Recent trends in home and work smoking bans

Objectives: Home and work smoking bans at the national and state level in the USA, and their relation to smoking prevalence and to tobacco control policies, are examined.

Data: The Current Population Survey's 1992/93 and 1998/99 tobacco use supplement surveys are the primary data source, supplemented with information on state level tobacco control policies.

Methods: The national and state rate of bans are estimated, and changes over the course of the 1990s and their relation to smoking rates and tobacco control policies are examined.

Results: The prevalence of work and home bans has increased considerably between 1992/93 and 1998/99. By 1999, over 65% of the population age 15 and above work in places with smoking bans, and over 60% live in homes with bans. We found that states with lower than average ban rates in 1993 tended to have had larger increases in ban rates between 1993 and 1999. We also found that home and work bans became more prevalent in states with initially low smoking rates, and that the growth in home bans coincided with a declining prevalence of smoking. States with higher levels of bans by 1999 also tended to have higher cigarette taxes, stricter clean air laws, and media/comprehensive campaigns in place.

Conclusions: The results indicate that lower smoking rates are associated with higher rates of work and home bans, although substantial progress has also been made by those states with initially low rates of bans. While further work is needed to establish the direction of causality, it would appear that reductions in smoking rates, either through stronger tobacco control policies or otherwise, may reduce exposure to tobacco smoke not only by reducing the number of smokers, but also through increasing the number of firms and homes with smoking restrictions.

     

The impact of anti-tobacco industry prevention messages in tobacco producing regions: evidence from the US truth campaign

Background: Adolescents who live in tobacco producing regions may not respond favourably to anti-industry ads. Objective: To examine whether state level involvement in tobacco production appears to limit the effectiveness of anti-industry ads to prevent tobacco use among adolescents in the USA. Design: Time trend analyses were done using repeated cross sectional data from six waves of the Legacy Media Tracking Survey, which were collected between 1999 and 2003. Setting and participants: 28 307 adolescents, ages 12–17 years, were classified as living in: tobacco producing states (TPS) (n = 1929); non-tobacco producing states (non-TPS) with low tobacco control funding comparable to TPS (n = 5323); non-TPS with relatively high funding (n = 15 076); and non-TPS with established anti-industry ad campaigns (n = 5979). Main outcome measures: Reactions to anti-industry ads; strength of anti-industry attitudes/beliefs; changes in anti-industry attitudes/beliefs over time. Results: Ad reactions did not differ by state type. Multivariate adjusted time trend analyses indicated significant, comparable increases in anti-industry attitudes/beliefs since the onset of the truth® campaign, in both TPS and non-TPS. Mediation analyses indicated that these increases were due, in part, to campaign exposure. Conclusions: Adolescents who live in tobacco producing regions appear to be as responsive to anti-industry ads as their counterparts in non-tobacco producing regions. This study provides further evidence for the effectiveness of such ads.     

The effectiveness of television advertising campaigns on generating calls to a national Quitline by Māori

Methods: Monthly Quitline call data and calls within one hour of a television commercial (TVC) being shown were analysed for the 2002–2003 period. Data on target audience rating points (TARPs) and expenditure on TVCs were also used (n = 2319 TVC placements). Results: Māori were found to register with the Quitline at higher rates during the most intense six campaign months (15% more registrations compared to less intense months). The most effective campaign generated 115 calls per 100 TARPs by Māori callers within one hour of TVC airing (the "Every cigarette" campaign). A more Māori orientated campaign with both health and cultural themes generated 91 calls per 100 TARPs from Māori callers. For these two campaigns combined, the advertising cost per new registration with the Quitline by a Māori caller was $NZ30–48. Two second hand smoke campaigns that did not show the Quitline number were much less effective at 25 and 45 calls per 100 TARPs. Conclusions: These television advertising campaigns were effective and cost effective in generating calls to a national Quitline by Māori. Health authorities should continue to explore the use of both "threat appeal" style media campaigns and culturally appropriate campaigns to support Quitline use by indigenous peoples.     

