Smoking behaviour among young adults: beyond youth prevention

Objective: There is a widespread assumption that smoking behaviour is largely established by the age of 18 years. As a result, smoking prevention has focused almost exclusively upon youth. However, recent trends suggest that young adulthood may be an important—and largely overlooked—period in the development of regular smoking behaviour. The current study sought to examine patterns of tobacco use among young adults (aged 18–29 years) and to address the implications for tobacco control policy.

Design: Data are presented from the 2003 Canadian Tobacco Use Monitoring Survey, a national survey of smoking behaviour (n = 10 559, response rate 89%).

Main outcome measures: Measures of smoking behaviour, smoking initiation, susceptibility to smoking, and occupational status.

Results: A total of 1.4 million or 28% of young adults in Canada currently smoke, the highest proportion among all age groups. The prevalence of daily smoking rose from 8% among youth to 22% among young adults, and approximately one fifth of smokers tried their first cigarette after the age of 18 years. Smoking behaviour among young adults was also distinct from older smokers: young adults were more likely to be occasional smokers and reported lower daily consumption. Finally, smoking prevalence and cessation rates varied substantially within subgroups of young adults, as characterised by occupational setting.

Conclusions: Dramatic increases in the proportion and intensity of smoking occurs after the age of 18 years. Smoking behaviour among young adults is distinct from both youth and older adults, and warrants immediate attention from the public health community.

     

Educational inequalities in smoking among men and women aged 16 years and older in 11 European countries

Objective: To determine those groups who are at increased risk of smoking related diseases, we assessed in which male and female generations smoking was more prevalent among lower educated groups than among the higher educated, in 11 European countries.

Design: Cross sectional analysis of data on smoking, covering the year 1998, from a social survey designed for all member states of the European Union.

Subjects: Higher and lower educated men and women aged 16 years and older from 11 member states of the European Union.

Outcome measures: Age standardised prevalence rates by education and prevalence odds ratios of current and ever daily smoking comparing lower educated groups with higher educated groups.

Results: A north–south gradient in educational inequalities in current and ever daily smoking was observed for women older than 24 years, showing larger inequalities in the northern countries. Such a gradient was not observed for men. A disadvantage for the lower educated in terms of smoking generally occurred later among women than among men. Indications of inequalities in smoking in the age group 16–24 years were observed for all countries, with the exception of women from Greece and Portugal.

Conclusions: Preventing and reducing smoking among lower educated subgroups should be a priority of policies aiming to reduce inequalities in health in Europe. If steps are not taken to control tobacco use among the lower educated groups specifically, inequalities in lung cancer and other smoking related diseases should be anticipated in all populations of the European Union, and both sexes.

     

Psychosocial work conditions, social capital, and daily smoking: a population based study

Objective: To investigate the associations between psychosocial conditions at work, social capital/social participation, and daily smoking.

Design/setting/participants/measurements: The 2000 public health survey in Scania is a cross sectional postal questionnaire study with a 59% participation rate. A total of 5180 persons aged 18–64 years that belonged to the work force and the unemployed were included in this study. Logistic regression models were used to investigate the associations between psychosocial factors at work/unemployment, social participation, and daily smoking. Psychosocial conditions at work were defined according to the Karasek-Theorell demand–control/decision latitudes into relaxed, active, passive, and jobstrain categories. The multivariate analyses included age, country of origin, education and economic stress.

Results: 17.2% proportion of all men and 21.9% of all women were daily smokers. The jobstrain (high demands/low control) and unemployed categories had significantly higher odds ratios of daily smoking among both men and women compared to the relaxed (low demands/high control) reference category. The passive (low demands/low control), jobstrain, and unemployed categories were also significantly associated with low social participation. Low social participation was significantly and positively associated with daily smoking within each of the psychosocial work conditions and unemployed categories.

Conclusions: The positive association between low social capital/low social participation and daily smoking is well known. However, both social participation and daily smoking are associated with psychosocial work conditions and unemployment. Psychosocial work conditions and unemployment may affect daily smoking both directly and through a pathway including social participation.

