Centre for Population Health Sciences
University of Edinburgh
A systematic review of the effectiveness
of policies and interventions to reduce
socio-economic inequalities in smoking
among youth.
Report March 2013
Amanda Amos
Tamara Brown
Stephen Platt
SILNE - Tackling socio-economic inequalities in smoking: learning from natural experiments by time trend
analyses and cross-national comparisons
1
Project team
Amanda Amos, Professor of Health Promotion
Tamara Brown, Research Fellow
Stephen Platt, Professor of Health Policy Research
Centre for Population Health Sciences
School of Molecular, Genetic and Population Health Sciences
The University of Edinburgh
Medical School
Teviot Place
Edinburgh
Scotland
EH8 9AG
Phone: (+44)-(0)131-650-3237
Fax: (+44)-(0)131-650-6909
Acknowledgements
The project team would like to thank members of the SILNE project and members of the European
Network for Smoking and Tobacco Prevention (ENSP) who helped in the search for grey literature.
2
Table of Contents
EXECUTIVE SUMMARY................................................................................................................ 4
1
INTRODUCTION ....................................................................................................................... 6
1.1
Background ........................................................................................................................................... 6
1.2
Aims and objectives .............................................................................................................................. 8
2
METHODS ................................................................................................................................ 10
2.1
Search strategy ................................................................................................................................... 10
2.2 Study selection.................................................................................................................................... 11
2.2.1
Study selection process ................................................................................................................... 11
2.2.2
Inclusion criteria .............................................................................................................................. 11
2.2.3
Data extraction ................................................................................................................................ 13
2.2.4
Quality assessment .......................................................................................................................... 13
2.2.5
Data synthesis .................................................................................................................................. 14
3
RESULTS .................................................................................................................................. 16
3.1
Introduction ........................................................................................................................................ 16
3.2 Impact of population-level policies and interventions on smoking inequalities in youth .................... 21
3.2.1 Smoking restrictions in cars, schools, workplaces and other public places .......................................... 21
3.2.1
Controls on advertising, promotion and marketing of tobacco....................................................... 29
3.2.2
Mass media campaigns .................................................................................................................... 32
3.2.3
Increases in price/tax of tobacco products ...................................................................................... 33
3.2.4
Controls on access to tobacco products .......................................................................................... 37
3.2.5
School-based prevention ................................................................................................................. 43
3.2.6
Multiple policy interventions ........................................................................................................... 48
3.3
Impact of individual level cessation services and support on smoking inequalities in youth ............... 51
4
DISCUSSION ............................................................................................................................ 55
5
CONCLUSIONS ........................................................................................................................ 60
6
REFERENCES .......................................................................................................................... 61
7
APPENDICES ........................................................................................................................... 65
7.1
7.2
7.3
7.4
7.5
7.6
7.7
7.8
7.9
Appendix A Search strategies: electronic searches, handsearching and searching for grey literature . 65
Appendix B WHO European countries and other stage 4 countries ..................................................... 77
Appendix C Inclusion/exclusion form .................................................................................................. 78
Appendix D Included studies-Youth .................................................................................................... 80
Appendix E Excluded studies-Youth .................................................................................................... 83
Appendix F Data extraction - Youth .................................................................................................... 86
Appendix G Quality assessment ........................................................................................................ 152
Appendix H Summary of equity impact of youth polices/interventions ............................................ 154
Appendix I Equity impact model of youth policies/interventions by SES measure ............................ 161
3
EXECUTIVE SUMMARY

Smoking is the single most important preventable cause of premature mortality in
Europe and a major cause of inequalities in health.

While there is good evidence on what types of tobacco control policies are effective
in reducing smoking uptake in young people, little is known about what is effective
in reducing inequalities in smoking in young people.

The aim of this report was to undertake a systematic review of the effectiveness of
policies and interventions in reducing socioeconomic inequalities in smoking among
youth.

The systematic review included primary studies involving young people (aged 1125), published between January 1995 and January 2013, which assessed the impact of
smoking prevention policies and interventions, and smoking cessation support, by
socioeconomic status.

Any type of tobacco control intervention, of any length of follow-up, with any type
of smoking-related outcome was included. A broad range of smoking related
outcomes and socioeconomic variables was included.

The equity impact(s) of each intervention/policy on smoking-related outcomes was
assessed as either being positive (reduced inequality), neutral (no difference by
socioeconomic status) or negative (increased inequality).

Very few studies were found to have assessed the equity impact of the
policy/intervention and all were from tobacco control. Thirty-three studies were
included in the review, of which 31 were population level tobacco control
policies/interventions and two were individual level cessation support interventions.
The types of policies/intervention included were: smoking restrictions in cars,
schools, workplaces and other public places (9); controls on the advertising,
promotion and marketing of tobacco (3); mass media campaigns (1); increases in
price/tax of tobacco products (6); controls on access to tobacco products (5); schoolbased prevention programmes (5); multiple policy interventions (3) and individual
cessation support (2). (One study was included in two types of policies/intervention
category).

Assessing the overall equity impact of different types of interventions/policies was
complicated by studies having different outcome measures and length of follow-up.
However, overall there was no consistent equity effect for each type of tobacco
4
control policy/intervention. Most interventions had, on balance, either a negative (11)
or neutral (15) equity impact. One had a mixed impact.

Only six of the 31 population level prevention studies showed the potential to
produce a positive equity impact. These included three US studies of increasing the
price/tax of tobacco products, two US studies on age-of-sales laws and one UK study
of a smoking prevention programme (ASSIST). The two smoking cessation studies
both used text-messaging interventions. The New Zealand study had a short-term
neutral equity impact and the US study had a short-term positive equity impact.

Very few studies have assessed the equity impact of policies and interventions on
smoking prevention or cessation in youth. There is therefore little available evidence
to inform tobacco control policy and interventions that are aimed at reducing
socioeconomic inequalities in youth smoking. There is a need to strengthen the
evidence base for the equity impact of tobacco control interventions which target
young people.
5
1 INTRODUCTION
1.1 Background
Smoking prevalence rates differ substantially within European countries according to
people’s educational level, occupational class and income level; and smoking is the largest
single contributor to socioeconomic inequalities in mortality in Northern Europe. The
patterning of smoking by socioeconomic status (SES) within a country reflects the stage of
the tobacco epidemic in that country. In general smoking is initially taken up by higher SES
groups, followed by lower SES groups. Higher SES groups are then the first to show
declines in smoking, followed by lower SES groups.1 The tobacco epidemic is also gendered
in that men first take up smoking, followed by women.2 Most countries in the European
Union (EU) are characterised as being in the fourth (last) stage of the epidemic. In these
countries lower SES groups have higher rates of smoking prevalence, higher levels of
cigarette consumption and lower rates of quitting.3;4 Some EU countries are at a slightly
earlier stage. This is reflected in the differential patterning of smoking by SES and gender,
where the clear relationship between low SES and smoking found in men is only starting to
emerge in women.
SES is an important determinant of smoking uptake in young people. Parental smoking
status, which is related to SES, is a predictor of smoking uptake in young people.5;6
However, the relationship between SES and smoking uptake is generally less clear than that
for adult smoking, reflecting the difficulty of assessing SES among adolescents. Commonly
used adult measures of SES such as educational attainment, occupation and income are not
relevant for adolescents. However, some surveys have developed measures of youth SES,
including the Health Behaviour in School-aged Children survey (HBSC). The HBSC, which
is carried out in 39 countries, mostly in Europe, uses a measure of ‘family affluence’ (FAS)
to assess participants’ SES. The 2005/6 survey found that, as with adult smoking, the
relationship between youth smoking and SES varied between countries depending on their
stage of the tobacco epidemic and gender.7 Low family affluence was significantly
associated with weekly smoking among girls in nearly half the countries, but in only a few
countries among boys. This pattern was strongest for girls in countries in stage four of the
tobacco epidemic (North and Western Europe, Canada, USA). In Eastern and Southern
Europe (mostly Stage 3 countries such as Ukraine, Estonia, Russia), family affluence was
generally not associated with smoking. Fifteen year old girls from low affluent families in
North Europe were also more likely to have started smoking earlier i.e. at age 13 or younger.
6
Since the 1990s, many European countries have implemented new and stronger tobacco
control policies including smokefree legislation covering smoking in public places, bans on
tobacco advertising and promotion, and tax increases. There is good evidence on what is
effective in reducing adult smoking amongst the general population. A review of the
international evidence by the World Bank in 20038 identified six cost-effective policies
which they concluded should be prioritised in comprehensive tobacco control programmes:






price increases through higher taxes on cigarettes and other tobacco products
including measures to combat smuggling
comprehensive smokefree public and work places
better consumer information including mass media campaigns
comprehensive bans on the advertising and promotion of all tobacco products, logos
and brand names
large, direct health warnings on cigarette packs and other tobacco products
treatment to help dependent smokers stop, including increased access to medications
These priorities have been endorsed by World Health Organisation (WHO)9 and form the
basis of the Framework Convention on Tobacco Control (FCTC), the first international
public health treaty.10
Reviews on smoking prevention in young people have endorsed the importance of these
measures for preventing smoking uptake, though the evidence on effective youth cessation
support is less strong than that for adults.5 The recent US Surgeon General’s report on
Preventing Tobacco Use Among Youth and Young Adults6 stated that the evidence is
sufficient to conclude that mass media campaigns, comprehensive community programmes,
comprehensive statewide tobacco control programmes and increases in cigarette prices
reduce smoking initiation and prevalence in youth (and taxes also reduce prevalence among
young adults). They also concluded that certain types of school programmes can produce at
least short-term effects in reducing youth smoking prevalence.
What is much less certain is how ‘real world’ policies and interventions that reduce overall
smoking prevalence within the general population impact on socioeconomic inequalities in
smoking. Tackling these socioeconomic inequalities in smoking is central to reducing the
health inequalities gap and is the fundamental underpinning aim of the “SILNE” project,11
“Tackling socioeconomic inequalities in smoking: learning from natural experiments by time
trend analyses and cross-national comparisons”. SILNE is a three-year European project, coordinated by the University of Amsterdam, Department of Public Health, Academic Medical
Centre, the Netherlands, with financial support from the European Commission Seventh
7
Framework Programme; ‘Developing methodologies to reduce inequities in the determinants
of health’ programme (grant agreement no. 278273). The SILNE project involves twelve
European partners who will deliver the seven work packages which make up the project.
This systematic review is part of Work Package 6 of the SILNE project.
There have been two previous reviews on the equity impact of tobacco control
interventions.12;13 In 2008 the Centre for Reviews and Dissemination (CRD) at the
University of York published a systematic review of the equity impact of tobacco control on
young people and adults,12 focussing on population level interventionsa (not individual-level
smoking cessation interventions) published up to January 2006. In 2010 the Department of
Health’s Policy Research Programme, through the Public Health Research Consortium
(PHRC), funded a study of tobacco control and inequalities in health in England.13 This
study included a review of the evidence on the effectiveness of interventions to reduce adult
smoking amongst socioeconomically deprived populations, which built on the CRD review
and included evidence published from January 2006 until September 2010. It included both
population-level interventions and individual-level cessation support interventions. The
PHRC review concluded that there was limited evidence to inform tobacco control policy
and interventions that are aimed at reducing socioeconomic inequalities in smoking
behaviour.
While considerable progress has been made in tobacco control in many countries in the EU
in recent years, there is considerable variation in the strength and comprehensiveness of
tobacco control policies and their implementation.14 However, while overall smoking
prevalence is reducing; the social gradient is not. Addressing inequalities in smoking is a key
public health priority, starting with improving our understanding of the equity impact of
existing policies and interventions.
1.2 Aims and objectives
The overarching aims of Work Package 6 are to undertake a systematic review of the
effectiveness of policies and interventions to reduce socioeconomic inequalities in smoking
among youth and adults, and to assess the implications of this evidence for understanding the
effects of such policies and interventions in countries within the EU.
Population level control interventions have been defined as ‘those applied to populations, groups, areas, jurisdictions or
institutions with the aim of changing the social, physical, economic or legislative environments to make them less
conducive to smoking.’
a
8
This report focuses on the findings of the systematic review of the effectiveness of policies
and interventions to reduce socio-economic inequalities in smoking among youth. It has two
objectives:
1. To identify and review the strengths and limitations of the published evidence on the
effectiveness of policies (at the population level) to prevent and/or reduce smoking
amongst
socioeconomically
deprived
populations
as
compared
to
higher
socioeconomic groups, and implications for European and other countries at stage 4 b
of the tobacco epidemic.
2. To identify and review the strengths and limitations of the published evidence on
the effectiveness of tobacco control interventions (at the individual level) to prevent
and/or reduce smoking amongst socioeconomically deprived populations as
compared to higher socioeconomic groups, and implications for European and other
countries at stage 4 of the tobacco epidemic.
b
The 4 stages of the tobacco epidemic are described: Stage 1, characterised by low uptake of smoking and low cessation
rates; Stage 2, characterised by increases in smoking rates among women and an increase to 50% or more among men;
Stage 3, typified by a marked downturn in smoking prevalence among men, and a plateau and then gradual decline in
women; and Stage 4, marked by further declines in smoking prevalence among men and women, with numbers of new
smokers starting to decrease. Richmond, R. Addiction 2003;98 (5).
9
2 METHODS
2.1 Search strategy
A comprehensive search strategy was developed to encompass studies published from
January 1995 to May 2012. The search included published papers identified through
searches of relevant electronic databases, and papers pending publication identified through
handsearching of key journals, and contacting key tobacco control experts. A database of
relevant references was produced using Reference Manager 12 software package. Details of
the search strategies, including hand searching and searching for grey literature, can be
found in Appendix A.
The following databases were searched:

