What public health strategies are needed to reduce smoking initiation?

Parent's awareness of, and influence on, their 14-17-year-old child's vaping and smoking behaviours; an analysis of 3242 parent-child pairs in Australia

BACKGROUND

Vaping by young people in Australia is a rapidly emerging public health issue. Evidence shows that parental behaviours and attitudes can play a key role in influencing adolescent behaviours. Considering the health harms of vaping and evidence that it can be a gateway to tobacco smoking for never-smokers, it is important to understand whether parents' smoking and vaping behaviours influence their teenage children's smoking and vaping behaviours.

METHODS

Online cross-sectional surveys as part of the Generation Vape study, conducted in Australia in 2021/2022, were used to assess parents' influence on, and awareness of, one of their 14-17-year-old child's vaping and smoking behaviours. Participants were 3242 parents and 3242 14-17-year-old teenage children.

RESULTS

The risk of vaping and smoking uptake among 14-17-year-old teenagers was 42% (p = 0.003) and 97% (p < 0.001) higher, respectively, if their parent was an ever-vaper. The risk of vaping and smoking uptake among teenagers was 81% (p < 0.001) and 159% (p < 0.001) higher, respectively, if their parent was an ever-smoker. Parents of teenagers who have not vaped were considerably better at correctly predicting this (97% correct) than parents of teenagers who have vaped (70% correct). Compared to parents, teenagers tended to have less agreement with statements suggesting vaping is unsafe or harmful, and more agreement with statements suggesting vaping is relatively safe.

CONCLUSIONS

Parental smoking and vaping behaviours are associated with those of their children. Hence, it is important that both tobacco and vaping control policies and interventions are designed to influence behaviours of all demographics, consistent with the evidence.

National and Provincial Prevalence of Cigarette Smoking in Iran; A Systematic Analysis of 12 Years of STEPS Experience

BACKGROUND

Smoking is a modifiable risk factor for six of the eight leading causes of death. Despite the great burden, there is lack of data regarding the trend of cigarette smoking in Iran. We described the national and provincial prevalence of cigarette smoking and its 12-year time trend utilizing six rounds of Iranian stepwise approach for surveillance of non-communicable disease (STEPS) surveys.

METHODS

We gathered data from six STEPS surveys done in 2005, 2007, 2008, 2009, 2011, and 2016 in Iran. To estimate the data of missing years, we used two separate statistical models including the mixed model and spatio-temporal analysis.

RESULTS

The overall prevalence rate of cigarette smoking was 14.65% (12.81‒16.59) in 2005 and 10.63% (9.00‒12.57) in 2016 in Iran. The prevalence of cigarette smoking in 2005 and 2016 was 25.15% (23.18‒27.11) and 19.95% (17.93%‒21.97%) for men and 4.13% (2.43‒6.05) and 1.31% (0.06-3.18) for women, respectively. The prevalence of smoking in different provinces of Iran ranged from 20.73% (19.09‒22.47) to 9.67% (8.24‒11.34) in 2005 and from 15.34% (13.68‒17.12) to 6.41% (5.31‒7.94) in 2016. The overall trend of smoking was downward, which was true for both sexes and all 31 provinces. The declining annual percent change (APC) of the prevalence trend was -2.87% in total population, -9.91% in women, and -2.08% in men from 2005 to 2016.

CONCLUSION

Although the prevalence of smoking had a decreasing trend in Iran, this trend showed disparities among sexes and provinces and this epidemiological data can be used to modify smoking prevention programs.

Community Pharmacies' Promotion of Smoking Cessation Support Services in Saudi Arabia: Examining Current Practice and Barriers

BACKGROUND

Community pharmacists' interventions have been found to be highly effective. However, to date, there has been little information about pharmacists' potential roles and perceived barriers to providing smoking cessation. This study aimed to assess the potential role of community pharmacists in supporting their patients to quit smoking by summarizing their self-reported level of current activities, confidence, and perceived barriers; Methods: A self-administered questionnaire was used for a cross-sectional study in Saudi Arabia. As part of the questionnaire, demographic characteristics were measured, as well as confidence, perceived berries, and level of smoking cessation activities (asking, advising, assessing, assisting, and arranging, including follow-up).; Results: 370 community pharmacists practicing responded to the survey. Pharmacists indicated high activity rates about advising and assessing patients in quitting smoking, with lower rates of assisting and arranging, including following up. The rate of recording smoking status was very low. There were significant differences between gender, source of education, years practicing as a licensed pharmacist, attended an education or training program on smoking cessation, and interest in providing smoking and perceived practice of smoking cessation. Pharmacists are confident about providing smoking cessation activities. Barriers to providing smoking cessation services include unable to follow up, lack of counseling space, lack of educational materials, and lack of time.; Conclusions: Saudi Arabian community pharmacists actively offer smoking cessation services, which may reduce smoking-related health issues. It appears that pharmacists need to be empowered by team-based, systematic, comprehensive approaches to overcome barriers and enhance their confidence.

Smoking Intensity Increases Diaphragm Muscle Injury: A Clinicopathologic Study

BACKGROUND

Studying the effects of smoking intensity is important to evaluate the risk of tobacco use on a range of illnesses, such as as sarcopenia among the elderly. Thus, this study aimed to analyze the effects of pack-years of cigarette smoking on the diaphragm muscle (DIAm) histopathology of postmortem samples.

METHODS

Subjects were divided into three groups: never-smoker (n = 46); less than 30 pack-years of smoking (n = 12); and more than 30 pack-years of smoking (n = 30). Diaphragm samples were stained with Picrosirius red and hematoxylin and eosin stain for general structure.

RESULTS

Participants with more than 30 pack-years of cigarette smoking had a significant increase in adipocytes, blood vessels and collagen deposit, as well as an increase in histopathological alterations.

CONCLUSIONS

Pack-years of smoking was associated with DIAm injury. However, further clinicopathological studies are needed to confirm our findings.

Response of legal and illegal cigarette prices to a tax increase in Ethiopia

BACKGROUND

In 2020, Ethiopia passed a landmark tax proclamation implementing an evidence-based mixed excise system aimed at curbing tobacco use. This study evaluates the impact of the tax increase of more than 600% on both legal and illegal cigarette prices in order to gauge the impact of the tax reform in the presence of a sizeable illicit cigarette market.

METHODS

Data on 1774 cigarette prices were obtained from retailers during Empty Cigarette Pack Surveys in the capital and major regional cities conducted in 2018 and 2022. Packs were categorised as 'legal' or 'illicit' using criteria from the tobacco control directives. Descriptive and regression analyses were used to study the cigarette price changes during the period of 2018-2022, capturing the impact of the 2020 tax increase.

RESULT

Prices of both legal and illegal cigarettes increased in response to the tax increase. In 2018, the stick prices ranged from ETB0.88 (Ethiopian birr) to ETB5.00 for legal cigarettes while they ranged from ETB0.75 to ETB3.25 for illegal ones. In 2022, a legal stick sold for ETB01.50-ETB2.73 and an illegal stick for ETB1.92-ETB8.00. The average real price of legal and illegal brands increased by 18% and 37%, respectively. The multivariate analysis confirms that prices of illicit cigarettes grew faster compared with the legal ones. By 2022, illicit brands were on average more expensive compared with their legal counterparts. This result is statistically significant at p<0.01.

CONCLUSION

The prices of both legal and illegal cigarettes increased following the 2020 tax increase, with the average real cigarette price increasing by 24%. As a result, the tax increase likely had a positive impact on public health despite a sizeable illicit cigarette market.

Cigarette smoking, opioid consumption, and pain intensity after major surgery: An observational study

BACKGROUND

Chronic exposure to nicotine may change pain perception and promote opioid intake. This study aimed to evaluate the putative effect of cigarette smoking on opioid requirements and pain intensity after surgery.

METHODS

Patients who underwent major surgery and received intravenous patient-controlled analgesia (IV-PCA) at a medical center between January 2020 and March 2022 were enrolled. Patients' preoperative smoking status was assessed using a questionnaire by certified nurse anesthetists. The primary outcome was postoperative opioid consumption within 3 days after surgery. The secondary outcome was the mean daily maximum pain score, assessed using a self-report 11-point numeric rating scale, and the number of IV-PCA infusion requests within three postoperative days. Multivariable linear regression models were used to calculate the regression coefficient (beta) and 95% confidence interval (CI) for the association between smoking status and outcomes of interest.

