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

Objective

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

Setting and participants

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

Results

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

Conclusion

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

Price and cigarette consumption in Europe

Objective

To analyse the variation in demand for tobacco according to price of cigarettes across the European region.

Design

Cross‐sectional study.

Setting

All the 52 countries of the European region.

Participants

For each European country, data were collected on annual per adult cigarette consumption (2000), smoking prevalence (most recent), retail price of a pack of local and foreign brand cigarettes (around 2000), the gross domestic product adjusted by purchasing power parities, and the adult population (2000).

Main outcome measure

Price elasticity of demand for cigarettes (that is, the change in cigarette consumption according to a change in tobacco price) across all the European countries, estimated by double‐log multiple linear regression.

Results

Controlling for male to female prevalence ratio, price elasticities for consumption were −0.46 (95% confidence interval (CI) −0.74 to −0.17) and −0.74 (95% CI −1.13 to −0.35) for local and foreign brand, respectively. The inverse relation between cigarette price and consumption was stronger in countries not in the European Union (price elasticity for foreign brand cigarettes of −0.8) as compared to European Union countries (price elasticity of −0.4).

Conclusions

The result that, on average, in Europe smoking consumption decreases 5–7% for a 10% increase in the real price of cigarettes strongly supports an inverse association between price and cigarette smoking.     

Youth smoking prevention and tobacco industry revenue

Objectives

Epidemiological surveys make it clear that youth smoking contributes to both current and future tobacco industry revenue: over 80% of adult smokers reportedly began smoking before age 18. This paper estimates annual and lifetime revenue from youth smoking, and highlights the association between declines in youth smoking and declines in tobacco industry revenue.

Main outcome measures

This paper reports the amount of tobacco industry revenue generated by youth smoking at two points in time (1997 and 2002), and describes the distribution of youth generated tobacco income among the major tobacco companies. The authors project the amount of tobacco industry revenue that will be generated by members of two cohorts (the high school senior classes of 1997 and 2002) over the course of their lifetimes.

Results

In 1997, youth consumed 890 million cigarette packs, generating $737 million in annual industry revenue. By 2002, consumption dropped to 541 million packs and revenue increased to nearly $1.2 billion. Fifty eight per cent of youth generated revenue goes to Philip Morris USA, 18% to Lorillard, and 12% to RJ Reynolds. The authors project that, over the course of their lives, the 1997 high school senior class will smoke 12.4 billion packs of cigarettes, generating $27.3 billion in revenue. The 2002 high school senior class is projected to smoke 10.4 billion packs, generating $22.9 billion in revenue over the course of their lives.

Conclusions

Cigarette price increases from 1997 to 2002 have resulted in greater revenue for the tobacco industry, despite declines in youth smoking prevalence. However, in the absence of further cigarette price increases, declines in youth smoking are projected to lead ultimately to a loss of approximately $4 billion in future tobacco industry revenue from a single high school cohort.     

Asian herbal‐tobacco cigarettes: “not medicine but less harmful”?

Objective

To describe the development and health claims of Asian herbal‐tobacco cigarettes.

Methods

Analysis of international news sources, company websites, and the transnational tobacco companies'' (TTC) documents. PubMed searches of herbs and brands.

Results

Twenty‐three brands were identified, mainly from China. Many products claimed to relieve respiratory symptoms and reduce toxins, with four herb‐only products advertised for smoking cessation. No literature was found to verify the health claims, except one Korean trial of an herb‐only product. Asian herbal‐tobacco cigarettes were initially produced by China by the 1970s and introduced to Japan in the 1980s. Despite initial news about research demonstrating a safer cigarette, the TTC analyses of these cigarettes suggest that these early products were not palatable and had potentially toxic cardiovascular effects. By the late 1990s, China began producing more herbal‐tobacco cigarettes in a renewed effort to reduce harmful constituents in cigarettes. After 2000, tobacco companies from Korea, Taiwan, and Thailand began producing similar products. Tobacco control groups in Japan, Taiwan, and Thailand voiced concern over the health claims of herbal‐tobacco products. In 2005, China designated two herbal‐tobacco brands as key for development.

