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.     

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

Objectives

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

Design

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

Participants

8367 Australian men aged 16–59 years.

Main outcome measures

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

Results

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

Conclusions

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

A randomised control study of a fully automated internet based smoking cessation programme

Objective

The objective of this project was to test the short term (90 days) efficacy of an automated behavioural intervention for smoking cessation, the “1‐2‐3 Smokefree” programme, delivered via an internet website.

Design

Randomised control trial. Subjects surveyed at baseline, immediately post‐intervention, and 90 days later.

Settings

The study and the intervention occurred entirely via the internet site. Subjects were recruited primarily via worksites, which referred potential subjects to the website.

Subjects

The 351 qualifying subjects were notified of the study via their worksite and required to have internet access. Additionally, subjects were required to be over 18 years of age, smoke cigarettes, and be interested in quitting smoking in the next 30 days. Eligible subjects were randomly assigned individually to treatment or control condition by computer algorithm.

Intervention

The intervention consisted of a video based internet site that presented current strategies for smoking cessation and motivational materials tailored to the user''s race/ethnicity, sex, and age. Control subjects received nothing for 90 days and were then allowed access to the programme.

Main outcome measures

The primary outcome measure was abstinence from smoking at 90 day follow up.

Results

At follow up, the cessation rate at 90 days was 24.1% (n  =  21) for the treatment group and 8.2% (n  =  9) for the control group (p  =  0.002). Using an intent‐to‐treat model, 12.3% (n  =  21) of the treatment group were abstinent, compared to 5.0% (n  =  9) in the control group (p  =  0.015).

Conclusions

These evaluation results suggest that a smoking cessation programme, with at least short term efficacy, can be successfully delivered via the internet.     

Decline in respiratory symptoms in service workers five months after a public smoking ban

Objective

To evaluate the effect of a total ban on smoking indoors in restaurants and other hospitality business premises in Norway, on respiratory symptoms among workers in the industry.

Methods

Phone interviews with 1525 employees in the hospitality business were conducted immediately before the enacting of the law. In a follow‐up study five months later, 906 of the workers from the baseline sample participated. Questions were asked on demographic variables, passive smoking exposure, personal smoking, attitudes towards the law, and five respiratory symptoms. Change in symptom prevalence was analysed with McNemar''s test and with analysis of variance (ANOVA) for repeated measures.

Results

The prevalence of all five symptoms declined after the ban; for morning cough from 20.6% to 16.2% (p < 0.01); for daytime cough from 23.2% to 20.9%; for phlegm cough from 15.3% to 11.8% (p < 0.05); for dyspnoea from 19.2% to 13.0% (p < 0.01); and for wheezing from 9.0% to 7.8%. ANOVA showed that the largest decline in symptom prevalence was seen among workers who themselves gave up smoking, and subjects with a positive attitude towards the law before it took effect.

Conclusion

A significant decrease in respiratory symptoms among service industry workers was found five months after the enacting of a public smoking ban.     

What contributed to the major decline in per capita cigarette consumption during California's comprehensive tobacco control programme?

Objectives

California experienced a notable decline in per capita cigarette consumption during its comprehensive tobacco control programme. This study examines what proportion of the decline occurred from: (1) fewer ever smokers in the population, (2) more ever smokers quitting, and (3) current smokers smoking less.

Design, subjects

Per capita cigarette consumption computed from cigarette sales and from adult respondents to the large, cross‐sectional, population‐based California Tobacco Surveys of 1990 (n  =  24 296), 1996 (n  =  18 616) and 2002 (n  =  20 525) were examined for similar trends.

Main outcome measure

Changes (period 1: 1990–1996; period 2: 1996–2002) in per capita cigarette consumption from self‐reported survey data were partitioned for the entire population and for demographic subgroups into the three components mentioned above.

Results

In periods 1 and 2, most of the decline in per capita cigarette consumption for the population as a whole was from current smokers smoking less followed by a reduction in ever smokers. The decline from smokers smoking less was particularly evident among young adults (18–29 years) in period 1. While the portion of the decline due to quitting in the entire population in period 1 was negligible, in period 2 it accounted for 22% of the total per capita decline. The decline from quitting in period 2 was mostly observed among women.

