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Sæbø G, Lund M. Is the perceived public stigma of smokers associated with value opposites? An exploratory cross-sectional analysis of Norwegian data 2011-2013. FRONTIERS IN SOCIOLOGY 2024; 8:1051189. [PMID: 38274842 PMCID: PMC10808314 DOI: 10.3389/fsoc.2023.1051189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Accepted: 12/19/2023] [Indexed: 01/27/2024]
Abstract
Smoker stigma is a likely unintended consequence of tobacco polices aiming to denormalise smoking. Little is known about the dissemination of stigmatising attitudes toward smokers at the population level, including their associations with personal values. Applying a theoretical approach that conceptualises stigma as a cultural (moral and intersubjective) issue, we analyse the spread of perceived public stigma of smokers in Norway and factors predicting agreement with such a perception. Using merged data from the biennial national survey Norwegian Monitor 2011 and 2013 (N = 7,792), we tested whether the tendency to agree with a perceived public stigma of smokers differs by four indexes of value opposites ('puritanism/emancipation,' 'conformity/individuality,' 'tolerance/intolerance,' 'status/anti-status'), controlling for smoking status, SES, and demographics. Descriptive statistics and block-wise logistic regression models were applied. In the total sample, 59.1% agree with the statement that 'most people think less of a person who smokes.' Two of the four indexes of value opposites tested were associated with tendencies to agree with the perceived public stigma of smokers ('puritanism/emancipation' and 'status/anti-status'). Smokers with current plans to quit expressed the highest perceived public stigma, while ex-smokers expressed a higher perceived public stigma than never-smokers. Women, young people and respondents with high SES agree with a public stigma of smokers more than men, older people and respondents with low SES do. The perceived public stigma of smokers is high in Norway and varies to some extent with personal values, but also with socio-demographics and especially smoking status.
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Affiliation(s)
- Gunnar Sæbø
- Norwegian Institute of Public Health, Oslo, Norway
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2
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Hall W, Gartner C, Morphett K. How has the brain disease model of addiction contributed to tobacco control? Drug Alcohol Depend 2023; 253:111033. [PMID: 38006672 DOI: 10.1016/j.drugalcdep.2023.111033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 10/09/2023] [Accepted: 11/13/2023] [Indexed: 11/27/2023]
Abstract
Our paper evaluates the extent to which the brain disease model of addiction (BDMA) has contributed to reducing the prevalence of tobacco smoking and tobacco-related harm over the past 20 years. We discuss the ways in which genetic and neuroscience research on nicotine addiction have contributed to our understanding of tobacco smoking. We then examine the extent to which the BDMA has produced more effective treatments to assist smoking cessation. We also assess the degree to which the BDMA has contributed to the tobacco control policies that have produced substantial reductions in tobacco-related morbidity and mortality in the two decades since the model was first proposed by Alan Leshner. We also assess whether the BDMA has reduced the stigmatisation of people who smoke tobacco.
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Affiliation(s)
- Wayne Hall
- The National Centre for Youth Substance Use Research, the University of Queensland, Australia.
| | - Coral Gartner
- The School of Public Health, The University of Queensland, Australia
| | - Kylie Morphett
- The School of Public Health, The University of Queensland, Australia
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3
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Laidsaar-Powell R, Butow P, Brown BB, Mander K, Young J, Stone E, Chin V, Banks E, Lim CYS, Rankin NM. Application of a revised model for coping with advanced cancer to qualitatively explore lung cancer survivors' experiences of ongoing physical effects, novel treatments, uncertainty, and coping. J Cancer Surviv 2023:10.1007/s11764-023-01417-x. [PMID: 37495907 DOI: 10.1007/s11764-023-01417-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Accepted: 06/15/2023] [Indexed: 07/28/2023]
Abstract
PURPOSE Lung cancer remains underrepresented in cancer survivorship research. This study aimed to understand survivors' physical/psychological challenges, experiences of immunotherapy (IO) and targeted therapy (TT), and psychological adjustment through application of the Roberts et al. (2017) advanced cancer adaptation of Folkman and Greer's appraisal and coping model. METHODS Adults 6-24 months post-initial treatment completion were recruited via an Australian cohort study. Participant demographic, clinical, quality of life, and distress data were obtained through the cohort database. Qualitative interviews were conducted and analyzed using Framework methods. Roberts et al. (2017)'s model informed data interpretation and presentation. RESULTS Twenty interviews were conducted (10 females; average age 69 years). Participants' diagnostic stages varied (stage I = 2, stage II = 4, stage III = 8, stage IV = 6); most had received IO/TT (n = 14) and were on average 17 months (range 10-24) post-diagnosis. Three themes were identified and mapped to the Roberts' framework: (1) Ongoing illness events: most participants reported functioning well despite ongoing physical effects. Those on IO/TT reported side effects; some were unexpected/serious. (2) Adjusting to life with lung cancer: most expressed hope for the future while simultaneously preparing for disease progression. Those receiving IO/TT experienced uncertainty given limited survival information. (3) Learning to live with lung cancer: participants described emotion, problem, and meaning based on coping strategies. CONCLUSIONS Findings may guide development of supportive care resources/interventions focused on uncertainty, IO/TT communication and decision-making, and coping. IMPLICATIONS FOR CANCER SURVIVORS Many people with lung cancer are living well with their ongoing illness. Despite challenges, many survivors are adapting to issues as they arise and are maintaining a sense of hope and optimism.
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Affiliation(s)
- Rebekah Laidsaar-Powell
- Centre for Medical Psychology and Evidence-Based Decision-Making (CeMPED), School of Psychology, Faculty of Science, The University of Sydney, Sydney, NSW, Australia.
| | - Phyllis Butow
- Centre for Medical Psychology and Evidence-Based Decision-Making (CeMPED), School of Psychology, Faculty of Science, The University of Sydney, Sydney, NSW, Australia
| | - Bernadette Bea Brown
- NHMRC Clinical Trials Centre, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Kimberley Mander
- NHMRC Clinical Trials Centre, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Jane Young
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
- The Daffodil Centre, The University of Sydney, a joint venture With Cancer Council, Sydney, NSW, Australia
| | - Emily Stone
- Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
- Department of Thoracic Medicine and Lung Transplantation, St Vincent's Hospital Sydney, Sydney, Australia
- School of Clinical Medicine, UNSW, Sydney, Australia
| | - Venessa Chin
- School of Clinical Medicine, UNSW, Sydney, Australia
- The Kinghorn Cancer Centre, 370 Victoria Street, Darlinghurst, Sydney, NSW, 2010, Australia
- The Garvan Institute of Medical Research, Sydney, NSW, Australia
| | - Emily Banks
- National Centre for Epidemiology and Population Health, Australian National University, Canberra, ACT, Australia
| | - Chloe Yi Shing Lim
- Centre for Medical Psychology and Evidence-Based Decision-Making (CeMPED), School of Psychology, Faculty of Science, The University of Sydney, Sydney, NSW, Australia
| | - Nicole M Rankin
- Centre for Health Policy, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Australia
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Al-Zalabani AH, Monshi SS, Al-Ahmadi AF, Ali AKA, Mirdad GA, Alanazi MM, Alsaedi MQ, Alanazi AM. Dissuasive cigarettes as a tobacco control measure: a scoping review. Tob Control 2023:tc-2023-057974. [PMID: 37414527 DOI: 10.1136/tc-2023-057974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Accepted: 06/28/2023] [Indexed: 07/08/2023]
Abstract
OBJECTIVE The aim was to identify and review the research literature on dissuasive cigarettes, including key concepts, types, sources of evidence and research gaps. DATA SOURCES PubMed, Scopus and Web of Science databases were searched up to January 2023 with no language or date restrictions. All study designs were included. Reference lists of the identified studies were manually searched. Studies on tobacco products other than cigarettes or on external cigarette packaging alone were excluded. STUDY SELECTION Two reviewers screened titles and abstracts independently using eligibility criteria. The full text of the selected articles was subsequently screened independently by two reviewers to confirm eligibility. DATA EXTRACTION Two reviewers independently extracted data from all studies using data abstraction forms. Results were reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews checklist. DATA SYNTHESIS We identified 24 original studies, 3 review articles and 4 commentary articles. Research on dissuasive cigarettes was reported from Australia, New Zealand, Europe and North America. We presented results in four themes: the concept of dissuasive cigarettes; approaches and types; potential benefits, barriers and concerns; and current research gaps. CONCLUSIONS Dissuasive cigarettes represent a promising strategy that could be used in tobacco control. Parallel implementation with plain packaging would be feasible and synergistic.
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Affiliation(s)
| | - Sarah S Monshi
- Department of Health Services Management, College of Public Health and Health Informatics, Umm Al-Qura University, Makkah, Saudi Arabia
| | | | - Ahmed Khalid A Ali
- Model of Care, Al-Madinah Health Cluster, Al-Madinah Al-Munawarah, Saudi Arabia
| | | | - Manal Muteb Alanazi
- Respiratory Therapy, College of Applied Medical Sciences, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Mawada Qabl Alsaedi
- Saudi Board Preventive Medicine Program, Al-Madinah Al-Munawarah, Saudi Arabia
| | - Abdullah M Alanazi
- Respiratory Therapy, College of Applied Medical Sciences, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
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5
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Dewhirst T. 'Beyond nicotine' marketing strategies: Big Tobacco diversification into the vaping and cannabis product sectors. Tob Control 2023; 32:402-404. [PMID: 34511407 DOI: 10.1136/tobaccocontrol-2021-056798] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2021] [Accepted: 08/16/2021] [Indexed: 11/03/2022]
Affiliation(s)
- Timothy Dewhirst
- Department of Marketing and Consumer Studies, Gordon S. Lang School of Business and Economics, University of Guelph, Guelph, ON N1G 2W1, Canada
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Marko S, Thomas SL, Pitt H, Daube M. The impact of responsible gambling framing on people with lived experience of gambling harm. FRONTIERS IN SOCIOLOGY 2023; 8:1074773. [PMID: 36960306 PMCID: PMC10028136 DOI: 10.3389/fsoc.2023.1074773] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Accepted: 02/07/2023] [Indexed: 06/17/2023]
Abstract
BACKGROUND The framing of health issues influences how people think about and respond to these topics. Gambling has largely been framed as an issue of personal responsibility, with the gambling industry, governments and some researchers promoting responsible gambling strategies as a way to address gambling harm. While there is evidence that the internalization of personal responsibility can negatively impact gamblers, this study aimed to explore how people who have experienced gambling harm interpret and apply personal responsibility frames and 'gamble responsibly' messages in their lives. METHODS In-depth semi-structured interviews were conducted via Zoom and telephone with 15 gamblers who had been harmed by their own gambling and six affected others who had been harmed by someone else's gambling. This study was informed by public health and critical qualitative approaches to inquiry. The data were analyzed using reflexive thematic analysis. RESULTS Four themes were constructed from the data. First, gamblers and affected others generally conceptualized gambling and gambling harm as being the responsibility of the individual because it was perceived as the outcome of individual behavior. Second, they attempted to apply responsibility to their own experience either as gamblers who tried to stop or reduce their gambling, or affected others who felt responsible for helping the gambler in their lives. Third, gamblers and affected others were negatively impacted when it was perceived the gambler could not 'control' their gambling or had not done enough to take responsibility. Finally, gamblers and affected others recommended responsible gambling strategies be reframed to be more effective at addressing gambling harm. CONCLUSION This study provides evidence further supporting research demonstrating that personal responsibility frames may have unintended or negative consequences for gamblers and affected others. It underscores the need to reframe public messages about gambling away from responsible gambling, and toward research-based messages that can complement broader legislative changes and other measures to protect individuals.
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Affiliation(s)
- Sarah Marko
- Institute for Health Transformation, Faculty of Health, Deakin University, Geelong, VIC, Australia
| | - Samantha L. Thomas
- Institute for Health Transformation, Faculty of Health, Deakin University, Geelong, VIC, Australia
| | - Hannah Pitt
- Institute for Health Transformation, Faculty of Health, Deakin University, Geelong, VIC, Australia
| | - Mike Daube
- Faculty of Health Sciences, Curtin University, Perth, WA, Australia
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Hefler M, Durkin SJ, Cohen JE, Henriksen L, O'Connor R, Barnoya J, Hill SE, Malone RE. New policy of people-first language to replace 'smoker', 'vaper' 'tobacco user' and other behaviour-based labels. Tob Control 2023; 32:133-134. [PMID: 36806099 PMCID: PMC9985717 DOI: 10.1136/tc-2023-057950] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2023]
Affiliation(s)
- Marita Hefler
- Menzies School of Health Research, Charles Darwin University, Casuarina, Northern Territory, Australia .,NHMRC Centre of Research Excellence in Achieving the Tobacco Endgame, The University of Queensland, Herston, Queensland, Australia
| | - Sarah J Durkin
- Centre for Behavioural Research in Cancer, Cancer Council Victoria, Melbourne, Victoria, Australia
| | - Joanna E Cohen
- Institute for Global Tobacco Control, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Lisa Henriksen
- Stanford Prevention Research Center, Stanford University School of Medicine, Palo Alto, California, USA
| | - Richard O'Connor
- Department of Health Behavior, Roswell Park Cancer Institute, Buffalo, New York, USA
| | - Joaquin Barnoya
- Departamento de Investigacion, Unidad de Cirugia Cardiovascular, Guatemala, Guatemala.,Integra Cancer Institute, Guatemala, Guatemala
| | - Sarah E Hill
- Sydney School of Public Health, The University of Sydney, Sydney, New South Wales, Australia.,School of Social and Political Science, University of Edinburgh, Edinburgh, UK
| | - Ruth E Malone
- Social and Behavioral Sciences, University of California, San Francisco, California, USA
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The great decline in adolescent risk behaviours: Unitary trend, separate trends, or cascade? Soc Sci Med 2023; 317:115616. [PMID: 36563586 DOI: 10.1016/j.socscimed.2022.115616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Revised: 12/08/2022] [Accepted: 12/10/2022] [Indexed: 12/23/2022]
Abstract
In many high-income countries, the proportion of adolescents who smoke, drink, or engage in other risk behaviours has declined markedly over the past 25 years. We illustrate this behavioural shift by collating and presenting previously published data (1990-2019) on smoking, alcohol use, cannabis use, early sexual initiation and juvenile crime in Australia, England, the Netherlands, New Zealand, and the USA, also providing European averages where comparable data are available. Then we explore empirical evidence for and against hypothesised causes of these declines. Specifically, we explore whether the declines across risk behaviours can be considered 1) a 'unitary trend' caused by common underlying drivers; 2) separate trends with behaviour-specific causes; or 3) the result of a 'cascade' effect, with declines in one risk behaviour causing declines in others. We find the unitary trend hypothesis has theoretical and empirical support, and there is international evidence that decreasing unstructured face-to-face time with friends is a common underlying driver. Additionally, evidence suggests that behaviour-specific factors have played a role in the decline of tobacco smoking (e.g. decreasing adolescent approval of smoking, increasing strength of tobacco control policies) and drinking (e.g. more restrictive parental rules and attitudes toward adolescent drinking, decreasing ease of access to alcohol). Finally, declining tobacco and alcohol use may have suppressed adolescent cannabis use (and perhaps other risk behaviours), but evidence for such a cascade is equivocal. We conclude that the causal factors behind the great decline in adolescent risk behaviours are multiple. While broad contextual changes appear to have reduced the opportunities for risk behaviours in general, behaviour-specific factors have also played an important role in smoking and drinking declines, and 'knock-on' effect from these behavioural domains to others are possible. Many hypothesised explanations remain to be tested empirically.