BIOSIS

CINAHL Plus

Cochrane Library (Cochrane Database of Systematic Reviews; Database of Abstracts
of Reviews of Effects; Cochrane Central Register of Controlled Trials; Health
Technology Assessment Database)

EMBASE

ERIC

Conference Proceedings Citation Index

MEDLINE

PsycINFO

Science Citation Index Expanded

Social Science Citation Index.
This search was supplemented by handsearching of four key journals from January 2012 to
the end of July 2012 to identify articles ‘in press’ published on the journals’ websites:

Addiction

Nicotine and Tobacco Research

Social Science and Medicine

Tobacco Control
10
Three key reviews were also searched for relevant primary studies: the York review,12 the
PHRC review,13 and a report by the US Surgeon General on Preventing Tobacco Use
Among Youth and Young Adults6 which was published during the production of this review.
Bibliographies of included studies were also searched for further relevant studies. Members
of SILNE and members of the ENSP were asked to identify any relevant studies not
identified by the extensive searching of the electronic databases and the handsearching.
Update search
The electronic search strategy was rerun in the three databases which yielded the majority of
the included studies from the initial search (EMBASE, MEDLINE and PsycINFO) to
identify studies published between May 2012 and end of January 2013. In February 2013,
the same four key journals were handsearched to identify articles published on the journals’
websites (but not yet listed in electronic databases) for publication in journal issues up to
April 2013. See appendix A for details.
2.2 Study selection
2.2.1 Study selection process
Articles retrieved from the searches were screened by title and abstract, to identify potentially
relevant studies. An initial screen of the first 200 references imported into Reference Manager
from MEDLINE were screened by title and abstract by two reviewers (AAc and TBd) to clarify
inclusion and exclusion criteria and establish consistency. The remaining references were screened
by title and abstract by one reviewer (TB) and checked by a second reviewer (AA). A second
screen of full text articles was then carried out by one reviewer (TB) and checked by a
second reviewer (AA). Any disagreements between reviewers were resolved by discussion at
each stage and, if necessary, a third reviewer (SPe) was consulted.
2.2.2 Inclusion criteria
All primary study designs based in a WHO European country or non-European country at
stage 4 of the tobacco epidemic were eligible for inclusion (see Appendix B for list of
included countries).
The inclusion ages for the youth review were 11-25 years and, for the adult review, 18+
years. Smoking uptake continues until around the age of 25 years, which is why this cut-off
c
AA=Amanda Amos
TB=Tamara Brown
e
SP=Stephen Platt
d
11
was chosen for the youth review; it also enables comparisons to be made across studies set
within different countries where age of leaving secondary education can vary considerably.
However, many adult focused interventions target smokers aged 18 years and older. Thus 18
years and older was used to categorise adult interventions. In the rare cases where studies
straddled both age categories they were included in both the youth and adult reviews.
When the inclusion ages for the youth review were defined this was with a focus on studies
relating to smoking initiation. This inclusion criterion was later modified for studies
evaluating smokefree legislation in light of studies that included all ages of children.
In order to assess the equity impact of tobacco control measures in the general population,
we included both population-level policies and interventions, and individual-level
interventions which aimed to reduce adult smoking or to prevent youth starting to smoke.
Studies of population-level policies and interventions cover secondhand smoke (SHS)
exposure by SES, the strength or reach of policy coverage by SES, and the impact by SES of
the 'voluntary' adoption/spread/strength of smokefree policies, i.e., where countries do not
have comprehensive legislation.
In order to be included in the reviews an article must have assessed the equity impact of a
tobacco control intervention or policy, and have presented results with a differentiation
between high and low socioeconomic groups. In other words, the review only included
studies which reported differential smoking-related outcomes for at least two socioeconomic
groups.
Any type of tobacco control intervention, of any length of follow-up, with any type of
smoking-related outcome was included. A broad range of smoking related outcomes, either
self-reported or observed/validated, was included: initiation and cessation rates, quit
attempts, intentions to smoke/quit, prevalence, exposure to SHS, policy reach, social
norms/attitudes, use of quitting services and sources of smoking (i.e. vending machines).
Socioeconomic variables included income, education, and occupational social class, arealevel socio-economic deprivation (including neighbourhood and school-level SES), housing
tenure, subjective social status and health insurance. Proxy measures for youth SES were
also included, such as free school meals, parental educational, occupation and income.
12
A measure of SES had to be reported in the abstract of the electronic references in order to
be included.
Evidence identified through handsearching, searching of key reviews, or
contacting experts, could be included if a measure of SES was reported in the main body of
the text even if the abstract did not report that SES was assessed. If grey literature, such as
reports not published as journal articles, was identified by experts as assessing equity impact
then this evidence could be included even if the abstract did not report that SES was
assessed. In addition, such reports that were written in non-English were included if an
English synopsis was provided (and otherwise met the inclusion criteria). Only studies
published since 1995 in full-text and in English language were included. No settings were
excluded. See Appendix C for inclusion/exclusion form.
The SILNE review excluded interventions targeted exclusively at one socioeconomic group
and also excluded studies which reported socio-demographic data only (without any
socioeconomic data). For example, ethnicity alone was not considered to be an appropriate
indicator of SES for this review as the smoking patterns associated with ethnicity differ from
one country to another. Interventions that focused solely on tobacco products other than
cigarettes (e.g. cigars, smokeless tobacco, waterpipes) or tobacco replacement products were
excluded, unless used as part of a smoking cessation programme. Interventions that focused
solely on outcomes for providers of a smoking cessation intervention were excluded unless
results were also reported for high versus low socioeconomic participant groups. Papers
reporting study protocol and design only without reporting the impact of the intervention or
policy were excluded.
2.2.3 Data extraction
Data from the included studies were extracted by one reviewer (TB) and independently
checked by another reviewer (AA). Data relating to population characteristics, study design
and outcomes were extracted into data extraction forms. Data from studies presented in
multiple publications were extracted and reported as a single study with all other relevant
publications listed in the report. Data extraction from non-English reports (grey literature) was
limited because it was derived from an English synopsis provided by an expert; therefore the
synopsis is reported directly in the text (not in data extraction tables).
2.2.4 Quality assessment
All included studies were assessed for methodological quality by one reviewer (TB) and
independently checked by another reviewer (SP). The exception to this was non-English
13
language reports (grey literature); where any reference to quality was derived from an
English synopsis and reported directly in the text. Methodological quality was assessed by
adapting the method used in the York review.12 Each study was assessed on a scale of
quality of execution using the six item checklist of quality of execution adapted from the
criteria developed for the Effective Public Health Practice Project in Hamilton, Ontario.15
Certain items of quality are not applicable to all study designs, for example, randomisation
and comparability are not applicable to cross-sectional study designs. We added a new
criterion of ‘generalisability’ (external validity) and assessed whether the findings of each
study were generalisable at a national, regional, or local level.
2.2.5 Data synthesis
Given the variations in study methodologies, intervention types and outcome measures, the
results are presented in the form of a narrative synthesis and according to intervention type
(population level policies/interventions and individual level cessation support interventions).
In order to provide a simple basis for comparing the methodology of each study a typology
of study designs was devised (Table 1).
Table 1 Typology of study designs
Code
Study design
1.0
Population-based observational
1.1
Cross-sectional
1.2
Repeat cross-sectional
1.3
Cohort longitudinal
1.4
Econometric analyses (cross-sectional data)
2.0
Intervention-based observational
2.1
Single intervention (before and after, same participants)
2.2
Single intervention with internal comparison
2.3
Comparison between different types of intervention
3.0
Intervention-based experimental
3.1
Randomised controlled trial (individual or cluster)
3.2
Non-randomised controlled trial
3.3
Quasi-experimental trial
4.0
Qualitative
4.1
Cross-sectional
4.2
Repeat cross-sectional
4.3
Longitudinal
14
The equity impact of each intervention/policy is summarised by adapting a model used in the
York review16:

The null hypothesis that for any given socio-economic characteristic related to
education, occupation or income, there is no social gradient in the effectiveness of the
intervention i.e. a neutral equity impact.

The hypothesis of a positive equity impact defined as evidence that groups such as
lower occupational groups, those with a lower level of educational attainment, the
less affluent, those living in more deprived areas, are more responsive to the
intervention.