     

Perceived importance of being thin and smoking initiation among young girls

Background: Smoking among adolescents remains unacceptably high and the difference in potential risk factors for smoking initiation between male and female adolescents has been explored. Although the association between smoking initiation and dieting behaviour has been observed among girls, the mechanism of the association is unknown.

Objective: To examine prospectively the association between perceived importance of being thin at baseline and smoking initiation among girls.

Design: A four year prospective cohort survey including perceived importance of being thin at baseline and smoking behaviour, conducted in 1993 and 1996.

Setting and participants: 273 Massachusetts female adolescents aged 12–15 years at baseline who reported having smoked no more than one cigarette by the time of the baseline survey, drawn from households sampled by random digit dialling.

Main outcome measure: Progression to established smoking, defined as having smoked 100 or more cigarettes in their lifetime.

Results: After adjusting for age, smoking status at baseline, and race/ethnicity, girls who valued thinness most strongly and somewhat strongly were both more likely to have become established smokers, compared to the girls who valued thinness least strongly. The odds ratios are 4.5 (95% confidence interval (CI), 1.4 to 16.7) and 3.4 (95% CI 1.04 to 10.9), respectively.

Conclusions: The level of perceived importance of being thin among young female adolescents predicts future smoking initiation. Smoking prevention programmes designed for female adolescents may therefore benefit from the inclusion of content related to importance of being thin.

     

Smoking behaviour and toxin exposure during six weeks use of a potential reduced exposure product: Omni

Objective: To determine smoking behaviour, acceptability, and toxin exposure when smokers switch to the potential reduced exposure product—Omni cigarette.

Design: 12 week randomised, crossover study of Omni versus own cigarettes.

Participants: 19 light/ultralight and 15 regular smokers.

Outcomes: Cigarettes/day, smoking topography, craving, withdrawal symptoms, urinary cotinine plus its glucuronide (total cotinine), nicotine plus its glucuronide (total nicotine), and carcinogen metabolites (4-(methylnitrosamino)-1-(3-pyridyl)-1-butanol plus its glucuronides and 1-hydroxypyrene).

Results: When switched to Omni, smokers smoked the same number of cigarettes/day, smoked Omni cigarettes less intensely (total puff volume = –11%) and had slightly lower total cotinine (–18%) levels than their own cigarettes, but had a slightly greater carbon monoxide boost/cig (+21%). Craving and withdrawal ratings were similar with Omni and own cigarettes. Carcinogen metabolite levels were somewhat but not significantly lower with Omni. About half of smokers rated Omni as better for their health and about two thirds stated it was weaker and worse tasting than their own cigarettes.

Conclusions: Although Omni may be an adequate behavioural and pharmacological substitute for traditional cigarettes, it may not decrease carcinogen exposure and may increase carbon monoxide. Replications with larger sample sizes and longer follow up are needed. These results indicate the need for regulation of reduced exposure and reduced risk claims.

     

Changes in population attitudes about where smoking should not be allowed: California versus the rest of the USA

Background: The decade long California Tobacco Control Program is unique to the nation in its duration, emphasis, and level of funding. Programme emphasis is on changing social norms about smoking as a means to discourage smoking and thus reduce the harmful health effects of tobacco to the population.

Methods: Data from the 1992–93, 1995–96, and 1998–99 Tobacco Use Supplements to the national Current Population Survey (n > 175 000 each period) were used to examine changes in norms regarding where smoking should "not be allowed at all" in both California and in the rest of the USA. Venues queried were restaurants, hospitals, work areas, bars, indoor sports venues, and indoor shopping malls.

Results: There were substantial increases in the percentages of the adult population (18+ years) stating that smoking should not be allowed in the venues queried in California by 1998–99 compared to 1992–93; only modest increases were observed in the rest of the USA. In fact, for most venues, the percentages for the rest of the USA were lower in 1998–99 than in California in 1992–93. Further, the percentage increase over this period in respondents stating that smoking should not be allowed in four or more of the six venues was 30% in California and 23% in the rest of the USA. The most dramatic percentage increase in California occurred among current smokers (93%).

Conclusions: A strong, comprehensive tobacco control programme such as California's can influence population norms, including those of smokers, with respect to where smoking should not be allowed.

