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.     

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.     

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.     

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.     

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.     

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.     

The California Tobacco Control Program's effect on adult smokers: (1) Smoking cessation

Objectives

To estimate national population trends in long‐term smoking cessation by age group and to compare cessation rates in California (CA) with those of two comparison groups of states.

Setting

Retrospective smoking history of a population sample from the US: from CA, with a comprehensive tobacco‐control programme since 1989 with the goal of denormalising tobacco use; from New York and New Jersey (NY & NJ), with similar high cigarette prices but no comprehensive programme; and from the tobacco‐growing states (TGS), with low cigarette prices, no tobacco‐control programme and social norms relatively supportive of tobacco use.

Participants

Respondents to the Current Population Survey–Tobacco Use Supplements (1992–2002; n = 57 918 non‐Hispanic white ever‐smokers).

Main outcome measures

The proportion of recent ever‐smokers attaining long‐term abstinence (quit ⩾1 year) and the successful‐quit ratio (the proportion of all ever‐smokers abstinent ⩾1 year).

Results

Nationally, long‐term cessation rates increased by 25% from the 1980s to the 1990s, averaging 3.4% per year in the 1990s. Cessation increased for all age groups, and by >40% (p<0.001) among smokers aged 20–34 years. For smokers aged <50 years, higher cigarette prices were associated with higher quitting rates. For smokers aged <35 years, quitting rates in CA were higher than in either comparison group (p<0.05). Half of the ever‐smokers had quit smoking by age 44 years in CA, 47 years in NY & NJ, and by age 54 years in TGS.

