The California Tobacco Control Program's effect on adult smokers: (2) Daily cigarette consumption levels

Objective

To investigate the association of the California Comprehensive Tobacco Control Program with self‐reported population trends of cigarette consumption during 1992–2002.

Setting and Participants

Participants were non‐Hispanic white daily smokers (aged 20–64 years, n = 24 317) from the Tobacco Use Supplements to the Current Population Survey (1992–2002). We compared age‐specific trends in consumption among daily smokers in three groups of states with differing tobacco control initiatives: California (CA; high cigarette price/comprehensive programme), New York and New Jersey (high cigarette price/no comprehensive programme), and tobacco‐growing states (TGS; low cigarette price/no comprehensive programme).

Results

There was a general decline in cigarette consumption across all age groups in each category of states between 1992 and 2002, except the oldest age group in the TGS . The largest annual decline in the average number of cigarettes per day was observed among daily smokers in CA who were aged ⩾35 years (−0.41 cigarettes/day/year (95% CI −0.52 to −0.3)). This rate was significantly higher than the −0.22 cigarettes/day/year (95% CI −0.3 to −0.16; p<0.02) observed in same‐age daily smokers from New York and New Jersey, and significantly higher than the rate in same‐age daily smokers from the TGS (−0.15 cigarettes/day/year (95% CI −0.22 to −0.08; p<0.002)). There were no significant differences across state groups in the decline observed in daily smokers aged 20–34 years. In 2002, only 12% of daily smokers in CA smoked more than a pack per day, which was significantly lower than the 17% in New York and New Jersey, which again was significantly lower than the 25% in the TGS.

Conclusions

The California Tobacco Control Program was associated with significant declines in cigarette consumption among daily smokers aged ⩾35 years of age, which in turn should lead to declines in tobacco‐related health effects. The decline in consumption among young adult smokers was a national trend.Established statistical models from cohort studies have consistently demonstrated that smoking‐related diseases, especially lung cancer, vary exponentially with consumption level and smoking duration.^1,2,3,4 A significant reduction in the cigarette consumption level is therefore expected to reduce future risk of lung cancer in the population, which is demonstrated by several studies.^5,6,7 In recent years, there has been a call for harm‐reduction strategies to influence smoking levels in continuing smokers⁸; however, there are few studies of population trends and influences on cigarette consumption.^9,10Individual consumption levels differ considerably with age in the US. Typically, consumption levels increase in young adults, remaining relatively stable in middle‐aged adults, and decline in seniors.^9,11,12 Although public health strategies to reduce tobacco‐related disease have focused on promoting quitting and discouraging initiation,¹³ there is evidence that these strategies may also reduce cigarette consumption levels in the population. In this analysis, we assess the association of the California Tobacco Control Program with declines in cigarette consumption, in comparison with states having only high cigarette prices or with no tobacco control programme. Numerous studies have identified that increases in tobacco‐taxes lead to increases in cigarette prices and result in significant reductions in tobacco smoking behaviour.¹⁴ The decrease in cigarette consumption due to price increase has been shown to be a major contributor to the overall reduction in tobacco‐smoking behaviour,¹⁵ and many smokers reduce cigarette consumption before making an attempt to quit.¹⁶The California Comprehensive Tobacco Control Program that was introduced in 1989 was the first large state‐specific programme in the USA.¹⁷ This programme used funding from a dedicated increase in the tobacco excise tax to support a mass‐media counter‐advertising campaign, “grassroots” activism, particularly aimed at protecting non‐smokers from exposure to second‐hand smoke, school and community initiatives against smoking, and smoking cessation services. This programme introduced the first statewide ban on smoking in the workplace in 1994, which has been associated with reduced consumption levels among continuing smokers.^{18,19,20,21,22} From the start of the programme in 1989 to 2002, annual per capita cigarette sales in California (CA) declined by 60%, compared with 40% for the rest of the USA.²³In this report, we investigate the effect of the California Tobacco Control Program on daily consumption levels of daily smokers of differing age groups. We compare population trends for non‐Hispanic white daily smokers from CA with those in two comparison groups of states that have similar large combined populations and different tobacco control initiatives. One group is the top TGS with >90% of US tobacco production during the study period,²⁴ that had low excise taxes²⁵ and no comprehensive programme throughout the 1990s; this group includes Kentucky, Tennessee, North Carolina, South Carolina, Virginia and Georgia. The other group is New York and New Jersey, two neighbouring states that have a combined population size similar to CA and the TGS with tobacco excise taxes similar to CA during the 1990s²⁵ but no comprehensive tobacco control programme.For our analyses, we used state‐specific estimates of cigarette consumption among smokers from surveys of tobacco use in the US conducted by the Bureau of the Census between 1992 and 2002 in the Tobacco Use Supplements to the Current Population Survey (TUS‐CPS).     

Smoking cessation attempts among adolescent smokers: a systematic review of prevalence studies

Objective

To synthesise estimates of the prevalence of cessation attempts among adolescent smokers generally, and according to age and level of cigarette consumption.

Data sources

PubMed, ERIC, and PsychInfo databases and Internet searches of central data collection agencies.

Study selection

National population‐based studies published in English between 1990 and 2005 reporting the prevalence, frequency and/or duration of cessation attempts among smokers aged ⩾10 to <20 years.

Data extraction

Five reviewers determined inclusion criteria for full‐text reports. One reviewer extracted data on the design, population characteristics and results from the reports.

Data synthesis

In total, 52 studies conformed to the inclusion criteria. The marked heterogeneity that characterised the study populations and survey questions precluded a meta‐analysis. Among adolescent current smokers, the median 6‐month, 12‐month and lifetime cessation attempt prevalence was 58% (range: 22–73%), 68% (range 43–92%) and 71% (range 28–84%), respectively. More than half had made multiple attempts. Among smokers who had attempted cessation, the median prevalence of relapse was 34, 56, 89 and 92% within 1 week, 1 month, 6 months, and 1 year, respectively, following the longest attempt. Younger (age<16 years) and non‐daily smokers experienced a similar or higher prevalence of cessation attempts compared with older (age ⩾16 years) or daily smokers. Moreover, the prevalence of relapse by 6 months following the longest cessation attempt was similar across age and smoking frequency.

Conclusions

The high prevalence of cessation attempts and relapse among adolescent smokers extends to young adolescents and non‐daily smokers. Cessation surveillance, research and program development should be more inclusive of these subgroups.An estimated 150 million adolescents worldwide use tobacco. Approximately half of these young smokers will die of tobacco‐related diseases in later life.¹ Adolescent smokers are also subject to more immediate health consequences, such as respiratory and non‐respiratory effects,^2,3 changes in serum cholesterol⁴ and nicotine dependence and withdrawal.⁵ Although preventing the initiation of smoking remains a major goal of tobacco control, prevention programs directed at adolescents have shown limited effectiveness to date.⁶ Moreover, once adolescents start smoking, the impact of prevention programs, whether on experimental or regular smokers, is small and inconsistent across studies.^7,8,9,10 It is estimated that adolescent smokers who reach a consumption level of at least 100 cigarettes will continue to smoke for another 16–20 years.¹¹ Even brief periods of smoking cessation during adolescence have been associated with positive subjective health changes, such as improved respiratory health and a general sense of feeling healthier, fitter and more energetic.^12,13Among adolescents in the early stages of smoking onset, alternating periods of smoking and abstinence are common.^14,15 Yet longitudinal studies show that only 3–12% of adolescent daily or regular smokers^{16,17,18,19,20} and 10–46% of adolescent non‐daily or occasional smokers^18,20,21,22 no longer smoke 1–3 years later. This suggests that the likelihood of achieving abstinence, although generally low, is greater if a cessation attempt occurs at lower levels of consumption. Other reports, however, provide evidence that even adolescent smokers in the early stages of smoking onset experience difficulty attempting cessation.²³ Indeed, symptoms of nicotine dependence, which make cessation difficult, can develop soon after smoking initiation.^5,24,25Recent reviews advocate the intensification of efforts to develop and implement smoking cessation programs for adolescents.^26,27 Correspondingly, initiatives have been established with the goal that every adolescent tobacco user have access to appropriate and effective cessation interventions by the year 2010.²⁸ In addition, in the US, the goal of increasing cessation attempts among adolescent smokers has been incorporated into a set of nationwide public health goals.²⁹ This has created a critical need to document the prevalence of cessation attempts among adolescent smokers. Therefore, the present study summarises the measures used to estimate attempts at smoking cessation and quantifies the prevalence, frequency and duration of cessation attempts among adolescent smokers, generally, and according to age and level of cigarette consumption.     

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.     

Occasional tobacco use among young adult women: a longitudinal analysis of smoking transitions

Objective

To describe prospective transitions in smoking among young adult women who were occasional smokers, and the factors associated with these transitions, by comparing sociodemographic, lifestyle and psychosocial characteristics of those who changed from occasional smoking to daily smoking, non‐daily smoking or non‐smoking.

