The Brazil SimSmoke Policy Simulation Model: The Effect of Strong Tobacco Control Policies on Smoking Prevalence and Smoking-Attributable Deaths in a Middle Income Nation

Background

Brazil has reduced its smoking rate by about 50% in the last 20 y. During that time period, strong tobacco control policies were implemented. This paper estimates the effect of these stricter policies on smoking prevalence and associated premature mortality, and the effect that additional policies may have.

Methods and Findings

The model was developed using the SimSmoke tobacco control policy model. Using policy, population, and smoking data for Brazil, the model assesses the effect on premature deaths of cigarette taxes, smoke-free air laws, mass media campaigns, marketing restrictions, packaging requirements, cessation treatment programs, and youth access restrictions. We estimate the effect of past policies relative to a counterfactual of policies kept to 1989 levels, and the effect of stricter future policies. Male and female smoking prevalence in Brazil have fallen by about half since 1989, which represents a 46% (lower and upper bounds: 28%–66%) relative reduction compared to the 2010 prevalence under the counterfactual scenario of policies held to 1989 levels. Almost half of that 46% reduction is explained by price increases, 14% by smoke-free air laws, 14% by marketing restrictions, 8% by health warnings, 6% by mass media campaigns, and 10% by cessation treatment programs. As a result of the past policies, a total of almost 420,000 (260,000–715,000) deaths had been averted by 2010, increasing to almost 7 million (4.5 million–10.3 million) deaths projected by 2050. Comparing future implementation of a set of stricter policies to a scenario with 2010 policies held constant, smoking prevalence by 2050 could be reduced by another 39% (29%–54%), and 1.3 million (0.9 million–2.0 million) out of 9 million future premature deaths could be averted.

Conclusions

Brazil provides one of the outstanding public health success stories in reducing deaths due to smoking, and serves as a model for other low and middle income nations. However, a set of stricter policies could further reduce smoking and save many additional lives. Please see later in the article for the Editors'' Summary     

Youth are more sensitive to price changes in cigarettes than adults

Virtually all smoking begins in our population's youth and remains as a habit into those smokers' elder years. If we desire to halt smoking in its infancy, we should seek to deter and induce cessation in the youth years. It has been cited that taxation is an effective means to deter smoking at all ages, particularly efficacious in the youth population. This paper explores the merits of this method of preventative medicine, and intends to investigate differences between the price elasticity of cigarette demand between various cohorts, particularly the adult versus the youth population. We use a two-variable log-log, ordinary least-squares econometric regression to determine the extent that price alterations have on participation rates and quantity smoked. Our results show that youth are quite responsive to price increases showing a decrease of 14 percent prevalence in smoking for a 10 percent increase in price; whereas, the adult population is relatively less responsive to such price changes, exhibiting nearly a 2 percent decrease in prevalence for a 10 percent increase in price. We conclude that taxation is an effective means of socially-enacted preventative medicine in deterring youth smoking.     

The Effect of Tobacco Control Measures during a Period of Rising Cardiovascular Disease Risk in India: A Mathematical Model of Myocardial Infarction and Stroke

Background

We simulated tobacco control and pharmacological strategies for preventing cardiovascular deaths in India, the country that is expected to experience more cardiovascular deaths than any other over the next decade.

Methods and Findings

A microsimulation model was developed to quantify the differential effects of various tobacco control measures and pharmacological therapies on myocardial infarction and stroke deaths stratified by age, gender, and urban/rural status for 2013 to 2022. The model incorporated population-representative data from India on multiple risk factors that affect myocardial infarction and stroke mortality, including hypertension, hyperlipidemia, diabetes, coronary heart disease, and cerebrovascular disease. We also included data from India on cigarette smoking, bidi smoking, chewing tobacco, and secondhand smoke. According to the model''s results, smoke-free legislation and tobacco taxation would likely be the most effective strategy among a menu of tobacco control strategies (including, as well, brief cessation advice by health care providers, mass media campaigns, and an advertising ban) for reducing myocardial infarction and stroke deaths over the next decade, while cessation advice would be expected to be the least effective strategy at the population level. In combination, these tobacco control interventions could avert 25% of myocardial infarctions and strokes (95% CI: 17%–34%) if the effects of the interventions are additive. These effects are substantially larger than would be achieved through aspirin, antihypertensive, and statin therapy under most scenarios, because of limited treatment access and adherence; nevertheless, the impacts of tobacco control policies and pharmacological interventions appear to be markedly synergistic, averting up to one-third of deaths from myocardial infarction and stroke among 20- to 79-y-olds over the next 10 y. Pharmacological therapies could also be considerably more potent with further health system improvements.