Conclusion

Successful smoking cessation increased by 25% during the1990s in the US. Comprehensive tobacco‐control programmes were associated with greater cessation success than were with high cigarette prices alone, although both effects were limited to younger adults.There is considerable evidence that cigarette smoking will cause the premature death of approximately half of those who start and continue to smoke, with half of these deaths occurring before age 70 years.^1,2 Public health efforts to rapidly reduce the estimated 438 000 smoking‐related deaths in the US each year have targeted increasing successful quitting among current smokers.^1,3 The British Doctors Study² evaluated the relationship between age of smoking cessation and later mortality. The study suggests that smokers who quit successfully by age 35 years may avoid much of the excess mortality risk from smoking, those who quit successfully by age 50 years will avoid approximately half of the excess mortality risk accrued by continuing smokers and those who quit by age 60 years will avoid about one‐third of the excess mortality risk. These ages are useful cut‐points to assess progress towards tobacco‐control goals in population groups.There are several reasons to expect that successful cessation rates may have increased in the US during the 1990s. Many health economists feel that price increases are among the most effective policy approaches to reduce smoking behaviour.⁴ Significant increases in cigarette prices have consistently been associated with reductions in both per capita cigarette usage and smoking prevalence, with the latter presumed to occur largely through increased quitting.⁵ Real cigarette prices increased nationally in the US during the 1980s and 1990s, with the largest increase imposed by the tobacco industry in 1999, associated with the consolidated settlement in 1998 of lawsuits brought by attorneys general from 46 states.⁶ In addition, during the 1990s, many individual states increased their excise taxes on tobacco products.⁷ These high prices may have encouraged more smokers both to try to quit and to successfully maintain cessation. Thus, quitting indices should have increased across the US, with more marked increases seen in states with higher cigarette prices.In addition, during the 1990s, nicotine replacement products such as the nicotine patch and nicotine gum became widely available, following randomised trials that showed their efficacy.⁸ Older smokers and those who smoked more heavily were more likely to use these cessation aids; by 2001, approximately 40% of smokers aged >35 years had used nicotine replacement products to assist in quitting, leading to an expectation that the major increase in successful quitting would occur in older smokers.⁹During the 1990s, there were marked differences among US states in initiatives targeting tobacco cessation. Thus, it is of interest to assess changes in quitting rates not only for the US as a whole but also among groups of states that differed in their tobacco‐control initiatives. Among US states, California (CA) was the first to begin a comprehensive tobacco control programme in 1989, which had one specific programme goal to encourage smoking cessation and a broader mandate to change community norms regarding tobacco use.^10,11 Through the 1990s, CA was unique in spending an average of $3.67 per person per year on a comprehensive public health programme to change smoking‐related norms.¹² The programme included price increases and other interventions, and a mass media campaign in which about one‐quarter of the advertisements encouraged smokers to quit.¹³ There is considerable evidence that such a mass media programme can effectively motivate smokers to initiate an attempt to quit.^14,15,16 CA also pioneered the Smokers'' Helpline, an evidence‐based cessation approach^17,18 that has been an integral part of the CA Tobacco‐Control Program since 1993.¹⁹ In addition, CA passed the first state‐wide law banning smoking in the workplace in 1995, and there is mounting evidence that smoke‐free workplaces encourage smoking cessation.²⁰ Thus, it might be expected that CA would have higher rates of successful smoking cessation than states without such a comprehensive tobacco control programme.In comparison, the adjacent states of New York and New Jersey (NY & NJ) have a combined population size similar to CA, and both were similar to CA in the level of cigarette excise taxes during the 1980s and 1990s, yielding similar high cigarette prices.⁷ However, neither state supported a comprehensive tobacco‐control programme during the 1990s, with funding for tobacco control averaging about $0.20 per capita in NY during this time, and less in NJ (Ursula Bauer, personal communication 2005). It might be expected that NY & NJ would have lower rates of smoking cessation than CA and higher cessation rates than states with lower excise taxes and cigarette prices during the study period.A third contrasting group are the six US states that accounted for >90% of tobacco production in the US during the study period.²¹ These have consistently had among the lowest excise taxes and cigarette prices in the nation,⁷ and none had a state‐specific tobacco‐control programme in the 1990s. In addition, evidence suggests that social norms are more supportive of tobacco use in tobacco‐growing regions.²² These tobacco‐growing states (TGS) are Kentucky, Tennessee, North Carolina, South Carolina, Virginia and Georgia, which together have a population slightly larger than CA, or NY & NJ. These states might be expected to show the lowest rates of successful smoking cessation during the study period.In this report, we assess changes in rates of successful smoking cessation from the 1980s to the 1990s in the US as a whole. We consider trends in cessation rates for three age groups of smokers: young adults (20–34 years), early middle‐aged adults (35–49 years) and late middle‐aged adults (50–64 years). We then compare rates of cessation in the 1990s for the three comparison groups of states: CA (high cigarette price and a comprehensive tobacco‐control programme), NY & NJ (high price but no comprehensive programme) and the TGS (neither high price nor programme). We limit consideration to non‐Hispanic whites because of considerable differences in tobacco‐use behaviour among race or ethnic groups that may confound the analysis,²³ and do not assess trends in cessation within state groups because of small sample sizes.     

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     

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.     

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.     

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.     

Effectiveness of biomedical risk assessment as an aid for smoking cessation: a systematic review

Objective

To determine the efficacy of biomedical risk assessment (eg, exhaled carbon monoxide (CO), or genetic susceptibility to lung cancer) as an aid for smoking cessation.

Data sources

Cochrane Tobacco Addiction Group Specialized Register, Cochrane Central Register of Controlled Trials, Medline (1966–2004) and EMBASE (1980–2004).

Study selection

Randomised controlled smoking cessation interventions using biomedical tests with at least 6 months follow‐up.

Data extraction

Two reviewers independently screened all search results (titles and abstracts) for possible inclusion. Each reviewer then extracted data from the selected studies, and assessed their methodological quality based on the CONSORT (Consolidated Standards of Reporting Trials) statement criteria.

Data synthesis

Of 4049 retrieved references, eight trials were retained for data extraction and analysis. Three trials isolated the effect of exhaled CO on smoking cessation rates resulting in the following ORs and 95% CIs: 0.73 (0.38 to 1.39), 0.93 (0.62 to 1.41) and 1.18 (0.84 to 1.64). Measurement of exhaled CO and spirometry were used together in three trials, resulting in the following ORs (95% CI): 0.60 (0.25 to 1.46), 2.45 (0.73 to 8.25) and 3.50 (0.88 to 13.92). Spirometry results alone were used in one other trial with an OR (95% CI) of 1.21 (0.60 to 2.42). Ultrasonography of carotid and femoral arteries performed on light smokers gave an OR (95% CI) of 3.15 (1.06 to 9.31).