Conclusion

Asian herbal‐tobacco cigarettes claim to reduce harm, but no published literature is available to verify these claims or investigate unidentified toxicities. The increase in Asian herbal‐tobacco cigarette production by 2000 coincides with the Asian tobacco companies'' regular scientific meetings with TTCs and their interest in harm reduction. Asia faces additional challenges in tobacco control with these culturally concordant products that may discourage smokers from quitting.     

Cost of tobacco-related diseases, including passive smoking, in Hong Kong

Background

Costs of tobacco‐related disease can be useful evidence to support tobacco control. In Hong Kong we now have locally derived data on the risks of smoking, including passive smoking.

Aim

To estimate the health‐related costs of tobacco from both active and passive smoking.

Methods

Using local data, we estimated active and passive smoking‐attributable mortality, hospital admissions, outpatient, emergency and general practitioner visits for adults and children, use of nursing homes and domestic help, time lost from work due to illness and premature mortality in the productive years. Morbidity risk data were used where possible but otherwise estimates based on mortality risks were used. Utilisation was valued at unit costs or from survey data. Work time lost was valued at the median wage and an additional costing included a value of US$1.3 million for a life lost.

Results

In the Hong Kong population of 6.5 million in 1998, the annual value of direct medical costs, long term care and productivity loss was US$532 million for active smoking and US$156 million for passive smoking; passive smoking accounted for 23% of the total costs. Adding the value of attributable lives lost brought the annual cost to US$9.4 billion.

Conclusion

The health costs of tobacco use are high and represent a net loss to society. Passive smoking increases these costs by at least a quarter. This quantification of the costs of tobacco provides strong motivation for legislative action on smoke‐free areas in the Asia Pacific Region and elsewhere.     

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

Background

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

Methods

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

Results

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

Conclusion

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

Risk factors for tobacco dependence in adolescent smokers

Objective

To study the incidence of conversion to tobacco dependence (TD) and the prevalence of the TD state in relation to several potential determinants in a sample of adolescent smokers.

Methods

Questionnaires were administered every 3–4 months to document TD symptoms, amount of cigarette consumption, and depression symptoms in a prospective cohort of 1293 grade 7 students in a convenience sample of 10 schools.

Results

Over 54 months of follow‐up, 113 of 344 novice smokers converted to TD. The referent series for the analysis of incidence comprised 823 person‐surveys. The prevalence series included 1673 person‐surveys, contributed by 429 smokers. Conversion to TD and TD status were associated with the intensity of recent (that is, past 3‐month) cigarette consumption (adjusted incidence rate ratio (aIRR) 1.63 (95% confidence interval (CI) 1.36 to 1.97) and adjusted prevalence odds ratio (aPOR) 1.35 (95% CI 1.23 to 2.48) per 100 cigarettes per month), slowest CYP2A6 activity (aIRR 4.19 (95% CI 1.38 to 12.76) and aPOR 2.30 (95% CI 1.29 to 4.09)), depression score (aIRR 1.61 (95% CI 1.17 to 2.21) and aPOR 1.47 (95% CI 1.22, 1.75) per 1‐unit change). Additional determinants included, for conversion to TD, time since onset of cigarette use (aIRR 0.76 (95% CI 0.58 to 1.00) per year) and, for the TD state, positive TD status six months ago (aPOR 3.53 (95% CI 2.41 to 5.19)).

Conclusions

TD risk in adolescents is associated with intensity of recent cigarette consumption, while the role of more distant cigarette consumption appears small; subjects with slow nicotine metabolism and those with more depression symptoms are at increased risk of becoming tobacco dependent. The risk of being tobacco dependent is considerably higher in subjects who had previously developed the TD state.     

An ethnographic study of tobacco control in hospital settings

Background

Tobacco control in hospital settings is characterised by a focus on protection strategies and an increasing expectation that health practitioners provide cessation support to patients. While practitioners claim to have positive attitudes toward supporting patient cessation efforts, missed opportunities are the practice norm.

Objective

To study hospital workplace culture relevant to tobacco use and control as part of a mixed‐methods research project that investigated hospital‐based registered nurses'' integration of cessation interventions.