Design

Longitudinal study with mailed questionnaires.

Participants/setting

Women aged 18–23 years in 1996 were randomly selected from the Medicare Australia database, which provides the most complete list of people in Australia.

Main outcome measures

Self‐reported smoking status at survey 1 (1996), survey 2 (2000) and survey 3 (2003), for 7510 participants who took part in all three surveys and who had complete data on smoking at survey 1.

Results

At survey 1, 28% (n = 2120) of all respondents reported smoking. Among the smokers, 39% (n = 829) were occasional smokers. Of these occasional smokers, 18% changed to daily smoking at survey 2 and remained daily smokers at survey 3; 12% reported non‐daily smoking at surveys 2 and 3; 36% stopped smoking and remained non‐smokers; and 33% moved between daily, non‐daily and non‐smoking over surveys 2 and 3. Over the whole 7‐year period, approximately half stopped smoking, one‐quarter changed to daily smoking and the remainder reported non‐daily smoking. Multivariate analysis identified that a history of daily smoking for ⩾6 months at baseline predicted reversion to daily smoking at follow‐up. Being single and using illicit drugs were also associated with change to daily or non‐daily smoking, whereas alcohol consumption was associated with non‐daily smoking only. Compared with stopping smoking, the change to daily smoking was significantly associated with having intermediate educational qualifications. No significant associations with depression and perceived stress were observed in the multivariate analysis.

Conclusions

Interventions to reduce the prevalence of smoking among young women need to take account of occasional smokers, who made up 39% of all smokers in this study. Targeted interventions to prevent the escalation to daily smoking and to promote cessation should allow for the social context of smoking with alcohol and other drugs, and social and environmental influences in vocational education and occupational settings.The transition to young adulthood is a critical period in establishing patterns of tobacco use, with the prevalence of smoking increasing through to the mid‐1920s.^1,2 It is a time when there are opportunities to prevent smoking and to promote cessation among those who may be amenable to quitting before they become committed smokers.³ The tobacco industry also sees the passage to young adulthood as an opportune time—but for the adoption and consolidation of smoking habits.⁴Among adolescents and young adults, occasional smoking is often regarded as a transitional, experimental phase preceding daily smoking, and rates of occasional smoking are generally higher among younger adults than among older adults.^5,6,7 Occasional smoking in late adolescence has been associated with an eightfold increase in the probability of becoming a daily smoker after 3 years.⁸A number of longitudinal studies have tracked changes in smoking behaviour among occasional smokers over periods of up to 2 years.^3,5,7,9 These studies, which have mostly focused on adolescents or older adults, showed that up to one‐quarter of baseline occasional smokers became daily smokers in the follow‐up periods. Furthermore, a substantial proportion (>40%) of occasional smokers continue to smoke occasionally, while around one‐third stop smoking.^3,5,9 Studies on college students have found that over the course of 4 years, up to 20% of baseline occasional smokers became daily smokers.^10,11Little is known about what differentiates occasional smokers who become daily smokers from those who continue to smoke occasionally and from those who stop smoking. In a study of 45–69‐year‐old smokers in Sweden, Lindstrom et al⁷ examined the sociodemographic and psychosocial characteristics of baseline occasional smokers who became daily smokers, who remained occasional smokers or who stopped smoking at the 1 year follow‐up. Those who stopped or remained occasional smokers were younger, unmarried, highly educated and were snuff consumers to a greater extent than the reference population (baseline daily smokers, ex smokers and never smokers), and those who became daily smokers had poorer psychosocial resources.⁷ A study examining changes in occasional smoking among college students found that positive beliefs about the functional value of smoking and the use of smoking to control negative effects predicted a change to daily smoking.¹¹This paper focuses on the longitudinal patterns of tobacco use among women who were occasional smokers in early adulthood. In addition to the well‐established health risks of smoking, women who smoke are also at risk of decreased fertility, increased risk of complications during pregnancy, miscarriage, stillbirth and neonatal deaths, and lower birth weight babies.¹²Data from a large, prospective, population‐based study were used to describe patterns of smoking behaviour among baseline occasional smokers over a 7‐year period. Our method provided an opportunity to examine the characteristics of young women who progressed from occasional smoking to daily smoking, those who continued occasional tobacco use and those who stopped smoking.     

Women's smoking history prior to entering the US Navy: a prospective predictor of performance

Objective

To examine whether women''s tobacco use prior to entering the US Navy is predictive of subsequent career performance. A priori predictions were that smoking at entry into the Navy would be related to early attrition, poorer job performance, more disciplinary problems and lower likelihood of re‐enlistment.

Methods

A prospective cohort analysis of 5487 women entering the US Navy between March 1996 and March 1997 was conducted. Navy attrition/retention and career performance measures, such as time in service, early attrition, type of discharge, misconduct, number of promotions, demotions and unauthorised absences, highest paygrade achieved, and re‐enlistment were examined.

Results

Compared with never smokers, daily smokers at entry into the US Navy had subsequent career outcomes consistently indicating poorer job performance (eg, early attrition prior to serving a full‐term enlistment, more likely to have a less‐than‐honourable discharge, more demotions and desertions, lower achieved paygrade and less likely to re‐enlist). Other types of smokers consistently fell between never and daily smokers on career outcome measures.

Conclusions

For women entering the US Navy, being a daily smoker is a prospective predictor of poorer performance in the Navy. Future research should evaluate the effectiveness of cessation intervention with smoker‐enlistees prior to their entering the Navy, to assess the impact on subsequent career outcomes.More than 435 000 Americans die each year as a result of cigarette smoking. One in every five American deaths are cigarette related, including 30% of all cancer deaths (87% of lung cancer deaths), 21% of coronary heart disease deaths, 18% of stroke deaths and 82% of chronic obstructive pulmonary disease deaths.^1,2 Use of other forms of tobacco (eg, cigars, pipes, snuff or dip) is also associated with significantly elevated morbidity and mortality,³ as is chronic exposure to secondhand smoke.^4,5,6 Smoking also imposes a considerable financial burden on society, with treatment of smoking‐related diseases costing US$50–73 billion/year⁷ and US$584 million in the US Department of Defense.⁸ In both the civilian and military sectors, smoking has been linked to disability and job‐related outcomes, including decreased productivity, increased absenteeism, and long and more frequent work breaks.^8,9Tobacco use is of particular concern to the US Department of Defense because, historically, the military has had higher and heavier rates of tobacco use than civilians.^10,11,12 Although smoking in the military decreased dramatically from 1980 to the mid‐1990s,¹³ there was a significant increase from 1998 to 2002, marking the first increase in two decades.¹⁰ Past‐month cigarette smoking continues to exceed “Healthy People 2010” objectives of 12%, with 33.8% of military personnel smoking in the past month in 2002.¹⁰Previous research indicates that cigarette smoking in the military has adverse effects on personnel health, performance, physical fitness and attrition.^14,15,16 Numerous studies have concluded that there are negative relationships between smoking and success in combat training among military personnel.^17,18 Smokers tend to exercise less and perform more poorly on military physical fitness tests.^14,19,20 In addition, studies show high rates of smoking persist even after discharge from military service.^21,22 A recent concern among military health officials is the skyrocketing smoking rates among soldiers in Iraq, the post‐deployment implications of which are not yet known.Another adverse effect of smoking that has recently gained attention is early attrition from military service. First‐term attrition is one of the most serious and costly personnel problems faced by the US military.²³ A study of a large number of US Air Force recruits conducted by Klesges and colleagues¹⁵ found smoking to be the best single predictor of early discharge over a 12‐month period, with smoking associated with US$130 million/year in excess training costs extrapolated across all the military services. The study sample of Klesges et al¹⁵ was predominantly men and did not report the effects of smoking separately for men and women, so it might be questioned whether the smoking and early attrition effects would hold for women as well as men.This study examined an all‐female cohort of women entering the US Navy between March 1996 and March 1997. Self‐reported cigarette smoking just prior to entering the Navy was examined as a prospective predictor of performance in the Navy over a possible 7–8 year follow‐up period. Groups based on self‐reported smoking history as “daily smokers,” non‐daily “other smokers” and “never smokers” at entry into the Navy were examined to prospectively assess the relationship between smoking history reported just prior to entering the Navy and subsequent career performance.     

Physician assessment of patient smoking in Indonesia: a public health priority

Objective

To explore Indonesian physician''s smoking behaviours, their attitudes and clinical practices towards smoking cessation.

Design

Cross‐sectional survey.

Setting

Physicians working in Jogjakarta Province, Indonesia, between October and December 2003.

Subjects

447 of 690 (65%) physicians with clinical responsibilities responded to the survey (236 men, 211 women), of which 15% were medical faculty, 35% residents and 50% community physicians.

Results

22% of male (n = 50) and 1% of female (n = 2) physicians were current smokers. Approximately 72% of physicians did not routinely ask about their patient''s smoking status. A majority of physicians (80%) believed that smoking up to 10 cigarettes a day was not harmful for health. The predictors for asking patients about smoking were being male, a non‐smoker and a medical resident. The odds of advising patients to quit were significantly greater among physicians who perceived themselves as sufficiently trained in smoking cessation.

