Adult tobacco use levels after intensive tobacco control measures: New York City, 2002-2003

A systematic review and network meta-analysis of population-level interventions to tackle smoking behaviour

This preregistered systematic review and meta-analysis (PROSPERO: CRD 42022311392) aimed to synthesize the effectiveness of all available population-level tobacco policies on smoking behaviour. Our search across 5 databases and leading organizational websites resulted in 9,925 records, with 476 studies meeting our inclusion criteria. In our narrative summary and both pairwise and network meta-analyses, we identified anti-smoking campaigns, health warnings and tax increases as the most effective tobacco policies for promoting smoking cessation. Flavour bans and free/discounted nicotine replacement therapy also showed statistically significant positive effects on quit rates. The network meta-analysis results further indicated that smoking bans, anti-tobacco campaigns and tax increases effectively reduced smoking prevalence. In addition, flavour bans significantly reduced e-cigarette consumption. Both the narrative summary and the meta-analyses revealed that smoking bans, tax increases and anti-tobacco campaigns were associated with reductions in tobacco consumption and sales. On the basis of the available evidence, anti-tobacco campaigns, smoking bans, health warnings and tax increases are probably the most effective policies for curbing smoking behaviour.

Legal and regulatory instruments for NCD prevention: a scoping review and descriptive analysis of evaluations in OECD countries

CONTEXT

Public health law is an important tool in non-communicable disease (NCD) prevention. There are different approaches available for achieving policy objectives, including government, co-, quasi- and self-regulation. However, it is often unclear what legal design features drive successes or failures in particular contexts. This scoping review undertakes a descriptive analysis, exploring the design characteristics of legal instruments that have been used for NCD prevention and implemented and evaluated in OECD countries.

METHODS

A scoping review was conducted across four health and legal databases (Scopus, EMBASE, MEDLINE, HeinOnline), identifying study characteristics, legal characteristics and regulatory approaches, and reported outcomes. Included studies focused on regulation of tobacco, alcohol, unhealthy foods and beverages, and environmental pollutants.

FINDINGS

We identified 111 relevant studies evaluating 126 legal instruments. Evaluation measures most commonly assessed implementation, compliance and changes to the built and lived environment. Few studies evaluated health or economic outcomes. When examining the design and governance mechanisms of the included legal instruments, government regulation was most commonly evaluated (n = 90) and most likely to be reported effective (64%). Self-regulation (n = 27) and quasi-regulation (n = 5) were almost always reported to be ineffective (93% and 100% respectively). There were few co-regulated instruments evaluated (n = 4) with mixed effectiveness. When examining public health risks, food and beverages including alcohol were more likely to be self- or quasi-regulated and reported as ineffective more often. In comparison, tobacco and environmental pollutants were more likely to have government mandated regulation. Many evaluations lacked critical information on regulatory design. Monitoring and enforcement of regulations was inconsistently reported, making it difficult to draw linkages to outcomes and reported effectiveness.

CONCLUSIONS

Food and alcohol regulation has tended to be less successful in part due to the strong reliance on self- and quasi-regulation. More work should be done in understanding how government regulation can be extended to these areas. Public health law evaluations are important for supporting government decision-making but must provide more detail of the design and implementation features of the instruments being evaluated - critical information for policy-makers.

Geographic Patterns in U.S. Lung Cancer Mortality and Cigarette Smoking

BACKGROUND

Despite the success of smoking cessation campaigns, lung cancer remains the leading cause of cancer death in the U.S. Variations in smoking behavior and lung cancer mortality are evident by sex and region.

METHODS

Applying geospatial methods to lung cancer mortality data from the National Vital Statistics System and county-level estimates of smoking prevalences from the NCI's Small Area Estimates of Cancer-Related Measures, we evaluated patterns in lung cancer mortality rates (2005-2018) in relation to patterns in ever cigarette smoking prevalences (1997-2003).

RESULTS

Overall, ever smoking spatial patterns were generally associated with lung cancer mortality rates, which were elevated in the Appalachian region and lower in the West for both sexes. However, we also observed geographic variation in mortality rates that is not explained by smoking. Using Lee's L statistic for assessing bivariate spatial association, we identified counties where the ever smoking prevalence was low and lung cancer rates were high. We observed a significant cluster of counties (n = 25; P values ranging from 0.001 to 0.04) with low ever smoking prevalence and high mortality rates among females around the Mississippi River region south of St. Louis, Missouri and a similar and smaller cluster among males in Western Mississippi (n = 12; P values ranging from 0.002 to 0.03) that has not been previously described.

CONCLUSIONS

Our analyses identified U.S. counties where factors other than smoking may be driving lung cancer mortality.

IMPACT

These novel findings highlight areas where investigation of environmental and other risk factors for lung cancer is needed.

Effectiveness of Indiana's Statewide Smoke-Free Indoor Air Law in Reducing Prevalence of Adult Cigarette Smoking

Indiana recently implemented a statewide smoke-free indoor air law that has prohibited smoking in both restaurants and non-hospitality workplaces. Evidence for the effectiveness of the recent statewide smoke-free indoor law may persuade 14 states that do not have any statewide smoke-free laws to enact such laws. We evaluated the effectiveness of Indiana's State Smoke-Free Air Law, implemented July 2012, in reducing adult smoking prevalence. We analyzed samples of U.S. adults using a nonequivalent control group design with multi-year, cross-sectional data from the 2011-2016 Behavioral Risk Factor Surveillance System ( N= 2,259,014). Four state groups with different levels of comprehensiveness in regard to statewide smoke-free indoor air laws in 2011-2016 served as the comparison groups, namely those with: (1) no law; (2) a partial law (prohibiting smoking in either one or two of these three settings, namely non-hospitality workplaces, restaurants, and bars); (3) a comprehensive law (prohibiting smoking in all non-hospitality workplaces, restaurants, and bars); and (4) those that changed from a partial to a comprehensive law. We used a difference-in-differences approach with multiple logistic regressions to assess the net effect of the policy with a secular trend removed. The decline rate of cigarette smoking in Indiana was steeper, from 21.2% in 2011-2012 to 17.8% in 2013-2016, than in states in our four comparison groups, which suggests a significant reduction in adult cigarette smoking prevalence above and beyond the downward secular trend observed. All the comparison groups showed higher odds of cigarette smoking than Indiana (adjusted odds ratios range from 1.08 to 1.16). Although a long-term effect of Indiana's State Smoke-Free Air Law has yet to be evaluated, current data indicate that such a policy appears to be effective in reducing smoking prevalence. The implementation of statewide smoke-free indoor air laws in all restaurants and non-hospitality workplaces may help reduce smoking rates in the 14 states that still do not have any statewide smoke-free indoor air laws.

Effects of an 80% cigarette price increase on quit attempts, successful quitting and smoking intensity among Korean adult smokers: results from nationally representative longitudinal panel data

OBJECTIVES

South Korea implemented an unprecedented cigarette tax increase in 2015, raising its cigarette price by 80%. This study evaluated the extent to which the 2015 cigarette tax increase affected Korean adult smokers in terms of quit attempts, successful quitting and smoking intensity.

METHODS

Data were drawn from a nationally representative longitudinal study, the Korean Welfare Panel Study (waves 9-12, 2014-2017). Korean adults who smoked before the 2015 cigarette tax increase comprised the sample (n=2114). We used the multiple logistic regressions to examine factors of quit attempts and successful quitting and the generalised estimating equations to estimate changes in smoking intensity among continued smokers.