Conclusions

Smoke-free laws and substantially increased tobacco taxation appear to be markedly potent population measures to avert future cardiovascular deaths in India. Despite the rise in co-morbid cardiovascular disease risk factors like hyperlipidemia and hypertension in low- and middle-income countries, tobacco control is likely to remain a highly effective strategy to reduce cardiovascular deaths. Please see later in the article for the Editors'' Summary     

Reducing tobacco consumption: public policy alternatives for Canada.

The costs of smoking are extensive, not only in fiscal terms but also in terms of human suffering. A review of several major public policies reveals that concerted efforts by all levels of government and by the public can have an effect on the rate of consumption of tobacco. Specifically, increases in price through taxation, anti-smoking messages, restrictions on smoking behaviour and increased public pressure are effective in reducing smoking. Serious joint efforts in the area of public policy should be pursued to control the effects of this hazardous practice in Canada.     

Behavioral approaches in tobacco control

In most Western societies, there is an abundance of information on what needs to be done to control the use of tobacco. This paper presents different strategies for addressing tobacco control. Many of the strategies such as increasing taxes, increasing control over promotion of tobacco, and the restriction of smoking should be made a priority. However, there is still the need to provide help for the smoker to quit. The evidence with regards to effective ways of getting smokers to quit and the effectiveness of different modalities is reviewed. Programs found to be effective include self-help, individual counseling, and group counseling. Counseling programs appear to double the effect of success compared to no program. Nicotine replacement therapy has been demonstrated to be an important adjunct therapy to the behavioral programs. Issues regarding the cessation of tobacco by youth need to be addressed distinctively from adult cessation. Relapse prevention for both youth and adults needs to become a major focus of programs dealing with smokers who want to quit.     

Comparison of tobacco control scenarios: quantifying estimates of long-term health impact using the DYNAMO-HIA modeling tool

Background

There are several types of tobacco control interventions/policies which can change future smoking exposure. The most basic intervention types are 1) smoking cessation interventions 2) preventing smoking initiation and 3) implementation of a nationwide policy affecting quitters and starters simultaneously. The possibility for dynamic quantification of such different interventions is key for comparing the timing and size of their effects.

Methods and Results

We developed a software tool, DYNAMO-HIA, which allows for a quantitative comparison of the health impact of different policy scenarios. We illustrate the outcomes of the tool for the three typical types of tobacco control interventions if these were applied in the Netherlands. The tool was used to model the effects of different types of smoking interventions on future smoking prevalence and on health outcomes, comparing these three scenarios with the business-as-usual scenario. The necessary data input was obtained from the DYNAMO-HIA database which was assembled as part of this project. All smoking interventions will be effective in the long run. The population-wide strategy will be most effective in both the short and long term. The smoking cessation scenario will be second-most effective in the short run, though in the long run the smoking initiation scenario will become almost as effective. Interventions aimed at preventing the initiation of smoking need a long time horizon to become manifest in terms of health effects. The outcomes strongly depend on the groups targeted by the intervention.

Conclusion

We calculated how much more effective the population-wide strategy is, in both the short and long term, compared to quit smoking interventions and measures aimed at preventing the initiation of smoking. By allowing a great variety of user-specified choices, the DYNAMO-HIA tool is a powerful instrument by which the consequences of different tobacco control policies and interventions can be assessed.     