Conclusions

Lack of training in smoking cessation seems to be a major obstacle to physicians actively engaging in smoking cessation activities. Indonesian physicians need to be educated on the importance of routinely asking their patients about their tobacco use and offering practical advice on how to quit smoking.Tobacco use is one of the greatest causes of preventable deaths and disease in human history. According to the World Bank, four‐fifths of the world''s 1.1 billion smokers live in low‐income or middle‐income countries.¹ East Asian and Pacific countries currently account for about 38% of the world''s smokers and men, especially those aged 30–49 years, account for about 80% of these smokers.² In Indonesia, 59% of male, but only <5% of women, smoke.³ Notably, the rates of tobacco use, especially among adolescents and young adults in East Asia, continue to rise.¹ Although reliable national data are unavailable for Indonesia, estimates in 2004 showed a high incidence rate of tobacco‐attributable mortality and morbidity.⁴ For example, in 2002, the International Agency of Research on Cancer Globocan estimated that the age‐standardised mortality of respiratory tract cancer in Indonesia among men was 68.5 per 100 000 population, but that among women was only 21.5 per 100 000 population.⁵Nations such as Indonesia continue to bear significant health and socioeconomic burdens associated with tobacco use, primarily due to aggressive tobacco industries marketing and the slow progress in tobacco control activities resulting from a strong dependency of the national economy on the tobacco trade.⁶ To reduce the economic and health burden from cigarette smoking, effective measures for smoking cessation and tobacco control are clearly needed. Public health education, and governmental policies such as taxation on sales and restrictions on advertisement may serve as useful tools to limit the use of tobacco products.^7,8 Currently, such measures are lacking in Indonesia.Smoking behaviour and attitudes towards smoking cessation by healthcare providers in Western countries have been studied extensively.^9,10,11 Research findings suggest that asking about smoking and offering advice about cessation help smokers quit.^{12,13,14,15,16} Of equal importance is the observation that the smoking status of healthcare providers may influence their willingness to offer smoking cessation advice to smokers.^16,17 Unfortunately, limited research is available on non‐Western countries in regard to behaviours, perceptions and attitudes towards smoking among physicians and other healthcare providers.^16,18,19,20Understanding the attitudes of health professionals towards cessation of tobacco use is an important early step in the development of a country''s comprehensive anti‐tobacco initiative. This step is especially important in countries like Indonesia, where there are few anti‐tobacco initiatives and physicians play a particularly important role as opinion leaders and role models. To understand physician''s attitudes towards tobacco, we conducted a survey of physicians to explore a range of issues including smoking behaviours, and their attitudes and clinical practices regarding smoking.     

Smoking, quitting and mortality in an elderly cohort of 56,000 Hong Kong Chinese

Background

Although the harms of smoking are well established, it is unclear how they extend into old age in the Chinese.

Aim

To examine the relationship of smoking with all‐cause and major cause‐specific mortality in elderly Chinese men and women, respectively, in Hong Kong.

Methods

Mortality by smoking status was examined in a prospective cohort study of 56 167 (18 749 men, 37 416 women) Chinese aged ⩾65 years enrolled from 1998 to 2000 at all the 18 elderly health centres of the Hong Kong Government Department of Health.

Results

After a mean follow‐up of 4.1 years, 1848 male and 2035 female deaths occured among 54 214 subjects (96.5% successful follow‐up). At baseline, more men than women were current smokers (20.3% vs 4.0%) and former smokers (40.8% vs 7.9%). The adjusted RRs (95% CI) for all‐cause mortality in former and current smokers, compared with never smokers, were 1.39 (1.23 to 1.56) and 1.75 (1.53 to 2.00) in men and 1.43 (1.25 to 1.64) and 1.38 (1.14 to 1.68) in women, respectively. For current smokers, the RRs (95% CI) for all‐cause mortality were 1.59 (1.39 to 1.82), 1.72 (1.48 to 2.00) and 1.84 (1.43 to 2.35) for daily consumption of 1–9, 10–20 and >21 cigarettes, respectively (p for trend <0.001). RRs (95% CI) were 1.49 (1.30 to 1.72) and 2.20 (1.88 to 2.57) in former and current smokers for all deaths from cancer, and 1.24 (1.04 to 1.47) and 1.57 (1.28 to 1.94) for all cardiovascular deaths, respectively. Quitters had significantly lower risks of death than current smokers from all causes, lung cancer, all cancers, stroke and all cardiovascular diseases.

Conclusions

In old age, smoking continues to be a major cause of death, and quitting is beneficial. Smoking cessation is urgently needed in rapidly ageing populations in the East.Many Western prospective studies have shown that much of the all‐cause mortality, including lung cancer, cardiovascular disease (CVD) and chronic obstructive pulmonary disease (COPD) are caused by cigarette smoking.^1,2,3 Globally, tobacco‐related deaths are rising, mainly because of increasing cigarette consumption in developing countries, especially China.⁴Prospective studies of smoking and mortality in China are few,^5,6,7,8,9 and evidence from elderly people, especially women, is sparse. Some Western studies have found a lower risk of mortality from smoking in old age than in middle age.^10,11 Prospective studies are needed to monitor the growing tobacco epidemic particularly in rapidly developing regions and rapidly ageing populations. However, these populations, including mainland Chinese, are mostly in the early stage of the epidemic, and prospective studies⁸ would underestimate the risks, especially in elderly smokers. In Hong Kong, with a largely ethnic Chinese population, tobacco consumption reached its peak about 20 years earlier than in mainland China, but about 20 years later than in developed Western countries, such as the US.^12,13,14 Evidence from elderly Chinese in Hong Kong can forewarn what will happen to their counterparts in the rest of China and also in other developing Asian countries. Only two papers, one from a large community‐based case–control study¹⁴ and the other from a small prospective study,¹⁵ have reported the association between smoking and mortality in elderly Chinese in Hong Kong. This prospective study examined the relationship of smoking with all‐cause and major cause‐specific mortality in elderly Chinese men and women, respectively, in Hong Kong.     

Tobacco-related disease mortality among men who switched from cigarettes to spit tobacco

Background

Although several epidemiological studies have examined the mortality among users of spit tobacco, none have compared mortality of former cigarette smokers who substitute spit tobacco for cigarette smoking (“switchers”) and smokers who quit using tobacco entirely.

Methods

A cohort of 116 395 men were identified as switchers (n = 4443) or cigarette smokers who quit using tobacco entirely (n = 111 952) when enrolled in the ongoing US American Cancer Society Cancer Prevention Study II. From 1982 to 31 December 2002, 44 374 of these men died. The mortality hazard ratios (HR) of tobacco‐related diseases, including lung cancer, coronary heart disease, stroke and chronic obstructive pulmonary disease, were estimated using Cox proportional hazards regression modelling adjusted for age and other demographic variables, as well as variables associated with smoking history, including number of years smoked, number of cigarettes smoked and age at quitting.

Results

After 20 years of follow‐up, switchers had a higher rate of death from any cause (HR 1.08, 95% confidence interval (CI) 1.01 to 1.15), lung cancer (HR 1.46, 95% CI 1.24 to 1.73), coronary heart disease (HR 1.13, 95% CI 1.00 to 1.29) and stroke (HR 1.24, 95% CI 1.01 to 1.53) than those who quit using tobacco entirely.

Conclusion

The risks of dying from major tobacco‐related diseases were higher among former cigarette smokers who switched to spit tobacco after they stopped smoking than among those who quit using tobacco entirely.Several epidemiological studies have examined morbidity and mortality among users of spit tobacco (spit‐tobacco users),^1,2 but none have compared the mortality of former cigarette smokers who substitute spit tobacco for cigarette smoking (“switchers”) to those of smokers who quit using tobacco entirely. Comprehensive reviews by the US Surgeon General,³ and the International Agency for Research on Cancer⁴ and others⁵ have concluded that evidence is sufficient that the use of spit tobacco causes several types of cancer in humans. Although the evidence linking use of spit tobacco to increased risk of cardiovascular diseases is limited,⁶ these products cause acute increases in heart rate and blood pressure, as well as long‐term adverse effects on blood pressure and lipid profiles.⁷We compared mortality of switchers to those of former cigarette smokers who quit using tobacco entirely among men enrolled in a large prospective cohort.     

Effect of local youth-access regulations on progression to established smoking among youths in Massachusetts

Objective

To test whether community‐level restrictions on youth access to tobacco (including both ordinances and enforcement) are associated with less smoking initiation or less progression to established smoking among adolescents.

Design

Prospective cohort study of a random sample of adolescents in Massachusetts whose smoking status was assessed by telephone interviews at baseline and 2‐year follow‐up, and linked to a state‐wide database of town‐level youth‐access ordinances and enforcement practices.

Participants

A random sample of 2623 adolescents aged 12–17 years who lived in 295 towns in Massachusetts in 2001–2 and were followed in 2003–4.