Conclusions

Rather than near‐term benefits from smokers quitting, population health benefits from reduced per capita cigarette consumption will likely occur over the longer term from fewer people becoming ever smokers, and more less‐addicted smokers eventually quitting successfully.     

Non-smokers seeking help for smokers: a preliminary study

Objectives

To examine the phenomenon of non‐smokers spontaneously taking action to seek help for smokers; to provide profiles of non‐smoking helpers by language and ethnic groups.

Setting

A large, statewide tobacco quitline (California Smokers'' Helpline) in operation since 1992 in California, providing free cessation services in English, Spanish, Mandarin, Cantonese, Korean, and Vietnamese.

Subjects

Callers between August 1992 and September 2005 who identified themselves as either white, black, Hispanic, American Indian, or Asian (n  =  349 110). A subset of these were “proxies”: callers seeking help for someone else. For more detailed analysis, n  =  2143 non‐smoking proxies calling from October 2004 through September 2005.

Main outcome measures

Proportions of proxies among all callers in each of seven language/ethnic groups; demographics of proxies; and proxies'' relationships to smokers on whose behalf they called.

Results

Over 22 000 non‐smoking proxies called. Proportions differed dramatically across language/ethnic groups, from mean (±95% confidence interval) 2.7 (0.3)% among English‐speaking American Indians through 9.3 (0.3)% among English‐speaking Hispanics to 35.3 (0.7)% among Asian‐speaking Asians. Beyond the differences in proportion, however, remarkable similarities emerged across all groups. Proxies were primarily women (79.2 (1.7)%), living in the same household as the smokers (65.0 (2.1)%), and having either explicit or implicit understandings with the smokers that calling on their behalf was acceptable (90.0 (1.3)%).

Conclusions

The willingness of non‐smokers to seek help for smokers holds promise for tobacco cessation and may help address ethnic and language disparities. Non‐smoking women in smokers'' households may be the first group to target.     

Nicotine replacement therapy for long-term smoking cessation: a meta-analysis

Objective

To assess if the effect of a single treatment episode with nicotine replacement therapy (NRT) enhances smoking cessation over many years.

Data sources

Meta‐analysis of all randomised controlled trials of NRT with final follow‐up more than one year after the start of treatment. Twelve eligible trials were identified, all placebo‐controlled, having final follow‐ups ranging from 2–8 years. All had earlier follow‐ups at 12 months. They comprised 2408 active and 2384 placebo treatment participants.

Data synthesis

The odds ratio (OR) in favour of NRT at final follow‐up was 1.99 (95% confidence interval (CI) 1.50 to 2.64). There was no evidence that the effect varied according to length of final follow‐up (β  =  0.92, p  =  0.28) or duration of initial NRT treatment (β  =  0.99, p > 0.5). The overall relapse rate between the 12 months and final follow‐up was 30.0% (95% CI 23.5% to 37.5%). This rate did not differ between NRT and control groups (OR 1.11, 95% CI 0.78 to 1.59), or length of initial NRT treatment. There was also no evidence that it varied according to length of final follow up. Due to relapse, the overall efficacy of NRT treatment in terms of additional ex‐smokers declined from 10.7% over and above placebo (6.6% to 14.8%) after one year to 7.2% (3.8% to 11.3%) at an average of 4.3 years follow up.

Conclusions

The relative efficacy of a single course of NRT remains constant over many years. The majority of relapse after 12 months occurs within the first or second year and is not detectable thereafter, suggesting that NRT has a permanent effect on smoking cessation. However, initial relapse after one year has the effect of diminishing the number of ex‐smokers that can be ultimately attributed to NRT. Results after only 6–12 months of follow‐up, as used in existing reviews and treatment guidelines, will overestimate the lifetime benefit and cost‐efficacy of NRT by about 30%. Because the long‐term benefit of NRT is modest, tobacco dependence treatment might be better viewed as a chronic disorder, requiring repeated episodes of treatment.     