Design

The study was conducted at two hospitals situated in British Columbia, Canada. Data collection included 135 hours of field work including observations of ward activities and designated smoking areas, 85 unstructured conversations with nurses, and the collection of patient‐care documents on 16 adult in‐patient wards.

Results

The findings demonstrate that protection strategies (for example, smoking restrictions) were relatively well integrated into organisational culture and practice activities but the same was not true for cessation strategies. An analysis of resources and documentation relevant to tobacco revealed an absence of support for addressing tobacco use and cessation. Nurses framed patients'' tobacco use as a relational issue, a risk to patient safety, and a burden. Furthermore, conversations revealed that nurses tended to possess only a vague awareness of nicotine dependence.

Conclusion

Overcoming challenges to extending tobacco control within hospitals could be enhanced by emphasising the value of addressing patients'' tobacco use, raising awareness of nicotine dependence, and improving the availability of resources to address addiction issues.     

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.     

Industry sponsored anti-smoking ads and adolescent reactance: test of a boomerang effect

Objective

To examine whether adolescents'' exposure to youth smoking prevention ads sponsored by tobacco companies promotes intentions to smoke, curiosity about smoking, and positive attitudes toward the tobacco industry.

Design

A randomised controlled experiment compared adolescents'' responses to five smoking prevention ads sponsored by a tobacco company (Philip Morris or Lorillard), or to five smoking prevention ads sponsored by a non‐profit organisation (the American Legacy Foundation), or to five ads about preventing drunk driving.

Setting

A large public high school in California''s central valley.

Subjects

A convenience sample of 9th and 10th graders (n  =  832) ages 14–17 years.

Main outcome measures

Perceptions of ad effectiveness, intention to smoke, and attitudes toward tobacco companies measured immediately after exposure.

Results

As predicted, adolescents rated Philip Morris and Lorillard ads less favourably than the other youth smoking prevention ads. Adolescents'' intention to smoke did not differ as a function of ad exposure. However, exposure to Philip Morris and Lorillard ads engendered more favourable attitudes toward tobacco companies.

Conclusions

This study demonstrates that industry sponsored anti‐smoking ads do more to promote corporate image than to prevent youth smoking. By cultivating public opinion that is more sympathetic toward tobacco companies, the effect of such advertising is likely to be more harmful than helpful to youth.     

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.     

A group randomised trial of two methods for disseminating a smoking cessation programme to public antenatal clinics: effects on patient outcomes

Objective

To assess the differential effectiveness of two methods of disseminating a smoking cessation programme to public hospital antenatal clinics.

Design

Group randomised trial.

Setting

22 antenatal clinics in New South Wales, Australia.

Intervention

Clinics were allocated to a simple dissemination (SD) condition (11 clinics) which received a mail‐out of programme resources or to an intensive dissemination (ID) condition (11 clinics) which included the mail‐out plus feedback, training, and ongoing support with midwife facilitator.

Main outcome measures

Independent cross sectional surveys of women on a second or subsequent visit undertaken pre‐dissemination and 18 months after dissemination. Outcomes were: (1) levels of smoking status assessment by clinic staff; (2) proportion of women identifying as having been smokers at their first visit who reported receiving cessation advice; (3) proportion of these women who had quit (self report and expired air carbon monoxide (CO)); and (4) smoking prevalence among all women (self report and CO).

Subjects

5849 women pre‐dissemination (2374 SD, 3475 ID) and weighted sample of 5145 women post‐dissemination (2302 SD, 2843 ID).

Results

There were no significant differences between the groups on change on any outcome. Change in either group was minimal. In the post‐dissemination survey, the cessation proportions were 6.4% (SD) and 10.5% (ID).

Conclusions

Relatively modest strategies for encouraging incorporation of smoking cessation activities into antenatal care were not effective in the long term. Alternative strategies should be implemented and evaluated. The findings reinforce the importance of a whole population approach to tobacco control.     

The fraction of ischaemic heart disease and stroke attributable to smoking in the WHO Western Pacific and South-East Asian regions

Background

Tobacco will soon be the biggest cause of death worldwide, with the greatest burden being borne by low and middle‐income countries where 8/10 smokers now live.