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Coindard G, Acquadro M, Chaumont R, Arnould B, Boisnault P, Collignon-Portes R, Duhot D, Raineri F, Tugaut B, Aubin HJ. Attitudes & behaviors toward the management of tobacco smoking patients: qualitative study with French primary care physicians. BMC PRIMARY CARE 2022; 23:10. [PMID: 35172740 PMCID: PMC8759174 DOI: 10.1186/s12875-021-01620-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Accepted: 12/14/2021] [Indexed: 11/11/2022]
Abstract
Background Smoking cessation is a major public health issue. In France, primary care physicians (PCP) are the first contact points for tobacco management. The objective of this study was to understand how PCPs are involved in the management of smoking cessation: ownership, commitment, barriers. Methods A qualitative study was conducted using group and individual semi-structured techniques with PCPs. A thematic analysis of verbatim transcripts was performed to identify concepts and sub-concepts of interest. Saturation was evaluated retrospectively to ensure adequate sample size. Results A sample of 35 PCPs were interviewed, 31 in four focus groups and four in individual interviews. PCPs discussed their roles in the management of tobacco smoking cessation, including the different strategies they are using (e.g., Minimal Intervention Strategy, Motivational Interviewing), the multiple barriers encountered (e.g., lack of time, patients’ resistance to medical advice), the support resources and the treatment and intervention they prescribed (e.g. nicotine replacement therapy, supporting therapist). Conclusions This study provides a better understanding of the beliefs, attitudes, and behaviors of PCPs in managing smoking cessation. Guiding and encouraging patients toward smoking cessation remains a major objective of PCPs. While PCPs reported that progress has been made in recent years in terms of tools, technology and general awareness, they still face major barriers, some of which could be overcome by appropriate training. Supplementary Information The online version contains supplementary material available at 10.1186/s12875-021-01620-8.
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Blended-eLearning Impact on Health Worker Stigma Toward Alcohol, Tobacco, and Other Psychoactive Substance Users. Int J Ment Health Addict 2022. [DOI: 10.1007/s11469-022-00914-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
Abstract
This study evaluated factors affecting the completion of blended-eLearning courses for health workers and their effect on stigma. The two courses covered the screening and management of harmful alcohol, tobacco, and other substance consumption in a lower-middle-income country setting. The courses included reading, self-reflection exercises, and skills practice on communication and stigma. The Anti-Stigma Intervention-Stigma Evaluation Survey was modified to measure stigma related to alcohol, tobacco, or other substances. Changes in stigma score pre- and post-training period were assessed using paired t-tests. Of the 123 health workers who registered, 99 completed the pre- and post-training surveys, including 56 who completed the course and 43 who did not. Stigma levels decreased significantly after the training period, especially for those who completed the courses. These findings indicate that blended-eLearning courses can contribute to stigma reduction and are an effective way to deliver continuing education, including in a lower-middle-income country setting.
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McCarthy S, Thomas S, Marko S, Pitt H, Randle M, Cowlishaw S. Women's perceptions of strategies to address the normalisation of gambling and gambling-related harm. Aust N Z J Public Health 2022; 46:821-828. [PMID: 35735793 DOI: 10.1111/1753-6405.13264] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Revised: 02/01/2022] [Accepted: 04/01/2022] [Indexed: 01/17/2023] Open
Abstract
OBJECTIVE Research has demonstrated that gambling is becoming increasingly normalised for women. As limited research has sought to understand women's perspectives on this issue, we sought women's opinions about the factors that may contribute to the normalisation of gambling for women, and the strategies that may counter this normalisation. METHODS Semi-structured interviews were conducted with 41 women in young and middle adulthood, aged 20-40 years. RESULTS Participants suggested that gambling was normal for women because gambling environments had been designed to appeal to women, newer technologies had removed the stigma of attending physical venues, and the growing equality and independence of women. To de-normalise gambling, women suggested addressing the influential role of marketing, designing new public education strategies, addressing the availability and accessibility of gambling, and restricting engagement with gambling products. CONCLUSION This study highlighted women's perceptions of strategies to address the normalisation of gambling and the importance of providing risk information paired with broader policy reform and prevention initiatives to address the range of determinants that normalise gambling for women. IMPLICATIONS FOR PUBLIC HEALTH Involving women in advocacy and understanding their perspectives is important in developing relevant public health responses to the normalisation of gambling for women.
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Affiliation(s)
- Simone McCarthy
- Institute for Health Transformation, Faculty of Health, Deakin University, Victoria
| | - Samantha Thomas
- Institute for Health Transformation, Faculty of Health, Deakin University, Victoria
| | - Sarah Marko
- Institute for Health Transformation, Faculty of Health, Deakin University, Victoria
| | - Hannah Pitt
- Institute for Health Transformation, Faculty of Health, Deakin University, Victoria
| | - Melanie Randle
- Faculty of Business and Law, University of Wollongong, New South Wales
| | - Sean Cowlishaw
- Department of Psychiatry, The University of Melbourne, Victoria
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12
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Marko S, Thomas SL, Robinson K, Daube M. Gamblers' perceptions of responsibility for gambling harm: a critical qualitative inquiry. BMC Public Health 2022; 22:725. [PMID: 35413823 PMCID: PMC9004097 DOI: 10.1186/s12889-022-13109-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 03/29/2022] [Indexed: 12/31/2022] Open
Abstract
Background Gambling has traditionally been conceptualised as an issue of addiction and personal responsibility. While there are now clear public health models that recognise that gambling harm is caused by a range of socio-cultural, environmental, commercial and political determinants, government and industry messages about gambling are still largely personal responsibility focused. Given the well-recognised issues associated with personal responsibility paradigms, this study sought to understand how gamblers themselves conceptualised responsibility for gambling harm. Methods A qualitatively led online panel survey was conducted with 363 adult gamblers in New South Wales and Victoria, Australia. Participants were asked to respond to what they thought were the causes of gambling harm, and what could be done to prevent harm. A reflexive thematic analysis was conducted. Results Six common tropes were constructed from gamblers’ responses: (1) Gambling in moderation; (2) Personal responsibility for rational behaviour; (3) Character flaws; (4) Personal responsibility to seek help; (5) More education is needed; and (6) Governments are responsible for action – but motivation and efficacy are questioned. Gamblers primarily understood gambling harm as being a matter of personal responsibility, and government responsibility was generally seen as limited to providing information to facilitate informed gambling choices. Conclusions This study demonstrates that gamblers’ perceptions of gambling harm are similar to the personal responsibility framings and tropes present in industry and government messaging strategies. Refocusing public communication strategies away from ‘responsible gambling’ messaging, and towards evidence-based approaches, will be an important part of addressing the harms associated with gambling.
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Affiliation(s)
- Sarah Marko
- Institute for Health Transformation, Faculty of Health, Deakin University, Melbourne, Australia.
| | - Samantha L Thomas
- Institute for Health Transformation, Faculty of Health, Deakin University, Melbourne, Australia
| | - Kim Robinson
- School of Health and Social Development, Faculty of Health, Deakin University, Melbourne, Australia
| | - Mike Daube
- Faculty of Health Sciences, Curtin University, Perth, Australia
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13
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Exposure to Tobacco Smoking in Vehicles, Indoor, and Outdoor Settings in Germany: Prevalence and Associated Factors. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19074051. [PMID: 35409733 PMCID: PMC8998599 DOI: 10.3390/ijerph19074051] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Revised: 03/12/2022] [Accepted: 03/23/2022] [Indexed: 11/16/2022]
Abstract
Little is known on whether secondhand smoke (SHS) exposure in vehicles, indoor, and outdoor settings is similarly patterned in terms of different socio-epidemiological indicators in Germany. This study aims to estimate the current national-level prevalence and associated socio-epidemiological indicators of SHS exposure in vehicles, indoor, and outdoor settings in the German population, using current data from a representative household survey. We used cross-sectional data (N = 3928 respondents aged 14–99 years) from two waves of the DEBRA survey (German Study on Tobacco Use), conducted between January and March 2020. The reported prevalence of SHS exposure during the last seven days was 19% in vehicles, 25% in indoor settings, and 43% in outdoor settings. We found that younger age and current smoking were consistently associated with higher SHS exposure. Furthermore, people with low education were more likely to be exposed to SHS in vehicles and indoor settings than people with high education. This study found that the prevalence of SHS exposure in vehicles, indoor, and outdoor settings is a relevant feature of everyday life in Germany, especially for younger people and people with lower education, leading to potentially persistent socioeconomic and tobacco-attributable inequalities in morbidity and mortality.
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Hoek J, Edwards R, Waa A. From social accessory to societal disapproval: smoking, social norms and tobacco endgames. Tob Control 2022; 31:358-364. [PMID: 35241613 DOI: 10.1136/tobaccocontrol-2021-056574] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Affiliation(s)
- Janet Hoek
- Department of Public Health, University of Otago, Wellington, New Zealand
| | - Richard Edwards
- Department of Public Health, University of Otago, Wellington, New Zealand
| | - Andrew Waa
- Department of Public Health, University of Otago, Wellington, New Zealand
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Loyal D, Sutter AL, Auriacombe M, Serre F, Rascle N. The Pregnant Smoker Stigma Scale – Public Stigma (P3S-PS): development and validation in general French population. Women Health 2022; 62:157-167. [DOI: 10.1080/03630242.2022.2030449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Deborah Loyal
- INSERM U1219, Bordeaux University, Bordeaux, France
- CRPMS EA 3522, Paris University, Paris, France
| | - Anne-Laure Sutter
- INSERM U1219, Bordeaux University, Bordeaux, France
- Perinatal Psychiatry Unit, Charles Perrens Hospital, Bordeaux, France
| | - Marc Auriacombe
- CNRS USR 3413, SANPSY, Bordeaux University, Bordeaux, France
- Addictology Unit, Charles Perrens Hospital, Bordeaux, France
| | - Fuschia Serre
- CNRS USR 3413, SANPSY, Bordeaux University, Bordeaux, France
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East K, McNeill A, Thrasher JF, Hitchman SC. Social norms as a predictor of smoking uptake among youth: a systematic review, meta-analysis and meta-regression of prospective cohort studies. Addiction 2021; 116:2953-2967. [PMID: 33538370 DOI: 10.1111/add.15427] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Revised: 09/20/2020] [Accepted: 01/20/2021] [Indexed: 01/08/2023]
Abstract
BACKGROUND AND AIMS Social norms towards smoking are a key concept in tobacco control policy and research. However, the influence and strength of different types of social norms on youth smoking uptake is unclear. This study aimed to examine, quantify and compare evidence of the longitudinal associations between different types of social norms towards smoking and youth smoking uptake (initiation and escalation). METHODS Systematic review searching four databases (MEDLINE, EMBASE, PsycInfo, CINAHL) from January 1998 to October 2020. Evidence synthesis via narrative review, meta-analysis pooling unadjusted associations (initiation only, due to heterogeneity in escalation outcomes) and meta-regression comparing effect sizes by norm type and study characteristics. Studies included observational prospective cohort studies using survey methodology with youth aged ≤24 years. Measurements included longitudinal associations between descriptive norms (perceived smoking behaviour) and injunctive norms (perceived approval/disapproval of smoking) among social network(s) and subsequent smoking initiation or escalation. RESULTS Thirty articles were identified. In the narrative review, smoking initiation (but not escalation) was consistently predicted by two norms: parental and close friend smoking. Associations between smoking uptake and other descriptive norms (smoking among siblings, family/household, partner, peers, adults) and all injunctive norms (perceived approval of smoking among parents, siblings, close friends/peers, partner, teachers, people important to you, the public) were less consistent or inconclusive. In the meta-analysis pooling unadjusted associations, 17 articles were included (n = 27 767). Smoking initiation was predicted by the following descriptive norms: smoking among parents [Odds Ratio (OR) = 1.88, 95% Confidence Interval (CI) = 1.56-2.28], close friends (OR = 2.53, 95% CI = 1.99-3.23), siblings (OR = 2.44, 95% CI = 1.93-3.08), family/household (OR = 1.55, 95% CI = 1.36-1.76) and adults (OR = 1.34, 95% CI = 1.02-1.75), but not peers (OR = 1.14, 95% CI = 0.92-1.42). Smoking initiation was also predicted by two injunctive norms, perceived approval of smoking among parents (OR = 1.74, 95% CI = 1.27-2.38) and the public (OR = 4.57, 95% CI = 3.21-6.49), but not close friends/peers (OR = 2.36, 95% CI = 0.86-6.53) or people important to the individual (OR = 1.24, 95% CI = 0.98-1.58). CONCLUSIONS In this systematic review (narrative and meta-analysis), descriptive norms of parents' and close friends' smoking behaviour appeared to be consistent predictors of youth smoking initiation, more so than the descriptive norms of more distal social networks and injunctive norms.