Use of nicotine replacement therapy to reduce or delay smoking but not to quit: prevalence and association with subsequent cessation efforts

Objective

To assess the prevalence of nicotine replacement therapy (NRT) use for purposes other than quitting smoking and examine the relation of this non‐standard NRT use (NSNRT) with subsequent smoking cessation efforts.

Design

A population based cohort study of adult smokers who were interviewed by telephone at baseline (2001–2) and at two year follow‐up. The association between NSNRT use to cut down on smoking or to delay smoking before baseline and cessation attempts and smoking outcomes at two year follow‐up was assessed using logistic regression to adjust for multiple potential confounding factors.

Setting

Massachusetts, USA.

Subjects

1712 adult smokers in Massachusetts who were selected using a random digit dial telephone survey.

Main outcome measures

Quit attempt in 12 months before follow‐up, NRT use at quit attempt in 12 months before follow‐up, smoking cessation by follow‐up, or 50% reduction in cigarettes smoked per day between baseline and follow‐up.

Results

18.7% of respondents reported ever having used NSNRT. In a multiple logistic regression analysis, there was no statistically significant association between past NSNRT use and quit attempts (OR_{cut down}  = 0.89, 95% CI 0.59 to 1.33; OR_delay  = 1.29, 95% CI 0.73 to 2.29), smoking cessation (OR_{cut down}  = 0.74, 95% CI 0.43 to 1.24; OR_delay  = 1.22, 95% CI 0.60 to 2.50) or 50% reduction in cigarettes smoked per day (OR_{cut down}  = 0.93, 95% CI 0.62 to 1.38; OR_delay  = 0.80, 95% CI 0.43 to 1.49) at follow‐up. Past use of NRT to cut down on cigarettes was associated with use of NRT at a follow‐up quit attempt (OR_{cut down}  = 2.28, 95% CI 1.50 to 3.47) but past use of NRT to delay smoking was not (OR_delay  = 1.25, 95% CI 0.67 to 2.34).

Conclusions

Use of NRT for reasons other than quitting smoking may be more common than was previously estimated. This population based survey finds no strong evidence that NRT use for purposes other than quitting smoking is either harmful or helpful.     

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.     

Increased reach and effectiveness of a statewide tobacco quitline after the addition of access to free nicotine replacement therapy

Background

Tobacco users receiving behavioural and pharmacological assistance are more likely to quit. Although telephone quitlines provide population access to counselling, few offer pharmacotherapy.

Objective

To assess change in cessation rates and programme impact after the addition of free nicotine replacement therapy (NRT) to statewide quitline services.

Design, setting, participants

An observational study of cohorts of callers to the Minnesota QUITPLAN^SM Helpline before (n  =  380) and after (n  =  373) the addition of access to free NRT.

Intervention

Mailing of NRT (patch or gum) to callers enrolling in multi‐session counselling.

Main outcome measure

Thirty‐day abstinence six months after programme registration.

Results

The number of callers increased from 155 (SD 75) to 679 (180) per month pre‐NRT to post‐NRT (difference 524, 95% confidence interval (CI) 323 to 725). Post‐NRT, the proportion of callers enrolling in multi‐session counselling (23.4% v 90.1%, difference 66.6%, 95% CI 60.8% to 71.6%) and using pharmacotherapy (46.8% v 86.8%, difference 40.0%, 95% CI 31.3% to 47.9%) increased. Thirty‐day abstinence at six months increased from 10.0% pre‐NRT to 18.2% post‐NRT (difference 8.2%, 95% CI 3.1% to 13.4%). Post‐NRT the average number of new ex‐smokers per month among registrants increased from 15.5 to 123.6 (difference 108.1, 95% CI 61.1 to 155.0). The cost per quit pre‐NRT was $1362 (SD $207). The cost per quit post‐NRT was $1934 ($215) suggesting a possible increase in cost per quit (difference $572, 95% CI −$12 to $1157).