Objective

This study aimed to quantify the direct burden of smoking for cardiovascular diseases (CVD) by calculating the population attributable fractions (PAF) for fatal ischaemic heart disease (IHD) and stroke (haemorrhagic and ischaemic) for all 38 countries in the World Health Organization Western Pacific and South East Asian regions.

Design and subjects

Sex‐specific prevalence of smoking was obtained from existing data. Estimates of the hazard ratio (HR) for IHD and stroke with smoking as an independent risk factor were obtained from the ∼600 000 adult subjects in the Asia Pacific Cohort Studies Collaboration (APCSC). HR estimates and prevalence were then used to calculate sex‐specific PAF for IHD and stroke by country.

Results

The prevalence of smoking in the 33 countries, for which relevant data could be obtained, ranged from 28–82% in males and from 1–65% in females. The fraction of IHD attributable to smoking ranged from 13–33% in males and from <1–28% in females. The percentage of haemorrhagic stroke attributable to smoking ranged from 4–12% in males and from <1–9% in females. Corresponding figures for ischaemic stroke were 11–27% in males and <1–22% in females.

Conclusions

Up to 30% of some cardiovascular fatalities can be attributed to smoking. This is likely an underestimate of the current burden of smoking on CVD, given that the smoking epidemic has developed further since many of the studies were conducted.     

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.     

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.     

Mortality, morbidity and costs attributable to smoking in Germany: update and a 10-year comparison

Objective

To assess the negative health consequences and associated costs of cigarette smoking in Germany in 2003 and to compare them with the respective results from 1993.

Methods

The number of deaths, years of potential life lost (YPLL), direct medical and indirect costs caused by active cigarette smoking in Germany in 2003 is estimated from a societal perspective. The method is similar to that applied by Welte et al, who estimated the cost of smoking in Germany in 1993. Therefore, a direct comparison of the results was possible. Methodological and data differences between these two publications and their effect on the results are analysed.

Results

In 2003, 114 647 deaths and 1.6 million YPLL were attributable to smoking. Total costs were €21.0 billion, with €7.5 billion for acute hospital care, inpatient rehabilitation care, ambulatory care and prescribed drugs; €4.7 billion for the indirect costs of mortality; and €8.8 billion for costs due to work loss days and early retirement. From 1993 to 2003, the proportionate mortality attributable to smoking remained relatively stable, rising from 13.0% to 13.4%. The smoking‐attributable deaths in men is lowered by 13.7% whereas that in women increased by 45.3%. Total real direct costs rose by 35.8%, and total real indirect costs declined by 7.1%, rendering an increase of 4.7% to real total costs. Accountable factors are changes in cigarette smoking prevalence and in disease‐specific mortality and morbidity, as well as a rise in general healthcare expenditure.

Conclusions

Despite the growing knowledge about the hazards of smoking, the smoking‐attributable costs increased in Germany. Further, female mortality attributable to smoking is much higher than it was in 1993.As a result of the devastating health consequences of smoking, many countries have implemented anti‐smoking measures. For example, Ireland and Italy banned smoking in all public buildings and at all workplaces, including pubs and restaurants. Several publications have shown that Germany is still rather friendly to the tobacco industry.¹ This is also supported by recent decisions not to implement a smoking ban or to prohibit smoking in all public places. However, Germany increased the tax on tobacco products three times since 2004, which decreased cigarette sales and smoking prevalence in the age group 12–17 years.^2,3The first cost‐of‐smoking study for Germany used 1993 as the reference year,⁴ and was published by some of us. Since then, three other studies have been published: one is by Ruff et al,⁵ which cannot be used for comparison because of a lack of methodological transparency, and two by Wegner et al,^6,7 which considered only indirect costs. Thus, costs of smoking can be compared with only the first study.This study presents the most recent estimate for both direct and indirect costs of cigarette smoking in Germany, based on the latest available data and referring to the year 2003. As a similar method was applied, costs of smoking can be directly compared between 1993 and 2003.     

Smoking in Scottish youths: personal income, parental social class and the cost of smoking

Objective

To examine the relation of young people''s personal income and parental social class with smoking from early to mid adolescence.

Design

Longitudinal, school based, study of a cohort of 2586 eleven year‐olds followed up at ages 13 and 15.

