Curbing adolescent smoking: a review of the effectiveness of various policies

Tobacco-related mortality is one of the biggest killers in American medicine. Evidence suggests that if adolescents can be kept tobacco-free, most will never start using tobacco. Therefore, tobacco control policies directed at the youth population could provide an effective method for sustaining long-term reductions in smoking in all segments of the population. Many forms of tobacco control policies have been implemented including restrictive laws, public campaigns, and taxation duties; there has been disagreement over which is most effective. We investigate the efficacy of various methods of tobacco control in youth and present a review of the published evidence. Econometric data for both youth access restrictions and environmental tobacco smoke restrictions afford ambiguous results. Results vary in a continuum from a moderate negative effect toward, ironically, a marginal positive effect on smoking. While information dissemination policies may be somewhat effective on the onset, they are limited in their effect and eventually diminish over time. We conclude that increases in price affect teen smoking to a great degree. Most estimates show that for a 10 percent increase in prices, which could be implemented by a tax per pack, a 15 percent decrease in cigarettes consumed could be accomplished. Taxation policies are an effective means of preventative medicine.     

Cigarette smoking by socioeconomic group,sex, and age: effects of price,income, and health publicity.

OBJECTIVE--To assess effects of price, income, and health publicity on cigarette smoking by age, sex, and socioeconomic group. DESIGN--Econometric multiple regression analysis of data on cigarette smoking from the British general household survey. SUBJECTS--Random sample of adult population in Britain interviewed for biennial general household surveys 1972-90. MAIN OUTCOME MEASURES--Changes in cigarette consumption and prevalence of smoking. RESULTS--Price elasticities of demand for cigarettes (percentage change in cigarette consumption for a 1% change in price) were significant at -0.5 (95% confidence interval -0.8 to -0.1) for men and -0.6 (-0.9 to -0.3) for women, were highest in socioeconomic group V (-1.0 for men and -0.9 for women), and lowest (not significantly different from zero) in socioeconomic groups I and II. The gradient in price elasticities by socioeconomic group was significant for men (F = 5.6, P = 0.02) and for women (F = 6.1, P = 0.02). Price was a significant factor in cigarette consumption by age for women in every age group and for men aged 25-34. Cigarette consumption by young men aged 16-34 increased with income. There was a significant decrease in smoking over time by women in socioeconomic groups I and II and by men in all age and social groups except socioeconomic group V attributable to health publicity. Price significantly affected smoking prevalence in socioeconomic group V (-0.6 for men and -0.5 for women) and for all women (-0.2). CONCLUSIONS--Men and women in lower socioeconomic groups are more responsive than are those in higher socioeconomic groups to changes in the price of cigarettes and less to health publicity. Women of all ages, including teenagers, appear to have been less responsive to health publicity than have men but more responsive to price. Response to health publicity decreased linearly with age. Real price increases in cigarettes could narrow differences between socioeconomic groups in smoking and the related inequalities in health, but specific measures would be necessary to ameliorate effects on the most deprived families that may include members who continue to smoke. The use of a policy to steadily increase cigarette tax is likely to help achieve the government''s targets for smoking and smoking related diseases.     

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.     

Expansion of gambling in Canada: implications for health and social policy

Canada experienced a dramatic increase in legalized gambling in the 1990s, primarily because of governments'' need to increase revenue without additional taxation. This article examines gambling from a public health perspective. The major public health issues include gambling addiction, family dysfunction and gambling by youth. Debates have emerged about the health, social and economic costs and benefits of gambling. Stakeholder and social policy groups have expressed concern about the impact of expanded gambling on the quality of life of individuals, families and communities. Epidemiological studies show that the prevalence of gambling in the general adult population is low but increasing. Of particular concern is the high though steady prevalence of gambling among youth. New technologies have been linked to gambling-related problems such as addiction to gambling by video lottery terminals. Gambling by means of the Internet represents another emerging issue. The article concludes with recommendations for health and social policy related to gambling. These recommendations incorporate a broad public health approach to create a strong research program and to balance risks and benefits.     

