Recommendations to advance equity in tobacco control

Strengthening tobacco control research: key factors impacting policy outcomes and health equity

In this policy brief, we explore several potential drivers of heterogeneity in policy outcomes that can be examined in tobacco control policy evaluations, expanding the evidence base to contribute to continued, equitable progress in reducing tobacco-related health outcomes. We discuss these factors in the context of a hypothetical evaluation of the impact of smoke-free laws on current smoking and quit attempts in the Tobacco Nation. Despite a similar policy environment within the Tobacco Nation, there is variation in the strength of smoke-free law coverage across states. This commentary considers how policy design and other contextual factors, including co-occurring policies, and differential impacts across subgroups, may influence policy-attributable outcomes across time and space.

Hunger and housing: Economic disparities in current and daily tobacco use among high school students in the United States in 2021

Introduction

Economic disparities in tobacco use and dependence are well-documented among adults but not adolescents. This study aims to examine economic disparities in patterns of tobacco use among a nationally representative sample of high school students in Spring 2021.

Methods

We analyzed data from n = 6750 US high school student via the 2021 Adolescent Behaviors and Experiences Survey (ABES). We estimated the association between experiencing homelessness and food insecurity (analyzed independently) and current (past 30-day) and daily (all 30 days) use of four tobacco products (e-cigarettes; cigarettes; cigars; smokeless). Models controlled for sex, race/ethnicity, age, and sexual identity.

Results

Overall, ∼1.8 % experienced homelessness and 23.7 % experienced food insecurity. Experiencing homeless was significantly associated with greater odds of current use for e-cigarette (aOR: 3.43), cigarettes (aOR: 5.58), cigars (aOR: 10.47), and smokeless tobacco (aOR: 4.41) as well as greater risk for daily use of e-cigarettes (aOR: 2.66), cigarettes (aOR: 10.94), and cigars (aOR: 5.23) but not smokeless tobacco (aOR: 2.48; 95 %CI: 0.51-12.16). Food insecurity was significantly associated with greater odds of current use of e-cigarettes (aOR: 2.00), cigarettes (aOR: 2.15), and cigars (aOR: 2.44) but not smokeless (aOR: 1.04; 95 % CI: 0.56-1.93). No association was observed between food insecurity and daily tobacco use.

Conclusion

Substantial economic disparities in tobacco use were observed in a nationally representative sample of high school students. Interventions should consider prioritizing economic determinants of health during adolescence, including a focus on preventing youth tobacco use as well as addressing upstream determinants of homelessness and food insecurity.

Modeling the Effects of Policies that Restrict Tobacco Retail Outlets on Prenatal Smoke Exposure and Perinatal Health Care Utilization

Tobacco retail outlet (TRO) density has been associated with increased cotinine levels in pregnant persons and their children. As such, the higher densities of TROs may represent higher levels of active smoking during pregnancy. The purpose of this study is to simulate the reduction in cotinine (a biomarker of smoke exposure) and health care utilization that could occur in pregnant persons under enactment of several candidate TRO reduction policy recommendations. Using existing retail outlet data from the state of North Carolina and from the Newborn Epigenetic Study (NEST), the present study created hypothetical policy-informed datasets of TROs that a) limited the number of TROs to the same density as the 2014 San Francisco (SF) policy (Policy 1), b) set the minimum distance to 500 feet between TROs from a school and from other TROs (Policy 2), c) restricted the types of TROs to exclude pharmacies (Policy 3), and d) a combination of Policies 1-3 (Policy 4). We estimated the effects of each policy individually and in a separate model with their combined effects in terms of the reduction on cotinine levels and health care utilization, as measured by number of visits to the emergency department (ED). We found that the hypothetical policies were likely to be effective in reducing maternal cotinine and ED visits, with the majority of the mothers in the dataset demonstrating reductions in these outcomes after implementation of the policies. We found that Policy 1 led to moderate reductions in TRO exposure for the majority of the sample as well as stratified by race/ethnicity. Additionally, Policy 4 had slightly larger estimated effects than Policy 1, but could be more onerous to implement in practice. Overall, we identified evidence supporting the efficacy of TRO reduction strategies that could impact smoke exposure during pregnancy in our diverse sample in North Carolina.

Tobacco endgame measures and their adaptation in selected European countries: A narrative review synthesis

Due to the continued detrimental effects of tobacco use, a growing number of countries are embracing the idea of tobacco endgame, meaning ending the tobacco epidemic instead of controlling it. This narrative review aims to synthesize and update the evidence from earlier scientific reviews on effective tobacco endgame measures, as well as to assess their integration to current national strategies among European countries with official tobacco endgame goals. The synthesis of the prior scientific literature found most evidence on product-focused and some evidence for supply-focused policies. Little evidence was detected for user- and institutional-focused measures. An update for the tobacco-free generation measure showed uncertainty in reducing smoking prevalence, especially for adolescents' reactions to age-restrictive laws. All the countries that established a tobacco endgame strategy have included product standards in their measures, predominantly based on European Union regulations on conventional tobacco products, yet standards above this level and considering other products were also common. Cessation measures were given strong emphasis in strategies, yet none of the countries linked these to specific endgame measures. Despite commonly mentioning vulnerable groups, such as youth and pregnant women, adoption of measures to reduce tobacco use among these groups was scarce. Lastly, the decline in tobacco use seems to be modest, implying challenges in meeting the endgame goals. To meet these goals, European countries should reinforce the implementation of known effective tobacco control measures such as tax increases. Furthermore, new innovative strategies and measures to meet the objective of an endgame should be explored.

Commercial tobacco endgame themes in the Australian media from 2000 to 2021

BACKGROUND

Conventional tobacco control is dominated by demand-reduction measures, whereas commercial tobacco endgame (endgame) policies address the key drivers that maintain the tobacco epidemic, such as Tobacco Industry interference in policymaking, the addictiveness of commercial tobacco products and their widespread availability via retail outlets. While Australia has been a pioneer in tobacco control, Australian Governments are yet to commit to endgame policies. The media play an important role reflecting and influencing public opinion and policymaker positions, and can help set the agenda for policy innovation.

METHOD

Media articles mentioning tobacco endgame goals and policies published between 2000 and 2021 were identified by searching Factiva and Google (News). We used reflexive thematic analysis (RTA) to identify themes in the articles, supported by content analysis, to describe elements of the data and sentiment analysis to categorise the article sentiment. A deductive-inductive approach was applied in the RTA, coding text from the articles against predefined codes, while also generating new codes where novel themes were identified. Codes were then grouped and summarised.

RESULTS

One hundred and ninety-three articles were included for analysis. The media discourse focused on three policies: tobacco-free generation; banning or phasing out retail supply of tobacco; and mandating a very low nicotine content standard for cigarettes. A broad range of themes in the articles supported endgame policies, including the large health toll from tobacco, government responsibility to act and the total social costs far outweighing any economic benefit from the tobacco market. Opposing themes included the purported failures of 'prohibition', illicit trade, 'nanny statism' and impact on retail trade. Equity themes were scarce. The benefits of a smoke-free society were described at a societal level, rather than the personal benefits for individuals.

CONCLUSION

Media articles on the tobacco endgame in Australia generally contained positive sentiment about endgame policies. When engaging with the media, endgame advocates should be aware of, and ready to counter, opposing themes such as the purported failures of 'prohibition', 'nanny state' rhetoric or a growth in illicit tobacco trade.