Conclusions

Scarcity and limited quality of the current evidence does not support the hypothesis that biomedical risk assessment increases smoking cessation as compared with the standard treatment.Despite increasing scientific knowledge about health hazards due to cigarette consumption, there is, in many countries, an increase in the prevalence of smoking among young people.^1,2 The gap between knowledge and smoking cessation has been attributed, partly, to smokers'' underestimation of their personal risks of smoking‐related illness.^3,4A possible strategy for increasing quit rates might be to provide a personalised feedback on the physical effects of smoking by physiological measurements. We can distinguish three different types of feedback: the first one explores biomarkers of smoking exposure (cotinine and carbon monoxide (CO)); the second one gives information on smoking‐related disease risk (eg, lung cancer susceptibility according to CYP2D6 genotyping)⁵; and the third one depicts smoking‐related harm (eg, atherosclerotic plaque and impaired lung functions).⁶ The rationale for such interventions is to promote risk awareness and motivation to accelerate changes in smoking‐behaviour.^7,8Individual studies have provided conflicting data on the effect of physiological feedback.^{9,10,11,12,13,14,15,16,17} We aimed to review the data on smoking cessation rates from controlled trials using feedback on the physiological effects of smoking or on the genetic susceptibility to smoking‐related diseases. This article is a shortened version of our Cochrane review.¹⁸     

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.     

Does smoking increase sick leave? Evidence using register data on Swedish workers

Objective

To examine the effect of smoking on sick leave.

Methods

Nationally representative data on 14 272 workers aged 16–65 years from the 1988–91 waves of the Swedish Survey of Living Conditions were used for the analyses. The data are linked to register‐based data, on the annual number of absences due to sickness, from the National Board of Social Insurance. As outcome variable, the annual number of days of sick leave was used. This outcome was analysed as a function of smoking status and an extensive number of control variables, including occupational risk factors, work characteristics and health status.

Results

Smoking was found to increase the annual number of days of absence by 10.7 compared with never smoking. Controlling for risk factors at work, and thereby accounting for some of the selection of smokers into riskier jobs, reduced the effect to 9.7 days, corresponding to 38% of all annual absences due to sickness. Moreover, controlling for health status further reduced the effect of smoking to 7.7 days. The effect of smoking on sick leave was similar for men and women.

