Trends in Social Norms Towards Smoking Between 2002 and 2015 Among Daily Smokers: Findings From the International Tobacco Control Four Country Survey (ITC 4C)

A reduced exposure heated tobacco product was introduced then abruptly taken off United States shelves: results from a tobacco harm reduction natural experiment

BACKGROUND

A heated tobacco product (HTP) authorized for purchase in the United States by the Food and Drug Administration as a reduced harm product was removed from the market after about 2 years of sales. Adults who used the HTP were surveyed to determine the impact of the introduction and removal of the HTP on past and current tobacco behaviors.

METHODS

Adults who were using the HTP before its United States market removal (n = 502) completed a cross-sectional online survey to determine their tobacco use behaviors at three timepoints: prior to HTP initiation, just before HTP market removal, and at the time of the survey which was administered approximately 10 months post-removal. Descriptive statistics summarized outcome variables and paired bivariate testing was used to compare percent change between timepoints. Multivariable logistic regression and general linear models estimated associations of tobacco use behaviors and cigarette consumption.

RESULTS

Overall, significantly fewer adults consumed cigarettes while using HTP than before they tried the product (63.0% vs. 89.9%, p value < 0.0001) and the number of cigarettes consumed per week (CPW) decreased (106.3-39.0, p value < 0.0001). After HTP removal, the percent of adults who consumed cigarettes increased non-significantly (63.0-67.5%, p value = 0.0544) while CPW increased significantly (39.0-76.6 CPW, p value < 0.0001). At the time of the survey, over 25% of the sample continued to use the HTP and 7.2% reported use of no tobacco products. Electronic nicotine delivery system use had increased significantly from the prior period (27.4% increase, p value < 0.0001).

CONCLUSION

This study demonstrates reduction or elimination of combustible cigarette smoking while adults were using HTPs and some increased smoking after market removal, albeit at lower levels. If unable to find satisfying alternatives, adults who smoke and transition to reduced harm products may return to smoking or purchase products illicitly if their preferred products are removed from the regulated market.

Does Tobacco Smoking Increase Social Isolation? A Mendelian Randomization Study

In this study, we aimed to investigate the causal effect of smoking on social isolation among older adults in England. Data from older adults of European ancestry who participated in 1 or more waves of the English Longitudinal Study of Ageing, from wave 1 (2002/2003) to wave 9 (2018/2019), were analyzed (n = 43,687 observations from 7,008 individuals; mean age = 68.50 years). The effect of current smoking on social isolation (ranging from 0 to 5) was estimated by 2-stage least squares regression using a polygenic score (PGS) for smoking cessation as the instrument. A low PGS for smoking cessation predicted current smoking (per 1-standard-deviation lower PGS, coefficient = 0.023, 95% confidence interval (CI): 0.015, 0.030; F = 36.420). The second-stage regression showed that current smoking increased social isolation by 1.205 points (95% CI: 0.308, 2.101). The association was larger for persons with higher socioeconomic backgrounds: 2.501 (95% CI: -0.024, 5.026) and 0.696 (95% CI: -0.294, 1.686) for those with higher and lower educational levels, respectively. This study showed that current smoking instrumented by a PGS for smoking cessation was associated with social isolation. Assuming that the PGS served as a valid instrument in this study, the findings support an effect of smoking on social isolation.

Assessing the profile of support for potential tobacco control policies targeting availability in Great Britain: a cross-sectional population survey

AIM

To examine the level of support for tobacco availability policies across Great Britain (GB) and associations between support for policy and sociodemographic, smoking and quitting characteristics.

METHODS

A cross-sectional representative survey (the Smoking Toolkit Study) of adults in GB (n=2197) during September 2021. Logistic regressions estimated the associations between support for each policy and sociodemographic and smoking characteristics.

FINDINGS

There was majority support for requiring retailers to have a license which can be removed if they sell to those under-age (89.6%) and for restrictions on the sale of cigarettes and tobacco near schools (69.9%). More supported than opposed raising the legal age of sale of cigarettes and tobacco to 21 (49.2% supported; 30.7% opposed; 20.1% unsure) and reducing the number of retailers selling tobacco in neighbourhoods with a high density of tobacco retailers (46.5% supported; 23.3% opposed; 30.2% unsure). More opposed than supported a ban on the sale of cigarettes and tobacco to everyone born after a certain year from 2030 onward (a 'tobacco-free generation') (41.3% opposed; 34.5% supported; 24.2% unsure). Age was positively associated with support for raising the age of sale and inversely associated with requiring tobacco retailer licenses. Women were more likely to support raising the age of sale and reducing the number of retailers.

