Socioeconomic inequalities in smoking cessation in 11 European countries from 1987 to 2012

Vaping and socioeconomic inequalities in smoking cessation and relapse: a longitudinal analysis of the UK Household Longitudinal Study

BACKGROUND

Smoking is a key cause of socioeconomic health inequalities. Vaping is considered less harmful than smoking and has become a popular smoking cessation aid, and therefore has potential to reduce inequalities in smoking.

METHODS

We used longitudinal data from 25 102 participants in waves 8-10 (2016 to early 2020) of the UK Household Longitudinal Study to examine how vaping affects socioeconomic inequalities in smoking cessation and relapse. Marginal structural models were used to investigate whether vaping mediates or moderates associations between educational attainment and smoking cessation and relapse over time. Multiple imputation and weights were used to adjust for missing data.

RESULTS

Respondents without degrees were less likely to stop smoking than those with a degree (OR: 0.65; 95% CI 0.54-0.77), and more likely to relapse (OR: 1.74; 95% CI 1.37-2.22), but this inequality in smoking cessation was not present among regular vapers (OR: 0.99; 95% CI 0.54-1.82). Sensitivity analyses suggested that this finding did not hold when comparing those with or without any qualifications. Inequalities in smoking relapse did not clearly differ by vaping status.

CONCLUSIONS

Vaping may be especially helpful as a cessation aid for smokers without degree level education and therefore may help reduce inequalities in smoking. Nevertheless, other supports or aids may be needed to reach the most disadvantaged (ie, those with no qualifications) and to help people avoid relapse after cessation, though we did not find clear evidence suggesting that vaping would increase inequalities in relapse.

Smoking cessation rate and predictors of successful quitting in Jordan: A cross-sectional study

Tobacco smoking in Jordan is the highest in the Middle East, with health consequences and economic burdens. Smoking cessation improves health and grows the economy. This study aimed to determine the prevalence of smoking cessation in Jordan and to identify the determinants of effective quitting. This cross-sectional study was conducted using an online survey directed towards the general population of Jordan. The questionnaire was formulated in Arabic and inquired about sociodemographic factors, health status, behaviors, smoking habits, previous quitting attempts, utilization of smoking cessation services, attitudes towards quitting, and barriers to quitting. Data were analyzed using Statistical Package for Social Science version 25. A total of 463 participants were included in this study. Twenty-one percent of them were ex-smokers (n = 97), 86% were male, 63.3% were from the middle governorates, and 29.2% were 24 years old or younger. The rate of sustained quitting for at least 3 months among participants was 13.6%. The factors associated with successful quitting included age > 50 years (P = .001), practicing regular physical activity (P = .003), using more than 1 tobacco product (P = .000), smoking waterpipes or e-cigarettes (P = .000 and .015, respectively), lower levels of nicotine dependence (P = .009), duration of smoking (P = .000), higher number of smoking cessation attempts (P = .000), having 1 or more chronic diseases (P = .049), and having DM (P = .003). More than half of the ex-smokers needed 2 to 5 attempts before successfully quitting smoking. There was a low rate of utilization of smoking cessation services and medications in both groups. On the other hand, there is a high rate of use of other smoking methods, particularly waterpipes and e-cigarettes, as an aid for quitting. Current smokers reported being in a stressful situation as a barrier to quitting significantly more often than did ex-smokers (P = .013). Both groups had moderately positive attitudes toward quitting. Ex-smokers had significantly better attitudes toward their ability to manage stress, weight gain, and increased appetite after quitting (P = .004, .004, and .007, respectively). This study provides valuable insights into the complex dynamics of smoking behavior, cessation attempts, and attitudes. These findings can inform the development of targeted smoking cessation programmes and policies.

Selective Reduction of Socioeconomic Disparities in the Experimental Tobacco Marketplace: Effects of Cigarette and E-cigarette Flavor Restrictions

INTRODUCTION

Cigarette smoking accounts for >30% of the socioeconomic gap in life expectancy. Flavored restrictions claim to promote equity; however, no previous studies have compared the effect of cigarette and e-cigarette flavor restrictions among individuals who smoke with lower and higher socioeconomic status (SES).

AIMS AND METHODS

In a between-group within-subject design, individuals with lower (n = 155) and higher (n = 125) SES completed hypothetical purchasing trials in the experimental tobacco marketplace (ETM). Conditions were presented in a 2 × 2 factorial design (cigarette flavors restricted or unrestricted and e-cigarette flavors restricted or unrestricted) with increasing cigarette prices across trials.

RESULTS

Results show (1) SES differences in cigarette, e-cigarette, and NRT purchases under unrestricted policies, with lower SES showing higher cigarette demand and lower e-cigarette and NRT substitution than higher SES, (2) cigarette restrictions decreased cigarette and increased NRT purchases among lower SES, but no significant changes among higher SES, (3) decreased SES differences in cigarette demand under cigarette restrictions, but persistence under e-cigarette restrictions or their combination, (4) persistence of SES differences in e-cigarette purchases when all restrictions were enforced, and (5) waning of SES differences in NRT purchasing under all restrictions.

CONCLUSIONS

Flavor restrictions differentially affected individuals based on SES. Within-group comparisons demonstrated restrictions significantly impacted lower SES, but not higher SES. Between-group comparisons showed SES differences in cigarette purchasing decreased under cigarette restrictions, but persisted under e-cigarette-restrictions or their combination. Additionally, SES differences in NRT substitution decreased under flavor restrictions. These findings highlight the utility of the ETM to investigate SES disparities.

IMPLICATIONS

With increasing trends of socioeconomic differences in smoking prevalence and cessation rates, smoking-related health disparities are expected to continue to widen. Restricting menthol flavor in cigarettes while enhancing the availability and affordability of NRT have the potential to alleviate SES disparities in tobacco use, therefore, positively impacting health equity. However, this effect may depend on flavor availability in other tobacco products.

Independent associations of education, intelligence, and cognition with gastrointestinal diseases and the mediating effects of risk factors: a Mendelian randomization study

Background

Education, intelligence and cognition affect occupational performance and socioeconomic status and may influence virous diseases development. However, the impact of these factors on gastrointestinal diseases and their mediating risk factors remains unclear.

Methods

We utilized genome-wide association studies from European ancestry populations to perform two-sample Mendelian randomization analyses, aiming to estimate genetic instruments associated with education, intelligence, or cognition in relation to 24 gastrointestinal diseases Subsequently, we evaluated 14 potential mediators of this association and calculated the corresponding mediated proportions through two-step Mendelian randomization analyses.

Result

As the dominant factor in gastrointestinal diseases, education had a statistically significant association with 2 gastrointestinal diseases (acute pancreatitis, gastroesophageal reflux) and a suggestive association with 6 diseases (cirrhosis, alcoholic liver disease, cholecystitis, cholelithiasis, chronic gastritis and gastric ulcer). Of the 14 mediators, smoking and adiposity traits played a major role in mediating the effects.

Conclusion

The study demonstrated the causal, independent impact of education on specific gastrointestinal diseases. Smoking and adiposity traits emerged as primary mediators, illuminating potential avenues for targeted interventions for prevention of them.

Factors associated with attempting and succeeding in smoking cessation following a National Tobacco Control Plan: Analysis of two nationwide surveys (2010 and 2017)

INTRODUCTION

Lower rates of smoking cessation among disadvantaged groups contribute to widening health-disparities. With this recognition, in 2010 free-of-charge/subsidized smoking cessation services became available to all Israeli residents through the not-for-profit health plans.

METHODS

Based on two cross-sectional National Social Surveys, data on adult ever-smokers were used (n = 2,998 in 2010 and 2,859 in 2017). The outcome variable comprised three categories: no quit attempt, unsuccessful quit attempt and successful quit attempt. Changes over-time and demographic, socioeconomic, health- and smoking-related factors associated with quitting attempts and success were tested in the pooled sample, using multivariable multinomial logistic regression models.

RESULTS

The pooled sample of the two surveys included 2,611 participants (44.2%) who were successful quitters, 1,941 (32.7%) who reported an unsuccessful quit attempt, and 1,305 (23.1%) smokers who did not attempt to quit. Compared to 2010, ever-smokers in 2017 were less likely to report an unsuccessful quit attempt (adjusted OR = 0.81, 95%CI: 0.70-0.94). The likelihood of successfully quitting was similar in both surveys. Older age and self-reported health problem were associated with higher likelihood of quitting attempt. Meeting living expenses, being overweight/obese, engaging in physical activity and heavy smoking were associated with higher likelihood of successful smoking cessation; while environmental tobacco exposure was associated with 43% lower likelihood of successful cessation. Finally, there was an interaction between education and ethnicity. Higher education level was associated with a greater likelihood both to attempt to quit smoking and to succeed among Jewish participants, while the opposite phenomenon was observed among Arab smokers.

CONCLUSIONS

Despite the availability of subsidized smoking cessation services, social disparities in smoking cessation rates persist. Efforts should focus on proactively reaching subpopulations with low cessation rates, using tailored strategies for successful smoking cessation. Promoting smoke free homes and workplaces should be prioritized.

