Youth tobacco access: trends and policy implications

Training secondary school students as anti-smoke ambassadors using the service-learning model: A cluster randomized controlled trial with hybrid type 1 effectiveness-implementation design study protocol

BACKGROUND

Evidence shows that using the AWARD (Ask, Warn, Advise, Refer, Do-it-again) model with service-learning model in youngsters may be an appropriate strategy to refer young smokers for early smoking cessation services. Therefore this study aims to promote smoking cessation by training secondary school students as anti-smoke ambassadors (ASAs) with increased knowledge, skills and self-efficacy on smoking cessation and AWARD model using service-learning model.

METHODS

A cluster randomized controlled trial will be conducted in 14 secondary schools in Hong Kong. Also, a hybrid type 1 effectiveness-implementation design with the Reach Effectiveness Adoption Implementation Maintenance (RE-AIM) framework will be adopted. For the intervention group, participants (n = 184) will attend a 3-hour training workshop, followed by hands-on sessions supervised by trained nursing students, then a 6-month smoker referral competition and an award presentation ceremony. The control group (n = 184) will only attend the 3-hour training workshop. The research assistant will contact participants at the start and the end of training program, and at 3, 6, and 12 months after the end of the training program by telephone to complete a set of questionnaires. Participating secondary schools, participating nursing students, ASAs, and responsible organizational staff will be randomly invited for a one-to-one semi-structured interview. The primary outcome will be the number of smokers who referred by secondary school students. Descriptive statistics, mixed between-within-subjects ANOVA, logistic regressions, and content analysis will be used.

DISCUSSION

This study will bridge the gap in existing literature by determining the effectiveness and exploring facilitators and barriers in implementing our intervention with the use of the AWARD model and service-learning model in training young people to refer smokers to anti-smoke organizations in the real-world. This can enhance our community capacity and enable youngsters to take a proactive role to support smoking cessation.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT05897346. Registered on 11 May 2023.

How do New Zealand youth perceive the smoke-free generation policy? A qualitative analysis

INTRODUCTION

Aotearoa New Zealand (NZ) plans to introduce a smoke-free generation (SFG) policy, alongside denicotinisation and reducing the availability of tobacco products. The SFG has a clear rationale, yet we know little about how young people, those the policy targets, perceive it. To inform policy design, communication and implementation, we explored how NZ youth perceived the SFG.

METHODS

We undertook in-depth interviews with a sample of 20 youth aged 17 or 18 and explored their knowledge of the SFG, and how they perceived its individual and societal implications. We interpreted the data using a reflexive thematic analysis approach.

RESULTS

We identified two overarching themes. The first theme, 'societal good and protection from harm', reflected benefits participants associated with the SFG, which outweighed perceptions of lost freedoms. The second theme, 'privileging personal choice', corresponded to two small groups within the sample. The first preferred measures they considered less restrictive, such as increasing the purchase age, and some came to support the SFG as they rationalised their views. The second subgroup expressed more entrenched opposition and felt the SFG deprived them of a choice.

CONCLUSIONS

Young people's deep reflection on the SFG led most to view it as liberating rather than restrictive. Communications that avoid prompting heuristic-based responses could encourage youth to reflect on the policy and elicit strong support from the group the SFG aims to benefit.

Addressing Intergenerational Inequity in Tobacco-Harm: What Helps Children of Smokers to Remain Nonsmokers?

INTRODUCTION

Children of people who smoke are more likely to take up smoking themselves. In Aotearoa New Zealand (NZ), adolescent smoking declined dramatically between 2000 and 2016 despite limited change in parental smoking, demonstrating that the cycle can be broken.

AIMS AND METHODS

This study aimed to identify modifiable factors associated with never smoking in Year 10 students (14-15 years) who had at least one caregiver who smoked. We used data from the Youth Insights Survey (2016 and 2018, pooled, N = 5,422) and identified students with at least one caregiver (mother, father, grandparent, other caregiver) who smoked (N = 2,205). To investigate modifiable factors potentially associated with nonsmoking we used logistic regression with marginally adjusted prevalence estimates.