RESULTS

A total of 1162 consecutive patients were categorized into never smokers (n = 968), former smokers (n = 45), and current smokers (n = 149). Current smoking was significantly associated with greater postoperative opioid consumption (beta: 0.296; 95% CI, 0.068-0.523), higher pain scores (beta: 0.087; 95% CI, 0.009-0.166), and more infusion requests (beta: 0.391; 95% CI, 0.073-0.710) compared with never smokers. In a dose-dependent manner, smoking quantity (cigarette per day) was positively correlated with both intraoperative (Spearman's rho: 0.2207, p = 0.007) and postoperative opioid consumption (Spearman's rho: 0.1745, p = 0.033) among current smokers.

CONCLUSION

Current cigarette smokers experienced higher acute pain, had more IV-PCA infusion requests, and consumed more opioids after surgery. Multimodal analgesia with nonopioid analgesics and opioid-sparing techniques, along with smoking cessation should be considered for this population.

Prevalence of Use and Knowledge about Tobacco Products and Their Harmful Effects among University Students in Southern Croatia

Understanding students' attitudes toward smoking and tobacco products is essential for effective smoking prevention interventions. This questionnaire-based cross-sectional survey aims to determine the prevalence of use and knowledge about cigarettes, heated tobacco products, and electronic cigarettes and their harmful effects among university students. The survey was conducted using a self-administered online questionnaire among 1184 students. Questions were related to the respondents' demographic characteristics, tobacco use patterns, and opinions about exposure to health warnings and tobacco product advertising messages. Data were analyzed using descriptive statistics and generalized linear regression analysis. The results showed that 30.2% of the students use tobacco products (74.5% smoked conventional cigarettes; 7.9% used electronic cigarettes; and 17.6% used heated tobacco products). The median (interquartile range) score of the students' knowledge (maximum = 27) was 16 (12-22). The results showed that students from technical, social, humanities, natural, and biotechnology scientific programs had lower levels of knowledge about tobacco products and their harmful effects than biomedical students (p ≤ 0.001). In addition, past and current use of tobacco products was significantly associated with higher overall knowledge of tobacco products and their harmful effects (adjusted odds ratio (OR) 1.90, % confidence interval (CI) 1.09-3.31, p = 0.023; OR 1.41, CI 1.08-1.84, p = 0.011). The research findings confirm the lack of knowledge and misconceptions about the harmful effects associated with tobacco product use. They also emphasize the need for better prevention and awareness of the harmful effects of smoking on human health.

Educators' perceptions of e-cigarettes in Australian secondary schools

INTRODUCTION

Secondary schools are a setting in which e-cigarette use among students has increased significantly, resulting in an urgent need for educators to develop and implement strategies to curb youth vaping. Research assessing school-based vaping prevention efforts is limited and largely confined to the US. This study assessed Australian secondary school staff members' experiences with e-cigarettes and explored (i) the presence of e-cigarette policies and educational programs, (ii) barriers to policy development and implementation, and (iii) desired support.

METHODS

Public, Catholic, and Independent secondary schools across Australia were sent an invitation to participate in this study, which involved completion of an online survey. A total of 218 school staff members (55% women) participated. Respondents included school principals, teachers, and other staff members. Data collection occurred May to September 2022. Both quantitative and qualitative data were collected.

RESULTS

Nearly half (46%) of all school staff members surveyed reported finding a student with an e-cigarette on campus at least monthly, and one-third (36%) of principals reported suspending or expelling students at least monthly for e-cigarette possession or use. The vast majority of those surveyed agreed that e-cigarette use is increasingly becoming a problem in secondary schools (93%) and reported being concerned about e-cigarette use by students (94%). Only half (51%) reported that their school had an e-cigarette policy in place. The discreet appearance of e-cigarettes (83%) and difficulties pinpointing from where the vapor/scent is coming (73%) were the most frequently reported barriers to policy enforcement.

CONCLUSIONS

The results of this study suggest that e-cigarettes present a threat to secondary school environments. There is an urgent need to develop, implement, and enforce both school- and government-level e-cigarette policies to prevent and reduce youth vaping in Australian secondary schools.

Cigarette smoking during breastfeeding in Papua New Guinea: Prevalence and demographic and socio-economic predictors

BACKGROUND

Cigarette smoking during breastfeeding is reported to contribute to significant changes in the composition of breast milk not only by reducing its protective features but also affecting infants' response to breastfeeding and breast milk. However, studies on the prevalence of cigarette smoking and associated factors during breastfeeding are limited in Papua New Guinea (PNG). This study estimates the prevalence of cigarette smoking and its association with demographic and economic factors among breastfeeding women in PNG.

METHODS

We used weighted survey data from the 2016-2018 PNG Demographic and Health Survey (PNGDHS). A weighted sample of 3,822 women who were breastfeeding during the survey were included in the study. The outcome variable in the present study is current cigarette smoking. A multiple logistic regression analysis was used to estimate the association between current cigarette smoking status and socio-demographic and economic variables of breastfeeding women. The regression analysis results were reported using adjusted odds ratios (aOR) with their respective 95% confidence intervals (CIs).

RESULTS

From the weighted sample, the prevalence of cigarette smoking among breastfeeding women was 21.9%; of which 60.8% smoked daily. The mean number of cigarettes smoked in the last 24 hours preceding the survey was 6.05(SD = 5.99). Multiple logistic regression analysis revealed that breastfeeding women who were from the Momase (aOR: 2.337, CI: 1.786-3.058, p<0.001) and Highlands (AOR: 1.589, CI: 1.213-2.082, p = 0.001), had no religious affiliation (aOR: 3.665, CI: 1.235-10.877, p = 0.019), and households with daughters as household heads (aOR: 1.901, CI: 1.231-2.935, p = 0.004) and being in more than one union (aOR: 2.374, CI: 1.805-3.123, p<0.001) were significantly more likely to smoke cigarette compared to women from southern region, those affiliated to Anglican church, those with husband as household heads, and being in one union respectively.

CONCLUSION

Cigarette smoking among breastfeeding women in PNG is relatively high, and region of residence, religion, relationship to household head, and the number of unions remain independent predictors. Interventions should target the individual socio-economic and cultural contexts within which breastfeeding occurs.

Perceived Loneliness, Peer, and Parental Relationship With Smoking: A Cross-Sectional Analysis of Adolescents Across South-East Asia

Tobacco use among youth in the South-East Asian region is quite prevalent. This study aims to examine if psychosocial factors (perceived loneliness, peer, and parental relationships) were associated with adolescent smoking, and whether the effects were different according to sex and age. Data came from the Global School-based Student Health Surveys collected between 2012 and 2015 in Brunei, Cambodia, Indonesia, Laos, Malaysia, Philippines, Thailand, Timor-Leste, and Vietnam. 64 578 (males = 48.5%) adolescents aged 13-18 completed the survey. Prevalence of past-month cigarette use was 10.6%. Adolescent smoking was associated with loneliness (OR = 1.75), lack of close friends (OR = 1.43), and lack of parental understanding (OR = 1.35). There was significant interactions between sex with loneliness, close friends, and parental understanding (p < .001). Interactions indicated having no close friends is associated with smoking and is stronger for females than males. Conversely, loneliness was associated with smoking more strongly in males than females. Results indicate that psychosocial factors are linked to adolescent smoking in South-East Asia, suggesting a further need for research on the relation of psychosocial factors with smoking, and their underlying factors.

Health Literacy in Early Childhood: A Systematic Review of Empirical Studies

Early childhood plays a key role in the formation of healthy habits and the establishment of health literacy. Nonetheless, there are only a few research studies focusing on the health literacy level of children under the age of eight. The aim of our systematic review is to explore empirical research on health literacy related to early childhood. The research was conducted in accordance with the PRISMA protocol. This systematic review examines 12 studies published between 2013–2022. Results show that research focuses on different domains of health literacy for children. In relation to children’s food literacy, children understand the relationship between health and nutrition and they realize the health impact of obesity. The habits connected to oral health are strongly associated with parents’ knowledge of and behaviours around oral health. Results related to health care situations show that children are able to be actively involved in decision-making processes in connection with their health. Exploring young children’s health literacy is essential in order to be able to plan health promotion interventions, embedded into early childhood education. Picture-based messages or story-based messages supported by illustrations can help measure health literacy in early childhood and can support the formation of health literacy.