The hypothesis of a negative equity impact defined as evidence that groups such as
higher occupational groups, those with a higher level of educational attainment, the
more affluent, or those who live in more affluent areas are more responsive to the
intervention.
The main strengths and limitations of each study, particularly internal and external validity,
are considered when discussing the equity impact of each intervention. Particular attention is
given to the issue of generalisability: to what extent are results from interventions and
policies carried out in various countries transferable across Europe despite differences in
tobacco control policies, stage of the tobacco epidemic, socioeconomic conditions, and other
factors? We draw conclusions about the strengths and weaknesses of the current evidence of
the impact of tobacco control and other policy interventions on reducing socioeconomic
inequalities in smoking in youths and adults (equity impact) and identify the most effective
and promising interventions.
15
3 RESULTS
3.1 Introduction
The initial electronic search produced 12,605 references after duplicates were removed. Two
hundred and eighty-seven references were identified as potentially relevant to the reviews
and 286 references were successfully obtained as full-text journal articles. Of these 286 fulltext articles, 171 were excluded. Sixteen of the remaining 115 studies focused on young
people and were included in the youth review. In addition to these 16 studies, a further 10
studies (11 papers) were identified through handsearching, searching of key reviews and
contacting experts. Three of these 10 studies17-19 were identified in one paper by Mercken et
al20 which included secondary analyses of these three primary studies, and these four papers
are classed as three studies. An update of the searches was carried out in January 2013
which included both electronic searching, handsearching and contact with experts, which
identified a further seven relevant studies .
In summary, a total of 33 studies were included in the youth review; of which 31 studies
were population level polices/interventions and two studies were individual level cessation
support interventions. Appendix D contains bibliographic details for all the included youth
studies including details of source. The details of studies that were excluded at the stage of
screening the full-text articles, for the initial electronic search (n=13) and for the updated
electronic search (n=7) are listed in Appendix E with reasons for exclusion.
The findings of these 33 included studies are presented by intervention type. A summary of
studies by design and type of intervention are summarised in Table 2. Population-level
interventions (which aimed to change social norms, smoking behaviour and/or access to
tobacco) included: smoking restrictions in cars, schools, workplaces and other public places;
controls on advertising, promotion and marketing of tobacco; anti-tobacco mass media
campaigns; increases in price/tax of tobacco products; controls on access to tobacco
products, school-based prevention programmes, and multiple policy interventions.
Individual-level cessation support interventions included two interventions using mobile
phone text messaging.
Data extraction tables and quality assessment, grouped by intervention type, can be found in
Appendices F and G, respectively. Textual and visual summaries of the data can be found in
Appendices H and I, respectively. It should be noted that whilst the equity impact graph
16
(Appendix I) is meant to provide a visual representation of the equity impact of the various
population-level policies/interventions; it should be interpreted in conjunction with the
narrative descriptions of the results.
17
Figure 1 Study selection flow chart
Electronic search May 2012
Titles and abstracts screened
n = 12,605
excluded from title and
abstract
Full papers ordered
n = 287
n = 12,318
screened
n = 286
EXCLUDED (full text)
n = 171
INCLUDED
N = 115
(13 youth + 34 adult policy +
133 adult cessation)*
update electronic search
January 2013
titles and abstracts
n = 1149
youth included
n = 16
update full papers screened
n = 42
update included
n = 16
youth
handsearching, reviews,
experts
update excluded
n = 26
n = 11
(7 youth + 13 adult policy +
8)***
update youth
n=2
update youth
handsearch, experts
n=5
total number youth studies
n = 33**
population-level studies
n = 31
individual-level cessation
studies
n=2
*9 papers assessed in more than 1 review; **1 paper = secondary analyses of 3 papers, so 4 papers
classed as 3 studies;***2 papers assessed in more than 1 review
18
Table 2 Summary of studies by design and intervention type*
Design code Intervention type
Smoking restrictions in cars, schools, workplaces, and other public places
1.2
Akhtar 2010
1.1
Galan 2012
1.2
MacKay 2010
1.2
Millett 2013
1.2
Moore 2011
1.2
Moore 2012
1.1
Nabi-Burza 2012
1.1
Noach 2012
2.1
Woodruff 2000
Controls on advertising, promotion and marketing of tobacco
1.1
Gilpin & Pierce 1997
3.1
Hammond 2011
1.1
Pucci 1998
Mass media campaigns
1.2
Vallone 2009
Increases in price/tax of tobacco products
1.1
Biener 1998
1.1
Gilpin & Pierce 1997
1.3
Glied 2002
1.4
Gruber 2000
1.4
Madden 2007
1.1
Perretti-Watel 2010
Controls on access to tobacco products
1.3
Kim 2006
1.1
Lipperman-Kreda 2012
1.2
Millett 2011
1.2
Schneider 2011
1.1
Widome 2012
School-based prevention programmes
3.1
Bacon 2001
3.1
Crone 2003**
3.1
De Vries 2006**
3.1
Campbell 2008**
3.3
Menrath 2012
Multiple policy interventions***
1.2
Helakorpi 2008
1.3
Pabayo 2012
19
1.2
White 2008
Individual cessation support
3.1
Rodgers 2005
3.3
Ybarra 2013
* Studies can be categorised in more than one intervention type; **Study identified in Mercken 2012; ***Interventions that
have several elements and/or papers that try to assess the relative impact of several policy interventions over a period of
time
20
3.2 Impact of population-level policies and interventions on smoking
inequalities in youth
3.2.1 Smoking restrictions in cars, schools, workplaces and other public
places
A total of nine studies assessed the socio-economic impact of smoking restrictions in public
places; one intervention study21 five repeat cross-sectional studies22-26 and three single crosssectional studies.27-29 Three studies explored the impact of national comprehensive
smokefree legislation on primary school children’s exposure to secondhand smoke (SHS),
one of which was set in Scotland22 one in Wales25and one study pooled data from Scotland,
Wales and Northern Ireland.26 Two studies examined whether smokefree legislation was
associated with change in hospital admissions for childhood asthma in Scotland23 and
England.24 One study examined smoking behaviour in cars with children present, amongst
smoking parents in the US.27 A further two studies explored the impact of voluntary
compliance with smoking restrictions on smoking behaviour in secondary school children,
one of which was set in Spain29 and one in Israel.28 An intervention study assessed the
impact of an organisational (workplace) smokefree ban in 19 year old female US Navy
recruits, using a before and after experimental study design.30
Only the two school-based studies of comprehensive smokefree legislation22;25 scored the
maximum according to study design. All the study samples except two27;28 were
representative of the study population. All cross-sectional studies used credible data
collection methods, and all repeat cross-sectional studies had a sufficient number of
participants included in analysis in each wave. The US intervention study30 had partially
validated data collection instruments and an acceptable level of attrition for post-intervention
data but not at the 3-month follow-up. It is reasonably likely that the observed effects of
smokefree legislation in Scotland, Wales and Northern Ireland; and the smokefree workplace
ban30 were attributable to the interventions under investigation.
The comprehensive smokefree legislation studies including two studies of hospital
admissions for asthma are all generalisable on a national level (all UK based). The Spanish
study29 results of voluntary compliance are likely to be generalisable at the regional level.
The study population in the Israeli study28 of voluntary compliance, was heterogeneous; with
a broad range of ethnic, religious and socioeconomic subpopulations and is not generalisable
to other WHO European or stage 4 countries. It was unclear how generalisable the results
21
were from the study of smoking in cars amongst US parents.27 The workplace study
population was specific to female young US Navy recruits only30.
National smokefree policies
Three studies from the changes in child exposure to environmental tobacco smoke (CHETS)
study were included: CHETS Scotland,22 CHETS Wales25 and a CHETS UK study.26
Individual data from the Scottish22 and Welsh25 studies are described separately and are also
included in the pooled analyses of UK data along with data from Northern Ireland.26 The
Scottish, Welsh and Northern Irish studies applied repeat cross-sectional class-based
surveys, in order to explore the impact of smokefree legislation on 11 year old children’s
exposure to SHS; using biochemical measures (salivary cotinine levels).
The smokefree legislation in Scotland22 was associated with a decline in cotinine levels
across all socio-economic groups. The greatest absolute decline in cotinine levels was among
the lowest self-reported family socioeconomic classification (SEC) and family affluence
scale (FAS) groups, even after adjusting for parental smokers (e.g. 0.10ng/ml in SEC1 vs
0.28ng/ml in SEC4). However, a linear regression model suggests that relative inequality
between socio-economic groups had widened; the decline in SHS exposure among children
from lower SES households was greater in absolute terms but smaller in relative terms,
compared with changes in SHS exposure among children from higher SES households.
Cotinine levels remained the highest in children from the lowest SEC/FAS groups.
The likelihood of providing a sample containing an undetectable level of cotinine increased
significantly after smokefree legislation in Wales25 among children from high SES
households [relative risk ratio (RRR) = 1.44, 95% CI = 1.04–2.00, p=0.03] and medium SES
households (RRR = 1.66, 95% CI = 1.20–2.30, p<0.01), while exposure among children
from lower SES households remained unchanged (RRR=0.93, 95% CI=0.62-1.40, p=0.72).
Parental smoking in the home, car-based SHS exposure, and perceived smoking prevalence
were highest among children from low SES households. Parental smoking in the home and
children’s estimates of adult smoking prevalence declined only among children from higher
SES households. Children’s estimates of people smoking in the streets outside buildings
declined greatest and approached statistical significance amongst children from high-SES
households only.25
In summary, in Wales25 post-legislation reductions in SHS exposure were limited to children
from higher SES households whose exposure was already significantly lower prior to
22
smokefree legislation. Children from lower SES households continued to have high levels of
exposure (though these had not increased), particularly in homes and cars, and to perceive
that smoking is the norm among adults. Therefore the smokefree legislation was potentially
associated with increased socioeconomic disparity in terms of SHS exposure amongst
children. Average cotinine concentrations among children in the Scottish study were
substantially higher than in the Welsh study, and children’s SHS exposure outside of the
home was perhaps greater in Scotland, with impacts of the smokefree legislation therefore
greater overall in Scotland than in Wales, and distributed among all socio-economic groups.
One UK study26 pooled data from the Scottish, Welsh and Northern Irish CHETS studies.
The pooled data were used to examine socioeconomic patterning (using the FAS) in
children’s SHS exposure, and parental restrictions on smoking in private spaces (cars,
home). Participants were non-smokers (self-reported non-smokers providing saliva samples
containing <15ng/ml cotinine) in their final year at 304 primary schools in Scotland (n =
111), Wales (n = 71) and Northern Ireland (n = 122). Multinomial regressions were used to
assess change in SHS exposure as measured by cotinine levels; and change in home-smoking
restrictions. Binary logistic regression models examined car-based smoking. The pooled data
was adjusted for country and age, and clustering was accounted for. The data set comprised
10, 867 children (5347 baseline/5520 follow-up), average age was 11.2 years. SES varied
significantly between survey years, with affluence being higher at follow-up survey.
Percentages of children with undetectable concentrations of cotinine increased from 31.0%
(n = 1715) to 41.0% (n = 2251) following legislation overall, and from 20.1% to 34.2%,
44.9% to 51.0% and 38.6% to 42.9% in Scotland, Wales and Northern Ireland, respectively.
26
Regression analysis indicated that the relative risk of children’s samples containing no
detectable cotinine increased significantly following legislation. However this was accounted
for by decreases in samples containing low levels of cotinine rather than decreases in
samples containing higher levels of cotinine; and this was the case in all three countries and
after adjusting for parental smoking and smoking restriction levels in homes and cars. 26
Children of high SES were significantly more likely to have no detectable cotinine and
significantly less likely to have high levels of cotinine following the smokefree legislation
compared to lower SES children, and this remained significant following adjustment for
country, parental smoking and private smoking restrictions. The study26 author’s report that
the gap between low and high SES children appears to have widened following the
23
legislation, in terms of children with no detectable cotinine levels. A trend towards widening
inequality was also seen within each individual country for no detectable cotinine levels.
Gradients for higher cotinine levels remain unchanged.
Two studies evaluated the impact of national smokefree legislation on emergency hospital
admissions for asthma in children aged less than fifteen years: one set in Scotland23 and one
set in England.24 Both study samples were representative of the general population and
generalisable on a national scale. Both studies used SES quintiles based on the Index for
Multiple Deprivation and both studies applied binomial regression models to assess hospital
admissions. The English study24 also produced admission rate ratios, which is the ratio of the
actual admission rate in relation to the rate projected by the underlying trend.
A Scottish study23 assessed the impact of national smokefree legislation on hospital
admissions for childhood asthma by linking data from the Scottish Morbidity Record and
death-certificate data to identify all hospital admissions and deaths before arrival at the
hospital that occurred from January 2000 through October 2009. Before the legislation was
implemented, admissions for asthma were increasing at a mean rate of 5.2% per year (95%
confidence interval [CI], 3.9 to 6.6). After implementation of the legislation, there was a
reduction of 18.2% (95% CI, 14.7 to 21.8; P<0.001) in the annual rate of asthma admissions,
resulting in a net reduction in asthma admissions of 13.0% per year (95% CI, 10.4 to 15.6).
The study accounted for asthma deaths and showed that the decrease in admissions was not
due to an increase in the incidence of deaths before arrival at the hospital. There were no
significant interactions between hospital admissions for asthma and quintile of SES. All SES
subgroups were associated with significant reduction in admissions.
An English study24 assessed the impact of national smokefree legislation on hospital
admissions for childhood asthma, using Hospital Episode Statistics over 8.5 years (April
2002 to November 2010). Before the implementation of the legislation, there was a mean
increase in the admission rate for asthma of 2.2% per year (adjusted rate ratio 1.02; 95% CI:
1.02–1.03). After implementation of the legislation, there was a significant immediate
reduction in the admission rate of 8.9% (adjusted rate ratio 0.91; 95% CI: 0.89–0.93) and a
reduction in time trend of 3.4% per year (adjusted rate ratio 0.97; 95% CI: 0.96–0.98).
Overall, the legislation was associated with a net 12.3% reduction of hospital admissions for
childhood asthma in the first year. This change was equivalent to 6802 fewer hospital
admissions in the first 3 years after implementation. The results were very similar when