RESULTS

Overall, 41% of students had at least one caregiver who smoked. In this group, the majority (65%) had never smoked themselves. After adjustment, never-smoking was more prevalent among students attending low-deprivation (more affluent) schools (73% had never smoked) compared to high-deprivation schools (44%); students not exposed to others' smoking inside the home (72%) or in cars (70%) in the past week compared to those exposed (59% and 51%, respectively); and students whose parents would be upset if they were caught smoking (68% vs 49% for those whose parents would not be upset), or who had high self-esteem (69% vs 55% for those with low self-esteem).

CONCLUSIONS

Modifiable factors independently associated with non-smoking in adolescents with caregiver(s) who smoked were: nonexposure to smoking inside the home and in cars, parental expectations of nonsmoking, and high self-esteem.

IMPLICATIONS

Even in countries like NZ with relatively low adult smoking rates, children's exposure to caregiver smoking may be prevalent, particularly in structurally disadvantaged populations. This study suggests that action to promote smokefree homes and cars, build high self-esteem in young people, and communicate expectations of non-smoking are likely to help children of people who smoke to remain nonsmokers. A comprehensive approach that also addresses "upstream" factors (eg, socioeconomic deprivation) and underlying causes of structural inequity (eg, institutional racism) is needed. Such policy and community action may help to break intergenerational cycles of tobacco use and health inequity.

The kids aren't alright: The effects of medical marijuana market size on adolescents

We exploit shocks to US federal enforcement policy to assess how legal medical marijuana market size affects youth marijuana use and consequences for youth traffic-related fatalities. Using hand-collected data on state medical marijuana patient rates to develop a novel measure of market size, we find that legal market growth increases youth marijuana use. Likely mechanisms are lower prices and easier access. Youth die more frequently from alcohol-involved car accidents, suggesting complementarities for youths. The consequences of marijuana legalization for youth are not immediate, but depend on how supply-side regulations affect production and prices.

A Rapid Evaluation of the US Federal Tobacco 21 (T21) Law and Lessons From Statewide T21 Policies: Findings From Population-Level Surveys

BACKGROUND

On December 20, 2019, the minimum age for purchasing tobacco in the US was raised nationally to 21 years. We evaluated this law (Tobacco 21 [T21]) 1 year after implementation. We also compared states with versus without T21 policies during 2019 to explore potential equity impacts of T21 policies.

METHODS

We examined shifts in tobacco access among 6th through 12th graders using the National Youth Tobacco Survey. To explore equity of state T21 policies among youths and young adults, the associations with tobacco use were explored separately for race and ethnicity by using data from the 2019 Behavioral Risk Factor Surveillance System (for persons aged 18 to 20 years) and the 2019 Youth Risk Behavior Survey (for high school students).

RESULTS

The overall percentage of 6th to 12th graders perceiving that it was easy to buy tobacco products from a store decreased from 2019 (67.2%) to 2020 (58.9%). However, only 17.0% of students who attempted buying cigarettes in 2020 were unsuccessful because of their age. In the 2019 BRFSS, those aged 18 to 20 years living in a state with T21 policies had a lower likelihood of being a current cigarette smoker (adjusted prevalence ratio [APR], 0.58) or smoking cigarettes daily (APR, 0.41). Similar significant associations were seen when analyses were restricted to only non-Hispanic White participants but not for participants who were non-Hispanic Black, non-Hispanic Asian, Hispanic, or of other races or ethnicities. Consistent findings were seen among high school students.

CONCLUSION

Greater compliance with the federal T21 law is needed as most youth who attempted buying cigarettes in 2020 were successful. Comparative analysis of states with versus states without statewide T21 policies in 2019 suggest the policies were differentially more protective of non-Hispanic White participants than other participants. Equitable and intensified enforcement of T21 policies can benefit public health.