RESULTS

After the cigarette tax increase, 60.9% (n=1334) of baseline smokers attempted to quit and 34.7% of the attempters succeeded in quitting. The smokers aged ≥ 65 years and light smokers both attempted more (p<0.01) and succeeded more (p<0.05) in quitting than smokers aged 35-44 years and heavy smokers, respectively. The successful quitting was not significantly associated with income levels. Depressive symptoms, first cigarette use before age 19 and smoking a pack or more a day at baseline were associated with failures in quitting. Smoking intensity among continued smokers decreased after the cigarette tax increase (p<0.001), but such a decrease was not observed in light smokers, young smokers and high-income smokers.

CONCLUSION

The current study findings imply that the Korean government may consider implementing periodic increases in cigarette tax which should reflect the rate of inflation and income growth. Smoking cessation programmes need to address depressive symptoms.

Is Perceived Stigma in Clinical Settings Associated With Poor Health Status Among New York City's Residents of Color?

OBJECTIVES

Our objectives were to assess rates of perceived stigma in health care (clinical) settings reported by racially diverse New York City residents and to examine if this perceived stigma is associated with poorer physical and mental health outcomes.

METHODS

We analyzed data from the 2016 New York City Community Health Survey. We applied bivariable and multivariable methods to assess rates of perceived stigma, and perceived stigma's statistical relationship with health care access, physical health status, and mental health status controlling for sociodemographics and health insurance status.

RESULTS

Perceived stigma was associated with poorer health care access [odds ratio (OR)=7.07, confidence interval (CI)=5.32-9.41), depression (OR=3.80, CI=2.66-5.43), diabetes (OR=1.86, CI=1.36-2.54), and poor overall general health (OR=0.43, CI=0.33-0.57). Hispanic respondents reported the highest rate of perceived stigma among racial and ethnic minority groups (mean=0.07, CI=0.05-0.08).

CONCLUSIONS

We found that perceived stigma in health care settings was a potential barrier to good health. Prior studies have illustrated that negative health outcomes are common for patients who avoid or delay care; thus, the unfortunate conclusion is that even in a diverse, heterogeneous community, stigma persists and may negatively affect well-being. Therefore, eliminating stigma in clinical settings should be a top priority for health care providers and public health professionals seeking to improve health equity.

Relationships between smoking duration, smoking intensity, hypothetical tobacco price increases, and smoking habit change intention among current smokers in Shanghai

Objectives

We conducted a cross-sectional study to explore the effect of a hypothetical tobacco retail price increase on smoking habit change intention, and the role of smoking duration and intensity in smoking change intention.

Methods

In 2016 and 2017, we collected questionnaire data from 36,698 residents aged over 18 years in Songjiang district, Shanghai. Chi-square tests and weighted logistic regression were used for data analyses.

Results

The prevalence of current smoking was 19.78% (men: 48.36% and women: 0.22%). A total of 10.83% (men: 10.89% and women: 2.04%) and 9.39% of smokers (men: 9.42% and women: 6.12%) expressed the intention to smoke less or quit, respectively, given tobacco retail price increases. If the current tobacco retail price doubled, 75% of smokers stated that they would smoke less and 60% of smokers would consider quitting. Smokers with longer smoking duration and lower smoking intensity were more sensitive to tobacco price increases and more likely to change their smoking habits.

Conclusions

An increase in tobacco retail prices could induce some smokers to change their smoking behavior, particularly those with longer smoking duration and lower smoking intensity. A tobacco retail price increase is recommended, which should apply to all cigarette brands.

Smoke-Free Policies and Smoking Cessation in the United States, 2003-2015

(1) Background: Smoking restrictions have been shown to be associated with reduced smoking, but there are a number of gaps in the literature surrounding the relationship between smoke-free policies and cessation, including the extent to which this association may be modified by sociodemographic characteristics. (2) Methods: We analyzed data from the Tobacco Use Supplement to the Current Population Survey, 2003-2015, to explore whether multiple measures of smoking restrictions were associated with cessation across population subgroups. We examined area-based measures of exposure to smoke-free laws, as well as self-reported exposure to workplace smoke-free policies. We used age-stratified, fixed effects logistic regression models to assess the impact of each smoke-free measure on 90-day cessation. Effect modification by gender, education, family income, and race/ethnicity was examined using interaction terms. (3) Results: Coverage by workplace smoke-free laws and self-reported workplace smoke-free policies was associated with higher odds of cessation among respondents ages 40-54. Family income modified the association between smoke-free workplace laws and cessation for women ages 25-39 (the change in the probability of cessation associated with coverage was most pronounced among lower-income women). (4) Conclusions: Heterogeneous associations between policies and cessation suggest that smoke-free policies may have important implications for health equity.

Clean indoor air laws, cigarette excise taxes, and smoking: Results from the current population survey-tobacco use supplement, 2003-2011

There was an increase in the number and coverage of state and local clean indoor air laws in the US during the past fifteen years. These laws coincided with increases in federal, state, and local cigarette excise taxes. In light of these changes, the objective of this study was to examine the association between clean indoor air laws, cigarette excise taxes and smoking patterns between 2003 and 2011. Using data on 62,165 adult participants in the 2003 and 2010/2011 Current Population Survey-Tobacco Use Supplement who reported smoking cigarettes in the past year, we examined the association of state and county workplace, bar, and restaurant clean indoor air laws and cigarette excise taxes with quitting and current every-day smoking. Between 2003 and 2011, quitting increased and daily smoking among those who continued to smoke decreased significantly. Participants living in states and counties with higher excise taxes and more comprehensive clean indoor air laws had a higher likelihood of quitting and lower likelihood of everyday smoking. Based on the assumption of no uncontrolled confounding, changes in taxes and laws accounted for 64.8% of the increase in smoking cessation and all of the reduction in everyday smoking. Implementation of state and county-level clean indoor air laws and cigarette taxes appears to have achieved the intended goal of encouraging smokers to either quit or reduce their frequency of smoking.

State-Level Affordability of Factory-Made Cigarettes among Current US Smokers: Findings from the ITC US Survey, 2003-2015

Cigarette affordability measures the price smokers pay for cigarettes in relation to their incomes. Affordability can be measured using the relative income price of cigarettes (RIP), or the price smokers pay to purchase 100 packs of 20 cigarettes divided by their per capita household income. Using longitudinal data from 7046 smokers participating in the International Tobacco Control (ITC) US Survey, the purpose of this study was to test whether affordability significantly changed following the US federal tax increase implemented on 1 April 2009. This study also estimated temporal trends in affordability from 2003-2015 at state and national levels using small area estimation methods and segmented linear mixed effects regression models. RIP increased slightly during 2003-2008. This was followed by a 30% increase during 2008-2010, indicating cigarettes were less affordable after the federal tax increase. RIP continued to increase during 2010-2013 but decreased during 2013-2015, suggesting cigarettes have recently become more affordable for US smokers. State-level trends in RIP were consistent with overall national trends. Controlling for other factors, a $1 increase in the state excise tax was significantly associated with a 9% increase in RIP, indicating state taxes reduced affordability. Tax-induced price increases must keep pace with underlying economic conditions to ensure cigarettes do not become more affordable over time.

