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

Objective

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

Methods

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

Results

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

Conclusions

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

Legislation reduces exposure to second-hand tobacco smoke in New Zealand bars by about 90%

Aim

To measure exposure to second‐hand smoke (SHS) in New Zealand bars before and after comprehensive smoke‐free legislation enacted on 10 December 2004.

Methods

Cotinine is the main specific metabolite of nicotine and a well‐established biomarker for SHS exposure. We measured cotinine levels in saliva of non‐smoking volunteers before and after a 3 h visit to 30 randomly selected bars in 3 cities across the country. Two measures of cotinine before the smoke‐free law change during winter and spring 2004, and two follow‐up measurements in the same volunteers and venues during winter and spring 2005, were included.

Results

Before the smoke‐free law change, in all bars and in all volunteers, exposure to SHS was evident with an average increase in saliva cotinine of 0.66 ng/ml (SE 0.03 ng/ml). Increases in cotinine correlated strongly with the volunteers'' subjective observation of ventilation, air quality and counts of lit cigarettes. However, even venues that were judged to be “seemingly smoke free” with “good ventilation” produced discernable levels of SHS exposure. After the law change, there remained some exposure to SHS, but at much lower levels (mean saliva cotinine increase of 0.08 ng/ml, SE 0.01 ng/ml). Smoking indoors in bars was almost totally eliminated: in 2005 only one lit cigarette was observed in 30 visits.

Conclusions

Comprehensive smoke‐free legislation in New Zealand seems to have reduced exposure of bar patrons to SHS by about 90%. Residual exposures to SHS in bars do not result from illicit smoking indoors.Before December 2004, smoking was prohibited in most, but not all, workplaces in New Zealand. Bars, restaurants and hotels were not required to be smoke free. This changed on 10 December 2004 when the Smokefree Environments Amendment Act 2003 came into force. Since that time, smoking is not permitted in any indoor place of work. After Ireland, which passed its legislation in March 2004, New Zealand was one of the first countries to introduce national, comprehensive smoke‐free legislation.The purpose of this study was to measure the impact of this legislation on personal exposures to second‐hand smoke (SHS) in New Zealand bars. Previous papers^1,2,3 have described exposures of bar workers in Ireland, New York and Scotland before and after legislation. The effects of reduced exposures to SHS on the respiratory health of employees in this industry have also been documented.^3,4 However, we know of no other study that has examined the effects of smoke‐free laws on exposures of the patrons of bars and hotels. In an earlier publication,⁵ we have described in greater detail the analytical methods and findings at baseline.     

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

Objective

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

Data sources

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

Study selection

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

Data extraction

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

Data synthesis

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

Conclusions

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

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

Objective

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

Methods

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

Results

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

Conclusions

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

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

Objective

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

Methods

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

Results

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

Conclusion

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

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

Objective

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

Data sources

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

Study selection

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

Data extraction

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

Data synthesis

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

Conclusions

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

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

Objective

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

Design

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

Participants

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

Main outcome measures

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

Results

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

Conclusions

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

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

Objective

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

Design

Cross‐sectional survey.

Setting

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

Subjects

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

Results

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

Conclusions

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

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

Study objective

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

Design

A long‐term prospective cohort study.

Setting

Zutphen, The Netherlands.

Participants

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

Measurements

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

Main results

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

Conclusions

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

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

Objective

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

Design

Longitudinal study with mailed questionnaires.

Participants/setting

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

Main outcome measures

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

Results

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

Conclusions

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

The US Public Health Service "treating tobacco use and dependence clinical practice guidelines" as a legal standard of care

Background

The important factors in evaluating the role of clinical practice guidelines (CPGs) in medical malpractice litigation have been discussed for several years, but have focused on broad policy implications rather than on a concrete example of how an actual guideline might be evaluated. There are four items that need to be considered in negligence torts: legal duty, a breach of that duty, causal relationship between breach and injury, and damages.

Objective

To identify the arguments related to legal duty.

Results

The Treating Tobacco Use and Dependence (revised 2000) CPG, sponsored by the US Public Health Service, recommends effective and inexpensive treatments for nicotine addiction, the largest preventable cause of death in the US, and can be used as an example to focus on important considerations about the appropriateness of CPGs in the judicial system. Furthermore, the failure of many doctors and hospitals to deal with tobacco use and dependence raises the question of whether this failure could be considered malpractice, given the Public Health Service guideline''s straightforward recommendations, their efficacy in preventing serious disease and cost‐effectiveness.

Conclusion

Although each case of medical malpractice depends on a multitude of factors unique to individual cases, a court could have sufficient basis to find that the failure to adequately treat the main cause of preventable disease and death in the US qualifies as a violation of the legal duty that doctors and hospitals owe to patients habituated to tobacco use and dependence.The use of clinical practice guidelines (CPGs)—sets of suggestions reflecting informed opinion on how to treat illnesses or conditions generally derived from scientific studies comparing the effectiveness of various clinical approaches^1,2—as evidence to support expert testimony in medical malpractice litigation or as legal standards of care approved by the court has been discussed for several years.^{3,4,5,6,7,8,9,10,11} These discussions have focused on broad policy implications, such as simplifying medical malpractice trials, eliminating expert witness bias or reducing doctors'' practice of defensive medicine, rather than giving concrete examples of how actual guidelines might be evaluated by courts.Despite the strong evidence that a doctor''s intervention is an effective form of smoking cessation treatment,^12,13,14 in 2003, only 63.6% of US smokers who had a routine check‐up that year were advised by a doctor to quit smoking.¹⁵ Furthermore, although treatment of nicotine addiction is often considered to be “prevention”, there is growing evidence that it should be considered to be “treatment”, as smoking cessation as a treatment is as effective or more effective than other treatments recommended for heart failure.^{16,17,18,19,20} This failure of many doctors and hospitals to deal with tobacco use and dependence despite the availability of effective treatment raises the question of whether this failure could be considered malpractice. An important element of answering this question requires an analysis of a clinician''s duty to adequately treat a patient who smokes.     

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

Objective

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

Design

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

Setting

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

Subjects

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

Main outcome measures

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

Results

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

Conclusions

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

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

Objective

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

Setting and Participants

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

Results

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

Conclusions

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

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

Background

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

Aim

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

Methods

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

Results

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

Conclusions

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

Prevalence of smoking among major movie characters: 1996-2004

Background

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

Objective

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

Design and methods

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

Results

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

Conclusions

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

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

Objective

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

Design

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

Setting

General population of Germany.

Participants and methods

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

Outcome measures

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

Results

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

Conclusions

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

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.     

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

Objective

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

Design

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

Methods

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

Results

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

Conclusions

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