Effect of local restaurant smoking regulations on progression to established smoking among youths

Background: While smoke-free restaurant laws are intended to protect the public from secondhand smoke exposure, they may also discourage smoking among adolescents. There is no evidence from longitudinal studies to test this hypothesis. Objective: To examine the effect of local restaurant smoking regulations on progression to established smoking among adolescents. Design, setting, and subjects: A cohort of 2623 Massachusetts youths, ages 12–17 years at baseline, was interviewed via random digit dial telephone survey in 2001–2002 and followed up two years later. A generalised estimating equations (GEE) logistic regression analysis was used and controlled for potential individual, household, and town level confounding factors. Main outcome measure: Progression to established smoking during the two year follow up period (defined as having smoked 100 or more cigarettes in one''s life). Results: Compared to youths living in towns with weak regulations, those living in towns with strong regulations (complete restaurant smoking bans) had less than half the odds of progression to established smoking (odds ratio (OR) 0.39, 95% confidence interval (CI) 0.24 to 0.66). The association was stronger for youths in towns with strong regulations in effect for two or more years (OR 0.11, 95% CI 0.03 to 0.37), although it was still present for those in towns with strong regulations in effect for less than two years (OR 0.55, 95% CI 0.33 to 0.90). No relationship was found between living in a town with a medium restaurant smoking regulation (restriction of smoking to enclosed, separately ventilated areas) and rates of progression to established smoking. Conclusions: Local restaurant smoking bans may be an effective intervention to prevent youth smoking.     

Medicaid reimbursement for prenatal smoking intervention influences quitting and cessation

Background

40% of births in the USA are covered by Medicaid and smoking is prevalent among recipients. The objective of this study was to evaluate the association between levels of Medicaid coverage for prenatal smoking cessation interventions on quitting during pregnancy and maintaining cessation after delivery.

Methods

Population based survey study of 7513 post‐partum women from 15 states who: participated in Pregnancy Risk Assessment Monitoring System (PRAMS) during 1998–2000; smoked at the beginning of their pregnancy; and had Medicaid coverage. Participating states were categorised into three levels of Medicaid coverage for smoking cessation interventions during prenatal care: extensive (pharmacotherapies and counselling); some (pharmacotherapies or counselling); or none. Quit rates among women who smoked before pregnancy and rates of maintaining cessation were examined.

Results

Higher levels of coverage during prenatal care for smoking cessation interventions were associated with higher quit rates; 51%, 43%, and 39% of women quit in states with extensive, some, and no coverage, respectively. Compared to women in states with no coverage, women in states with extensive coverage had 1.6 times the odds of quitting smoking (odds ratio (OR) 1.58, 95% confidence interval (CI) 1.00 to 2.49). Maintenance of cessation after delivery was associated with extensive levels of Medicaid coverage; 48% of women maintained cessation in states with extensive coverage compared to 37% of women in states with no coverage. Compared to women in states with no coverage, women with extensive coverage had 1.6 times the odds of maintaining cessation (OR 1.63, 95% CI 1.04 to 2.56).

Conclusions

Prenatal Medicaid coverage for both pharmacotherapies and counselling is associated with higher rates of quitting and continued cessation. This suggests policymakers can promote cessation by broadening smoking cessation services in Medicaid prenatal coverage.     

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.     

Exposure to cigarette promotions and smoking uptake in adolescents: evidence of a dose-response relation

