Smoking in Scottish youths: personal income, parental social class and the cost of smoking

Objective

To examine the relation of young people''s personal income and parental social class with smoking from early to mid adolescence.

Design

Longitudinal, school based, study of a cohort of 2586 eleven year‐olds followed up at ages 13 and 15.

Setting

West of Scotland.

Participants

93% baseline participation, reducing to 79% at age 15.

Main outcome measures

Ever smoked (age 11), current and daily smoking (ages 13 and 15) and the proportion of income spent on tobacco (13 and 15) based on recommended retail prices of usual brands.

Results

Strong independent effects of parental social class and personal income were found at 11 years, both reducing with age. The higher incomes of lower class participants attenuated the social class effect on smoking at ages 11 and 13, but not at 15. Analysis within class groups showed variation in the effect of income on smoking, being strongest among higher class youths and weak or non‐existent among lower class youths. This was despite the fact that the proportion of weekly income apparently spent on tobacco was greater among lower class youths.

Conclusions

The results confirm the importance of personal income and parental social class for youth smoking, but they also show that personal income matters more for those from higher class backgrounds. This suggests both that lower class youths have greater access to tobacco from family and friends and to cheaper sources of cigarettes from illegal sources. This complicates the relation between fiscal policies and smoking and might have the unintended consequence of increasing class differentials in youth smoking rather than the reverse.     

Vulnerability to smoking after trying a single cigarette can lie dormant for three years or more

Objective

To examine the development of smoking behaviour among adolescents who, at age 11, had tried cigarettes just once.

Design

A five‐year prospective study.

Setting

36 schools in South London, England.

Subjects

A socioeconomically and ethnically diverse sample of students completed questionnaires annually from age 11–16. A total of 5863 students took part, with an annual response rate ranging from 74–85%. 2041 (35%) provided smoking status data every year.

Main outcome measures

Current smoking (smoking sometimes or more often) for the first time. Cotinine assays provided biochemical verification of smoking status.

Results

Students who at age 11 reported having tried smoking cigarettes just once (n = 260), but were not smoking at the time, were more likely to take‐up smoking at a later age than those that had not tried smoking (n = 1719), even after a gap of up to three years of not smoking. The odds of starting to smoke at age 14 were 2.1 times greater (95% confidence interval 1.2 to 3.5) in the age 11 “one time triers” than the “non‐triers”, even once sex, ethnicity, deprivation, parental smoking and conduct disorder were adjusted for.

Conclusions

This is the first clear demonstration of a “sleeper effect” or period of dormant vulnerability. Our findings have implications for understanding the development of cigarette use and for policies to reduce smoking in young people. Preventing children from trying even one cigarette may be important, and the design of interventions should recognise adolescents who have smoked just once, several years previously, as potentially vulnerable to later smoking uptake.     

22 years on: the impact and relevance of the UK No Smoking Day

Objectives

To evaluate the impact and relevance of the national awareness day “No Smoking Day” 22 years after it was launched.

Design

Triangulation of data from a variety of sources. Retrospective surveys conducted one week and three months after No Smoking Day, media coverage, website activity, and volume of calls to national smokers'' helplines.

Main outcome measures

Self reports of awareness and smoking behaviour changes one week and three months after No Smoking Day. Volume of media coverage, visits to No Smoking Day website, and volumes of calls to smokers'' helplines.

Results

Follow up at one week indicates awareness of No Smoking Day is lower in 2004 than in 1986 but still high at 70% for all smokers. The decline in participation from 18% of aware smokers in 1994 to 7% in 2001 has been reversed and in 2005 19% quit or reduced their smoking on No Smoking Day. Three months after No Smoking Day awareness was 78% in 2004, lower than in previous studies but still high and equivalent to 9 965 000 smokers when applied to the population estimate of UK smokers. Likewise participation has decreased but at 14% in 2004 is equivalent to an estimated 1 840 000 (1 in 7 of UK smokers) claiming to quit or reduce their consumption on the Day. Among those who participated, 11% were still not smoking more than three months after the Day, equivalent to an estimated 85 000 smokers (0.7% of UK smokers). Media volume has increased even though campaign spend has remained relatively constant and calls to national smokers'' helplines on No Smoking Day are typically four times those received on an average day.

Conclusions

These data suggest that after 22 years No Smoking Day continues to be successful in reaching smokers. With a budget insufficient to pay for advertising, this public awareness campaign supported by local activities appears to be effective in helping smokers to stop.     

Are comprehensive environmental changes as effective as health education for smoking cessation?