Focus: Addiction: Smoking Use and Cessation Among People with Serious Mental Illness

Smoking rates in people with serious mental illness (SMI) are disproportionately high compared to the general population. It is a leading contributor to the early mortality in this population. Smoking cessation rates are low in this group, though patients are motivated to quit. Unfortunately, health care providers do not always prioritize smoking cessation for this population. This review provides an overview of prevalence rates, biological effects that maintain smoking, and evidence-based treatments for smoking cessation in SMI. In addition, objective and qualitative data from a chart review of 78 patients with SMI prescribed smoking cessation treatment at one community mental health center are described. Of these, 30 (38.5 percent) were found to either quit (16/78) or reduce (14/78) smoking. Varenicline appeared to be particularly effective. Review of the literature and results of this study suggest that smoking cessation pharmacotherapies are effective for SMI patients and should be offered to those who smoke.     

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.     

Taxes and the tobacco wars

In this issue (see pages 187 to 191) Dr. Vivian H. Hamilton and associates demonstrate that tax reductions introduced in 5 Canadian provinces in 1994 slowed the rate of decline in cigarette consumption in those jurisdictions. Although both reductions and increases in taxation have been shown to influence tobacco consumption, changes in smoking habits must also be understood in the context of battles being waged on other fronts in the tobacco wars. In addition, more finely detailed analyses are needed to determine the impact of taxation and other factors on the smoking habits of specific subgroups of the population, particularly teenagers.     

Smoking among Yale medical school faculty

A 1985 survey of a random sample of faculty at the Yale University School of Medicine investigated smoking prevalence and attitudes. The overall prevalence of cigarette smoking was estimated to be 9.8 percent, much lower than the prevalence in the general population. A higher proportion of women than men were current cigarette smokers. With regard to department affiliation, surgeons were most frequently current cigarette smokers, with psychiatrists having the lowest prevalence of current cigarette smoking and the highest percentage of people who had never smoked. In general, attitudes toward smoking were negative.     

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.     

Epidemiology and prevention of smoking in Tunisia: current situation and perspectives

This paper describes the trends in tobacco sales and smoking prevalence in the Tunisian population, estimates the consequences of smoking on mortality of this population, and discusses anti-tobacco actions: educational actions, legislative measures and price increases. Sales Data were collected from the Tunisia tobacco company. Smoking prevalence data from surveys, conducted by several institutes, and numbers of deaths by causes have been estimated from WHO for the year 1998. Tobacco sales increased from 4.96 g per adult per day in 1981, to 6.3 g, in 1993, then decreased widely. The proportion of smokers was 30% in 1996. 55% among men versus 5.6% among women. Among 17 to 24 years old young adults, the proportion of smokers was 29.2% in 1994 (50% among men versus 3.9%, among women). Mortality attributable to tobacco in Tunisia has been estimated to 6430 deaths in 1997 (5580 among men versus 850 among women). These deaths represent 22% of the total male deaths and 4% of the female ones. Anti-tobacco measures have been reinforced by the enactment of anti-tobacco law. Proportion of young smokers remaining elevated, it is expected that consequences of the tobacco addiction in Tunisia, in term of mortality, will be even heavier in the next two decades, if efficient anti-tobacco actions are not implemented.     

Prevalence of hardcore smoking in England,and associated attitudes and beliefs: cross sectional study

Objective To quantify the prevalence and characteristics of hardcore smokers in England.Design Cross sectional survey.Setting Interview in respondents'' household.Participants 7766 adult cigarette smokers.Main outcome measures Hardcore smoking defined by four criteria (less than a day without cigarettes in the past five years; no attempt to quit in the past year; no desire to quit; no intention to quit), all of which had to be satisfied.Results Some 16% of all smokers were categorised as hardcore. Hardcore smoking was associated with nicotine dependence, socioeconomic deprivation, and age, rising from 5% in young adults aged 16-24 to 30% in those aged ≥ 65 years. Hardcore smokers displayed distinctive attitudes towards and beliefs about smoking. In particular they were likely to deny that smoking affected their health or would do so in the future. Prevalence of hardcore smoking was almost four times higher than in California.Conclusion Hardcore smoking presents a serious challenge to public health efforts to reduce the prevalence of smoking, but the proportion of hardcore smokers does not necessarily increase as overall prevalence in a population declines. More hardcore smokers could be persuaded to quit, but this will require interventions that are targeted to the particular needs and perceptions of both socially disadvantaged and older smokers.     