The waterpipe: An emerging global risk for cancer

Tobacco smoking continues to be the leading preventable cause of morbidity and mortality worldwide. Each year more than 5 million smokers die prematurely because of their habit wreaking havoc on the welfare of families and communities worldwide. While cigarettes remain the main tobacco killer worldwide, for many youth tobacco use and addiction is maintained by means other than cigarettes. In particular, over the past decade, waterpipe smoking (a.k.a. hookah, shisha, narghile) has become increasingly popular among youth in the Middle East, and is rapidly spreading globally. Available evidence suggests that waterpipe smoking is associated with many of the known risks of tobacco smoking, particularly cancer. Despite these worrisome signs, policies and interventions to address this emerging public health problem have been lagging behind. In this short review I discuss briefly the evidence generated mostly in the past decade about the global spread of waterpipe smoking and its cancer risk potential.     

The Impact of Taxation Reduction on Smoking in Youth between 1990 and 1999: Results from a Reconstructed Cohort Analysis of the Canadian Community Health Surveys

Background

Increases in taxation can contribute to smoking control. In the early 1990’s, tobacco smuggling rates in Canada increased dramatically. Governments responded with a substantial reduction in taxes on tobacco products. This study examines the impact of these tax changes on smoking in youth in Canada.

Methods

Data on smoking from three consecutive cycles of the Canadian Community Health Surveys were combined and analyzed using a reconstructed cohort approach. Age, sex and calendar year specific rates of smoking experimentation and the onset of daily smoking were estimated for youth. Estimates apply to the entire Canadian population.

Results

There was a strong increase in smoking in youth in the years following the reduction in tobacco taxes. The increase was stronger in women. The rates returned to pre-1990 rates by about 2002. The number of excess daily smokers for people born between 1977 and 1985 that can be linked to the taxation reduction is about 190,000.

Interpretation

There is strong evidence that reduction of tobacco taxes to combat smuggling had an adverse impact on smoking rates in youth.     

What factors influence smoking prevalence and smoke free policy enactment across the European Union Member States

Background

Smoking prevention should be a primary public health priority for all governments, and effective preventive policies have been identified for decades. The heterogeneity of smoking prevalence between European Union (EU) Member States therefore reflects, at least in part, a failure by governments to prioritise public health over tobacco industry or possibly other financial interests, and hence potentially government corruption.The aims of this study were to test the hypothesis that smoking prevalence is higher in countries with high levels of public sector corruption, and explore the ecological association between smoking prevalence and a range of other national characteristics in current EU Member States.

Methods

Ecological data from 27 EU Member States were used to estimate univariate and multivariate correlations between smoking prevalence and the Transparency International Corruption Perceptions Index, and a range of other national characteristics including economic development, social inclusion, quality of life and importance of religion. We also explored the association between the Corruption Perceptions Index and measures of the extent to which smoke-free policies have been enacted and are enforced.

Results

In univariate analysis, smoking prevalence was significantly higher in countries with higher scores for corruption, material deprivation, and gender inequality; and lower in countries with higher per capita Gross Domestic Product, social spending, life satisfaction and human development scores. In multivariate analysis, only the corruption perception index was independently related to smoking prevalence. Exposure to tobacco smoke in the workplace was also correlated with corruption, independently from smoking prevalence, but not with the measures of national smoke-free policy implementation.

Conclusions

Corruption appears to be an important risk factor for failure of national tobacco control activity in EU countries, and the extent to which key tobacco control policies have been implemented. Further research is needed to assess the causal relationships involved.     

Modeling the Potential Effects of New Tobacco Products and Policies: A Dynamic Population Model for Multiple Product Use and Harm

Background

Recent declines in US cigarette smoking prevalence have coincided with increases in use of other tobacco products. Multiple product tobacco models can help assess the population health impacts associated with use of a wide range of tobacco products.

Methods and Findings

We present a multi-state, dynamical systems population structure model that can be used to assess the effects of tobacco product use behaviors on population health. The model incorporates transition behaviors, such as initiation, cessation, switching, and dual use, related to the use of multiple products. The model tracks product use prevalence and mortality attributable to tobacco use for the overall population and by sex and age group. The model can also be used to estimate differences in these outcomes between scenarios by varying input parameter values. We demonstrate model capabilities by projecting future cigarette smoking prevalence and smoking-attributable mortality and then simulating the effects of introduction of a hypothetical new lower-risk tobacco product under a variety of assumptions about product use. Sensitivity analyses were conducted to examine the range of population impacts that could occur due to differences in input values for product use and risk. We demonstrate that potential benefits from cigarette smokers switching to the lower-risk product can be offset over time through increased initiation of this product. Model results show that population health benefits are particularly sensitive to product risks and initiation, switching, and dual use behaviors.