24
based on admissions data alone, as there were few recorded deaths prior to admission.
Reductions in asthma admissions did not differ by SES.
Both studies23;24 were sufficiently similar to enable comparison and show that both the
English and Scottish smokefree legislation were associated with significant reductions in
admissions for asthma across all SES subgroups i.e. a neutral equity impact. The relative
rate of admissions before the legislation was higher in Scotland compared to England, and
relative reductions in hospital admissions after the legislation were higher in Scotland
compared with England, however the net overall reduction in hospital admissions was
similar in both studies (12-13%).
Neither study determined the extent to which the observed reduction in asthma was due to
reduced exposure to SHS by setting (public places, home, car) or reduction in smoking
among children. The impact on results of changes in the treatment of asthma and diagnostic
coding of asthma cannot be ruled out. However both studies assessed asthma which required
hospitalisation (i.e. severe asthma).
Smokefree car policies
Pooled data from the CHETS26 study showed that in the UK as a whole and also within
England, Northern Ireland and Wales, as SES increased, the likelihood of partial or no home
smoking restrictions (rather than full smoking restrictions) decreased significantly, whilst the
odds of smoking being allowed inside the family car also decreased significantly. These
trends remained after adjustment for parental smoking and there was no change in inequality
following legislation i.e. a neutral equity impact.
A US study27 determined the prevalence of parents smoking in their cars with children
present and how often paediatric health care providers advised parents to have smoke-free
cars. The study used baseline data from 10 control sites (in 8 US states) from a cluster RCT
‘Clinical Efforts Against Secondhand Smoke Exposure’ which was an intervention to
address parental tobacco use within the paediatric clinic setting. The study sample were
parents or legal guardians who accompanied a child to the visit; were at least 18 years old;
spoke English; had smoked at least a puff of a cigarette in the past 7 days and completed a
baseline enrolment survey for which they received $5 cash.
25
Parents who smoked were asked about smoking behaviours in their car and receipt of smokefree car advice at the visit. Parents were considered to have a “strictly enforced smoke-free
car policy” if they reported having a smoke-free car policy and nobody had smoked in their
car within the past 3 months. The measure of SES used was level of education (high school
or less versus some college or college graduates). Analyses were limited to parents who
smoked and who reported having a car that they owned or travelled in frequently, it was
unclear how representative this study sample was of the SES of the general population.
Twenty-nine percent of 795 parents reported a smokefree car policy and 48% reported that
smoking occurred with children present in the car. Fourteen percent of smoking parents
reported being asked if they had a smoke-free car, and 12% reported being advised to have a
smoke-free car policy by a paediatric health care provider. Of those who smoked with
children present in the car, only 5% were counselled about having a smoke-free car.
No significant association was found between parents education level and having a strictly
enforced smokefree car policy. However, parents of children aged less than one year were
more likely to have strict smoke-free car policies if they were college educated (OR:2.42;
95% CI: 1.21 to 4.83, p = 0.013). Strict smoke-free car policies were more common when
parents were both light smokers (smoked 10 cigarettes or less per day) and college educated
(OR: 2.88; 95% CI: 1.24 to 6.66, p = 0.013).
Voluntary compliance with smoking restrictions in schools
Two cross-sectional studies explored the impact of voluntary compliance with smoking
restrictions on smoking behaviour in secondary school children, one of which was set in
Spain29 and one in Israel.28 The smoking outcomes were not biochemically validated and
were based on self-report.
In Madrid smoking has been banned in schools since August 2002 however at the time of
this survey29 among smokers aged 15 to 16 years, 50.6% had smoked on school premises
during the last thirty days with significant variability (0% to 100%) between schools. A
lower probability of smoking on school premises was found among adolescents whose
fathers had a university education (OR 0.43; 95% CI: 0.19 to 0.96) or among those who did
not know the level of studies of their father (OR 0.39; 95% CI: 0.16 to 0.94) compared with
those with fathers who had a very low level of educational attainment. A lower probability of
smoking on school premises was found for state subsidized private schools (OR 0.20; 95%
26
CI: 0.11 to 0.35) and non-subsidized private schools (OR 0.30; 95% CI: 0.14 to 0.62) when
compared with that for public schools. Employment status of either parent, educational level
of the mother, SES of the school census tract, written reference to a smoking control policy
and educational activities about smoking prevention were not significantly associated with
smoking on school premises among student smokers.
In Israel28 there was no comprehensive smokefree ban at the time of the survey and most
Israeli adolescents (average age 15 years) were exposed to SHS (total: 85.6%; home: 40%;
school: 31.4%; entertainment: 73.3%; other: 16.3%). Parental education was not a significant
determinant of smoking in school but correlates of exposure at school differed from those at
home. Adolescents whose fathers had less than 12 years of education were more exposed to
SHS at home, than were teenagers whose fathers had a degree from a university or college
(OR = 1.48; CI: 1.09 to 1.99, p = 0.0111). Adolescents with less-educated mothers were
more exposed to SHS at home than teenagers with mothers with degrees from a university or
college (OR = 1.39; CI: 1.02 to 1.90, p = 0.0366). The high levels of SHS exposure among
Israeli adolescents were characterized by different patterns of exposure among different
population subgroups. Israel is a heterogeneous country; with a broad range of ethnic,
religious and socioeconomic populations and the results are not generalisable to other WHO
European or stage 4 countries.
Workplace smokefree policies
One intervention study assessed the impact of an organisational (workplace) smokefree ban
(24-hours, 8-weeks) in 19 year old female US Navy recruits, using a before and after
experimental study design.30 Among the 4393 recruits who provided entry (before) and
graduation (after) survey data, 41.4% (n = 1819) reported any smoking in the 30 days before
entering compared with 25% that reported being a smoker at graduation (after), which was a
significant reduction. Slightly over two-thirds (n = 724) of “smokers” who responded to the
follow-up survey had resumed smoking three months after graduation, and 32% (n = 340)
reported not smoking. Among past month smokers at entry (before), the relapse rate at the
three month follow-up after graduation was 81%. Daily smokers at entry (before) had the
highest relapse rate (89%) at the three month follow-up after graduation. The study did not
aim to assess differential impact by SES but reported that education did not significantly
predict smoking relapse. It was not reported whether there was a difference by SES in
change over time.
27
A response bias is present in this study; there was a low response rate (39%) at the 3-month
follow-up, and non-respondents had a slightly higher past 30 day smoking rate at baseline
than did respondents. In addition, the definition of ‘smoker’ differed at graduation (post 8
weeks) from baseline and 3-month follow-up. The group of smokers assessed for relapse was
broadly defined and included daily smokers, occasional smokers, experimenters, or former
smokers. As well as these quality-related issues, the study only included female recruits and
results may not be generalisable to a civilian population or setting.
Summary
The evidence relating to smokefree restrictions is limited to eight cross-sectional studies and
an intervention study of a workplace 24-hour 8-week smoking ban.
National comprehensive smokefree restrictions are associated with declines in SHS exposure
in primary school children but the equity effect may vary according to how exposure is
measured (absolute levels or relative levels), on the pre-ban level of exposure and the
balance between sources of exposure i.e. public places versus home. Prior to the CHETS
studies, scant attention has been paid to whether adoption of private smoking restrictions
following smokefree legislation has been patterned by SES.
Pooled data from Scotland, Wales and Northern Ireland following national smokefree
legislation showed that declines in exposure occurred predominantly among children with
low exposure before legislation, and from more affluent families, leading to increased
socioeconomic disparity (negative equity impact). Substantial socioeconomic gradients in
proportions of children with higher SHS exposure levels remained unchanged. Children from
lower SES households continued to perceive that smoking is the norm among adults whereas
smoking as a perceived norm declined amongst high-SES children.
Pooled data from Scotland, Wales and Northern Ireland following national smokefree
legislation showed that there was no change in inequality following legislation. As SES
increased, the likelihood of partial or no home smoking restrictions (rather than full smoking
restrictions) decreased significantly, whilst the odds of smoking being allowed inside the
family car also decreased significantly. Only one US study was included, of parental
smoking behaviour in cars it was found that parent’s education level interacted with a child’s
age and the number of cigarettes smoked per day, both of which were significant predictors
of car smoking policy. Parents with higher SES that were light smokers were more likely to
28
have a strict no smoking car policy and higher SES parents with children less than one year
were also more likely to have a smokefree car policy.
English and Scottish national smokefree legislation was associated with a significant
reduction in childhood asthma admissions which did not differ by SES (neutral equity
impact).
When reviewing whether students comply with smoking restrictions in secondary schools
where there is no enforced and comprehensive smokefree ban, it is apparent that parental
education may influence smoking behaviour of adolescents and smoking behaviour amongst
adolescents is also influenced by the setting (home/school). Two school-based studies in two
very different countries showed conflicting results. A study in Israel where there was no
comprehensive smokefree ban showed high levels of SHS exposure among Israeli
adolescents which were characterized by different patterns of exposure among different
religious groups; however parental education was not a significant determinant of smoking
in schools. Second-hand smoke exposure from outside the home and school settings was
sizeable and overall SHS exposure and SHS exposure at home was greater among lower SES
adolescents. In a study in Spain where there were school smoking bans but variable
enforcement; adolescents whose fathers had a lower level of educational attainment were
more likely to smoke on school premises.
A 24-hour 8-week workplace ban in the US Navy did reduce the proportion of women
smoking immediately post-ban but most had relapsed by 3-month follow-up. Education did
not significantly predict smoking relapse however the response rate to the follow-up was low
and non-respondents were more likely to be smoking.
3.2.1 Controls on advertising, promotion and marketing of tobacco
Three very different US studies assessed the equity impact of controls on the advertising,
promotion and marketing of tobacco products including; a retrospective survey31 of the
impact on smoking initiation of cigarette prices and tobacco industry marketing budgets
conducted in the US in 1993 of nearly 141,00 respondents aged 17 to 38 years that would
have been aged between 14 and 21 years old between 1979 and 1989, an RCT32 of a short
online survey of brand appeal of cigarette packaging, and an observational field study of
advertising density with school ‘buffer zones’.33 The RCT consisted of a convenience
internet sample and it was not clear if it was representative of the study population. In
addition there were some significant differences among the women at baseline between
29
treatment groups which may have affected the results: education varied by condition, with
the highest level of education in the standard pack condition, and number of cigarettes
smoked per day was significantly higher in the plain pack condition compared with the
standard pack condition among current smokers. All three studies used credible data
collection methods. It is reasonably likely that the observed effects of cigarette packaging
were attributable to the intervention under investigation and that these results are likely to be
generalisable at a national level. The observational field study of advertising density with
school buffer zones may only be generalisable at the local level as the study population were
limited to neighbourhoods in Boston, Massachusetts, US and no details of the 6 Boston
neighbourhoods were provided.
One retrospective survey31 conducted in the US in 1993 of nearly 141,00 respondents aged
17 to 38 years that would have been aged between 14 and 21 years old between 1979 and
1989 examined trends in smoking initiation by cigarette prices and tobacco industry
marketing budget. Adolescent initiation rates decreased from 1979 to 1984 but increased
thereafter. Initiation rates were highest among high school dropouts and lowest amongst
those who eventually attended college. In 1988 the initiation rate was 9.9% for those who
did not graduate from high school, 6.9% for high-school graduates reporting no college and
3.7% for those reporting at least some college education. The equity results from the study
can only be tentative because the study does not directly assess the effect of changes in the
tobacco marketing budget or cigarette prices on smoking initiation rates by education level.
The study simply highlights that cigarette prices and tobacco marketing budget increased
during this decade as did smoking initiation rates amongst adolescents, and that marketing
expenditure may be associated with an increase in smoking initiation especially in young
people with lower levels of education.
A recent RCT of a short online survey intervention32 examined brand appeal of cigarette
packaging amongst women aged 18 to 19 years in the US. The convenience sample was
randomised to four experimental conditions which viewed eight cigarette packages one at a
time displayed in random order and according to the four experimental conditions: (1)
female-oriented packages (standard condition); (2) female-oriented packages with brand
imagery, including colours and graphics, but with descriptors (e.g. slims) removed; (3)
female-oriented packages without brand imagery and descriptors (i.e., plain packages); and
(4) popular U.S. brands of “ regular ” or non – female- oriented packages.
30
Women in the high income and high education categories endorsed a greater number of
positive smoker traits (female/male, glamorous/not glamorous, cool/not cool, popular/not
popular, attractive/unattractive, slim/overweight, and sophisticated/not sophisticated) than
those in the low income and low education categories. High income respondents were more
likely to endorse smoking and weight control beliefs compared with respondents reporting
low (OR = 1.70, 95% CI = 1.12 – 2.60) and medium income (OR = 1.73, 95% CI = 1.09 –
2.73) and those who did not state their income (OR = 2.17, 95% CI = 1.29 – 3.65). The
reactions to and perceptions of the different types of packs was the same by SES for nearly
all the measures. No significant differences in pack selection were observed for smoking
status, age, income, education, ethnicity, or weight concerns.
An observation field study33 assessed youth exposure to stationary outdoor tobacco
advertising density within FDA 1,000 foot buffer zones around schools in 6 Boston
neighbourhoods in the US. The overall advertising density for schools in all neighbourhoods
combined was higher for middle (10.1) and high schools (9.9) than for elementary schools
(6.3). The majority of outdoor tobacco advertising was in the neighbourhoods with the