OBJECTIVE: To assess whether a dose-response relation exists between the number of cigarette promotional items (CPIs) owned by an adolescent, and smoking behaviour. DESIGN AND SETTING: Voluntary, self administered survey of 1265 sixth through to 12th grade students (ages 10-19 years), representing 79-95% of all students attending five rural New Hampshire and Vermont public (state funded) schools in October 1996. The association between the number of CPIs owned by students and smoking behaviour was examined using multivariate regression methods. OUTCOME MEASURES: Adjusted odds of being a smoker (>/= 100 cigarettes lifetime) and, among never and experimental smokers, adjusted cumulative odds of having higher levels on a smoking uptake index given the number of CPIs owned. RESULTS: One third of students owned a CPI (n = 406). Among owners, 211 owned one, 82 owned two, 57 owned three, 24 owned four, 23 owned five, and 7 students owned six CPIs. The number of CPIs owned by students was not associated with grade in school but was significantly higher in males, those with poorer school performance, those who perceived high prevalence of peer smoking, and those with higher exposure to peer and family smoking. The more items a student owned, the greater the chances of being a smoker. For example, smoking prevalence was 11.2% for those not owning a CPI, 41.5% for those owning two, 58.5% for those owning four, and 71.4% for those owning six CPIs. The dose-response relation remained after controlling for confounding; compared with those who did not own a CPI, the likelihood of being a smoker was significantly higher for those who owned one CPI, with an adjusted odds ratio (OR) of 2.7 (95% confidence interval (CI) 1.7 to 4.1); OR was 3.4 (95% CI 1.9 to 5.9) for those owning two CPIs, and 8.4 (95% CI 5.0 to 14.2) for those owning three or more CPIs. After excluding smokers, there was a crude dose-response association between CPI ownership and higher rates of experimentation with cigarettes among sixth to ninth graders (ages 11-15 years) only (n = 543). After controlling for confounding influences, the dose-response relation remained, with the likelihood of being higher on the smoking uptake index rising with the number of CPIs owned: one CPI, adjusted cumulative OR 1.7 (95% CI 1.1 to 2.60); two CPIs, OR 2.5 (95% CI 1.2 to 5.1); and three or more CPIs, OR 4.8 (95% CI 1.9 to 12.2). CONCLUSIONS: This study offers evidence of a dose-response relation between the number of CPIs owned by adolescents and higher likelihood of experimental and established smoking. The dose-response relation persists after controlling for confounding influences. These data provide further support of a causal relation between tobacco promotional campaigns and smoking behaviour among adolescents.     

Adolescent smoking decline during California's tobacco control programme

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

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

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

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

     

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

Objectives

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

Design

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

Setting

An occupational setting in a radiator manufacturing factory in Japan.

Subjects

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

Main outcome measurements

Smoking cessation rates at the end of each time period.

Results

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

Conclusions

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

New tobacco products: do smokers like them?

Background

There is little information about smokers who tried potentially reduced exposure products (PREPs) (Eclipse^®, Omni^®, Advance Lights^®, Accord^®, or Ariva^®), why they tried them, if they liked these products, and if they will continue to use them.

Objectives

The objectives of this qualitative study were to understand: (1) how smokers who tried PREPs learned about them, (2) reasons for first trying PREPs, (3) which PREP(s) they tried, (4) what they thought of the product at first trial, (5) reasons for continuing or discontinuing use, and (6) whether they would recommend PREPs to others.

Design

In October 2002, 16 focus group sessions were conducted with current cigarette smokers aged 30–50 years: eight groups in Chattanooga, Tennessee, and eight in Dallas, Texas. Specific focus groups were composed of white men, white women, African American men, African American women, Hispanic men, or Hispanic women.

Results

The majority of the participants learned about PREPs through advertising or promotion, family, friends, and co‐workers; major reasons given for first trying PREPs were that the products were free or inexpensive, they wanted to stop smoking, they believed the product claims of fewer health risks, or they were curious; most of them tried Eclipse^® probably because the focus groups were conducted in the same cities where Eclipse^® was introduced; most participants did not like PREPs; most discontinued the use of PREPS, some who continued to use them did so infrequently and also kept smoking their regular brands of cigarettes; and most would not recommend PREPs, although a few might recommend them to specific groups (for example, new smokers, the young, women, curious or health conscious people).

Conclusions

Although most established smokers did not like the PREPs they tried and will not recommend them to anyone, a minority of established smokers believe that there may be a market for these products.     

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.     

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).     