Conclusion

The addition of free NRT to a state quitline is followed by increases in participation and abstinence rates resulting in an eightfold increase in programme impact. These findings support the addition of access to pharmacological therapy as part of state quitline services.     

Nicotine replacement therapy, professional therapy, snuff use and tobacco smoking: a study of smoking cessation strategies in southern Sweden

Objectives

The strategies used to support smoking cessation among quitters were investigated according to year of smoking cessation and sociodemographic characteristics.

Methods

The 2004 public health survey in Skåne, Sweden, is a cross‐sectional study. A total of 27 757 people aged 18–80 answered a postal questionnaire. The participation rate was 59%. Different strategies to support smoking cessation—that is, no therapy, nicotine replacement (NRT), professional therapy and snus (snuff) use, were investigated among quitters according to year of smoking cessation, and demographic and socioeconomic characteristics.

Results

14.9% of the men and 18.1% of the women were daily smokers. The prevalence of daily snus use was 19.5% among men but only 2.3% among women. Stratifying the data according to year of smoking cessation (1938–2004) revealed a significant increase in active smoking cessation strategies such as NRT, professional therapy and snus use. NRT was more common among women (23.6%) than men (14.8%) among smokers who quit in 2000–4, but snus use was more common among men (30.4% versus 8.7%). No replacement or other therapy at all was significantly more common among women (63.6%) than men (52.1%). People aged 35–80 years used more nicotine replacement than people aged 18–34, while men aged 18–34 used snus to quit smoking significantly more than men aged 55–80.

Conclusions

Snus is used commonly among men as a support for smoking cessation in Sweden. Women use pharmacological NRT to a greater extent, but this can probably not compensate for the much higher extent of snuff use as a cessation strategy among men.     

Smokers' reactions to reduced ignition propensity cigarettes

Background

On 28 June 2004, New York State (NY) became the first jurisdiction to require cigarettes to meet a reduced ignition propensity (RIP) standard. This law resulted in cigarette manufacturers modifying nearly all of their brands sold in NY. However, the same cigarette brands sold in other states were not modified to meet the RIP standard.

Objectives

This paper examines relationships between the RIP law and smokers'' awareness of changes in the performance of their cigarettes (that is, going out more frequently, change in taste), and smoking behaviour.

Methods

Data for this analysis come from a nationwide survey of 2088 adult smokers (> 18 years of age) conducted in the USA between July and December 2004. 143 of the smokers included in the survey were residents of NY while the remainder were from other states (n  =  1945). Survey participants were asked whether their cigarettes “ever go out between puffs” and whether they had noticed any change in the taste of their cigarettes in the past 12 months.

Results

NY smokers were three times more likely than smokers in other states to report that their cigarettes often went out between puffs (17.3% v 5.6%). However, NY smokers appeared no more likely to report noticing differences in cigarette taste, an intention to quit smoking, or to have made quit attempts.

Conclusions

A significant minority of smokers in NY reported noticing changes in the performance of their cigarettes following the RIP law, as would be expected. However, the RIP law appears to have had no impact on the smoking habits of New Yorkers, countering arguments made by cigarette manufacturers that the law would impact consumer acceptability.     

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.     

Adolescent snus use in Finland in 1981-2003: trend, total sales ban and acquisition

Objective

To study changes in adolescent snus use from 1981 to 2003, the effects of the total snus sales ban (1995) and snus acquisition.

Design

Biennial postal surveys in 1981–2003.

Setting and participants

Entire Finland; 12‐, 14‐, 16‐, and 18‐year‐olds (n  =  73 946; 3105−8390 per year).

Main outcome measures

Snus use (experimental, daily/occasionally), snus acquisition (2001, 2003).