Objectives

To compare the effectiveness of health education on smoking cessation for all smokers regardless of their willingness to quit smoking and cumulative environmental changes including designation of smoking places, legislation, and price rise.

Design

Comparison of smoking cessation rates over two time periods: the period of health education on smoking cessation (1997–1999), and the period of cumulative environmental changes (2002–2004).

Setting

An occupational setting in a radiator manufacturing factory in Japan.

Subjects

All habitual male smokers who remained in the worksite through the pertinent time period (n  =  202 in the period of health education and n  =  170 in the period of environmental changes).

Main outcome measurements

Smoking cessation rates at the end of each time period.

Results

The smoking cessation rates over the periods of health education and environmental changes were 8.9% and 7.1%, respectively. There was no difference between these two proportions in a χ² test (p  =  0.513). The age adjustment did not significantly alter the cessation rate.

Conclusions

Cumulative environmental changes are fairly effective in promoting smoking cessation, and may yield similar smoking cessation rates as a health education intervention reaching all smokers regardless of their willingness to quit smoking.     

Industry sponsored anti-smoking ads and adolescent reactance: test of a boomerang effect

Objective

To examine whether adolescents'' exposure to youth smoking prevention ads sponsored by tobacco companies promotes intentions to smoke, curiosity about smoking, and positive attitudes toward the tobacco industry.

Design

A randomised controlled experiment compared adolescents'' responses to five smoking prevention ads sponsored by a tobacco company (Philip Morris or Lorillard), or to five smoking prevention ads sponsored by a non‐profit organisation (the American Legacy Foundation), or to five ads about preventing drunk driving.

Setting

A large public high school in California''s central valley.

Subjects

A convenience sample of 9th and 10th graders (n  =  832) ages 14–17 years.

Main outcome measures

Perceptions of ad effectiveness, intention to smoke, and attitudes toward tobacco companies measured immediately after exposure.

Results

As predicted, adolescents rated Philip Morris and Lorillard ads less favourably than the other youth smoking prevention ads. Adolescents'' intention to smoke did not differ as a function of ad exposure. However, exposure to Philip Morris and Lorillard ads engendered more favourable attitudes toward tobacco companies.

Conclusions

This study demonstrates that industry sponsored anti‐smoking ads do more to promote corporate image than to prevent youth smoking. By cultivating public opinion that is more sympathetic toward tobacco companies, the effect of such advertising is likely to be more harmful than helpful to youth.     

Use of nicotine replacement therapy in socioeconomically deprived young smokers: a community-based pilot randomised controlled trial

Background

Smoking is common in young people, particularly in disadvantaged groups, and continued smoking has a major impact on quality and quantity of life. Although many young smokers want to stop smoking, little is known about the design and effectiveness of cessation services for them.

Objective

To determine whether nicotine replacement therapy (NRT) when combined with counselling is effective in young smokers in a deprived area of Nottingham, UK

Methods and subjects

We surveyed smoking prevalence and attitudes to smoking and quitting in young people accessing an open access youth project in a deprived area of Nottingham, and used the information gained to design a community based smoking cessation service incorporating a randomised controlled trial of nicotine patches against placebo given in association with individual behavioural support. We resurveyed smoking prevalence among project attendees after completing the pilot study.

Results

Of 264 young people surveyed (median age 14 years, range 11–21), 49% were regular smokers. A total of 98 young people were recruited and randomised to receive either active nicotine patches on a six week reducing dose regimen (49 participants), or placebo (49 participants). Adherence to therapy was low, the median duration being one week, and 63 participants did not attend any follow up. At four weeks, five subjects receiving active NRT and two receiving placebo were abstinent, and at 13 weeks none were. Adverse effects were more common in the active group but none were serious. Smoking prevalence among 246 youth project attendees surveyed after the trial was 44%.

Conclusions

This study suggests that NRT in this context is unlikely to be effective in young smokers, not least because of low adherence to therapy. It also suggests that young smokers want help with smoking cessation, but that establishing the efficacy of smoking cessation services for young people who need them most will be very difficult.     

Parental smoking and children's respiratory health: independent effects of prenatal and postnatal exposure

Objectives

Adverse effects have been reported of prenatal and/or postnatal passive exposure to smoking on children''s health. Uncertainties remain about the relative importance of smoking at different periods in the child''s life. We investigate this in a pooled analysis, on 53 879 children from 12 cross‐sectional studies—components of the PATY study (Pollution And The Young).