Examining quit attempts and successful quitting after recent cigarette tax increases

As cigarette smoking rates decline, an important policy question is whether increasing cigarette taxes will continue to encourage smoking cessation. We tested this question following recent tobacco tax increases. Data were from the Minnesota Adult Tobacco Survey, a serial cross-sectional telephone survey conducted statewide, and was limited to past-year cigarette smokers in 2010 (n = 1029) and 2014 (n = 1382). Weighted estimates were calculated of the prevalence of past year smokers, smokers who attempted to quit smoking, and those who successfully quit by demographics, tobacco use, use of evidence-based cessation assistance to quit, and smoker perceptions of the tax increases. Among past year smokers, almost 60% reported a quit attempt in both years, 12.8% successfully quit in 2010 and 15.6% in 2014. Although older age, daily smoking, mean cigarettes per day, and more days of e-cigarette use, were associated with quit attempts in unadjusted models, only the perceived tax increase effect (AOR = 8.9; 95% CI 6.3-12.5) and low nicotine dependence (AOR = 1.9, 95% CI 1.3-2.7) were associated with making a quit attempt in adjusted models. Successful 12-month quits were predicted by college education (AOR = 3.2, 95% CI 1.3-7.8), the use of cessation support (AOR = 2.1, 95% CI 1.3-3.6), and reporting the tax increase helped maintain a quit (AOR = 12.3, 95% CI 7.5-20.1). These findings suggest that a large tax increase is effective in promoting quitting even in the presence of strong tobacco control measures such as indoor smoking bans and other smoking restrictions, mass media campaigns, and universal access to cessation support.

Recommendations for linking client data with clinic services to improve our ability to make inferences

Concise statement: Skinner et al’s proposed minimum dataset for global stop-smoking services is an essential tool for improving tobacco dependence treatment. We suggest insertion of additional items on treatment cost and cessation aids, including e-cigarettes, as well as items linking program- and individual-level to allow for stronger inferences about the effectiveness of specific services and cessation aids.

Longitudinal Associations of Local Cigarette Prices and Smoking Bans with Smoking Behavior in the Multi-Ethnic Study of Atherosclerosis

BACKGROUND

Few studies have examined associations of geographically proximal cigarette prices with within-person changes in smoking outcomes or assessed interactions between cigarette prices and smoking bans.

METHODS

We linked neighborhood cigarette prices (inflation-adjusted) at chain supermarkets and drug stores and bar/restaurant smoking ban policies to cohort participants (632 smokers from the Multi-Ethnic Study of Atherosclerosis, 2001-2012, baseline mean age 58 years) using geocoded retailer and participant addresses. We used fixed-effects models to investigate associations of within-person changes in price and ban exposures with within-person changes in five smoking outcomes: current smoking, heavy (≥10 cigarettes) smoking, cessation, relapse, and intensity (average number of cigarettes smoked per day, natural log transformed). We assessed intensity associations among all smokers, and heavy (≥10 cigarettes per day) and light (<10) baseline smokers. Finally, we tested interactions between cigarette price and bans.

RESULTS

A $1 increase in price was associated with a 3% reduction in risk of current smoking (adjusted risk ratio [aRR]: 0.97; 95% confidence interval [CI] = 0.93, 1.0), a 7% reduction in risk of heavy smoking (aRR: 0.93; CI = 0.87, 0.99), a 20% increase in risk of smoking cessation (aRR: 1.2; CI = 0.99, 1.4), and a 35% reduction in the average number of cigarettes smoked per day by heavy baseline smokers (ratio of geometric means: 0.65; CI = 0.45, 0.93). We found no association between smoking bans and outcomes, and no evidence that price effects were modified by the presence of bans.

CONCLUSIONS

Results underscore the importance of local prices, but not hospitality smoking bans, in influencing older adults' smoking behaviors.

Differences in nicotine dependence, smoke exposure and consumer characteristics between smokers of machine-injected roll-your-own cigarettes and factory-made cigarettes

BACKGROUND

Consumption of machine-injected roll-your-own (RYO) filtered cigarettes made from pipe tobacco increased almost 7-fold from 2008 to 2011 in the United States.

METHODS

We used data from the Pennsylvania Adult Smoking Study to compare the differences in sociodemographic, smoking topography, nicotine dependence, and cotinine levels between 280 smokers using factory made (FM) cigarettes and 68 smokers using RYO cigarettes.

RESULTS

RYO smokers were older (41 vs. 37, P = 0.053), had significantly lower levels of income (P < 0.001) and education (P = 0.007), and were less likely to be fully employed (P = 0.009). RYO smokers consumed more cigarettes per day [CPD] (21 vs. 15, P < 0.001), and had a higher mean score on the Fagerström Test for Cigarette/Nicotine Dependence (5.2 vs. 4.1, P < 0.001). The main reasons for choosing RYO cigarettes were the lower cost (68%) and believed they are less harmful (12%). The average cost per pack of FM cigarettes was $5.74 vs. $1.13 for RYO. In multiple regression analyses, RYO smokers had significantly lower cotinine levels across all levels of CPD. Among smokers of king-size cigarettes, mean interpuff interval (P < 0.05) and total smoke duration (P < 0.01) per cigarette was significantly greater in RYO smokers. In laboratory measurements, RYO cigarettes contained more tobacco by weight than FM cigarettes, but weight varied by both tobacco and cigarette tube brands.

CONCLUSIONS

Machine-injected RYO cigarettes made from pipe tobacco are cheaper than FM cigarettes but may have higher abuse liability. Smokers who might otherwise reduce their cigarette consumption or quit altogether may continue to smoke RYO cigarettes due to their affordability.

Associations of Bar and Restaurant Smoking Bans With Smoking Behavior in the CARDIA Study: A 25-Year Study

Indoor smoking bans have often been associated with reductions in smoking prevalence. However, few studies have evaluated their association with within-person changes in smoking behaviors. We linked longitudinal data from 5,105 adults aged 18-30 years at baseline from the Coronary Artery Risk Development in Young Adults (CARDIA) Study (1985-2011) to state, county, and local policies mandating 100% smoke-free bars and restaurants by census tract. We used fixed-effects models to examine the association of smoking bans with within-person change in current smoking risk, smoking intensity (smoking ≥10 cigarettes/day on average vs. <10 cigarettes/day), and quitting attempts, using both linear and nonlinear adjustment for secular trends. In models assuming a linear secular trend, smoking bans were associated with a decline in current smoking risk and smoking intensity and an increased likelihood of a quitting attempt. The association with current smoking was greatest among participants with a bachelor's degree or higher. In models with a nonlinear secular trend, pooled results were attenuated (confidence intervals included the null), but effect modification results were largely unchanged. Findings suggest that smoking ban associations may be difficult to disentangle from other tobacco control interventions and emphasize the importance of evaluating equity throughout policy implementation.

