148 young people in 2018, 12 policy stakeholders, 13 trading standards officers and 27 retailers. We observed 30 retail premises before and after implementation. Data were integrated using the Medical Research Council's process evaluation framework.

Results

Ever smoking continued to decline alongside the emergence of e-cigarettes, with a slight slowing in decline for regular use. Tobacco Products Directive regulations were described by stakeholders as well implemented, and observations indicated good compliance. Young people described e-cigarettes as a fad and indicated limited interaction with the components of the Tobacco Products Directive regulations. In primary statistical analyses in Wales [i.e. short (to 2017) and long term (to 2019)], growth in ever use of e-cigarettes prior to Tobacco Products Directive regulations did not continue after implementation. Change in trend was significant in long-term analysis, although of similar magnitude at both time points (odds ratio 0.96). Data from England and Scotland exhibited a similar pattern. Smoking followed the opposite pattern, declining prior to the Tobacco Products Directive regulations, but plateauing as growth in e-cigarette use stalled.

Limitations

Alternative causal explanations for changes cannot be ruled out because of the observational design.

Conclusions

Young people's ever and regular use of e-cigarettes appears to have peaked around the time of the Tobacco Products Directive regulations and may be declining. Although caution is needed in causal attributions, findings are consistent with an effect of regulations. Our analysis provides little evidence that e-cigarettes renormalise smoking. More recent data indicate that declines in smoking are plateauing.

Future work

International comparative work to understand differences in use of e-cigarettes, and tobacco, within varying regulatory frameworks is a priority.

Study registration

This study is registered as ResearchRegistry4336.

Funding

This project was funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme and will be published in full in Public Health Research; Vol. 11, No. 5. See the NIHR Journals Library website for further project information.

Short-Term Effects of Recreational Cannabis Legalization on Youth Cannabis Initiation

PURPOSE

As recreational cannabis is legalized, it is critical to know the impacts of legalization on youth cannabis use. Existing research generates conflicting results and does not shed light on channels of effects. This study investigates the impacts of legalization on youth cannabis initiation and overall cannabis use prevalence.

METHODS

We used Interrupted Time Series design and data from nationally-representative repeated cross-sectional Canadian surveys spanning 16 years. The primary outcomes were cannabis initiation rates and cannabis use prevalence among youths. The secondary outcomes were self-reported age of first cannabis use, ease of cannabis access, and perception of cannabis harm among youths.

RESULTS

After legalization, cannabis initiation rate among youths was 2.7 percentage points (95% confidence interval: 1.7-3.7; p < .01) or 69% higher, although there was no significant increase in the overall prevalence of cannabis use. Furthermore, there was a 4-month delay in the average age of first cannabis use among youths aged 17-18 years (95% confidence interval: 2.6-5.5 months; p < .01). The legalization was associated with greater perception of cannabis harm but also easier access to cannabis.

DISCUSSION

The impacts of legalization on youth cannabis use after 1 year are mixed. Although we observed an increase in cannabis initiation among youths who had never used cannabis, there was no change in the overall prevalence of cannabis use, implying a possible offsetting increase in cannabis cessation among existing users. To achieve legalization's goal of reducing youth cannabis use, policy measures are needed to curb youth cannabis access and initiation.

A cross-national comparison of the linkages between family structure histories and early adolescent substance use

Family structure can influence adolescent health with cascading implications into adulthood. Life course theory emphasizes how this phenomenon is dynamic across time, contextualized in policy systems, and grounded in processes of selection and socialization. This study used data from the U.S. (National Longitudinal Survey of Youth 1979 Child and Young Adults, n = 6,236) and U.K. (Millennium Cohort Study, n = 11,095) to examine associations between a single mother family structure between ages 0-14 and early adolescent substance use at age 14 across time and place, using inverse probability of treatment weighting to explore how results varied by selection into family structure. In both countries, single parenthood, regardless of its timing during childhood, consistently predicted adolescent substance use when samples were re-weighted to resemble the overall population. However, when samples were re-weighted so that their background characteristics resembled those of actual single parent families, there was little evidence that single parenting posed risks, suggesting that single parenting might matter less for adolescents who are likely to experience it (and vice versa). In addition, more generous welfare policy in the U.K. than in the U.S. did not appear to have ameliorated the observed role of single parenting in adolescent substance use. Findings supported a model of disadvantage saturation, where single parenting has little additional impact over the myriad other disadvantages that single parent families tend to experience, rather than a model of cumulative disadvantage, where single parenting compounds or adds to other disadvantages. Policy and interventions might more valuably focus on these other disadvantages than on family structure.

Trends in Deaths Attributable to Smoking in China, Japan, United Kingdom, and United States From 1990 to 2019

Objectives: This study aimed to estimate the long-term trends of deaths attributable smoking in China, Japan, the United Kingdom (UK) and the United States (US).