Methods

Effects were estimated, within each study, of three exposures: mother smoked during pregnancy, parental smoking in the first two years, current parental smoking. Outcomes were: wheeze, asthma, “woken by wheeze”, bronchitis, nocturnal cough, morning cough, “sensitivity to inhaled allergens” and hay fever. Logistic regressions were used, controlling for individual risk factors and study area. Heterogeneity between study‐specific results, and mean effects (allowing for heterogeneity) were estimated using meta‐analytical tools.

Results

There was strong evidence linking parental smoking to wheeze, asthma, bronchitis and nocturnal cough, with mean odds ratios all around 1.15, with independent effects of prenatal and postnatal exposures for most associations.

Conclusions

Adverse effects of both pre‐ and postnatal parental smoking on children''s respiratory health were confirmed. Asthma was most strongly associated with maternal smoking during pregnancy, but postnatal exposure showed independent associations with a range of other respiratory symptoms. All tobacco smoke exposure has serious consequences for children''s respiratory health and needs to be reduced urgently.     

Reconsidering stress and smoking: a qualitative study among college students

Background

Although it is widely acknowledged among adult smokers that increases in smoking are often precipitated by stressful events, far less attention has been given to smoking during times of stress among youth.

Aims

To address this gap by drawing attention to the social utility of smoking in contexts associated with stress among college students.

Design

Face‐to‐face semistructured interviews with college freshmen at a large midwestern university in the US.

Participants

Male and female low‐level smokers (n = 24), defined as those who reported regular weekday smoking (typically 3–4 cigarettes a day) and smoking at parties on weekends, were interviewed once in person. In addition, 40 brief interviews with smokers were conducted during final examination.

Measurements

Interviews focused on a range of issues including current smoking behaviour and reasons for smoking. As part of the interview, students were given a deck of cards that listed a range of reasons for smoking. Participants were asked to select cards that described their smoking experience in the past 2 weeks. Those who selected cards that indicated smoking when stressed were asked to explain the reasons why they did so.

Results

A review of qualitative responses reveals that smoking served multiple functions during times of stress for college students. Cigarettes are a consumption event that facilitates a brief social interaction during study times when students feel isolated from their friends. Cigarettes also serve as an idiom of distress, signalling non‐verbally to others that they were stressed. Students described smoking to manage their own stress and also to help manage “second‐hand stress” from their friends and classmates.

Conclusions

Moving away from an individual‐focused analysis of stress to a broader assessment of the social contexts of smoking provides a more nuanced account of the multifunctionalilty of cigarettes in students'' lives. Qualitative research draws attention to issues including the need for smoking and socialising during examination time, smoking as a way to take a break and refocus, notions of second‐hand stress and smoking to manage social relationships.In the past decade, several US‐based studies have reported significant levels of smoking among college students, with approximately 30% of college students reporting having smoked in the past 30 days, and 40% reporting having smoked in the past year.^1,2 Studies have found that a majority of college students who smoke are social smokers, meaning that they smoke more often with others than when alone, particularly when drinking, and that they smoke at low levels.^3,4 To understand better the patterns of low‐level tobacco use, qualitative research was conducted to examine closely the contexts in which students smoked. It has been suggested that a better understanding of the social context of smoking may help enhance tobacco control research and practice.⁵ Two broad contexts that begged consideration were positive social contexts in which tobacco use occurred (such as parties where alcohol was consumed), and contexts associated with stress, be this stressful life events (such as the taking of exams) or stressful events related to the management of social relationships and shifts in identity at this time of transition in life.This article highlights major findings of qualitative research on smoking in contexts associated with stress among college students. It is well established in the general population that increases in smoking are often precipitated by stressful events.^6,7 We draw attention to the social utility of smoking in contexts associated with stress, acknowledging that tobacco use also has psychological and physiological effects when used as a form of stress management and self‐medication.Three major issues guided the research: (1) to explore the extent to which students use smoking as a multifunctional tool for stress management; (2) to determine whether students use smoking as an idiom of distress and a means of showing empathy when a friend is under stress; and (3) to provide details on the complex of motivations that lead students to smoke during examination time.     

Smokers and non-smokers talk about regulatory options in tobacco control

Objective

Community members are occasionally polled about tobacco control policies, but are rarely given opportunities to elaborate on their views. We examined laypeople''s conversations to understand how 11 regulatory options were supported or opposed in interactions.

Design

Qualitative design; purposive quota sampling; data collection via focus groups.

Setting

Three locations in Sydney, Australia.