Main outcome measures

The relationship between the strength of local youth access restrictions (including both ordinances and level of enforcement) and (1) never‐smokers'' smoking initiation rates and (2) experimenters'' rate of progression to established smoking was tested in a multilevel analysis that accounted for town‐level clustering and adjusted for potential individual, household and town‐level confounders.

Results

Over 2 years, 21% of 1986 never‐smokers initiated smoking and 25% of 518 experimenters became established smokers. The adjusted odds ratio (OR) for smoking initiation was 0.89 (95% CI 0.61 to 1.31) for strong versus weak youth‐access policies and 0.93 (95% CI 0.67 to 1.29) for medium versus weak policies. The adjusted OR for progression to established smoking among adolescents who had experimented with smoking was 0.79 (95% CI 0.45 to 1.39) for strong versus weak local smoking restrictions and 0.85 (95% CI 0.50 to 1.45) for medium versus weak restrictions.

Conclusions

This prospective cohort study found no association between community‐level youth‐access restrictions and adolescents'' rate of smoking initiation or progression to established smoking over 2 years.Nearly 90% of smokers start smoking during adolescence.¹ Consequently, preventing teenagers from starting to smoke is a public health priority.^2,3 To start smoking, adolescents need access to tobacco products. A teenager''s first few cigarettes usually come from friends or family members, but, once smoking becomes more established, youths turn to commercial sources of cigarettes (eg, stores and vending machines) to ensure a reliable supply.^3,4,5,6 They are able to do so despite laws in all US states that ban the sale of tobacco to minors, because compliance with these laws is limited.^3,7,8If youths could be prevented from easily obtaining cigarettes from commercial sources, it is hypothesised that fewer youths would become smokers.^3,8 Efforts to reduce youth access to tobacco have focused on enforcing bans on tobacco sales to minors in retail stores—the source of most tobacco bought by youths. A complementary strategy bans self‐service displays of tobacco products in retail stores. These displays facilitate youth access to tobacco by encouraging shoplifting and by minimising a young person''s contact with a salesperson, thereby making it more likely that a sale will occur.^3,8,9,10 Cigarette sales in vending machines have also been targeted because vending machines are more important tobacco sources for younger teens who have more difficulty in buying tobacco in stores.^3,8 Effective strategies include banning vending machine sales of cigarettes or limiting vending machines to adults‐only locations. Equipping vending machines with locking devices that must be deactivated by a clerk who presumably verifies the purchaser''s age has little evidence of efficacy.³Measures to restrict youths'' access to tobacco products have been widely advocated since the early 1990s and are now incorporated into global tobacco control efforts.¹¹ The World Health Organization''s Framework Convention on Tobacco Control includes a provision requiring ratifying nations to adopt and implement laws that prohibit the sale of tobacco to minors.¹² In the US, the federal Synar amendment has, since 1996, required all states to have and enforce youth‐access laws and document a specific level of compliance or risk loss of federal block grant funds.¹³ Many US communities have gone beyond state laws and adopted local ordinances with stronger youth‐access provisions.^3,7,14 In Massachusetts, for example, the number of towns with some form of youth‐access regulation increased from 35 (10%) in 1994 to 244 (70%) in 2000.³Despite the widespread adoption of youth‐access restrictions, this approach remains controversial because evidence to support its efficacy in reducing adolescent smoking is limited.^{3,8,11,15,16,17} In 2004, a systematic review of interventions to reduce minors'' access to commercial sources of tobacco products was conducted by the Cochrane Tobacco Addiction Group. It concluded that active enforcement of youth‐access laws could reduce illegal sales to minors, but found little evidence that these interventions reduced the prevalence of adolescent smoking or perceived ease of access to tobacco products.^18,19 An earlier meta‐analysis also found no evidence that increases in merchant compliance with youth‐access laws were associated with the prevalence of youth smoking,²⁰ although that review''s methods were challenged.¹⁷Another source of evidence comes from observational studies. These do not test specific interventions but examine the association between adolescent''s exposure to youth‐access laws or perceived ease of access to tobacco products and their prevalence of smoking. These studies have conflicting results. A cross‐sectional study of adolescents in 314 towns in Massachusetts found no consistent association between living in a town with a youth‐access ordinance and prevalence of adolescent smoking or perceived ease of access to tobacco products, but the study had no data on the extent to which merchants actually complied with the laws.²¹ By contrast, a cross‐sectional study of 75 communities in Oregon found a small positive linear relationship between a town''s measured rate of illegal sales to minors and the prevalence of smoking of 11th graders, but not of 8th graders.²² A cross‐sectional analysis of 11 towns in Illinois found that teenagers in towns with higher rates of illegal tobacco sales to minors were more likely to initiate but not to continue to smoke,²³ However, the cross‐sectional design of these studies limits their ability to support causal inferences. Among 12 communities in New York, those reaching a high (>80%) rate of retailer compliance with youth‐access laws had a smaller increase in adolescents'' rate of frequent smoking over 4 years, as measured by two cross‐sectional school surveys.²⁴Few observational studies have used the stronger prospective cohort design. A cohort study of 592 adolescent non‐smokers in Massachusetts found that those living in towns with a local tobacco sales ordinance at baseline were less likely to progress to established smoking over 4 years than youths in towns without these ordinances. However, the finding lost statistical significance after adjustment for potential confounders and there was no information on actual compliance with the laws.²⁵ Gilpin et al²⁶ followed two cohorts of adolescent non‐smokers in California over 3 years. In the first cohort, followed when merchant compliance with youth access laws was low, smoking initiation rates did not differ between youths who initially perceived that cigarettes were difficult or easy to obtain. In the second cohort, conducted after overall merchant compliance state‐wide had improved, youths who perceived that cigarettes were hard to obtain were less likely to initiate smoking.The current study adds to the existing literature on the effect of youth access restriction in several ways.¹ It includes data from a representative cohort of adolescents living in a large number of communities that range in size and demographic characteristics.² A town‐level clustered multilevel analysis allows us to control for a large variety of individual, environmental and town‐level characteristics, including the community''s baseline anti‐smoking sentiment.³ A longitudinal design provides stronger evidence for causal inferences.⁴ The extent to which youth‐access laws are actually enforced is measured.⁵ The study deconstructs smoking uptake into two components: youths'' experimentation with tobacco products and their progression to established tobacco use. Restrictions on youth‐access laws are hypothesised to affect the latter more than the former.^3,8     

Residual tobacco smoke: measurement of its washout time in the lung and of its contribution to environmental tobacco smoke

Background

Tobacco smoking entails inhaling millions of fine particles with each puff, and it is intuitive that after smoking a cigarette it will take a certain time to washout residual tobacco smoke (RTS) from the lungs with subsequent breaths.

Objectives

To study the washout time of 0.3–1.0 µm particles after the last puff in 10 volunteer smokers by using equipment capable of measuring particle concentration in real time in the exhaled air.

Result

Mean (standard deviation (SD)) lung RTS washout time was 58.6 (23.6) s, range 18–90 s, and corresponded to 8.7 (4.6) subsequent breathings. The contribution of individual and overall RTS to indoor pollution was calculated by subtracting incremental background particle concentration from room concentration after 10 consecutive re‐entries of smokers after the last puff into a room of 33.2 m³, with an air exchange rate per hour in the range of 0.2–0.4. Mean (SD) individual RTS contribution consisted of 1402 (1490) million particles (range 51–3611 million), whereas RTS increased room 0.3–1.0 µm particle concentration from a baseline of 22 283 particles/l to a final room concentration of 341 956 particles/l, corresponding to a total increase in particulate matter (2.5) from a background of 0.56 up to 3.32 µg/m³.

Conclusion

These data reveal a definite although marginal, role of RTS as a source of hidden indoor pollution. Further studies are needed to understand the relevance of this contribution in smoke‐free premises in terms of risk exposure; however, waiting for about 2 min before re‐entry after the last puff would be enough to avoid an unwanted additional exposure for non‐smokers.Environmental tobacco smoke (ETS) is considered to be the most important source of indoor pollution and a recognised health risk factor.^1,2 Despite a putative lower exposure to toxic substances of tobacco, its effect on human tissues and organs seems to be almost as dangerous as active smoke.³ ETS monitoring carried out by means of particulate matter measurements showed that the smoke of a few cigarettes can contribute to indoor pollution up to levels exceeding outdoor limits,^1,4 and even higher than those produced by recent diesel engines.⁵ Research in this field conducted in the past 20 years led to the enactment of smoking policy rules in many countries, whose enforcement was linked to improvement in the health status of citizens.⁶ Where smoking is restricted, smokers are required to smoke outdoors, and often light up in the vicinity or in front of the buildings; they then re‐enter the buildings through common entrances immediately after finishing their cigarettes. To date, the retention time of mainstream smoke in the lung residual tobacco smoke (RTS) after the last puff has been investigated for volatile organic compounds,^7,8 but not yet for particulate matter, and its contribution to indoor ETS pollution has not been fully evaluated.⁹ New technologies in the field of aerosol analysers have recently made it possible to measure aerosol particles in the exhaled air in real time.¹⁰ We carried out this study to measure the retention time of tobacco smoke particulate matter after the last puff and to evaluate the contribution of RTS to ETS pollution.     