A Nationally Representative Study of the Hardening Hypothesis Among Educational Groups Over Four Decades

INTRODUCTION

As smoking prevalence has decreased, there has been debate about "hardening" (smokers are more resistant to established tobacco control measures) or "softening" (smokers are more responsive to interventions) of the remaining smoking population. Despite growing evidence to reject the "hardening" hypothesis, there is lack of long-term population-based studies to test this hypothesis by educational level.

AIMS AND METHODS

Repeated cross-sectional population-based surveys during 1978-2014 and in 2018 were utilized. The target population consisted of ~5000 25-64-year-old Finns annually. The data included 109 257 respondents of which 53 351 ever-smoking individuals were included in the analyses. Response rates varied between 84% and 43%. Five hardening indicators considering smoking frequency, intensity and smoking cessation were used as the dependent variables. The main independent variable was study year (time). Statistical analyses were based on regression models using restricted cubic splines by educational level.

RESULTS

Contrary to the hardening hypothesis, hardening indicators showed softening over time among all educational groups. However, educational groups differed from each other. Compared with the highly educated, the quit ratio was lower, number of cigarettes per day (CPD) was higher, the proportions of daily smokers among current smokers and heavy smokers among daily smokers were higher among the less educated.

CONCLUSIONS

In accordance with growing evidence, also the Finnish smoking population has "softened" over time. Although the change has been predominantly in the same direction for all educational groups, the rate of change has been stronger among the highly educated, highlighting the continued burden of smoking among the less educated.

IMPLICATIONS

Even though "softening" of smoking has occurred, lighter smoking also poses health risks. Therefore, tobacco control policies and cessation services should be developed and targeted to a greater extent also for people who smoke less than daily and for those who smoke fewer CPD. Furthermore, interventions should focus on special requirements of the lower educational groups to promote health equity.

Factors associated with predictors of smoking cessation from a Norwegian internet-based smoking cessation intervention study

INTRODUCTION

We examined if we could identify predictors for smoking cessation at six months post cessation, among smokers enrolled in a large Norwegian population-based intervention study.

METHODS

We followed 4333 (72.1% women) smokers who enrolled in an internet-based smoking cessation intervention during 2010–2012. The baseline questionnaire collected information on sociodemographic and lifestyle factors, including current snus use. The cessation outcome was self-reported no smoking past seven days, at six months. We used logistic regression to estimate odds ratios (ORs) with 95% confidence intervals, to identify predictors of smoking cessation, adjusting for potential confounders.

RESULTS

Women (OR=1.30; 95% CI: 1.01–1.69) compared with men, and those with medium (OR=1.31; 95% CI: 1.02–1.68) and longer (OR=1.42; 95% CI: 1.06–1.90) education compared with those with shorter education, were more likely to be successful quitters.

Overall, being a student (OR=0.56; 95% CI: 0.37–0.85) compared with having full-time work, and a moderate to high Fagerström test for nicotine dependence (FTND) score (OR=0.69; 95% CI: 0.55–0.87) compared with a low score, were predictors for unsuccessful cessation. Current snus use was a predictor for unsuccessful cessation compared to no snus use for both men (OR=0.49; 95% CI: 0.28–0.88) and women (OR=0.49; 95% CI: 0.32–0.75).

CONCLUSIONS

Our study identifies female sex and longer education as predictors for successful smoking cessation, while a medium or high FTND score, being a student, and current snus use, were predictors for unsuccessful smoking cessation. Only current snus use was a predictor for unsuccessful cessation for both sexes. Our results indicate that smokers should be warned that snus use may prevent successful smoking cessation.

Socioeconomic inequalities in tobacco cessation among Indians above 15 years of age from 2009 to 2017: evidence from the Global Adult Tobacco Survey (GATS)

BACKGROUND

Tobacco is strongly associated with socioeconomic status (SES), however evidence on differences in tobacco cessation by socio-economic attributes remains fragmented, especially in developing countries. The present study aims to estimate socioeconomic inequalities in tobacco cessation among Indian men and women above 15 years of age.

METHODS

Two rounds of the Global Adult Tobacco Survey (2009-2010 and 2016-2017), India was used to estimate the association between socioeconomic indicators (wealth index and educational attainment) with tobacco cessation using a multinomial modeling approach.

RESULTS

After adjusting for SES and demographic variables, we found significantly lower odds in tobacco cessation rates among respondents of GATS-2 (2016-2017) compared to GATS-1 (2009-2010). Additionally, huge regional variations in smoking and smokeless tobacco cessation rates were observed. Population belonging to the low wealth-asset score had higher odds of cessation compared to the high asset index. While greater educational attainment was seen to have a positive effect on cessation, the results were insignificant. Individuals belonging to the northeastern geographic region were seen to have the lowest odds of cessation. Though awareness about the health hazards of tobacco increased, cessation declined for both men and women. Quitting smokeless tobacco among men and women was observed to be lower than smoking.

CONCLUSION

This study is the first to provide national-level evidence on the association between tobacco cessation and socioeconomic attributes among Indians above 15 years of age. Findings suggest the need to scale up tobacco cessation services separately for men and women, and also for smoking and smokeless tobacco forms.

Burden of current and past smoking across 28 European countries in 2017: A cross-sectional analysis

INTRODUCTION

Most studies use the prevalence of current smoking as an indicator to quantify the burden of smoking. However, length and intensity of smoking, as well as time since cessation for former smokers are also known to impact smoking-related health risks. The aim of this study was to quantify and compare the burden of smoking across the European Union (EU) using a range of smoking burden indicators.

METHODS

We conducted a cross-sectional analysis using data from the March 2017 Eurobarometer 87.1 (n=27901, people aged ≥15 years) in 28 European Union Member States (EU MS) and the Tobacco Control Scale. We defined five indicators of smoking burden including the prevalence of current and ever smoking, length of smoking, pack-years, and discounted pack-years, and ranked EU MS by each indicator. Two-level linear and logistic regressions were performed to assess the association between these indicators and sociodemographic and tobacco policy factors.

RESULTS

Wide variations across the EU countries were observed in all smoking burden indicators. While some MS ranked consistently high (e.g. Greece, France) or consistently low (e.g. Ireland, United Kingdom) in all indicators, we found substantial discrepancies in ranking depending on the indicator used for MS such as Malta, Denmark, Finland and the Netherlands. All indicators of smoking burden were lower among women and respondents without financial difficulties; however, the magnitude of those inequalities varied two-fold among the different indicators.

CONCLUSIONS

Using a range of smoking burden indicators can be more informative than relying on prevalence alone. Our analysis highlights the limitations of relying solely on prevalence of current smoking to estimate the burden of smoking and the potential value of more nuanced indicators. We recommend that multiple and more nuanced indicators that consider former smokers, intensity and duration of smoking should be utilized to monitor tobacco use and evaluate tobacco control policies.

How do Europeans quit using tobacco, e-cigarettes and heated tobacco products? A cross-sectional analysis in 28 European countries

OBJECTIVES

While smoking tobacco remains a substantial cause of harm in Europe, novel products such as electronic cigarettes or e-cigarettes (ECs) and heated tobacco products (HTPs) have entered the market recently. While debate still persists over the role of these novel products, they are now in widespread use. This study aimed to explore the prevalence and methods of attempts to quit EC and HTP.

SETTING

We analysed the 2020 Eurobarometer survey, which collected data in 28 European countries.

PARTICIPANTS

A representative sample of individuals residing in these countries aged ≥15 years.

PRIMARY AND SECONDARY OUTCOME MEASURES

Multilevel regression analyses were performed to assess differences in quit attempts and cessation methods among tobacco smokers and exclusive EC/HTP users separately.

RESULTS

51.1% of current tobacco smokers and 27.1% of exclusive EC or HTP users reported having ever made a quit attempt. The majority of former and current smokers (75.8%) who made a quit attempt did so unassisted, with 28.8% reporting at least one attempt using a cessation aid. The most popular cessation aids were nicotine replacement therapy or other medication (13.4%) and ECs (11.3%). 58.8% of exclusive EC or HTP users who had made a quit attempt did so unassisted, with 39.5% reporting the use of a cessation aid.

CONCLUSION

Most EC and HTP users in Europe try to quit unassisted, although more of them report the use of a cessation aid compared with tobacco smokers. Cessation support services should take into consideration the increasing numbers of users of EC and HTP who may be trying to quit.

Socioeconomic Inequalities in Elective and Nonelective Hospitalizations in Older Men

IMPORTANCE

Among older adults, there is limited and inconsistent evidence on the association between socioeconomic position (SEP) and elective and nonelective hospitalization.

OBJECTIVE

To evaluate the association between SEP and all-cause and cause-specific elective and nonelective hospitalization and hospital length of stay among older men.

DESIGN, SETTING, AND PARTICIPANTS

This population-based, prospective cohort study used data from the Concord Health and Aging in Men Project (CHAMP). CHAMP recruited 1705 men aged 70 years or older between January 28, 2005, and June 4, 2007, in Sydney, Australia. Data were analyzed from February 1 to September 30, 2021.

EXPOSURES

Indicators of SEP, including education (university degree certificate, diploma or no postschool qualifications), occupation (professionals and managers; small employers and self-employed; or lower clerical, service, sales workers, skilled, and unskilled workers), and source of income (other sources of income than government pension, reliance on government pensions and other sources of income, or reliant solely on a government pension), and a cumulative SEP score (tertiles) as SEP indicators; 3-level variables present high, intermediate, and low SEP.