Conclusions

Smoking showed a large positive effect on the annual number of sick leaves. Hence, the results suggest that the gains to preventing and/or reducing smoking, in terms of reduced production losses, may be large. However, since the large effect of smoking persists when controlling for a range of health factors and occupational factors, the results also suggest that much of the higher number of absences among smokers may be explained by factors other than reduced health. The estimates should be viewed as upper bounds of the effect of smoking on sick leave, since smoking is potentially an endogenous variable.The adverse health consequences of smoking are well established.¹ Moreover, the healthcare costs of smoking have been found to constitute a non‐negligible part of the total healthcare costs in developed countries.² The indirect costs, in terms of productivity losses, however, typically constitute the major part of the economic burden. Estimates of the costs of smoking from different countries differ because of differences in the prevalence of smoking, of course, but also because of differences in the cost per smoker. Although smoking has been estimated to account for 8% of total healthcare costs in the US, 3.8% in Canada, and 3.7% in Germany, smoking accounts for only 1.5% of healthcare costs in Sweden according to recent estimates.^3,4,5,6 Several studies do not include lost productivity due to absence from sickness (hereafter sickness absence), because no sufficient data are available.^3,4,5Knowledge about the relationship between smoking and sickness absences is of importance from several perspectives. For employers, such knowledge is necessary for assessing the potential benefits of implementing smoking policies/practices at the workplace. At a higher societal level, such knowledge is necessary for policy makers to judge the potential benefits of societal interventions against smoking. Moreover, estimates of the costs of smoking depend on reliable estimates of the effect of smoking on sick leave.The link between smoking and sick leave may be explained by several different mechanisms, though. Smokers differ from non‐smokers in several respects that may be hard to measure. Studies have shown that smokers choose riskier jobs than non‐smokers, which may partly reflect differences in attitudes towards risks.⁷ Smokers have also been found to be more frequently involved in other risky activities, such as alcohol consumption and driving without a seat belt.^8,9 This means that a positive correlation between smoking and sickness absences may partly reflect smokers'' tendency to choose riskier jobs and activities than non‐smokers, which, in turn, may make them more likely to be absent. For policy purposes, it is crucial to distinguish between these “selection” effects and the causal effect that smoking has on sick leave.Prior studies on smoking and sick leave have largely ignored potential selection effects. Moreover, non‐representative, and in many cases small samples, have been used, making it difficult to draw any general conclusions from the findings. Halpern et al,¹⁰ for instance, used data on 300 employees at a specific US air company. Robbins et al,⁸ with a greater sample size, used data on 87 991 individuals serving in the US army. Both Yen et al¹¹ and Bertera¹² used data on workers from specific manufacturing companies, whereas Parkes¹³ used data on 185 student nurses, and Van Tuinen and Land¹⁴ used data on 406 health workers.Among studies using representative samples, the outcome measure has typically been limited in several important respects. Typically, the outcome measure has been based on self‐reported absences that have often concerned a limited time period. In Sindelar et al,¹⁵ the outcome measure was a binary indicator of self‐reported sickness absence in the previous week. Similarly, Bush and Wooden¹⁶ and Wooden and Bush¹⁷ used an outcome measure that concerned any sickness absence during the previous 2 weeks. Leigh¹⁸ used self‐reported information on the yearly number of hours of sickness absence. Obviously, measurement errors in such self‐reports may bias the results in unknown directions. For Swedish conditions, Roberts¹⁹ analysed the effect of smoking on the annual number of sick leaves in one of the few studies using register‐based information on sick leave.In this paper, the relationship between smoking and sick leave was analysed using a nationally representative dataset, where survey data were linked to register‐based data on annual sick leaves. In the analyses, we were able to control for a wide range of factors that may otherwise confound the relationship between smoking and sickness absence, such as occupational risk factors and various health‐related behaviours.     

Prevalence of smoking among major movie characters: 1996-2004

Background

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

Objective

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

Design and methods

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

Results

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

Conclusions

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

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.     

"Accommodating" smoke-free policies: tobacco industry's Courtesy of Choice programme in Latin America

Objective

To understand the implementation and effects of the Courtesy of Choice programme designed to “accommodate” smokers as an alternative to smoke‐free polices developed by Philip Morris International (PMI) and supported by RJ Reynolds (RJR) and British American Tobacco (BAT) since the mid‐1990s in Latin America.

Methods

Analysis of internal tobacco industry documents, BAT “social reports”, news reports and tobacco control legislation.

Results

Since the mid‐1990s, PMI, BAT and RJR promoted Accommodation Programs to maintain the social acceptability of smoking. As in other parts of the world, multinational tobacco companies partnered with third party allies from the hospitality industry in Latin America. The campaign was extended from the hospitality industry (bars, restaurants and hotels) to other venues such as workplaces and airport lounges. A local public relations agency, as well as a network of engineers and other experts in ventilation systems, was hired to promote the tobacco industry''s programme. The most important outcome of these campaigns in several countries was the prevention of meaningful smoke‐free policies, both in public places and in workplaces.