Conclusion

Our model incorporates the variety of tobacco use behaviors and risks that occur with multiple products. As such, it can evaluate the population health impacts associated with the introduction of new tobacco products or policies that may result in product switching or dual use. Further model development will include refinement of data inputs for non-cigarette tobacco products and inclusion of health outcomes such as morbidity and disability.     

Prevalence and Patterns of Tobacco Use in Bangladesh from 2009 to 2012: Evidence from International Tobacco Control (ITC) Study

Background

Smoking and passive smoking are collectively the biggest preventable cause of death in Bangladesh, with major public health burden of morbidity, disability, mortality and community costs. The available studies of tobacco use in Bangladesh, however, do not necessarily employ nationally representative samples needed to monitor the problem at a national scale. This paper examines the prevalence and patterns of tobacco use among adults in Bangladesh and the changes over time using large nationally representative comparable surveys.

Methods

Using data from two enumerations of the International Tobacco Control (ITC) Bangladesh Project conducted in 2009 and 2012, prevalence estimates are obtained for all tobacco products by socio-economic determinants and sample types of over 90,000 individuals drawn from over 30,000 households. Household level sample weights are used to obtain nationally representative prevalence estimates and standard errors. Statistical tests of difference in the estimates between two time periods are based on a logistic regression model that accounts for the complex sampling design. Using a multinomial logit model, the time trend in tobacco use status is identified to capture the effects of macro level determinants including changes in tobacco control policies.

Results

Between 2009 and 2012, overall tobacco use went down from 42.4% to 36.3%. The decline is more pronounced with respect to smokeless tobacco use than smoking. The prevalence of exclusive cigarette smoking went up from 7.2% to 10.6%; exclusive bidi smoking remained stable at around 2%; while smoking both cigarette and bidi went down from 4.6% to 1.8%; exclusive smokeless tobacco use went down from 20.2% to 16.9%; and both smokeless tobacco use and smoking went down from 8.4% to 5.1%. In general, the prevalence of tobacco use is higher among men, increases from younger to older age groups, and is higher among poorer people. Smoking prevalence is the highest among the slum population, followed by the tribal population, the national population and the border area population, suggesting greater burden of tobacco use among the disadvantaged groups.

Conclusions

The overall decline in tobacco use can be viewed as a structural shift in the tobacco market in Bangladesh from low value products such as bidi and smokeless tobacco to high value cigarettes, which is expected with the growth in income and purchasing power of the general population. Despite the reduction in overall tobacco use, the male smoking prevalence in Bangladesh is still high at 37%. The world average of daily smoking among men is 31.1%. The Tobacco Control Act 2005 and the Amendment have yet to make a significant impact in curbing tobacco usage in Bangladesh. The findings in this paper further suggest that the tobacco control policies in Bangladesh need to include targeted interventions to restrain the use of particular types of tobacco products among specific demographic and socio-economic groups of the population, such as smoked tobacco among men, smokeless tobacco among women, and both smoked and smokeless tobacco among those living in rural areas, those in low socio-economic status and those belonging to the tribal and the slum population.     

Effect of Exposure to Smoking in Movies on Young Adult Smoking in New Zealand

Onscreen Smoking Is a Form of Tobacco Marketing

Tobacco advertising has been prohibited in New Zealand since 1990, and the government has set a goal of becoming a smokefree nation by 2025. However, tobacco marketing persists indirectly through smoking in motion pictures, and there is strong evidence that exposure to onscreen smoking causes young people to start smoking. We investigated the relationship between exposure to smoking in movies and youth smoking initiation among New Zealand young adults. Data from an online survey of 419 smokers and non-smokers aged 18 to 25 were used to estimate respondents’ exposure to smoking occurrences in 50 randomly-selected movies from the 423 US top box office movies released between 2008 and 2012. Analyses involved calculating movie smoking exposure (MSE) for each respondent, using logistic regression to analyse the relationship between MSE and current smoking behaviour, and estimating the attributable fraction due to smoking in movies.