"You Do It Through the Grapevine": A Bourdieusian Analysis of Under-Age Access to Tobacco Among Adolescents From Seven European Cities

Despite efforts to reduce adolescent smoking via minimum age-of-sale legislation, many young people continue to access tobacco through a mix of social and commercial sources. Little is known about the roles of habitus, capital, and social topographies in shaping under-age access to tobacco. This article draws on Bourdieu's theory of practice and data generated from 56 focus groups with 14- to 19-year-olds across seven European cities to answer the question "via what sources and by what means do adolescents obtain tobacco?" We find that adolescents use a range of personal capitals (social, cultural, and economic) to access tobacco, with the specific constitution and deployment of these capitals varying according to the regularities of different fields. Since adolescents access tobacco via culturally embedded practices, attempts to curtail this access are more likely to be effective if they are multi-pronged, culturally informed, and attuned to the lived experiences of adolescent smokers.

New Zealand Youth19 survey: vaping has wider appeal than smoking in secondary school students, and most use nicotine-containing e-cigarettes

OBJECTIVE

To investigate smoking and vaping in secondary school students (aged 13-18 years) in New Zealand (NZ) following the introduction of 'pod' e-cigarettes, which have been associated with the rapid escalation of youth vaping elsewhere.

METHODS

Data on smoking and vaping were collected in 2019 as part of a comprehensive youth health survey (N=7,721).

RESULTS

Vaping was 2-3 times more prevalent than smoking, with 10% of students vaping regularly (monthly or more often), and 6% weekly or more often, compared with 4% and 2%, respectively, for tobacco smoking. Nicotine-containing e-cigarettes were sometimes or always used by 80% of regular and 90% of weekly vapers. Regular and weekly smoking was rare in low deprivation (affluent) areas, whereas regular and weekly vaping prevalence was similar across the socioeconomic spectrum. More than 80% of ever-vapers (N=2732) reported they were non-smokers when they first vaped, and 49% of regular vapers (N=718) had never smoked.

CONCLUSIONS

A significant proportion of New Zealand adolescents, many of whom have never smoked, use nicotine-containing e-cigarettes regularly. Implications for public health: Vaping is less harmful than smoking, but it is not harmless. Public health action is needed to support young non-smokers to remain smokefree and vape-free.

Association between density and proximity of tobacco retail outlets with smoking: A systematic review of youth studies

BACKGROUND

Reducing the retail availability of tobacco has been proposed as a component of tobacco endgame, yet it is not known whether retail availability has a direct impact on smoking behaviours. A narrative review and a meta-analysis have been undertaken to examine the density and proximity of tobacco retail outlets, but were limited in scope, exposure and outcome variables. The aim of this current study was to undertake a systematic review of the international literature on the density and proximity of tobacco retail outlets to homes, schools and communities and their association with smoking behaviours among youth.

METHODS

We reviewed and critically appraised the evidence documenting the association between density or proximity of tobacco retail outlets and smoking behaviours among school-age youth (18 and under), between 1 January 1990 and 21 October 2019. We reviewed original quantitative research that examined the associations of tobacco retail outlet density and proximity with individual smoking status or population-level smoking prevalence; initiation of smoking; frequency of tobacco use; sales to minors; purchasing by minors; susceptibility to smoking among non-smokers; perceived prevalence of smoking, and quitting behaviours.

FINDINGS

Thirty-five peer-reviewed papers met the inclusion criteria. This review provided evidence of a relationship between density of tobacco retail outlets and smoking behaviours, particularly for the density near youths' home. A study using activity spaces also found a significant positive association between exposure to tobacco retail outlets and daily tobacco use. The review did not provide evidence of an association between the proximity of tobacco retail outlets to homes or schools and smoking behaviours among youth.

CONCLUSIONS

The existing evidence supports a positive association between tobacco retail outlet density and smoking behaviours among youth, particularly for the density near youths' home. This review provides evidence for the development and implementation of policies to reduce the density of tobacco retail outlets to reduce smoking prevalence among youth.

Evidence From Qualitative Studies of Youth About the Impacts of Tobacco Control Policy on Young People in Europe: A Systematic Review

INTRODUCTION

A range of tobacco control policies endeavor to prevent smoking uptake in young people, yet relatively little is known about how such interventions impact young people's engagement with smoking. We reviewed existing qualitative evidence on young people and smoking in Europe to assess whether, in what ways and why young people comply with, adapt to, resist, or circumvent tobacco control policies in their respective countries.