The California Tobacco Control Program's effect on adult smokers: (3) Similar effects for African Americans across states

Objective

To compare trends in African‐American (AA) and non‐Hispanic white (NHW) smoking between states categorised as having three different levels of tobacco control practice in the 1990s.

Setting and participants

Analysis of 1992–3 to 2001–2 Tobacco Use Supplements to the Current Population Survey for differences in adult (20–64 years) daily smoking prevalence for AAs and NHWs across states: California (CA; high cigarette price/comprehensive programme), New York (NY) and New Jersey (NJ; high cigarette price/no comprehensive programme), and tobacco growing states (TGS; low cigarette price/no comprehensive programme).

Results

From 1992–3 to 2001–2, there were large declines in AA smoking across states (2.7–3.8% decrease/year, adjusted for age, income, education, gender; p<0.05). Adjusted NHW smoking prevalence declined significantly only in CA. AA prevalence declined significantly and did not differ across state groups. In all years, in all state groups, adjusted prevalence was either not significantly different or was lower for AAs than for NHWs. More recent cohorts of AAs appeared to have taken up smoking at lower rates than older cohorts.

Conclusion

There were uniformly large declines in AA smoking from 1992–3 to 2001–2 across states, independent of type of tobacco control strategy. Further research is needed into factors associated with smoking declines among AAs.Historically, smoking prevalence and smoking‐related diseases have been higher in the US African‐American (AA) adult population compared with the non‐Hispanic white (NHW) population.^1,2 However, in recent years the prevalence gap between AAs and NHWs has closed.³ Apparently, lower initiation rates among AAs have persisted resulting in lower adult prevalence rates.^4,5 These changes in AA smoking behaviour may be due to an increased response to tobacco control measures, including higher cigarette prices. An important question is how the smoking rates have changed for AAs and for NHWs across states with different tobacco control strategies.The first comprehensive state‐wide tobacco control programme designed to increase social norms against smoking in the US began in California (CA) in 1989.⁶ This programme was unique in spending an average of US$3 per person per year on a public health programme to discourage smoking through the 1990s.⁷ It is the largest and the longest running programme in the US and its components include mass‐media programmes, clean indoor air laws, community and school programmes, and increased excise taxes. Thus, it might be expected that CA would have shown a greater reduction in smoking than states without such a tobacco control programme.New York (NY) and New Jersey (NJ) are adjacent states with a combined population size similar to CA. Neither state supported a major tobacco control programme in the 1990s, but both were similar to CA in the amount of excise tax levied on cigarettes⁸ and had similar high cigarette prices during the 1990s. It might be expected that these states would also have greater reductions in smoking than states with lower excise taxes during the study period.There are six US states that had significant economic activity (>US$100 million/year) from tobacco‐related agriculture during the study period.⁹ These tobacco‐growing states (TGS) were Kentucky, Tennessee, North Carolina, South Carolina, Virginia and Georgia, which together had a population slightly larger than either CA or NY and NJ. The TGS have consistently had some of the lowest excise taxes in the nation,⁸ and none had a major state‐specific tobacco control programme in the 1990s. There is also evidence that social norms are more supportive of tobacco use in these tobacco‐growing regions.¹⁰We used data from the Tobacco Use Supplements (TUS) to the Current Population Survey (TUS–CPS) from 1992–3 to 2001–2 to examine age‐specific smoking rates and particularly, how reductions in AA initiation previously reported for the 1980s and 1990s might be impacting prevalence rates compared to those among the NHW population. We compared trends for CA, a state with a comprehensive programme designed to increase social norms against smoking, with NY and NJ, states that markedly increased the price of cigarettes during this time period but limited tobacco control activity, and with the TGS, serving as a control group of states with low prices and limited state‐wide tobacco control activities.     

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.     

Nicotine pharmacokinetics and subjective effects of three potential reduced exposure products, moist snuff and nicotine lozenge

Objective

To compare nicotine pharmacokinetics and subjective effects of three new smokeless tobacco potential reduced exposure products (PREPs; Ariva, Revel and Stonewall) with moist snuff (Copenhagen) and medicinal nicotine (Commit lozenge).

Methods

10 subjects completed a randomised, within‐subject, crossover study. Subjects used one product for 30 min at each of the five laboratory sessions. Maximal nicotine concentration (C_max) was determined and area under the concentration time curve (AUC) was calculated for a 90‐min period (during use and 60 min after use). Nicotine craving, withdrawal symptoms and ratings of product effects and liking were measured during product use.

Results

Nicotine AUC and C_max were higher for Copenhagen than for any other product (p<0.002) and higher for Commit than for either Ariva or Revel (p<0.001). C_max for Commit was also higher than for Stonewall (p = 0.03). Craving was lowest during use of Copenhagen (p<0.03). Craving during use of Stonewall, Ariva and Commit was lower than during use of Revel (p<0.05). Withdrawal symptom score during use of Copenhagen was lower than during use of Revel (p = 0.009). Copenhagen scores were higher (p<0.005) than all other products in several measures of drug effects and liking (feel good effects, satisfaction, liking and desire for product, and strength of product).

Conclusion

The new smokeless tobacco PREPs result in lower nicotine concentrations and equivalent or lower reductions in subjective measures compared with medicinal nicotine. Since health effects of PREPs are largely unknown, medicinal nicotine should be preferentially encouraged for smokers or smokeless tobacco users wishing to switch to lower‐risk products.Over the past several years, a number of new tobacco products have been introduced, some of which are being marketed, either implicitly or explicitly, as having reduced toxicant exposure or decreased health risks. To assist in evaluating these potential reduced exposure products (PREPs), the United States Food and Drug Administration in 1999 asked the Institute of Medicine to formulate methods and standards by which PREPs could be assessed.¹ More recently, an expert panel was convened to develop guidelines for the evaluation of PREPs on both individual and population levels. Among the topics addressed was human clinical testing, which included recommendations on methods and biomarkers to assess PREPs.^2,3 The recommended evaluation of PREPs included conducting studies on the pharmacokinetic properties of the products and assessing misuse liability by measuring subjective responses to the products and ability of the products to suppress withdrawal.³The use of smokeless tobacco products, in lieu of cigarettes, has been suggested as a promising method by which to reduce tobacco‐related health consequences.⁴ Currently, tobacco companies including major cigarette‐manufacturing companies are test marketing smokeless and spitless tobacco products (eg, Camel Snus by Reynolds American, Taboka by Philip Morris) as a substitute for smoking. Although overall morbidity and mortality associated with the use of moist snuff or chewing tobacco is lower than the risks associated with cigarette smoking, health consequences such as increased rates of oral and pancreatic cancers remain.^5,6 Furthermore, health effects of all forms of smokeless tobacco are not equivalent. For example, an evaluation of the content of tobacco‐specific nitrosamines found large differences between the various forms and brands of smokeless tobacco.⁷ In a human study, a significant decrease in the uptake of tobacco carcinogens has been observed when users of conventional brands of smokeless tobacco switch to Swedish snus.⁸ A comparison of several brands of moist snuff products found significant differences between brands in the amount of unionised (free) nicotine^9,10,11 and in exposure to nicotine and heart rate response after use of a single dose of each product.¹² To accurately assess the potential health effects of a product and the factors associated with consumer use, it is therefore necessary to test each smokeless tobacco product individually, including evaluating the nicotine pharmacokinetics.The purposes of this study were to assess the pharmacokinetics and subjective responses of smokeless tobacco users when using three new PREPs and to compare them with a commonly used brand of moist snuff (Copenhagen) and the medicinal nicotine lozenge (4 mg Commit). The new smokeless tobacco products studied were (1) Ariva, a compressed powdered tobacco lozenge manufactured to contain low tobacco‐specific nitrosamines by Star Scientific marketed for use by smokers when they cannot or choose not to smoke; (2) Stonewall, another compressed powdered low tobacco‐specific nitrosamine tobacco lozenge from Star Scientific marketed as a spit‐free alternative for users of traditional moist snuff smokeless tobacco products; and (3) Revel, a spit‐free smokeless tobacco packet marketed by US Smokeless Tobacco for smokers seeking a discrete alternative to smoking.     

Effect of smoking regulations in local restaurants on smokers' anti-smoking attitudes and quitting behaviours

Objective

To examine the effect of smoking regulations in local restaurants on anti‐smoking attitudes and quitting behaviours among adult smokers.

Design

Hierarchical linear modelling (HLM) was used to assess the relationship between baseline strength of town‐level restaurant smoking regulation and follow‐up (1) perceptions of the social acceptability of smoking and (2) quitting behaviours.

Setting

Each of the 351 Massachusetts towns was classified as having strong (complete smoking ban) or weak (all other and no smoking restrictions) restaurant smoking regulations.