Effect of Smoking in Movies on New Zealand Youth

Exposure to smoking occurrences in movies was associated with current smoking status. After allowing for the influence of family, friends and co-workers, age and rebelliousness, respondents’ likelihood of smoking increased by 11% for every 100-incident increase in exposure to smoking incidents, (aOR1.11; p< .05). The estimated attributable fraction due to smoking in movies was 54%; this risk could be substantially reduced by eliminating smoking from movies currently rated as appropriate for youth. We conclude that exposure to smoking in movies remains a potent risk factor associated with smoking among young adults, even in a progressive tobacco control setting such as New Zealand. Harmonising the age of legal tobacco purchase (18) with the age at which it is legal to view smoking in movies would support New Zealand’s smokefree 2025 goal.     

Smoking and the sudden infant death syndrome: results from 1993-5 case-control study for confidential inquiry into stillbirths and deaths in infancy. Confidential Enquiry into Stillbirths and Deaths Regional Coordinators and Researchers.

OBJECTIVE--To investigate the effects of exposure to tobacco smoke and of parental consumption of alcohol and illegal drugs as risk factors for the sudden infant death syndrome after a national risk reduction campaign which included advice on prenatal and postnatal avoidance of tobacco smoke. DESIGN--Two year population based case-control study. Parental interviews were conducted for each infant who died and four controls matched for age and date of interview. SETTING--Three regions in England with a total population of 17 million people. SUBJECTS--195 babies who died and 780 matched controls. RESULTS--More index than control mothers (62.6% v 25.1%) smoked during pregnancy (multivariate odds ratio = 2.10; 95% confidence interval 1.24 to 3.54). Paternal smoking had an additional independent effect when other factors were controlled for (2.50; 1.48 to 4.22). The risk of death rose with increasing postnatal exposure to tobacco smoke, which had an additive effect among those also exposed to maternal smoking during pregnancy (2.93; 1.56 to 5.48). The population attributable risk was over 61%, which implies that the numbers of deaths from the syndrome could be reduced by almost two third if parents did not smoke. Alcohol use was higher among index than control mothers but was strongly correlated with smoking and on multivariate analysis was not found to have any additional independent effect. Illegal drug use was more common among the index parents, and paternal use of illegal drugs remained significant in the multivariate model (4.68; 1.56 to 14.05). CONCLUSIONS--This study confirms the increased risk of the sudden infant death syndrome associated with maternal smoking during pregnancy and shows evidence that household exposure to tobacco smoke has an independent additive effect. Parental drug misuse has an additional small but significant effect.     

Tobacco, alcohol and illicit drug use among Aboriginal youth living off-reserve: results from the Youth Smoking Survey

Background

Despite the high prevalence of smoking among Aboriginal youth, there is a paucity of research related to tobacco use and other risk behaviours among Aboriginal youth living off-reserve in Canada. We used data from the national Youth Smoking Survey to characterize non-traditional tobacco use, exposure to second-hand smoke, and alcohol and drug use among Aboriginal youth living off-reserve. We examined whether these youth were at increased health risk compared with non-Aboriginal youth.

Methods

We examined cigarette smoking behaviour, use of other tobacco products, use of alcohol and other drugs, and exposure to second-hand smoke among 2620 Aboriginal youth living off-reserve and 26 223 non-Aboriginal youth in grades 9 to 12 who participated in the 2008/09 Youth Smoking Survey.

Results

The prevalence of current smoking among the Aboriginal youth was more than double that among non-Aboriginal youth (24.9% v. 10.4%). Aboriginal youth also had a higher prevalence of regular exposure to second-hand smoke at home (37.3% v. 19.7%) and in cars (51.0% v. 30.3%). Aboriginal youth were more likely than non-Aboriginal youth to be current smokers, to be regularly exposed to second-hand smoke, to have tried marijuana and other illicit drugs, and to engage in binge drinking. They were less likely than non-Aboriginal youth to have tried to quit smoking.