METHODS

We undertook a systematic review of academic literature presenting qualitative research from Europe on smoking and young people (11-18 years), published from 2000 to 2015. Bibliographic searches (PubMed, PsycInfo, SSCI) produced 1357 records, from which 43 relevant articles were assessed for quality and 39 included in the review.

RESULTS

Most studies were from the United Kingdom (27), with a small number (one or two each) from other European countries (Denmark, Sweden, Switzerland, Belgium, Cyprus, Greece, Hungary, Ireland, and Spain). Only 16 articles (11 from United Kingdom) provided any evidence about the impacts of tobacco control policies on young people's smoking. These focused on smoke-free legislation (four), age of sale laws (four), plain packaging (three), and black market tobacco (one).

CONCLUSIONS

There is very little qualitative evidence exploring the impacts of tobacco control on youth smoking in Europe. To develop more effective smoking prevention policies that take account of local political, social, and cultural contexts, more qualitative research from a wider range of European countries is needed to understand how tobacco control impacts on young people's social worlds and smoking behaviors.

IMPLICATIONS

Smoking is the leading cause of premature mortality in Europe. However, there is little qualitative evidence exploring the impact of tobacco control policies on young people in Europe. Most comes from the United Kingdom and focuses on a narrow range of policies. Thus, we have a limited understanding of how and in what ways tobacco control policies reach young people, their engagement with these, and how local context affects their impact. More qualitative research is needed, from a wider range of countries and on a broader range of tobacco control policies, to strengthen the evidence-base for reducing youth smoking.

Impact of the WHO FCTC over the first decade: a global evidence review prepared for the Impact Assessment Expert Group

OBJECTIVE

To present findings of a narrative review on the implementation and effectiveness of 17 Articles of the WHO Framework Convention on Tobacco Control (FCTC) during the Treaty's first decade.

DATA SOURCES

Published reports on global FCTC implementation; searches of four databases through June 2016; hand-search of publications/online resources; tobacco control experts.

STUDY SELECTION

WHO Convention Secretariat global progress reports (2010, 2012, 2014); 2015 WHO report on the global tobacco epidemic; studies of social, behavioural, health, economic and/or environmental impacts of FCTC policies.

DATA EXTRACTION

Progress in the implementation of 17 FCTC Articles was categorised (higher/intermediate/lower) by consensus. 128 studies were independently selected by multiple authors in consultation with experts.

DATA SYNTHESIS

Implementation was highest for smoke-free laws, health warnings and education campaigns, youth access laws, and reporting/information exchange, and lowest for measures to counter industry interference, regulate tobacco product contents, promote alternative livelihoods and protect health/environment. Price/tax increases, comprehensive smoking and marketing bans, health warnings, and cessation treatment are associated with decreased tobacco consumption/health risks and increased quitting. Mass media campaigns and youth access laws prevent smoking initiation, decrease prevalence and promote cessation. There were few studies on the effectiveness of policies in several domains, including measures to prevent industry interference and regulate tobacco product contents.

CONCLUSIONS

The FCTC has increased the implementation of measures across several policy domains, and these implementations have resulted in measurable impacts on tobacco consumption, prevalence and other outcomes. However, FCTC implementation must be accelerated, and Parties need to meet all their Treaty obligations and consider measures that exceed minimum requirements.

Source of cigarettes among youth smokers in Malaysia: Findings from the tobacco and e-cigarette survey among Malaysian school adolescents (TECMA)

INTRODUCTION

Understanding how and where youth obtain tobacco products are major factors in the development of suitable intervention programs to reduce youth smoking. This study aimed to determine the source of cigarettes and the associated factors among Malaysian school adolescent smokers.

METHODS

Our sample consisted of 1348 youth aged 10-17 years who were current smokers (having smoked at least once in the last 30 days). The source of cigarettes (commercial, over-the-counter purchases; or social, borrowing or obtaining from someone else) was the dependent variable, and multivariable logistic regression was employed to determine its association with independent variables (i.e. sociodemographics, smoking behavior, and knowledge of laws prohibiting sales of cigarettes to youth).