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.     

Population-based retrospective study to investigate preexisting and new depression diagnosis among head and neck cancer patients

This study aimed to estimate the pre-cancer prevalence and post-cancer incidence of depression in older adult head and neck cancer patients. Using SEER-Medicare files, cancer was identified from SEER data and depression diagnosis was identified using Medicare claims. Of 3533 head and neck cancer patients, 10.6% were diagnosed with depression during the two years prior to cancer diagnosis, and an additional 8.9% developed depression in the year following cancer diagnosis. This study supports the critical need of screening for depression throughout cancer diagnosis and treatment, as well as a preventative approach in depression development in the older head and neck cancer patient population.     

Onchocerciasis: The Pre-control Association between Prevalence of Palpable Nodules and Skin Microfilariae

Background

The prospect of eliminating onchocerciasis from Africa by mass treatment with ivermectin has been rejuvenated following recent successes in foci in Mali, Nigeria and Senegal. Elimination prospects depend strongly on local transmission conditions and therefore on pre-control infection levels. Pre-control infection levels in Africa have been mapped largely by means of nodule palpation of adult males, a relatively crude method for detecting infection. We investigated how informative pre-control nodule prevalence data are for estimating the pre-control prevalence of microfilariae (mf) in the skin and discuss implications for assessing elimination prospects.

Methods and Findings

We analyzed published data on pre-control nodule prevalence in males aged ≥20 years and mf prevalence in the population aged ≥5 years from 148 African villages. A meta-analysis was performed by means of Bayesian hierarchical multivariate logistic regression, accounting for measurement error in mf and nodule prevalence, bioclimatic zones, and other geographical variation. There was a strong positive correlation between nodule prevalence in adult males and mf prevalence in the general population. In the forest-savanna mosaic area, the pattern in nodule and mf prevalence differed significantly from that in the savanna or forest areas.

Significance

We provide a tool to convert pre-control nodule prevalence in adult males to mf prevalence in the general population, allowing historical data to be interpreted in terms of elimination prospects and disease burden of onchocerciasis. Furthermore, we identified significant geographical variation in mf prevalence and nodule prevalence patterns warranting further investigation of geographical differences in transmission patterns of onchocerciasis.     

TT virus infection in children and adults who visited a general hospital in the south of Brazil for routine procedure

TT virus (TTV) is a newly described nonenveloped human virus, with a circular, negative-stranded DNA genome, that was first identified in the blood of a patient with posttransfusion hepatitis of unknown etiology. PCR primers and conditions used for TTV DNA amplification may greatly influence the level of TTV detection in serum. Three PCR assays, with different regions of the genome as targets, were used to test TTV DNA in 130 sera from children and adults visiting a hospital in the south of Brazil, most of them for routine procedure. Forty-four percent of adult sera and 73% of sera from children aged 0-10 years were TTV positive with at least one PCR assay. However, the three assays were able to detect only 33%, 35%, and 70% of the total positive samples. Our results showed a high prevalence of TTV infection in the south of Brazil, particularly among young children, and confirmed the necessity of performing several PCR assays to assess the true TTV prevalence in a determined population.     

Neovascular age-related macular degeneration risk based on CFH, LOC387715/HTRA1, and smoking

Background

Age-related macular degeneration (AMD) is the major cause of blindness in the elderly. Those with the neovascular end-stage of disease have irreversible loss of central vision. AMD is a complex disorder in which genetic and environmental factors play a role. Polymorphisms in the complement factor H (CFH) gene, LOC387715, and the HTRA1 promoter are strongly associated with AMD. Smoking also contributes to the etiology. We aimed to provide a model of disease risk based on these factors.