Interpretation

Current national estimates of smoking, and alcohol and illicit drug use among youth underestimate the prevalence of these behaviours among Aboriginal youth living off-reserve. Our findings highlight the need for culturally appropriate prevention and cessation policies and programs for this at-risk population.Compared with the general population in Canada, Aboriginal youth start smoking earlier¹ and have a higher prevalence of smoking,^1–3 with female Aboriginals at greatest risk.¹ Research has also shown that Aboriginal youth have high rates of binge drinking¹ and are more likely than non-Aboriginal youth to use marijuana.⁴Despite the high prevalence of smoking among Aboriginal youth in Canada, there is a paucity of research related to their patterns of tobacco use, especially among Aboriginals living off-reserve.⁵ Most Aboriginals in Canada live off-reserve,⁶ and those 15 years of age and older are more likely than non-Aboriginals to have chronic health conditions, to drink heavily and to smoke.⁷ Given that the Canadian Tobacco Control Strategy emphasizes targeting youth, young adults, First Nations, Inuit and other Aboriginal groups,⁸ a better understanding of tobacco use among Aboriginal youth living off-reserve is required.We conducted this study to examine patterns of tobacco use, exposure to second-hand smoke and the prevalence of alcohol and other drug use among Aboriginal youth living off-reserve. We compared these data with those for non-Aboriginal youth using nationally representative data from the 2008/09 Youth Smoking Survey.     

Childhood influences on youth obesity

We develop a model to estimate the influence of child and parental characteristics on the likelihood that a child will become an obese or overweight youth. We use this model to test whether it is possible to forecast obesity and overweight among youth. Comparing Receiver Operating Characteristic (ROC) scores from these forecasts, we find that a model using childhood covariates does as well in forecasting youth obesity and overweight as a model using the covariate values contemporaneous with the youth obesity and overweight outcomes. The datasets used in this paper, the National Longitudinal Survey of Youth (NLSY79) and the NLSY79 Children and Young Adults, provide data from 1986 to 2002, allowing for the study of a child's transition to and from obesity or overweight over a long period. Explanatory variables that significantly influence the likelihood of youth obesity or overweight outcomes include the mother's obesity status and education, the youth's mental health, and certain demographic features including race, sex, and family size. These factors provide potential targets for policies that could be implemented early in life among children most likely to become obese or overweight.     

Why do teens smoke? American Indian and Hispanic adolescents' perspectives on functional values and addiction

Tobacco use by the young is one of the greatest public health concerns in the United States and is targeted by a number of prevention and control programs. A fuller understanding of the social and cultural values that youths attach to smoking is important in achieving focused, effective prevention strategies. Drawing on data collected through individual and focus group interviews, this article examines reasons that Hispanic and American Indian youths give to explain their smoking. The analysis presented here focuses on two interrelated sets of reasons: the functional values of tobacco use (including mood management, peer influences, and image maintenance) and addiction. This article concludes with a discussion of the implications these data may have for prevention and cessation programs aimed at youth and outlines ideas for an anthropological research agenda on youth and tobacco.     

Tobacco Industry Manipulation of Tobacco Excise and Tobacco Advertising Policies in the Czech Republic: An Analysis of Tobacco Industry Documents

Background

The Czech Republic has one of the poorest tobacco control records in Europe. This paper examines transnational tobacco companies'' (TTCs'') efforts to influence policy there, paying particular attention to excise policies, as high taxes are one of the most effective means of reducing tobacco consumption, and tax structures are an important aspect of TTC competitiveness.

Methods and Findings

TTC documents dating from 1989 to 2004/5 were retrieved from the Legacy Tobacco Documents Library website, analysed using a socio-historical approach, and triangulated with key informant interviews and secondary data. The documents demonstrate significant industry influence over tobacco control policy. Philip Morris (PM) ignored, overturned, and weakened various attempts to restrict tobacco advertising, promoting voluntary approaches as an alternative to binding legislation. PM and British American Tobacco (BAT) lobbied separately on tobacco tax structures, each seeking to implement the structure that benefitted its own brand portfolio over that of its competitors, and enjoying success in turn. On excise levels, the different companies took a far more collaborative approach, seeking to keep tobacco taxes low and specifically to prevent any large tax increases. Collective lobbying, using a variety of arguments, was successful in delaying the tax increases required via European Union accession. Contrary to industry arguments, data show that cigarettes became more affordable post-accession and that TTCs have taken advantage of low excise duties by raising prices. Interview data suggest that TTCs enjoy high-level political support and continue to actively attempt to influence policy.