     

Stereotyping the smoker: adolescents' appraisals of smokers in film

Objective: To assess the relation between demographic factors and film smoking stereotypes in adolescents and the potential influence of smoker stereotypes on smoking susceptibility.

Design: A cross sectional questionnaire survey of school students (n = 3041) aged 12–13 and 16–17 years who were asked to describe the personal characteristics of female and male smokers in films.

Setting: 15 primary or intermediate schools and 10 secondary schools in Auckland, New Zealand.

Results: Appraisals of smokers in film were strongly influenced by age and sex with younger adolescents and males more likely to see female smokers as sexy, intelligent and healthy whereas older students and females more often appraised female smokers as stressed bored and depressed. Overall, image stereotypes (sexy, stylish) were more likely to be significantly associated with smoking susceptibility than emotional sensitivity stereotypes (stressed, depressed etc).

Conclusions: Adolescents differ significantly in their appraisal of smokers in films; however, image based stereotypes, rather than emotional sensitivity stereotypes, are significantly associated with smoking susceptibility.

     

Increase in common cold symptoms and mouth ulcers following smoking cessation

Design: Smokers were assessed one week before stopping smoking (baseline), then after one, two, and six weeks of smoking abstinence.

Participants: 174 smokers attending a seven week smoking cessation programme combining behavioural support with nicotine patches.

Main outcome measures: Self reports of cold symptoms, mouth ulcers, and smoking abstinence (validated using expired carbon monoxide) were recorded on each measurement occasion.

Results: Following one, two, and six weeks of smoking abstinence 73.0% (127/174), 57.5% (100/174), and 44.8% (78/174) of the participants, respectively, maintained continuous abstinence and provided reports of cold symptoms and mouth ulcers. For those abstinent from smoking for six weeks, relative to baseline, a significant increase in reports of the number of cold symptoms was observed following one and two weeks of smoking abstinence (p = 0.009 and p = 0.038, respectively) and an increase in reports of mouth ulcers after one and two weeks of abstinence (p = 0.004 and p = 0.008, respectively). Following one week of abstinence significant increases in reports of sore throat, coughing, deafness, and sneezing were observed (p = 0.049, p < 0.001, p< 0.039, and p < 0.003, respectively).

Conclusions: This is the first study to systematically document significant increases in cold symptoms and mouth ulcers following smoking cessation. Smokers should be informed that they have an increased chance of experiencing these symptoms on stopping smoking. Being psychologically prepared for these effects may reduce their impact on the attempt to stop smoking.

     

Airway disease risk from environmental tobacco smoke among coffeehouse workers in Turkey

Objectives: To examine the effect of ETS exposure on respiratory symptoms and pulmonary function and to compare workers in coffeehouses to those in other occupations in order to assess the risk of respiratory illness in this occupation.

Design: Cross sectional study.

Setting: The study area consisted of the three metropolitan districts of the city of Izmir, Turkey. 86 coffeehouses and 80 other small scale shops which had no known respiratory risk factor, located in the same area, were taken as the study group.

Subjects: 207 workers were assessed.

Main outcome measurements: Subjects answered a questionnaire about demographic and working characteristics, respiratory symptoms, and smoking behaviour. Physical examinations and spirometric measurements were carried out at the workplaces.

Results: There was a significant increase in respiratory symptoms in coffeehouse workers. Working in a coffeehouse showed a significant risk for chronic bronchitis (odds ratio (OR) 4.3). In coffeehouse workers, forced expiratory volume in one second (FEV₁) decreased 5.1%, forced vital capacity (FVC) 3.4%, FEV₁/FVC 1.6%, peak expiratory flow (PEF) 6.45%, and forced expiratory flow (FEF₂₅) 7.2%, FEF₅₀ 10%, and FEF_25–75 9.8%. Among workers who were described as having an "airway disease", coffeehouse workers were significantly greater in number. When age, body mass index, and smoking behaviour were controlled, working in a coffeehouse was strongly associated with "airway disease" compared to other workers (OR 5.35, 95% confidence interval 2.41 to 11.87).