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.     

Observed smoking in cars: a method and differences by socioeconomic area

Objectives

To establish a reproducible method to estimate he point prevalence of smoking and second‐hand smoke (SHS) exposure in cars, and to compare this prevalence between two areas of contrasting socioeconomic status.

Method

A method involving two teams of observers was developed and evaluated. It involved observing 16 055 cars in Wellington, New Zealand. Two of the observation sites represented a high and a low area of deprivation (based on a neighbourhood deprivation index) and three were in the central city.

Results

A 4.1% point prevalence of smoking in cars was observed (95% confidence interval (CI) 3.8% to 4.4%). There was a higher prevalence of smoking in cars in the high deprivation area relative to the other sites, and particularly compared to the low deprivation area (rate ratio relative to the latter 3.2, 95% CI 2.6 to 4.0). Of cars with smoking, 23.7% had other occupants being exposed to SHS. Cars with smoking and other occupants were significantly more likely to have a window open (especially if the smoker was not the driver). The observation method developed was practical, and inter‐observer agreement was high (κ value for the “smoking seen in car” category 0.95).

Conclusions

Observational studies can be an effective way of investigating smoking in cars. The data from this survey suggest that smoking in cars occurs at a higher rate in relatively deprived populations and hence may contribute to health inequalities. Fortunately, there are a number of policy options for reducing SHS exposure in cars including mass media campaigns and laws for smoke‐free cars.     

Changes in smoking prevalence in Ukraine in 2001-5

Objectives

To analyse trends in smoking prevalence in Ukraine from three surveys conducted in 2001–5, and to explore correlates of observed changes, in order to estimate the stage of tobacco epidemic in Ukraine.

Design

Repeated national interview surveys in Ukraine in 2001, 2002 and 2005.

Main outcome measure

Prevalence of current smoking among the population aged ⩾15 years.

Results

The age‐standardised prevalence of current smoking in Ukrainian men was 54.8% in 2001 and 66.8% in 2005. Among Ukrainian women, prevalence increased from 11.5% in 2001 to 20.0% in 2005. ORs for yearly increase in prevalence were estimated as 1.164 (95% CI 1.111 to 1.220) for men and 1.187 (1.124 to 1.253) for women, which implies that, on average, 3–4% of men and 1.5–2% of women living in Ukraine join the smoking population each year.

Conclusions

In Ukraine, smoking prevalence is increasing in most population groups. Among men, the medium deprivation group with secondary education has the highest smoking prevalence. Among women, while the most educated, young and those living in larger cities are the leading group for tobacco use, other groups are also increasing their tobacco use. Tobacco promotion efforts appear to have been significantly more effective in Ukraine than smoking control efforts. The decrease in real cigarette prices in Ukraine in 2001–5 could be the main factor explaining the recent growth in smoking prevalence.Ukraine is a large eastern European country with high smoking prevalence. Tobacco products are widely available at very low prices, and the transnational tobacco industry is extremely successful in promoting its products and lobbying for its interests in the legislative field. Advocacy of tobacco control has only recently achieved some success in the legislative field, with the first tobacco control law being adopted in late 2005. Ukraine ratified the Framework Convention on Tobacco Control in 2006, but there is still much cause for concern regarding the enforcement and effectiveness of the adopted legislative measures. Unfortunately, the government is not yet involved in nationwide surveillance of the tobacco problem, and the available data have mostly been gathered with funding from foreign donors. Several attempts have been made to measure the extent of the tobacco epidemic in the countries of the former Soviet Union (FSU).^{1,2,3,4,5,6,7} Most of these studies have shown rather high smoking prevalence among men (50–70%) and comparatively low prevalence among women (5–20%). Most countries in the FSU have similar smoking rates, while certain trends are shown to be related to the differences in how the transnational tobacco industry succeeds in every national tobacco market.⁶ Unfortunately, few studies have been published showing trends in smoking prevalence in the FSU.⁷ In Ukraine, two studies^3,4 provided point estimates of smoking prevalence.The aim of this study was to analyse trends in smoking prevalence in Ukraine, on the basis of three surveys conducted in 2001–5, and to explore correlates of observed changes in order to estimate the stage of the tobacco epidemic in Ukraine.     