RESULTS

Over half (54.3%) of current smokers obtained cigarettes from commercial sources, with a proportion nearly two times higher (84.2% vs 43.7%) among frequent smokers (i.e. those smoking more than 20 days per month) compared to less-frequent smokers, and among young males (56.5% vs 32.0%) compared young females. Multivariable logistic regression indicated that in urban areas, young females (AOR=12.5, 95% CI: 1.38-99.8) frequent smokers (AOR=4.41, 95% CI: 2.05-9.46), and those studying in lower (AOR=3.76, 95% CI: 1.41-10.02) and upper secondary (AOR=4.74, 95% CI: 1.72-13.06) school students were more likely to obtain cigarettes from a commercial source. On the other hand, in rural areas, only frequent smokers were more likely to get their cigarettes from commercial sources, whilst other variables were not significant.

CONCLUSIONS

The proportion of youth smokers who obtained cigarettes from commercial sources appeared to be high, suggesting that law enforcement and health promotion activities should be enhanced to reduce the rate of smoking among Malaysian youth.

New Zealand policy experts' appraisal of interventions to reduce smoking in young adults: a qualitative investigation

OBJECTIVES

Reducing smoking in young adults, particularly young Māori and Pacific, is vital for reducing tobacco harm and health inequalities in New Zealand (NZ). We investigated how NZ policy experts appraised the feasibility and likely effectiveness of interventions designed to reduce smoking prevalence among 18-24 year olds.

DESIGN

We used a qualitative design, conducting semistructured interviews and applying thematic analysis.

PARTICIPANTS

We interviewed 15 key informants, including politicians, senior policy analysts and leading tobacco control advocates. Participant selection was based on seniority and expertise and ensuring diverse perspectives were represented.

INTERVENTIONS

We examined nine interventions that could either promote greater mindfulness or introduce barriers impeding smoking uptake: smoke-free outdoor dining and bars; no tobacco sales where alcohol is sold; social marketing campaigns; real life stories (testimonials); life skills training; raise purchase age to 21; tobacco-free generation; smokers' licence; make tobacco retail premises R18.

RESULTS

The policies perceived as more effective denormalised tobacco; made it less convenient to access and use; highlighted immediate disadvantages (eg, impact on fitness); aligned with young people's values; and addressed the underlying causes of smoking (eg, stress). Participants highlighted some political barriers and noted concerns that some interventions might widen ethnic disparities. Exceptions were social marketing campaigns and extending smoke-free regulations to include outdoor areas of cafes and bars, which participants saw as politically feasible and likely to be effective.

CONCLUSIONS

Our findings suggest the merit of an approach that combines social marketing with regulation that makes accessing and using tobacco less convenient for young adults; however, political barriers may limit the regulatory options available in the short term. Strategies to support self-determination and address the underlying causes of smoking in young people warrant further investigation. Determining policy acceptability to Māori and Pacific, and likely effectiveness for these populations, should be key priorities.

"It's Easy to Get Fags": A Qualitative Study of Disadvantaged Young People's Perspectives on Cigarette Availability and Access

Introduction

Reducing young people's access to cigarettes is a key element of smoking prevention policies. This article explores how young people source cigarettes following the increase in the UK minimum age of sale from 16 to 18 years.

Methods

Semi-structured individual, paired and triadic interviews with 60 disadvantaged young people aged between 12 and 17. Participants were recruited from clubs and voluntary organizations offering advice and support to disadvantaged young people.

Results

Most participants said they sourced cigarettes from shops, but understandings of "buying cigarettes from shops" included using intermediaries for proxy purchases. Access from social sources was contingent on reciprocation, and blackmarket sources were avoided. The distinction between potential and actual sources reflected participants concerns about their presentation of self. Those who bought cigarettes directly from shops accrued status and power in negotiating social hierarchies. Participants therefore highlighted their smoking related competencies, that is, ability to secure regular retail access to tobacco, while downplaying the significant difficulties they experienced.