Social justice equity in healthy living medicine - An international perspective

Irrespective of geographical location, disadvantaged people are disproportionately affected by unnecessary disease and suffering caused by inequalities in health. Although equal access to opportunities for healthy living medicine regardless of legal, political, economic, or other circumstances should be a basic human right, it is increasingly improbable for scores of people, particularly in Africa, Asia, Latin America, and the Caribbean, to acquire this. In recent times, global initiatives have attempted to make 'healthy lifestyles' more equitable by pledging to be relevant to all economies, promoting prosperity, environmental protection, climate change interventions, and purposeful action to meet the needs of vulnerable populations, including women and children. Yet there remains much to be done to address and reduce the substantial international health equity gaps. Reducing disparities that disproportionately affect the lower end of social strata must entail collaborative and systemic action from important stakeholders across the whole system, an approach that translates theory and research into practice. Ideally, realist approaches that appreciate the importance of the context of problems and assume nothing works everywhere or for everyone, should be prioritised over linear/simple and non-scalable intervention strategies.

The Prevalence and Correlates of Gambling in Australian Secondary School Students

Youth gambling is associated with a range of harms. This study aimed to examine, among Australian adolescents, the prevalence of gambling (ever, in the last month, at-risk and problem), the most frequent gambling types and modalities, and to explore the student characteristics associated with gambling in the last month and with at-risk or problem gambling. Students aged 12–17 years from Victoria and Queensland answered gambling questions as part of the Australian Secondary School Alcohol and Drug (ASSAD) Survey in 2017. The ASSAD also included a series of questions about smoking, alcohol and other drug use, and mental health. A total of 6377 students from 93 schools were included in analysis. The prevalence of ever gambling and gambling in the last month was 31% and 6% respectively. Of students who had gambled in the last month, 34% were classified as at-risk and 15% were classified as problem gamblers. The most frequent types of gambling in the last month were horse or dog race and sports betting. Students who gambled in the last month did so most frequently via a parent or guardian purchasing or playing for them, at home or at a friends’ house, and online or using an app. Regression analysis indicated that male gender, having money available to spend on self, alcohol consumption in the last seven days, the number of types of advertisements seen in the last month, and the number of peer or family members who gambled in the last month, were significantly associated with the likelihood of students gambling in the last month. Male gender, some age categories, and exposure to more types of gambling advertising were also significant predictors of being classified as an at-risk or problem gambler. This large study of youth gambling provides data on gambling behaviours and related variables from a large sample of Australian secondary school students. Student characteristics, including male gender and exposure to more types of gambling advertising, were associated with an increased likelihood of gambling in the last month and of being classified as an at-risk or problem gambler. Further implications of the study findings are discussed.

Demographic perspectives on the rise of longevity

This article reviews some key strands of demographic research on past trends in human longevity and explores possible future trends in life expectancy at birth. Demographic data on age-specific mortality are used to estimate life expectancy, and validated data on exceptional life spans are used to study the maximum length of life. In the countries doing best each year, life expectancy started to increase around 1840 at a pace of almost 2.5 y per decade. This trend has continued until the present. Contrary to classical evolutionary theories of senescence and contrary to the predictions of many experts, the frontier of survival is advancing to higher ages. Furthermore, individual life spans are becoming more equal, reducing inequalities, with octogenarians and nonagenarians accounting for most deaths in countries with the highest life expectancy. If the current pace of progress in life expectancy continues, most children born this millennium will celebrate their 100th birthday. Considerable uncertainty, however, clouds forecasts: Life expectancy and maximum life span might increase very little if at all, or longevity might rise much faster than in the past. Substantial progress has been made over the past three decades in deepening understanding of how long humans have lived and how long they might live. The social, economic, health, cultural, and political consequences of further increases in longevity are so significant that the development of more powerful methods of forecasting is a priority.

Use of E-cigarettes and Other Tobacco Products and Progression to Daily Cigarette Smoking

OBJECTIVES

To identify predictors of becoming a daily cigarette smoker over the course of 4 years.

METHODS

We identified 12- to 24-year-olds at wave 1 of the US Population Assessment of Tobacco and Health Study and determined ever use, age at first use, and daily use through wave 4 for 12 tobacco products.

RESULTS

Sixty-two percent of 12- to 24-year-olds (95% confidence interval [CI]: 60.1% to 63.2%) tried tobacco, and 30.2% (95% CI: 28.7% to 31.6%) tried ≥5 tobacco products by wave 4. At wave 4, 12% were daily tobacco users, of whom 70% were daily cigarette smokers (95% CI: 67.4% to 73.0%); daily cigarette smoking was 20.8% in 25- to 28-year-olds (95% CI: 18.9% to 22.9%), whereas daily electronic cigarette (e-cigarette) vaping was 3.3% (95% CI: 2.4% to 4.4%). Compared with single product triers, the risk of progressing to daily cigarette smoking was 15 percentage points higher (adjusted risk difference [aRD] 15%; 95% CI: 12% to 18%) among those who tried ≥5 products. In particular, e-cigarette use increased the risk of later daily cigarette smoking by threefold (3% vs 10%; aRD 7%; 95% CI: 6% to 9%). Daily smoking was 6 percentage points lower (aRD -6%; 95% CI: -8% to -4%) for those who experimented after age 18 years.

CONCLUSIONS

Trying e-cigarettes and multiple other tobacco products before age 18 years is strongly associated with later daily cigarette smoking. The recent large increase in e-cigarette use will likely reverse the decline in cigarette smoking among US young adults.

Age at the onset of tobacco smoking in South Africa: a discrete-time survival analysis of the prognostic factors

Background

While knowledge of onset of smoking tobacco, and associated risk factors can aid the formulation of evidence-based policy and interventions, such information is scarce in South Africa. We assessed age at onset of tobacco smoking in South Africa and identified its risk factors.

Methods

We analysed data of 15,316 respondents aged 15–98 years from the 2012 South African National Health and Nutrition Examination Survey. Descriptive statistics and survival analysis techniques were used alongside weighted percentages.

Results

Overall lifetime prevalence of smoking was 20.5%. Among the 3360 ever-smoked respondents, the overall median age at smoking onset was 18 years (Inter-quartile range (IQR) =5) with 2% starting before age 10 while 60% had smoked before age 20. Likelihood of tobacco smoking was higher among adolescents (<=20 years) and those aged 20–29 years than those aged > = 60 years, thrice higher among males, 29% higher among urban dwellers and thrice higher in Western Cape and Free State than in North West Province. The onset of tobacco smoking was earlier among males, wealthier and “coloured” people from Northern and Eastern Capes.

Conclusion

The onset of tobacco smoking peaked at 15–22 years and varied by province, sex, location, race and other characteristics. The age restrictions on smoking in South Africa has changed over time, coupled with the recent open and electronic advertisement of tobacco, and social media could have influenced the earlier onset of tobacco smoking in South Africa. Stricter regulations on tobacco-related advertisement and sales should be implemented.

Longitudinal transitions of cigarettes and electronic nicotine delivery systems among adolescents: Construction of a retrospective cohort using recall data from a cross-sectional sample

INTRODUCTION

A major concern regarding non-cigarette tobacco or nicotine products (NCTNPs) is whether they facilitate or mitigate overall tobacco or nicotine use. We examined longitudinal transitions of cigarettes and electronic nicotine delivery systems (ENDS) by constructing a retrospective cohort based on the recall data of a cross-sectional sample.

METHODS

Using the Korea Youth Risk Behavior Survey, we constructed crosssectional data of 59576 adolescents into retrospective cohort data. Participants were categorized into 4 mutually exclusive tobacco or nicotine use states. We used a multistate Markov model to identify transitions between the states to calculate transition intensity ratios (TIRs), and examined the current use of tobacco or nicotine products to assess both gateway effects to cigarettes, and whether ENDS use helps adolescents quit cigarette smoking.

RESULTS

Compared with never use, use of ENDS was associated with an increased risk of initiation of cigarette use (TIR=6.8; 95% CI: 4.5-10.2). The risk of transitioning from cigarette ever use to ENDS, compared with never use to ENDS, was even more pronounced (TIR=44.1; 95% CI: 34.1-56.9). The prevalence of current cigarette smoking was higher among those who started ENDS then cigarettes, compared to those who began cigarette use without experimenting with ENDS (43.1% vs 35.8%). Moreover, 27.8% (95% CI: 23.6-32.0%) of adolescents who experimented first with cigarettes then moved to ENDS were current users of cigarettes, and 46.4% (95% CI: 42.1-51.1%) of these adolescents were current users of both cigarettes and ENDS.