Evaluating the Effectiveness of New York City Health Policy Initiatives in Reducing Cardiovascular Disease Mortality, 1990-2011

Beginning in 2002, New York City (NYC) implemented numerous policies and programs targeting cardiovascular disease (CVD) risk factors. Using death certificates, we analyzed trends in NYC-specific and US mortality rates from 1990 to 2011 for all causes, any CVD, atherosclerotic CVD (ACVD), coronary artery disease (CAD), and stroke. Joinpoint analyses quantified annual percent change (APC) and evaluated whether decreases in CVD mortality accelerated after 2002 in either NYC or the total US population. Our analyses included 1,149,217 NYC decedents. The rates of decline in mortality from all causes, any CVD, and stroke in NYC did not change after 2002. Among men, the decline in ACVD mortality accelerated during 2002-2011 (APC = -4.8%, 95% confidence interval (CI): -6.1, -3.4) relative to 1990-2001 (APC = -2.3%, 95% CI: -3.1, -1.5). Among women, ACVD rates began declining more rapidly in 1993 (APC = -3.2%, 95% CI: -3.8, -2.7) and again in 2006 (APC = -6.6%, 95% CI: -8.9, -4.3) as compared with 1990-1992 (APC = 1.6%, 95% CI: -2.7, 6.0). In the US population, no acceleration of mortality decline was observed in either ACVD or CAD mortality rates after 2002. Relative to 1990-2001, atherosclerotic CVD and CAD rates began to decline more rapidly during the 2002-2011 period in both men and women-a pattern not observed in the total US population, suggesting that NYC initiatives might have had a measurable influence on delaying or reducing ACVD mortality.

Facility-level, state, and financial factors associated with changes in the provision of smoking cessation services in US substance abuse treatment facilities: Results from the National Survey of Substance Abuse Treatment Services 2006 to 2012

Cigarette smoking is common among patients in substance abuse treatment. Tobacco control programs have advocated for integrated tobacco dependence treatment into behavioral healthcare, including within substance abuse treatment facilities (SATFs) to reduce the public health burden of tobacco use. This study used data from seven waves (2006 to 2012) of the National Survey of Substance Abuse Treatment Services (n=94,145) to examine state and annual changes in the provision of smoking cessation services within US SATFs and whether changes over time could be explained by facility-level (private vs public ownership, receipt of earmarks, facility admissions, acceptance of government insurance) and state-level factors (cigarette tax per pack, smoke free policies, and percent of CDC recommended tobacco prevention spending). Results showed that the prevalence of SATFs offering smoking cessation services increased over time, from 13% to 65%. The amount of tax per cigarette pack, accepting government insurance, government (vs private) ownership, facility admissions, and CDC recommended tobacco prevention spending (per state) were the strongest correlates of the provision of smoking cessation programs in SATFs. Facilities that received earmarks were less likely to provide cessation services. Adult smoking prevalence and state-level smoke free policies were not significant correlates of the provision of smoking cessation services over time. Policies aimed at increasing the distribution of tax revenues to cessation services in SATFs may offset tobacco-related burden among those with substance abuse problems.

A Prospective Cohort Study of Cigarette Prices and Smoking Cessation in Older Smokers

Background: Cigarette price increases effectively prevent smoking initiation and reduce cigarette consumption among young smokers. However, the impact of cigarette prices on smoking cessation among older smokers is less clear, particularly for those aged 65 years and older, a group that is at highest risk of smoking-related disease and will almost double in the United States between 2012 and 2050.Methods: Biennial questionnaires administered between 1997 and 2013 assessed smoking status for 9,446 Cancer Prevention Study-II Nutrition Cohort participants who were ≥50 years old and lived in Washington, DC, and 48 states. For each interval between biennial questionnaires, change in price per pack and average price level per pack were calculated. The separate associations between these price variables and smoking cessation during the same time interval were determined.Results: In multivariable-adjusted models, each $1.00 price increase was associated with a 9% higher rate of quitting [rate ratio (RR) = 1.09; 95% confidence interval (CI), 1.04-1.14). Each $1.00 increase in average price was associated with a 6% higher rate of quitting (RR = 1.06; 95% CI, 1.02-1.10). The association with average price was strongest among smokers aged 65 years and older (RR = 1.07; 95% CI, 1.04-1.11) and, for price change, for smokers with no major prevalent disease (RR = 1.13; 95% CI, 1.07-1.19).Conclusions: These results suggest that increasing cigarette prices will promote quitting even among smokers aged 65 years and older.Impact: Increasing cigarette prices through higher taxes could reduce smoking rates among older adults and decrease risk of smoking-related cancers and diseases in this high-risk group. Cancer Epidemiol Biomarkers Prev; 26(7); 1071-7. ©2017 AACR.

The effect of faith-based smoking cessation intervention during Ramadan among Malay smokers

Objectives: To study the effects of a faith-based smoking cessation intervention during Ramadan among Malay male smokers working in public offices. Methods: This was a quasi-experimental study conducted during Ramadan 2015. The intervention was developed based on the constructs within the Theory of Planned Behaviour. The intervention intended to increase the intention and the perceived behaviour control to stop smoking among Muslim smokers during Ramadan. The outcomes measured were changes in the Fagerstrom Test for Nicotine Dependence score and saliva cotinine levels. Data were collected at baseline (5 days before Ramadan), during Ramadan (21st day of Ramadan) and post-Ramadan (21 days after Ramadan). Statistical tests to examine changes within and between groups were carried out and the significance level was set at p < 0.05. Results: During Ramadan, the saliva cotinine level decreased significantly in both groups (p = 0.001 in the control group and p = < 0.001 in the intervention group). However, after Ramadan, it remained significant only in the intervention group (p = 0.025). A significant change between the groups was only noticed during Ramadan (p = 0.049). Conclusion: The reduction in the saliva cotinine level was found to be more sustainable post-Ramadan in the intervention group. This finding could indicate the positive effect of using this culturally-competent intervention to encourage smoking cessation during Ramadan.

Smoking Status and the Five-Factor Model of Personality: Results of a Cross-Sectional Study Conducted in Poland

Tobacco smoking is the single most important modifiable factor in increased morbidity and premature mortality. Numerous factors—including genetics, personality, and environment—affect the development and persistence of tobacco addiction, and knowledge regarding these factors could improve smoking cessation rates. This study compared personality traits between never, former, and current smokers, using the Five-Factor Model of Personality in a country with a turbulent smoking reduction process.: In this cross-sectional study, 909 Polish adults completed the Revised Neuroticism-Extraversion-Openness Personality Inventory. Our results showed that current smokers’ scores for extraversion, one of the five global dimensions of personality, were higher relative to never smokers. Neuroticism, openness to experience, agreeableness, and conscientiousness did not differ significantly according to smoking status. Facet analysis, which described each dimension in detail, showed that current smokers’ activity and excitement seeking (facets of extraversion) scores were higher relative to those of never and former smokers. In turn, current smokers’ dutifulness and deliberation (facets of conscientiousness) scores were lower than those found in former and never smokers. Never smokers scored the highest in self-consciousness (a facet of neuroticism) and compliance (a component of agreeableness). The study conducted among Polish individuals showed variation in personality traits according to their smoking status; however, this variation differed from that reported in countries in which efforts to reduce smoking had begun earlier relative to Poland. Knowledge regarding personality traits could be useful in designing smoking prevention and cessation programs tailored to individuals’ needs.

Food Service Guideline Policies on State Government-Controlled Properties

PURPOSE

Food service guideline (FSG) policies can impact millions of daily meals sold or provided to government employees, patrons, and institutionalized persons. This study describes a classification tool to assess FSG policy attributes and uses it to rate FSG policies.

DESIGN

Quantitative content analysis.