Conclusion

There is clear evidence of past and ongoing TTC influence over tobacco advertising and excise policy. We conclude that this helps explain the country''s weak tobacco control record. The findings suggest there is significant scope for tobacco tax increases in the Czech Republic and that large (rather than small, incremental) increases are most effective in reducing smoking. Please see later in the article for the Editors'' Summary     

Effect of Tobacco Control Policies on Information Seeking for Smoking Cessation in the Netherlands: A Google Trends Study

Background

The impact of tobacco control policies on measures of smoking cessation behaviour has often been studied, yet there is little information on their precise magnitude and duration. This study aims to measure the magnitude and timing of the impact of Dutch tobacco control policies on the rate of searching for information on smoking cessation, using Google Trends search query data.

Methods

An interrupted time series analysis was used to examine the effect of two types of policies (smoke-free legislation and reimbursement of smoking cessation support (SCS)) on Google searches for ‘quit smoking’. Google Trends data were seasonally adjusted and analysed using autoregressive integrated moving average (ARIMA) modelling. Multiple effect periods were modelled as dummy variables and analysed simultaneously to examine the magnitude and duration of the effect of each intervention. The same analysis was repeated with Belgian search query data as a control group, since Belgium is the country most comparable to the Netherlands in terms of geography, language, history and culture.

Results

A significant increase in relative search volume (RSV) was found from one to four weeks (21–41%) after the introduction of the smoking ban in restaurants and bars in the Netherlands in 2008. The introduction of SCS reimbursement in 2011 was associated with a significant increase of RSV (16–22%) in the Netherlands after 3 to 52 weeks. The reintroduction of SCS in 2013 was associated with a significant increase of RSV (9–21%) in the Netherlands from 3 to 32 weeks after the intervention. No effects were found in the Belgian control group for the smoking ban and the reintroduction of SCS in 2013, but there was a significant increase in RSV shortly before and after the introduction of SCS in 2011.

Conclusions

These findings suggest that these tobacco control policies have short-term or medium-term effects on the rate of searching for information on smoking cessation, and therefore potentially on smoking cessation rates.     

Burden of cancer attributable to tobacco smoking in member countries of the Association of Southeast Asian Nations (ASEAN), 2012

BackgroundCancer is an increasing problem in ASEAN (Association of Southeast Asian Nations). Tobacco use is a well-established risk factor for many types of cancers. Evidence on burden of cancer attributable to tobacco is essential to raise public and political awareness of the negative effects of tobacco on cancer and to be used to stimulate political action aims at reducing smoking prevalence in ASEAN member countries. The objective of this study was to estimate burden of cancer attributable to tobacco smoking in ASEAN, 2012.MethodsIn this study, smoking prevalence was combined with Relative Risks (RRs) of cancer to obtain Smoking Attributable Fractions (SAFs). Cancer incidence and mortality data among individuals aged 15 years and older were derived from GLOBOCAN 2012. Fourteen types of cancer were included in the analysis. Sensitivity analyses were conducted to examine the impact of the use of alternative RRs and the use of alternative prevalence of smoking in some countries.ResultsThe findings showed that tobacco smoking was responsible for 131,502 cancer incidence and 105,830 cancer mortality in ASEAN countries in 2012. In other words, tobacco smoking was accounted for 28.4% (43.3% in male and 8.5% in female) of cancer incidence and 30.5% (44.2% in male and 9.4% in female) of cancer mortality in ASEAN. When looking at the types of cancer, lung cancer showed the strongest association with tobacco smoking. Incidence of cancer and cancer mortality attributable to tobacco smoking varied by countries due to the differences in size of population, background risk of cancer, and prevalence of smoking in each country. According to the sensitivity analyses, RRs of lung cancer, pharynx cancer, and larynx cancer used in the estimates have significant impact on the estimates.ConclusionsAs about one-third of cancer incidence and mortality in ASEAN are attributable to tobacco smoking ASEAN member countries are strongly encouraged to put in place stronger tobacco control policies and to strengthen the existing tobacco control measure in order to effectively control cancer.