CONCLUSIONS

Based on the recall data of a cross-sectional sample, we demonstrate that ENDS experimentation increases the likelihood of cigarette smoking initiation. A significant proportion of these adolescents continue to use cigarettes. Moreover, those who experimented with cigarettes then ENDS also continue smoking cigarettes or both cigarettes and ENDS. We suggest comprehensive tobacco control policies for all tobacco/nicotine products and monitoring the timing of NCTNP initiation in cross-sectional surveys.

Contributors to the black-white life expectancy gap in Washington D.C

Although the black-white gap in life expectancy has been shrinking in the U.S., national improvement conceals ongoing disparities. Nowhere is this more evident than Washington D.C., where the black-white gap has persistently exceeded 10 years. Using 1999-2017 mortality data from the National Center for Health Statistics, we employed demographic techniques to pursue three aims: first, we created period life tables to examine longevity trends in Washington D.C.; second, we decomposed black-white life expectancy differences into 23 causes of death in three time periods (2000, 2008, 2016); third, we assessed age-specific contributions for each cause of death. Findings revealed that heart disease (4.14 years), homicide (2.43 years), and cancer (2.30 years) contributed most to the 17.23-year gap among males in 2016. Heart disease and cancer contributed most at ages 55-69; homicide contributed most at ages 20-29. Among females in 2016, heart disease (3.24 years), cancer (2.36 years), and unintentional injuries (0.85 years) contributed most to the 12.06-year gap. Heart disease and cancer contributed most at ages 55-69, and unintentional injuries at ages 50-59. Our investigation provides detailed evidence about contributors to the black-white longevity gap in Washington D.C., which can aid in the development of targeted public health interventions.

Quality and quantity of price elasticity of cigarette in Iran

OBJECTIVE

Effectiveness of tax policies to control cigarette consumption largely depends on the sensitivity of cigarette demand due to price change. Price elasticity is the measurement of this responsiveness. The main objective of this study is to measure quantity, and quality price elasticity of demand (PED) and cross-price elasticity of demand (XED) for Iranian and non-Iranian cigarette brands in Iran.

METHODS

This study used data from the 2017 Iranian household income and expenditures survey conducted in all 31 provinces of Iran. A total of 39,864 households were included in the survey. PED of quantity and quality and XED were estimated using restricted, unrestricted and quintile regression models.

RESULTS

Our results s show that the Iranian and non-Iranians brands cigarettes were price inelastic and elastic, respectively. XED between Iranian and non-Iranian brands was positive suggesting households' preference for Iranian brands of cigarettes over non-Iranian brands. Quintile regression results suggest that PED varied between -1.20 and -0.91 across the distribution of quantity demanded.

CONCLUSION

Imposing tax could be a useful policy tool to control smoking initiation and intensity in Iran. However, the effectiveness of such policy would depend on the better governance of taxation imposed on different brands of cigarettes.

Individual and social predictors of smoking and obesity: A panel study in Germany

This is a longitudinal study of changes in smoking behaviour as well as becoming overweight/obese (OW/OB) and the strength of their association with personal factors such as self-control, mental health, and socioeconomic status (SES) versus their connection with the behaviour of other household members. Furthermore, we investigate that in terms of roles within a household, who is more vulnerable towards the behaviour of others. We used a hybrid model that followed individual adults (person-level fixed-effect) who participated in a national representative panel survey in Germany, SOEP, between 2008 and 2016 and answered all SF-12 items (N = 6874). The count of members in a household showing the associated adverse health behaviour was the nested random-effect. Compared with other predictors, the likelihood of a person becoming OW/OB had the strongest association with the number of cohabits who were also OW/OB and it became worse as this number increased (OR 7.18, 95% CI: 2.10-24.54 and 12.44, 95% CI: 1.53-100.85, for men and women respectively, e.g. compared with being married 2.83, 95% CI: 2.28-3.53 and 1.82, 95% CI: 1.42-2.34). However, for smoking the same rapid trend was not observed. Particularly, becoming OW/OB in female (adult) children was strongly associated with the behaviour of others (compared with household head or partner). For smoking the strongest link with others was among women who were head of the household. For both behaviours, we found neither mental health nor self-control to be strong predictors. Our findings indicate that various factors do not play equal roles in changes in health behaviour and particularly for women, becoming OW/OB is strongly connected with the behaviour of others. We further discuss the potential importance of social norms that might be helpful in developing more effective policies incorporating social connections as well as norms.

The influence and interaction of exposure to pro-smoking and anti-smoking messaging on youth smoking behaviour and susceptibility

INTRODUCTION

Exposure to tobacco-related information is an important factor in youth smoking initiation. This study aims to explore the relationship between exposure to pro-smoking and anti-smoking media and adolescents’ current smoking status and susceptibility to smoking, as well as the interaction between exposure to pro-smoking and anti-smoking media information.

METHODS

This cross-sectional study was conducted in 2017. We recruited 12278 students from junior, senior and vocational high schools located in Shanghai, China. The exposure of participants to tobacco promotional and control messages over the past 30 days was examined, as well as current smoking and susceptibility to never smokers’ initiation. Odds ratios (ORs) and 95% confidence intervals (CIs) were estimated using complex samples procedure logistic regression, adjusting for related covariables.

RESULTS

There were 89.3% and 91.5% of adolescents exposed to tobacco pro-smoking and anti-smoking messages. Exposure was more prevalent among males, suburb school and vocational school students. Exposure to pro-tobacco and antitobacco messages, separately, increased and decreased the risk of current smoking and susceptibility to never-smokers’ smoking, respectively, especially among males and junior high school students. Risk was associated with the exposure level (p-trend<0.001). Tobacco control messaging was found to mitigate the influences of tobacco promotion on the risk of both current smoking (AOR=0.64; 95% CI: 0.41–0.99) and susceptibility to smoking (AOR=0.65; 95% CI: 0.46–0.93).

CONCLUSIONS

Exposure to tobacco-related messages was highly prevalent and associated with youth smoking and susceptibility to smoking. It is therefore important to enhance the comprehensiveness and enforcement of promotion bans. Given that tobacco control information can counter the impact of tobacco promotion information on smoking risk, the publicity and dissemination of tobacco control information should be consistently strengthened.

Consumption function and price elasticity of tobacco demand in Nigeria

INTRODUCTION

Tobacco consumption remains a major threat to population and public health globally. In response, an increase in the taxes levied on tobacco products has been found to be an effective intervention for controlling their use. In Nigeria, studies assessing the impact of excise taxes on tobacco use are less advanced. As such, this study evaluated the consumption function and price elasticity of tobacco demand in Nigeria.

METHODS

This study used cross-section data from the Harmonized Nigerian Living Standard Survey (HNLSS, 2009-2010). Quadratic Almost Demand System (QUAIDS) of tobacco budget share and unit value equations were specified. Within and between cluster variation in prices and quantities demanded were used to determine the price elasticity of tobacco demand.

RESULTS

Household size, food price index, level of education/literacy of household head and income were significant determinants of tobacco consumption. Also, rural and urban price elasticities of tobacco demand were -0.63 and -0.49 while the national price elasticity of tobacco demand was -0.62.

CONCLUSIONS

The results of this study show that for every 5% increase in the price of tobacco, there will be a corresponding reduction of about 3% in the quantity of tobacco demanded in the national and rural samples. While the same increase in the price of tobacco products will generate about 2% reduction in quantity of tobacco consumed in urban settings in Nigeria. This finding is consistent with earlier studies in low-and-middle income countries.

Global, regional and national burden of rheumatoid arthritis 1990-2017: a systematic analysis of the Global Burden of Disease study 2017

OBJECTIVES

To provide the level and trends of prevalence, incidence and disability adjusted life years (DALYs) for rheumatoid arthritis (RA) in 195 countries from 1990 to 2017 by age, sex, Socio-demographic Index (SDI; a composite of sociodemographic factors) and Healthcare Access and Quality (an indicator of health system performance) Index.