Methods and Findings

We genotyped polymorphisms in CFH and LOC387715/HTRA1 in a case–control study of 401 patients with neovascular AMD and 266 controls without signs of disease, and used the data to produce genetic risk scores for the European-descent population based on haplotypes at these loci and smoking history. CFH and LOC387715/HTRA1 haplotypes and smoking status exerted large effects on AMD susceptibility, enabling risk scores to be generated with appropriate weighting of these three factors. Five common haplotypes of CFH conferred a range of odds ratios (ORs) per copy from 1 to 4.17. Most of the effect of LOC387715/HTRA1 was mediated through one detrimental haplotype (carriage of one copy: OR 2.83; 95% confidence interval [CI] 1.91–4.20), with homozygotes being at particularly high risk (OR 32.83; 95% CI 12.53–86.07). Patients with neovascular macular degeneration had considerably higher scores than those without disease, and risk of blinding AMD rose to 15.5% in the tenth of the population with highest predicted risk.

Conclusions

An individual''s risk of developing AMD in old age can be predicted by combining haplotype data with smoking status. Until there is effective treatment for AMD, encouragement to avoid smoking in those at high genetic risk may be the best option. We estimate that total absence of smoking would have reduced the prevalence of severe AMD by 33%. Unless smoking habits change or preventative treatment becomes available, the prevalence of AMD will rise as a consequence of the increasing longevity of the population.     

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     

Impact of future cigarette smoking scenarios on mortality of the adult population in the United States, 2000–2050

Abstract

The prevalence of cigarette smoking in the United States has declined over the past few decades. However, some leveling‐off in prevalence rates has been observed in recent years, and the rate for teenagers and young adults has even turned upward. This paper considers four alternative scenarios of future cigarette smoking patterns in the United States for the population 25 and over and measures the impact these different scenarios would have on excess mortality due to smoking and on the sex and age distributions of deaths. Scenarios reflecting higher levels of smoking prevalence produce considerably more deaths than scenarios tied to lower levels. As many as two and one‐half million excess deaths would take place in the decade of the 2020's if a high prevalence, rather than low prevalence, assumption proves correct. Even when a constant prevalence, assumption proves correct. Even when a constant prevalence assumption is compared with a moderately‐declining prevalence assumption, as many as one million excess deaths would be generated during that decade alone. Lowering smoking prevalence rates would also change the population sex ratio by reducing deaths for males more than deaths for females, and by contributing to the aging of the population. The results are interpreted in terms of the overall impact of smoking on mortality and with regard to public and private policy decisions related to cigarette smoking.     

Socioeconomic Inequalities in Smoking and Smoking Cessation Due to a Smoking Ban: General Population-Based Cross-Sectional Study in Luxembourg

This study aimed to measure changes in socioeconomic inequalities in smoking and smoking cessation due to the 2006 smoking ban in Luxembourg. Data were derived from the PSELL3/EU-SILC (Panel Socio-Economique Liewen Zu Letzebuerg/European Union—Statistic on Income and Living Conditions) survey, which was a representative survey of the general population aged ≥16 years conducted in Luxembourg in 2005, 2007, and 2008. Smoking prevalence and smoking cessation due to the 2006 smoking ban were used as the main smoking outcomes. Two inequality measures were calculated to assess the magnitude and temporal trends of socioeconomic inequalities in smoking: the prevalence ratio and the disparity index. Smoking cessation due to the smoking ban was considered as a positive outcome. Three multiple logistic regression models were used to assess social inequalities in smoking cessation due to the 2006 smoking ban. Education level, income, and employment status served as proxies for socioeconomic status. The prevalence of smoking decreased by 22.5% between 2005 and 2008 (from 23.1% in 2005 to 17.9% in 2008), but socioeconomic inequalities in smoking persisted. Smoking prevalence decreased by 24.2% and 20.2% in men and women, respectively; this difference was not statistically significant. Smoking cessation in daily smokers due to the 2006 smoking ban was associated with education level, employment status, and income, with higher percentages of quitters among those with a lower socioeconomic status. The decrease in smoking prevalence after the 2006 law was also associated with a reduction in socioeconomic inequalities, including differences in education level, income, and employment status. Although the smoking ban contributed to a reduction of such inequalities, they still persist, indicating the need for a more targeted approach of smoke-free policies directed toward lower socioeconomic groups.