CONCLUSIONS

Requiring tobacco retailer licensing and restrictions on sales near schools received majority support. Other tobacco availability policies received substantial support despite considerable opposition.

Optimism and Longevity Among Japanese Older Adults

BACKGROUND

Optimism has been linked to better physical health across various outcomes, including greater longevity. However, most evidence is from Western populations, leaving it unclear whether these relationships may generalize to other cultural backgrounds. Using secondary data analysis, we evaluated the associations of optimism among older Japanese adults.

METHODS

Data were from a nationwide cohort study of Japanese older adults aged ≥65 years (Japan Gerontological Evaluation Study; n = 10,472). In 2010, optimism and relevant covariates (i.e., sociodemographic factors, physical health conditions, depressive symptoms, and health behaviors) were self-reported. Optimism was measured using the Japanese version of the Life Orientation Test-Revised (LOT-R). Lifespan was determined using mortality information from the public long-term care insurance database through 2017 (7-year follow-up). Accelerated failure time models examined optimism (quintiles or standardized continuous scores) in relation to percent differences in lifespan. Potential effect modification by gender, income, and education was also investigated.

RESULTS

Overall, 733 individuals (7%) died during the follow-up period. Neither continuous nor categorical levels of optimism were associated with lifespan after progressive adjustment for covariates (e.g., in fully-adjusted models: percent differences in lifespan per 1-SD increase in continuous optimism scores= -1.2%, 95%CI: -3.4, 1.1 higher versus lower optimism quintiles= -4.1%, 95%CI: -11.2, 3.6). The association between optimism and lifespan was null across all sociodemographic strata as well.

CONCLUSION

Contrary to the existing evidence from Western populations, optimism was unrelated to longevity among Japanese older adults. The association between optimism, as evaluated by the LOT-R, and longevity may differ across cultural contexts.

Pre-pregnancy lifestyle characteristics and risk of miscarriage: the Australian Longitudinal Study on Women's Health

Background

Previous studies of lifestyle characteristics and risk of miscarriage have mostly been retrospective and failed to account for induced abortions. We examine whether pre-pregnancy body-mass index, alcohol intake and smoking influence the risk of miscarriage after accounting for induced abortions.

Methods

We conducted a prospective cohort study of 9213 women with 26,594 pregnancies participating in the Australian Longitudinal Study on Women’s Health. We examined whether body-mass index, smoking and alcohol intake prior to pregnancy was associated with miscarriage. We estimated adjusted relative risks (RR) using generalized estimating equations with an exchangeable correlation matrix. We explored the impact of accounting for induced abortion by first excluding all induced abortions, and secondly including 50% of induced abortions in the comparison group.

Results

Of the 26,592 pregnancies which occurred during the follow-up period, 19% ended in a miscarriage. We observed an increased risk of miscarriage according to pre-pregnancy obesity compared to normal weight (adjusted RR 1.13; 95% CI 1.05, 1.21), smoking between 10 and 19 cigarettes per day compared to not smoking (adjusted RR 1.13; 95% CI 1.02, 1.25), but not smoking 20 or more cigarettes per day (adjusted RR 1.07; 95% CI 0.94, 1.21) and risky drinking (≥2 units per day; adjusted RR 1.15; 95% CI 1.03, 1.28) compared to low risk drinking (< 2 units per day). The results for smoking (adjusted RR 1.09 for 10–19 cigarettes per day; 95% CI 0.98, 1.21) was attenuated after including 50% of induced abortions in the comparison group.

Conclusions

We observed a modest increased risk of miscarriage according to obesity and risky alcohol intake prior to pregnancy. There was no evidence of a dose-response relationship with smoking, and the association between smoking and risk of miscarriage was attenuated after accounting for induced abortions.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-022-04482-9.

Social norms as a predictor of smoking uptake among youth: a systematic review, meta-analysis and meta-regression of prospective cohort studies

BACKGROUND AND AIMS

Social norms towards smoking are a key concept in tobacco control policy and research. However, the influence and strength of different types of social norms on youth smoking uptake is unclear. This study aimed to examine, quantify and compare evidence of the longitudinal associations between different types of social norms towards smoking and youth smoking uptake (initiation and escalation).