lowest median household incomes. The study probably underestimated advertising density
because it does not include point-of-purchase advertising, advertising inside stores that is
seen from the street, or advertising on taxis and buses.
Summary
Three very different US-based studies assessed the equity impact of controls on the
advertising, promotion and marketing of tobacco products.
One study showed that initiation rates of smoking amongst adolescents varied by level of
education; initiation rates were highest amongst high-school dropouts and lowest amongst
those who eventually attended college. Marketing expenditure may be associated with an
increase in smoking initiation especially in young people with lower levels of education.
Very tentatively, controlling the promotion of cigarettes through plain packaging might have
a positive effect on all young women and have a neutral equity effect for young women
because reactions to/perceptions of different types of packs were the same regardless of SES
for nearly all the measures.
31
Despite the FDA buffer zone policy, one study showed that tobacco advertising is targeted at
adolescents of low SES inside school buffer zones, particularly middle and high school
adolescents, and this has the potential to increase inequality in smoking behaviour amongst
youth. Banning all outdoor tobacco advertising would reduce exposure particularly in
children of lower SES.
3.2.2 Mass media campaigns
One telephone survey34 evaluated the impact of the US truth® campaign on awareness and
receptivity among youth aged 12 to 17 years. The truth® campaign is a branded counter
tobacco marketing campaign designed to prevent smoking among at-risk youth, primarily
through edgy television advertisements with an anti-tobacco industry theme. Seven waves of
Legacy Media Tracking Survey data were collected from September 2000 through to
January 2004. It was unclear how representative the study sample was of the study
population because response rates declined over the seven waves of data collection, from
60% to 30%.
Youth who lived in zip codes in which the median household income was less than or equal
to US$ 35,000 had a lower level of confirmed awareness of the campaign than respondents
in each of the other income categories (p< 0.05). There were no statistically significant
differences in confirmed awareness by median level of education, though there was a pattern
in which the proportion of confirmed awareness increased with education. There were no
differences in receptivity by median household income or median household education,
though there was a pattern of increasing receptivity with greater income and education.
During the campaign there was a gradual shift towards cable TV ownership and education is
positively associated with cable TV ownership. However the authors report that SES
differences were concentrated in the early years of the campaign when it was aired mainly
through network TV. The study controlled for year of survey administration and the effect of
the intervention over the seven waves of survey data. It is not reported whether the effect of
the intervention differed by SES over time.
Summary
This one study of a relatively large, lengthy and well-funded anti-tobacco mass media
campaign, using repeat cross-sectional data over four years, showed that youth who lived in
zip codes in which the median household income was less than or equal to US$ 35,000 had a
lower level of confirmed awareness than respondents in each of the other income categories.
32
Zip code level median household education was not associated with confirmed awareness
and there were no differences in receptivity by zip code level income or education. The
equity impact of the mass media campaign is unclear as the effect on campaign awareness
varied according to the SES variable that was measured (income/education) and the equity
impact in terms of receptivity appeared neutral.
3.2.3 Increases in price/tax of tobacco products
Six studies evaluated the equity impact of increases in the price or tax of cigarettes, the
majority of which were US-based studies using retrospective survey data. Two studies35;36
were econometric studies (report price elasticities), one of which used both longitudinal and
cross-sectional data.35 One study used retrospective cohort data37 and the remaining three
studies were single cross-sectional studies.31;38;39 Four of the study samples were
representative of the study populations and for two studies it was unclear if the samples were
representative.35;37 For three studies it was unclear if credible methods of data collection had
been used, due to lack of reported information in one case38 and unpublished data in the
other two studies.37;39 Two studies38;39 were likely to be generalisable at the regional level
and two studies31;35;36 at a national level.
A retrospective survey38 examined smokers aged 12 to 17 years perceptions of the impact of
statewide tobacco taxes in Massachusetts, USA. Teenage smokers from low income
households were much more likely than more affluent teenagers to report cutting the costs of
their smoking (by cutting down the amount smoked or, less often, by switching to cheaper
brands) in response to the price increase, rather than do nothing (OR 7.57; 95%CI: 1.55 to
36.98) or cutting costs rather than consider quitting (OR 14.72; 95%CI: 2.55 to 84.95).
Household income was unrelated to the choice between considering quitting and doing
nothing (OR 0.51; 95% CI: 0.13 to 2.77). Young low income smokers were not more likely
than wealthier teenagers to consider quitting. There appeared to be a positive equity impact
on smoking less and a neutral equity impact on quitting behaviour of statewide tobacco tax
increases. It should be noted that 53% of the teenagers who continued to smoke denied
having had any of the 3 potential reactions to price increase and so it is possible that the
study failed to measure an important variable.
33
One US retrospective survey31 examined trends in smoking initiation by cigarette prices and
tobacco industry marketing budget; results are reported in section 3.2.1. Initiation rates were
highest among high school dropouts and lowest amongst those who eventually attended
college. The study highlights that cigarette prices and tobacco marketing budget increased
during this decade as did smoking initiation rates amongst adolescents, and that price
increases did not reduce smoking initiation.
One US econometric study35 tested the assumption that policies targeting youth to reduce
smoking initiation will reduce lifetime smoking propensities. Estimates of the effect of
current taxes (taxes in the year of interview) on current adult smoking measured in 1984
(aged 19 to 28), 1992 (aged 27 to 35), and 1994 (aged 29 to 37) revealed that the age
coefficients were positive (measured in 1979) showing that there was a positive secular trend
in youth smoking. Youth from higher income families were less likely to smoke, whereas the
results were inconsistent for level of education between different types of analyses (probit
marginal effects and linear regression fixed effects). Participation elasticities for the three tax
current tax variables (1984, 1992, and 1994) using probit marginal effects or linear
regression fixed effects were −0.1 and−0.09, respectively.
The study estimated the effect of cigarette taxes at age 14 years (in 1979) on future overall
smoking behaviour, quitting and initiation using prospective longitudinal cohort data with
cross-sectional analyses. Cigarette tax at age 14 had the most effect on low income people at
ages 19-28 for current smoking but not late initiation or quitting according to longitudinal
data. The effect of cigarette tax at age 14 on subsequent smoking (at follow-up in 1992 and
1994) was not significant. Elasticities declined over time for low income people indicating
that by age 39 the effect of taxes at age 14 had largely disappeared. Low income (< $12,000
median in 1979) elasticity was -0.65, p<0.10 (at age 14), -0.33 (at age 24), -0.01 (at age 34),
and 0.15 (at age 39). Cigarette tax increases at age 14 reduced smoking and had a positive
equity effect on young people in their 20’s.
It should be noted that in some models (i.e. effect of cigarette tax at age 14 on current
smoking), results presented for the low income subgroup include a control for ‘current’ tax
(taxes in the year of interview), whereas other models (i.e. effect of cigarette tax at age 14 on
late initiation, quitting) did not control for current tax in low-income subgroup. It is difficult
to see how an effect of tax at age 14 could be determined if there is no adjustment for tax at
other subsequent time points.
34
A US econometric analysis36 using repeated cross-sectional data, evaluated the impact of
prices, clean air regulations and youth access restrictions on youth (13 to 18 years) smoking
in the 1990’s. Price was the only significant determinant of smoking. Price was the most
important determinant of smoking by 16-18 year olds but not for younger teenagers.
Sensitivity to price suggested cross-elasticity between price and income: for 16 to 18 year
olds: sensitivity to prices increased for teenagers with less educated parents, however
sensitivity to smoking intensity increased for those with more educated parents. For 16 to 18
year olds, the elasticity of participation was -4.39 (p<0.05) for those whose parents were
high school dropouts or graduates and -0.24 for parents with some college education. For
smoking intensity this trend was reversed with elasticities of -0.40 for high school and -2.39
(p<0.05) for college education. There was no pattern for younger teenagers (<16 years),
although participation elasticity was positive and statistically significant for high school
educated parents (2.72, p<0.05).
A survey39 conducted between 2005 and 2006 on a random sample of 2455 university
students in South-Eastern France, investigated young smokers’ (mean age 19.5 years)
retrospective reactions to an increase in cigarette prices. Daily smokers with low educated
parents were less likely to report reacting to the price increase, daily smokers who had at
least one parent that completed high school were more prone to report reacting to higher
cigarette price (OR 2.5; 95% CI: 1.6 to 4.0 for cheaper smoking versus no reaction; and OR
2.1; 95% CI: 1.4 to 3.3 for smoking less versus no reaction; in multivariate analysis, p <
0.001 and p< 0.01, respectively). Students who reported difficulties in financing their studies
were significantly more likely to purchase cheaper cigarettes (OR 1.9; 95% CI: 1.0 to 3.7; p<
0.1). It should be noted that overall, 32% said that they did not react to price increase, the
survey was regional rather than national and the reactions to price increase are only relevant
to daily smokers who did not quit, all of which may which may limit study generalisability.
We can’t tell whether these reactions to a price increase impacted on quitting but there
appeared to be a negative equity impact on smoking less.
An Irish study37 used retrospective cohort data to investigate the role of tobacco taxes from
1960 to 1998, in starting and quitting smoking and how this differed by level of education.
The data was derived from a single cross-sectional survey on women’s knowledge,
understanding and awareness of lifetime health needs, but mainly focussed on hormone
replacement therapy as part of an unpublished MA thesis at the University College Dublin.
The sample consisted of just over 700 women, mean age was 35 years and mean age started
35
smoking was 19 years. The SES measure used was education level (‘primary cert’/’junior
cert’/’leaving cert’/’third level’).
Higher cigarette tax levels were associated with later initiation of smoking which differed by
education level. Taxes had the greatest positive effect in terms of delaying smoking initiation
for women with intermediate level education and weakest effect among women with the
lowest education. The results were tentative because of the potential for recall bias (going
back 40 years in some cases) and the results are specific to a sample of Irish women aged 48
years or younger.
The measure of education level used in this study may not be
generalisable across time and to other countries. The SES subgroups were relatively small,
and during the study period cigarette tax was relatively low and there was increasing
awareness of the harms of smoking. Therefore study findings cannot be directly attributed to
the effects of increasing cigarette tax.
It should be noted that whilst data has been extracted for this review on smoking initiation
(because this is the outcome of relevance for youth), the study also reported smoking
cessation and showed inconsistent equity impact results for how tax effect differed by
education level, depending on the outcome measure (initiation and cessation). Cigarette
taxes had the greatest positive effect in terms of delaying smoking initiation for women with
intermediate level education and the weakest effect among women with the lowest
education. However cigarette taxes had the strongest effect on cessation among women with
the lowest education, and an equal impact on those with other levels of education.
Summary
The majority of evidence is from the US, and suggests there is variation in the evidence of
the equity impact of increases in cigarette tax or price on youth smoking behaviour and
variation in smoking behaviour amongst youth of different ages and different SES groups.
Two retrospective surveys showed contrasting results; one survey showed that low income
teenagers were more likely than more affluent teens to cut costs by cutting down smoking or
(less often) by switching to cheaper brands but were not more likely than more affluent
teenagers to consider quitting. However, only 53% of the teenagers who continued to smoke
denied having had any of the 3 potential reactions to the price increase. A regional survey of
French university student smokers showed that students with a lower SES were less likely to
36
have reacted to the cigarette price increase which included smoking less, however 32% of
students reported that they did not react to the price increase.
An Irish study showed that cigarette taxes were associated with later smoking initiation in
women with intermediate education but not for women with only a primary education.37
Two econometric studies showed contrasting results; one study showed that cigarette tax at
age 14 had a statistically significant negative effect on current smoking for low income
people but by age 39 years, the effect of taxes at age 14 had largely disappeared. In the other
study, the equity impact varied according to the age of the teenagers and there was no pattern
for younger teenagers. For older teenagers: sensitivity to prices increased for teenagers with
less educated parents, and sensitivity to smoking intensity increased for those teenagers with
more educated parents.
It does not appear that low income youth are consistently more responsive to tax/price
increases than high income youth groups: youth of lower SES are not more likely to stop
smoking when cigarette prices/taxes increase.
3.2.4 Controls on access to tobacco products
A total of five studies assessed the socio-economic impact of controls on access to tobacco
products. Three studies assessed the impact of legislation on age of sale of cigarettes. Two
single cross-sectional studies40;41 examined the impact of age-of-sale laws in the US on
retailer compliance and whether the impact differed by SES. One repeat cross-sectional
study examined the impact of UK legislation which increased the minimum age for the legal
purchase of cigarettes, and was set in secondary schools in England.42 A German study used
observational field data of new electronic locking devices on cigarette vending machines to
prevent underage purchasing of cigarettes in Cologne43. A prospective cohort study based in
the US, examined whether young, especially low SES females, are influenced by tobacco
control policies in terms of smoking initiation and transition.44
An English study examined whether there was any differential impact of UK legislation
which increased the minimum age for the legal purchase of cigarettes from 16 years to 18
years and which came into force in October 2007.42 The SES variable employed was
eligibility for free school meals (FSM) which is assessed on the basis of parental
employment status and income levels. Annual survey data was collected before and after the
37
legislation; from 2003 to 2008. There were baseline differences in age, gender and ethnicity
but these differences were controlled for in analyses.
Increasing the minimum age for purchase was associated with a significant reduction in