Conclusions: Workers in coffeehouses showed significant increases in respiratory symptoms and decreased pulmonary function. All workers need to gain an awareness of these occupational risks and working conditions should be improved immediately.

     

Current smoking and the risk of non-fatal myocardial infarction in the WHO MONICA Project populations

Background: Cohort studies have shown that smoking has a substantial influence on coronary heart disease mortality in young people. Population based data on non-fatal events have been sparse, however.

Objective: To study the impact of smoking on the risk of non-fatal acute myocardial infarction (MI) in young middle age people.

Methods: From 1985 to 1994 all non-fatal MI events in the age group 35–64 were registered in men and women in the WHO MONICA (multinational monitoring of trends and determinants in cardiovascular disease) project populations (18 762 events in men and 4047 in women from 32 populations from 21 countries). In the same populations and age groups 65 741 men and 66 717 women participated in the surveys of risk factors (overall response rate 72%). The relative risk of non-fatal MI for current smokers was compared with non-smokers, by sex and five year age group.

Results: The prevalence of smoking in people aged 35–39 years who experienced non-fatal MI events was 81% in men and 77% in women. It declined with increasing age to 45% in men aged 60–64 years and 36% in women, respectively. In the 35–39 years age group the relative risk of non-fatal MI for smokers was 4.9 (95% confidence interval (CI) 3.9 to 6.1) in men and 5.3 (95% CI 3.2 to 8.7) in women, and the population attributable fractions were 65% and 55%, respectively.

Conclusions: During the study period more than half of the non-fatal MIs occurring in young middle age people can be attributed to smoking.

     

Adolescent smoking decline during California's tobacco control programme

Objective: California's comprehensive tobacco control programme was 13 years old in 2002; by then, children entering adolescence at the start of the programme were young adults. This study examines whether adolescent smoking declined over this period, whether any decline carried through to young adulthood, and whether it was specific to California.

Setting and participants: Most data were from the 1990–2002 California Tobacco Surveys (CTS) (adolescents 12–17 years, > 5000/survey, young adults 18–24 years, > 1000/survey). Additional data were from the national 1992/93–2001/02 Current Population Survey (CPS) (young adults 18–24 years, > 15 000/survey).

Results: Over the 13 year period in California, ever puffing declined by 70% in 12–13 year olds, by 53% in 14–15 year olds from 1992–2002, and by 34% in 16–17 year olds from 1996–2002 (CTS). As noted, the decline commenced progressively later in each older group. Smoking experimentation (1+ cigarettes) and established smoking (> 100 cigarettes in lifetime) showed similar patterns. Compared to 1990, the percentage of California young adults (CTS data) who ever experimented declined by 14%, with half of the decline from 1999–2002. CPS young adult smoking prevalence (established and now smoke everyday or some days) was constant in the rest of the USA over the entire period, but California showed a recent 18% decline from 1998/99 to 2001/02.

Conclusions: California's comprehensive programme may have kept new adolescent cohorts from experimenting with cigarettes. Low young adolescent experimentation rates at programme start appeared to carry through to young adulthood, resulting in a recent drop in young adult smoking prevalence in California not observed in the rest of the USA.

     

Genetically decreased CYP2A6 and the risk of tobacco dependence: a prospective study of novice smokers

Objective: Case control studies in adults suggest that defective alleles in the gene that codes for the hepatic cytochrome P450 2A6 (CYP2A6) protect against nicotine dependence (ND) and higher levels of cigarette consumption. These two hypotheses were tested in young adolescents.

Design: Self reports of tobacco use and ND symptoms were collected every 3–4 months in a prospective study of 1293 grade 7 students from a convenience sample of 10 schools.

Subjects: 281 smokers with genetic data were analysed; those who were not already tobacco dependent and who had inhaled (n = 228) were followed 29.9 months on average, until they became dependent or were censored.

Main outcome measures: The association between metabolic activity, represented by CYP2A6 genotype, and conversion to dependence was analysed using Cox's proportional hazards model.