Conclusions

The presentational dimension of youth cigarette access highlights a need for caution in associating self-reported changes in young people's cigarette sources straightforwardly with access policies. The conflation of direct retail purchases with proxy purchases, and the interrelationship between commercial and social cigarette sources also raises issues for interpreting data on "usual" cigarette sources from national surveys. Findings suggest that some young people may still be both reliant on making retail cigarette purchases following the increase in the age of sale in the United Kingdom, and experiencing significant difficulties making these.

Implications

This study highlights the self-presentational dimension of youth cigarette access in a particular community context, and the important distinction between the apparent range of sources available and their social acceptability in young people's social networks. Young smokers tended to conflate direct retail purchases with proxy purchases, raising issues for interpreting survey data on "usual" cigarette source. The presentational dimension of youth cigarette access also highlights a need for caution in associating self-reported changes in young people's cigarette sources with access policies. Despite participants' stated easy access, few were able to buy cigarettes directly, underscoring the effectiveness of youth access policies.

Prospective Analysis of the Influence of Sport and Educational Factors on the Prevalence and Initiation of Smoking in Older Adolescents from Croatia

The prevalence of smoking among Croatian adolescents is alarmingly high, but no previous study has prospectively examined the sport- and academic-factors associated with smoking and smoking initiation. This study aimed to prospectively examine the associations between scholastic (educational) achievement and sport factors and smoking in 16- to 18-year-old adolescents. This two-year prospective cohort study included 644 adolescents who were 16 years of age at baseline (46% females). Baseline testing was implemented at the beginning of the 3rd year of high school (September 2014) when participants were 16 years old. Follow-up testing was completed at the end of the fourth year of high school, which occurred 20 months later. The evaluated predictor variables were educational-achievement- and sport-related-factors. The outcome variables were (i) smoking at baseline; (ii) smoking at follow-up; and (iii) smoking initiation over the course of the study. We assessed the associations between predictors and outcomes using logistic regression models adjusted for age, gender, socioeconomic status, and conflict with parents. The educational variables were consistently associated with smoking, with lower grade-point-average (Baseline: odd ratio (OR): 2.01, 95% confidence interval (CI): 1.61–2.55; Follow-up: 1.59, 1.31–1.94), more frequent absence from school (Baseline: OR: 1.40, 95% CI: 1.19–1.69; Follow-up: 1.30, 1.08–1.58), and lower behavioral grades (Baseline: OR: 1.80, 95% CI: 1.10–2.89; Follow-up: 1.57, 1.03–2.41) in children who smoke. Adolescents who reported quitting sports were at greater odds of being smokers (Baseline: 2.07, 1.31–3.32; Follow-up: 1.66, 1.09–2.56). Sport competitive achievement at baseline was protective against smoking initiation during following two-year period (0.45, 0.21–0.91). While the influence of the educational variables on smoking initiation has been found to be established earlier; sport achievement was identified as a significant protective factor against initiating smoking in older adolescents. Results should be used in development of an anti-smoking preventive campaign in older adolescents.

Sport and scholastic factors in relation to smoking and smoking initiation in older adolescents: a prospective cohort study in Bosnia and Herzegovina

OBJECTIVE

Sport and scholastic factors are known to be associated with cigarette smoking in adolescence, but little is known about the causality of this association. The aim of this study was to prospectively explore the relationships of different sport and scholastic factors with smoking prevalence initiation in older adolescents from Bosnia and Herzegovina.

METHODS

In this 2-year prospective cohort study, there were 872 adolescent participants (16 years at baseline; 46% females). The study consisted of baseline tests at the beginning of the third year (September 2013) and follow-up at the end of the fourth year of high school (late May to early June 2015). The independent variables were scholastic and sport-related factors. The dependent variables were (1) smoking at baseline, (2) smoking at follow-up and (3) smoking initiation over the course of the study. Logistic regressions controlling for age, gender and socioeconomic status were applied to define the relationships between independent and dependent variables.