SETTING

State government facilities in the United States.

PARTICIPANTS

Participants were from 50 states and District of Columbia in the United States.

MEASURES

Frequency of FSG policies and percentage alignment to tool.

ANALYSIS

State-level policies were identified using legal research databases to assess bills, statutes, regulations, and executive orders proposed or adopted by December 31, 2014. Full-text reviews were conducted to determine inclusion. Included policies were analyzed to assess attributes related to nutrition, behavioral supports, and implementation guidance.

RESULTS

A total of 31 policies met the inclusion criteria; 15 were adopted. Overall alignment ranged from 0% to 86%, and only 10 policies aligned with a majority of the FSG policy attributes. Western states had the most FSG policies proposed or adopted (11 policies). The greatest number of FSG policies were proposed or adopted (8 policies) in 2011, followed by the years 2013 and 2014.

CONCLUSION

The FSG policies proposed or adopted through 2014 that intended to improve the food and beverage environment on state government property vary considerably in their content. This analysis offers baseline data on the FSG landscape and information for future FSG policy assessments.

Peer Influence on Aggressive Behavior, Smoking, and Sexual Behavior: A Study of Randomly-assigned College Roommates

Identifying casual peer influence is a long-standing challenge to social scientists. Using data from a natural experiment of randomly-assigned college roommates (N = 2,059), which removes the threat of friend selection, we investigate peer effects on aggressive behavior, smoking, and concurrent sexual partnering. The findings suggest that the magnitude and direction of peer influence depend on predisposition, gender, and the nature of the behavior. Peer effects on individuals predisposed toward a given behavior tend to be larger than peer effects on individuals without such a predisposition. We find that the influence of roommates on aggressive behavior is more pronounced among male students than among female students; roommate effects on smoking are negative among female students and male students who did not smoke before college. For concurrent sexual partnering, a highly private behavior, we find no evidence of peer effects.

Concordance between timeline follow-back and single-question assessment of self-reported smoking in a clinical trial

BACKGROUND

Smoking cessation clinical trials assess tobacco abstinence using self-report and biomarkers. Optimum methods for each are unclear; a common question assesses smoking in the prior 7 days. In contrast, timeline follow-back (TLFB) is another technique often used to assess use of alcohol in treatment trials; it is used less frequently in studies of smoking cessation. The goal of this study was to assess concordance between the 7-day smoking question and a 7-day TLFB.

METHODS

Secondary analysis of data from a randomized clinical trial of smoking cessation was conducted at a busy, urban hospital emergency department (ED) from October 2010 to December 2012. At 1, 3, and 12 months, subjects were contacted by phone to assess smoking status. Those reporting abstinence at 3 months were asked to return for an in-person measurement of exhaled carbon monoxide. For this analysis, smoking status at 1 month was compared for subjects in response to 2 questions asked concurrently, addressing 7-day point prevalence tobacco use and a 7-day TLFB.

RESULTS

Of 780 subjects, 666 (85.4%) were available for 1-month follow-up. Of these, 99 (14.9%) reported no smoking in response to the 7-day question, and 96 (14.4%) reported no smoking in response to the 7-day TLFB. The overall proportionate agreement between the 2 methods was 98.6%, with a kappa of 0.95 (95% confidence interval [CI]: 0.91-0.98).

CONCLUSIONS

A single question that assesses smoking at 7 days provides excellent concordance with the more detailed TLFB. The single question appears adequate to assess self-reported tobacco use in clinical trials of smoking cessation.

Trends in Mortality Disparities by Area-Based Poverty in New York City, 1990-2010

Residing in a high-poverty area has consistently been associated with higher mortality rates, but the association between poverty and mortality can change over time. We examine the association between neighborhood poverty and mortality in New York City (NYC) during 1990-2010 to document mortality disparity changes over time and determine causes of death for which disparities are greatest. We used NYC and New York state mortality data for years 1990, 2000, and 2010 to calculate all-cause and cause-specific age-adjusted death rates (AADRs) by census tract poverty (CTP), which is the proportion of persons in a census tract living below the federal poverty threshold. We calculated mortality disparities, measured as the difference in AADR between the lowest and highest CTP groups, within and across race/ethnicity, nativity, and sex categories by year. We observed higher all-cause AADRs with higher CTP for each year for all race/ethnicities, both sexes, and US-born persons. Mortality disparities decreased progressively during 1990-2010 for the NYC population overall, for each race/ethnic group, and for the majority of causes of death. The overall mortality disparity between the highest and lowest CTP groups during 2010 was 2.55 deaths/1000 population. The largest contributors to mortality disparities were heart disease (51.52 deaths/100,000 population), human immunodeficiency virus (19.96/100,000 population), and diabetes (19.59/100,000 population). We show that progress was made in narrowing socioeconomic disparities in mortality during 1990-2010, but substantial disparities remain. Future efforts toward achieving health equity in NYC mortality should focus on areas contributing most to disparities.

Cost Effectiveness of a Sugar-Sweetened Beverage Excise Tax in the U.S

INTRODUCTION

Reducing sugar-sweetened beverage consumption through taxation is a promising public health response to the obesity epidemic in the U.S. This study quantifies the expected health and economic benefits of a national sugar-sweetened beverage excise tax of $0.01/ounce over 10 years.

METHODS

A cohort model was used to simulate the impact of the tax on BMI. Assuming ongoing implementation and effect maintenance, quality-adjusted life-years gained and disability-adjusted life-years and healthcare costs averted were estimated over the 2015-2025 period for the 2015 U.S.

POPULATION

Costs and health gains were discounted at 3% annually. Data were analyzed in 2014.

RESULTS

Implementing the tax nationally would cost $51 million in the first year. The tax would reduce sugar-sweetened beverage consumption by 20% and mean BMI by 0.16 (95% uncertainty interval [UI]=0.06, 0.37) units among youth and 0.08 (95% UI=0.03, 0.20) units among adults in the second year for a cost of $3.16 (95% UI=$1.24, $8.14) per BMI unit reduced. From 2015 to 2025, the policy would avert 101,000 disability-adjusted life-years (95% UI=34,800, 249,000); gain 871,000 quality-adjusted life-years (95% UI=342,000, 2,030,000); and result in $23.6 billion (95% UI=$9.33 billion, $54.9 billion) in healthcare cost savings. The tax would generate $12.5 billion in annual revenue (95% UI=$8.92, billion, $14.1 billion).

CONCLUSIONS

The proposed tax could substantially reduce BMI and healthcare expenditures and increase healthy life expectancy. Concerns regarding the potentially regressive tax may be addressed by reduced obesity disparities and progressive earmarking of tax revenue for health promotion.

Trends in cigarette, cigar, and smokeless tobacco use among New York City public high school youth smokers, 2001-2013

OBJECTIVE

This study aimed to describe the recent trends in youth smoking behaviors, and examine cigar and smokeless tobacco use patterns among youth smokers in New York City.

METHODS

Data, analyzed in 2014, were from the New York City Youth Risk Behavior Survey, a cross-sectional survey conducted bi-annually since 1997 in a representative sample of New York City public high school students (2001-2013), n = 59,122.

RESULTS

Cigarette smoking declined 53%, from 17.6% in 2001 to 8.2% in 2013 (p < 0.001). The proportion of cigar use among smokers doubled, from 22.2% in 2001 to 45.9% in 2013 (p < 0.001), while the proportion of smokeless tobacco use among smokers increased by 400% between 2001 and 2013 (4.2% vs. 21.2%, p < 0.001).