METHODS

Data from the Global Burden of Diseases, Injuries, and Risk Factors study (GBD) 2017 were used. GBD 2017 modelled the burden of RA for 195 countries from 1990 to 2017, through a systematic analysis of mortality and morbidity data to estimate prevalence, incidence and DALYs. All estimates were presented as counts and age-standardised rates per 100 000 population, with uncertainty intervals (UIs).

RESULTS

Globally, the age-standardised point prevalence and annual incidence rates of RA were 246.6 (95% UI 222.4 to 270.8) and 14.9 (95% UI 13.3 to 16.4) in 2017, which increased by 7.4% (95% UI 5.3 to 9.4) and 8.2% (95% UI 5.9 to 10.5) from 1990, respectively. However, the age-standardised rate of RA DALYs per 100 000 population was 43.3 (95% UI 33.0 to 54.5) in 2017, which was a 3.6% (95% UI -9.7 to 0.3) decrease from the 1990 rate. The age-standardised prevalence and DALY rates increased with age and were higher in females; the rates peaked at 70-74 and 75-79 age groups for females and males, respectively. A non-linear association was found between age-standardised DALY rate and SDI. The global age-standardised DALY rate decreased from 1990 to 2012 but then increased and reached higher than expected levels in the following 5 years to 2017. The UK had the highest age-standardised prevalence rate (471.8 (95% UI 428.9 to 514.9)) and age-standardised incidence rate (27.5 (95% UI 24.7 to 30.0)) in 2017. Canada, Paraguay and Guatemala showed the largest increases in age-standardised prevalence rates (54.7% (95% UI 49.2 to 59.7), 41.8% (95% UI 35.0 to 48.6) and 37.0% (95% UI 30.9 to 43.9), respectively) and age-standardised incidence rates (48.2% (95% UI 41.5 to 55.1), 43.6% (95% UI 36.6 to 50.7) and 36.8% (95% UI 30.4 to 44.3), respectively) between 1990 and 2017.

CONCLUSIONS

RA is a major global public health challenge. The age-standardised prevalence and incidence rates are increasing, especially in countries such as Canada, Paraguay and Guatemala. Early identification and treatment of RA is vital especially among females, in order to reduce the ongoing burden of this condition. The quality of health data needs to be improved for better monitoring of disease burden.

Prevalence and correlates of smoking and nicotine dependence: results of a nationwide cross-sectional survey among Singapore residents

BACKGROUND

Since the Singapore Mental Health Study in 2010 which reported a 16.0% prevalence rate for current smokers and 4.5% for nicotine dependence, new anti-smoking strategies have been implemented. The aim of this study was to compare smoking trends from the 2010 study with the second Singapore Mental Health Study in 2016 (SMHS 2016).

METHODS

A survey of 6126 individuals aged 18 years and above randomly selected among Singapore residents was conducted using the same methodology as the 2010 study. The measures used in this analysis were sociodemographic questions, the Composite International Diagnostic Interview which assessed for psychiatric disorders, the Fagerstrom Test for Nicotine Dependence and a list of chronic physical conditions that were prevalent in Singapore. Logistic regression analyses were used to test for associations between smoking/nicotine-dependence and other measures.

RESULTS

In the SMHS 2016, 16.1% were current smokers and 3.3% were nicotine-dependent. As compared with non-smokers, current smokers were more likely to be younger, male gender, of ethnic minority and had lower/vocational education level. Younger age, male gender, lower/vocational education and psychiatric disorders (major depression, bipolar disorder and alcohol use disorders) predicted nicotine dependence. No associations were found between nicotine dependence and any of the chronic conditions.

CONCLUSION

The prevalence of current smokers in the population has plateaued while that of nicotine dependence has decreased from 2010. However, the study did not investigate the use of e-cigarettes. Inequalities in smoking and nicotine dependence continue to pervade the population particularly among those of ethnic minority, lower/vocational education and the mentally ill.

Results of outdoor smoking bans at secondary schools on adolescents smoking behaviour: a quasi-experimental study

BACKGROUND

Research on the effectiveness of school smoking policies on adolescents' smoking behaviour remain inconclusive. This study evaluates the results of an outdoor school ground smoking ban at secondary schools on adolescents smoking behaviour, taking individual characteristics into account.

METHODS

Data on 2684 adolescents from 18 Dutch secondary schools (nine with and nine without an outdoor smoking ban) were obtained at two moments. Associations between outdoor school ground smoking bans, individual characteristics, and smoking prevalence and frequency were measured. Multilevel logistic regression analyses were used. At schools with a ban implementation fidelity was checked.

RESULTS

Although smoking prevalence and frequency appeared to make a slower increase at schools with an outdoor smoking ban compared with schools without an outdoor smoking ban, the differences were not significant. Differences between schools in the prevalence of smoking behaviour of students could mainly be explained by individual characteristics. Smoking prevalence and frequency were higher among adolescents with a positive attitude towards smoking and when significant others were more positive about smoking. Smoking prevalence and frequency were significantly lower when adolescents perceived it as easy not to smoke. Implementation fidelity was good at schools with a ban.

CONCLUSIONS

No short-term effects were found of an outdoor smoking ban. A longer follow-up time than 6 months is needed. In addition, future research should investigate effectiveness in relation to the enforcement of the ban, comprehensiveness of the ban and when it is prohibited to leave school grounds, as smoking behavior might be transferred off school grounds.

Smoking prevalence and attributable deaths in Thailand: predicting outcomes of different tobacco control interventions

Background

Despite substantial positive impacts of Thailand’s tobacco control policies on reducing the prevalence of smoking, current trends suggest that further reductions are needed to ensure that WHO’s 2025 voluntary global target of a 30% relative reduction in tobacco use is met. In order to confirm this hypothesis, we aim to estimate the effect of tobacco control policies in Thailand on the prevalence of smoking and attributed deaths and assess the possibilities of achieving WHO’s 2025 global target. This paper addresses this knowledge gap which will contribute to policy control measures on tobacco control. Results of this study can help guide policy makers in implementing further interventions to reduce the prevalence of smoking in Thailand.

Method

A Markov chain model was developed to examine the effect of tobacco control policies, such as accessibility restrictions for youths, increased tobacco taxes and promotion of smoking cessation programs, from 2015 to 2025. Outcomes included smoking prevalence and the number of smoking-attributable deaths. Due to the very low prevalence of female smokers in 2014, this study applied the model to estimate the smoking prevalence and attributable mortality among males only.

Results

Given that the baseline prevalence of smoking in 2010 was 41.7% in males, the target of a 30% relative reduction requires that the prevalence be reduced to 29.2% by 2025. Under a baseline scenario where smoking initiation and cessation rates among males are attained by 2015, smoking prevalence rates will reduce to 37.8% in 2025. The combined tobacco control policies would further reduce the prevalence to 33.7% in 2025 and 89,600 deaths would be averted.

Conclusion

Current tobacco control policies will substantially reduce the smoking prevalence and smoking-attributable deaths. The combined interventions can reduce the smoking prevalence by 19% relative to the 2010 level. These projected reductions are insufficient to achieve the committed target of a 30% relative reduction in smoking by 2025. Increased efforts to control tobacco use will be essential for reducing the burden of non-communicable diseases in Thailand.

Secondhand smoke exposure during pregnancy: a cross-sectional analysis of data from Demographic and Health Survey from 30 low-income and middle-income countries

BACKGROUND

Secondhand smoke (SHS) exposure during pregnancy increases the risk of infant stillbirth, congenital malformations, low birth weight and respiratory illnesses. However, little is known about the extent of SHS exposure during pregnancy. We assessed the prevalence of SHS exposure in pregnant women in low-income and middle-income countries (LMICs).

METHODS

We used Demographic and Health Survey data collected between 2008 and 2013 from 30 LMICs. We estimated weighted country-specific prevalence of SHS exposure among 37 427 pregnant women. We accounted for sampling weights, clustering and stratification in the sampling methods. We also explored associations between sociodemographic variables and SHS exposure in pregnant women using pairwise multinomial regression model.

FINDINGS

The prevalence of daily SHS exposure during pregnancy ranged from 6% (95% CI 5% to 7%) (Nigeria) to 73% (95% CI 62% to 81%) (Armenia) and was greater than active tobacco use in pregnancy across all countries studied. Being wealthier, maternal employment, higher education and urban households were associated with lower SHS exposure in full regression models. SHS exposure in pregnant women closely mirrors WHO Global Adult Tobacco Survey male active smoking patterns. Daily SHS exposure accounted for a greater population attributable fraction of stillbirths than active smoking, ranging from 1% of stillbirths (Nigeria) to 14% (Indonesia).