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Affiliation(s)
- Katherine East
- National Addiction Centre, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK.,Shaping Public Health Policies to Reduce Inequalities and Harm (SPECTRUM) Consortium, London, UK.,School of Public Health and Health Systems, Faculty of Applied Health Sciences, University of Waterloo, Waterloo, ON, Canada
| | - Ann McNeill
- National Addiction Centre, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK.,Shaping Public Health Policies to Reduce Inequalities and Harm (SPECTRUM) Consortium, London, UK
| | - James F Thrasher
- Department of Health Promotion, Education, and Behavior, Arnold School of Public Health, University of South Carolina, Columbia, SC, USA.,Department of Tobacco Research, Center for Population Health Research, National Institute of Public Health, Cuernavaca, Mexico
| | - Sara C Hitchman
- National Addiction Centre, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
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17
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Loyal D, Sutter AL, Auriacombe M, Serre F, Calcagni N, Rascle N. Stigma Attached to Smoking Pregnant Women: A Qualitative Insight in the General French Population. Nicotine Tob Res 2021; 24:257-264. [PMID: 34546357 DOI: 10.1093/ntr/ntab190] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 09/17/2021] [Indexed: 11/12/2022]
Abstract
INTRODUCTION Cigarette consumption during pregnancy has major health consequences for women and unborn children. The stigma of smoking during pregnancy might hinder mothers-to-be's access to adequate healthcare and smoking cessation, especially in disadvantaged groups. This qualitative study was designed to describe extensively the public stigma associated with smoking during pregnancy. METHOD Participants were French adults recruited from the general population through social networks (N=100). They were asked to answer three pairs of open-ended questions regarding cognitions, emotions and behaviours elicited in the general population by pregnant smoking women. An inductive thematic analysis was performed and inter-judge agreement was computed on 30% of the corpus analysed deductively. Finally, independence (chi-square) between themes and gender, education, parenthood and smoking status was tested. RESULTS Themes (n=25) were defined regarding cognitions (n=9, e.g., irresponsible, thoughtless and unmindful, etc.), emotions (n=8, e.g., anger, disgust, etc.) and behaviours (n=8, e.g., inform and persuade, moralise and blame, etc.). Global inter-judge agreement was strong (κ=0.8). No difference was observed in themes according to gender, parental status or education, indicating a heterogenous awareness of stigma. However, some differences were observed according to smoking status (χ2 = 69.59, p = 0.02) (e.g., non-smokers more frequently stressed immorality). CONCLUSION The stigma associated with smoking during pregnancy includes various components that might be measured and targeted in interventions to improve access to adequate healthcare and smoking cessation in this specific population. IMPLICATIONS This qualitative study explores the stigma that the general French population attaches to pregnant women who smoke. Themes regarding cognitions (e.g., irresponsible, thoughtless and unmindful, etc.), emotions (e.g., anger, disgust, etc.) and behaviours (e.g., inform and persuade, moralise and blame, etc.) were identified. These themes could guide further research regarding scale development and anti-stigma interventions to support smoking cessation.
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Affiliation(s)
- Deborah Loyal
- INSERM U1219, Bordeaux University, F-33000 Bordeaux France.,CRPMS, EA 3522, Paris University, F-75000 Paris France
| | - Anne-Laure Sutter
- INSERM U1219, Bordeaux University, F-33000 Bordeaux France.,Charles Perrens Hospital, F-33000 Bordeaux France
| | - Marc Auriacombe
- Charles Perrens Hospital, F-33000 Bordeaux France.,CNRS USR 3413, SANPSY, Bordeaux University, F-33000 Bordeaux France
| | - Fuschia Serre
- CNRS USR 3413, SANPSY, Bordeaux University, F-33000 Bordeaux France
| | | | - Nicole Rascle
- INSERM U1219, Bordeaux University, F-33000 Bordeaux France
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18
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Lacy-Nichols J, Marten R. Power and the commercial determinants of health: ideas for a research agenda. BMJ Glob Health 2021; 6:bmjgh-2020-003850. [PMID: 33593758 PMCID: PMC7888370 DOI: 10.1136/bmjgh-2020-003850] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2020] [Revised: 10/19/2020] [Accepted: 11/11/2020] [Indexed: 12/31/2022] Open
Affiliation(s)
- Jennifer Lacy-Nichols
- Centre for Health Policy, The University of Melbourne School of Population and Global Health, Melbourne, Victoria, Australia
| | - Robert Marten
- Alliance for Health Policy and Systems Research, WHO, Geneva, Switzerland
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19
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Legleye S, Aubin HJ, Falissard B, Beck F, Spilka S. Experimenting first with e-cigarettes versus first with cigarettes and transition to daily cigarette use among adolescents: the crucial effect of age at first experiment. Addiction 2021; 116:1521-1531. [PMID: 33201553 DOI: 10.1111/add.15330] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Revised: 05/20/2020] [Accepted: 11/06/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND AIMS Most studies in English-speaking countries have found a positive association between e-cigarette experimentation and subsequent daily tobacco smoking among adolescents. However, this result may not be valid in other cultural contexts; in addition, few studies have assessed whether this association varies with the subject' age at the time of e-cigarette experimentation. This study aimed to estimate the association between experimenting first with e-cigarette (rather than tobacco) and subsequent daily smoking according to age at the time of experimentation. DESIGN Secondary analysis; risk ratios (RRs) computed using modified Poisson regressions with inverse probability weighting. SETTING A cross-sectional nation-wide representative survey performed in 2017 in France. PARTICIPANTS French adolescents (n = 24 111), aged 17 to 18.5 years, who had previously experimented with either e-cigarettes or tobacco. MEASURES Exposure was defined as the experimentation with e-cigarettes first (whether or not followed by experimentation with tobacco); the outcome as daily tobacco smoking at the time of data collection. Gender, age, literacy, socio-economic status, pre-exposure repeat school years and experimentation with drunkeness, 3 licit and 8 illicit drugs were adjusted for. Uncertainties about the sequence of events defining exposure were handled by the definition of three patterns of exposure, to avoid a misclassification bias. FINDINGS Exposure reduced the risk of transition to daily smoking: RR = 0.58, 95% confidence interval (CI) = 0.54, 0.62. This effect increased in a linear manner with age at exposure (RR = 0.87, 95% CI = 0.78; 0.98 for 1 year, P < 0.001): from RR = 1.30, 95% CI = 1.09; 1.54 at age 9 to RR = 0.38, 95% CI = 0.32; 0.45 at age 17. CONCLUSIONS Experimenting with e-cigarettes first (as opposed to tobacco first) appears to be associated with a reduction in the risk of daily tobacco smoking among French adolescents aged 17-18.5, but this risk varies negatively with age at experimentation, and early e-cigarette experimenters are at higher risk.
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Affiliation(s)
- Stéphane Legleye
- Université Paris-Sud, Université Paris-Saclay, faculté de médecine, faculté de médecine UVSQ, Inserm, Villejuif, 94800, France.,Institut national de la statistique et des études économiques, Montrouge, 92120, France
| | - Henri-Jean Aubin
- Université Paris-Sud, Université Paris-Saclay, faculté de médecine, faculté de médecine UVSQ, Inserm, Villejuif, 94800, France.,AP-HP. Université Paris Saclay, Villejuif, 94800, France
| | - Bruno Falissard
- Université Paris-Sud, Université Paris-Saclay, faculté de médecine, faculté de médecine UVSQ, Inserm, Villejuif, 94800, France
| | - François Beck
- Université Paris-Sud, Université Paris-Saclay, faculté de médecine, faculté de médecine UVSQ, Inserm, Villejuif, 94800, France.,Institut national de la statistique et des études économiques, Montrouge, 92120, France
| | - Stanislas Spilka
- Université Paris-Sud, Université Paris-Saclay, faculté de médecine, faculté de médecine UVSQ, Inserm, Villejuif, 94800, France.,AP-HP. Université Paris Saclay, Villejuif, 94800, France.,Observatoire français des drogues et des toxicomanies (OFDT), Paris, 75007, France
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20
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Sorgen LJ, Ferrer RA, Klein WMP, Kaufman AR. Smoking self-concept moderates the effects of self-affirmation on smoking-related beliefs and behavioral intentions. Psychol Health 2021; 37:964-984. [PMID: 33870815 DOI: 10.1080/08870446.2021.1912346] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVE Smoking stigmatization has been shown to hinder cigarette smoking cessation, especially among individuals with a strong smoker identity. Self-affirmation, a psychological threat-management coping strategy, can promote smoking cessation, and may mitigate the adverse consequences of stigmatization. DESIGN Data from an online sample of 1,020 U.S. adult smokers were analyzed using multiple linear regression. MAIN OUTCOME MEASURES Participants completed a self-affirmation (or no-affirmation control) writing task before viewing a smoking stigma (or non-stigma control) anti-smoking public service announcement video. Participants then reported smoking-related cognitions and behavioral intentions. RESULTS Among participants with strong-but not weak-ties to a smoker identity (smoking self-concept), self-affirming led to higher quit intentions compared to the control condition. Among participants with weak-but not strong-smoking self-concepts, those who self-affirmed had lower intentions to switch completely to e-cigarettes relative to the control condition. Exposure to stigmatization reduced intentions to seek cessation counseling, particularly among those with weak smoking self-concepts. CONCLUSION Findings demonstrate the critical role that smoking identity centrality plays in moderating reactions to both affirming and stigmatizing stimuli. Additional research is needed to better understand how self-affirmation and stigma-reduction interventions can be tailored and implemented in natural contexts.
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Affiliation(s)
- Lia J Sorgen
- Behavioral Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, MD, USA
| | - Rebecca A Ferrer
- Behavioral Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, MD, USA
| | - William M P Klein
- Behavioral Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, MD, USA
| | - Annette R Kaufman
- Behavioral Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, MD, USA
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21
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Diaz Gomez C, Morel A, Sedano I, Aubin HJ. The Efficacy of Primavera, a Prevention Programme on Alcohol and Tobacco Use among 10-12-Year-Old Schoolchildren: A Randomized Controlled Cluster Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:3852. [PMID: 33916906 PMCID: PMC8067627 DOI: 10.3390/ijerph18083852] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Revised: 03/21/2021] [Accepted: 04/01/2021] [Indexed: 11/26/2022]
Abstract
Alcohol and tobacco use is a major health problem and one of the first causes of the burden of disease and mortality. School-based alcohol and tobacco use prevention programmes that have demonstrated efficacy are most often based on psychosocial skill development, individuals' experiential learning strategies, and community resources. Furthermore, early and prolonged interventions have been recommended. Primavera is a pluri-annual, generic, multimodal, experiential-oriented prevention program. It runs over a three-year period from the last year of primary school to the second year of secondary school. This randomized controlled cluster study aimed at assessing the effects of the Primavera programme compared to a control prevention intervention among schoolchildren from 10 to 12 years in eight secondary schools in a particular French geographical area. The primary outcomes were lifetime tobacco use and past-month alcohol use. Data were collected at baseline and over three follow-up time points. In all, 287 and 266 questionnaires, respectively, were collected at baseline from the Primavera group and from the control group. Attrition was 45% and 41%, respectively. The SARS-COV2 pandemic crisis made it impossible for questionnaires to be collected during the final year. After adjustment, children from the Primavera group were less likely to report current alcohol use at the end of the first year (odds ratio = 0.39, 95% CI: 0.18-0.78) and past-month alcohol use at the end of the second year (odds ratio = 0.07, 95% CI: 0.01-0.66) compared to those from the control group. The results for psychosocial skills and alcohol and tobacco use denormalization were contrasted. Primavera is shown to be effective in reducing alcohol use among schoolchildren.
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Affiliation(s)
| | | | | | - Henri-Jean Aubin
- Centre de Recherche en Epidémiologie et Santé des Populations (CESP), French Institute of Health and Medical Research (INSERM) U 1018, University Paris-Saclay, Hopital Paul Brousse AP-HP, 94800 Villejuif, France
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22
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Bardach A, Rodríguez MB, Ciapponi A, Augustovski F, Andrea A, Soto N, Virgilio S, Reynales-Shigematsu LM, Roberti J, Pichón-Riviere A. Smoke-Free Air Interventions in Seven Latin American Countries: Health and Financial Impact to Inform Evidence-Based Policy Implementation. Nicotine Tob Res 2021; 22:2149-2157. [PMID: 32697824 DOI: 10.1093/ntr/ntaa133] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2020] [Accepted: 07/16/2020] [Indexed: 01/18/2023]
Abstract
INTRODUCTION Disease burden due to tobacco smoking in Latin America remains very high. The objective of this study was to evaluate the potential impact of implementing smoke-free air interventions on health and cost outcomes in Argentina, Bolivia, Brazil, Chile, Colombia, Mexico, and Peru, using a mathematical model. AIMS AND METHODS We built a probabilistic Monte Carlo microsimulation model, considering natural history, direct health system costs, and quality of life impairment associated with main tobacco-related diseases. We followed individuals in hypothetical cohorts and calculated health outcomes on an annual basis to obtain aggregated 10-year population health outcomes (deaths and events) and costs. To populate the model, we completed an overview and systematic review of the literature. Also, we calibrated the model comparing the predicted disease-specific mortality rates with those coming from local national statistics. RESULTS With current policies, for the next 10 years, a total of 137 121 deaths and 917 210 events could be averted, adding 3.84 million years of healthy life and saving USD 9.2 billion in these seven countries. If countries fully implemented smoke-free air strategies, it would be possible to avert nearly 180 000 premature deaths and 1.2 million events, adding 5 million healthy years of life and saving USD 13.1 billion in direct healthcare. CONCLUSIONS Implementing the smoke-free air strategy would substantially reduce deaths, diseases, and health care costs attributed to smoking. Latin American countries should not delay the full implementation of this strategy. IMPLICATIONS Tobacco smoking is the single most preventable and premature mortality cause in the world. The Framework Convention on Tobacco Control, supported by the World Health Organization, introduced a package of evidence-based measures for tobacco control. This study adds quality evidence on the potential health effects and savings of implementing smoke-free air policies in countries representing almost 80% of the Latin America and the Caribbean population.