MAIN OUTCOMES AND MEASURES

All-cause and cause-specific elective and nonelective hospitalizations, number of hospitalizations, and length of stay were the study outcomes, ascertained through data linkage. Associations were quantified using competing-risks survival regression and negative binomial regression.

RESULTS

A total of 1566 men (mean [SD] age, 76.8 [5.4] years) were included. During a mean (SD) 9.07 (3.53) years of follow-up, 1067 men had at least 1 elective hospitalization, and 1255 men had at least 1 nonelective hospitalization. No associations were found between SEP and elective hospitalizations. Being in the lowest tertile for educational level (subhazard ratio [SHR], 1.32; 95% CI, 1.11-1.58), occupational position (SHR, 1.30; 95% CI, 1.12-1.50), sources of income (SHR, 1.33; 95% CI, 1.17-1.52), and cumulative SEP tertile groups (SHR, 1.45; 95% CI, 1.24-1.68) were all associated with having at least 1 nonelective hospitalization compared with those in the highest tertiles. Significant associations were found between being in the lowest SEP groups and increased numbers and longer length of stay of nonelective hospitalizations.

CONCLUSIONS AND RELEVANCE

In this prospective cohort study, low SEP was inversely associated with nonelective hospitalizations but not elective hospitalization in older men in Australia. These findings point to the existence of socioeconomic inequalities in health care use, indicative of a need to take action to reduce these inequalities.

Tobacco control in Europe: progress and key challenges

We discuss progress made with respect to reducing the burden of disease caused by tobacco use within the WHO European Region and outline major issues and challenges regarding ongoing implementation of tobacco control policy. Although 50 of 53 countries in the WHO European Region are parties to the WHO Framework Convention for Tobacco Control (FCTC), smoking prevalence varies tremendously between European countries. While smoking rates are decreasing slowly, faster declines among smokers with a higher socioeconomic status are leading to growing inequalities in tobacco use. Governments in Europe increasingly formulate visions of 'tobacco-free' societies and it is encouraging that the European Commission aims to achieve a tobacco-free Europe in 2040 as part of its Europe's Beating Cancer Plan. While core WHO FCTC measures still have to be fully implemented in many European countries, some countries are implementing more advanced measures such as plain packaging, banning of characterising flavours from tobacco products, tobacco retailer licensing and extensions of smoking bans into spaces such as cars, outdoor areas and public streets. Remaining challenges include protecting tobacco control policymaking from tobacco industry interference, insufficient dedicated budget for scientific research and the need for Europe-wide monitoring data on use of tobacco and nicotine products.

Associations Between Adolescent Mental Health and Health-Related Behaviors in 2005 and 2015: A Population Cross-Cohort Study

PURPOSE

Adolescent mental ill-health is a growing concern. There is little understanding of changes over time in the associations between mental health and health-related behaviors and outcomes (such as substance use, antisocial behavior, and obesity). We investigate whether the associations between different health and health-related outcomes in adolescence are changing over time in two recent cohorts of adolescents born 10 years apart.

METHODS

Data from two UK birth cohort studies, the Avon Longitudinal Study of Parents and Children (ALSPAC, born 1991-92, N = 5,627, 50.7% female) and Millennium Cohort Study (MCS, born 2000-2, N = 11,318, 50.6% female) at age 14 are analyzed. The health outcomes of focus are depressive symptoms, substance use (alcohol, smoking, cannabis, and other drugs), antisocial behaviors (assault, graffiti, vandalism, shoplifting and rowdy behavior), weight (body mass index [BMI]), weight perception (perceive self as overweight), and sexual activity (had sexual intercourse). Regression analyses are conducted to examine associations between these variables with cohort as a moderator to examine cohort differences.

RESULTS

The directions of associations between mental-health and health-related behaviors (e.g., smoking) are similar over time; however, their strength across the distribution has changed. While smoking and alcohol use behaviors are decreasing in adolescents, those that endorse these behaviors in 2015 are more likely to have co-occurring mental ill-health than those born in 2005. Similarly, higher BMI is more strongly associated with depressive symptoms in 2015 compared to 2005.

CONCLUSIONS

Adverse health-related outcomes such as greater substance use, mental health difficulties, and higher BMI appear to be more likely to cluster together in the more recent cohort, with implications for public health planning, service provision, and lifelong disease burden.

Smoking Cessation in Lower Socioeconomic Groups: Adaptation and Pilot Test of a Rolling Group Intervention

Background

Socioeconomic inequalities in smoking rates persist and tend to increase, as evidence-based smoking cessation programs are insufficiently accessible and appropriate for lower socioeconomic status (SES) smokers to achieve long-term abstinence. Our study is aimed at systematically adapting and pilot testing a smoking cessation intervention for this specific target group.

Methods

First, we conducted a needs assessment, including a literature review and interviews with lower SES smokers and professional stakeholders. Next, we selected candidate interventions for adaptation and decided which components needed to be adopted, adapted, or newly developed. We used Intervention Mapping to select effective methods and practical strategies and to build a coherent smoking cessation program. Finally, we pilot tested the adapted intervention to assess its potential effectiveness and its acceptability for lower SES smokers.

Results

The core of the adapted rolling group intervention was the evidence-based combination of behavioral support and pharmacotherapy. The intervention offered both group and individual support. It was open to smokers, smokers who had quit, and quitters who had relapsed. The professional-led group meetings had a fixed structure. Themes addressed included quitting-related coping skills and health-related and poverty-related issues. Methods applied were role modeling, practical learning, reinforcement, and positive feedback. In the pilot test, half of the 22 lower SES smokers successfully quit smoking. The intervention allowed them to “quit at their own pace” and to continue despite a possible relapse. Participants appraised the opportunities for social comparison and role modeling and the encouraging atmosphere. The trainers were appreciated for their competencies and personal feedback.

Conclusions

Our adapted rolling group intervention for lower SES smokers was potentially effective as well as feasible, suitable, and acceptable for the target group. Further research should determine the intervention's effectiveness. Our detailed report about the adaptation process and resulting intervention may help reveal the mechanisms through which such interventions might operate effectively.

Trends in inequalities in disability in Europe between 2002 and 2017

BACKGROUND

Monitoring socioeconomic inequalities in population health is important in order to reduce them. We aim to determine if educational inequalities in Global Activity Limitation Indicator (GALI) disability have changed between 2002 and 2017 in Europe (26 countries).

METHODS

We used logistic regression to quantify the annual change in disability prevalence by education, as well as the annual change in prevalence difference and ratio, both for the pooled sample and each country, as reported in the European Union Statistics on Income and Living Conditions (EU-SILC) and the European Social Survey (ESS) for individuals aged 30-79 years.

RESULTS

In EU-SILC, disability prevalence tended to decrease among the high educated. As a result, both the prevalence difference and the prevalence ratio between the low and high educated increased over time. There were no discernible trends in the ESS. However, there was substantial heterogeneity between countries in the magnitude and direction of these changes, but without clear geographical patterns and without consistency between surveys.

CONCLUSIONS

Socioeconomic inequalities in disability appear to have increased over time in Europe between 2002 and 2017 as per EU-SILC, and have persisted as measured by the ESS. Efforts to further harmonise disability instruments in international surveys are important, and so are studies to better understand international differences in disability trends and inequalities.

The social gradient in smoking: individual behaviour, norms and nicotine dependence in the later stages of the cigarette epidemic

The cigarette epidemic tends to develop in a similar pattern across diverse populations in different parts of the world. First, the prevalence of smoking increases, then it plateaus and finally it declines. The decline in smoking prevalence tends to be more pronounced in higher social strata. The later stages of the cigarette epidemic are characterized by emerging and persisting socioeconomic gradients in smoking. Due to its detrimental health consequences, smoking has been the subject of extensive research in a broad range of academic disciplines. I draw on literature from both the social and medical sciences in order to develop a model in which physiological nicotine dependence, individual smoking behaviour and norms surrounding smoking in the immediate social environment are related through reflexive processes. I argue that the emergence and persistence of social gradients in smoking at the later stages of the cigarette epidemic can be attributed to a combination of the pharmacological properties of nicotine, network homophily and the unequal distribution of material and non-material resources across social strata.

Area-level differences in the prices of tobacco and electronic nicotine delivery systems - A systematic review

OBJECTIVE

To examine associations between area-level characteristics (socioeconomic status, racial or ethnic characteristics, age, and any other characteristics that may be associated with vulnerability) and the prices of tobacco products and electronic nicotine delivery systems (ENDS).

DATA SOURCES

We searched MEDLINE, EconLit and Scopus, unpublished and grey literature, hand-searched four specialty journals, examined references of relevant studies, and contacted key informants.

STUDY SELECTION

We considered all studies that quantitatively examined area-level variations in the prices of tobacco products and ENDS. We included all studies that examined any area-level measures regardless of the geographic location, language or time of publication. At least two reviewers independently screened the articles. We identified 20 studies.

DATA EXTRACTION

At least two reviewers independently extracted the characteristics, methods, and main results and assessed the quality of each included study.