INTERPRETATION

We have demonstrated that SHS exposure during pregnancy is far more common than active smoking in LMICs, accounting for more stillbirths than active smoking. Protecting pregnant women from SHS exposure should be a key strategy to improve maternal and child health.

Progress of smoke-free policy adoption at district level in Indonesia: A policy diffusion study

BACKGROUND

Even though Indonesia has not ratified the Framework Convention on Tobacco Control (FCTC), district and provincial stakeholders are increasingly adopting smoke-free policies (SFPs). This study aimed to 1) assess whether local SFP adoption in Indonesia followed a horizontal or vertical diffusion pattern and 2) identify district characteristics that are associated with the SFP adoption.

METHODS

Policy documents enacted during 2004-2015 were compiled from 33 provinces and 510 districts in Indonesia. First, we described the geographical distributions of the policy adoption. Second, we ran logistic regression to assess the associations of district SFP adoption with having adjacent districts that had adopted SFPs (i.e. horizontal diffusion) and being situated in a province that had adopted SFPs (i.e. vertical diffusion). Third, the associations between district characteristics (population density, GDP, tobacco production) and SFP adoption were assessed using logistic regression.

RESULTS

By 2015, a total of 17 provinces and 143 districts had adopted SFPs. Districts with SFPs were more concentrated in the western part of Indonesia. Adoption was more likely in districts of which adjacent districts had already adopted SFPs (OR: 2.02; 95%CI: 1.26-3.23), and less likely when the province had already adopted SFPs (OR: 0.19; 95%CI: 0.11 - 0.34). Adoption was more likely in districts with higher GDP (OR high vs low GDP: 3.28; 95%CI: 1.80-5.98) and higher population density (OR high vs low density: 6.57; 95%CI: 3.63-11.9). High tobacco production showed a strong inverse association with SPF adoption (OR high vs. no production: 0.36; 95%CI: 0.17-0.74).

CONCLUSIONS

Smoke-free policy adoption in Indonesian districts followed a horizontal diffusion pattern, with poorer and rural districts lagging behind in their policy adoption. Our results indicate that local-level policy development is important for smoke-free policy adoption in countries with decentralised governments, but that effective advocacy is needed to counteract tobacco industry interference.

Age of initiation of cigarette smoking and smokeless tobacco use among western Alaska Native people: Secondary analysis of the WATCH study

Objective

This study examined self-reported age of tobacco initiation (cigarette smoking and smokeless tobacco [ST] use) and explored potential sex and generational group influences on tobacco use onset among Alaska Native (AN) adult ever tobacco users.

Methods

Secondary analysis of consolidated data from the Western Alaska Tribal Collaborative for Health (WATCH) study comprised 2800 AN adult ever tobacco users (1490 women, 1310 men; mean age = 39.2 years) from two rural western Alaska regions. ST use data were limited to one region. Logistic regression was used to examine potential sex and generational group (age 18–29, 30–49, ≥50) effects on initiation at ≤13 years of age.

Results

Thirty-seven percent of the sample reported using any tobacco product by age 13 years. Initiation of any ST use by age 13 was greater than for cigarette smoking (52.7% vs. 18.2%), and women were more likely than men to report initiation of any ST use at ≤13 years (52.6% vs. 38.4%). Nearly one-third of ever smokers (31%) initiated in young adulthood (ages 18–29). For ST use, logistic regression analyses revealed significant sex differences (women more likely to initiate by 13 years of age than men) and generational group effects with younger and middle age groups more likely to report initiation ≤13 years compared to the eldest participants. For smoking, no sex differences were observed but the youngest generational group was more likely to report initiation by age 13 compared to the eldest group.

Conclusions

Earlier age of tobacco initiation is found among younger generations of AN people. Findings highlight the need to focus prevention efforts on initiation of smoking in young adulthood and uptake of ST use among girls.

•

Younger Alaska Native (AN) adults reported earlier tobacco initiation than older adults.

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Women reported earlier age of smokeless tobacco (ST) initiation than men.

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Almost one third of ever smokers (29%) had initiated in young adulthood (age 18–29).

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Prevention efforts are needed for ST use in AN girls and smoking in young adults.

Adolescent Smoking in Hong Kong: Prevalence, Psychosocial Correlates, and Prevention

Preventing adolescent smoking is important as smoking is typically initiated by young people. This article reviews the prevalence, psychosocial correlates, and prevention of smoking in Hong Kong adolescents. The past 30-day smoking prevalence in adolescents decreased from 9.6% in 2003 to 2.5% in 2017. Tobacco advertisements, parental and best friends smoking, nonintact families, poor family relationships, lower socioeconomic status, being a new immigrant, poor knowledge of smoking-related harm, positive attitudes toward smoking, overestimation of peer smoking, and depressive symptoms were positively associated with smoking outcomes, whereas positive youth development, authoritative mother and permissive father, family functioning, school competence, and stronger tobacco industry denormalization beliefs were protective against smoking. Along with tobacco tax increase, ban on tobacco advertisements, smoke-free law and pictorial warnings, educational efforts through theater performances, social norms campaigns, and positive adolescent training programs have been conducted to prevent adolescent smoking. To achieve the ultimate goal of tobacco endgame, further tax increase, plain packaging, banning point-of-sale display of tobacco products, smoke-free area extension, and raising minimum age of purchase should be implemented. The government proposed law to ban e-cigarettes, and heated tobacco products should be passed soon to protect children and adolescents from using these products.

Is adolescent e-cigarette use associated with smoking in the United Kingdom?: A systematic review with meta-analysis

INTRODUCTION

Though smoking is a public health problem the use of e-cigarettes has been associated with a reduction in smoking in developed countries. However, public health experts have raised concerns about the association of e-cigarette use with an increase in traditional cigarette smoking in adolescents. Review-level evidence is generally supportive of this concern, but as it is mainly based on studies from the USA we investigated if e-cigarette use is associated with traditional cigarette smoking in adolescents (aged 10–19 years) in the UK.

METHODS

We conducted a systematic review of empirical studies. Databases (PubMed, Medline via ProQuest, CINAHL and SCOPUS) were searched between January 2005 and May 2018 using search terms based on the concepts: adolescents, traditional cigarette smoking, e-cigarettes, and UK. Using pre-defined inclusion and exclusion criteria, a total of eight studies (involving 73076 adolescents) were included in this review. Three of the included studies were eligible to be combined in a meta-analysis. The CASP appraisal tool was used to assess study quality while risk of bias was assessed using ROBINS-I.

RESULTS

Studies included in the meta-analysis showed that adolescents who use e-cigarettes are up to six times more likely to smoke traditional cigarettes. Furthermore, results showed that traditional cigarette smoking can also precede e-cigarette use in adolescents and there was increased likelihood of an increase in initial product use (e-cigarette or traditional cigarette) when the alternate product was initiated.

CONCLUSIONS

Public health policy makers in the UK still need clear conclusions about the effects and safety of e-cigarettes.

Assessing the strength of secondary school tobacco policies of schools in the COMPASS study and the association to student smoking behaviours

OBJECTIVES

The school environment is an ideal setting to introduce policies to prevent smoking behaviour. However, there may be variability in the strength of school board and secondary school tobacco policies, which may affect student smoking behaviours. This study assessed the strength of a sample of school board and secondary school tobacco policies and examined the association with student smoking behaviours.

METHODS

Tobacco policies from school boards (n = 21/26) and secondary schools (n = 43/81) that participated in the COMPASS study during 2015-2016 were obtained online. A standardized instrument was used to assess the strength of school board and secondary school tobacco policies on four domains. Using the sample of students from schools with identified policies (n = 22,696), separate multilevel regression models examined the association between school policy scores and a student's susceptibility to smoking, ever smoking, current smoking, and perceived support of the school environment.

RESULTS

The mean school board tobacco policy score was 13.7/40 and the mean secondary school tobacco policy score was 11.3/40. Students were significantly less likely to report current smoking (OR 0.95, 95% CI 0.91-0.99) and more likely to report a supportive school environment (OR 1.06, 95% CI 1.04-1.08) with each four-unit (i.e., 10%) increase in school tobacco policy score.