Participants

63 smokers and 75 non‐smokers, men and women, from three age groups (18–24, 35–44, 55–64 years), recruited primarily via telephone.

Measurements

Semi‐structured question route; data managed in NVivo; responses compared between groups.

Results

Laypeople rejected some regulatory proposals and certain arguments about taxation and the cost of cessation treatments. Protecting children and hypothecating tobacco excise for health education and care were highly acceptable. Plain packaging, banning retail displays and youth smoking prevention received qualified support. Bans on political donations from tobacco corporations were popular in principle but considered logistically fraught. Smokers asked for better cessation assistance and were curious about cigarette ingredients. Justice was an important evaluative principle. Support was often conditional and unresolved arguments frequent. We present both sides of these conflicts and the ways in which policies were legitimised or de‐legitimised in conversation.

Conclusions

Simple measures of agreement used in polls may obscure the complexity of community responses to tobacco policy. Support was frequently present but contested; some arguments that seem self‐evident to advocates were not so to participants. The detailed understanding of laypeople''s responses provided through qualitative methods may help frame proposals and arguments to meet concerns about justice, effectiveness and feasibility.     

Discrete choice experiment of smoking cessation behaviour in Japan

Background

In spite of gradual increases in tobacco price and the introduction of laws supporting various anti‐tobacco measures, the proportion of smokers in Japan''s population is still higher than in other developed nations.

Objective

To understand what information and individual characteristics drive smokers to attempt to quit smoking. These determinants will help to realise effective tobacco control policy as a base for understanding of cessation behaviour.

Method

Discrete choice experiments on a total of 616 respondents registered at a consumer monitoring investigative company.

Results

The effect of price is greater on smokers with lower nicotine dependence. For smokers of moderate and low dependency, short term health risks and health risks caused by passive smoking have a strong impact, though the existence of penalties and long term health risks have little influence on smokers'' decisions to quit. For highly dependent smokers, non‐price attributes have little impact. Furthermore, the effects of age, sex and knowledge are also not uniform in accounting for smoking cessation.

Conclusion

Determinants of smoking cessation vary among levels of nicotine dependency. Therefore, how and what information is provided needs to be carefully considered when counselling smokers to help them to quit.     

Five in a row--reactions of smokers to tobacco tax increases: population-based cross-sectional studies in Germany 2001-2006

Objective

To assess reactions of smokers to five waves of tobacco tax increases in Germany.

Design

A 10‐wave cross‐sectional study, with assessments before and after the tax increases.

Setting

General population of Germany.

Participants and methods

10 representative samples from the general population with a total number of 27 608 people aged ⩾14 years, including 8548 smokers (31% of the total sample), were interviewed.

Outcome measures

Reflection on smoking behaviour, and smoking behaviour (quitting, reducing, switching to a cheaper brand or no change) before and after tobacco tax increases.

Results

Before the tax increases, one third to more than half of the smokers reflected on their smoking behaviour, 9.7–13.9% intended to quit, 23.4–34.7% intended to reduce smoking and 10.8–16.4% intended to switch to cheaper tobacco products, whereas 36.1–52.1% did not intend any change at all. After the tax increases, one fourth to more than one third reported to have reflected on their smoking behaviour, 4.0–7.9% quit smoking owing to the increase, 11.5–16.6% reduced consumption and 11.0–19.9% switched to cheaper products. Significant associations were found between the height of the price increase and the intentions and reactions of smokers.