RESULTS

School absence at the baseline study was a significant predictor of smoking initiation during the course of the study (OR 1.4, 95% CI 1.1 to 1.8). Those who reported quitting sports at baseline showed an increased risk of smoking at the end of the study (OR 1.4, 95% CI 1.1 to 2.0) and of smoking initiation (OR 1.8, 95% CI 1.3 to 2.0). Adolescents who reported lower competitive achievements in sport were at a higher risk of (1) smoking at baseline (OR 1.5, 95% CI 1.1 to 2.1), (2) smoking at follow-up (OR 1.5, 95% CI 1.1 to 2.1) and (3) smoking initiation (OR 1.6, 95% CI 1.1 to 2.6).

CONCLUSIONS

In developing accurate antismoking public health policies for older adolescents, the most vulnerable groups should be targeted. The results showed that most participants initiated smoking before 16 years of age. Therefore, further investigations should evaluate the predictors of smoking in younger ages.

Impact of laws restricting the sale of tobacco to minors on adolescent smoking and perceived obtainability of cigarettes: an intervention-control pre-post study of 19 European Union countries

AIMS

To estimate the impact of introducing sales restriction laws in Europe by measuring changes in adolescent smoking prevalence and perceived obtainability of cigarettes over time in countries that have recently introduced sales restriction laws (intervention countries). These countries were compared with countries where such laws were already in force (control countries). The secondary aim was to test whether these trends differed between adolescents of higher and lower socio-economic position (SEP).

DESIGN

Repeated cross-sectional data were used in a quasi-experimental pre-post design. Intervention countries raised tobacco sales restrictions to 18 years in 2007, 2008 or 2009. Control countries have had sales restrictions of 18 years since at least 2004.

SETTING

Nineteen European Union (EU) countries in 2007 and 2011.

PARTICIPANTS

Data of 97 245 15- and 16-year-old adolescents from the 2007 and 2011 European Survey Project on Alcohol and other Drugs (ESPAD) surveys.

MEASUREMENTS

Dependent variables were smoking status (weekly smoking versus non-smoking or less than weekly smoking) and perceived obtainability of tobacco (easy versus difficult). Key independent variables were time (2007 or 2011), intervention exposure (intervention or control country) and their interaction (time × intervention). Covariates included sex, SEP, the tobacco control scale (TCS), gross domestic product (GDP) and adult smoking prevalence.

FINDINGS

We did not find a difference in the change in smoking prevalence between intervention and control countries [odds ratio (OR) = 1.00, 95% confidence interval (CI) = 0.93-1.07]. However, sales restrictions were associated with a significantly greater decrease in perceived ease of cigarette obtainability in intervention countries (OR = 0.75, 95% CI = 0.70-0.80). No significant differential effects between high and low SEP adolescents were found (OR = 1.01, 95% CI = 0.81-1.25).

CONCLUSION

Laws prohibiting the sales of tobacco to minors in Europe do not appear to be associated with a reduction in adolescent smoking rates, but lower the perceived obtainability of cigarettes irrespective of their socio-economic position.

Impact of removing point-of-sale tobacco displays: data from a New Zealand youth survey

INTRODUCTION

The tobacco industry increasingly invests in point-of-sale (POS) marketing. In July 2012, New Zealand required the removal of POS tobacco displays concurrently with increased enforcement and penalties for selling tobacco to minors, and additional restrictions on tobacco sponsorship. We evaluated the impact of these measures using a before-after study.

METHODS

We analysed data from annual surveys of more than 25 000 year 10 (14-15 years) students from 2007 and 2011 to 2014. Measures included prevalence of smoking-related behaviours and strength of association between visiting tobacco-retailing stores and smoking behaviours.

RESULTS

Between 2011 and 2014, smoking experimentation (had smoked ever but smoked less than monthly currently) decreased from 23% in 2011 to 17% in 2014 (adjusted odds ratio (aOR) 0.73, 95% CI 0.69 to 0.78); current smoking (at least monthly) prevalence from 9% to 7% (aOR 0.71, 0.64 to 0.79) and initiation in the last year from 13% to 11% (aOR 0.91, 0.84 to 0.98). Attempted purchase of cigarettes in the past 30 days among smokers decreased from 30% in 2012 to 26% in 2013 (aOR 0.77, 0.63 to 0.91). Positive associations between frequency of visiting tobacco-retailing stores and smoking-related behaviours weakened post-implementation.