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Affiliation(s)
- Ariel Bardach
- Institute for Clinical Effectiveness and Health Policy (IECS), Buenos Aires, Argentina.,National Scientific and Technical Research Council (CONICET), Buenos Aires, Argentina
| | - María Belén Rodríguez
- Institute for Clinical Effectiveness and Health Policy (IECS), Buenos Aires, Argentina
| | - Agustín Ciapponi
- Institute for Clinical Effectiveness and Health Policy (IECS), Buenos Aires, Argentina.,National Scientific and Technical Research Council (CONICET), Buenos Aires, Argentina
| | - Federico Augustovski
- Institute for Clinical Effectiveness and Health Policy (IECS), Buenos Aires, Argentina.,National Scientific and Technical Research Council (CONICET), Buenos Aires, Argentina
| | - Alcaraz Andrea
- Institute for Clinical Effectiveness and Health Policy (IECS), Buenos Aires, Argentina
| | - Natalie Soto
- Institute for Clinical Effectiveness and Health Policy (IECS), Buenos Aires, Argentina
| | - Sacha Virgilio
- Institute for Clinical Effectiveness and Health Policy (IECS), Buenos Aires, Argentina
| | | | - Javier Roberti
- Institute for Clinical Effectiveness and Health Policy (IECS), Buenos Aires, Argentina.,National Scientific and Technical Research Council (CONICET), Buenos Aires, Argentina
| | - Andrés Pichón-Riviere
- Institute for Clinical Effectiveness and Health Policy (IECS), Buenos Aires, Argentina.,National Scientific and Technical Research Council (CONICET), Buenos Aires, Argentina
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23
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East KA, Hitchman SC, McNeill A, Ferguson SG, Yong HH, Cummings KM, Fong GT, Borland R. Trends in Social Norms Towards Smoking Between 2002 and 2015 Among Daily Smokers: Findings From the International Tobacco Control Four Country Survey (ITC 4C). Nicotine Tob Res 2021; 23:203-211. [PMID: 31532483 PMCID: PMC7789950 DOI: 10.1093/ntr/ntz179] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Accepted: 09/12/2019] [Indexed: 11/14/2022]
Abstract
OBJECTIVE To assess trends in daily smokers' social norms and opinions of smoking between 2002 and 2015 in Canada, the United States, the United Kingdom, and Australia. METHOD Data were from wave 1 (2002) to wave 9 (2013-2015) of the longitudinal International Tobacco Control Four Country Survey (Canada, the United States, the United Kingdom, Australia), involving 23 831 adult daily smokers. Generalized estimating equation logistic regression models, adjusted for demographics and survey design effects, assessed associations of wave and country with outcomes: (A) over half of five closest friends smoke, (B) agreeing that people important to you believe you should not smoke, (C) agreeing that society disapproves of smoking, and (D) negative opinion of smoking. RESULTS Between 2002 and 2015, adjusting for covariates, (A) over half of five closest friends smoke did not change (56% vs. 55%; adjusted odds ratio [AOR] = 0.95 [95% Confidence Interval = 0.85-1.07]), (B) agreeing that people important to you believe you should not smoke generally decreased (89% vs. 82%; AOR = 0.54 [0.46-0.64]) despite an increase around 2006-2007, (C) agreeing that society disapproves of smoking increased between 2002 and 2006-2007 (83% vs. 87%; AOR = 1.38 [1.24-1.54]) then decreased until 2013-2015 (78%; AOR = 0.74 [0.63-0.88]), and (D) negative opinion of smoking decreased between 2002 and 2010-2011 (54% vs. 49%; AOR = 0.83 [0.75-0.91]) despite an increase around 2005-2006 and at the final wave (2013-2015). Except friend smoking, Canada had the greatest, and the United Kingdom the lowest, antismoking social norms and opinions. CONCLUSIONS Except friend smoking and opinion of smoking, daily smokers' social norms became less antismoking between 2002 and 2015 despite increases around 2006-2007. Several potential explanations are discussed yet remain undetermined. IMPLICATIONS Increasingly comprehensive tobacco control policies alongside decreasing smoking prevalence in Canada, the United States, the United Kingdom, and Australia have led to the assumption that smoking has become denormalized in these countries. Absent from the literature is any formal assessment of social norms towards smoking over time. Contrary to our hypotheses, this study found that the injunctive social norms of daily smokers became less antismoking between 2002 and 2015, despite increases around 2006-2007. There was no change over time in the proportion of daily smokers who report that over half of their five closest friends smoke.
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Affiliation(s)
- Katherine A East
- National Addiction Centre, Institute of Psychiatry, Psychology, and Neuroscience, King’s College London, London, UK
- UK Centre for Tobacco and Alcohol Studies, Nottingham, UK
| | - Sara C Hitchman
- National Addiction Centre, Institute of Psychiatry, Psychology, and Neuroscience, King’s College London, London, UK
- UK Centre for Tobacco and Alcohol Studies, Nottingham, UK
| | - Ann McNeill
- National Addiction Centre, Institute of Psychiatry, Psychology, and Neuroscience, King’s College London, London, UK
- UK Centre for Tobacco and Alcohol Studies, Nottingham, UK
| | - Stuart G Ferguson
- College of Health and Medicine, University of Tasmania, Hobart, TAS, Australia
| | - Hua-Hie Yong
- Cancer Council Victoria, Melbourne, VIC, Australia
- School of Psychology, Deakin University, Geelong, VIC, Australia
| | - K Michael Cummings
- Department of Psychiatry and Behavioural Sciences, Medical University of South Carolina, Charleston, SC
| | - Geoffrey T Fong
- Department of Psychology, University of Waterloo, Waterloo, ON, Canada
- School of Public Health and Health Systems, University of Waterloo, Waterloo, ON, Canada
- Ontario Institute for Cancer Research, Toronto, ON, Canada
| | - Ron Borland
- Cancer Council Victoria, Melbourne, VIC, Australia
- School of Psychological Sciences, University of Melbourne, Melbourne, VIC, Australia
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24
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Saetta S, Kivits J, Frohlich K, Minary L. Stigmatisation et santé publique : le côté obscur des interventions anti-tabac. SANTE PUBLIQUE (VANDOEUVRE-LES-NANCY, FRANCE) 2021; 32:473-478. [PMID: 35724162 DOI: 10.3917/spub.205.0473] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Tobacco control strategies, considered legitimate and effective, are rarely the subject of critical analysis in France. This is specifically true with regard to their potentially harmful effects, particularly against people who continue to smoke. This article introduces this debate, focusing on the potentially stigmatizing effects of anti-smoking policies. It has been attested by numerous international studies, and by a study in France, that the general process of tobacco denormalization has led to the stigmatization of smokers who then may be subject to discrimination. To the extent that smoking is now concentrated in the most disadvantaged socio-economic populations in France, the latter are thus more exposed to stigma. While underscoring the need to develop targeted interventions against them, this article also warns and calls for vigilance regarding the potential iatrogenic effects of these interventions. It is therefore necessary to develop research and evaluations on this subject in order to accurately measure the effects of these interventions, particularly in terms of stigmatization and self-stigma, and to ensure that public health actors do not generate more problems than they solve.
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25
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Hanafin J, Clancy L. A qualitative study of e-cigarette use among young people in Ireland: Incentives, disincentives, and putative cessation. PLoS One 2020; 15:e0244203. [PMID: 33370351 PMCID: PMC7769428 DOI: 10.1371/journal.pone.0244203] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Accepted: 12/04/2020] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Smoking prevalence in Ireland is falling in all age groups, but e-cigarette use is rising among young people. This qualitative study explores young people's accounts of e-cigarette use in Ireland. METHODS Semi-structured individual (22) and focus group (8) interviews were conducted with 62 young people aged 18-22 years, recruited from a higher-education institution and youth organisations working with early school-leavers across Dublin. All were smokers or ex-smokers; 41 had tried e-cigarettes, 11 continued as dual users. We identified themes using thematic data analysis. RESULTS Three broad themes were identified: incentivising features, disincentivising features, and ambivalent and unsuccessful cessation, named putative smoking cessation. Incentivising features included price, pleasing taste/ flavours, and the possibility of indoor use. Disincentivising features related to adverse health effects (pain, discomfort, sore throat, coughing, headache) and unpleasant physical effects (bad taste, problems resulting from device faults). Other disincentives were over-consumption arising from inability to control intake, "greater addictiveness", product taste, and device faults. Putative cessation refers to the conflict between participants' expected use of e-cigarettes as a smoking cessation/reduction aid and their observed reality of e-cigarettes' failure in this regard, with reported outcomes including: failure to quit or reduce; continued or resumed cigarette and/or roll-your-own smoking; dual use of e-cigarettes and other tobacco products; and inability to quit e-cigarettes. CONCLUSIONS Participants were sceptical about e-cigarettes' "purported relative healthiness", concerned about addictiveness and potential long-term health consequences, and critically aware of advertising and industry strategies. E-cigarettes were viewed as being less denormalised, in part because they could be used in indoor spaces where smoking is banned in Ireland. Although price, taste, and perceived renormalisation were important motivators for young people's use of e-cigarettes, they wanted to quit smoking. The regulation of e-cigarettes through age restriction of access, licensing of outlets, pricing, point of sale and advertising restrictions as well as through the banning of indoor use should be considered by legislators and tobacco control policymakers.
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Affiliation(s)
- Joan Hanafin
- TobaccoFree Research Institute Ireland (TFRI), FOCAS Institute, TU Dublin, Dublin, Ireland
| | - Luke Clancy
- TobaccoFree Research Institute Ireland (TFRI), FOCAS Institute, TU Dublin, Dublin, Ireland
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26
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McCausland K, Jancey J, Leaver T, Wolf K, Freeman B, Maycock B. Motivations for use, identity and the vaper subculture: a qualitative study of the experiences of Western Australian vapers. BMC Public Health 2020; 20:1552. [PMID: 33059652 PMCID: PMC7559168 DOI: 10.1186/s12889-020-09651-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Accepted: 10/07/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Vaping is a relatively new practice, and therefore its symbolic meanings and social practices are yet to be fully understood, especially within Australia where the practice is strictly regulated. This study aimed to examine vapers motivations for use, reinforcing influences, and association with the vaper subculture. METHODS Working from a constructivist epistemology and a symbolic interaction framework, in-depth interviews were conducted with a purposive sample of 37 current (89%) and former (11%) adult vapers, 70% male, mean age of 32.5. Data was analysed via thematic analysis. RESULTS Vapers largely started vaping to quit smoking and underwent common experiences during their initiation phase. Subsequently, vapers tended to adopt one of two dominant identities, that of the 'cloud chaser' or the 'substitute', which some users moved between during different stages of their vaping career. The social and symbolic meaning of e-cigarettes and vaping varied and involved concepts of harm reduction, addiction, pleasure, stigma and community, and for some, connection to the vaper subculture. CONCLUSIONS Understanding the complexities of vaping, and the nuanced differences of 'cloud chasers' and 'substitute' vapers may have important implications for health communication, research and policy. E-cigarette users within this sample were not a homogeneous group and differed in their motivations for use, association with the vaper subculture and relationship with the vape community. These findings provide new insights into the socialisation process and subsequent identity adoption of vapers within the unique regulatory environment of Western Australia.
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Affiliation(s)
- Kahlia McCausland
- Collaboration for Evidence, Research and Impact in Public Health, School of Public Health, Curtin University, Bentley, Western Australia, 6102, Australia.
| | - Jonine Jancey
- Collaboration for Evidence, Research and Impact in Public Health, School of Public Health, Curtin University, Bentley, Western Australia, 6102, Australia
| | - Tama Leaver
- School of Media, Creative Arts and Social Inquiry, Curtin University, Bentley, Western Australia, Australia
| | - Katharina Wolf
- School of Marketing, Curtin University, Bentley, Western Australia, Australia
| | - Becky Freeman
- School of Public Health, University of Sydney, Sydney, New South Wales, Australia
| | - Bruce Maycock
- Collaboration for Evidence, Research and Impact in Public Health, School of Public Health, Curtin University, Bentley, Western Australia, 6102, Australia.,Present affiliation: College of Medicine and Health, University of Exeter, Devon, South West England, UK
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Are smoking cessation behaviours among daily smokers associated with a perceived public stigma of smokers? Cross-sectional analyses of Norwegian data 2011–2013. J Smok Cessat 2020. [DOI: 10.1017/jsc.2020.25] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
AbstractIntroductionPerceived stigma may be an unintended consequence of tobacco denormalization policies among remaining smokers. Little is known about the role of perceived stigmatization in cessation behaviours.AimsTo test if perceived public smoker stigma is associated with recent attempts to cease smoking and future cessation plans among adult daily smokers.MethodsUsing merged data from the biennial national survey Norwegian Monitor 2011 and 2013 (N daily smokers = 1,029), we performed multinomial and ordinal regression analyses to study the impact of perceived public stigma (measured as social devaluation and personal devaluation) on recent quit attempts, short-term intention to quit and long-term intention to quit, controlling for confounders. One additional analysis was performed to investigate the relationship between stigma and intention to quit on quit attempts.ResultsA significant association between perceived social devaluation and recent quit attempts was found (OR 1.76). Perceived stigma was not associated with future quit plans. Personal devaluation was not associated with any cessation outcome. The role of perceived social devaluation on quit attempts was mainly found among smokers with intentions to quit.ConclusionThese findings indicate that stigma measured as social devaluation of smokers is associated with recent quit attempts, but not with future quit plans.