CONCLUSIONS

Youth cigarette smoking rates in New York City decreased, while cigar smoking and smokeless tobacco use among smokers increased considerably. These data highlight trends in youth smoking behaviors within the context of New York City's comprehensive tobacco control program and stress the need for additional activity to spur further declines in cigarette smoking and reverse the trends in cigar and smokeless tobacco use among New York City youth. Results demonstrate the need for continuous surveillance and action by the public health community to counteract tobacco industry promotion of other products.

Complexity and dynamism from an urban health perspective: a rationale for a system dynamics approach

In a variety of urban health frameworks, cities are conceptualized as complex and dynamic yet commonly used epidemiological methods have failed to address this complexity and dynamism head on due to their narrow problem definitions and linear analytical representations. Scholars from a variety of disciplines have also long conceptualized cities as systems, but few have modeled urban health issues as problems within a system. Systems thinking in general and system dynamics in particular are relatively new approaches in public health, but ones that hold immense promise as methodologies to model and analyze the complexity underlying urban processes to effectively inform policy actions in dynamic environments. This conceptual essay reviews the utility of applying the concepts, principles, and methods of systems thinking to the study of complex urban health phenomena as a complementary approach to standard epidemiological methods using specific examples and provides recommendations on how to better incorporate systems thinking methods in urban health research and practice.

Public opinions on tax and retail-based tobacco control strategies

BACKGROUND

While tobacco taxes and smoke-free air regulations have significantly decreased tobacco use, tobacco-related illness accounts for hundreds of thousands of annual deaths. Experts are considering additional strategies to further reduce tobacco consumption.

METHODS

We investigated smokers' (n=2118) and non-smokers' (n=2210) opinions on existing and theoretical strategies, including tax and retailer-based strategies in New York City, across three cross-sectional surveys.

RESULTS

Compared with smokers, non-smokers were significantly more likely (p<0.05) to favour all tobacco control strategies. Overall, 25% of smokers surveyed favoured increasing taxes on cigarettes, climbing to 60% if taxes were used to fund healthcare programmes. Among non-smokers, 72% favoured raising taxes, increasing to 83% if taxes were used to fund healthcare programmes. 54% of non-smoking New Yorkers favoured limiting the number of tobacco retail licences, as did 30% of smokers. The most popular retail-based strategies were raising the minimum age to purchase cigarettes from 18 to 21, with 60% of smokers and 69% of non-smokers in favour, and prohibiting retailers near schools from selling tobacco, with 51% of smokers and 69% of non-smokers in favour. Keeping tobacco products out of customers' view, prohibiting tobacco companies from paying retailers to display or advertise tobacco products and prohibiting price promotions were favoured by more than half of non-smokers surveyed, and almost half of smokers.

CONCLUSIONS

While the support level varied between smokers and non-smokers, price and retail-based tobacco control strategies were consistently supported by the public, providing useful information for jurisdictions examining emerging tobacco control strategies.

Smoking Habits of the Homeless

The homeless population in the United States remains high, with over 600,000 homeless on any given night, and surveys in multiple homeless communities have found smoking rates to range from 68 to 80%, 3–4 times the national average (Baggett, Tobey, & Rigotti, 2013). This high rate is of grave concern to this vulnerable population, as cigarette smoking is the leading preventable cause of premature death in the United States, and cardiovascular disease and cancers of the lung and airway secondary to smoking are the leading causes of death within the homeless population (Porter, Houston, Anderson & Maryman, 2011). Over the last two decades, moves to curb smoking in New York City through taxation and bans on indoor smoking resulted in significantly lower smoking rates throughout the city (Coady et al., 2012). However, as primary care providers to the homeless, we have noted continued high rates of smoking among our patients despite the citywide success of cessation programs, and whether the changes over the last two decades have affected smoking rates in this vulnerable population has not been assessed in the literature. We conducted a survey of 224 homeless adults in New York City shelter walk-in clinics in the 2013 calendar year to assess the current prevalence of smoking in this population, and assess the impact of restrictions, specifically precipitous elevation in prices.

Increases in smoking cessation interventions after a feedback and improvement initiative using electronic health records -- 19 community health centers, New York City, October 2010-March 2012

Quitting smoking substantially reduces smokers' risk for smoking-related morbidity and mortality and can increase life expectancy by up to a decade. Most smokers want to quit and make at least one medical provider visit annually. Health care providers can play an important role in helping smokers quit by documenting patients' tobacco use, advising smokers to quit, and providing evidence-based cessation treatments or referrals for treatment, but many providers and practices do not regularly take these actions. Systems to increase provider screening and delivery of cessation interventions are available; in particular, electronic health records (EHRs) can be powerful tools to facilitate increased cessation interventions. This analysis reports on an EHR-based pay-for-improvement initiative in 19 community health centers (CHCs) in New York City (NYC) that sought to increase smoking status documentation and cessation interventions. At the end of the initiative, the mean proportion of patients who were documented as smokers in CHCs had increased from 24% to 27%, whereas the mean proportion of documented smokers who received a cessation intervention had increased from 23% to 54%. Public health programs and health systems should consider implementing strategies to equip and train clinical providers to use information technology to increase delivery of cessation interventions.

Institution-to-institution mentoring to build capacity in 24 local US health departments: best practices and lessons learned

Introduction

Institutional mentoring may be a useful capacity-building model to support local health departments facing public health challenges. The New York City Department of Health and Mental Hygiene conducted a qualitative evaluation of an institutional mentoring program designed to increase capacity of health departments seeking to address chronic disease prevention. The mentoring program included 2 program models, a one-to-one model and a collaborative model, developed and implemented for 24 Communities Putting Prevention to Work grantee communities nationwide.

Methods

We conducted semi-structured telephone interviews to assess grantees’ perspectives on the effectiveness of the mentoring program in supporting their work. Two interviews were conducted with key informants from each participating community. Three evaluators coded and analyzed data using ATLAS.ti software and using grounded theory to identify emerging themes.

Results

We completed 90 interviews with 44 mentees. We identified 7 key program strengths: learning from the New York City health department’s experience, adapting resources to local needs, incorporating new approaches and sharing strategies, developing the mentor–mentee relationship, creating momentum for action, establishing regular communication, and encouraging peer interaction.

Conclusion

Participants overwhelmingly indicated that the mentoring program’s key strengths improved their capacity to address chronic disease prevention in their communities. We recommend dissemination of the results achieved, emphasizing the need to adapt the institutional mentoring model to local needs to achieve successful outcomes. We also recommend future research to consider whether a hybrid programmatic model that includes regular one-on-one communication and in-person conferences could be used as a standard framework for institutional mentoring.

Epidemiology and public health policy of tobacco use and cardiovascular disorders in low- and middle-income countries

All forms of tobacco lead to an increased risk of cardiovascular disorders. During the past few decades, the number of people who consume tobacco has increased worldwide because of an overall increase in the global population. It is estimated that close to 80% of the >1.3 billion people who smoke tobacco in the world are in low- and middle-income countries. Smokeless forms of tobacco are also widely consumed in low- and middle-income countries, including chewable and snuffed forms. Lack of targeted and effective strategies to control tobacco consumption contributes to a large burden of cardiovascular disorders in low- and middle-income countries, where cardiovascular disorders have become the leading cause of morbidity and mortality. In this review, we evaluate the epidemiology of tobacco use in low- and middle-income countries and assess the public health policies needed to control tobacco use in such regions for the prevention of cardiovascular disorders and other tobacco-related morbidities and mortality.