CONCLUSIONS

The vast majority of school board and secondary school tobacco policies were missing components and therefore could not be considered comprehensive. Stronger school tobacco policies may help to reduce student current smoking behaviours.

The ecology of multilevel intervention research

Behavior change research to promote health and prevent disease increasingly relies on a complex set of interacting characteristics across levels of influence such as biological, psychological, behavioral, interpersonal, and environmental. How to best develop health-related interventions that incorporate the individual, the macro-environment, and their interactions remains a challenge. This article considers a set of key dimensions that constitute what we refer to as the ecology of research across a broad context of multilevel research (MLR), spanning fundamental multilevel research (FMLR), multilevel intervention research (MLIR), and multilevel implementation science (MIS). With the goal of promoting improvements in MLIR, we describe the inherent interdependencies among aspects of research and consider how the growth and development of evidence and resources influence the cross-talk among researchers from different perspectives (e.g., disciplines and domains). We propose a framework that highlights opportunities to reduce barriers and address gaps in areas critical to generating an evidence base through MLR, MLIR, and MIS. Overall, we aim to support strategic decisions that can accelerate our understanding of ML health outcomes and interactions among factors within and across levels, with the goal of strengthening the effectiveness of ML interventions across health-related outcomes.

The price of tobacco and its effects on smoking behaviors in Korea: The 2015 Korea Community Health Survey

This study investigated the effects of the price of tobacco on smoking behaviors in Korean adult smokers using a population-based survey. Current smokers or former smokers who quit smoking <1 year prior to the survey were selected from the data of 2015 Korea Community Health Survey (N = 45,686). The effects of the price of tobacco on smoking behaviors were measured. The major effects were defined as quitting, reducing smoking and using electronic cigarettes (e-cigarettes). Chi-square tests and multiple logistic regression analyses were performed. After tobacco prices increased, 3.8%, 22.8% and 5.4% of subjects quit, reduced smoking and switched to e-cigarettes. The adjusted odds ratio (aOR) for reducing smoking was significantly higher in subjects with a lower household income and lower education level than in those with a greater income and higher education level among current smokers. Subjects who started smoking at an older age, who smoked a smaller number of cigarettes smoked per day and who had been exposed to anti-smoking campaigns and anti-smoking information were more likely to reduce smoking after the price of tobacco increased. Younger subjects were less likely to reduce smoking, but they were more likely to use e-cigarettes after the price of tobacco increased. Low-income subjects were sensitive to increases in the price of tobacco. Additional strategies are required to change the smoking behaviors of heavy smokers. Future studies should investigate the long-term effects of increasing the price of tobacco, especially on younger adults, on smoking behaviors.

Association of secondhand smoke and depressive symptoms in nonsmoking pregnant Women: A systematic review and meta-analysis

BACKGROUND

Globally about 30% of adult women and 40% of children are exposed to secondhand smoke (SHS) from active smokers. SHS exposure of pregnant women has been associated with postpartum depression. Unexposed women in pregnancy had lower rates of postpartum depression than women exposed to SHS. This systematic review aimed to determine the association of depressive symptoms and exposure to SHS in nonsmoking pregnant women.

METHOD

The case-controlled, cross-sectional, and cohort studies with a comparison group were included. Studies including women who had smoking history during pregnancy were excluded. The comprehensive electronic databases, CINAHL, EMBASE, and Medline were searched.

RESULT

Of the 2777 records screened, seven studies were included in the review for data extraction. The bias of studies was assessed using the RoBANS. We synthesized two studies that showed depressive symptoms at any time during pregnancy and postpartum significantly increased (ORs = 1.77 [95% CI = 1.12 - 2.79]; p = 0.01; I²= 28%, 4103 women, two studies), and significantly increased the odds of antenatal suicidal ideation in SHS exposed women (ORs = 1.75 [95% CI = 1.14 - 2.70]; p = 0.01; I²= 51%, 2670 women, two studies). Lack of studies from counties with the highest smoking rates was a limitation.

CONCLUSIONS

SHS exposure during pregnancy showed a significant increase in the odds of depressive symptoms. Furthermore, research is required to clarify to association between SHS and depression.

Prevalence and perception of cigarette smoking among out of school adolescents in Birnin Kebbi, North-western Nigeria

Introduction

cigarette smoking is on the increase among adolescents' especially in developing countries and is a leading cause of premature morbidity and mortality worldwide. Adolescents incorrectly perceive that cigarette smoking is less risky than other behaviors such as alcohol consumption and drug use. This study assessed the prevalence and perception of out of school adolescents on cigarette smoking in Birnin kebbi metropolis of Kebbi state.

Methods

This is a cross-sectional mixed methods study. For quantitative data, respondents were selected using two-staged sampling technique. Semi structured interviewer-administered questionnaire was used. Univariate and bivariate analysis was done as appropriate using Epi-info software. Focus Group Discussion guide was used for qualitative data collection. Narrative synthesis was used for qualitative data analysis.

Results

The proportion of respondents who had ever smoked cigarettes was 32.2% while 20.8% currently smoke. Most of the respondents (84.1%) perceived that cigarette smoking was harmful and that passive smoking was dangerous to their health (70.8%). Smokers had a significantly lower risk perception about smoking compared to non-smokers (p < 0.005).

Conclusion

The prevalence of cigarette smoking among out of school adolescents is high with smokers having lower risk perception compared to non-smokers. There is an urgent need to create awareness about the specific dangers associated with cigarette smoking, the transient nature of its perceived benefits and the fact that the risks associated with smoking are severe.

A decade of cigarette taxation in Bangladesh: lessons learnt for tobacco control

Bangladesh has achieved a high share of tax in the price of cigarettes (greater than the 75% benchmark), but has not achieved the expected health benefits from reduction in cigarette consumption. In this paper we explore why cigarette taxation has not succeeded in reducing cigarette smoking in Bangladesh. Using government records over 2006–2017, we link trends in tax-paid cigarette sales to cigarette excise tax structure and changes in cigarette taxes and prices. We analysed data on smoking prevalence from Bangladesh Global Adult Tobacco Surveys to study consumption of different tobacco products in 2009 and 2017. Drawing on annual reports from tobacco manufacturers and other literature, we examine demand- and supply-side factors in the cigarette market. In addition to a growing affordability of cigarettes, three factors appear to have undermined the effectiveness of tax and price increases in reducing cigarette consumption in Bangladesh. First, the multitiered excise tax structure widened the price differential between brands and incentivized downward substitution by smokers from higher-price to lower-price cigarettes. Second, income growth and shifting preferences of smokers for better quality products encouraged upward substitution from hand-rolled local cigarettes (bidi) to machine-made low-price cigarettes. Third, the tobacco industry’s market expansion and differential pricing strategy changed the relative price to keep low-price cigarettes inexpensive. A high tax share alone may prove inadequate as a barometer of effective tobacco taxation in lower-middle income countries, particularly where the tobacco tax structure is complex, tobacco products prices are relatively low, and the affordability of tobacco products is increasing.

Tobacco use among non-elderly adults with and without criminal justice involvement in the past year: United States, 2008-2016

BACKGROUND

Tobacco use remains the leading cause of preventable disease and death in the United States and is concentrated among disadvantaged populations, including individuals with a history of criminal justice involvement. However, tobacco use among individuals with a history of criminal justice involvement has been understudied in the United States, and data are needed to inform policy and practice.

METHODS

We used data from the 2008-2016 National Survey on Drug Use and Health (unweighted N = 330,130) to examine trends in tobacco use, categories of tobacco use, characteristics of cigarette use, and health care utilization and tobacco use screening among individuals (aged 18-64) with and without a history of criminal justice involvement in the past year. We used multiple logistic and Poisson regression models with predictive margins to provide adjusted prevalence estimates.

RESULTS

The weighted sample in each year was, on average, representative of 8,693,171 individuals with a history of criminal justice involvement in the past year and 182,817,228 individuals with no history of criminal justice involvement in the past year. Tobacco use was significantly more common among individuals with a history of criminal justice involvement compared with individuals with no criminal justice involvement, and disparities increased over time (Difference in adjusted relative differences: - 10.2% [95% CI - 17.7 to - 2.7]). In 2016, tobacco use prevalence was more than two times higher among individuals with a history of criminal justice involvement (62.9% [95% CI 59.9-66.0] vs. 27.6% [95% CI 26.9-28.3]). Individuals with a history of criminal justice involvement who smoked reported a significantly earlier age of cigarette initiation, more cigarettes used per day, and higher levels of nicotine dependence and chronic obstructive pulmonary disease. Individuals with a history of criminal justice involvement were less likely to report an outpatient medical visit in the past year and, among those reporting an outpatient medical visit, were less likely to be asked about tobacco use, but paradoxically, more likely to report being advised to quit.