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Williams J, Rakovac I, Loyola E, Sturua L, Maglakelidze N, Gamkrelidze A, Mauer-Stender K, Mikkelsen B, Breda J. A comparison of self-reported to cotinine-detected smoking status among adults in Georgia. Eur J Public Health 2020; 30:1007-1012. [PMID: 32588045 PMCID: PMC7536257 DOI: 10.1093/eurpub/ckaa093] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Self-reported measures of tobacco use may have limited validity, particularly among some populations. This study aims to validate self-reported smoking measures among Georgian adults participating in the 2016 STEPS survey using cotinine biomarker measurements, and to explore potential differences according to sociodemographic characteristics. Additionally, this paper examines how the estimated prevalence of smoking in the population varies according to measurement type. METHODS Using the WHO standardized STEPS methodology, adults self-reported their smoking status. In a later stage of the survey, a subset of participants provided a urine sample, which was tested for cotinine. Using each participant's objective cotinine measurement and their self-reported smoking status, we calculated the sensitivity, specificity and positive predictive value of self-reported smoking. Next, we calculated the estimated prevalence of smokers according to the type of measurement. RESULTS Results indicated high sensitivity (83.37%, 95% CI: 76.79-88.37%) among males and relatively low sensitivity (38.60% CI: 29.23-48.90%) among females. According to self-report, the prevalence of smokers was 26.44% (23.61-29.48%), while according to cotinine detection, the prevalence of smokers was 32.27% (29.16-35.55%). Among all subgroups, the self-reported prevalence of smoking was significantly lower than the cotinine-detected prevalence. CONCLUSIONS To the best of our knowledge, this is the first time that the validity of the STEPS self-reported tobacco indicator has been tested. Self-reported measures of smoking status may lead to an under-estimation of smoking prevalence among Georgian adults, especially women. These findings suggest that integration of biochemical measures of smoking into tobacco use studies may be an important investment.
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Affiliation(s)
- Julianne Williams
- WHO European Office for Prevention and Control of Noncommunicable Diseases, Division of Noncommunicable Diseases and Health Through the Lifecourse, WHO Regional Office for Europe, Moscow, Russian Federation
| | - Ivo Rakovac
- WHO European Office for Prevention and Control of Noncommunicable Diseases, Division of Noncommunicable Diseases and Health Through the Lifecourse, WHO Regional Office for Europe, Moscow, Russian Federation
| | - Enrique Loyola
- WHO European Office for Prevention and Control of Noncommunicable Diseases, Division of Noncommunicable Diseases and Health Through the Lifecourse, WHO Regional Office for Europe, Moscow, Russian Federation
| | - Lela Sturua
- Noncommunicable Disease Department, National Center for Disease Control and Public Health, Tbilisi, Georgia
| | - Nino Maglakelidze
- Noncommunicable Disease Department, National Center for Disease Control and Public Health, Tbilisi, Georgia
| | - Amiran Gamkrelidze
- Noncommunicable Disease Department, National Center for Disease Control and Public Health, Tbilisi, Georgia
| | - Kristina Mauer-Stender
- Division of Noncommunicable Diseases and Health Through the Lifecourse, WHO Regional Office for Europe, UN City, Copenhagen, Denmark
| | - Bente Mikkelsen
- Division of Noncommunicable Diseases and Health Through the Lifecourse, WHO Regional Office for Europe, UN City, Copenhagen, Denmark
| | - João Breda
- WHO European Office for Prevention and Control of Noncommunicable Diseases, Division of Noncommunicable Diseases and Health Through the Lifecourse, WHO Regional Office for Europe, Moscow, Russian Federation
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González-Salgado IDL, Rivera-Navarro J, Sureda X, Franco M. Qualitative examination of the perceived effects of a comprehensive smoke-free law according to neighborhood socioeconomic status in a large city. SSM Popul Health 2020; 11:100597. [PMID: 32478163 PMCID: PMC7251368 DOI: 10.1016/j.ssmph.2020.100597] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Revised: 05/06/2020] [Accepted: 05/07/2020] [Indexed: 11/17/2022] Open
Abstract
Smoke-free legislations aim to protect non-smokers from second-hand smoke (SHS) exposure and improve population health outcomes. The aim of this study was to explore residents' perceptions to understand how people living in distinctive SES neighborhoods are differently affected by comprehensive smoke-free laws in a large city like Madrid, Spain. We conducted a qualitative project with 37 semi-structured interviews and 29 focus group discussions in three different SES neighborhoods within the city of Madrid. Constructivist grounded theory was used to analyze the transcripts. One core category arose in our analyses: Neighborhood inequalities in second-hand smoke (SHS) exposure in outdoor places. The enactment of the comprehensive smoke-free law resulted in unintended consequences that affected neighborhoods differently: relocation of smokers to outdoor setting, SHS exposure, noise disturbance and cigarette butt littering. Changes in the urban environment in the three neighborhoods resulted in the denormalization of smoking in outdoor public places, which was more clearly perceived in the high SES neighborhood. Changes in the built environment in outdoor areas of hospitality venues were reported to actually facilitate smoking. Comprehensive smoke-free laws resulted in denormalization of smoking, which might be effective in reducing SHS exposure. Extending smoking bans to outdoor areas like bus stops and hospitality venues is warranted and should include a public health inequalities perspective.
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Affiliation(s)
| | - Jesús Rivera-Navarro
- Sociology and Communication Department, Social Science Faculty, University of Salamanca, Salamanca, Spain
| | - Xisca Sureda
- Public Health and Epidemiology Research Group, School of Medicine, University of Alcalá, Alcalá de Henares, Madrid, Spain
- Department of Epidemiology & Biostatistics, Graduate School of Public Health & Health Policy, City University of New York, New York, NY 10027, United States
- Tobacco Control Research Group, Institut d’Investigació Biomèdica de Bellvitge-IDIBELL, l’Hospitalet de Llobregat, Barcelona, Spain
- Consortium for Biomedical Research in Respiratory Diseases (CIBER en Enfermedades Respiratorias, CIBERES), Madrid, Spain
| | - Manuel Franco
- Public Health and Epidemiology Research Group, School of Medicine, University of Alcalá, Alcalá de Henares, Madrid, Spain
- Department of Epidemiology & Biostatistics, Graduate School of Public Health & Health Policy, City University of New York, New York, NY 10027, United States
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
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Robert PO, Grard A, Mélard N, Mlinarić M, Rimpelä A, Richter M, Kunst AE, Lorant V. The effect of school smoke-free policies on smoking stigmatization: A European comparison study among adolescents. PLoS One 2020; 15:e0235772. [PMID: 32663217 PMCID: PMC7360046 DOI: 10.1371/journal.pone.0235772] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Accepted: 06/22/2020] [Indexed: 11/18/2022] Open
Abstract
The increasing denormalization of smoking by tobacco control policies and a normative smoke-free climate may shift power towards adolescent non-smokers. It is unclear, however, how common stigmatization of smokers is among adolescents or how stigmatization relates to the denormalization of smoking in their school and social environment. This paper aims to measure (1) whether stigmatization among European adolescents varies according to smoking status and socioeconomic position (SES), and (2) whether stigmatization is greater in school environments in which smoking is denormalized (i.e. those with low smoking rates and strong school tobacco policies). Data on 12,991 adolescents were collected in 55 schools in seven European countries (SILNE R-survey, 2016/17). We applied Stuber’s adapted scale of perceived stereotyping and discrimination towards smokers to smoking status and five variables indicating a power shift towards non-smokers: the school’s tobacco control policy (STP) score, the percentage of adolescents in the school who smoke, parents’ level of education, students’ academic performance, and the percentage of their friends who smoke. Multilevel regressions were applied to the global score for perceived stigmatization. Discrimination against smokers and stereotyping of smokers were frequently reported. Smokers reported less ‘perceived stigmatization of smoking’ than non-smokers (Beta = -0.146, p < 0.001). High-SES students reported stereotyping and discrimination more frequently than lower-SES students. The perception of stigmatization was lower among students whose academic performance was poor (Beta = -0.070, p < 0.001) and among those who had friends who smoked (Beta = -0.141, p < 0.001). Stigmatization was lower in schools with greater exposure to smoking and was not associated with the school’s STP score. Perceived stigmatization of smoking is common among European adolescents. Smokers themselves, however, perceive stigmatization less often than non-smokers. Strong school tobacco policies do not increase stigmatization, but a social environment that is permissive of smoking decreases perceived stigmatization.
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Affiliation(s)
- Pierre-Olivier Robert
- Institute of Health and Society, Université Catholique de Louvain, Brussels, Belgium
- * E-mail:
| | - Adeline Grard
- Institute of Health and Society, Université Catholique de Louvain, Brussels, Belgium
| | - Nora Mélard
- Institute of Health and Society, Université Catholique de Louvain, Brussels, Belgium
| | - Martin Mlinarić
- Institute of Medical Sociology (IMS), Medical Faculty, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - Arja Rimpelä
- Faculty of Social Sciences (SOC), Unit of Health Sciences, Tampere University, Tampere, Finland
- Department of Adolescent Psychiatry, Pitkäniemi Hospital, Tampere University Hospital, Tampere, Finland
| | - Matthias Richter
- Institute of Medical Sociology (IMS), Medical Faculty, Martin Luther University Halle-Wittenberg, Halle (Saale), Germany
| | - Anton E. Kunst
- Department of Public Health, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Vincent Lorant
- Institute of Health and Society, Université Catholique de Louvain, Brussels, Belgium
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31
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Dono J, Miller C, Ettridge K, Wilson C. The role of social norms in the relationship between anti-smoking advertising campaigns and smoking cessation: a scoping review. HEALTH EDUCATION RESEARCH 2020; 35:179-194. [PMID: 32276270 DOI: 10.1093/her/cyaa008] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/18/2019] [Accepted: 02/26/2020] [Indexed: 06/11/2023]
Abstract
A systematic scoping review of anti-smoking mass media campaign literature provided opportunity to explore how social normative theories and constructs are used to influence smoking cessation. Synthesis of findings was constrained by significant heterogeneity. Nevertheless, the results indicate that a broader conceptualization of social norm is worthy of further exploration. Perceptions of what others think and do contributed in multiple ways to the relationship between anti-smoking messaging and quitting outcomes. Furthermore, integrating research on social norms, social identity and communication may improve understanding of why quitting intentions are enhanced in some circumstances but reactance and counter-arguing responses corresponding to lower quitting intentions occur in others. Integrating a broader theoretical understanding of normative influences into campaign development and evaluation may prove useful in demonstrating the effectiveness of this approach in behaviour change campaigns.
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Affiliation(s)
- Joanne Dono
- School of Psychology, University of Adelaide, North Terrace, SA 5000, Australia
- Health Policy Centre, South Australian Health and Medical Research Institute, North Terrace, Adelaide, SA 5000, Australia
| | - Caroline Miller
- Health Policy Centre, South Australian Health and Medical Research Institute, North Terrace, Adelaide, SA 5000, Australia
- School of Public Health, University of Adelaide, North Terrace, Adelaide, SA 5000, Australia
| | - Kerry Ettridge
- School of Psychology, University of Adelaide, North Terrace, SA 5000, Australia
| | - Carlene Wilson
- Olivia Newton John Cancer Wellness and Research Centre, Heidelberg 3084, VIC, Australia
- School of Psychology and Public Health, La Trobe University, Bundoora 3084, VIC, Australia Flinders Centre for Innovation in Cancer, College of Medicine and Public Health, Flinders University, Bedford Park, SA 5042, Australia
- Flinders Centre for Innovation in Cancer, College of Medicine and Public Health, Flinders University, Bedford Park, SA 5042, Australia
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32
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Leszko M, Keenan-Devlin L, Adam EK, Buss C, Grobman W, Simhan H, Wadhwa P, Mroczek DK, Borders A. Are personality traits associated with smoking and alcohol use prior to and during pregnancy? PLoS One 2020; 15:e0232668. [PMID: 32421742 PMCID: PMC7233577 DOI: 10.1371/journal.pone.0232668] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Accepted: 04/20/2020] [Indexed: 11/23/2022] Open
Abstract
Cigarette smoking and alcohol consumption during pregnancy can have detrimental effects on the developing fetus, including fetal alcohol syndrome and low birth weight. Surprisingly little is known about the association of personality traits with smoking and alcohol consumption in the specific subpopulation of pregnant women. This study analyzed data from a geographically diverse sample of 603 pregnant women, aged 18 years and older, who provided information regarding their smoking and drinking habits before and during pregnancy. We compared women who consumed alcohol or smoked cigarettes before pregnancy with women who quit or continued smoking or drinking during pregnancy. Associations between personality and maladaptive behaviors prior to and during pregnancy were modeled using logistic regression. The study revealed that women who scored high on openness to experience were significantly more likely to continue alcohol consumption during pregnancy (OR = 1.07, 95% CI 1.01, 1.14, p = .02). This association was maintained after adjusting for potential confounds. This study demonstrated a significant relationship between personality traits and women's likelihood of continued alcohol consumption prior to and during pregnancy. Understanding personality-based determinants of health-detrimental behavior is important in order to design interventions that aim at decreasing rates of maladaptive health behaviors among pregnant women.