Changes in smoking prevalence in Russia, 1996-2004

Objectives

In Russia, smoking prevalence has historically been high in men and relatively low in women. Female smoking prevalence is predicted to rise but assessment of changes has been limited by the lack of comparable data. Changes in the prevalence of smoking in Russia between 1996 and 2004, and whether theses changes differed by sociodemographic groups, were investigated.

Design

Repeated national interview surveys in 1996 (731 men and 868 women) and 2004 (727 men and 864 women) aged 18 years or more.

Main outcome measure

Prevalence of current smoking.

Results

The age standardised prevalence of smoking in 1996 and 2004 was 61% and 63%, respectively in men and 15% and 16%, respectively in women (both p values > 0.4). In men, the prevalence of smoking seemed to decline in those with university education (from 51% to 40%, p  =  0.085). Among women, smoking appeared to increase in those with university education (from 10% to 17%, p  =  0.071) and low levels of self‐reported material deprivation (from 11% to 18%, p  =  0.053). There was a pronounced increase in prevalence among women living in villages (from 8% to 14%, p  =  0.049); the strong urban/rural gradient seen in 1996 became considerably weaker by 2004.

Conclusions

Overall smoking prevalence in both men and women in Russia remained stable between 1996 and 2004 but, given the sample size, a moderate increase in female smoking cannot be ruled out. In men, smoking increased among the least educated and declined in the most educated. In women the opposite appeared to occur, in addition to an increase in smoking in rural areas. More long term monitoring of smoking patterns in Russia, especially among women, using sufficiently large surveys, is required.     

Health consequences of smoking 1-4 cigarettes per day

Objectives: To determine the risk in men and women smoking 1–4 cigarettes per day of dying from specified smoking related diseases and from any cause. Design: Prospective study. Setting: Oslo city and three counties in Norway. Participants: 23 521 men and 19 201 women, aged 35–49 years, screened for cardiovascular disease risk factors in the mid 1970s and followed throughout 2002. Outcomes: Absolute mortality and relative risks adjusted for confounding variables, of dying from ischaemic heart disease, all cancer, lung cancer, and from all causes. Results: Adjusted relative risk (95% confidence interval) in smokers of 1–4 cigarettes per day, with never smokers as reference, of dying from ischaemic heart disease was 2.74 (2.07 to 3.61) in men and 2.94 (1.75 to 4.95) in women. The corresponding figures for all cancer were 1.08 (0.78 to 1.49) and 1.14 (0.84 to 1.55), for lung cancer 2.79 (0.94 to 8.28) and 5.03 (1.81 to 13.98), and for any cause 1.57 (1.33 to 1.85) and 1.47 (1.19 to 1.82). Conclusions: In both sexes, smoking 1–4 cigarettes per day was associated with a significantly higher risk of dying from ischaemic heart disease and from all causes, and from lung cancer in women. Smoking control policymakers and health educators should emphasise more strongly that light smokers also endanger their health.     

Designated "no smoking" areas provide from partial to no protection from environmental tobacco smoke