regular smoking among youth aged between 11 and 15 years (adjusted OR 0.67; 95% CI
0.55 to 0.81, p=0.0005). This effect was not significantly different in pupils eligible for FSM
compared with those who were not eligible (adjusted OR 1.29; 95% CI 0.95 to 1.76, p=0.10
for interaction term). Regular smoking was not significantly different in pupils eligible for
FSM compared with those that were not (adjusted OR 1.29; 95% CI 0.95 to 1.76, p=0.10).
The percentage of regular smokers who usually bought cigarettes from a vending machine
decreased significantly in the non-FSM but not in the FSM group. The percentage of regular
smokers who usually bought cigarettes from friends and relatives or from other people
increased significantly in the non-FSM but not the FSM group after the introduction of age
restriction. Regular smokers eligible for FSM were significantly more likely to be given
cigarettes by their parents in 2006 (p<0.001) but this was no longer the case in 2008
(p=0.42). The percentage of pupils who stated that they found it difficult to buy cigarettes
from a shop did not increase in those eligible for FSM (25.2% to 33.3%; p=0.21) but did
increase significantly in others (21.2% to 36.9%; p<0.01) between 2006 and 2008. The
percentage of regular smokers who were successful in buying cigarettes from a shop during
their latest attempt decreased significantly in the non-FSM but not the FSM group between
2006 and 2008. No differences in ease of purchase were found between pupils eligible for
FSM and those not before or after the legislation (2006: p=0.34, 2008: p=0.55).
It should be noted that although the response rate for schools was only 58% in 2008, the
sampling frame ensured that schools participating in the survey closely reflect the
composition of schools in England generally. However, the national smokefree legislation
and alcohol restrictions were also introduced during this time which may confound these
results.
The German Sources of Tobacco for Pupils (STOP) study43 compared the number of
vending machines and other commercial sources before and after new legislation which
involved electronic locking devices on vending machines to prevent underage (<16 years)
purchasing of cigarettes in Germany. Three geocoders made an inventory of commercial
cigarette sources in 2005, 2007 and 2009 and mapped using Geographic Information System
to produce a density of sources before and after the legislation. Cologne was selected as the
38
area of study because it had existing sociogeographical data, however the authors report data
to show that Cologne data appears comparable with Germany as a whole.
The number of commercial sources declined by 12% from 2005 to 2009, resulting mainly
from the removal of 44% of outdoor cigarette vending machines (indoor machines decreased
by 5%). The lower the income level in a district, the higher the availability of cigarettes
(Pearson’s r = .595; p = .009). Convenience cigarette sources reduced by only 0.9%, and
supermarket and drug stores increased by only 2.6%. The study did not report whether the
decline in commercial source by retail category (outdoor and indoor vending machines,
convenience stores, supermarkets and drug stores) varied by the income level of districts.
The same occurred for the alternative indicators such as youth unemployment (Pearson’s r =
.548; p = .019), the percentage of people receiving social welfare (Pearson’s r = .485; p =
.041), and the percentage of pupils attending low-qualifying schools (Pearson’s r = .473; p =
.048).
In 2005 as well as in 2009, there were significantly fewer commercial cigarette sources in
districts with above average SES than in districts with below average SES. This can be seen
in terms of absolute as well as relative numbers. The density of commercial cigarette sources
in 2005 in districts with above average SES was 3.20 per 1,000 inhabitants and 4.84 per
1,000 inhabitants in the districts with below average SES. In 2009, the numbers were 2.63
per 1,000 inhabitants and 4.44 per 1,000 inhabitants, respectively. The differences between
socially advantaged and disadvantaged districts appeared to be significant in both years
(2005: t(15) = 9.017, p < .001 and 2009: t(17) = 6.915, p < .001). This study showed that
electronic locking devices on vending machines to prevent underage (<16 years) purchasing
of cigarettes in Germany was not associated with a decrease in inequalities of access to
cigarettes, for youth.
A US study41 evaluated the relationship of point-of-sale tobacco advertising and
neighbourhood characteristics (including 150% below the poverty level) to underage sales of
tobacco. Study authors used three data sources: observations of the advertising environment
in stores; records of age-of-sale tobacco checks where an undercover minor working with
law enforcement attempted to purchase tobacco; and demographic data from the Year 2000
U.S. census. Analyses were conducted on 467 of 655 licensed tobacco vendors in Minnesota,
USA. Compliance failure was defined as the sale of tobacco to a youth, regardless of
whether the store clerk examined the minor’s ID.
39
The study did not find a significant association between store advertising characteristics or
neighbourhood poverty level and stores’ compliance check failure. Of a total of 467 stores,
48 failed the compliance check. Tobacco shops were most likely to fail compliance checks
(44%) and supermarkets were least likely to fail (3%). The poverty level of stores ‘block
group’ was not associated with compliance failure. Stores in ‘block groups’ with a greater
percentage of people living in poverty were not more likely to fail the compliance check.
The study sample was representative and the results are generalisable at a regional level.
Only vendors with a current license can sell tobacco in state of Minnesota but this is not the
case across all US states. Also stores who repeatedly violate youth access laws have their
license rescinded. The study authors report that compliance checks may not be a very valid
measure of commercial tobacco accessibility for minors.
Another US study40 examined contextual, community and retail characteristics associated
with youth access to tobacco through commercial sources. Data sources were access surveys
carried out by four buyers who were over 18 years of age (mean age 19 years) but who were
judged to appear younger by an independent panel. Purchase attempts were made at 997
tobacco outlets in 50 mid-sized California cities by a team of two buyers. At each outlet a
single buyer attempted to purchase a pack of Marlboro or Newport cigarettes (the most
popular cigarette brands among high school-aged students). If asked about their age they
stated that they were over 18 years old, and if asked for an age ID they indicated they had
none. If a sale was refused, the buyers left without attempting to pressure the clerk. The main
outcome measure was retailer compliance with underage tobacco sales laws.
Overall, the rate of retailer non-compliance with underage tobacco sales laws in the 997
selected outlets was 14.3%. Buyer’s actual age, being a male clerk and asking young buyers
about their age were each positively associated with successful cigarette purchases. Buyer’s
actual age and minimum age signs increased the likelihood that clerks requested
identification (ID). A greater percentage of residents (within each city) with at least a college
degree was associated with increased likelihood of non-compliance with underage tobacco
sales laws. A lower percentage of residents with at least a college degree was associated with
retailers asking for an ID. Higher cigarette prices of Marlboro but not Newport were
associated with higher median household income.
40
Although the study authors state that there were no significant differences between the
sampled and the un-sampled cities in relation to population size, ethnic diversity, household
size and median household incomes, there was no data reported to clarify the
representativeness of the study sample and therefore the generalisability of the study results.
A US national longitudinal study of adolescent health (Add Health) was a school based
survey of the health related behaviours of adolescents using follow-up in-home surveys.44
‘Add Health’ used state level tobacco policy on age of sale scores developed by the US
National Cancer Institute, evaluating 9 items for each state each year (statewide
enforcement, random inspections, graduated penalties, photo identification, free distribution,
minimum age, packaging, vending machines, and clerk intervention).
The analyses were restricted to female adolescents, and showed that stronger state level
tobacco policies were associated with lower likelihood of smoking initiation and adverse
transition among low SES women, although the effect sizes were small. The positive policy
effects for initiation were strongest for low SES females, whose odds ratio was 0.95 (0.98 for
middle SES, 1.00 for high SES). For initiation, school level smoking rates did not vary
substantially across low, middle, and high SES groups (OR=1.01, 0.99 and 1.00,
respectively. For statewide enforcement, the odds ratios of initiation were significantly lower
for the low (0.89) and middle (0.91) SES female groups; on the other hand, the policy had no
effect on the high SES female group (OR=1.00). For random inspections the odds ratios of
initiation were significantly lower for low (0.88) and middle (0.90) SES female groups.
Photo identification had a significant positive effect on the low SES female group
(OR=0.85), but not on the middle SES female group (OR=0.95, NS) and on high SES
females (OR=1.10, NS). Other policies had a pattern similar to the significant ones.
It should be noted that this US cohort uses longitudinal data with a seven year gap in the data
used to assess transition from adolescence to young adulthood, and this gap may have
missed other important mediators.
Summary
Five studies of controls on access to tobacco products showed mixed results for equity
impact. Although four of the five studies focussed on age of sale legislation, the German
study of vending machines was unique, and in addition, the range of outcomes reported with
the studies varied.
41
Increasing the minimum age for the purchase of tobacco in England was associated with a
significant reduction in overall youth smoking and regular smoking was not significantly
different in pupils eligible for FSM compared with those that were not and so the legislation
was neutral with regard to equity. However smokefree legislation also came into force
during the time of this study and could have contributed to the reduction in overall youth
smoking. In addition there were significant differences in the percentages of adolescents
eligible for FSM compared to those not eligible for FSM in terms of higher rates of
accessing cigarettes from a variety of sources, which showed negative equity impact
differences.
New legislation which involved electronic locking devices on vending machines to prevent
underage purchasing of cigarettes in Germany has not been associated with a decrease in
inequalities of access to cigarettes, for youth. The supply density of cigarette vending
machines in Germany was greater in socially disadvantaged areas, both before and after new
legislation to prevent underage access; there were also greater decreases in the number of
vending machine sources in socially advantaged areas.
Two US studies reporting retailer compliance with age-of-sale laws showed inconsistent
results for SES. A US study41 evaluating the relationship of point-of-sale tobacco advertising
and neighbourhood characteristics to underage sales of tobacco did not find a significant
association between store advertising characteristics or poverty and stores’ compliance check
failure. A study of compliance with underage tobacco sales laws in California40 showed that
higher education was a significant predictor of underage tobacco sales and youth in
communities with higher educational levels may have easier access to cigarettes from
commercial sources.
A US national longitudinal study of adolescent health showed that stronger state level
tobacco policies on age of sale were associated with lower likelihood of smoking initiation
and adverse transition among low SES adolescent girls, although the effect sizes were small.
It is difficult to ascertain how access to tobacco translates into smoking prevalence and how
stricter enforcement of access laws would help to reduce the gap between low and high SES
in terms of smoking prevalence. Increasing age of sale and restricting youth access do not
appear to be widening the gap between high and low SES but the evidence is limited and
only two studies report smoking outcomes rather than supply outcomes.
42
3.2.5 School-based prevention
Five RCTs assessed the socio-economic impact of school-based smoking prevention
programmes. Two interventions were drug prevention programmes which included elements
of smoking prevention.45;46 One RCT examined the effects of a school-based drug prevention
programme which included smoking prevention in school children aged 11 years in Florida,
US.45 One quasi-randomised trial46 in 53 public secondary schools in northern Germany
evaluated the effects of two validated life skills programmes: ‘Fit and Strong for Life’ and
‘Lions Quest’.
Three intervention studies focused on smoking prevention. One RCT investigated whether a
peer group pressure and social influence intervention reduced the percentage of adolescents
who start to smoke, in the Netherlands.17 The European Smoking Prevention Framework
(ESFA) study assessed the impact of a social influence school-based intervention with
parental and community involvement on smoking uptake amongst adolescents in six
European countries.19 The ‘A Stop Smoking in Schools Trial’ (ASSIST) assessed the
effectiveness of a peer-led intervention that aimed to prevent smoking uptake in secondary
schools in England and Wales.18 Two of the studies did not report socioeconomic impact on
initial analyses; however a paper by Mercken et al.20 was identified which performed
secondary analyses of the socioeconomic impact of these three intervention studies17-19 using
the SES variables reported within the original primary studies.
The secondary analysis included a review to identify ‘high-quality European intervention
studies with clear overall effects that could be selected for secondary analyses'. Included
intervention studies had to be published in the international scientific literature in English
language, since 1995 and conducted in Europe since 1990. This procedure resulted in the
inclusion of three school-based intervention studies. The three studies were reanalysed using
the definitions of variables as defined in the original studies. Multilevel modelling
techniques were used; models were estimated using the restricted iterative generalized least
squares (RIGLS) estimation procedure combined with first-order penalized quasi-likelihood
within MLWin 2.10 beta. The multilevel model was tested separately for adolescents in each
of the categories of the included SES indicators.
It is unclear how representative all five study samples were of the respective study
populations. The groups in three of the studies17-19 had comparable characteristics at
baseline. Attrition rates were acceptable for three studies18;45;46 but relatively high for the
43
other two studies17;19. The ASSIST study was the only study to biochemically validate
measures of self-reported smoking, and scored highest for quality.18 It is likely that the
observed effects of each of the five interventions were attributable to the interventions.
Two studies evaluated school-based programmes which included elements of smoking
prevention: one based in the US and one in Germany.46 One RCT examined the effects of a
school-based drug prevention programme which included smoking prevention in school
children.45 The study was published as a paper presented at the Annual Conference of the
American Educational Research Association and assesses the impact of a school-based drug
prevention programme ‘Too Good for Drugs II’ (TGFD II) on student’s behaviours and risk
and protective factors. Students in six middle schools in Florida, US were randomised to 9
lesson units (40 minutes each) taught by a trained classroom teacher or TGFD II instructor;
including social and emotional competencies, reducing risk factors and building protective
factors; emphasising cooperative learning activities, role-play and skills building methods.
Students were followed-up 20 weeks after the 9 week intervention. The school-based