CONCLUSIONS

The introduction of a POS display ban and concurrent measures was followed by significant reductions in initiation, experimental and regular smoking, attempted purchase of cigarettes, and reduced association between visiting tobacco-retailing stores and smoking behaviours. The findings suggest that POS display bans are important components of strategies to reduce smoking initiation among youth and young people.

Realistically furthering the goals of public health by cannabis legalization with strict regulation: Response to Kalant

Cannabis Policy Framework respond to select issues from Kalant's Commentary (in this issue).

Youth Preferences for Roll-Your-Own Versus Factory-Made Cigarettes: Trends and Associations in Repeated National Surveys (2006-2013) and Implications for Policy

INTRODUCTION

We investigated trends in roll-your-own (RYO) and factory-made (FM) cigarette use over time among youth in New Zealand (NZ), a high RYO use country. We also explored factors associated with RYO use.

METHODS

We analyzed data from an annual survey of NZ students (14-15 years old) from 2006-2013. Smokers were asked whether they usually smoked RYO or FM cigarettes, and provided details of their source of supply. We estimated prevalences and developed a binary logistic regression model to explore determinants of RYO use.

RESULTS

Between 6663 (2006) and 3143 (2013) current smokers responded. Each year, around 80% reported usually smoking RYO or FM cigarettes. The proportion reporting usual RYO use was 45% (95% confidence interval [CI] ±3%) in 2006, reducing to 40% (95% CI ±3%) in 2013 (trend test: P < .001). By contrast, the proportions reporting usual FM use increased slightly over time from 36% (95% CI ±3%) in 2006 to 38% (95% CI ±3%) in 2013 (trend test: P < .001). Usual RYO use was more common amongst regular smokers, those who initiated smoking younger, who belonged to low or medium socioeconomic status groups, and whose friends and family both smoked.

CONCLUSIONS

RYO use is very high among NZ youth who smoke. Preference for RYO cigarettes amongst longer-term, regular smokers suggests RYO tobacco supports and maintains youth smoking. There was some initial evidence that a 2010 differential tax increase on RYO tobacco was associated with a shift away from usual RYO use amongst those who sourced tobacco from caregivers or friends. Additional measures such as further differential excise tax increases appear warranted.

Disadvantaged youth and smoking in mature tobacco control contexts: a systematic review and synthesis of qualitative research

OBJECTIVE

To review qualitative research and synthesise findings about socioeconomically disadvantaged and socially marginalised adolescents and young adults in mature tobacco control contexts.

DATA SOURCES

Searches of PubMed and MEDLINE, additional purposive searches in Google Scholar, PsycINFO, grey literature, specialist journals and reference lists for English language articles published after 2000. Search terms were qualitative, youth or adolescent or young adult, smoking/tobacco and vulnerable populations or disadvantage or socioeconomic inequality. The most recent update of the search was undertaken in January 2014.

STUDY SELECTION

Twenty articles, reporting on 17 studies, from 902 initial records were included. Inclusion criteria were: qualitative study undertaken in a country in the final stage of the tobacco epidemic and with comprehensive tobacco control measures in place, participants were youth who were socioeconomically disadvantaged or members of an identified subgroup with higher smoking prevalence and/or resided in a geographical area of low socioeconomic status. The target age range was 10-24.

DATA EXTRACTION

Data were independently extracted by one author, summarised and reviewed, compared and re-reviewed at multiple time points.

DATA SYNTHESIS

The majority of studies were from the UK, with the remainder from the USA, Australia and New Zealand. The review used a thematic analysis approach, and started with an open question: 'what does qualitative research tell us about disadvantaged young people and smoking?' The synthesis provides insights into the social context of smoking for marginalised and disadvantaged young people, group affiliation and identity, the role of smoking in social capital and sources of cigarettes.

CONCLUSIONS

Surprisingly few qualitative studies focused exclusively on smoking and disadvantaged young people were found. Future qualitative studies on the intersection between specific psychosocial characteristics associated with disadvantage and increased smoking risk would be of use to inform approaches to reduce socioeconomic differentials in smoking prevalence.