Results

Snus experimentation grew in popularity before the total sales ban in 16‐ and 18‐year‐old boys and after the ban in all age and sex groups. A decrease was seen between 2001 and 2003, except for 18‐year‐old boys. Daily/occasional use mainly followed the same pattern in boys while in girls the daily/occasional use was rare and no significant changes were observed. In 2003, boys experimented with snus more often than girls (12‐year‐olds 1% v 0%, 14‐year‐olds 9% v 4%, 16‐year‐olds 30% v 12%, 18‐year‐olds 44% v 18%). Hardly any girls used snus daily/occasionally, but 1% of 14‐year‐old boys, 7% of 16‐year‐olds, and 9% of 18‐year‐olds did. Of daily/occasional users, 84% acquired snus from friends or acquaintances, 55% from tourist trips to neighbouring countries (Estonia, Sweden), and 7% through sport teams; 24% obtained it from under‐the‐counter sources. For experimenters, the corresponding figures were 79%, 18%, 0.3%, and 5%.

Conclusions

The total sales ban did not stop snus use; instead, the increase continued after the ban. Friends who travel to neighbouring countries act as go‐betweens reselling snus. Snus is used even by the youngest adolescents, thus contributing to the nicotine dependence process.     

Smoke-free laws and secondhand smoke exposure in US non-smoking adults, 1999-2002

Objectives

To investigate the relationship between smoke‐free law coverage and secondhand smoke (SHS) exposure in the United States non‐smoking adult population.

Design

We used data from the 1999–2002 National Health and Nutrition Examination Survey, a cross‐sectional survey designed to monitor the health and nutritional status of the US population. Serum cotinine levels were available for 5866 non‐smoking adults from 57 survey locations. Each location was categorised into one of three groups indicating extensive, limited, and no coverage by a smoke‐free law.

Main outcome measures

The proportion of adults with SHS exposure, defined as having serum cotinine levels ⩾ 0.05 ng/ml.

Results

Among non‐smoking adults living in counties with extensive smoke‐free law coverage, 12.5% were exposed to SHS, compared with 35.1% with limited coverage, and 45.9% with no law. Adjusting for confounders, men and women residing in counties with extensive coverage had 0.10 (95% confidence interval (CI) 0.06 to 0.16) and 0.19 (95% CI 0.11 to 0.34) times the odds of SHS exposure compared to those residing in counties without a smoke‐free law.

Conclusions

These results support the scientific evidence suggesting that smoke‐free laws are an effective strategy for reducing SHS exposure.     

Trends in the prevalence of smoking in Russia during the transition to a market economy

Background

Changes in smoking, particularly an increase in women, were predicted to follow the aggressive campaigns of multinational tobacco companies in transitional Russia. However, such changes have not yet been demonstrated unequivocally.

Objective

To examine smoking trends by gender, education and area of residence.

Methods

Data from 10 rounds of the Russia Longitudinal Monitoring Survey (1992–2003), consisting of more than 3000 men and 4000 women in each round, were used. The mean reported ages of first smoking in current smokers were compared between 10‐year birth cohorts.

Results

Between 1992 and 2003, smoking prevalence doubled among women from 6.9% (95% CI 6.3% to 7.6%) to 14.8% (13.9% to 15.7%) and increased among men from 57.4% (95% CI 56.0% to 58.8%) to 62.6% (61.1% to 64.1%). In both sexes, the rise was significantly greater in the least educated, markedly so in women (a doubling vs a 1.5‐fold rise in the most educated). Although prevalence of smoking among women was considerably higher in Moscow and St Petersburg than in rural areas, the dramatic threefold increase in prevalence in rural women was significantly greater than in the main cities (36%, p<0.001). The mean age of first smoking was significantly lower in women born after 1960, but in men it was stable between cohorts.