Conclusions

Courtesy of Choice remains an effective public relations campaign to undermine smoke‐free policies in Latin America. The tobacco companies'' accommodation campaign undermines the implementation of measures to protect people from second‐hand smoke called for by the World Health Organization Framework Convention on Tobacco Control, perpetuating the exposure to tobacco smoke in indoor enclosed environments.Latin Americans are highly exposed to second‐hand tobacco smoke (SHS) both in public places and in workplaces.^1,2 In 2001, the Pan American Health Organization launched its “Smoke Free Americas” initiative³ to “raise awareness of the harm caused by secondhand tobacco smoke, and support efforts to achieve more smoke‐free environments in the Americas.” There is longstanding strong public concern over the effects of SHS in Latin America. In 1997, research conducted for Philip Morris International (PMI) showed that about 80% of respondents in four Latin American countries agreed that “Other people''s tobacco smoke poses a long term health risk to nonsmokers.”⁴ These results reflect a stronger consensus that SHS is hazardous than Philip Morris (PM) found in the US in 1989—62% of non‐smokers and 32% of smokers—as the movement for smoke‐free workplaces and public places was beginning to accelerate them.⁵ A 2001 survey conducted for the World Health Organization (WHO) in the main urban areas of Argentina showed strong public support (94%; 96% non‐smokers and 89% smokers) for the creation of smoke‐free places to avoid SHS.⁶ Public opinion polls conducted in 2006 in Argentina⁷ and Uruguay⁸ reported that 92% of respondents agreed that “SHS is dangerous for nonsmokers'' health”, showing an increase in public concern about SHS by 12% since 1997.The main barrier to progress in implementing smoke‐free policies in Latin America has been the efforts by two transnational tobacco companies, PMI and British American Tobacco (BAT), which control almost the entire cigarette market in the region through their subsidiaries (PMI 40%, BAT 60%). Similar to the voluntary self‐regulating advertising codes, which the tobacco companies use to fight restrictions on tobacco advertising,^9,10 the tobacco industry has orchestrated public relations campaigns in Latin America since the mid‐1990s to avoid legislated smoke‐free policies.^11,12 As in the US, beginning in the late 1980s,¹¹ this effort mobilised the hospitality industry to block meaningful tobacco control legislation to preserve the social acceptability of smoking and to protect industry profits. These programmes, known as Accommodation in the US and Courtesy of Choice in most parts of the rest of the world,^11,13,14,15 encourage the voluntary creation of smoking and non‐smoking sections in the hospitality industry as an alternative to legislation requiring 100% smoke‐free environments. Also, as in the US, the tobacco industry sought to present ventilation as the “solution” to SHS.¹⁶As of April 2007, 12 Latin American countries (Bolivia, Brazil, Chile, Ecuador, Guatemala, Honduras, Mexico, Panama, Paraguay, Peru, Uruguay and Venezuela) had ratified the WHO Framework Convention on Tobacco Control (FCTC). The FCTC, the first international public health treaty, calls for the implementation of “effective legislative, executive, administrative or other measures … at the appropriate governmental level to protect all persons from exposure to tobacco smoke” (Article 4.1) “in indoor workplaces, public transport, indoor public places and, as appropriate, other public places.” (Article 8).¹⁷ Given the fact that the only truly effective protection from SHS is the creation of 100% smoke‐free environments,¹⁸ in 2003, Venezuela approved a state law (in Monagas¹⁹) and between 2005 and 2006, Argentina passed and regulated two provincial laws (in Santa Fe and Tucumán) to establish 100% smoke‐free public places and workplaces. In March 2006, Uruguay became the first 100% smoke‐free country in the Americas. In response to this movement, one can expect the tobacco industry to accelerate its Accommodation efforts as a way of undermining such effective smoke‐free policies to implement FCTC.     

Media advocacy, tobacco control policy change and teen smoking in Florida

Objective

To assess whether media advocacy activities implemented by the Florida Tobacco Control Program contributed to increased news coverage, policy changes and reductions in youth smoking.

Methods

A content analysis of news coverage appearing in Florida newspapers between 22 April 1998 and 31 December 2001 was conducted, and patterns of coverage before and after the implementation of media advocacy efforts to promote tobacco product placement ordinances were compared. Event history analysis was used to assess whether news coverage increased the probability of enacting these ordinances in 23 of 67 Florida counties and ordinary least square (OLS) regression was used to gauge the effect of these policies on changes in youth smoking prevalence.

Results

The volume of programme‐related news coverage decreased after the onset of media advocacy efforts, but the ratio of coverage about Students Working Against Tobacco (the Florida Tobacco Control Program''s youth advocacy organisation) relative to other topics increased. News coverage contributed to the passage of tobacco product placement ordinances in Florida counties, but these ordinances did not lead to reduced youth smoking.