curriculum also involved community partners and parents; and the theoretical basis included
Social Learning Theory, Problem Behaviour Theory and Social Development Theory.
At the end of the intervention, 8% (48/588) of students in the intervention group indicated
greater likelihood of actual tobacco use compared with 12% (45/375) of students in the
control group, and this difference was statistically significant. There was no statistically
significant difference between the groups at 20 weeks follow-up. The overall findings of the
comparison of change scores for treatment students indicated the programme was similarly
effective in impacting on students risk and protective factors regardless of economic status
(perception of peer resistance skills; positive attitudes toward non-drug use, perceptions of
peer normative substance use, perceptions of peer disapproval of substance use, association
with prosocial peers, perceptions of locus of control self-efficacy).
A significant interaction effect for treatment students was seen between level of risk and
protective factor scores and SES (measured by free/reduced lunch status) at the end of
intervention and 20-week follow-up. Significant trends appeared between low and high SES
in the areas of ‘perceived peer norms’ and ‘perceived peer approval of substance use’ at the
end of the intervention and in addition with ‘association with prosocial peers’ at 20-week
follow-up. The direction of the effect by SES is not reported.
44
One RCT investigated whether a peer group pressure and social influence intervention
reduced the percentage of adolescents who start to smoke, in 26 junior secondary education
schools in the Netherlands.17 The intervention consisted of three lessons on knowledge,
attitudes, and social influence, followed by a class agreement not to start or to stop smoking
for five months and a class based competition.
At five months 9.6% of the non-smokers at baseline had started to smoke in the intervention
group, whereas 14.2% started to smoke in the control group (N = 1388, OR = 0.61, 95% CI
= 0.41–0.90). After 1-year follow-up, the effect was no longer significant. At 5 months,
smoking behaviour was significantly lower in adolescents who indicated that their parents
had mid to high completed education (OR = 0.35, 95% CI = 0.13–0.95). The intervention did
not result in smoking fewer cigarettes among adolescents who indicated that their parents
had lower education (OR = 0.80, 95% CI = 0.37–1.72). The additional analyses stratified by
gender and SES showed that the intervention was only effective at 5 months follow-up
among boys with higher parental educational levels (OR = 0.24, 95% CI = 0.07–0.79). All
significant intervention effects disappeared at 12 months follow-up.17
The ESFA study assessed the impact of a social influence school-based intervention with
parental and community involvement on smoking uptake amongst adolescents in six
European countries.19 In Finland, Denmark, UK and Portugal schools or regions were
randomly assigned whereas in Spain and The Netherlands the study design was quasirandomised. Since the strongest and significant long-term effects after 24 and 30 months
were found in the Portuguese sample, only data of the ESFA study in Portugal were
reanalysed on the impact by SES and so only results for Portugal are discussed within this
review.
The Portuguese intervention consisted of lessons on the effects of tobacco, reasons for (not)
smoking, social influence processes, refusal skills and decision making and a smoke-free
competition. Due to the fact that peer-led programmes were uncommon in the ESFA
countries, programmes were teacher-led. Teachers received 48 hours of training, a manual
and smoking cessation material. Schools received the ESFA no-smoking policy manual and
non-smoking posters. For the parents, information was offered on how to discuss nonsmoking with their adolescents. Pharmacists furthermore offered cessation courses for 150
parents. At the community level, the Portuguese Health Minister and mayor of the
community introduced the ESFA study on the national no smoking day.19
45
At 30 months, 41.8% of the never smokers at baseline had started to smoke in the
intervention group, compared to 53.8% of the never smokers at baseline in the control group
(N = 1304, OR = 0.62, 95% CI = 0.48–0.80). The results were mixed depending on the SES
indicator used (mother/father and full-time/not full-time jobs were not included as a measure
of SES in our review). The intervention was significant in reducing smoking uptake among
adolescents who indicated having no to only a low amount of spending money (OR = 0.62,
95% CI = 0.46–0.84). This statistically significant effect was not seen among adolescents
reporting receiving mid to high amounts of spending money (OR = 0.57, 95% CI = 0.32–
1.03). Although the actual odds ratio is smaller for the ‘mid to high’ spending money
subgroup compared with the ‘none to low’ spending money subgroup, the lack of
significance here is due to the wider confidence intervals, which are explained by the
relatively small numbers in the subgroup with ‘mid to high’ spending money (n=182).
Additional analyses stratified by gender and SES showed that the intervention was mostly
effective among girls.19 Pocket money was used as a proxy measure and there may not be a
strong association between adolescents’ pocket money and household income. As Mercken
et al.20 state; those adolescents with less pocket money may well have parents with higher
levels of education or income.
The ASSIST study assessed the effectiveness of a peer-led intervention that aimed to prevent
smoking uptake in secondary schools in S.W. England and Wales.18 Influential students were
trained by external professionals to act as peer supporters during informal interactions
outside the classroom to encourage peers not to smoke. During the 10-week intervention
period, peer supporters undertook informal conversations about smoking with their peers
when travelling to and from school, in breaks, at lunchtime and after school in their free
time.
At 1-year follow-up, the OR of being a smoker in intervention compared with control group
was 0·77 (95% CI 0·59–0·99). At 2-year follow-up, the corresponding OR of 0·85 (0·72–
1·01) was not significant (p=0·067). For the high-risk group (occasional, experimental, or
ex-smokers at baseline), the OR at 1-year follow-up was 0·75 (0·56–0·99) and at 2-year
follow-up was 0·85 (0·70–1·02). In a three-tier multi-level model using data from all three
follow-ups the odds of being a smoker in the intervention group compared with the control
group was 0.78 (95% CI = 0.64–0.96).18 The original primary study paper found no evidence
of a differential effect by FSM entitlement (0.99 (95% CI =0.65-1.51)).
46
The secondary data analysis20 combined data from the three follow-up periods and
conducted a multi-level analysis using three measures of SES: FAS, FSM and school located
in the Valleys (which are areas of deprivation). No significant main effect of the intervention
was found for FAS or FSM entitlement, though a trend was visible for FSM. The
intervention was significant among schools located in the valleys but not in schools in other
locations. Additional analyses showed that in Valley schools the intervention was also
effective among those with low FAS score, and a gender analysis showed that the
intervention was mostly effective among lower SES girls.
Summary
The overall findings from the five school-based studies are mixed in terms of the impact by
SES, the results also varied by the type of SES used to measure effect, and over time
(shorter-term benefit appeared to attenuate over time).
The findings from a substance abuse prevention programme set in schools were equally
effective for students regardless of SES, however the study did not ask about current
smoking behaviour and the outcome was intention to smoke in the next 12 months rather
than actual smoking behaviour.45 The results of this prevention programme relate to scores
for substance use which includes (but is not limited to) tobacco use and so this limits study
findings. A German study46 of two life skills programmes had a positive effect on smoking
prevention regardless of SES; with socially disadvantaged children benefitting equally
(neutral equity impact).
The Netherlands study had a significant effect among higher SES adolescents only and in the
short-term only, and appeared to widen inequalities (negative equity impact).17 The ESFA
study showed mixed results depending on the specific SES indicator used; when using
spending money as a SES indicator, the intervention did appear to decrease inequalities in
smoking.19 However, the amount of spending money which an adolescent has may not be
strongly associated with household income. For example, in Scotland low SES adolescents
have higher levels of disposable income than higher SES adolescents.47 ESFA interventions
differed between countries and Portugal received the most intensive teacher training; so
results may only be generalisable to that type of intervention in that country. Process
evaluation of ESFA included self-report of exposure to each element of the intervention and
showed it was reasonably likely that the observed effects were attributable to the schoolbased elements of the intervention rather than outside school elements.
47
The most promising findings in terms of equity impact were for ASSIST which used a social
network approach in which adolescents delivered the intervention. While this intervention
also showed mixed results depending on the specific SES indicator used, it was effective at
one year and most effective for adolescents in deprived areas, particularly among low SES
girls (positive equity impact). However, the beneficial effects of the intervention seemed to
attenuate over time.18
3.2.6 Multiple policy interventions
Three studies assessed the socio-economic impact of multiple policy interventions: two
repeat cross-sectional studies48;49 and a prospective cohort study.50 One repeat crosssectional study49 was set in Australia and examined the impact of tobacco control policy on
smoking prevalence. The other repeat cross-sectional study48 assessed the impact of the
1976 Tobacco Control Act (TCA) on smoking initiation across socioeconomic groups of
Finnish youth. A prospective cohort study described the association between smoking
intolerance in schools, restaurants and corner shops near secondary schools, and the
initiation of smoking in a convenience sample of adolescents (mean age 13 years) in
Montreal, Canada.50
The cohort study50 used a convenience sample and it was unclear whether the study sample
was representative of the study population or whether the study results are generalisable. The
Australian study49 reported changing retention rates which meant that the characteristics of
the student sample in school years 11 and 12 were likely to differ systematically across the
survey years, which could have affected the prevalence rates (instead of, or as well as,
tobacco control policy). Both the Australian and Finnish studies were large population
surveys with results that are likely to be generalisable at the national level.
An Australian national survey49 examined whether SES was associated with changes in
smoking prevalence among adolescents during three phases of tobacco control activity: low
tobacco-control funding (1992-1996) and high tobacco-control activity (1984-1991 and
1997-2005) which included smoking restrictions and increased tax. Random samples of
students aged 12 to 17 years from each Australian state and territory and three main
education sectors, completed anonymous surveys of cigarette use as part of a larger survey
assessing the use of alcohol and illicit drugs between 1987 and 2005. There was a significant
and substantial reduction in the likelihood of smoking among all SES groups for older (1617 years) and younger students (12-15 years) between 1987 and 2005. Overall, for younger
48
students (12-15) the reductions differed by SES (interactions p <0.01), with reductions in all
smoking behaviours, greater for students from higher SES groups. Among older students
(16-17), only the reductions in committed smoking (cigarette use on at least three of the
previous seven days) differed across SES groups (interaction p < 0.01), and again reductions
were greater among students from higher SES groups.
Between 1990 and 1996 the proportion of younger and older students involved with smoking
increased significantly. Among younger students, the increase in monthly and weekly
smoking was greater among lower SES students. Between 1996 and 2005 the prevalence of
monthly and weekly smoking decreased significantly among both younger and older
students, and these decreases were consistent across SES groups. The magnitude of the
decreases in smoking prevalence between 1996 and 2005 did not differ significantly between
SES groups for most indicators of smoking behaviour. For committed smoking, the
interaction between year and SES was of borderline significance for students from both age
groups, suggesting that the decrease may not be consistent across SES groups. It should be
noted that co-operation rates of the schools declined over time from 85% in 1987 to 63% in
2005 and the changing prevalence estimates might be the result of different survey samples.
A Finnish study48 assessed the impact of the 1976 TCA on smoking initiation across
socioeconomic groups. The TCA prohibited smoking in most public places, including public
transport; and the sale of tobacco products to those below 16 years of age; and required
obligatory health warnings on packages. The study used annual cross-sectional postal survey
data from 1978 to 2002 to assess the impact of the TCA on smoking prevalence (defined as
ever smoked daily for at least a year). The study authors defined the critical age range for
smoking initiation as 13 to 20 years. Most of the analyses were focussed on the three largest
socioeconomic groups (upper white collar workers, lower white collar workers, blue collar
workers manual workers).
Amongst men the secular cohort trend showed a decline in smoking only in upper white
collar workers before the TCA (stable for lower white collar and blue collar) and this trend
remained unchanged after the TCA, with no difference for the interaction between SES and
trend. Among women the secular cohort trend was increasing in each SES group before the
TCA and was reversed after the TCA, evenly across SES groups. For women, the general
cohort trend after the TCA differed from the secular cohort trend before the TCA, and this
differed by SES. In cohorts reaching the smoking initiation age after the TCA, the
49
prevalence of ever smoking remained relatively stable among white collar female workers
but tended to decline among blue collar female workers (OR 0.88; 95% CI: 0.72 to 1.02), in
contrast to the sharply increasing trend in older cohorts.
In terms of study validity, the average response rate during 1978 to 2002 was 70% among
men and 79% among women and the response rate declined during this period, in both
genders and all age groups. The decline was faster among men than women, and in younger
than older age groups, which may have biased the study results. Other tobacco control
policies came into force during the study period which could have influenced the study
results and explain some of the variability in smoking initiation by SES: the 1976 TCA was
supplemented by a total tobacco advertising ban in 1978, and the environmental tobacco
smoke amendment (of the TCA) in 1995. In addition, tobacco prices rose substantially (real
price increase 27%) in 1975–1976.
A Canadian study described the association between smoking intolerance (the extent to
which smoking is socially unacceptable) in schools, restaurants and corner stores near
schools and the initiation of smoking in adolescents. ‘The Natural History of Nicotine
Dependence in Teens Study’50 involved completion of questionnaires administered in the
classroom, every 3 months from 1999 to 2005 by students average age 13 years, in seven
English and three French language secondary public schools in Canada. The study used a
convenience sample which produced a 55% student response rate.
Students in smoking-intolerant schools (access and restrictions) were less likely to initiate
smoking than students in smoking-tolerant schools (Hazard ratio [HR] = 0.83; 95% CI: 0.68,
1.01). Students attending schools located in neighbourhoods with smoking-intolerant
restaurants were less likely to initiate smoking (HR 0.85; 95% CI: 0.68 to 1.07). There was
no association between corner store smoking intolerance and smoking initiation. The HR’s