Conclusions

Price increases lead to a substantial reflection on smoking and intended and realised behaviour changes such as reduced consumption and switching to cheaper tobacco products. These effects are more pronounced the more the price rises. Therefore, taxation policy will lead to quitting and reducing smoking. However, complementary measures should also be taken to prevent smokers switching to cheaper tobacco products, which would reduce the effectiveness of taxation policy.Smoking remains the leading cause of preventable death worldwide.¹ Tax increases are regarded as the most effective single intervention to reduce demand for tobacco.² Studies on the relationship between cigarette taxes and consumption of cigarettes have shown that the higher the tax increase, the greater the reduction in sales.^3,4 This reduction may result from non‐smokers who do not initiate smoking and from smokers who reduce the number of cigarettes they smoke or who quit completely as a reaction to higher prices—that is, to limit consumption. Another way to compensate for the price increase reported by smokers is to switch to a cheaper brand, to cheaper tobacco products such as hand‐rolled tobacco or to cheaper sources for cigarettes to minimise expenditures.^5,6,7Complementary to analysis of sales data, population surveys help in getting a better insight into the various possible reactions of smokers: do price increases affect them? If yes, which reactions are intended and realised; do price increases motivate smokers to quit, to reduce smoking intensity or to compensate for the costs by switching to a cheaper brand? Although there are numerous studies on the relationship between use and price relying on individual data,^{8,9,10,11,12,13,14} these studies only assess current (and past) use and the intensity of smoking (usually smoking status and cigarettes per day). Until now, only Biener et al¹⁵ have studied perceptions of smokers on the effect of tobacco taxes in Massachusetts, USA, and their reactions to tax increases after the increase in more detail.¹⁵This study examines the reactions of smokers before and after five steps of tobacco tax increase from 2002 to 2005 in Germany. To our knowledge, this is the first study using the population survey approach to assess both intentions before a tobacco tax increase and reactions after the tax increase, using several indicators of smoking behaviour and not only smoking status and daily use. Further, the row of five steps of tobacco increase during a short period offered the unique opportunity to study the same question repeatedly with comparable methods. It was hypothesised that future tax increases would provoke a substantial proportion of smokers to reflect on their smoking and intent to behaviour changes, and that implemented tax increases would result in reactions such as quitting, reduced consumption and strategies to minimise expenditures at least in some smokers.     

Mortality and life expectancy in relation to long-term cigarette, cigar and pipe smoking: the Zutphen Study

Study objective

To study the effect of long‐term smoking on all‐cause and cause‐specific mortality, and to estimate the effects of cigarette and cigar or pipe smoking on life expectancy.

Design

A long‐term prospective cohort study.

Setting

Zutphen, The Netherlands.

Participants

1373 men from the Zutphen Study, born between 1900 and 1920 and studied between 1960 and 2000.

Measurements

Hazard ratios for the type of smoking, amount and duration of cigarette smoking, obtained from a time‐dependent Cox regression model. Absolute health effects of smoking are expressed as differences in life expectancy and the number of disease‐free years of life.

Main results

Duration of cigarette smoking was strongly associated with mortality from cardiovascular disease, lung cancer and chronic obstructive pulmonary disease, whereas both the number of cigarettes smoked as well as duration of cigarette smoking were strongly associated with all‐cause mortality. Average cigarette smoking reduced the total life expectancy by 6.8 years, whereas heavy cigarette smoking reduced the total life expectancy by 8.8 years. The number of total life‐years lost due to cigar or pipe smoking was 4.7 years. Moreover, cigarette smoking reduced the number of disease‐free life‐years by 5.8 years, and cigar or pipe smoking by 5.2 years. Stopping cigarette smoking at age 40 increased the life expectancy by 4.6 years, while the number of disease‐free life‐years was increased by 3.0 years.

Conclusions

Cigar or pipe smoking reduces life expectancy to a lesser extent than cigarette smoking. Both the number of cigarettes smoked and duration of smoking are strongly associated with mortality risk and the number of life‐years lost. Stopping smoking after age 40 has major health benefits.Smoking has been recognised as a health hazard for many years. Smoking causes a wide range of diseases, including cancer, chronic obstructive pulmonary disease (COPD) and cardiovascular diseases (CVD), and smoking cessation has impressive health benefits.^1,2,3 Cigarette smoking cessation decreases the risk of diseases and also increases life expectancy. Even stopping at age 60 gains about 3 years of life expectancy.⁴ Much less is known about the adverse effects of long‐term cigar or pipe smoking.^5,6,7Smoking has both long‐ and short‐term effects. As smoking habits change during life, information on long‐term smoking history is required to obtain correct estimates of the long‐term health effects of smoking. Because in most studies the level of detail on smoking history is limited, the impact of various aspects of the smoking history remains unclear. Leffondré et al⁸ show the importance of information on smoking duration, intensity and time since cessation in this respect. Although smoking duration has been associated with mortality before, most studies focused on cancer mortality rather than on CVD and COPD mortality.^{9,10,11,12,13,14,15}In epidemiological studies, hazard ratios are commonly used to express the impact on mortality. Hazard ratios express effects for one exposure group relative to the effect of the unexposed group—that is, the reference group—but do not give information regarding absolute public health effects. Therefore, life expectancies should be calculated. Although concepts like life expectancy are more informative and readily grasped by all, they are not reported frequently.The objective of this study is to assess the relationships between long‐term cigarette, cigar or pipe smoking, and duration and the number of cigarettes smoked, and mortality. To obtain accurate effect estimates, we used repeated measures of smoking habits collected in a 40‐year period and adjusted for potential confounders. In addition to hazard ratios, we present our results also in terms of changes in life expectancy at age 40 and the number of disease‐free years of life due to cigarette and cigar or pipe smoking.     