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Affiliation(s)
- Magdalena Leszko
- Department of Psychology, University of Szczecin, Szczecin, Poland
| | - Lauren Keenan-Devlin
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, NorthShore University Health System, University of Chicago Pritzker School of Medicine, Evanston, IL, United States of America
| | - Emma K. Adam
- Institute for Policy Research, Evanston, IL, United States of America
- School of Education and Social Policy, Northwestern University, Evanston, IL, United States of America
| | - Claudia Buss
- Health and Disease Research Program, University of California Irvine, Irvine, CA, United States of America
- Charité, Universitätsmedizin Berlin, Berlin, Germany
| | - William Grobman
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Evanston, IL, United States of America
- Center for Healthcare Studies, Institute for Public Health and Medicine, Chicago, IL, United States of America
| | - Hyagriv Simhan
- Division of Maternal-Fetal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pa, United States of America
- Division of Obstetrical Services, Magee Women’s Hospital, Pittsburgh, Pa, United States of America
| | - Pathik Wadhwa
- Health and Disease Research Program, University of California Irvine, Irvine, CA, United States of America
| | - Daniel K. Mroczek
- Department of Psychology, Northwestern University, Weinberg College of Arts & Sciences, Evanston, IL, United States of America
| | - Ann Borders
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, NorthShore University Health System, University of Chicago Pritzker School of Medicine, Evanston, IL, United States of America
- Center for Healthcare Studies, Institute for Public Health and Medicine, Chicago, IL, United States of America
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33
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Gupta A, Braunack-Mayer A, Smithers L, Harford J, Coveney J. Good and bad sugars: Australian adults’ perspectives on sugar in their diet. CRITICAL PUBLIC HEALTH 2020. [DOI: 10.1080/09581596.2020.1745150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
- Adyya Gupta
- School of Health and Society, Faculty of Social Sciences, University of Wollongong, Wollongong, NSW, Australia
| | - Annette Braunack-Mayer
- School of Health and Society, Faculty of Social Sciences, University of Wollongong, Wollongong, NSW, Australia
- School of Public Health, Level 9, Adelaide Health and Medical Sciences Building, The University of Adelaide, Adelaide, South Australia, Australia
| | - Lisa Smithers
- School of Public Health, Level 9, Adelaide Health and Medical Sciences Building, The University of Adelaide, Adelaide, South Australia, Australia
| | - Jane Harford
- Australian Research Centre for Population Oral Health, Level 9, Adelaide Health and Medical Sciences Building, The University of Adelaide, Adelaide, South Australia, Australia
| | - John Coveney
- Global Food, Culture and Health, Sturt Road, Bedford Park, Flinders University, Adelaide, South Australia, Australia
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Drovandi A, Teague PA, Glass B, Malau-Aduli B. Australian University Student Perceptions of Health Messages on Cigarette Sticks. HEALTH COMMUNICATION 2020; 35:456-464. [PMID: 30676104 DOI: 10.1080/10410236.2019.1567442] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
Abstract
University students are exposed to casual smoking, increasing their risk of developing nicotine addiction, which can extend into adulthood. A novel anti-tobacco intervention being investigated is the use of health warnings on individual cigarette sticks. We explored the perceptions of university students on the effectiveness of health warnings on cigarette packaging and individual cigarette sticks. An online survey was distributed to first-year university students enrolled at a regional university in North-Eastern Australia. Participants rated on 5-point Likert scales and commented using open-text comment boxes, the effectiveness of current cigarette packaging warnings, and 12 text warnings (divided into four themes; immediate and short-term consequences [ISC], long-term and mortality consequences [LMC], social and financial consequences [SFC], and supportive messages to quit [SMQ]) on individual cigarette sticks, in preventing non-smokers from smoking, and in encouraging current smokers to quit. Participants (n = 479; Mean age = 22 years) rated three themes (ISC, LMC, and SFC) as being overall more effective (all p < .001) than current packaging warnings (Odds Ratios = 5.93 [4.51-7.80], 3.60 [2.79-4.64], and 2.86 [2.21-3.69] respectively). Participants described a desensitisation to current packaging warnings, and the novel warnings displayed potentially overcoming this issue, with over 85% agreeing that individual cigarette sticks should include health warnings. Health warnings on cigarette sticks may serve as an effective means in reducing tobacco use, with the provision of this additional intervention for communicating the health and other negative consequences of smoking likely reinforcing the effects of current packaging warnings.
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Affiliation(s)
- Aaron Drovandi
- College of Medicine and Dentistry, James Cook University
| | | | - Beverley Glass
- College of Medicine and Dentistry, James Cook University
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35
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Livingston M, Holmes J, Oldham M, Vashishtha R, Pennay A. Trends in the sequence of first alcohol, cannabis and cigarette use in Australia, 2001-2016. Drug Alcohol Depend 2020; 207:107821. [PMID: 31927161 PMCID: PMC7614940 DOI: 10.1016/j.drugalcdep.2019.107821] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Revised: 12/08/2019] [Accepted: 12/11/2019] [Indexed: 01/08/2023]
Abstract
BACKGROUND Recent analyses of data from the US found that young people were increasingly engaging in cannabis use before alcohol and cigarettes. These shifts are important for public health, but it is not clear whether such trends extend beyond the US. The aim of this study is to examine whether and how the age and sequencing of initiation into alcohol, cannabis and cigarette use has changed in Australia since the early 2000s. METHODS Data came from six waves of the Australian National Drug Strategy Household Survey, spanning 2001-2016. We used data from 18 to 21 year-olds (n = 6849) and examined trends in the age at first use for each of the three substances plus any changes in the order of initiation. RESULTS The mean age of initiation increased steadily for all three substances (e.g. from 14.9 in 2001 to 16.4 in 2016 for alcohol), while the prevalence of any use declined. There were some changes in ordering of use. For example, in 2001, 62 % of respondents who used both cigarettes and cannabis had first used cigarettes at an earlier age than cannabis, compared with 41 % in 2016. Young people who used both alcohol and cannabis remained more likely to try alcohol before cannabis across the study period. CONCLUSIONS Our results partly replicated US findings, with differences potentially reflecting the substantially different environment around these substances in the US compared to Australia. The age of initiation for alcohol, cigarette and cannabis use in Australia has increased sharply over the past 15 years.
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Affiliation(s)
- Michael Livingston
- Centre for Alcohol Policy Research, La Trobe University, Melbourne, Australia; Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.
| | - John Holmes
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Melissa Oldham
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Rakhi Vashishtha
- Centre for Alcohol Policy Research, La Trobe University, Melbourne, Australia
| | - Amy Pennay
- Centre for Alcohol Policy Research, La Trobe University, Melbourne, Australia
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36
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Unger JB, Chaloupka FJ, Vallone D, Thrasher JF, Nettles DS, Hendershot TP, Swan GE. PhenX: Environment measures for Tobacco Regulatory Research. Tob Control 2020; 29:s35-s42. [PMID: 31992662 DOI: 10.1136/tobaccocontrol-2018-054469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2018] [Revised: 06/16/2018] [Accepted: 06/19/2018] [Indexed: 11/04/2022]
Abstract
OBJECTIVE A Working Group (WG) of tobacco regulatory science experts identified measures for the tobacco environment domain. METHODS This article describes the methods by which measures were identified, selected, approved and placed in the PhenX Toolkit. FINDINGS The WG identified 20 initial elements relevant to tobacco regulatory science and determined whether they were already in the PhenX Toolkit or whether novel or improved measures existed. In addition to the 10 complementary measures already in the Toolkit, the WG recommended 13 additional measures: aided and confirmed awareness of televised antitobacco advertising, interpersonal communication about tobacco advertising, media use, perceived effectiveness of antitobacco advertising, exposure to smoking on television and in the movies, social norms about tobacco (for adults and for youth), worksite policies, youth cigarette purchase behaviours and experiences, compliance with cigarette packaging and labelling policies, local and state tobacco control public policies, and neighbourhood-level racial/ethnic composition. Supplemental measures included youth social capital and compliance with smoke-free air laws and with point of sale and internet tobacco marketing restrictions. Gaps were identified in the areas of policy environment (public and private), communications environment, community environment and social environment (ie, the norms/acceptability of tobacco use). CONCLUSIONS Consistent use of these tobacco environment measures will enhance rigor and reproducability of tobacco research.
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Affiliation(s)
- Jennifer B Unger
- Department of Preventive Medicine, University of Southern California Keck School of Medicine, Los Angeles, California, USA
| | - Frank J Chaloupka
- Department of Health Policy and Administration and Health Policy Center, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Donna Vallone
- Department of Research and Evaluation, Truth Initiative, Washington, Washington, DC, USA
| | - James F Thrasher
- Arnold School of Public Health, University of South Carolina, Columbia, South Carolina, USA
| | | | | | - Gary E Swan
- Stanford Prevention Research Center, Stanford University School of Medicine, Stanford, California, USA
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Maher L, Iversen J, Geddes L. Mapping out a research agenda on alcohol and other drug stigma: Commentary on Seear. Drug Alcohol Rev 2020; 39:114-115. [PMID: 31943453 DOI: 10.1111/dar.13030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Accepted: 12/12/2019] [Indexed: 11/30/2022]
Affiliation(s)
- Lisa Maher
- Viral Hepatitis Epidemiology and Prevention Program, Kirby Institute for Infection and Immunity, Faculty of Medicine, UNSW Sydney, Sydney, Australia.,Burnet Institute, Melbourne, Australia
| | - Jenny Iversen
- Viral Hepatitis Epidemiology and Prevention Program, Kirby Institute for Infection and Immunity, Faculty of Medicine, UNSW Sydney, Sydney, Australia
| | - Louise Geddes
- Viral Hepatitis Epidemiology and Prevention Program, Kirby Institute for Infection and Immunity, Faculty of Medicine, UNSW Sydney, Sydney, Australia
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East KA, Hitchman SC, McNeill A, Thrasher JF, Hammond D. Social norms towards smoking and vaping and associations with product use among youth in England, Canada, and the US. Drug Alcohol Depend 2019; 205:107635. [PMID: 31765990 PMCID: PMC6905149 DOI: 10.1016/j.drugalcdep.2019.107635] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Revised: 07/30/2019] [Accepted: 08/03/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND This study assesses differences in social norms towards smoking and vaping among youth across countries (England, Canada, US) and smoking and vaping status. METHODS Data are from the 2017 ITC Youth Tobacco and Vaping Survey, among youth age 16-19 in England (N = 3444), Canada (N = 3327), and US (N = 3509). Prevalence of friend smoking, friend vaping, peer approval of smoking, and peer approval of vaping were estimated. Adjusted logistic regression models were estimated for each norm to assess associations with country, smoking status, and vaping status, adjusting for sociodemographics, alcohol use, and marijuana use. RESULTS 47% and 52% reported friend smoking and vaping respectively. Perceived peer approval of vaping (44%) was almost double that of smoking (23%). Compared with England, fewer Canadian and US youth reported friend smoking (Canada: AOR = 0.71 [95% CI = 0.62-0.82]; US: AOR = 0.54 [0.47-0.62]) and peer approval of smoking (Canada: AOR = 0.74 [0.63-0.87]; US: AOR = 0.78 [0.67-0.91]), yet more reported peer approval of vaping (Canada: AOR = 1.23 [1.08-1.41]; US: AOR = 1.30 [1.14-1.48]). More Canadian than English youth reported friend vaping (AOR = 1.17 [1.02-1.36]). Friend smoking, peer approval of smoking, and friend vaping were more common among smokers and vapers (all p < .02). Peer approval of vaping was more common among vapers but less common among smokers (all p < .044). CONCLUSIONS Youth had more positive vaping than smoking norms. English youth reported the most pro-smoking but least pro-vaping norms in adjusted models; this was unexpected given country differences in regulatory environments. Norms towards both products were associated with use, with some evidence of cross-product associations between norms and behaviours.
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Affiliation(s)
- Katherine A East
- National Addiction Centre, Institute of Psychiatry, Psychology and Neuroscience, King's College London, UK; UK Centre for Tobacco and Alcohol Studies, UK.
| | - Sara C Hitchman
- National Addiction Centre, Institute of Psychiatry, Psychology and Neuroscience, King's College London, UK; UK Centre for Tobacco and Alcohol Studies, UK.
| | - Ann McNeill
- National Addiction Centre, Institute of Psychiatry, Psychology and Neuroscience, King's College London, UK; UK Centre for Tobacco and Alcohol Studies, UK.
| | - James F Thrasher
- Department of Health Promotion, Education, and Behavior, Arnold School of Public Health, University of South Carolina, USA; Department of Tobacco Research, Center for Population Health Research, National Institute of Public Health, Mexico.
| | - David Hammond
- School of Public Health and Health Systems, University of Waterloo, Canada.