Per-pack price reductions available from different cigarette purchasing strategies: United States, 2009-2010

OBJECTIVE

Following cigarette excise tax increases, smokers may use cigarette price minimization strategies to continue their usual cigarette consumption rather than reducing consumption or quitting. This reduces the public health benefits of the tax increase. This paper estimates the price reductions for a wide-range of strategies, compensating for overlapping strategies.

METHOD

We performed regression analysis on the 2009-2010 National Adult Tobacco Survey (N=13,394) to explore price reductions that smokers in the United States obtained from purchasing cigarettes. We examined five cigarette price minimization strategies: 1) purchasing discount brand cigarettes, 2) using price promotions, 3) purchasing cartons, 4) purchasing on Indian reservations, and 5) purchasing online. Price reductions from these strategies were estimated jointly to compensate for overlapping strategies.

RESULTS

Each strategy provided price reductions between 26 and 99cents per pack. Combined price reductions were possible. Additionally, price promotions were used with regular brands to obtain larger price reductions than when price promotions were used with generic brands.

CONCLUSION

Smokers can realize large price reductions from price minimization strategies, and there are many strategies available. Policymakers and public health officials should be aware of the extent that these strategies can reduce cigarette prices.

Equity impact of population-level interventions and policies to reduce smoking in adults: a systematic review

BACKGROUND AND AIMS

There is strong evidence about which tobacco control policies reduce smoking. However, their equity impact is uncertain. The aim was to assess the effectiveness of population-level interventions/policies to reduce socioeconomic inequalities in adult smoking.

METHODS

Systematic review of studies of population-level interventions/policies reporting smoking-related outcomes in adults of lower compared to higher socioeconomic status (SES). References were screened and independently checked. Studies were quality assessed. Results are presented in a narrative synthesis. Equity impact was assessed as: positive (reduced inequality), neutral (no difference by SES), negative (increased inequality), mixed (equity impact varied) or unclear.

RESULTS

117 studies of 130 interventions/policies were included: smokefree (44); price/tax (27); mass media campaigns (30); advertising controls (9); cessation support (9); settings-based interventions (7); multiple policies (4). The distribution of equity effects was: 33 positive, 36 neutral, 38 negative, 6 mixed, 17 unclear. Most neutral equity studies benefited all SES groups. Fourteen price/tax studies were equity positive. Voluntary, regional and partial smokefree policies were more likely to be equity negative than national, comprehensive smokefree policies. Mass media campaigns had inconsistent equity effects. Cigarette marketing controls were equity positive or neutral. Targeted national smoking cessation services can be equity positive by achieving higher reach among low SES, compensating for lower quit rates.

CONCLUSIONS

Few studies have assessed the equity impact of tobacco control policy/interventions. Price/tax increases had the most consistent positive equity impact. More research is needed to strengthen the evidence-base for reducing smoking inequalities and to develop effective equity-orientated tobacco control strategies.

Mind the public health leadership gap: the opportunities and challenges of engaging high-profile individuals in the public health agenda

BACKGROUND

Public health leadership has been criticized as being ineffective. The public health profession is relatively small. Critics have argued that there is over-emphasis on technical aspects and insufficient use of the 'community as a source of public health actions'.

METHODS

The paper analyses the resources, motivations and skills utilized by high-profile individuals who have made contributions to the public health agenda. The phenomenon of celebrity diplomacy is critiqued. Two exemplars are discussed: Jamie Oliver and Michael Bloomberg. The risks of involving celebrities are also considered.

RESULTS

Leaders for public health demonstrate 'a paradoxical blend of personal humility and professional will' to make the 'right decisions happen'. While they may have ego or self-interest, in this context, at least, they channel their ambition for the public health cause, not themselves.

CONCLUSIONS

Leaders from outside public health may have no understanding of what public health is nor consider their work as part of a wider public health agenda. It is important to understand why they become leaders for public health. This will inform a strategy for how others may be encouraged to collaborate for public health causes. Some key points for working with high-profile leaders for public health are identified.

Public support for smoke-free air strategies among smokers and nonsmokers, New York City, 2010-2012

INTRODUCTION

From 2010 through 2012, the New York City Department of Health and Mental Hygiene engaged in multiple smoke-free-air activities in collaboration with community, institution, and government partners. These included implementing a law prohibiting smoking in all parks and beaches as well as working to increase compliance with existing Smoke-free Air Act provisions.

METHODS

We investigated trends in awareness of existing smoke-free rules publicized with new signage and public support for new smoke-free air strategies by using 3 waves of survey data from population-based samples of smoking and nonsmoking adults in New York City (2010-2012). Analyses adjusted for the influence of sociodemographic characteristics.

RESULTS

Among both smokers and nonsmokers, we observed increased awareness of smoke-free regulations in outdoor areas around hospital entrances and grounds and in lines in outdoor waiting areas for buses and taxis. Regardless of smoking status, women, racial/ethnic minorities, and adults aged 25 to 44 years were more likely than men, non-Hispanic whites, and adults aged 65 years or older to support smoke-free air strategies.

CONCLUSION

New signage was successful in increasing population-wide awareness of rules. Our analysis of the association between demographic characteristics and support for tobacco control over time provide important contextual information for community education efforts on secondhand smoke and smoke-free air strategies.

Designing a quality improvement program with electronic health records: New York City's Health eQuits

Despite clear recommendations for identifying and intervening with smokers, clinical preventive practice is inconsistent in primary care. Use of electronic health records could facilitate improvement. Community health centers treating low-income and Medicaid recipients with greater smoking prevalence than the general population were recruited for a pilot program. Key design elements used to engage centers' participation include designating a project champion at each organization, confirming ability to transmit data for reporting and participation, and offering money to facilitate initial engagement; however, financial incentives did not motivate all organizations. Other methods to elicit participation and to motivate practice change included building on centers' previous experiences with similar programs, utilizing existing relationships with state cessation centers, and harnessing the "competitive" spirit-sharing both good news and areas for improvement to stimulate action. These experiences and observations may assist others in designing programs to improve clinical interventions with smokers.

Six components necessary for effective public health program implementation

Public health programs succeed and survive if organizations and coalitions address 6 key areas. (1) Innovation to develop the evidence base for action; (2) a technical package of a limited number of high-priority, evidence-based interventions that together will have a major impact; (3) effective performance management, especially through rigorous, real-time monitoring, evaluation, and program improvement; (4) partnerships and coalitions with public- and private-sector organizations; (5) communication of accurate and timely information to the health care community, decision makers, and the public to effect behavior change and engage civil society; and (6) political commitment to obtain resources and support for effective action. Programs including smallpox eradication, tuberculosis control, tobacco control, polio eradication, and others have made progress by addressing these 6 areas.