Results: During follow up 67 subjects (29.4%) became dependent. Relative to CYP2A6*1/*1, having 1–2 copies of the inactive CYP2A6*2 or *4 variant was a strong risk factor for developing dependence (hazard ratio 2.8, 95% confidence 1.3 to 6.3). Subjects with 1–2 partially inactive CYP2A6*9 or *12 variants were not at increased risk. Mean past-week cigarette consumption at the end of follow up (controlling for age, sex, and number of months since first inhalation) among dependent subjects was 29.1 among normal inactivators, compared to 17.2, and 12.7 among slower (1–2 copies of *9 or *12), and slowest (1–2 copies of *2 or *4) inactivators, respectively (p = 0.09).

Conclusion: Adolescents with 1–2 copies of CYP2A6*2 or *4 are at substantially increased risk of becoming dependent but smoke less once dependent. Genetic risk for ND may need to be considered in the conceptualisation of tobacco control programmes for adolescents.

     

Impact of the graphic Canadian warning labels on adult smoking behaviour

Objective: To assess the impact of graphic Canadian cigarette warning labels on current adult smokers.

Design: A random-digit-dial telephone survey was conducted with 616 adult smokers in south western Ontario, Canada in October/November 2001, with three month follow up.

Main outcome measures: Smoking behaviour (quitting, quit attempts, and reduced smoking), intentions to quit, and salience of the warning labels.

Results: Virtually all smokers (91%) reported having read the warning labels and smokers demonstrated a thorough knowledge of their content. A strong positive relation was observed between a measure of cognitive processing—the extent to which smokers reported reading, thinking about, and discussing the new labels—and smokers' intentions to quit (odds ratio (OR) 1.11, 95% confidence interval (CI) 1.07 to 1.16; p < 0.001). Most important, cognitive processing predicted cessation behaviour at follow up. Smokers who had read, thought about, and discussed the new labels at baseline were more likely to have quit, made a quit attempt, or reduced their smoking three months later, after adjusting for intentions to quit and smoking status at baseline (OR 1.07, 95% CI 1.03 to 1.12; p < 0.001).

Conclusions: Graphic cigarette warning labels serve as an effective population based smoking cessation intervention. The findings add to the growing literature on health warnings and provide strong support for the effectiveness of Canada's tobacco labelling policy.

     

Households contaminated by environmental tobacco smoke: sources of infant exposures

Objectives: To examine (1) whether dust and surfaces in households of smokers are contaminated with environmental tobacco smoke (ETS); (2) whether smoking parents can protect their infants by smoking outside and away from the infant; and (3) whether contaminated dust, surfaces, and air contribute to ETS exposure in infants.

Design: Quasi-experiment comparing three types of households with infants: (1) non-smokers who believe they have protected their children from ETS; (2) smokers who believe they have protected their children from ETS; (3) smokers who expose their children to ETS.

Setting: Homes of smokers and non-smokers.

Participants: Smoking and non-smoking mothers and their infants 1 year.

Main outcome measures: ETS contamination as measured by nicotine in household dust, indoor air, and household surfaces. ETS exposure as measured by cotinine levels in infant urine.

Results: ETS contamination and ETS exposure were 5–7 times higher in households of smokers trying to protect their infants by smoking outdoors than in households of non-smokers. ETS contamination and exposure were 3–8 times higher in households of smokers who exposed their infants to ETS by smoking indoors than in households of smokers trying to protect their children by smoking outdoors.

Conclusions: Dust and surfaces in homes of smokers are contaminated with ETS. Infants of smokers are at risk of ETS exposure in their homes through dust, surfaces, and air. Smoking outside the home and away from the infant reduces but does not completely protect a smoker's home from ETS contamination and a smoker's infant from ETS exposure.

     

Impact of different aspects of social participation and social capital on smoking cessation among daily smokers: a longitudinal study

Objective: To investigate differences in different aspects of social participation and social capital among baseline daily smokers that had remained daily smokers, become intermittent smokers, or stopped smoking at one year follow up.

Design/setting/participants/measurements: 12 507 individuals, aged 45–69 years, interviewed at baseline between 1992 and 1994 and at a one year follow up were investigated in this longitudinal study. The three groups of baseline daily smokers were compared to the reference population (baseline intermittent smokers and non-smokers) according to different aspects of social participation and social capital. A multivariate logistic regression model was used to assess differences in different aspects of social participation and social capital.