Methods: Using 2000–2019 death data from Global Burden of Disease (GBD) 2019, we estimated age-period-cohort effects on smoking attributable mortality, and decomposed of differences in smoking-attributable deaths in 1990 and 2019 into demographic factors.

Results: From 1990 to 2019, smoking-attributable deaths increased in China, which was due to population growth and demographic aging. From 1990 to 2019, both age-standardized smoking attributable mortality rates trended downward across countries. Among four countries, age rate ratios (RRs) for smoking-attributable mortality increased with age, while period and cohort RRs decreased with year.

Conclusion: The age-standardized mortality rates, period effects and cohort effects of smoking attributable mortality in China, Japan, UK, and US have been declining in both sexes from 1990 to 2019, which suggests that smoke-free policies, help to quit tobacco use, improved health education, more accessible healthcare service, and increased taxes have been effective. Additionally, increased smoking attributable deaths in elderly should got more attention.

Smoking in social housing among adults in England, 2015-2020: a nationally representative survey

OBJECTIVES

To analyse associations between living in social housing and smoking in England and to evaluate progress towards reducing disparities in smoking prevalence among residents of social housing compared with other housing types.

DESIGN

Cross-sectional analysis of nationally representative data collected between January 2015 and February 2020.

SETTING

England.

PARTICIPANTS

105 562 adults (≥16 years).

PRIMARY AND SECONDARY OUTCOME MEASURES

Linear and logistic regression were used to analyse associations between living in social housing (vs other housing types) and smoking status, cigarettes per day, time to first cigarette, exposure to others' smoking, motivation to stop smoking, quit attempts and use of cessation support. Analyses were adjusted for sex, age, social grade, region and year.

RESULTS

Adults living in social housing had two times the odds of being a smoker (OR_adj=2.17, 95% CI 2.08 to 2.27), and the decline in smoking prevalence between 2015 and 2020 was less pronounced in this high-risk group (-7%; OR_adj=0.98, 95% CI 0.96 to 1.01) than among adults living in other housing types (-24%; OR_adj=0.95, 95% CI 0.94 to 0.96; housing tenure-survey year interaction p=0.020). Smokers living in social housing were more addicted than those in other housing types (smoking within 30 min of waking: OR_adj=1.50, 95% CI 1.39 to 1.61), but were no less motivated to stop smoking (OR_adj=1.06, 95% CI 0.96 to 1.17) and had higher odds of having made a serious attempt to quit in the past year (OR_adj=1.16, 95% CI 1.07 to 1.25). Among smokers who had tried to quit, those living in social housing had higher odds of using evidence-based cessation support (OR_adj=1.22, 95% CI 1.07 to 1.39) but lower odds of remaining abstinent (OR_adj=0.63, 95% CI 0.52 to 0.76).

CONCLUSIONS

There remain stark inequalities in smoking and quitting behaviour by housing tenure in England, with declines in prevalence stalling between 2015 and 2020 despite progress in the rest of the population. In the absence of targeted interventions to boost quitting among social housing residents, inequalities in health are likely to worsen.

Inequalities in Smoking and Quitting-Related Outcomes Among Adults With and Without Children in the Household 2013-2019: A Population Survey in England

INTRODUCTION

Smoking among those who live with children is an important influence on smoking initiation among children. This study assessed socioeconomic inequalities in smoking and quitting-related outcomes among all adults with and without children in the household.

AIMS AND METHODS

Monthly repeat cross-sectional household survey of adults (16+) from 2013-2019 in England (N = 138 583). We assessed the association between cigarette smoking and quitting-related outcomes and having children in the household, and whether these relationships were moderated by occupational social grade (categories AB-E from most to least advantaged). Trends in smoking prevalence among adults with and without children in the household were explored.

RESULTS

In adjusted analysis, the association of having children in the household with smoking prevalence depended on social grade: smoking prevalence was between 0.71 (95% confidence interval 0.66-0.77) and 0.93 (0.88-0.98) times lower among social grades AB-D with children in the household relative to those without. Conversely, it was 1.11 (1.05-1.16) times higher among social grade E. Yearly prevalence declined similarly among those with and without children (both prevalence ratio: 0.98, 95% confidence interval 0.97-0.99). Motivation to stop smoking was higher among those with children than those without, but lower among disadvantaged than more advantaged groups. Social grades D-E had greater heavy smoking, but higher prevalence of past-month quit attempts.

CONCLUSIONS

Among the most disadvantaged social grade in England, smoking prevalence was higher in those with children in the household than without. To attenuate future smoking-related inequalities, there is an urgent need to target support and address barriers to quitting and promote longer-term quit success.

IMPLICATIONS

In the most disadvantaged occupational social grade, having children in the household was associated with higher smoking prevalence compared with not having children. This contrasts with all other social grades in which there was lower comparative smoking prevalence among those with than without children in the household. Without attention this disparity could exacerbate existing and future health inequalities related to smoking.