DATA SYNTHESIS

Overall, cigarette prices were found to be lower in lower socioeconomic status neighbourhoods, and in neighbourhoods with a higher percentage of youth, and Blacks or African Americans. We identified too few studies that examined price differences for cigarillos, chewing tobacco, roll-your-own, and ENDS to reach any conclusions.

CONCLUSIONS

Our findings are in keeping with tobacco industry documents that detailed how manufacturers used race, class, and geography to target vulnerable populations and suggest that regulations that can limit industry price manipulation such as minimum, maximum, and uniform prices, and high specific excise taxes should be considered. More frequent and systematic monitoring of tobacco prices and ENDS is warranted.

Changes in smoker characteristics in England between 2008 and 2017

AIMS

At a time of declining smoking prevalence in England, it is useful to document any changes in the characteristics of smokers. This has implications for targeting tobacco control policies and interventions. This study compared the characteristics of smokers from 2008 to 2017 to assess changes in smoking and quitting patterns and socio-demographic profile.

DESIGN AND SETTING

Analysis of annual trends in results from repeated cross-sectional surveys of representative samples of the population in England from 2008 to 2017.

PARTICIPANTS

The study included 208 813 adults aged 16+.

MEASUREMENTS

Information was gathered on age, sex, social grade and region, cigarette consumption, cigarette dependence as measured by time to first cigarette of the day, daily smoking, smoking roll-your-own cigarettes, attempts to cut down, use of an e-cigarette or nicotine replacement therapy, attempts to cut down or quit, use of support in quit attempts and whether the quit attempt was abrupt.

FINDINGS

During the period, mean daily cigarette consumption [B = -0.30, 95% confidence interval (CI) = -0.33 to -0.27] and the time to first cigarette score decreased (B = -0.03, 95% CI = -0.03 to -0.02). The proportion of smokers attempting to cut down or quit decreased (odds ratio (OR) range = 0.96-0.97, 95% CI range = 0.95-0.97). Use of behavioural support [odds ratio (OR) = 0.89, 95% CI = 0.86-0.92] or no support decreased (OR = 0.98, 95% CI = 0.96-0.99), while use of pharmacological support, including e-cigarettes, increased (OR = 1.04, 95% CI = 1.02-1.05). There was no significant change in the difference in social grade between smokers and non-smokers comparing 2008 with 2017. Changes in smoking and quitting behaviour were independent of changes in socio-demographic characteristics.

CONCLUSIONS

Between 2008 and 2017 in England, smokers appear to have become less dependent on cigarettes but less likely to try to quit or cut down. Of those who tried to quit, fewer used behavioural support and more used pharmacological support. The proportion from more disadvantaged backgrounds did not change significantly.

24-Year trends in educational inequalities in adult smoking prevalence in the context of a national tobacco control program: The case of Brazil

Brazil was a low and middle-income country (LMIC) in the late-1980s when it implemented a robust national tobacco-control program (NTCP) amidst rapid gains in national incomes and gender equality. We assessed changes in smoking prevalence between 1989 and 2013 by education level and related these changes to trends in educational inequalities in smoking. Data were from four nationally representative cross-sectional surveys (1989, n = 25,298; 2003 n = 3845; 2008 n = 28,938; 2013 n = 47,440, ages 25-69 years). We estimated absolute (slope index of inequality, SII) and relative (relative index of inequality, RII) educational inequalities in smoking prevalence, separately for males and females. Additional analyses stratified by birth-cohort to assess generational differences. Smoking declined significantly between 1989 and 2013 in all education groups but declines among females were steeper in higher-educated groups. Consequently, both absolute and relative educational inequalities in female smoking widened threefold between 1989 and 2013 (RII: 1.31 to 3.60, SII: 5.3 to 15.0), but absolute inequalities in female smoking widened mainly until 2003 (SII: 15.8). Conversely, among males, declines were steeper in higher-educated groups only in relative terms. Thus, relative educational inequalities in male smoking widened between 1989 and 2013 (RII: 1.58 to 3.19) but mainly until 2008 (3.22), whereas absolute equalities in male smoking were unchanged over the 24-year period (1989: 21.1 vs. 2013: 23.2). Younger-cohorts (born ≥1965) had wider relative inequalities in smoking vs. older-cohorts at comparable ages, particularly in the youngest female-cohorts (born 1979-1988). Our results suggest that younger lower-SES groups, especially females, may be particularly vulnerable to differentially higher smoking uptake in LMICs that implement population tobacco-control efforts amidst rapid societal gains.

Factors associated with abstinence after a recent smoking cessation attempt across 28 European Union member states

INTRODUCTION

There is a lack of information regarding factors associated with successful smoking cessation on a population and European Union (EU)-wide level. Our study seeks to explore individual and country-level factors associated with abstinence after a recent smoking cessation attempt across the EU.

METHODS

We obtained data from the March 2017 Special Eurobarometer 87.1 (n=27901). Regression analysis was performed on a subset of 1472 individuals who made quit attempts in the past 12 months. Sociodemographic, policy and country-level factors were assessed using logistic regression among smokers and ex-smokers who attempted to quit approximately 12 months before the survey date. We defined and examined the Cessation Ratio (ratio of number of recent quitters to those who did not succeed) across 28 EU Member States.

RESULTS

In all, 14.9% (n=1018) of current smokers and 8.80% (n=454) of ex-smokers attempted to quit in approximately the last 12 months (n=1472). Cessation Ratios ranged from 0.182 (95% CI: 0.045–0.319) in Estonia to 1.060 (95% CI: 0.262–1.860) in Sweden. There is a quadratic, U-shaped relationship between odds of quitting and smoking prevalence. The lowest odds of cessation were observed at a prevalence of 26.3%, with higher odds of cessation observed above and below this point. Respondents who reported financial difficulties were less likely to quit (AOR=0.66; 95% CI: 0.52–0.83). There was no association of likelihood of success with other sociodemographic factors or the Tobacco Control Scale treatment score.

CONCLUSIONS

These findings highlight a need for exploring reasons behind the variation in likelihood of abstinence following a recent quit attempt, in order to design policies targeted at population groups or countries that need greater support.

Enhancing implementation of smoke-free places: A comparative qualitative study across seven European cities

BACKGROUND

Advocacy, resources and intersubjective reasonable arguments are known as factors that contribute to smoke-free (SF) adoption and implementation in Chinese and Anglo-Saxon places. Less is known about how the implementation of smoking bans differs across European places. The aim of this qualitative comparative study is to identify and classify the SF policy implementation processes and types undertaken at the local level in seven European cities according to the views of local bureaucrats and sub-national stakeholders.

METHOD

Semi-structured expert interviews (n = 56) with local decision makers and stakeholders were conducted as qualitative part of the comparative SILNE-R project in Belgium (Namur), Finland (Tampere), Germany (Hanover), the Republic of Ireland (Dublin), the Netherlands (Amersfoort), Italy (Latina), and Portugal (Coimbra). Qualitative interviews were analyzed using the framework analysis.

RESULTS

Implementation of SF environments predominantly focuses on indoor bans or youth-related settings. Progressive-hungry (Dublin), moderate-rational (Tampere), upper-saturated (Hanover, Amersfoort), and lower saturated (Namur, Coimbra, Latina) implementation types can be distinguished. These four types differ with regards to their engagement in enhancing SF places as well as along their level of perceived tobacco de-normalization and public smoking visibility. In all municipalities SF environments are adopted at national levels, but are differently implemented at the local level due national policy environments, enforcement strategies and the level of collaboration. Major mechanisms to expand SF regulations were found to be scientific evidence, public support, and the child protection frame. However, counter-mechanisms of closure occur if data on declining prevalence and new youth addiction trends trigger low prioritization.

CONCLUSIONS

This study found four SF implementation types two mechanisms of progressive expansion and defensive closure. Development and enhancement of smoking bans requires a suitable national policy environment and indirect national-level support of self-governed local initiatives. Future SF policies can be enhanced by laws pertaining to places frequented by minors.

Socioeconomic Inequalities in e-Cigarette Use in Korea: Comparison with Inequalities in Conventional Cigarette Use Using Two National Surveys

Socioeconomic inequalities in conventional cigarette smoking are well established in developed countries. The aim of this study was to investigate socioeconomic inequalities in e-cigarette use in Korea, in comparison with inequalities in conventional cigarette use. Data from the Korea National Health and Nutrition Examination Survey (KNHANES) and the Korea Community Health Survey (KCHS) were analyzed. The years of data collected were 2013 to 2016 for the KNHANES and 2014 to 2016 for the KCHS, respectively. The age-adjusted prevalence of ever and current e-cigarette use and conventional cigarette use was calculated according to socioeconomic status indicators, including education, occupation, and income. The prevalence of ever e-cigarette use in men increased from 12.1% in 2013 to 19.2% in 2016 in the KNHANES, and from 13.4% in 2014 to 17.9% in 2016 in the KCHS. Ever and current e-cigarette use was concentrated among current smokers and was much more prevalent among men and also more common among younger age groups in men and women. There was higher prevalences of conventional cigarette use among men and women with less education, manual occupational class and lower income, with the differences more pronounced for women. There was higher ever and current use of e-cigarettes among women with less education, manual occupational class and lower income, but among men there was much less difference in e-cigarette use by these indicators of socio-economic status.