Setting

West of Scotland.

Participants

93% baseline participation, reducing to 79% at age 15.

Main outcome measures

Ever smoked (age 11), current and daily smoking (ages 13 and 15) and the proportion of income spent on tobacco (13 and 15) based on recommended retail prices of usual brands.

Results

Strong independent effects of parental social class and personal income were found at 11 years, both reducing with age. The higher incomes of lower class participants attenuated the social class effect on smoking at ages 11 and 13, but not at 15. Analysis within class groups showed variation in the effect of income on smoking, being strongest among higher class youths and weak or non‐existent among lower class youths. This was despite the fact that the proportion of weekly income apparently spent on tobacco was greater among lower class youths.

Conclusions

The results confirm the importance of personal income and parental social class for youth smoking, but they also show that personal income matters more for those from higher class backgrounds. This suggests both that lower class youths have greater access to tobacco from family and friends and to cheaper sources of cigarettes from illegal sources. This complicates the relation between fiscal policies and smoking and might have the unintended consequence of increasing class differentials in youth smoking rather than the reverse.     

Reconsidering stress and smoking: a qualitative study among college students

Background

Although it is widely acknowledged among adult smokers that increases in smoking are often precipitated by stressful events, far less attention has been given to smoking during times of stress among youth.

Aims

To address this gap by drawing attention to the social utility of smoking in contexts associated with stress among college students.

Design

Face‐to‐face semistructured interviews with college freshmen at a large midwestern university in the US.

Participants

Male and female low‐level smokers (n = 24), defined as those who reported regular weekday smoking (typically 3–4 cigarettes a day) and smoking at parties on weekends, were interviewed once in person. In addition, 40 brief interviews with smokers were conducted during final examination.

Measurements

Interviews focused on a range of issues including current smoking behaviour and reasons for smoking. As part of the interview, students were given a deck of cards that listed a range of reasons for smoking. Participants were asked to select cards that described their smoking experience in the past 2 weeks. Those who selected cards that indicated smoking when stressed were asked to explain the reasons why they did so.

Results

A review of qualitative responses reveals that smoking served multiple functions during times of stress for college students. Cigarettes are a consumption event that facilitates a brief social interaction during study times when students feel isolated from their friends. Cigarettes also serve as an idiom of distress, signalling non‐verbally to others that they were stressed. Students described smoking to manage their own stress and also to help manage “second‐hand stress” from their friends and classmates.

Conclusions

Moving away from an individual‐focused analysis of stress to a broader assessment of the social contexts of smoking provides a more nuanced account of the multifunctionalilty of cigarettes in students'' lives. Qualitative research draws attention to issues including the need for smoking and socialising during examination time, smoking as a way to take a break and refocus, notions of second‐hand stress and smoking to manage social relationships.In the past decade, several US‐based studies have reported significant levels of smoking among college students, with approximately 30% of college students reporting having smoked in the past 30 days, and 40% reporting having smoked in the past year.^1,2 Studies have found that a majority of college students who smoke are social smokers, meaning that they smoke more often with others than when alone, particularly when drinking, and that they smoke at low levels.^3,4 To understand better the patterns of low‐level tobacco use, qualitative research was conducted to examine closely the contexts in which students smoked. It has been suggested that a better understanding of the social context of smoking may help enhance tobacco control research and practice.⁵ Two broad contexts that begged consideration were positive social contexts in which tobacco use occurred (such as parties where alcohol was consumed), and contexts associated with stress, be this stressful life events (such as the taking of exams) or stressful events related to the management of social relationships and shifts in identity at this time of transition in life.This article highlights major findings of qualitative research on smoking in contexts associated with stress among college students. It is well established in the general population that increases in smoking are often precipitated by stressful events.^6,7 We draw attention to the social utility of smoking in contexts associated with stress, acknowledging that tobacco use also has psychological and physiological effects when used as a form of stress management and self‐medication.Three major issues guided the research: (1) to explore the extent to which students use smoking as a multifunctional tool for stress management; (2) to determine whether students use smoking as an idiom of distress and a means of showing empathy when a friend is under stress; and (3) to provide details on the complex of motivations that lead students to smoke during examination time.