Objective: To determine the efficacy of designated "no smoking" areas in the hospitality industry as a means of providing protection from environmental tobacco smoke (ETS), and whether certain design features assist in achieving this end. Methodology: In the greater metropolitan region of Sydney, a representative group of 17 social and gaming clubs, licensed to serve alcoholic beverages and in which, apart from designated areas, smoking occurs, agreed to participate. In each establishment, simultaneous single measurements of atmospheric nicotine, particulate matter (10 µm; PM10) and carbon dioxide (CO₂) levels were measured in a general use area and in a designated "no smoking" area during times of normal operation, together with the levels in outdoor air (PM10 and CO₂ only). Analyses were made of these data to assess the extent to which persons using the "no smoking" areas were protected from exposure to ETS. Results: By comparison with levels in general use areas, nicotine and particulate matter levels were significantly less in the "no smoking" areas, but were still readily detectable at higher than ambient levels. For nicotine, mean (SD) levels were 100.5 (45.3) µg/m³ in the areas where smoking occurred and 41.3 (16.1) µg/m³ in the "no smoking" areas. Corresponding PM10 levels were 460 (196) µg/m³ and 210 (210) µg/m³, while outdoor levels were 61 (23) µg/m³. The reduction in pollutants achieved through a separate room being designated "no smoking" was only marginally better than the reduction achieved when a "no smoking" area was contiguous with a smoking area. CO₂ levels were relatively uninformative. Conclusion: Provision of designated "no smoking" areas in licensed (gaming) clubs in New South Wales, Australia, provides, at best, partial protection from ETS—typically about a 50% reduction in exposure. The protection afforded is less than users might reasonably have understood and is not comparable with protection afforded by prohibiting smoking on the premises.     

Healthcare provider smoking cessation advice among US worker groups

Objective

Among workers in dusty occupations, tobacco use is particularly detrimental to health because of the potential synergistic effects of occupational exposures (for example, asbestos) in causing disease. This study explored the prevalence of smoking and the reported smoking cessation discussion with a primary healthcare provider (HCP) among a representative sample of currently employed US worker groups.

Methods

Pooled data from the 1997–2003 National Health Interview Survey (NHIS) were used to estimate occupation specific smoking rates (n = 135 412). The 2000 NHIS Cancer Control Module was used to determine (among employed smokers with HCP visits) the prevalence of being advised to quit smoking by occupation (n = 3454).

Results

The average annual prevalence of current smoking was 25% in all workers. In 2000, 84% of smokers reported visiting an HCP during the past 12 months; 53% reported being advised by their physician to quit smoking (range 42%–66% among 30 occupations). However, an estimated 10.5 million smokers were not advised to quit smoking by their HCP. Workers with potentially increased occupational exposure to dusty work environments (including asbestos, silica, particulates, etc), at high risk for occupational lung disease and with high smoking prevalence, had relatively low reported discussions with an HCP about smoking cessation, including farm workers (30% overall smoking prevalence; 42% told to quit), construction and extractive trades (39%; 46%), and machine operators/tenderers (34%; 44%).

Conclusion

The relatively low reported prevalence of HCP initiated smoking cessation discussion, particularly among currently employed workers with potentially synergistic occupational exposures and high current smoking prevalence, needs to be addressed through educational campaigns targeting physicians and other HCPs.     

Working to make an image: an analysis of three Philip Morris corporate image media campaigns

Objective

To describe the nature and timing of, and population exposure to, Philip Morris USA''s three explicit corporate image television advertising campaigns and explore the motivations behind each campaign.

Methods

: Analysis of television ratings from the largest 75 media markets in the United States, which measure the reach and frequency of population exposure to advertising; copies of all televised commercials produced by Philip Morris; and tobacco industry documents, which provide insights into the specific goals of each campaign.

Findings

Household exposure to the “Working to Make a Difference: the People of Philip Morris” averaged 5.37 ads/month for 27 months from 1999–2001; the “Tobacco Settlement” campaign averaged 10.05 ads/month for three months in 2000; and “PMUSA” averaged 3.11 ads/month for the last six months in 2003. The percentage of advertising exposure that was purchased in news programming in order to reach opinion leaders increased over the three campaigns from 20%, 39% and 60%, respectively. These public relations campaigns were designed to counter negative images, increase brand recognition, and improve the financial viability of the company.

Conclusions

Only one early media campaign focused on issues other than tobacco, whereas subsequent campaigns have been specifically concerned with tobacco issues, and more targeted to opinion leaders. The size and timing of the advertising buys appeared to be strategically crafted to maximise advertising exposure for these population subgroups during critical threats to Philip Morris''s public image.