Long-term trends in smoking prevalence and its socioeconomic inequalities in Korea, 1992-2016

BACKGROUND

The aim of this study was to investigate long-term trends in smoking prevalence and its socioeconomic inequalities in Korea.

METHODS

Data were collected from 10 rounds of the Social Survey of Statistics Korea between 1992 and 2016. A total of 524,866 men and women aged 19 or over were analyzed. Age-adjusted smoking prevalence was calculated according to three major socioeconomic position indicators: education, occupational class, and income. The prevalence difference, prevalence ratio, slope index of inequality (SII), and relative index of inequality (RII) were calculated to examine the magnitude of inequality in smoking.

RESULTS

Smoking prevalence among men decreased from 71.7% in 1992 to 39.7% in 2016, while smoking prevalence among women decreased from 6.5% in 1992 to 3.3% in 2016. Socioeconomic inequalities in smoking prevalence according to the three socioeconomic position indicators were found in both men and women throughout the study period. In general, absolute and relative socioeconomic inequalities in smoking, measured by prevalence difference and prevalence ratio for education and occupational class, widened during the study period among Korean men and women. In men, the SII for income increased from 7.6% in 1999 to 10.8% in 2016 and the RII for income also increased from 1.11 in 1999 to 1.31 in 2016. In women, the SII for income increased from 0.1% in 1999 to 2.4% in 2016 and the RII for income increased from 1.39 in 1999 to 2.25 in 2016.

CONCLUSION

Pro-rich socioeconomic inequalities in smoking prevalence were found in men and women. Socioeconomic inequalities in smoking have increased in parallel with the implementation of tobacco control policies. Tobacco control policies should be developed to decrease socioeconomic inequalities in cigarette use in Korea.

Trends in Absolute and Relative Educational Inequalities in Adult Smoking Since the Early 2000s: The Case of Germany

Introduction

Since the early 2000s, several tobacco control policies have been implemented in Germany. Current research is inconsistent about how strengthening tobacco control can affect social inequalities in smoking. This study examines whether educational inequalities in adult smoking have widened in Germany since 2003.

Methods

Data were used from four cross-sectional national health surveys conducted between 2003 and 2012 (n = 54,197; age = 25-69 years). Participants who smoked daily or occasionally were classified as smokers. The regression-based Slope Index of Inequality and Relative Index of Inequality (RII) were calculated to estimate the extent of absolute and relative educational inequalities in smoking, respectively.

Results

In each survey year, smoking was associated with lower education. Overall, crude and age-standardized smoking rates declined over time. Stratified by education, trends of declining smoking rates were observed only in the high and medium education groups, whereas no statistically significant trend was found in the low education group. Relative educational inequalities in smoking increased significantly in men (2003: RII=1.74, 95% confidence interval 1.46 to 2.07; 2012: RII = 2.25, 95% confidence interval 1.90 to 2.67; p-trend = .019). Absolute educational inequalities in smoking were not found to have changed significantly during the study period.

Conclusions

In the course of declining smoking rates, educational inequalities in smoking persisted in both absolute and relative terms. In men, relative inequalities in smoking may even have widened within only 9 years. Tobacco control policies should not only be targeted at the entire population but also attempt to reduce social inequalities in smoking by focusing more on socially disadvantaged groups.

Implications

Smoking is associated with lower education in most European countries and contributes to social inequalities in health. Since the beginning of the 2000s, Germany has implemented a variety of tobacco control policies to reduce smoking in the population. This study reveals that despite a general decline in adult smoking, educational inequalities in smoking have persisted and even widened in Germany since 2003. The findings emphasize that more targeted efforts are needed to tackle smoking-induced inequalities in health.

Smokers' strategies across social grades to minimise the cost of smoking in a period with annual tax increases: evidence from a national survey in England

OBJECTIVES

To assess associations between smokers' strategies to minimise how much their smoking costs and cost of smoking among smokers across three social grades during a period of annual tax increases in England.

DESIGN

Repeat cross-sectional.

SETTING

England, May 2012-December 2016.

PARTICIPANTS

16 967 adult smokers in 56 monthly surveys with nationally representative samples.

MEASURES AND ANALYSIS

Weighted generalised additive models assessed associations between four cost-minimising strategies (factory-made and roll-your-own (RYO) cigarette consumption levels, illicit and cross-border purchases) and cost of smoking (£/week). We adjusted for inflation rate, age, gender and secular and seasonal trends.

RESULTS

Cost of smoking did not increase above the rate of inflation. Factory-made cigarette consumption decreased, while proportion of RYO and, to a much lesser extent, illicit and cross-border purchases increased. These trends were only evident in lowest social grade. Cost of smoking was 12.99% lower with consumption of 10 fewer factory-made cigarettes (95% CI -13.18 to -12.80) and 5.86% lower with consumption of 10 fewer RYO cigarettes (95% CI -5.66 to -6.06). Consumption levels accounted for 60% of variance in cost. Cross-border and illicit tobacco purchases were associated with 9.64% (95% CI -12.94 to -6.33) and 9.47% (95% CI -12.74 to -6.20) lower costs, respectively, but due to low prevalence, accounted for only 0.2% of variation. Associations were similar across social grades, although weaker for illicit and cross-border purchases and stronger for consumption in higher social grades compared with lower social grades.

CONCLUSION

During a period of annual tax increases, the weekly cost of smoking did not increase above inflation. Cost-minimising strategies increased, especially among more disadvantaged smokers. Reducing cigarette consumption and switching to RYO tobacco explained a large part of cost variation, while use of illicit and cross-border purchasing played only a minor role.

Understanding the multitude of barriers that prevent smokers in lower socioeconomic groups from accessing smoking cessation support: A literature review

One explanation for the increasing smoking-related health inequalities is the limited access of lower socioeconomic status (SES) smokers to smoking cessation support. In order to understand this limited access - and to eventually improve accessibility - we provide a structured overview of the barriers that lower SES smokers face in the successive phases of access to cessation support. Our literature review included 43 papers on barriers of access to cessation support for lower SES smokers, published before June 2016. We used the access to health care framework to categorize the extracted barriers into (a) either the abilities of smokers or dimensions of cessation support and (b) one of the successive phases of access to support. We found that lower SES smokers encounter many barriers. They are present in all phases of access to cessation support, and different barriers may be important in each of these phases. We also found that each phase transition is hampered by barriers related to both the abilities of smokers and the dimensions of cessation support, and that these barriers tend to interact, both with each other and with the disadvantaged living conditions of lower SES smokers. In conclusion, reducing smoking-related health inequalities by improving lower SES smokers' access to smoking cessation support requires a comprehensive approach. Our structured overview of barriers may serve as a starting point for tailoring such an approach to the multitude of barriers that prevent lower SES smokers from accessing cessation support, while simultaneously taking into account their disadvantaged living conditions.

"Like you are fooling yourself": how the "Stoptober" temporary abstinence campaign supports Dutch smokers attempting to quit

Background

The Stoptober temporary abstinence campaign challenges smokers to engage in a collective quit attempt for 28 days. The campaign is based on social contagion theory, SMART (i.e., Specific, Measurable, Attainable, Realistic and Time-sensitive) goal setting and PRIME (i.e., Plans, Responses, Impulses, Motives and Evaluations) theory. Although Stoptober was found to yield impressive 28-day quit rates, relapse rates remained substantial. Therefore, we examined how Stoptober supported smokers in their attempt to quit and how the campaign’s effectiveness could be strengthened.

Methods

In 2016, we conducted semi-structured interviews with 23 Stoptober participants in the Netherlands. Data were analyzed thematically.

Results

Respondents explained how social contagion-based components had familiarized them with Stoptober, motivated them to participate, and created a pro-smoking cessation social norm. Setting SMART goals was reported as “fooling yourself”, since it distracted respondents from their goal of quitting for good and helped them perceive that temporary abstinence was achievable. Respondents also illustrated the usefulness of PRIME theory. They typically used an individual selection of available supports that varied over time. To achieve long-term abstinence, respondents expressed the need for additional social network support and interactive, personalized and professional support during and after the campaign.

Conclusions

Stoptober supports smokers in their attempts to quit and generally according to the campaign’s theoretical principles. Added to available evidence, this finding supports the continuation and wider implementation of Stoptober, while connecting the campaign to social networks and regular smoking-cessation services to help improve long-term abstinence rates.

Electronic supplementary material

The online version of this article (10.1186/s12889-019-6833-y) contains supplementary material, which is available to authorized users.

Thirty-eight-year trends of educational differences in smoking in Finland

Objectives

Smoking is declining, but it is unevenly distributed among population groups. Our aim was to examine the socio-economic differences in smoking during 1978–2016 in Finland, a country with a history of strict tobacco control policy.

Methods

Annual population-based random sample data of 25–64-year-olds from 1978 to 2016 (N = 104,315) were used. Response rate varied between 84 and 40%. In addition to logistic regression analysis, absolute and relative educational differences in smoking were examined.

Results

Smoking was more prevalent among the less educated but declined in all educational groups during the study period. Both absolute and relative differences in smoking between the less and highly educated were larger at the end of the study period than at the beginning. Cigarette price seemed to have a larger effect on the smoking among the less educated.