Subjects

1712 adult smokers of Massachusetts aged ⩾18 years at baseline who were interviewed via random‐digit‐dial telephone survey in 2001–2 and followed up 2 years later.

Main outcome measures

Perceived social acceptability of smoking in restaurants and bars, and making a quit attempt and quitting smoking.

Results

Among adult smokers who had made a quit attempt at baseline, living in a town with a strong regulation was associated with a threefold increase in the odds of making a quit attempt at follow‐up (OR = 3.12; 95% CI 1.51 to 6.44). Regulation was found to have no effect on cessation at follow‐up. A notable, although marginal, effect of regulation was observed for perceiving smoking in bars as socially unacceptable only among smokers who reported at baseline that smoking in bars was socially unacceptable.

Conclusions

Although local restaurant smoking regulations did not increase smoking cessation rates, they did increase the likelihood of making a quit attempt among smokers who had previously tried to quit, and seem to reinforce anti‐social smoking norms among smokers who already viewed smoking in bars as socially unacceptable.Despite the proliferation of restaurant and bar smoking ordinances, very little is known about their specific effects on smokers'' attitudes towards smoking in public places and actual quitting behaviours. The effect of clean indoor air ordinances on smokers is of particular interest given that these types of bans may discourage smoking by strengthening anti‐smoking community norms and in turn influencing quitting behaviours. That is, the social unacceptability of smoking in restaurants and bars may be a potential mechanism in reducing smoking behaviours. Glantz has argued that the tobacco industry''s opposition to restaurant and bar smoking bans is primarily due to the strong message that smoking is no longer socially acceptable.⁶ A recent cross‐sectional study showed that strong local restaurant and bar regulations are associated with more negative attitudes towards the social acceptability of smoking in restaurants and bars among adults who eat out or go out primarily in their towns.⁷ It is known that public smoking restrictions limit smokers'' opportunities to smoke, thus raising the costs of smoking (eg, having to go outside to smoke), which may reduce the perceived benefits of this behaviour (eg, social camaraderie and “pleasure” of smoking a cigarette after a meal).Several studies have shown that smoking restrictions in the workplace encourage smokers to quit or cut back on cigarette consumption.^8,9 According to a recent review of 26 studies on the effects of smoke‐free workplaces across the US, Australia, Canada and Germany, completely smoke‐free workplaces are associated with reductions in prevalence of smoking and fewer cigarettes smoked per continuing smoker.⁹ One study reported that strong local clean indoor air ordinances in California during 1990–1 were associated with an absolute quit rate (over the previous 6 months) 7.6% higher than in areas with no workplace laws.¹⁰ Another study conducted in Canada during the same time period found a 21% reduction in the odds of being a smoker in areas with high coverage versus those with low coverage of smoking bylaws.¹¹ These worksite studies have generally found that completely smoke‐free workplaces are associated with smoking cessation and reduction in cigarette consumption.However, of the 26 studies reviewed by Fichtenberg and Glantz, only two employed longitudinal data and none were specific to restaurants and bar regulations.⁹ The use of cross‐sectional data prevents determination of whether the regulations caused the reduced smoking or whether states and towns with lower smoking rates are more likely to adopt such regulations. These studies are also limited by their failure to control for town‐level factors that may confound the relationship between the presence of regulations and the observed levels of smoking. Furthermore, the few studies reviewed grouped together different smoking restriction sites (eg, worksites, schools, restaurants, public places), and assessed only state‐level rather than local laws.Another limitation of current research is that none has investigated how restaurant smoking regulations influence smokers'' attitudes and behaviours by existing attitudes towards smoking and smokers'' quitting behaviour. Smoking regulations in restaurants may have a stronger effect on smokers who have begun to change their perception of the social unacceptability of smoking in public places and on smokers who are already motivated to quit. Most research efforts have assumed homogeneity in attitudes and behaviours by examining the effect of bans on all adults and all smokers. Prochaska et al^12,13, for example, have characterised quitting as a process, with smokers classified according to their stage of change from precontemplation (earliest stage) to maintenance (last stage). A large variation exists in the quitting process—smokers often do not exhibit a steady progression through this change sequence¹⁴ and achievement of successful cessation often includes regression to a previous stage.¹⁵ Additionally, two obvious reasons for the limited research are the small samples used in many studies and the lack of longitudinal data to support stratified analyses. These data allowed us to investigate in detail heterogeneity in smoking regulation effects across attitudes and quitting behaviours among a smoker cohort.To help address the weaknesses of previous research, our study focused on the effect of smoking regulations over the 2‐year follow‐up period on two outcomes: (1) anti‐smoking attitudes among smokers who did or did not report anti‐smoking attitudes at baseline and (2) quitting behaviours among smokers who had or had not made a past year quit attempt at baseline. To our knowledge, this is the first longitudinal study to assess the effect of restaurant smoking restrictions on smokers'' attitudes towards smoking in restaurants and bars, quit attempts and actual quitting behaviour.     

Costs and benefits of smoking cessation aids: making a case for public reimbursement of nicotine replacement therapy in Australia

Background

Tobacco smoking is the leading preventable cause of morbidity and mortality in Australia and other developed countries. Of the pharmacological aids that are available for smoking cessation, bupropion (Zyban SR) is eligible for public reimbursement on the Australian Pharmaceutical Benefits Scheme (PBS), whereas nicotine replacement therapy (NRT) is not. Information on the cost‐effectiveness and financial impact of public reimbursement of these strategies can better inform debate about their inclusion or exclusion in public reimbursement schemes.

Objective

To estimate the cost‐effectiveness of bupropion and NRT, and the potential financial impact of public reimbursement of NRT in Australia.

Design

A cost‐effectiveness analysis using a deterministic Markov model, and cost per disability‐adjusted life year (DALY) averted over a lifetime as the outcome measure.

Population

Current smokers, motivated to quit, in Australia in 2000.

Interventions

(1) NRT; (2) bupropion; and (3) a combined strategy using bupropion as the first‐line treatment and NRT in those who fail to quit smoking or have adverse reactions to bupropion.

Results

Quitting smoking can increase life expectancy of current smokers by 1–7.6 years depending on age at cessation and sex. Providing bupropion to current smokers who are motivated to quit would cost A$7900 (95% uncertainty interval A$6000 to A$10 500) for each DALY averted; NRT patches would cost A$17 000 (A$9000 to A$28 000) for each DALY averted, with similar results even if used as a second‐line treatment following initial failure to quit using bupropion. If 6% of current smokers were to use NRT following inclusion on the PBS, this would result in an annual cost of A$40–110 million to the PBS depending on the listed price.

Conclusions

Compared with other drugs included on the PBS, bupropion and NRT are both highly cost‐effective smoking cessation interventions, and including NRT on the PBS would have a moderate financial impact. Given the sizeable health burden of smoking, and the large individual benefits of quitting smoking, increasing the availability of alternative aids and uptake of these strategies through public reimbursement would be a positive and rational step towards further reducing tobacco‐related disease burden in Australia and other countries where NRT is currently not subsidised.Tobacco smoking is the largest preventable cause of morbidity and mortality in Australia and other developed countries. Despite projected declines in tobacco‐related diseases in line with decreasing prevalence, tobacco is still expected to be among the leading causes of disease burden in 2016.¹ Worldwide, it is the second highest cause of death and fourth highest cause of disease burden.Effective policies to control tobacco use are crucial. Although preventing individuals from starting smoking is an important aim of tobacco control, cessation in current smokers is also critical. As nicotine is highly addictive, smokers often require assistance to maintain abstinence. Modestly effective cessation aids are available, including pharmacological agents, such as bupropion (Zyban SR) and nicotine replacement therapy (NRT).^2,3Australia has implemented many strong tobacco control policies. The retail price of tobacco in Australia is among the top three worldwide.⁴ Advertising and promoting tobacco products has been totally banned, pictorial pack warnings have recently been implemented, opportunities to smoke cigarettes in public places are severely limited and there is legislation in place forcing an upcoming ban of smoking in bars and hotels.^5,6,7 Despite these measures, nearly one in five Australian adults still smoke daily, indicating the need for further strategies to encourage cessation.⁸In 1995, the Australian government rejected a recommendation by the Pharmaceutical Benefits Advisory Committee to include NRT on the public reimbursement scheme—the Pharmaceutical Benefits Scheme (PBS).⁹ By contrast, bupropion was made available on the PBS in February 2001.¹⁰ The continued exclusion of NRT and inclusion of bupropion may or may not be a rational decision. Valid and comparable information on the cost‐effectiveness and financial implications of including these interventions on the PBS are important inputs into this debate.The cost‐effectiveness of both NRT and bupropion has been studied previously.² A lack of consistency in the methods of these studies, however, makes comparisons difficult, and the context‐specific nature of inputs into cost‐effectiveness analyses such as disease outcomes means that these results may not be applicable to the Australian setting.^2,11 This study aims to evaluate the cost‐effectiveness of NRT and bupropion in the Australian context, as well as the potential financial impact of including NRT on the PBS.     