Conclusions

For the first time, it has been shown unequivocally that smoking among women increased markedly during the transition to a market economy in Russia. The already high prevalence of smoking among men has continued to rise. These changes are likely to reflect the activity of the tobacco industry and provide further evidence of the harms of privatisation. Effective tobacco control policies are urgently needed.The collapse of the Soviet Union led to massive changes in the region''s cigarette industry; state‐owned tobacco monopolies were privatised, and the transnational tobacco companies (TTCs) invested heavily.¹ This led to a massive surge in advertising and a change in distribution strategies, which were shown by tobacco industry documents to be targeted particularly at women, young people and those living in cities, and which were accompanied by a weakening in tobacco control legislation as a result of aggressive lobbying by the industry.^2,3,4,5 Cigarette consumption across the region increased almost exponentially.⁶In Russia alone, the TTCs invested approximately US$1.7 billion between 1992 and 2000, gaining a collective market share of over 60% and increasing by fourfold the production capacity in their newly acquired factories.¹ Various numbers of new brands were introduced; Japan Tobacco International, for example, introduced eight new brands in 1999 alone.⁷ Advertising, which had been non‐existent in Soviet times, escalated massively to promote such brands as an indispensable part of the “western lifestyle”.^8,9 By the mid 1990s, it was estimated that up to 50% of all billboards in Moscow and 75% of plastic bags in Russia carried tobacco advertising;¹⁰ tobacco soon became the product most heavily advertised outdoors, with three major transnationals ranked as the first, second and third heaviest advertisers.¹¹ After the initial targeting of urban areas, industry documents state that the focus was on expanding marketing efforts to other regions of Russia.^12,13 Since the transition, tobacco control policies in Russia have largely been dictated by the tobacco industry. In 1995, for example, a new law on advertising was implemented, based on the industry''s voluntary code of conduct,^14,15 and changes to the federal bill on Limitation of Tobacco Consumption, signed in 2001, were described by the St Petersburg Times as “a textbook demonstration of the lobbyist''s art”.¹⁶Although the tobacco epidemic in men in Russia, as in the rest of the former Soviet Union (FSU), is well established,¹⁷ and smoking rates among men have been high for decades, rates have failed to decline, as models of the tobacco epidemic would predict.^18,19 In women, the tobacco epidemic is at an earlier stage. Survey data show far higher rates of smoking among young than among older women, particularly in countries targeted by the TTCs, which, combined with comparisons with historical data, suggest an increase in smoking rates among women. However, such an increase is yet to be established unequivocally, as previous efforts to examine these and other trends in the tobacco epidemic have been limited by the lack of truly comparable data and the small sample size of repeated surveys.^19,20In addition to the marked changes in the region''s tobacco industry, the need to address these research gaps is underlined by the fact that the accumulated burden of tobacco‐related disease among men <75 years of age in the FSU is the highest in the world.²¹ More than half of Russian men smoke,^19,20 and estimates indicate that smoking presently accounts for nearly half of male deaths and just <4% of female deaths.²² This work will also further efforts to understand the impacts of privatisation of the tobacco industry, which continues to be promoted by the International Monetary Fund.^4,18In this paper, we used data from the Russia Longitudinal Monitoring Survey (RLMS), a large panel study comprising data collected in 10 rounds between 1992 and 2003, to study trends in smoking and to explore in detail the impact of the entry of TTCs on smoking habits. We hypothesised, based largely on the actions of the privatised tobacco companies now active in Russia, that smoking among women would increase, the age of smoking uptake would fall, and that rates of smoking among women in rural areas would tend to increase towards those already observed in urban areas. In men, we predicted little change in smoking rates, but an increase in educational inequalities in smoking.     

Assessing the impact of smoking cessation services on reducing health inequalities in England: observational study

Objective

NHS stop smoking services are expected to play a key part in achieving the infant mortality and life expectancy health inequality targets in England by reducing smoking prevalence in deprived areas. This paper assesses the extent to which services have made a contribution to reducing inequalities in smoking between 2003–4 and 2005–6.

Methods

Synthetic estimates of baseline smoking prevalence data were compared with national monitoring data about the numbers of smokers in receipt of services and the proportion who self report quitting at four weeks. The social distribution of service recipients and quitters was compared with estimates of smoking prevalence to assess impact on inequalities. Comparisons were made between officially designated disadvantaged areas (the Spearhead Group) and others.