Conclusions

Socio-economic differences in smoking among the Finnish adult population have increased since the 1970s until 2016. Further actions are needed, especially focusing on lower socio-economic positions, to tackle inequalities in health. They should include support for smoking cessation and larger cigarette tax increases.

Electronic supplementary material

The online version of this article (10.1007/s00038-019-01228-x) contains supplementary material, which is available to authorized users.

An Update on Hardening: A Qualitative Review

Introduction

This review examines the evidence for the hardening hypothesis; that is, the prevalence of (1) becoming a former smoker is decreasing over time due to (2) decreased quit attempts, or (3) decreased success on a given quit attempt.

Methods

PubMed, EMBASE, PsychINFO, trial registries, and other databases were searched for population-based surveys that reported whether one of the aforementioned three outcomes decreased over time.

Results

None of the 26 studies found that conversion from current to former smoking, number of quit attempts, or success on a given quit attempt decreased over time and several found these increased over time. These results appeared to be similar across survey dates, duration of time examined, number of data points, data source, outcome definitions, and nationality.

Conclusions

These results convincingly indicate hardening is not occurring in the general population of smokers. On the other hand, the prevalence of smoking is declining less among older and women smokers, and smokers with low education, low income, psychological problems, alcohol or drug abuse, medical problems, and greater nicotine dependence, than among those without these characteristics, presumably due to less quitting. Why this has not lead to decreased success in stopping smoking in the general population is unclear.

Implications

Some have argued that a greater emphasis on harm reduction and more intensive or dependence-based treatments are needed because remaining smokers are those who are less likely to stop with current methods. This review finds no or little evidence for this assumption. Psychosocial factors, such as low education and psychiatric problems, predict less ability to quit and appear to becoming more prevalent among smokers. Why this is not leading to decreased quitting in the general population is an anomaly that may be worth trying to understand.

Cognitive, Behavioral, and Situational Influences on Relapse to Smoking After Group Treatment for Tobacco Dependence

Socioeconomic disparities in treatment failure rates for evidence-based tobacco dependence treatment are well-established. Adapted cognitive behavioral treatments are extensively tailored to meet the needs of lower socioeconomic status (SES) smokers and dramatically improve early treatment success, but there is little understanding of why treatment failure occurs after a longer period of abstinence than with standard treatment, why early treatment success is not sustained, and why long-term treatment failure rates are no different from standard treatments. We sought to understand the causes of treatment failure from the perspective of diverse participants who relapsed after receiving standard or adapted treatment in a randomized control trial. We used a qualitative approach and a cognitive-behavioral framework to examine themes in responses to a semi-structured post-relapse telephone interview. The primary causes of relapse were familiar (i.e., habit, stress, unanticipated precipitating events). The adapted treatment appeared to improve the management of habits and stress short-term, but did not adequately prepare respondents for unanticipated events. Respondents reported that they would have benefited from continued support. New therapeutic targets might include innovative methods to reduce long-term treatment failure by delivering extended relapse prevention interventions to support early treatment success. Trial Registration: Clinicaltrials.gov NCT02785536.

The impact of a social norms approach on reducing levels of misperceptions around smokefree hospital entrances amongst patients, staff, and visitors of a NHS hospital: a repeated cross-sectional survey study

BACKGROUND

Smoking is a cause of avoidable morbidity and mortality. In the United Kingdom (UK) the national smoking ban inside hospital buildings is widely adhered to. There is a perception it has led to smokers congregating around hospital entrances (Selbie D. 2016, It's time for a truly smokefree NHS. Public Health Matters Blog. Public Health England). Efforts to shift social norms and create positive smokefree environments might be strengthened by delivering social norms messages. This study explored the impact of a social norms approach campaign to reduce levels of misperceptions surrounding support for smokefree hospital entrances.

METHOD

Repeated cross sectional study design. Staff, patients, and hospital visitors at Pinderfields National Health Service (NHS) Hospital (Wakefield, United Kingdom (UK)) completed a survey before and after implementation of a public health social norms campaign (n = 481 surveyed before; n = 459 surveyed after). The main outcome measure was difference between perceived and reported levels of support for smokefree hospital entrances.

RESULTS

There were high levels of support for smokefree hospital entrances. The majority of participants agreed that patients (n = 849, 90% agreed), staff (n = 863, 92% agreed), and visitors (n = 850, 90% agreed) should not smoke in the hospital entrance. Participants underestimated the proportion of others who self-reported keeping the entrance smokefree. Over 90% of respondents reported not smoking in the hospital entrance, but the perception was that between 50 to 75% of hospital staff, patients, and visitors did not smoke in the hospital entrance. The mean percentage of hospital staff, patients, and visitors who respondents thought did not smoke in entrances was higher for respondents responding after, compared to those responding before, the campaign. There was an overall significant effect of time on attitudes towards smoking in the entrances; in all instances the mean percentage of hospital staff, patients, and visitors the participants believed agreed that hospital entrances should be smokefree was higher for those responding after, compared with before, the campaign.

CONCLUSIONS

People hold misperceptions of the proportion of people who choose to smoke in the hospital entrance. The social norms approach campaign was associated with a strengthening of positive social norms. Such campaigns should be considered by Trusts as one evidence-based based tactic to denormalise smoking, increase support for smokefree policies.

Trends in Inequality in Cigarette Smoking Prevalence by Income According to Recent Anti-smoking Policies in Korea: Use of Three National Surveys

Objectives

This study examined trends in inequality in cigarette smoking prevalence by income according to recent anti-smoking policies in Korea.

Methods

The data used in this study were drawn from three nationally representative surveys, the Korea National Health and Nutrition Examination Survey, the Korea Community Health Survey, and the Social Survey of Statistics Korea. We calculated the age-standardized smoking prevalence, the slope index of inequality, and the relative index of inequality by income level as a socioeconomic position indicator.

Results

Smoking prevalence among men decreased during the study period, but the downward trend became especially pronounced in 2015, when the tobacco price was substantially increased. Inequalities in cigarette smoking by income were evident in both genders over the study period in all three national surveys examined. Absolute inequality tended to decrease between 2014 and 2015 among men. Absolute and relative inequality by income decreased between 2008 and 2016 in women aged 30-59, except between 2014 and 2015.

Conclusions

The recent anti-smoking policies in Korea resulted in a downward trend in smoking prevalence among men, but not in relative inequality, throughout the study period. Absolute inequality decreased over the study period among men aged 30-59. A more aggressive tax policy is warranted to further reduce socioeconomic inequalities in smoking in young adults in Korea.

Individualised tobacco affordability in the UK 2002-2014: findings from the International Tobacco Control Policy Evaluation Project

OBJECTIVE

The existing measures of tobacco affordability (smokers' purchasing power for tobacco) use national estimates of income and average cigarette prices, and exclude roll-your-own (RYO) tobacco. This study developed an individualised measure of tobacco affordability using smokers' own incomes and factory-made (FM) or RYO tobacco purchase prices, and explored how it was impacted by taxation changes, individual characteristics and purchase patterns.

DESIGN

Cross-sectional survey data collated from 10 waves of a longitudinal cohort study.

DATA SOURCES

Adult smokers (n=4062) from the International Tobacco Control Policy Evaluation Project United Kingdom (UK), surveyed between 2002 and 2014, providing 8943 observations over 10 surveys.

ANALYSIS

Affordability was calculated as the percentage of annual income remaining with the individuals after their annual tobacco expenditure. Multilevel linear regression models were used with affordability as the outcome using time, sex, age, geographical region, ethnicity, education, nicotine dependence and tobacco purchase source as the predictor variables.

RESULTS

Affordability of FM cigarettes decreased significantly from 91.5% (±95% CI: 91.0% to 91.9%) in 2002 to 87.8% (87.0% to 88.5%) in 2014; and RYO from 96.3% (95.7% to 96.9%) in 2006 to 93.7% (93.0% to 94.4%) in 2014. Affordability was significantly lower for FM than RYO. Year-on-year decreases were not statistically significant. Tobacco was more affordable for males, those with higher education, less dependent smokers and those purchasing from non-store (potentially illicit) or non-UK sources.

CONCLUSIONS

An individualised measure of tobacco affordability provided useful insights on the impact of tobacco taxes, social inequalities and purchase patterns in the UK. Although tobacco became less affordable, the annual rate of decline was low, suggesting annual tax rises were not large enough.

Time-discounting and tobacco smoking: a systematic review and network analysis

Background: Tobacco smoking harms health, so why do people smoke and fail to quit? An explanation originating in behavioural economics suggests a role for time-discounting, which describes how the value of a reward, such as better health, decreases with delay to its receipt. A large number of studies test the relationship of time-discounting with tobacco outcomes but the temporal pattern of this relationship and its variation according to measurement methods remain unclear. We review the association between time-discounting and smoking across (i) the life course, from initiation to cessation, and (ii) diverse discount measures.

Methods: We identified 69 relevant studies in Web of Science and PubMed. We synthesized findings across methodologies and evaluated discount measures, study quality and cross-disciplinary fertilization.