Conclusion

This study adds to the growing literature supporting the use of media advocacy as a tool to change health‐related policies. However, results suggest caution in choosing policy goals that may or may not influence health behaviour.Many scholars contend that media advocacy—the strategic use of mass media and grassroots community organising to advance health policy—is a powerful strategy to generate news coverage about tobacco control, strengthen tobacco control policy and reduce tobacco use.^1,2,3 The news media bring policy initiatives to public and policymaker agendas^4,5 and frame issues in ways of consequence for health policy.⁶ As a result, the short‐term goals of media advocacy are increasing in the volume of news coverage on a public health issue and framing coverage in ways that support policy solutions.^7,8 This is most easily accomplished when grassroots organisations mobilise to draw the attention of news media to an issue.^7,8,9 News coverage of grassroots efforts puts pressure on policymakers to devise and/or implement specific solutions to public health problems. The intermediate goal of media advocacy is thus to facilitate passage of policies conducive to public health. In the long term, these policies should promote healthier environments and create meaningful changes in health behaviour.^7,8However, at the same time several authors note the shortage of research examining the role of news coverage in changing tobacco control policy and behaviour.^10,11,12 The evidence base supporting media advocacy as a reliable strategy for advancing health policy and changing health behaviour is limited.¹³ Although one large study provides strong evidence that media advocacy contributed to meaningful changes in drunk‐driving behaviour,^14,15,16 efforts to document the effectiveness of media advocacy for tobacco control are limited by constraints of case‐study methodologies for causal inferences,^17,18,19,20 characterised by inconsistent results,^20,21,22 focused on short‐run changes in news overage rather than long‐term policy and behaviour change,^21,22,23 and/or confounded by other components within multifaceted community interventions.^24,25 This study adds to this evidence base by assessing the effects of media advocacy, implemented as part of the Florida Tobacco Control Program (FTCP), on news coverage, tobacco control policy and smoking behaviour in Florida.The FTCP was a comprehensive education, marketing, prevention and enforcement campaign launched in 1998 to reduce smoking among Florida teens. The programme had three primary components: “truth”, a youth‐targeted media campaign; Students Working Against Tobacco (SWAT), a statewide youth anti‐tobacco group, and school‐based tobacco use prevention education.^26,27 Evaluators observed substantial reductions in youth behaviour within 2 years of the programme''s inception, far outpacing national declines,^26,27 and several studies show that the FTCP contributed to these reductions.^27,28,29The FTCP''s media advocacy strategy, a secondary programme component, involved sending press releases and working with reporters to promote FTCP programmes, media training for local SWAT leaders and promoting media events coordinated with local SWAT activities. After the budget crisis between March 1999 and June 1999, when the Florida legislature cut annual programme funding from $70 million to $38.7 million,³⁰ the FTCP initiated local mobilisation and media advocacy efforts to promote Tobacco Product Placement Ordinances (TPPOs). These ordinances, designed to reduce youth smoking by removing the visual and physical availability of cigarettes, would require retailers to place cigarettes and other tobacco products behind the counter. Local SWAT chapters used media advocacy to complement other efforts (community mobilisation, local events and presentations to county officials) in a combined effort to promote TPPOs at the county level.These efforts were seemingly met with success; between July 1999 and March 2002, 23 of 67 Florida counties passed TPPOs. However, the extent to which media advocacy and resulting news coverage contributed to these policies is unknown, and studies have not assessed whether these policies reduced teen smoking. Three conditions would strengthen conclusions about whether media advocacy contributed to the programme''s success. Firstly, programme‐related news coverage should increase after the onset of media advocacy efforts (hypothesis 1). Secondly, counties that received greater news coverage of SWAT events should be more likely to adopt TPPOs (hypothesis 2). Thirdly, counties that adopted TPPOs should witness greater subsequent declines in youth smoking than counties that did not (hypothesis 3). This paper tests these hypotheses by combining county news coverage estimates with county‐specific data on tobacco control policy and smoking behaviour.