Results: The baseline daily smokers that remained daily smokers at the one year follow up had significantly increased odds ratios of non-participation in study circles in other places than at work, meeting of organisations other than unions, theatre/cinema, arts exhibition, church, sports events, large gatherings of relatives, and private parties compared to the reference population. The baseline daily smokers that had become intermittent smokers at the one year follow up had significantly increased odds ratios of non-participation in church services. The baseline daily smokers that had stopped smoking had increased odds ratios of non-participation in having attended a meeting of organisations other than labour unions during the past year, having been to a theatre or cinema, and of having visited an arts exhibition during the past year. All three categories of baseline daily smokers had significantly decreased odds ratios of non-participation in night club/entertainment.

Conclusions: The baseline daily smokers that had remained daily smokers at the one year follow up had particularly high rates of non-participation compared to the reference population in both activities specifically related to social capital, such as other study circles, meetings of organisations other than labour unions, and church attendance and cultural activities such as theatre/cinema and arts exhibition, although significantly lower participation in cultural activities and meetings of other organisations was also observed among daily smokers that had stopped smoking. All three baseline daily smoker groups had higher rates of having visited a night club during the past year.

     

Effect of smokeless tobacco (snus) on smoking and public health in Sweden

Method: Narrative review of published papers and other data sources (for example, conference abstracts and internet based information) on snus use, use of other tobacco products, and changes in health status in Sweden.

Results: Snus is manufactured and stored in a manner that causes it to deliver lower concentrations of some harmful chemicals than other tobacco products, although it can deliver high doses of nicotine. It is dependence forming, but does not appear to cause cancer or respiratory diseases. It may cause a slight increase in cardiovascular risks and is likely to be harmful to the unborn fetus, although these risks are lower than those caused by smoking. There has been a larger drop in male daily smoking (from 40% in 1976 to 15% in 2002) than female daily smoking (34% in 1976 to 20% in 2002) in Sweden, with a substantial proportion (around 30%) of male ex-smokers using snus when quitting smoking. Over the same time period, rates of lung cancer and myocardial infarction have dropped significantly faster among Swedish men than women and remain at low levels as compared with other developed countries with a long history of tobacco use.

Conclusions: Snus availability in Sweden appears to have contributed to the unusually low rates of smoking among Swedish men by helping them transfer to a notably less harmful form of nicotine dependence.

     

Cost effectiveness of a community based research project to help women quit smoking

Objective: To estimate the cost effectiveness of a four year, multifaceted, community based research project shown previously to help women quit smoking.

Design: A quasi-experimental matched control design.

Setting: Two counties in Vermont and two in New Hampshire, USA.

Subjects: Women aged 18–64 years.

Methods: Costs were the grant related expenditures converted to 2002 US$. Survey results at the end of the intervention were used to estimate the numbers of never smokers, former smokers, light smokers, and heavy smokers in the intervention and comparison counties, and 1986 life tables for populations of US women categorised by smoking status to estimate the gain in life expectancy.

Main outcome measures: Cost effectiveness ratios, as dollars per life-year saved, for the intervention only and for total grant costs (intervention, evaluation and indirect costs).

Results: The cost effectiveness ratio for the intervention, in 2002 US$ per life-year saved, discounted at 3%, was $1156 (90% confidence interval (CI) $567 to ∞), and for the total grant, $4022 (90% CI $1973 to ∞). When discounted at 5%, these ratios were $1922 (90% CI $1024 to $15 647), and $6683 (90% CI $3555 to $54 422), respectively.

Conclusion: The cost effectiveness ratios of this research project are economically attractive, and are comparable with other smoking cessation interventions for women. These observations should encourage further research and dissemination of community based interventions to reduce smoking.

     

Prevalence and correlates of internet cigarette purchasing among adult smokers in New Jersey

Objective: To examine the prevalence and correlates of internet cigarette purchasing among adult smokers.

Design: Analysis of internet purchasing in data from a population based telephone survey of New Jersey households. Logistic regression was used to determine factors associated with internet cigarette purchasing, adjusting for year, demographic, and smoking behaviour variables.