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Schreuders M, Kuipers MA, Mlinarić M, Grard A, Linnansaari A, Rimpela A, Richter M, Perelman J, Lorant V, van den Putte B, Kunst AE. The association between smoke-free school policies and adolescents' anti-smoking beliefs: Moderation by family smoking norms. Drug Alcohol Depend 2019; 204:107521. [PMID: 31476644 DOI: 10.1016/j.drugalcdep.2019.06.023] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Revised: 05/01/2019] [Accepted: 06/11/2019] [Indexed: 11/25/2022]
Abstract
BACKGROUND Smoke-free school policies (SFSPs) may influence adolescents' smoking through the development of anti-smoking beliefs. We assessed which types of anti-smoking beliefs (health, social and societal) are associated with SFSPs and whether these associations were different for adolescents in smoking permissive versus prohibitive families. METHODS Survey data was collected in 2016-2017 from 10,980 adolescents between 14-16 years old and 315 staff in 55 schools from seven European cities. We separately measured adolescent-perceived SFSP and staff-reported SFSP at the school-level. Associations between SFSP and anti-smoking health, social and societal beliefs were studied using multi-level logistic regression, adjusting for demographics and school-level smoking prevalence. We tested for interactions between family norms and SFSP, and estimated associations for adolescents in permissive and prohibitive families, respectively. RESULTS Adolescent-perceived SFSP was not significantly associated with anti-smoking health (OR:1.08, 95%CI:0.94-1.25), social (OR:0.89, 95%CI:0.75-1.04) and societal beliefs (OR:1.15, 95%CI:0.99-1.33). Staff-reported SFSP were associated with anti-smoking health beliefs (OR:1.12, 95%CI:1.01-1.24), but not with social (OR:0.94, 95%CI:0.83-1.07) or societal beliefs (OR:1.02, 95%CI:0.90-1.14). Most results were comparable between adolescents in smoking prohibitive and permissive families. However, in smoking prohibitive families, adolescent-perceived SFSP were associated with societal beliefs (OR:1.24, 95%CI:1.06-1.46), but not in permissive families (OR:1.06, 95%CI:0.90-1.25). Also, in smoking permissive families, staff-reported SFSP were associated with more pro-smoking social beliefs (OR:0.83, 95%CI:0.72-0.96), but not in prohibitive families (OR:1.05, 95%CI:0.92-1.16). CONCLUSIONS We found evidence that SFSP are associated with some anti-smoking beliefs, but more so among adolescents from smoking prohibitive families than from permissive families.
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Affiliation(s)
- Michael Schreuders
- Department of Public Health, Amsterdam UMC, University of Amsterdam, Amsterdam Public Health Institute, Amsterdam, the Netherlands.
| | - Mirte Ag Kuipers
- Department of Public Health, Amsterdam UMC, University of Amsterdam, Amsterdam Public Health Institute, Amsterdam, the Netherlands
| | - Martin Mlinarić
- Institute of Medical Sociology, Medical Faculty, Martin Luther University, Halle-Wittenberg, Germany
| | - Adeline Grard
- Institute of Health and Society, Université catholique de Louvain, Brussels, Belgium
| | - Anu Linnansaari
- Faculty of Social Sciences, Unit of Health Sciences, Tampere University, Tampere, Finland
| | - Arja Rimpela
- Faculty of Social Sciences, Unit of Health Sciences, Tampere University, Tampere, Finland; Department of Adolescent Psychiatry, Tampere University Hospital, Tampere, Finland
| | - Matthias Richter
- Institute of Medical Sociology, Medical Faculty, Martin Luther University, Halle-Wittenberg, Germany
| | - Julian Perelman
- National School of Public Health, NOVA University of Lisbon, Lisbon, Portugal
| | - Vincent Lorant
- Institute of Health and Society, Université catholique de Louvain, Brussels, Belgium
| | - Bas van den Putte
- Faculty of Social and Behavioural Sciences, University of Amsterdam, Amsterdam Public Health Institute, Amsterdam, the Netherlands
| | - Anton E Kunst
- Department of Public Health, Amsterdam UMC, University of Amsterdam, Amsterdam Public Health Institute, Amsterdam, the Netherlands
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El Amin SET. School Smoking Policies and Health Science Students' Use of Cigarettes, Shisha, and Dipping Tombak in Sudan. Front Public Health 2019; 7:290. [PMID: 31681722 PMCID: PMC6804594 DOI: 10.3389/fpubh.2019.00290] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Accepted: 09/25/2019] [Indexed: 11/13/2022] Open
Abstract
The relationship between school smoking policies and students' tobacco use is ambiguous, and little is known about the effect of these policies in low- and middle-income countries. This study was designed to assess the effects of schools' smoking policies and the exposure to residential smoking on cigarette smoking and the use of different kinds of tobacco products by Health Science students. Self-reports of cigarette smoking, use of shisha (smoking of fruits-mixed tobacco using a bowl and a connected hose); dipping tombak (local smokeless tobacco that users usually place inside oral cavity in the groove behind the lower lip), and tobacco use on school premises are analyzed. A cross-sectional survey was carried out using a modified self-report questionnaire, originally developed by WHO, among a representative sample of 1,590 third-year HSS from 25 schools drawn from 13 universities, using a multi-stages sampling technique. The response rate was 100% for schools and 68% for students. A multilevel analysis was performed by nesting student-level in school-level variables. Results from the adjusted models revealed that, when students reported awareness of smoking restriction, they were more likely to be current smokers (OR = 2.91; 95% CI: 1.68–5.02; p = 0.021) and shisha users (OR = 2.17; 95% CI: 1.54–3.06; p = 0.021). Results from additional analysis performed among tobacco users only, showed increased risk of smokers and tombak dippers who smoked or dipped on school premises (OR = 2.38; 95% CI: 1.34–4.25; p = 0.003, OR = 2.60; 95% CI: 1.22–5.56; p = 0.013, respectively). Current smokers (OR = 3.12; 95% CI: 1.98–4.92; p = ≤ 0.001), ever smokers (OR = 1.66; 95% CI: 1.31–2.10; p = ≤ 0.001) and shisha users (OR = 1.73; 95% CI: 1.36–2.21; p = ≤ 0.001) were exposed to residential smoking on one or more days during the previous 7 days. High percentages of those who used any kind of tobacco products reported being aware of school smoking policies, indicating no clear evidence that school smoking policies had an effect on use of any of the mentioned tobacco products. The lack of compliance with school policies shows the need for further policy enforcement and sustainability, taking into account the effect of residential smoking and social influences.
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Cortland CI, Shapiro JR, Guzman IY, Ray LA. The ironic effects of stigmatizing smoking: combining stereotype threat theory with behavioral pharmacology. Addiction 2019; 114:1842-1848. [PMID: 31140666 DOI: 10.1111/add.14696] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Revised: 10/01/2018] [Accepted: 05/17/2019] [Indexed: 12/01/2022]
Abstract
AIMS Public service announcements often create media messages intended to stigmatize negative behaviors to reduce and prevent these behaviors. Drawing on social and cognitive psychology, we hypothesize that stigmatizing messages can create stereotype threat would be associated with shorter latency to first cigarette in the laboratory compared to the control condition. DESIGN A double-blind, randomized, controlled trial in which participants completed two smoking lapse tasks, one at baseline and one post-intervention/control. SETTING An experimental psychopharmacology laboratory in the western United States. PARTICIPANTS A community sample of non-treatment-seeking daily smokers (n = 77) received either a stereotype threat (n = 39) or neutral/control (n = 38) message. INTERVENTION Participants received either a stereotype threat message that stigmatized smoking or a control message. MEASUREMENTS The primary outcome measure was participants' ability to delay smoking during the smoking lapse task in the experimental session FINDINGS: The difference in delay time during the experimental session at the point where 50% of each group had smoked was 3 minutes. Cox proportional hazard models revealed that participants in the stereotype threat group were significantly less able to delay initiating smoking compared to the control group (hazard ratio = 0.504, P = 0.010, 95% confidence interval = 0.30, 0.85), after controlling for baseline latency to smoke. CONCLUSIONS Messages that elicit negative stereotypes of smokers operated as 'smoking-promoting messages' in the context of our controlled laboratory investigation.
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Affiliation(s)
- Clarissa I Cortland
- Department of Psychology, The University of California, Los Angeles, CA, USA
| | - Jenessa R Shapiro
- Department of Psychology, The University of California, Los Angeles, CA, USA
| | - Iris Y Guzman
- Department of Psychology, The University of California, Los Angeles, CA, USA
| | - Lara A Ray
- Department of Psychology, The University of California, Los Angeles, CA, USA
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Hammett P, Fu SS, Nelson D, Clothier B, Saul JE, Widome R, Danan ER, Burgess DJ. A Proactive Smoking Cessation Intervention for Socioeconomically Disadvantaged Smokers: The Role of Smoking-Related Stigma. Nicotine Tob Res 2019; 20:286-294. [PMID: 28398492 DOI: 10.1093/ntr/ntx085] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2016] [Accepted: 04/06/2017] [Indexed: 11/14/2022]
Abstract
Introduction Smoking denormalization has been paralleled by reduced smoking prevalence, but smoking rates among socioeconomically disadvantaged populations remain high. The social unacceptability of smoking has also led to increased perceptions of smoking-related stigma. By examining how smoking stigma influences cessation intervention effectiveness, we can better tailor interventions to socioeconomically disadvantaged smokers. Aims and Methods Data are from a randomized controlled trial evaluating the effectiveness of a proactive cessation intervention on abstinence. Current smokers enrolled in Minnesota Health Care Programs were randomized to proactive outreach (n = 1200) or usual care (n = 1206). The intervention included mailings, telephone outreach, counseling, and access to free cessation treatments. Using baseline measurements, groups with lower (n = 1227) and higher (n = 1093) perceived stigma were formed. Intervention, stigma, and their interaction term were added to a logistic regression modeling abstinence at 12 months. Results Lower perceived smoking-related stigma was associated with less support for quitting, lower rates of physician quitting advice, and less motivation for quitting. A logistic regression modeling abstinence found a significant intervention × stigma interaction. The proactive intervention was more effective among smokers with lower perceived smoking-related stigma (odds ratio 1.94, 95% confidence interval, 1.29 to 2.92) than those with higher perceived smoking-related stigma (odds ratio 1.04, 95% confidence interval, 0.70 to 1.55). Discussion Smokers with lower perceived smoking-related stigma had social environments that were conducive to smoking, received less physician advice to quit, and were less motivated to quit than higher stigma smokers. Despite these barriers, the intervention was more effective for lower stigma smokers, suggesting that proactive outreach is an efficient treatment for these hard-to-reach smokers. Implications Smoking denormalization has led to increased perceptions of smoking-related stigma among many smokers; however, little is known about how this stigma influences the cessation process. In the present study, smokers with lower levels of perceived smoking-related stigma lived in social environments that were more conducive to smoking and were less motivated to quit than higher stigma smokers. Despite these barriers, our proactive outreach cessation intervention was more effective for lower stigma smokers, suggesting that interventions which utilize proactive outreach to stimulate interest in quitting and offer facilitated access to free cessation treatments are an effective treatment approach for these hard-to-reach smokers. These strategies may be particularly effective for motivating smokers enrolled in government-subsidized health insurance programs to take advantage of cessation resources.
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Affiliation(s)
- Patrick Hammett
- Division of Epidemiology and Community Health, University of Minnesota School of Public Health, MN.,Department of Medicine, University of Minnesota Medical School, MN.,VA HSR&D Center for Chronic Disease Outcomes Research (CCDOR), Minneapolis VA Health Care System, MN
| | - Steven S Fu
- Division of Epidemiology and Community Health, University of Minnesota School of Public Health, MN.,Department of Medicine, University of Minnesota Medical School, MN
| | - David Nelson
- Division of Epidemiology and Community Health, University of Minnesota School of Public Health, MN.,Department of Medicine, University of Minnesota Medical School, MN
| | - Barbara Clothier
- Division of Epidemiology and Community Health, University of Minnesota School of Public Health, MN
| | | | - Rachel Widome
- VA HSR&D Center for Chronic Disease Outcomes Research (CCDOR), Minneapolis VA Health Care System, MN
| | - Elisheva R Danan
- Division of Epidemiology and Community Health, University of Minnesota School of Public Health, MN.,Department of Medicine, University of Minnesota Medical School, MN
| | - Diana J Burgess
- Division of Epidemiology and Community Health, University of Minnesota School of Public Health, MN.,Department of Medicine, University of Minnesota Medical School, MN
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Tane MP, Hefler M, Thomas DP. Smokefree leadership among the Yolŋu peoples of East Arnhem Land, Northern Territory: a qualitative study. Glob Health Promot 2019; 27:100-108. [PMID: 31232171 DOI: 10.1177/1757975919829405] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
This qualitative study examined smokefree leadership among the Yolŋu people, Indigenous landowners of East Arnhem Land. Despite disproportionately high smoking prevalence, the study found that most people enacted smokefree leadership within families and communities. While there was broad concern about not impinging on the autonomy of others, Indigenous health workers regularly advised clients, family and community members to quit smoking. This followed a general belief that the issue of smoking was best raised by health workers, rather than traditional leaders. Protecting children from second-hand smoke and preventing smoking initiation was important to all participants irrespective of their smoking status. An enduring and highly valued cultural connection to ŋarali' (tobacco) remains an essential part of the sacred practices of the funeral ceremony, an important and unique social utility. The study found consensus among participants that this would not change. Navigating traditional connections to ŋarali' in a context where most people are still addicted to commercial tobacco is challenging and requires respectful and culturally compelling approaches. Tobacco control initiatives with the Yolŋu should therefore utilise existing smokefree leaders within the social context in which ŋarali' is valued and used, an approach that may resonate with other Indigenous Australian nations and communities.