Prevalence of smoking among major movie characters: 1996-2004

Background

Reports of a relationship between watching smoking in movies and smoking among adolescents have prompted greater scrutiny of smoking in movies by the public health community.

Objective

To assess the smoking prevalence among adult and adolescent movie characters, examine trends in smoking in movies over time, and compare the data with actual smoking prevalence among US adults and adolescents.

Design and methods

Smoking status of all major human adolescent and adult movie characters in the top 100 box office hits from 1996 to 2004 (900 movies) was assessed, and smoking prevalence was examined by Motion Picture Association of America (MPAA) rating and year of release.

Results

The movies contained 5944 major characters, of whom 4911 were adults and 466 were adolescents. Among adult movie characters, the overall smoking prevalence was 20.6%; smoking was more common in men than in women (22.6% v 16.1%, respectively, p<0.001), and was related to MPAA rating category (26.9% for movies rated R (restricted, people aged <17 years require accompanying adult), 17.9% for PG‐13 (parents strongly cautioned that some material might be inappropriate for children) and 10.4% for G/PG (general audiences, all ages; parental guidance suggested for children), p<0.001). In 1996, the smoking prevalence for major adult movie characters (25.7%) was similar to that in the actual US population (24.7%). Smoking prevalence among adult movie characters declined to 18.4% in 2004 (p for trend <0.001), slightly below that for the US population for that year (20.9%). Examination of trends by MPAA rating showed that the downward trend in smoking among adult movie characters was statistically significant in movies rated G/PG and R, but not in those rated PG‐13. A downward trend over time was also found for smoking among adolescent movie characters. There was no smoking among adult characters in 43.3% of the movies; however, in 39% of the movies, smoking prevalence among adult characters was higher than that in the US adult population in the year of release.

Conclusions

Smoking prevalence among major adolescent and adult movie characters is declining, with the downward trend among adult characters weakest for PG‐13‐rated movies. Although many movies depict no adult smoking, more than one third depict smoking as more prevalent than that among US adults at the time of release.Recent research has established that there is an association between watching smoking in movies and smoking among adolescents.^{1,2,3,4,5,6,7} This has prompted greater scrutiny of the movie industry by the public health community,⁸ and has highlighted the need to understand better how and why smoking is depicted in movies. As smoking among movie characters considerably influences smoking among youths, the public health community needs data on its frequency and reach. Just as quantitative measures of smoking among the general population are used to assess the effectiveness of public health campaigns on smoking, quantitative measures could be used to assess the success of public health campaigns aimed at reducing depictions of smoking in movies. Smoking in movies is generally quantified through content analysis, in which a specified sample frame of movies is assessed according to a set of predefined criteria. Previous studies generally agree that (1) smoking is depicted in most movies^{9,10,11,12,13,14,15}; (2) smoking in movies increases as Motion Picture Association of America rating increases from G to R^9,14,15; (3) movie characters who smoke do not represent the typical smoker (in that they are more likely to be affluent, good looking and powerful than are typical smokers)^9,12; and (4) smoking in movies is rarely depicted in the context of negative health outcomes.^9,10,12,15Content analyses vary in the way they quantify movie smoking, and this makes it difficult to compare results across studies. One objective measure of smoking in movies is the smoking prevalence among major characters. This type of assessment requires coders to determine the number of major characters (however this is defined) and also to determine whether or not each character is depicted as a smoker. The overall smoking prevalence among characters and yearly time trends can then be determined, as can prevalence rates by movie and character traits (eg, sex or age). Although the smoking prevalence among characters has not been measured in all content analyses, it is reported in many of them, and is remarkably consistent. McIntosh et al¹³ reported a smoking rate of 21% among characters in films released in the 1980s. Dalton et al⁹ and Omidvari et al¹⁶ reported rates of 25% and 21%, respectively, for movies released in the 1990s. We report time trends for smoking prevalence among adult and adolescent movie characters for the top 100 US box office hits released over a 9‐year period to better understand recent trends in smoking among movie characters.     

Smokers living in deprived areas are less likely to quit: a longitudinal follow-up

Objective

To follow up smokers to examine whether the likelihood of quitting smoking varied by area deprivation, and whether smoking history, health status, personality characteristics, social support and stressful situations contributed to differences in area deprivation in quit rates.