CONCLUSIONS

Novel programs and tobacco control policies are needed to address persistently high rates of tobacco use and reduce cardiovascular morbidity and mortality among individuals with a history of criminal justice involvement.

Implementation phase of the Tobacco-Free Parks Ordinance: a policy evaluation using photographic data

OBJECTIVE

Mecklenburg County (Charlotte, North Carolina) Board of County Commissioners took the unique step of passing a Tobacco-Free Parks Ordinance designating most county parks as tobacco-free including all smoking products, smokeless tobacco, and e-cigarettes. The objective of the baseline phase of the Ordinance evaluation sought to assess whether signage in the parks was associated with the presence of tobacco-use litter.

STUDY DESIGN

A qualitative study was conducted with photography as the method of observation across Mecklenburg County parks in North Carolina.

METHODS

A representative sample of 42 parks was selected from the 186 county park properties. Photographs were taken at a list of specific types of locations within each park, with attention to signage and tobacco-use litter (butts, e-cigarette).

RESULTS

Tobacco-use evidence was mostly found in parks' picnic areas (67%) and walking trails (67%), with least found in parks' athletic courts (23%). At least 80% of parks have some tobacco litter. Evidence of tobacco use was not significantly associated with signage.

CONCLUSION

Little research has focused on the effect of local public policies limiting tobacco use in public outdoor spaces. Findings from this evaluation have potential to inform policy implementation efforts regarding efforts to limit tobacco use in public spaces.

Nicotine dependence among adolescents in the European Union: How many and who are affected?

Background

Nicotine dependence during adolescence increases the risk of continuing smoking into adulthood. The magnitude of nicotine dependence among adolescents in the European Union (EU) has not been established. We aimed to estimate the number of nicotine dependent 15-year-old adolescents in the EU, and identify high-risk groups.

Methods

The number of nicotine dependent 15-year-olds in the EU was derived combining: (i) total number of 15-year-olds in the EU (2013 Eurostat), (ii) smoking prevalence among 15-year-olds (2013/2014 HBSC survey) and (iii) proportion of nicotine dependent 15-year-olds in six EU countries (2013 SILNE survey). Logistic regression analyses identified high-risk groups in the SILNE dataset.

Results

We estimated 172 636 15-year-olds were moderately to highly nicotine dependent (3.2% of all 15 years old; 35.3% of daily smokers). In the total population, risk of nicotine dependence was higher in males, adolescents with poor academic achievement, and those with smoking parents or friends. Among daily smokers, only lower academic achievement and younger age of smoking onset were associated with nicotine dependence.

Conclusion

According to our conservative estimates, more than 172 000 15-year-old EU adolescents were nicotine dependent in 2013. Prevention of smoking initiation, especially among adolescents with poor academic performance, is necessary to prevent a similar number of adolescents getting addicted to nicotine each consecutive year.

Parental smoking, rejection of parental smoking, and smoking susceptibility and behaviors in Hong Kong adolescents

INTRODUCTION

We explored the role of rejection of parental smoking in the association between parental smoking and smoking in adolescents.

METHODS

In 2010-11 cross-sectional survey, 61,810 Hong Kong secondary school students (mean age 14.6 years, 50.5% boys) reported their smoking (never, not susceptible; never, susceptible; ever, not current; current), paternal and maternal smoking, and whether they accepted paternal and maternal smoking (acceptance/rejection). We used multinomial logistic regression to estimate the odds ratios (ORs) and 95% confidence intervals (CIs) of students' smoking in relation to acceptance and rejection of parental smoking, compared with no parental smoking.

RESULTS

The OR (95% CI) of "never, susceptible", "ever, not current", and "current", compared with "never, not susceptible", in relation to acceptance of paternal smoking was 1.81 (1.67-1.96), 2.46 (2.25-2.69), and 2.79 (2.51-3.10), respectively. The corresponding ORs for rejection were 0.70 (0.64-0.76), 1.23 (1.13-1.35), and 0.47 (0.40-0.56). The OR (95% CI) of "never, susceptible", "ever, not current", and "current", compared with "never, not susceptible", in relation to acceptance of maternal smoking was 2.05 (1.80-2.33), 2.57 (2.29-2.88), and 6.33 (5.39-7.44), respectively. The corresponding ORs for rejection were 0.85 (0.69-1.05), 1.59 (1.39-1.81), and 2.14 (1.71-2.68). No overlapping was observed between the 95% CIs for acceptance and rejection of paternal or maternal smoking.

CONCLUSIONS

While adolescent smoking was associated with parental smoking, especially in those who accepted parental smoking, the association was attenuated or reversed in those who rejected parental smoking.

Inequities in coverage of smokefree outdoor space policies within the United States: school grounds and playgrounds

Background

Previous studies have found extensive geographic and demographic differences in tobacco use. These differences have been found to be reduced by effective public policies, including banning smoking in public spaces. Smokefree outdoor spaces reduce secondhand smoke exposure and de-normalize smoking.

Methods

After previously publishing a study of smokefree indoor and outdoor space policies, it was brought to the authors’ attention that the dataset used in analyses was incomplete (Lowrie et al., BMC Public Health 17:456, 2017). The current manuscript is a corrected version. Here, we include analyses for outdoor space policies. We evaluated regional and demographic differences in the proportion of the population (both adult and child) covered by smokefree outdoor space policies for school grounds and playgrounds enacted in the United States prior to 2014.

Results

Children had a low level of protection in playgrounds and schools (8% covered nationwide in both settings). Significant differences in coverage were found by ethnicity, region, income, and education (p < 0.001). The odds of having a smokefree playgrounds policy was lower for jurisdictions with higher proportions of poor households, households with no high school diploma, whites and the Alaska/Hawaii region. Increased ethnic heterogeneity was found to be a significant predictor of increased odds of having a smokefree playgrounds policy, meaning that diversity is protective, with differential effect by region (p < 0.001) – which may relate to urbanicity.

Conclusions

Disparities in smokefree outdoor space policies have potential to exacerbate existing health inequities. A national increase in smokefree outdoor space policies to protect children in playgrounds and schools is a crucial intervention to reduce such inequities.

Inequalities in health and health risk factors in the Southern African Development Community: evidence from World Health Surveys

Background

Socioeconomic inequalities in health have been documented in many countries including those in the Southern African Development Community (SADC). However, a comprehensive assessment of health inequalities and inequalities in the distribution of health risk factors is scarce. This study specifically investigates inequalities both in poor self-assessed health (SAH) and in the distribution of selected risk factors of ill-health among the adult populations in six SADC countries.

Methods

Data come from the 2002/04 World Health Survey (WHS) using six SADC countries (Malawi, Mauritius, South Africa, Swaziland, Zambia and Zimbabwe) where the WHS was conducted. Poor SAH is reporting bad or very bad health status. Risk factors such as smoking, heavy drinking, low fruit and vegetable consumption and physical inactivity were considered. Other environmental factors were also considered. Socioeconomic status was assessed using household expenditures. Standardised and normalised concentration indices (CIs) were used to assess socioeconomic inequalities. A positive (negative) concentration index means a pro-rich (pro-poor) distribution where the variable is reported more among the rich (poor).

Results

Generally, a pro-poor socioeconomic inequality exists in poor SAH in the six countries. However, this is only significant for South Africa (CI = − 0.0573; p < 0.05), and marginally significant for Zambia (CI = − 0.0341; P < 0.1) and Zimbabwe (CI = − 0.0357; p < 0.1). Smoking and inadequate fruit and vegetable consumption were significantly concentrated among the poor. Similarly, the use of biomass energy, unimproved water and sanitation were significantly concentrated among the poor. However, inequalities in heavy drinking and physical inactivity are mixed. Overall, a positive relationship exists between inequalities in ill-health and inequalities in risk factors of ill-health.

Conclusion

There is a need for concerted efforts to tackle the significant socioeconomic inequalities in ill-health and health risk factors in the region. Because some of the determinants of ill-health lie outside the health sector, inter-sectoral action is required.