METHODS

Systematic review searching four databases (MEDLINE, EMBASE, PsycInfo, CINAHL) from January 1998 to October 2020. Evidence synthesis via narrative review, meta-analysis pooling unadjusted associations (initiation only, due to heterogeneity in escalation outcomes) and meta-regression comparing effect sizes by norm type and study characteristics. Studies included observational prospective cohort studies using survey methodology with youth aged ≤24 years. Measurements included longitudinal associations between descriptive norms (perceived smoking behaviour) and injunctive norms (perceived approval/disapproval of smoking) among social network(s) and subsequent smoking initiation or escalation.

RESULTS

Thirty articles were identified. In the narrative review, smoking initiation (but not escalation) was consistently predicted by two norms: parental and close friend smoking. Associations between smoking uptake and other descriptive norms (smoking among siblings, family/household, partner, peers, adults) and all injunctive norms (perceived approval of smoking among parents, siblings, close friends/peers, partner, teachers, people important to you, the public) were less consistent or inconclusive. In the meta-analysis pooling unadjusted associations, 17 articles were included (n = 27 767). Smoking initiation was predicted by the following descriptive norms: smoking among parents [Odds Ratio (OR) = 1.88, 95% Confidence Interval (CI) = 1.56-2.28], close friends (OR = 2.53, 95% CI = 1.99-3.23), siblings (OR = 2.44, 95% CI = 1.93-3.08), family/household (OR = 1.55, 95% CI = 1.36-1.76) and adults (OR = 1.34, 95% CI = 1.02-1.75), but not peers (OR = 1.14, 95% CI = 0.92-1.42). Smoking initiation was also predicted by two injunctive norms, perceived approval of smoking among parents (OR = 1.74, 95% CI = 1.27-2.38) and the public (OR = 4.57, 95% CI = 3.21-6.49), but not close friends/peers (OR = 2.36, 95% CI = 0.86-6.53) or people important to the individual (OR = 1.24, 95% CI = 0.98-1.58).

CONCLUSIONS

In this systematic review (narrative and meta-analysis), descriptive norms of parents' and close friends' smoking behaviour appeared to be consistent predictors of youth smoking initiation, more so than the descriptive norms of more distal social networks and injunctive norms.

Exploring How Social Media Exposure and Interactions Are Associated With ENDS and Tobacco Use in Adolescents From the PATH Study

INTRODUCTION

Tobacco use is a current public health epidemic that puts individuals at risk for many health conditions and diseases, and adolescents are at high risk for the initiation and persistence of tobacco use behaviors partly due to engagement with social media content. The objective of this study is to examine the association between engaging in social media behaviors and patterns of electronic nicotine delivery systems (ENDS) and tobacco use at a 1-year follow-up among 11 279 adolescents from the PATH study.

METHODS

Five social media variables were questioned at Wave 2 and then compared to ENDS and tobacco status transitions (i.e., initiation, persistence, and escalation) at a 1-year follow-up, respectively. Survey-weighted multivariable logistic regression models were used to calculate adjusted odds ratios and 95% confidence interval.

RESULTS

Passive behaviors on social media were related to higher likelihoods of starting to use ENDS and other tobacco products. Additionally, active behaviors on social media were related to higher likelihoods for the initiation and persistence of tobacco use. In particular, sending tobacco content to other users was further associated with a higher likelihood of escalation of tobacco product use.

DISCUSSION

Both exposure to and interactions with social media tobacco content had a significant impact on the patterns of ENDS and tobacco use in adolescents. Due to the amount of time adolescents spend engaging with online content, social media may be a critical place in which to intervene, possibly with the use of antitobacco or tobacco prevention messages.

IMPLICATIONS

The results of this study have implications for public health and the policies surrounding adolescents and their exposure to social media. Reducing the ENDS and tobacco content to which adolescents are exposed has the potential to decrease the instances of initiation and persistence of ENDS and tobacco use. Intervening on social media may prevent or slow the progression of ENDS and tobacco use, and increase motivation and actions toward the cessation of tobacco use in adolescents.