South African platinum mine employees reduce smoking in 5 years

Background

South Africa adopted comprehensive tobacco control policies in the 1990s. Smoking has since declined in the general population, but there is little information on the effect of the campaign in labour‐intensive industries, especially the mining industry where workers are exposed to dust, which may interact with tobacco smoke to cause respiratory disease.

Objectives

To determine the prevalence of, and trends in, smoking in employees of a South African platinum mining company, from 1998 to 2002, and to describe some demographic factors associated with their smoking habits.

Methods

This study used smoking data collected during annual fitness‐to‐work medical examinations. Employees were categorised into never, ever, continuous, new and ex‐smokers. Data were analysed by race and age group. Age‐standardised smoking prevalance rates were compared with rates in the South African general population.

Results

There were 80 713 records of 25 274 mine employees for the 5‐year period. The decrease in smoking prevalence over this period was significant in both black and white men, but was greater in the former (from 42.9% to 29.8%, and from 47.2% to 44.7%, respectively). In 2002, the prevalence of smoking in black mine employees was 12.1% lower than that in black men in the general population. The prevalence of smoking decreased in black mine employees in all age groups (p<0.001); no such trend was seen for white mine employees. The proportion of light smokers increased significantly from 59.9% to 64.7%, with a corresponding significant decrease in the proportion of moderate and heavy smokers from 28.0% to 25.4%, and from 12.1% to 9.8%, respectively.

Conclusion

This study showed a significant decrease in smoking prevalence over a relatively short period, despite the fact that there was no smoking cessation programme in the company. The decline can be largely attributed to the South African government''s antismoking initiative and supports the drive to continue to increase excise taxes on cigarette products. Nevertheless, the relatively high prevalence of smoking in some groups of mine employees highlights the need for workplaces to support the government''s initiatives to curb smoking by establishing smoking cessation and prevention programmes.The Tobacco Products Control Act (Act 83 of 1993) was promulgated in South Africa at the beginning of 1994,¹ with the main thrust being printed health warnings on tobacco product packaging. Although excise taxes began to increase slightly from 1991, the significant change came in the same year that the Act was promulgated when excise tax on cigarettes was increased to 50% of the retail price.² As a result, the nominal excise tax more than quadrupled from 1993 to 2001. The prevalence of smoking in the general South African population decreased from 32.6% in 1993 (51.4% in males and 12.9% in females) to 28.5% in 1998.³ In 1999, the Act was amended (the Tobacco Products Control Amendment Act, Act 12 of 1999) to what is considered to be one of the most progressive tobacco control legislations worldwide¹ and included restrictions on smoking in enclosed public places and a ban on tobacco advertising. Smoking prevalence in the general population continued to drop to 27.1% in 2000 but was still high among males (43.8%, compared with 11.7% among females).³ The most significant decreases were detected among males, black people, young adults and low‐income households.³People in labour‐intensive jobs, such as mining, tend to smoke more than those employed in more sedentary jobs.⁴ The Economics of Tobacco Control Project reported an overall prevalence of smoking in the mining sector as 43.5% in 2000.⁴ In 1997, Kleinschmidt⁵ found that white miners were more likely to smoke than black miners (odds ratio = 2.98). In South Africa, data on race are still collected to identify and eliminate population disparities. Churchyard et al⁶ reported a prevalence of 37% among black gold miners aged >40 years for the same year. A higher proportion of white gold miners reportedly smoked (86%) in the earlier years.⁷Smoking potentiates the effect of dust on respiratory impairment^8,9 and miners who smoke are thus at a higher risk than the general population of developing chronic obstructive pulmonary disease,^10,11 pulmonary tuberculosis,^11,12 lung cancer^13,14,15 and hearing loss.¹⁶ Hnizdo⁸ estimated that the attributable fractions for severe airflow obstruction were 8% for dust alone, 42% for smoking and 40% for the combined effect of silica dust and smoking. These diseases also place an economic burden on the mines as South African miners with these diseases are eligible for compensation,¹⁷ regardless of smoking history.The objectives of this study were to determine the prevalence of smoking and cigarette consumption in platinum mine employees from 1998 to 2002, to describe smoking and cigarette consumption trends, and to identify some sociodemographic factors associated with smoking.     

Economic effect of a smoke-free law in a tobacco-growing community

Objective

To determine whether Lexington, Kentucky''s smoke‐free law affected employment and business closures in restaurants and bars. On 27 April 2004, Lexington‐Fayette County implemented a comprehensive ordinance prohibiting smoking in all public buildings, including bars and restaurants. Lexington is located in a major tobacco‐growing state that has the highest smoking rate in the US and was the first Kentucky community to become smoke‐free.

Design

A fixed‐effects time series design to estimate the effect of the smoke‐free law on employment and ordinary least squares to estimate the effect on business openings and closings.

Subjects and settings

All restaurants and bars in Lexington‐Fayette County, Kentucky and the six contiguous counties.

Main outcome measures

ES‐202 employment data from the Kentucky Workforce Cabinet; Business opening/closings data from the Lexington‐Fayette County Health Department, Environmental Division.

Results

A positive and significant relationship was observed between the smoke‐free legislation and restaurant employment, but no significant relationship was observed with bar employment. No relationship was observed between the law''s implementation and employment in contiguous counties nor between the smoke‐free law and business openings or closures in alcohol‐serving and or non‐alcohol‐serving businesses.

Conclusions

No important economic harm stemmed from the smoke‐free legislation over the period studied, despite the fact that Lexington is located in a tobacco‐producing state with higher‐than‐average smoking rates.Many studies have shown that smoke‐free laws implemented in US cities are not harmful to business activity. For example, one paper shows that New York City''s 1995 Smoke‐Free Air Act had no adverse effects on restaurant employment growth, which instead was three times higher than the rest of the state from 1993 to 1997.¹ Another study examined sales tax receipts in 15 cities with and without ordinances banning smoking in restaurants from 1986 to 1993, and found that smoke‐free ordinances did not negatively affect restaurant sales.² Similarly, Sciacca and Eckrem³ found that gross restaurant sales in Flagstaff, Arizona, increased between 16% and 25.8% per business 1 year after a smoke‐free ordinance was implemented. Other studies focused on bar and tourism receipts have shown no adverse effects of smoking ordinances on revenues.^4,5,6 A recent study of the El Paso, Texas, US smoke‐free ordinance, the strongest smoke‐free law in that state, found no changes in restaurant or bar revenues on the basis of a comparison of sales tax and mixed‐beverage tax data over the 12 years preceding and 1 year after the law was implemented.⁷ Scollo and Lal⁸ and Scollo et al,⁹ provide a comprehensive review of this literature.On 27 April, 2004, after an unsuccessful legal challenge, Lexington‐Fayette County, Kentucky, implemented a 100% smoke‐free ordinance, prohibiting smoking in all public buildings, including restaurants, bars, bowling alleys and other businesses. Currently, about 37% of the US population is protected by local or state‐wide smoke‐free laws.¹⁰ However, tobacco‐growing states typically have weak tobacco control laws and provide less public protection from secondhand smoke.¹¹ Lexington‐Fayette County was the first community in Kentucky, a national leader in burley tobacco production¹² and cigarette smoking,¹³ to enact such legislation. The purpose of our study is to determine whether the smoke‐free law affected: (1) employment in restaurants and bars in either Lexington‐Fayette or its contiguous counties or (2) the rate of business closures in food and drinking establishments in Lexington‐Fayette County.     

Out of the smokescreen II: will an advertisement targeting the tobacco industry affect young people's perception of smoking in movies and their intention to smoke?

Objective

To evaluate the effect of an antismoking advertisement on young people''s perceptions of smoking in movies and their intention to smoke.

Subjects/setting

3091 cinema patrons aged 12–24 years in three Australian states; 18.6% of the sample (n = 575) were current smokers.

Design/intervention

Quasi‐experimental study of patrons, surveyed after having viewed a movie. The control group was surveyed in week 1, and the intervention group in weeks 2 and 3. Before seeing the movie in weeks 2 and 3, a 30 s antismoking advertisement was shown, shot in the style of a movie trailer that warned patrons not to be sucked in by the smoking in the movie they were about to see.

Outcomes

Attitude of current smokers and non‐smokers to smoking in the movies; intention of current smokers and non‐smokers to smoke in 12 months.

Results

Among non‐smokers, 47.8% of the intervention subjects thought that the smoking in the viewed movie was not OK compared with 43.8% of the control subjects (p = 0.04). However, there was no significant difference among smokers in the intervention (16.5%) and control (14.5%) groups (p = 0.4). A higher percentage of smokers in the intervention group indicated that they were likely to be smoking in 12 months time (38.6%) than smokers in the control group (25.6%; p<0.001). For non‐smokers, there was no significant difference in smoking intentions between groups, with 1.2% of intervention subjects and 1.6% of controls saying that they would probably be smoking in 12 months time (p = 0.54).