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Affiliation(s)
- Moana Pera Tane
- Menzies School of Health Research, Charles Darwin University, Casuarina, NT, Australia
| | - Marita Hefler
- Menzies School of Health Research, Charles Darwin University, Casuarina, NT, Australia
| | - David P Thomas
- Menzies School of Health Research, Charles Darwin University, Casuarina, NT, Australia
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Booth P, Albery IP, Cox S, Frings D. Survey of the effect of viewing an online e-cigarette advertisement on attitudes towards cigarette and e-cigarette use in adults located in the UK and USA: a cross-sectional study. BMJ Open 2019; 9:e027525. [PMID: 31217318 PMCID: PMC6589002 DOI: 10.1136/bmjopen-2018-027525] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Revised: 05/20/2019] [Accepted: 05/22/2019] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES This study explored the potential for e-cigarette advertisements to (1) enhance attitudes towards cigarettes and/or (2) reduce barriers to e-cigarettes uptake. The study tested whether exposure to an online electronic cigarette advertisement changed attitudes towards cigarettes and e-cigarettes in smokers, non-smokers, e-cigarette users and dual users (smokers who also use e-cigarettes). DESIGN Cross-sectional study SETTING: Online survey PARTICIPANTS: Adults (n=964) aged 18 to 65 years old (M=36 years, SD=11.6) from the UK and USA. Participants were grouped into current non-smokers, e-cigarette users, dual users and smokers. INTERVENTIONS Participants viewed 1 of 15 randomly assigned online e-cigarette advertisements. PRIMARY MEASURES Three single seven-point Likert scales measuring health, desirability, social acceptability were completed pre and post advertisement exposure. RESULTS Post exposure all smoking groups showed a decrease or no change in how socially acceptable or desirable they rated cigarettes. Paradoxically, dual users rated cigarettes as being significantly healthier after viewing the advertisement (p=0.01) while all other smoking group ratings remained the same. There was an increase or no change in how all smoking groups perceived the healthiness and desirability of e-cigarettes CONCLUSIONS: We observed no evidence that exposure to an e-cigarette advertisement renormalises or encourages smoking in smokers, non-smokers or e-cigarette users. However, there is some indication that viewing an e-cigarette advertisement may increase duals users' perceptions of the health of smoking.
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Affiliation(s)
- Paula Booth
- Psychological Sciences Department, Applied Health and Communities College, School of Psychology, The University of East London, London, UK
| | - Ian P Albery
- Division of Psychology, School of Applied Sciences, London South Bank University, London, UK
| | - Sharon Cox
- Division of Psychology, School of Applied Sciences, London South Bank University, London, UK
| | - Daniel Frings
- Division of Psychology, School of Applied Sciences, London South Bank University, London, UK
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Helweg-Larsen M, Sorgen LJ, Pisinger C. DOES IT HELP SMOKERS IF WE STIGMATIZE THEM? A TEST OF THE STIGMA-INDUCED IDENTITY THREAT MODEL AMONG U.S. AND DANISH SMOKERS. SOCIAL COGNITION 2019; 37:294-313. [PMID: 31303688 DOI: 10.1521/soco.2019.37.3.294] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Research shows that smokers feel stigmatized, but does stigmatizing smokers do more harm than good? The model of stigma-induced identity threat was used to experimentally examine how U.S. and Danish smokers respond to stigma-relevant cues. Heavy smokers (112 Americans, 112 Danes) smoked a cigarette while giving a speech that was either video (stigma-visible condition) or audio recorded (stigma-concealed condition). Smokers high in self-concept reacted to the stigma-visible (as opposed to the stigma-concealed) condition with greater physiological reactivity (b = -2.80, p = .05), cognitive depletion (U.S. smokers, b = -0.06, p = .11), self-exempting beliefs (b = 0.32, p < .001), and less interest in stopping smoking (b = 0.28, p = .02). Thus, stigmatization led smokers toward emotional, cognitive, and attitudinal reactions that might make them less likely to quit. Future research should examine when smokers respond to stigmatization by quitting rather than with resistance or indifference.
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Jarman H. Normalizing Tobacco? The Politics of Trade, Investment, and Tobacco Control. Milbank Q 2019; 97:449-479. [PMID: 31099058 DOI: 10.1111/1468-0009.12393] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Indexed: 11/30/2022] Open
Abstract
Policy Points Tobacco industry denormalization is a key strategy for tobacco control that has been formalized in the WHO Framework Convention on Tobacco Control. International trade and investment laws are a potential threat to tobacco industry denormalization because they do not automatically incorporate denormalization and, in theory, treat tobacco firms like other commercial interests. Countries that seek to defend tobacco control policies against international trade and investment challenges need to have good governance in two senses: good governance as understood by tribunals and good-enough governance to manage the processes and requirements that enable policies to survive international challenges. CONTEXT Tobacco industry denormalization (TID), portraying tobacco product manufacturers as a deadly industry, is a major strategy for public health advocates. Using this strategy, activists around the world have successfully pushed for governments to enact tobacco control regulations, including the unprecedented international Framework Convention on Tobacco Control (FCTC). TID has been a distinctive legal and political strategy that has affected the place of tobacco in law and has both inspired and constrained those who would imitate the strategy in other areas of regulation, such as diet or alcohol. It is therefore a case study in the creation of a distinctive legal approach and of threats to that approach from the changing role of world trade and investment law, which creates a new set of venues that tobacco industry advocates can use to redefine tobacco as a normal good and to seek out "fair and equitable treatment" for their industry. METHODS I review legal and policy documents pertaining to two major challenges to tobacco control policies in Australia and Uruguay aimed at controlling industry branding. FINDINGS International trade and investment law challenges TID and raises fundamental questions about the role of the state in protecting public health. Recent trade disputes involving Uruguay and Australia illustrate this dynamic. Despite losing high-court challenges against packaging regulations in both countries, tobacco firms were still able to challenge states in a different way, through international trade and investment agreements. This article identifies the industry's strategies and the responses of those seeking to avoid renormalizing tobacco as a part of world trade. In particular, states must demonstrate that their tobacco control policies satisfy standards set by tribunals, which include standards of good governance, and they must prepare their policies in a way that reduces legal risk and requires good governance. CONCLUSIONS Although TID has strengthened the hand of tobacco control advocates, TID strategies alone are not sufficient to defend public regulations against extraterritorial legal challenges in an arena that resists the basic TID technique of singling out a particular industry. Public health advocates might also note the FCTC's aid in helping governments defend themselves against these challenges and consider similar international instruments for other areas.
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Beaupre LA, Hammal F, DeSutter C, Stiegelmar RE, Masson E, Finegan BA. Impact of a standardized referral to a community pharmacist-led smoking cessation program before elective joint replacement surgery. Tob Induc Dis 2019; 17:14. [PMID: 31582925 PMCID: PMC6751968 DOI: 10.18332/tid/101600] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Revised: 12/14/2018] [Accepted: 12/14/2018] [Indexed: 12/22/2022] Open
Abstract
INTRODUCTION Smokers undergoing total joint replacement (TJR) are more likely to develop infections and be re-admitted than non-smokers. The primary purpose of this study was to evaluate the effectiveness of standardized preoperative referral to a community-based pharmacist-led smoking cessation program compared to usual care for patients undergoing TJR. Secondarily, we evaluated the use of the smoking cessation program. METHODS A pre-post quasi-experimental study was conducted at a central intake clinic that prepares approximately 3000 TJR patients annually. Participants were recruited at a mean of 13±11.1 weeks preoperatively and provided informed consent. Participants in the ‘pre’ observational phase (OP) received usual care for smoking cessation. For ‘post’ intervention phase (IP) participants, a referral was sent to a community-based pharmacist-led smoking cessation program. Smoking status was validated on study entry using exhaled carbon monoxide. Participants’ smoking status was re-assessed using self-reported point prevalence abstinence at 6 months post-recruitment. RESULTS We enrolled 120/150 (80%) potential OP candidates and 104/286 (36%) potential IP candidates. The groups were similar on study entry; overall, the mean age of participants was 58.7±9.1 years and 103 (47%) were male. They reported medium nicotine dependence with 37±11.6 mean years smoked. At 6 months post-recruitment, 8 (7%) OP participants self-reported 30-day point prevalence abstinence compared to 21 (20%) IP participants (p=0.003). Only 58 (56%) IP participants complied with the pharmacist referral, with 19 (33%) of those seeing the pharmacist reporting point prevalence abstinence at 6 months compared to only 2 (4%) of the 45 participants who did not see the pharmacist (p<0.001). CONCLUSIONS Referral to a community smoking cessation program as preoperative standard of care is feasible and can enhance long-term quit rates, but voluntary participation led to low recruitment to the program.
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Affiliation(s)
- Lauren A Beaupre
- Collaborative Orthopaedic Research (CORe), Department of Physical Therapy, University of Alberta, Edmonton, Canada
| | - Fadi Hammal
- Department of Anesthesiology and Pain Medicine, University of Alberta, Edmonton, Canada
| | - Chrisopher DeSutter
- Collaborative Orthopaedic Research (CORe), Department of Surgery, University of Alberta, Edmonton, Canada
| | - Robert E Stiegelmar
- Collaborative Orthopaedic Research (CORe), Department of Surgery, University of Alberta, Edmonton, Canada
| | - Edward Masson
- Collaborative Orthopaedic Research (CORe), Department of Surgery, University of Alberta, Edmonton, Canada
| | - Barry A Finegan
- Department of Anesthesiology and Pain Medicine, University of Alberta, Edmonton, Canada
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Sanders E, Antin T, Hunt G, Young M. Is Smoking Queer? Implications of California Tobacco Denormalization Strategies for Queer Current and Former Smokers. DEVIANT BEHAVIOR 2019; 41:497-511. [PMID: 33311820 PMCID: PMC7731982 DOI: 10.1080/01639625.2019.1572095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Accepted: 08/09/2018] [Indexed: 06/12/2023]
Abstract
This article is concerned with normative conceptions of health structuring tobacco control strategies designed to "denormalize" tobacco use. Analysis of 201 interviews with non-heterosexual and/or non-cisgender adults in California revealed that participants implicated tobacco use in exacerbating health inequities and perpetuating harmful narratives of queer suffering, but also regarded smoking as a critical tool for self-care and symbol of resistance. Participant narratives suggest that using stigma in health promotion efforts which reinforce normative conceptions of health may be harmful to queer people whose social identities exist within ongoing legacies of pathology, health stigma, and deviance from hegemonic structural norms.
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Affiliation(s)
- Emile Sanders
- Critical Public Health Research Group Prevention Research Center Oakland, CA
- Center for Critical Public Health Institute for Scientific Analysis Alameda, CA
| | - Tamar Antin
- Critical Public Health Research Group Prevention Research Center Oakland, CA
- Center for Critical Public Health Institute for Scientific Analysis Alameda, CA
| | - Geoffrey Hunt
- Center for Critical Public Health Institute for Scientific Analysis Alameda, CA
- Centre for Alcohol and Drug Research Aarhus University Aarhus, Denmark
| | - Malisa Young
- Critical Public Health Research Group Prevention Research Center Oakland, CA
- Center for Critical Public Health Institute for Scientific Analysis Alameda, CA
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Jebet A, Kibet JK, Kinyanjui T, Nyamori VO. Environmental inhalants from tobacco burning: Tar and particulate emissions. SCIENTIFIC AFRICAN 2018. [DOI: 10.1016/j.sciaf.2018.e00004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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Yun L, Vanderloo L, Berry TR, Latimer-Cheung AE, O’Reilly N, Rhodes RE, Spence JC, Tremblay MS, Faulkner G. Assessing the social climate of physical (in)activity in Canada. BMC Public Health 2018; 18:1301. [PMID: 30482164 PMCID: PMC6258462 DOI: 10.1186/s12889-018-6166-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Accepted: 10/30/2018] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Ecological models suggest that a strategy for increasing physical activity participation within a population is to reconstruct the "social climate". This can be accomplished through 1) changing norms and beliefs, 2) providing direct support for modifying environments, and 3) implementing policies to encourage physical activity. Nevertheless, surveillance efforts have paid limited attention to empirical assessment of social climate. This study responds to this gap by assessing the social climate of physical activity in Canada. METHODS A representative sample of Canadian adults (n = 2519, male/female = 50.3%/49.7%, Mage = 49.1 ± 16.3 years) completed an online survey asking them to assess social climate dimensions including social norms of physical (in)activity, perceptions of who causes physical inactivity and who is responsible for solving physical inactivity, and support for physical activity-related policy. Descriptive statistics (frequencies) were calculated. Multinomial logistic regressions were constructed to identify whether demographic variables and physical activity participation associated with social climate dimensions. RESULTS Physical inactivity was considered a serious public health concern by 55% of the respondents; similar to unhealthy diets (58%) and tobacco use (57%). Thirty-nine percent of the respondents reported that they often see other people exercising. Twenty-eight percent of the sample believed that society disapproves of physical inactivity. The majority of respondents (63%) viewed the cause of physical inactivity as both an individual responsibility and other factors beyond an individuals' control. Sixty-seven percent of respondents reported physical inactivity as being both a private matter and a public health matter. Strong support existed for environmental-, individual-, and economic-level policies but much less for legislative approaches. The social climate indicators were associated with respondents' level of physical activity participation and demographic variables in expected directions. CONCLUSION This study is the first known attempt to assess social climate at a national level, addressing an important gap in knowledge related to advocating for, and implementing population-level physical activity interventions. Future tracking will be needed to identify any temporal (in)stability of these constructs over time and to explore the relationship between physical activity participation and indicators of the national social climate of physical activity.
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Affiliation(s)
- Lira Yun
- School of Kinesiology, University of British Columbia, Lower Mall Research Station 337, 2259 Lower Mall, Vancouver, British Columbia V6T 1Z4 Canada
| | | | - Tanya R. Berry
- Faculty of Kinesiology, Sport, and Recreation, University of Alberta, Edmonton, AB Canada
| | | | - Norman O’Reilly
- College of Business and Economics, University of Guelph, Guelph, ON Canada
| | - Ryan E. Rhodes
- School of Exercise Science, University of Victoria, Victoria, BC Canada
| | - John C. Spence
- Faculty of Kinesiology, Sport, and Recreation, University of Alberta, Edmonton, AB Canada
| | - Mark S. Tremblay
- Healthy Active Living and Obesity Research Group, Children’s Hospital of Eastern Ontario Research Institute, Ottawa, ON Canada
| | - Guy Faulkner
- School of Kinesiology, University of British Columbia, Lower Mall Research Station 337, 2259 Lower Mall, Vancouver, British Columbia V6T 1Z4 Canada
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