Participants: 3447 current cigarette smokers pooled from three cross sectional surveys conducted in 2000, 2001, and 2002.

Main outcome measures: Ever purchasing tobacco and usually buying cigarettes via the internet.

Results: Among all current cigarette smokers, ever having purchased tobacco via the internet increased from 1.1% in 2000 to 6.7% in 2002 and usually buying cigarettes via the internet increased from 0.8% in 2000 to 3.1% in 2002. Among current cigarette smokers with internet access, ever having purchased tobacco via the internet was higher among those who reported smoking 31 or more cigarettes per day (adjusted odds ratio (OR) 3.9, 95% confidence interval (CI) 1.5 to 10.2) and those without a past year quit attempt (adjusted OR 1.8, 95% CI 1.1 to 3.0). Usually purchasing cigarettes via the internet was higher among those aged 45–64 years (adjusted OR 4.4, 95% CI 1.1 to 17.1) and who reported having their first cigarette 30 minutes after waking (adjusted OR 3.3, 95% CI 1.2 to 9.2).

Conclusions: Although higher prices are known to reduce the demand for cigarettes, internet cigarette purchasing is likely to weaken this effect, particularly among heavy, more dependent smokers who are less interested in quitting.

     

Out of the Smokescreen: does an anti-smoking advertisement affect young women's perception of smoking in movies and their intention to smoke?

Objective: To evaluate the effect of an anti-smoking advertisement on young women's perceptions of smoking in movies and their intention to smoke.

Subjects/setting: 2038 females aged 12–17 years attending cinemas in New South Wales, Australia.

Design/intervention: Quasi-experimental study of patrons, who were surveyed after having viewed a movie at their local cinema. The control group was surveyed during week 1 and the intervention group, during week 2. Before seeing the movie in week 2, a 30 second anti-smoking advertisement was shown, which featured a well known female actor drawing attention to the prevalence of smoking in movies.

Outcomes: Attitude of current smokers and non-smokers to smoking in the movies; intention of current smokers and non-smokers to be smoking in 12 months time.

Results: Among non-smokers, 48.2% of the intervention subjects thought that the smoking in the movie they viewed was "not OK" compared with 28.3% of the control subjects (p < 0.0001). However, there was no difference among smokers in the intervention (26.4%) and control (16.9%) groups (p = 0.28). A higher percentage of current smokers in the intervention group indicated they were unlikely to smoke in 12 months time (47.8%) than smokers in the control condition (31.9%) (p = 0.03). For non-smokers, there was no difference in smoking intentions between conditions, with 95% saying they would be unlikely to be smoking in 12 months time.

Conclusions: This "real world" study suggests that placing an anti-smoking advertisement before movies containing smoking scenes can help to "immunise" young women against the influences of film stars smoking.

     

Impacts of the Master Settlement Agreement on the tobacco industry

Objective: To assess effects of the Master Settlement Agreement (MSA) and the four individual state settlements on tobacco company decisions and performance.

Design: 10-K reports filed with the US Securities and Exchange Commission, firm and daily data from the Center for Research in Security Prices, stock price indices, market share and advertising data, cigarette export and domestic consumption data, and newspaper articles were used to assess changes before (1990–98) and after (1999–2002) the MSA was implemented.

Subjects: Five major tobacco manufacturers in the USA.

Main outcome measures: Stockholder returns, operating performance of defendant companies, exports, market share of the original participants in the MSA, and advertising/promotion expenditures.

Results: Returns to investments in the tobacco industry exceeded returns from investments in securities of other companies, using each of four indexes as comparators. Domestic tobacco revenues increased during 1999–2002 from pre-MSA levels. Profits from domestic sales rose from levels prevailing immediately before the MSA. There is no indication that the MSA caused an increase in tobacco exports. Total market share of the original participating manufacturers in the MSA decreased. Total advertising expenditures by the tobacco companies increased at a higher rate than the 1990–98 trend during 1999–2002, but total advertising expenditures net of spending on coupons and promotions decreased.

Conclusion: The experience during the post-MSA period demonstrates that the MSA did no major harm to the companies. Some features of the MSA appear to have increased company value and profitability.