Design

Longitudinal data with a 6‐year follow‐up period were analysed using multilevel logistic regression. Area‐level deprivation was characterised by a composite measure that was the sum of the proportion of unemployed residents, the percentage of residents in blue‐collar occupations and the proportion with only elementary‐level education. Previously established predictors of smoking cessation, including education, age at smoking initiation, self‐assessed health, chronic illness, locus of control, neuroticism, negative life events, longlasting relationship difficulties, emotional social support and negative neighbourhood conditions were examined separately and in a combined model to assess whether they contributed to neighbourhood deprivation differences in quitting.

Participants

404 participants (residing in 83 areas) identified as smokers at baseline and who did not change their residential address over the follow‐up period.

Main outcome

Being a non‐smoker at follow‐up.

Results

Odds ratios of quitting decreased with greater area‐level deprivation, but differences reached significance only between the most and least deprived quartiles. Smoking history, health status, personality characteristics, social support and stressful situations did not contribute to the lower quitting rates seen among smokers in deprived areas.

Conclusions

Living in a deprived area seems to reduce the likelihood of quitting smoking; hence individual‐level tobacco control efforts should be complemented with area‐based interventions. However, we need to identify and understand the underlying factors associated with living in a deprived area that contributes to lower quitting rates.Extensive research has examined the socioeconomic influences on smoking. Most of this work has focused on socioeconomic determinants at the individual level, such as how smoking varies by education, occupational class and income.^1,2 Recent work has shown that deprivation characteristics of residential areas are associated with residents'' smoking, independent of their demographic and socioeconomic characteristics, and that smoking prevalence increases with area deprivation.^1,2,3,4 However, one of these studies showed that the relationship between smoking prevalence and area deprivation did not hold for all measures of area deprivation.³ A US study found no relationship between the degree of income inequality in states and smoking behaviour.⁵ These studies have hypothesised that area inequalities in smoking may be the consequence of a spatial patterning in smoking history, health status, personality characteristics, support and stressful situations that predisposes people in disadvantaged areas to smoke.The relationship between area deprivation and smoking has been examined only in cross‐sectional studies. There has been no longitudinal follow‐up of changes in smoking status of adults living in areas with different deprivation characteristics. Such an examination would help elucidate whether area of residence is likely to have a causal relationship on smoking, and whether any of the established individual‐level factors contribute to changes in smoking status.This study followed a group of smokers over 6 years to examine whether the likelihood of quitting varied between residents of areas differing in their deprivation characteristics. Furthermore, it investigated whether smoking history, health status, personality characteristics, coping, social support and stressful situations contributed to area deprivation inequalities in quitting.     

A group randomised trial of two methods for disseminating a smoking cessation programme to public antenatal clinics: effects on patient outcomes

Objective

To assess the differential effectiveness of two methods of disseminating a smoking cessation programme to public hospital antenatal clinics.

Design

Group randomised trial.

Setting

22 antenatal clinics in New South Wales, Australia.

Intervention

Clinics were allocated to a simple dissemination (SD) condition (11 clinics) which received a mail‐out of programme resources or to an intensive dissemination (ID) condition (11 clinics) which included the mail‐out plus feedback, training, and ongoing support with midwife facilitator.

Main outcome measures

Independent cross sectional surveys of women on a second or subsequent visit undertaken pre‐dissemination and 18 months after dissemination. Outcomes were: (1) levels of smoking status assessment by clinic staff; (2) proportion of women identifying as having been smokers at their first visit who reported receiving cessation advice; (3) proportion of these women who had quit (self report and expired air carbon monoxide (CO)); and (4) smoking prevalence among all women (self report and CO).

Subjects

5849 women pre‐dissemination (2374 SD, 3475 ID) and weighted sample of 5145 women post‐dissemination (2302 SD, 2843 ID).

Results

There were no significant differences between the groups on change on any outcome. Change in either group was minimal. In the post‐dissemination survey, the cessation proportions were 6.4% (SD) and 10.5% (ID).

Conclusions

Relatively modest strategies for encouraging incorporation of smoking cessation activities into antenatal care were not effective in the long term. Alternative strategies should be implemented and evaluated. The findings reinforce the importance of a whole population approach to tobacco control.     

Smoking and erectile dysfunction: findings from a representative sample of Australian men

Objectives

To examine whether there is an association between smoking and erectile dysfunction in a representative sample of Australian men.

Design

Secondary analysis of cross‐sectional survey data from the Australian Study of Health and Relationships.