Conclusions

This real‐world study suggests that placing an antismoking advertisement before movies containing smoking scenes can help to immunise non‐smokers against the influences of film stars'' smoking. Caution must be exercised in the type of advertisement screened as some types of advertising may reinforce smokers'' intentions to smoke.In the past decade, tobacco companies have devised increasingly innovative and aggressive strategies for attracting consumers.^1,2 Product placement in films popular with young people has been the focus of comment and criticism by numerous international health groups.Depictions of smoking are common in films³ and have decreased in recent decades.⁴ Sargent et al⁵ documented an overall increase in the depiction of smoking in films in the 1990s that seemed to coincide with restrictions in advertising.⁶ Lead characters portrayed as smokers are often likeable, rebellious, attractive and/or successful.⁷ Role models with such characteristics are often used in tobacco advertising.⁸ Escamilla et al⁹ analysed the portrayal of smoking in Hollywood films and found that smoking was highly prevalent in films featuring popular actresses.¹⁰ McIntosh et al¹¹ compared Hollywood''s depiction of smokers to real‐world demographics on smoking and found that smoking scenes in movies tend to ignore the negative consequences of smoking, a finding confirmed by Dalton et al¹² in 2002.There is mounting evidence linking Hollywood''s depiction of smoking in movies and adolescents'' attitudes to smoking and their smoking behaviour. Tickle et al¹³ showed that adolescents whose favourite movie stars use tobacco on screen are significantly more likely to be at a more advanced stage of smoking uptake and to have more favourable attitudes towards smoking than adolescents who choose non‐smoking stars. Studies^{14,15,16,17,18} provide even stronger evidence that viewing smoking in movies promotes smoking initiation among adolescents. A cohort study by Dalton et al¹⁹ in 2003 suggests that viewing smoking in movies strongly predicts whether or not adolescents initiate smoking and the effect increases significantly with greater exposure.Prominent researchers and public health advocates have called for action to reduce the impact of positive depictions of smoking in the media, including feature films screened in cinemas.²⁰A Californian study²¹ suggested that young people can be immunised against the influences of film stars smoking by showing a strong antismoking advertisement before those films that contain smoking scenes. A 2004 Australian study²² supported these findings. The findings of Pechmann and Shih²¹ and Edwards et al²² support the psychological Theory of Reasoned Action,^23,24 which states that the strength of a person''s intention to behave in a certain way is a function of attitudes towards the behaviour and the influence of general subjective norms on the behaviour. According to this theory, an antismoking advertisement may alter the positive attitudes towards smoking that are portrayed in movies and elicit more realistic normative perceptions of the practice of smoking. This should theoretically alter the viewer''s intention to smoke and subsequently reduce their likelihood of smoking in the future. The Elaboration Likelihood Model of Persuasion²⁵ suggests that attitude change can be either via the central route that utilises deliberate information processing to assess an issue or via the peripheral route that takes less effort and may even be subliminal. This model predicts that smoking scenes in movies influence young people via the peripheral route. An antismoking advertisement attempts to change attitudes through the central route that, according to the theory, is more enduring and more likely to lead to long‐term behavioural change.Cinema attendance and viewing films rated R under the US classification system increases exposure to onscreen depictions of smoking.²⁶ The majority of young people, including those of varied cultural background, attend the cinema on a regular basis.^27,28 A significant advantage in using this medium for an antismoking campaign is the potential to reach a large number of young people in a cost‐effective manner.^{21, 29}This paper evaluates the use of this approach in an intervention conducted in a real‐world cinema setting in Australia. The objective of the study was to evaluate the effect of an antismoking advertisement on young people''s perceptions of smoking in the following movie and their intention to smoke. It was hypothesised that when an antismoking advertisement is shown before a movie containing smoking scenes, viewers will be (1) less likely to approve of the smoking and (2) less likely to report an intention to smoke in the future. This study expands on the first real‐world cinema study of the effect of an antismoking advertisement on attitudes to smoking in movies and intention to smoke conducted by Edwards et al in 2004. It samples a larger, more geographically and culturally diverse population of both males and females with a broader age range. It also evaluates a very different type of antismoking advertisement that does not include the health effects of smoking or a quit message.     

Secondhand smoke levels in Scottish pubs: the effect of smoke-free legislation

Objective

To compare levels of particulate matter, as a marker of secondhand smoke (SHS) levels, in pubs before and 2 months after the implementation of Scottish legislation to prohibit smoking in substantially enclosed public places.

Design

Comparison of SHS levels before and after the legislation in a random selection of 41 pubs in 2 Scottish cities.

Methods

Fine particulate matter <2.5 μm in diameter (PM_2.5) was measured discreetly for 30 min in each bar on 1 or 2 visits in the 8 weeks preceding the starting date of the Smoking, Health and Social Care (Scotland) Act 2005 and then again 2 months after the ban. Repeat visits were undertaken on the same day of the week and at approximately the same time of the day.

Results

PM_2.5 levels before the introduction of the legislation averaged 246 μg/m³ (range 8–902 μg/m³). The average level reduced to 20 μg/m³ (range 6–104 μg/m³) in the period after the ban. Levels of SHS were reduced in all 53 post‐ban visits, with the average reduction being 86% (range 12–99%). PM_2.5 concentrations in most pubs post‐ban were comparable to the outside ambient air PM_2.5 level.

Conclusions

This study has produced the largest dataset of pre‐ and post‐ban SHS levels in pubs of all worldwide smoke‐free legislations introduced to date. Our results show that compliance with the Smoking, Health and Social Care (Scotland) Act 2005 has been high and this has led to a marked reduction in SHS concentrations in Scottish pubs, thereby reducing both the occupational exposure of workers in the hospitality sector and that of non‐smoking patrons.Public health policy in a growing number of countries has moved to control non‐smokers'' exposure to secondhand smoke (SHS), with recent legislation introduced in Ireland, Italy, Spain and Norway. The Smoking, Health and Social Care (Scotland) Act 2005 to ban smoking in substantially enclosed public places was implemented on 26 March 2006 with the aim of protecting non‐smokers from the health effects of SHS.¹A recent review of occupational exposure to SHS suggested that workers in the hospitality sector have among the highest exposures to SHS of all occupational groups.² Data on exposure to SHS across a wide range of entertainment establishments indicated that airborne nicotine concentrations were up to 18.5 times higher than in offices or domestic residences.³ Studies have shown that non‐smoking bar workers have salivary cotinine levels four times those of non‐smokers who live with partners who smoke.⁴ Data from New Zealand indicate that non‐smoking hospitality workers in establishments that permit smoking have salivary cotinine levels between 3 and 4 times those of non‐smoking workers in smoke‐free premises.⁵ One estimate indicates that between 1500 and 2000 non‐smokers'' deaths per year in Scotland can be attributed to SHS exposure.⁶ It has been suggested that SHS exposure may lead to the deaths of over 50 hospitality sector workers in the UK each year.⁷The introduction of smoke‐free legislation in other countries has been shown to dramatically reduce SHS levels. A recent analysis of the effect of the Norwegian legislation⁸ showed that total dust levels in 13 bars and restaurants reduced from an average level of 262 to 77 μg/m³, a 70% reduction, whereas a study in the USA indicated that respirable dust levels in a selection of 8 hospitality venues reduced to approximately 9% of the pre‐ban level.⁹ Similar work in New York State in a mixture of bars and restaurants measured levels of particulate matter <2.5 μm in diameter (PM_2.5), and found that mean levels decreased from 412 to 27 μg/m³ (93.5%).¹⁰ Mulcahy et al¹¹ measured changes in airborne nicotine levels as a result of the Irish smoking ban. Their study of 20 pubs showed nicotine reductions of approximately 83%.Although there are currently no air quality standards for PM_2.5 in the UK, both the US Environmental Protection Agency (EPA) and the World Health Organization (WHO) have issued air quality guidance for outdoor air pollution levels measured in PM_2.5.^12,13 The US EPA air quality guidance is divided into bands, and for PM_2.5 these bands are arranged at cut points of <15.4 μg/m³ (good), 15.5–40.4 μg/m³ (moderate), 40.5–65.4 μg/m³ (unhealthy for sensitive groups), 65.5–150.4 μg/m³ (unhealthy), 150.5–250.4 μg/m³ (very unhealthy) and >250.5 μg/m³ (hazardous). The US EPA standard for PM_2.5 has a 24 h averaged target of 65 μg/m³, with an annualised average of 15 μg/m³. The WHO recently revised its outdoor air quality guidance and now recommends a 24 h average limit of 25 μg/m^3, with an annual average not exceeding 10 μg/m³ measured in PM_2.5.¹³This paper describes our methods of measurement of SHS concentrations in a selection of Scottish pubs and examines the changes in SHS levels that occurred as a result of the implementation of the ban on 26 March 2006. It forms part of a comprehensive evaluation strategy to measure the effects of the introduction of the Scottish smoke‐free legislation.¹⁴