Results: In 44 out of 54 studies, smokers more greatly discounted the future than non-smokers and, in longitudinal studies, higher discounting predicted future smoking. Smokers with lower time-discount rates achieved higher quit rates. Findings were consistent across studies measuring discount rates using hypothetical monetary or cigarette reward scenarios. The methodological quality of the majority of studies was rated as ‘moderate’ and co-citation analysis revealed an isolation of economics journals and a dearth of studies in public health.

Conclusion: There is moderate yet consistent evidence that high time-discounting is a risk factor for smoking and unsuccessful cessation. Policy scenarios assuming a flat rate of population discounting may inadequately capture smokers’ perceptions of costs and benefits.

Smoking cessation patterns by socioeconomic status in Alaska

The ongoing disparity in smoking prevalence across levels of socioeconomic status (SES) is a significant concern in the tobacco control field, and surveillance of cessation-related activity is key to understanding progress. Historically, lower SES smokers have had much lower quit ratios but this measure can be insensitive to recent quit-related behavior. It is therefore important to examine recent quit-related behavior to assess progress toward addressing this disparity, especially in states with tobacco control programs that focus on this priority population.

We compared recent quit attempts and successes among non-Native lower SES Alaska smokers to those of higher SES using data from the 2012–2013 Alaska Behavioral Risk Factor Surveillance System (BRFSS). We assessed quit ratios, one-year and five-year quit rates, and six-month abstinence between the two groups.

Cessation-related measures restricted to those who smoked in the previous one year did not significantly vary by SES. However, five year quit rates were significantly lower for persons of lower SES vs. higher SES (14% vs. 32% respectively, p < .001). Results were consistent after adjustment for age, sex, and other factors.

Results showed that in the previous year, smokers of lower SES in Alaska were trying to quit and succeeding at similar rates as their higher SES counterparts. However, the equivalent pattern of quit success was not reflected in the five-year time frame. Tobacco control programs should monitor cessation trends using both recent and longer-term time frames for this population. More research is needed on reasons for fewer long-term quits among lower SES smokers.

•

Large disparities in smoking prevalence exist by socioeconomic status (SES).

•

Past-year successful and unsuccessful quit attempts were similar by SES.

•

But five-year quit rates for low SES smokers showed significantly less success.

•

Tracking of both recent and long term quit-related measures is key for surveillance.

Social climate on tobacco control in an advanced tobacco control country: A population-based study in Finland

Aims

Finland has implemented a gradually tightening tobacco control policy for decades. Recently the objective of a tobacco-free Finland was introduced. Still, the population's acceptance of tobacco control policy has not been measured. More knowledge is needed on differences in attitudes and factors associated with tobacco control opinions for future policy-making.

Methods

A population-based study with quantitative analysis. Attitudes on smoking and tobacco control policy were assessed within the National FINRISK 2012 Study in Finland involving 25-74-year-old adults (N = 4905). In analyses, smoking status groups were compared.

Results

In general, attitudes differed systematically by smoking status. Differences increased or decreased when moving from never smokers to other smoking groups. Similarities in attitudes were found particularly on youth smoking, while differences between smoking groups were notable on statements regarding smoking on balconies and availability of tobacco products. The adjusted analysis showed that smoking status was most strongly associated with attitudes on different tobacco control policy measures. Daily smokers viewed stricter tobacco control policy and workplace smoking bans more negatively than others, though they viewed societal support for quitters and sufficiency of tobacco control policy more positively compared with others. Differences were vast compared with non-smokers, but also occasional smokers differed from daily smokers.

Conclusions

Tightening tobacco control and workplace smoking bans were supported by the Finnish adult population, but societal support for quitters to a lesser extent. Attitude change, where smokers are seen as deserving help to quit smoking, is important.

The Impact of Tobacco Control Policies on Smoking Among Socioeconomic Groups in Nine European Countries, 1990-2007

Background

It is uncertain whether tobacco control policies have contributed to a narrowing or widening of socioeconomic inequalities in smoking in European countries during the past two decades. This paper aims to investigate the impact of price and non-price related population-wide tobacco control policies on smoking by socioeconomic group in nine European countries between 1990 and 2007.

Methods

Individual-level education, occupation and smoking status were obtained from nationally representative surveys. Country-level price-related tobacco control policies were measured by the relative price of cheapest cigarettes and of cigarettes in the most popular price category. Country-level non-price policies were measured by a summary score covering four policy domains: smoking bans or restrictions in public places and workplaces, bans on advertising and promotion, health warning labels, and cessation services. The associations between policies and smoking were explored using logistic regressions, stratified by education and occupation, and adjusted for age, Gross Domestic Product, period and country fixed effects.

Results

The price of popular cigarettes and non-price policies were negatively associated with smoking among men. The price of the cheapest cigarettes was negatively associated with smoking among women. While these favorable effects were generally in the same direction for all socioeconomic groups, they were larger and statistically significant in lower socioeconomic groups only.

Conclusions

Tobacco control policies as implemented in nine European countries, have probably helped to reduce the prevalence of smoking in the total population, particularly in lower socioeconomic groups. Widening inequalities in smoking may be explained by other factors. Policies with larger effects on lower socioeconomic groups are needed to reverse this trend.

Implications

Socioeconomic inequalities in smoking widened between the 1990s and the 2000s in Europe. During the same period, there were intensified tobacco control policies in many European countries. It is uncertain whether tobacco control policies have contributed to a narrowing or widening of socioeconomic inequalities in smoking in European countries. This study shows that tobacco control policies as implemented in the available European countries have helped to reduce the prevalence of smoking in the total population, particularly in lower socioeconomic groups. Widening inequalities in smoking may be explained by other factors.

Public smoking ban and socioeconomic inequalities in smoking prevalence and cessation: a cross-sectional population-based study in Geneva, Switzerland (1995-2014)

INTRODUCTION

Smoking bans were suggested to reduce smoking prevalence and increase quit ratio but their equity impact remains unclear. We aimed to characterise the socioeconomic status (SES)-related inequalities in smoking prevalence and quit ratio before and after the implementation of a public smoking ban.

METHODS

We included data from 17 544 participants in the population-based cross-sectional Bus Santé study in Geneva, Switzerland, between 1995 and 2014. We considered educational attainment (primary, secondary and tertiary) as a SES indicator. Outcomes were smoking prevalence (proportion of current smokers) and quit ratio (ex-smokers to ever-smokers ratio). We used segmented linear regression to assess the overall impact of smoking ban on outcome trends. We calculated the relative (RII) and slope (SII, absolute difference) indexes of inequality, quantifying disparities between educational groups in outcomes overall (1995-2014), before and after ban implementation (November 2009).

RESULTS

Least educated participants displayed higher smoking prevalence (RII=2.04, P<0.001; SII=0.15, P<0.001) and lower quit ratio (RII=0.73, P<0.001; SII=-0.18, P<0.001). As in other studies, smoking ban implementation coincided with a temporary reduction of smoking prevalence (P=0.003) and increase in quit ratio (P=0.02), with a progressive return to preban levels. Inequalities increased (P<0.05) in relative terms for smoking prevalence (RII_before=1.84, P<0.001 and RII_after=3.01, P<0.001) and absolute terms for both outcomes (smoking prevalence: SII_before=0.14, P<0.001 and SII_after=0.19, P<0.001; quit ratio: SII_before=-0.15, P<0.001 and SII_after=-0.27, P<0.001).

CONCLUSIONS

Implementation of a public smoking ban coincided with a short-lived decrease in smoking prevalence and increase in quit ratio but also with a widening in SES inequalities in smoking-related outcomes.

Improving tobacco dependence treatment outcomes for smokers of lower socioeconomic status: A randomized clinical trial

INTRODUCTION

Evidence-based treatments for tobacco dependence are significantly less effective for smokers of lower socioeconomic status which contributes to socioeconomic disparities in smoking prevalence rates and health. We aimed to reduce the socioeconomic gradient in treatment outcomes by systematically adapting evidence-based, cognitive-behavioral treatment for tobacco dependence for diverse lower socioeconomic smokers.

METHODS

Participants were randomized to adapted or standard treatment, received six 1-h group treatment sessions, and were followed for six months. We examined the effectiveness of the adapted treatment to improve treatment outcomes for lower socioeconomic groups.

RESULTS

Participants (n=227) were ethnically, racially, and socioeconomically diverse. The adapted treatment significantly reduced the days to relapse for the two lowest socioeconomic groups: SES1: M=76.6 (SD 72.9) vs. 38.3 (SD 60.1) days to relapse (RR=0.63 95% CI, 0.45, 0.88, p=0.0013); SES2: M=88.2 (SD 67.3) vs. 40.1 (SD 62.6 days to relapse (RR=0.57 95% CI, 0.18, 0.70, p=0.0024). Interactions between socioeconomic status and condition were significant for initial abstinence (OR=1.26, 95% CI 1.09, 1.46, p=0.002), approached significance for 3-month abstinence (OR=0.90, 95% CI 0.80, 1.01, p<0.071), and were not significant for 6-month abstinence (OR=0.99 95% CI 0.88, 1.10, p=0.795). No significant differences in long-term abstinence were observed.

CONCLUSION

Systematic adaption of evidence-based treatment for tobacco dependence can significantly improve initial and short-term treatment outcomes for diverse lower socioeconomic smokers and reduce inequities in days to relapse. Novel methods of providing targeted extended support are needed to improve long-term outcomes.