Trends in Social Norms Towards Smoking Between 2002 and 2015 Among Daily Smokers: Findings From the International Tobacco Control Four Country Survey (ITC 4C)

OBJECTIVE

To assess trends in daily smokers' social norms and opinions of smoking between 2002 and 2015 in Canada, the United States, the United Kingdom, and Australia.

METHOD

Data were from wave 1 (2002) to wave 9 (2013-2015) of the longitudinal International Tobacco Control Four Country Survey (Canada, the United States, the United Kingdom, Australia), involving 23 831 adult daily smokers. Generalized estimating equation logistic regression models, adjusted for demographics and survey design effects, assessed associations of wave and country with outcomes: (A) over half of five closest friends smoke, (B) agreeing that people important to you believe you should not smoke, (C) agreeing that society disapproves of smoking, and (D) negative opinion of smoking.

RESULTS

Between 2002 and 2015, adjusting for covariates, (A) over half of five closest friends smoke did not change (56% vs. 55%; adjusted odds ratio [AOR] = 0.95 [95% Confidence Interval = 0.85-1.07]), (B) agreeing that people important to you believe you should not smoke generally decreased (89% vs. 82%; AOR = 0.54 [0.46-0.64]) despite an increase around 2006-2007, (C) agreeing that society disapproves of smoking increased between 2002 and 2006-2007 (83% vs. 87%; AOR = 1.38 [1.24-1.54]) then decreased until 2013-2015 (78%; AOR = 0.74 [0.63-0.88]), and (D) negative opinion of smoking decreased between 2002 and 2010-2011 (54% vs. 49%; AOR = 0.83 [0.75-0.91]) despite an increase around 2005-2006 and at the final wave (2013-2015). Except friend smoking, Canada had the greatest, and the United Kingdom the lowest, antismoking social norms and opinions.

CONCLUSIONS

Except friend smoking and opinion of smoking, daily smokers' social norms became less antismoking between 2002 and 2015 despite increases around 2006-2007. Several potential explanations are discussed yet remain undetermined.

IMPLICATIONS

Increasingly comprehensive tobacco control policies alongside decreasing smoking prevalence in Canada, the United States, the United Kingdom, and Australia have led to the assumption that smoking has become denormalized in these countries. Absent from the literature is any formal assessment of social norms towards smoking over time. Contrary to our hypotheses, this study found that the injunctive social norms of daily smokers became less antismoking between 2002 and 2015, despite increases around 2006-2007. There was no change over time in the proportion of daily smokers who report that over half of their five closest friends smoke.

Social norms towards smoking and vaping and associations with product use among youth in England, Canada, and the US

BACKGROUND

This study assesses differences in social norms towards smoking and vaping among youth across countries (England, Canada, US) and smoking and vaping status.

METHODS

Data are from the 2017 ITC Youth Tobacco and Vaping Survey, among youth age 16-19 in England (N = 3444), Canada (N = 3327), and US (N = 3509). Prevalence of friend smoking, friend vaping, peer approval of smoking, and peer approval of vaping were estimated. Adjusted logistic regression models were estimated for each norm to assess associations with country, smoking status, and vaping status, adjusting for sociodemographics, alcohol use, and marijuana use.

RESULTS

47% and 52% reported friend smoking and vaping respectively. Perceived peer approval of vaping (44%) was almost double that of smoking (23%). Compared with England, fewer Canadian and US youth reported friend smoking (Canada: AOR = 0.71 [95% CI = 0.62-0.82]; US: AOR = 0.54 [0.47-0.62]) and peer approval of smoking (Canada: AOR = 0.74 [0.63-0.87]; US: AOR = 0.78 [0.67-0.91]), yet more reported peer approval of vaping (Canada: AOR = 1.23 [1.08-1.41]; US: AOR = 1.30 [1.14-1.48]). More Canadian than English youth reported friend vaping (AOR = 1.17 [1.02-1.36]). Friend smoking, peer approval of smoking, and friend vaping were more common among smokers and vapers (all p < .02). Peer approval of vaping was more common among vapers but less common among smokers (all p < .044).

CONCLUSIONS

Youth had more positive vaping than smoking norms. English youth reported the most pro-smoking but least pro-vaping norms in adjusted models; this was unexpected given country differences in regulatory environments. Norms towards both products were associated with use, with some evidence of cross-product associations between norms and behaviours.