A novel approach to estimating the prevalence of untaxed cigarettes in the USA: findings from the 2009 and 2010 international tobacco control surveys

BACKGROUND

Increases in tobacco taxes are effective in reducing tobacco consumption, but because of the addictive nature of cigarettes, smokers often seek out less expensive sources of cigarettes. The objective of this study is to estimate the prevalence of cigarette packs that are untaxed by the state in which the participant resides in a sample of US smokers at two time points.

METHODS

Data for this study were taken from the 2009 and 2010 waves of the International Tobacco Control United States Survey. Members of this nationally representative cohort of smokers were invited to send us an unopened pack of their usual brand of cigarettes.

RESULTS

In 2009, 318 packs were received from 401 eligible participants (79%). In 2010, 366 packs were received from 491 eligible participants (75%). In total, 20% of the packs in 2009 and 21% in 2010 were classified as untaxed by the participant's state of residence. The prevalence of untaxed cigarettes was higher in states with higher-excise taxes. Smokers who do not have a plan to quit were significantly more likely to have sent back a pack that was classified as untaxed by the participant's state of residence.

CONCLUSIONS

One in five packs were untaxed with rates higher in states with higher-excise taxes. It is unclear whether these estimates differ from the actual prevalence of cigarettes that are untaxed by a smoker's state of residence. Harmonisation of excise tax rates across all 50 US states might be one method of reducing or eliminating the incentive to avoid or evade these taxes.

A century of smoke

Tobacco kills 5 million people annually. By the mid 2020s, that figure will increase to about 10 million a year, with most of the deaths occurring in developing countries. This review explains how early technological and regulatory developments contributed to the epidemic, reveals the efforts of the tobacco industry to conceal its products' harmfulness, and stresses the role of the globalization of trade and marketing as a means of increasing consumption world-wide. The results of tens of thousands of studies published globally over the past 50 years point to an association between smoking and lung cancer and other adverse health effects, and the non-smoker's rights movement has exposed the wide-spread perils of 'secondhand' smoke. Yet, the tobacco industry continues its global expansion, and consumers in low- and middle-income countries are especially susceptible to its marketing tactics. This review ends by emphasising the need for a global public-health response, and identifies the Framework Convention on Tobacco Control as a significant effort. It stresses the need for accelerated action and innovative tobacco-control efforts, if the projected death toll is to be reduced in this century.

Cigarette price minimization strategies in the United States: price reductions and responsiveness to excise taxes

INTRODUCTION

Because cigarette price minimization strategies can provide substantial price reductions for individuals continuing their usual smoking behaviors following federal and state cigarette excise tax increases, we examined independent price reductions compensating for overlapping strategies. The possible availability of larger independent price reduction opportunities in states with higher cigarette excise taxes is explored.

METHODS

Regression analysis used the 2006-2007 Tobacco Use Supplement of the Current Population Survey (N = 26,826) to explore national and state-level independent price reductions that smokers obtained from purchasing cigarettes (a) by the carton, (b) in a state with a lower average after-tax cigarette price than in the state of residence, and (c) in "some other way," including online or in another country. Price reductions from these strategies are estimated jointly to compensate for known overlapping strategies.

RESULTS

Each strategy reduced the price of cigarettes by 64-94 cents per pack. These price reductions are 9%-22% lower than conventionally estimated results not compensating for overlapping strategies. Price reductions vary substantially by state. Following cigarette excise tax increases, the price reduction available from purchasing cigarettes by cartons increased. Additionally, the price reduction from purchasing cigarettes in a state with a lower average after-tax cigarette price is positively associated with state cigarette excise tax rates and border state cigarette excise tax rate differentials.

CONCLUSIONS

Findings from this large, nationally representative study of cigarette smokers suggest that price reductions are larger in states with higher cigarette excise taxes, and increase as cigarette excise taxes rise.

The impact of cigarette excise tax increases on purchasing behaviors among New York city smokers

OBJECTIVES

We examined the relationship between cigarette excise tax increases and tax-avoidant purchasing behaviors among New York City adult smokers.

METHODS

We analyzed data from the city's annual Community Health Survey to assess changes in rates of tax avoidance over time (2003-2010) and smokers' responses to the 2008 state cigarette tax increase. Multivariable logistic regression analysis identified correlates of buying more cigarettes on the street in response to the increase.

RESULTS

After the 2002 tax increase, the percentage of smokers engaged in tax-avoidant behavior decreased with time from 30% in 2003 to 13% in 2007. Following the 2008 tax increase, 21% of smokers reported buying more cigarettes from another person on the street. Low-income, younger, Black, and Hispanic smokers were more likely than respondents with other sociodemographic characteristics to purchase more cigarettes on the street.

CONCLUSIONS

To maximize public health impact, cigarette tax increases should be paired with efforts to limit the flow of untaxed cigarettes entering jurisdictions with high cigarette pack prices.

Evaluating New York City's smoke-free parks and beaches law: a critical multiplist approach to assessing behavioral impact

This article describes the evaluation of the law banning smoking in New York City's parks and beaches that went into effect in 2011. We discuss the practical and methodological challenges that emerged in evaluating this law, and describe how we applied the principles of critical multiplism to address these issues. The evaluation uses data from three complementary studies, each with a unique set of strengths and weaknesses that can provide converging evidence for the effectiveness of the law. Results from a litter audit and an observational study suggest the ban reduced smoking in parks and beaches. The purpose, methodology and baseline results from an ongoing survey that measures how frequently adults in NYC and across New York State notice people smoking in parks and on beaches are presented and discussed. Limitations are considered and suggestions are offered for future evaluations of similar policies.

Tobacco smoking: the leading cause of preventable disease worldwide

Tobacco smoking is the world's leading cause of avoidable premature mortality, reflecting the potent toxicity of tobacco smoke inhaled by smokers for decades. In the twentieth century, lung cancer was an early sentinel of the emergence of the still persisting epidemic of tobacco-caused disease. Smoking has declined in many countries, particularly the high-income countries, but low- and middle-income countries remain at risk because of the aggressive tactics of tobacco multinationals. The World Health Organization treaty, the Framework Convention on Tobacco Control, is a critical factor in countering these tactics and precipitating the end of the global epidemic of tobacco smoking.

Lessons learned from the implementation of a time-limited, large-scale nicotine replacement therapy giveaway program in New York City

Since 2006, the New York City (NYC) Department of Health and Mental Hygiene has conducted the Nicotine Patch and Gum Program (NPGP) in collaboration with 311, NYC's non-emergency information line. In two prior years, the program was conducted in collaboration with the New York State (NYS) Smokers' Quitline and with community-based organizations. The NPGP is an annual, brief, population-based nicotine replacement therapy (NRT) giveaway for NYC residents, complementing the NYS Quitline's year-round NRT distribution program. Since 2006, 168,000 smokers have enrolled, with the largest number of enrollees in 2010 (n = 40,000) and the smallest number in 2009 (n = 28,000). A 2003 program evaluation demonstrated that smokers who received NRT through the NPGP had higher quit rates than smokers who did not receive NRT; these results were replicated in 2006 and 2008. Lessons learned from implementing the NPGP include: 1) time-limited NRT interventions are important complements to year-round NRT distribution; 2) expanding NRT distribution to light smokers increases treatment reach; and 3) employing multiple enrollment mechanisms, including telephone and online options, extends program reach to diverse groups of smokers. The NPGP provides a model for other jurisdictions considering implementing time-limited, population-based NRT programs as a complementary strategy to enhance ongoing tobacco control efforts.