Participants

8367 Australian men aged 16–59 years.

Main outcome measures

Erectile dysfunction was identified in men who reported having had trouble keeping an erection when they wanted to, a problem which persisted for at least one month over the previous year. Variables examined in multivariate logistic regression analyses included age, education, presence of cardiovascular disease and diabetes, and current alcohol and tobacco consumption.

Results

Almost one in 10 of the respondents (9.1%) reported erectile dysfunction that lasted for at least one month over the previous year. More than a quarter (27.2%) of respondents were current smokers, with 20.9% smoking ⩽ 20 cigarettes per day, and 6.3% smoking > 20 cigarettes per day. Compared with non‐smokers, the adjusted odds ratios for erectile dysfunction were 1.24 (95% confidence interval (CI) 1.01 to 1.52, p  =  0.04) for those smoking ⩽ 20 cigarettes per day and 1.39 (95% CI 1.05 to 1.83, p  =  0.02) for those smoking > 20 cigarettes per day, after adjusting for other confounding factors. Older age, low level of education, and taking medications for cardiovascular disease were also independently and positively associated with erectile dysfunction. In contrast, moderate alcohol consumption (1–4 drinks per day) significantly reduced the likelihood of having erectile dysfunction.

Conclusions

Erectile dysfunction is a significant health concern affecting around one in 10 Australian men aged 16–59 years. Current smoking is significantly associated with erectile dysfunction in Australian males. This association was strengthened as the number of cigarettes smoked increased. Health promotion programmes could use the link between smoking and erectile dysfunction to help reduce smoking levels among men.     

Cost of tobacco-related diseases, including passive smoking, in Hong Kong

Background

Costs of tobacco‐related disease can be useful evidence to support tobacco control. In Hong Kong we now have locally derived data on the risks of smoking, including passive smoking.

Aim

To estimate the health‐related costs of tobacco from both active and passive smoking.

Methods

Using local data, we estimated active and passive smoking‐attributable mortality, hospital admissions, outpatient, emergency and general practitioner visits for adults and children, use of nursing homes and domestic help, time lost from work due to illness and premature mortality in the productive years. Morbidity risk data were used where possible but otherwise estimates based on mortality risks were used. Utilisation was valued at unit costs or from survey data. Work time lost was valued at the median wage and an additional costing included a value of US$1.3 million for a life lost.

Results

In the Hong Kong population of 6.5 million in 1998, the annual value of direct medical costs, long term care and productivity loss was US$532 million for active smoking and US$156 million for passive smoking; passive smoking accounted for 23% of the total costs. Adding the value of attributable lives lost brought the annual cost to US$9.4 billion.

Conclusion

The health costs of tobacco use are high and represent a net loss to society. Passive smoking increases these costs by at least a quarter. This quantification of the costs of tobacco provides strong motivation for legislative action on smoke‐free areas in the Asia Pacific Region and elsewhere.     

Effects of preoperative smoking cessation on the incidence and risk of intraoperative and postoperative complications in adult smokers: a systematic review

Objectives

To establish the effect of preoperative smoking cessation on the risk of postoperative complications, and to identify the effect of the timing of preoperative cessation.

Data sources

The Cochrane Library Database, PsycINFO, EMBASE, Medline, and CINAHL databases were searched, using the terms: “smoking”, “smoking‐cessation”, “tobacco‐use”, “tobacco‐abstinence”, “cigarett$”, “complication$”, “postoperative‐complication$”, “preoperative”, “perioperative” and “surg$”. Further articles were obtained from reference lists. The search was limited to articles on adults, written in English and published up to November 2005.

Study selection

Prospective cohort designs exploring the effects of preoperative smoking cessation on postoperative complications were included. Two reviewers independently scanned abstracts of relevant articles to determine eligibility. Lack of agreement was resolved through discussion and consensus. Twelve studies met the inclusion criteria.

Data extraction

Methodological quality was assessed by both reviewers, exploring validation of smoking status, clear definition of the period of smoking cessation, control for confounding variables and length of follow‐up.

Data synthesis

Only four of the studies specified the exact period of smoking cessation, with six studies specifying the length of the follow‐up period. Five studies revealed a lower risk or incidence of postoperative complications in past smokers than current smokers or reported that there was no significant difference between past smokers and non‐smokers.

Conclusions

Longer periods of smoking cessation appear to be more effective in reducing the incidence/risk of postoperative complications; there was no increased risk in postoperative complications from short term cessation. An optimal period of preoperative smoking cessation could not be identified from the available evidence.