Smoking and finances: baseline characteristics of low income daily smokers in the FISCALS cohort

BACKGROUND

Financial stress is a barrier to successful smoking cessation and a key predictor of relapse. Little is known about the financial situation of low-income Australian daily smokers. This study aims to describe and investigate associations between the financial functioning, tobacco use and quitting behaviours of low income daily smokers.

METHODS

Low-income Australian adult smokers in the 'Financial Intervention for Smoking Cessation Among Low-income Smokers (FISCALS) randomised clinical trial completed a structured telephone questionnaire.

RESULTS

The median number of cigarettes typically smoked by the 1047 participants was 23 per day. The median spent on tobacco per week was AU$80. Three quarters (73.0%) reported some financial stress and 43.2% reported smoking-induced deprivation. Financial stress was significantly associated with deprivation (IRR: 1.23, 95% CI 1.21, 1.26, p < 0.001). There were no significant associations either between adjusted financial stress or deprivation and motivation to quit or certainty of quit success.

CONCLUSIONS

Financial stress and smoking induced deprivation were prevalent among low-income daily smokers, but they were not associated with motivation to quit. Smoking cessation interventions need to be responsive to the role financial stress plays in reducing quit attempts and increasing relapse.

TRIAL REGISTRATION

Australian and New Zealand Clinical trials Registry ACTRN12612000725864 6/07/2012.

Association of risk factors with smoking during pregnancy among women of childbearing age: an epidemiological field study in Turkey

CONTEXT AND OBJECTIVE:

Smoking during pregnancy is an important risk factor for maternal and infant health that is preventable. This study aimed to investigate the risk factors associated with smoking behavior during pregnancy.

DESIGN AND SETTING:

A household-based probability sample survey of 1,510 women was conducted in the center of the city of Sivas, Turkey, between September 2013 and May 2014.

METHODS:

The prevalence of smoking during pregnancy was estimated according to independent variables by means of regression analysis.

RESULTS:

The prevalence of smoking during pregnancy was 16.5%. Logistic regression showed that being at a relatively young age (odds ratio, OR = 1.92, P = 0.025 for 15-24 age group; and OR = 2.45, P = 0.001 for 25-34 age group), having a low educational level (OR = 1.76, P = 0.032), being unmarried (OR = 1.48, P = 0.002) and living in an extended family (OR = 1.98, P = 0.009) were the factors associated with the risk of smoking during pregnancy.

CONCLUSIONS:

Systematic attention should be paid to socioeconomic inequalities, to support women towards quitting smoking before or at an early stage of their pregnancies. Younger women and particularly those in lower socioeconomic groups should be targeted. This will lead to better pregnancy status, especially among young women.

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.

The effect of policies regulating tobacco consumption on smoking initiation and cessation in Spain: is it equal across socioeconomic groups?

Background

In Spain, the Law 28/2005, which came into effect on January 2006, was a turning point in smoking regulation and prevention, serving as a guarantee for the progress of future strategies in the direction marked by international organizations. It is expected that this regulatory policy should benefit relatively more to lower socioeconomic groups, thus contributing to a reduction in socioeconomic health inequalities. This research analyzes the effect of tobacco regulation in Spain, under Law 28/2005, on the initiation and cessation of tobacco consumption, and whether this effect has been unequal across distinct socioeconomic levels.

Methods

Micro-data from the National Health Survey in its 2006 and 2011 editions are used (study numbers: 4382 and 5389 respectively; inventory of statistical operations (ISO) code: 54009), with a sample size of approximately 24,000 households divided into 2,000 census areas. This allows individuals’ tobacco consumption records to be reconstructed over five years before the initiation of each survey, as well as identifying those individuals that started or stopped smoking. The methodology is based on “time to event analysis”. Cox’s proportional hazard models are adapted to show the effects of a set of explanatory variables on the conditional probability of change in tobacco consumption: initiation as a daily smoker by young people or the cessation of daily smoking by adults.

Results

Initiation rates among young people went from 25% (95% confidence interval (CI), 23–27) to 19% (95% CI, 17–21) following the implementation of the Law, and the change in cessation rates among smokers was even greater, with rates increasing from 12% (95% CI, 11–13) to 20% (95% CI, 19–21). However, this effect has not been equal by socioeconomic groups as shown by relative risks. Before the regulation policy, social class was not a statistically significant factor in the initiation of daily smoking (p > 0.05); however, following the implementation of the Law, young people belonging to social classes IV-V and VI had a relative risk of starting smoking 63% (p = 0.03) and 82% (p = 0.02) higher than young people of higher social classes I-II. On the other hand, lower social class also means a lower probability of smoking cessation; however, the relative risk of cessation for a smoker belonging to a household of social class VI (compared to classes I-II) went from 24% (p < 0.001) lower before the Law to 33% (p < 0.001) lower following the law’s implementation.

Conclusion

Law 28/2005 has been effective, as after its promulgation there has been a decrease in the rate of smoking initiation among young people and an increase in the rate of cessation among adult smokers. However, this effect has not been equal by socioeconomic groups, favoring relatively more to those individuals belonging to higher social classes.

Life Course Changes in Smoking by Gender and Education: A Cohort Comparison Across France and the United States

Widening of educational disparities and a narrowing female advantage in mortality stem in good part from disparities in smoking. The changes in smoking and mortality disparities across cohorts and countries have been explained by an epidemic model of cigarette use but are also related to life course changes. To better describe and understand changing disparities over the life course, we compare age patterns of smoking in three cohorts and two nations (France and the United States) using smoking history measures from the 2010 French Health Barometer (N = 20,940) and the 2010 U.S. National Health Interview Survey Sample Adult File (N = 20,444). The results demonstrate statistically significant widening of gender and educational differences from adolescence to early and middle adulthood, thus accentuating the disparities already emerging during adolescence. In addition, the widening disparities over the life course have been changing across cohorts: Age differences in educational disparities have grown in recent cohorts (especially in France), while age differences in gender disparities have narrowed. The findings highlight the multiple sources of inequality in smoking and health in high-income nations.

Disadvantaged Social Groups and the Cigarette Epidemic: Limits of the Diffusion of Innovations Vision

The original four-stage model of the cigarette epidemic has been extended with diffusion of innovations theory to reflect socio-economic differences in cigarette use. Recently, two revisions of the model have been proposed: (1) separate analysis of the epidemic stages for men and women, in order to improve generalization to developing countries, and; (2) addition of a fifth stage to the smoking epidemic, in order to account for the persistence of smoking in disadvantaged social groups. By developing a cohort perspective spanning a 35-year time period in France and the USA, we uncover distinctive features which challenge the currently held vision on the evolution of smoking inequalities within the framework of the cigarette epidemic. We argue that the reason for which the model may not be fit to the lower educated is that the imitation mechanism underlying the diffusion of innovations works well with regard to adoption of the habit, but is much less relevant with regard to its rejection. Based on those observations, we support the idea that the nature and timing of the epidemic differs enough to treat the stages separately for high and low education groups, and discuss policy implications.

Socio-demographic and clinical factors contributing to smoking cessation among men: a four-year follow up study of the Korean Health Panel Survey

Background

To examine factors contributing to smoking cessation among male smokers, we looked at how socio-demographic and clinical characteristics influence stopping smoking with passage of time.

Methods

Data from the Korea Health Panel during 2009–2012 were used. In 2009 a total of 2,941 smokers were followed up until 2012. Statistical analysis using a generalized linear mixed model was performed for all smokers, and a subgroup analysis was also performed to determine whether individual characteristics influence smoking cessation differently based on health condition.

Results

Male smokers who have married or graduated college or above were more likely to succeed in smoking cessation. Those with chronic disease(s) were also more likely to quit smoking than those without. Among those without chronic disease, higher education showed significant association with smoking cessation, however, being married or ever married showed significant association with smoking cessation among those with chronic disease.

Conclusions

The finding that higher education helped smokers without chronic disease succeed in smoking cessation suggests that a smoking cessation campaign should focus on those with lower education. In addition, quit smoking programs may be particularly helpful for male smokers with chronic disease(s) who have never married.

Smoking on the margins: a comprehensive analysis of a municipal outdoor smoke-free policy

BACKGROUND

This study examined the formulation, adoption, and implementation of a ban on smoking in the parks and beaches in Vancouver, Canada.

METHODS

Informed by Critical Multiplism, we explored the policy adoption process, support for and compliance with a local bylaw prohibiting smoking in parks and on beaches, experiences with enforcement, and potential health equity issues through a series of qualitative and quantitative studies.

RESULTS

Findings suggest that there was unanimous support for the introduction of the bylaw among policy makers, as well as a high degree of positive public support. We observed that smoking initially declined following the ban's implementation, but that smoking practices vary in parks by location. We also found evidence of different levels of enforcement and compliance between settings, and between different populations of park and beach users.

CONCLUSIONS

Overall success with the implementation of the bylaw is tempered by potential increases in health inequities because of variable enforcement of the ban; greatest levels of smoking appear to continue to occur in the least advantaged areas of the city. Jurisdictions developing such policies need to consider how to allocate sufficient resources to enhance voluntary compliance and ensure that such bylaws do not contribute to health inequities.