Results

Short‐term cessation rates were lower in disadvantaged areas (52.6%) than elsewhere (57.9%) (p<0.001), but the proportion of smokers being treated was higher (16.7% compared with 13.4%) (p<0.001). The net effect was that a higher proportion of smokers in the most disadvantaged areas reported success (8.8%) than in more advantaged areas (7.8%) (p<0.001). Using the evidence‐based assumption that three‐quarters of short‐term quitters will relapse within one year, the absolute and relative rate gaps in smoking prevalence between Spearhead areas and others are estimated to fall by small but statistically significant amounts from 5.2 and 1.215 (CIs: 1.216 to 1.213) to 5.0 and 1.212 (CIs: 1.213 to 1.210) between 2003–4 and 2005–6.

Conclusion

NHS stop smoking services have probably made a modest contribution to reducing inequalities in smoking prevalence. To achieve government targets, however, requires both the development of more innovative cessation interventions for the most addicted smokers and action to ensure that other aspects of tobacco control policy make a larger contribution to inequality goals.     

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

Objective

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

Design

A five‐year prospective study.

Setting

36 schools in South London, England.

Subjects

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

Main outcome measures

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

Results

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

Conclusions

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

Health consequences of reduced daily cigarette consumption

Objective

To determine the risk of dying from specified smoking‐related diseases and from any cause in heavy smoking men and women (⩾15 cigarettes/day), who reduced their daily cigarette consumption by >50%.

Design

A prospective cohort study.

Setting

Three counties in Norway.

Participants

24 959 men and 26 251 women, aged 20–49 years, screened for risk factors of cardiovascular disease in the mid‐1970s, screened again after 3–13 years, and followed up throughout 2003.

Outcomes

Absolute mortality and relative risks adjusted for confounding variables, of dying from all causes, cardiovascular disease, ischaemic heart disease, all smoking‐related cancer and lung cancer.

Results

With sustained heavy smokers as reference, the smokers of both sexes who reduced their daily consumption (reducers) had the following adjusted relative risks (95% confidence interval (CI)): of dying from any cause, 1.02 (0.84 to 1.22); cardiovascular disease, 1.02 (0.75 to 1.39); ischaemic heart disease, 0.96 (0.65 to 1.41); smoking‐related cancer, 0.86 (0.57 to 1.29); and lung cancer, 0.66 (0.36 to 1.21). The difference in cigarette consumption between two examinations was not a significant predictor of death from any of the causes. A follow‐up from a third screening of the subgroup who were reducers at both second and third examinations (sustained reducers) did not have a lower risk than those who were heavy smokers at all three examinations.

Conclusions

Long‐term follow‐up provides no evidence that heavy smokers who cut down their daily cigarette consumption by >50% reduce their risk of premature death significantly. In health education and patient counselling, it may give people false expectations to advise that reduction in consumption is associated with reduction in harm.Does reduced daily cigarette consumption lead to lower mortality from the serious health consequences of cigarette smoking? In other words, does a reduction in consumption bring about reduction in harm?Numerous population studies have given ample evidence that quitting smoking entirely results in a marked reduction in the ill effects of smoking. Up to now, however, only one large prospective study has explored the long‐term effects of unassisted reduced smoking. Godtfredsen et al^1,2,3,4 have pioneered in this field by following up a population of nearly 20 000 men and women living in Copenhagen, Denmark (the Copenhagen Centre for Prospective Population Studies). After mean observation periods ranging from 13.8 to 18 years, they published their results in a series of articles.The aim of this paper is to determine the risk in heavy smokers who reduced their cigarette consumption by at least 50%, named “reducers”, compared with those who continued as heavy smokers. We report on a Norwegian population of 51 210 men and women, aged 20–49 years, who were examined in the mid‐1970s for cardiovascular disease risk factors and were examined again during the next 3–13 years at least once. These people were followed up throughout 2003 for deaths from serious smoking‐related diseases and from all causes. The mean observation period is 21.2 years, maximum 27 years. A subgroup attended three screenings. This gave us the possibility to compare those who were reducers at the two last screenings (sustained reducers) with those who were heavy smokers at all three screenings (sustained heavy smokers).     

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.