for cigarette use initiation for low SES schools were not significant. However, there was a
25% loss to follow-up of students over the five years and these students were more likely to
attend a low SES school, which may have impacted on the results.
Summary
The Australian survey49 showed that the magnitude of the decreases in smoking prevalence
between 1996 and 2005 did not differ significantly between SES groups for most indicators
of smoking behaviour, but there may be differences between younger and older youth.
50
However, there appeared to be an association between level of tobacco control funding and
smoking prevalence. There was also some evidence that low tobacco control funding had a
negative equity effect on smoking prevalence among 12-15 year olds but not older students.
The Finnish TCA48 was associated with a reduction in smoking initiation across all SES
groups. Among men, the 1976 TCA appears to have had the greatest impact on male white
collar employees. Among women, the apparent effect was very pronounced in all
socioeconomic groups and among blue collar female workers the cohort trend tended to
decline.
A convenience sample of pupils in Canada50 showed that cigarette use initiation was
associated with levels of smoking intolerance in schools and communities but that this did
not differ by SES. But there was evidence of response bias by SES which may have
impacted on the results.
3.3 Impact of individual level cessation services and support on
smoking inequalities in youth
There were only two individual cessation support interventions identified for youth which
assessed smoking outcomes by SES, one set in New Zealand and one in USA: both of which
used text-messaging as the mode of intervention.
The New Zealand study51 aimed to determine the effectiveness of a mobile phone text
messaging smoking cessation programme which provided advice, support and distraction for
smokers who owned a mobile phone and who wanted to quit smoking. Participants were
aged 16 years and over, with a mean age of 25 years. The intervention included five free
personalised text messages per day for one week prior to a negotiated quit date and for four
weeks after the quit date. The control participants received one free month of text messaging
if they participated until 26 weeks. A total of 1,705 smokers were recruited from adverts on
websites, media, email and text messaging mailing lists; and posters at tertiary education
institutions.
The RR of not smoking in the past week was 2.20 (95% CI 1.79 to 2.70) at 6 weeks, 1.55
(95% CI 1.30 to 1.84) at 12 weeks and 1.07 (95% CI 0.91 to 1.26) at 26 weeks (when all
participants with missing status were assumed to be smoking). The RR of not smoking (in
the past week) at six weeks by income level was presented as a forest plot and showed no
51
difference in effect by income level; all income levels showed significant positive effects of
the intervention.
Biochemically verified abstinence was only performed on a random selection of participants
and showed over-reporting of quit rates but this over reporting was not different between the
intervention and control group. The quit rate at 6 weeks was 28.1% in the intervention group
compared with 12.8% in the control group. Assuming the rate of true quitters was the same
as in the sample assessed for cotinine levels, then the quit rate at 6 weeks was 13.9% in the
intervention group compared with 6.2% in the control group and the absolute difference in
quit rates at 6 weeks is reduced to 7.7% from 15.3%.
Only 74% (n=1265) of participants were followed-up at 26 weeks and the attrition rate
differed significantly between the groups at 12 weeks and at 26 weeks (69% in intervention
group vs 79% in control group at 26 weeks). This meant there was some uncertainty about
between group differences at 26 weeks. In addition reported quit rates increased amongst the
control group from 13% at 6 weeks to 24% at 26 weeks, however this would have led to an
underestimation of treatment effects and all methods of data analyses showed a significant
difference in quit rates in favour of the intervention.
The US study52 targeted a diverse sample of motivated daily smokers aged 18 to 25 years,
owning their own mobile phone and ‘seriously thinking about quitting in the next 30 days’.
Two hundred and eleven young adults were randomised from 585 eligible participants and
the final sample included 164 participants: 101 in the intervention group and 63 in the
control group; mean age 22 years, 56% male, with 43% reporting an annual household
income of less than $15,000.
The 6-week text-messaging intervention was tailored to each young adult smoker based on
their quitting stage. Intervention participants also had access to a ‘Text Buddy’ similar to
that used in the New Zealand study51 and ‘Text Crave’ (immediate, on-demand messages
aimed at helping the participant through a craving); and a project
website
(StopMySmoking.com). The control group received a similar number of text messages, but
message content was aimed at improving sleep and exercise habits within the context of how
it would help the participant quit smoking. Control group messages were not tailored nor
were Text Buddy and Text Crave components available.
52
Intervention participants were significantly more likely to have quit at 4 weeks post quit
(39%) than those in the control group (21%; adjusted odds ratio [aOR] = 3.33, 95% CI:
1.48, 7.45); and this was also the case for 7-day point prevalence (44% vs. 27%; aOR = 2.55,
95% CI: 1.22, 5.30). However the impact was not sustained, and 40% of the intervention
participants had a quit status verified by a ‘significant other’ compared with 30% in the
control arm at 3 months post-quit, which was not statistically significant (OR = 1.62, 95%
CI:0.82, 3.21). Cessation rates among intervention participants were stable between 4 weeks
and 12 weeks, but increased among control participants
The intervention appeared to be more effective in young adults not currently enrolled in
higher education settings (45% intervention vs. 26% control had quit at 3 months, p = .07;
aOR of verified quit at 3 months = 2.7, 95% CI: 1.0 to 7.4). The US study52 was a feasibility
study with a relatively small sample size so it was not sufficiently powered particularly to
detect differences in subgroup results. Eight participants were manually assigned to
treatment groups (rather than randomly) due to an imbalance within study subgroups.
Summary
Two studies of text messaging smoking cessation interventions were included, one set in the
USA and one in New Zealand. Participants in both studies were mobile phone owners in
their late teens to early twenties, who were motivated to quit smoking. The New Zealand
study control participants received a passive control (one month free text messaging) and US
control participants received a text-messaging service that was not tailored (intervention
participants received a tailored text-messaging service).
The New Zealand study showed personalised mobile phone text messaging support could
double quit rates at 6 weeks amongst young adult smokers who wanted to quit, irrespective
of income level. The effect was still significant at 12 weeks but not at 26 weeks, in addition
there was an increase in quit rates amongst the control group and significantly more
intervention participants were lost to follow-up at 26 weeks.
The US study of a tailored text-messaging intervention compared to a non-tailored textmessaging intervention, showed a significant increase in quit rates in intervention group
participants compared with control group participants at 6 weeks that were not sustained at
12 weeks. Quit rates increased in control group participants. However youth not enrolled in
higher education (i.e. lower SES) appeared to benefit from the tailored text messaging
53
intervention with significantly positive quit rates at 12 weeks compared to youth enrolled in
higher education.
The New Zealand study showed a short-term neutral equity effect and the US study showed
a short-term positive equity effect. Quit rates increased in the control groups in both studies.
It is unclear how representative either study samples were of each study population, however
both studies cut across all settings and all locations.
54
4 DISCUSSION
Only one review, the CRD review, has previously assessed the equity impact of tobacco
control policies on youth smoking. No intervention, including restrictions on smoking in
schools and restrictions on sales to minors, provided any evidence about possible differential
effects by parental income, occupation or educational level for the youth population. The
review presented in this report has systematically assessed the available evidence on the
impact of population- and individual-level tobacco control interventions on socioeconomic
inequalities in youth smoking. It identified 31 studies which have evaluated the impact of
population level prevention policies/interventions and two individual level cessation support
interventions, on smoking in young people by SES, measured by income, occupation or
education.
Before presenting the main review findings it is important to consider the
strengths and limitations of both the review and the available evidence.
4.1 Strengths and limitations of the review
Considerable attempts were made to include published and ‘in press’ studies. However, it is
possible that some relevant studies might have been missed which had not been published in
the peer reviewed literature and/or which were not published in English. It is also possible
that papers which undertook analyses by SES were not included because these analyses were
not mentioned in their abstract. However, this review goes beyond the previous CRD review
in including all types of youth interventions (prevention and cessation, population and
individual levels) and also searching for non-tobacco control interventions and polices (eg
education, social policy) which assessed any smoking-related equity impacts. It also
included ‘in press’ articles from four key journals and asked European tobacco control
experts to provide any other relevant peer reviewed articles (non-English language) or grey
literature. We also developed a modified quality assessment tool which was designed to
enable us to assess the quality of the diverse range of types of interventions and study
designs encompassed in the included studies.
4.2 Strengths and limitations of the available evidence
There are major limitations in the available evidence, most importantly the very small
number of studies which have considered the equity impact of tobacco control interventions
aimed at young people. In addition, there was a lack of consistency on the reported outcome
measures and length of follow-up. There was also considerable variation in the quality of the
studies (Section 7.6 Appendix G). Several of the studies were pilot or feasibility studies
55
and/or involved small numbers of participants. Thus, their findings may not be replicable.
For several important areas of youth tobacco control eg social marketing, multifaceted
community programmes, mass media approaches using social media, combating
smuggling/reducing the black market, smokefree homes interventions and most forms of
cessation support, we found no evidence on equity impact. Nearly half the studies were from
North America (US and Canada) and a third from the UK, which raises concerns about their
generalisability and potential transferability to, or relevance for, countries in Europe which
have different social and cultural contexts and/or different levels of tobacco control. Finally,
a range of indicators of SES was used in papers (e.g. education level, income, area
deprivation, and other indicators) which made comparisons between studies difficult. Most
studies used education income level as a measure of SES but levels of educational attainment
and income vary between countries and generations.
4.3 Main findings and conclusions
Relatively few intervention studies have assessed their impact on socioeconomic inequalities
in youth smoking or other smoking-related outcomes (eg exposure to second-hand smoke).
Out of the original 12, 605 identified papers (which also included papers focusing on adults)
only 33 studies met the inclusion criteria and were included in the review and none were
from outwith tobacco control (Figure 1 and Table 2). The literature was international, with
nearly half of the studies being carried out in North America. Studies also included the UK,
the Netherlands, France, Spain, Finland, Israel, New Zealand and Australia.
Of the 33 studies included in the review 31 were population level tobacco control
policies/interventions and 2 were individual level cessation support interventions. The types
of policies/intervention included were: smoking restrictions in cars, schools, workplaces and
other public places (9); controls on the advertising, promotion and marketing of tobacco (3);
mass media campaigns (1); increases in price/tax of tobacco products (6); controls on access
to tobacco products (5); school-based prevention programmes (5); multiple policy
interventions (3) and individual cessation support (2). (One study was included in two types
of policies/intervention category).
4.3.1 Positive equity impact
Only six of the 31 population-level studies showed the potential to produce a positive equity
impact i.e. to reduce inequalities in youth smoking. These ‘positive’ studies included three
US studies of increasing the price/tax of tobacco products,35;36;38 two US studies on age-of56
sales laws,40;44 and UK one school-based smoking prevention programme.18 Three US
studies of cigarette price/tax increases35;36;38 demonstrated a positive effect on low SES
youth of increasing price/tax to reduce smoking. A US prospective cohort study44 showed
that stronger state level tobacco policies on age of sale were associated with a lower
likelihood of smoking initiation and adverse transition among low SES adolescent girls,
although the effect sizes were small. A study of compliance with underage tobacco sales
laws in California40 showed that higher education was a significant predictor of underage
tobacco sales and youth in communities with higher educational levels may have easier
access to cigarettes from commercial sources. One school-based smoking prevention study
(ASSIST), using a peer-delivered intervention through social networks, appeared to reduce
smoking inequalities in school-children in England and Wales. However, results were mixed
depending on the specific SES indicator used.
4.3.2 Equity impact by type of tobacco control policy/intervention
Assessing the overall equity impact of different types of interventions/policies was
complicated by studies having different outcome measures and length of follow-up. In some
studies different outcomes varied in equity impact or the same SES measure and outcome
varied by gender or by setting. For example, one school-based prevention programme
showed a positive effect only in high SES girls and had the potential to widen inequalities.
Which specific measures of SES were used appeared to influence the results across all types
of policy interventions. The equity impact could also vary depending on the timing of the
outcome measurement. For example, two of the school-based prevention programmes found
that the effect varied across time points; with beneficial intervention effects attenuating over
time. Similarly both cessation interventions using text-messaging showed a significant
beneficial effect that was not sustained in the longer-term. Thus, the summary of the equity
impact of policies/interventions was derived ‘on balance’ (Appendices H and I).
Overall there was no consistent equity effect for each type of tobacco control
policy/intervention. Most interventions had, on balance, either a negative (11) or neutral (15)
equity impact. One had a mixed impact. However, it should be borne in mind that studies of
policies associated with a neutral equity effect indicate that these policies have benefits for
youth across SES groups. For example, both the English and Scottish national smokefree
legislation were associated with significant reductions in admissions for asthma across all
SES subgroups.
57

Smoking restrictions in cars, schools, workplaces and other public places- None of
the nine studies showed a positive equity impact. Four had a negative equity impact,
four had a neutral impact, and one had both negative and neutral impacts. The studies
indicate that the equity impact of comprehensive smoking legislation in public places
may differ depending on the pre-ban level of exposure and the balance between
sources of exposure i.e. public places versus the home. While comprehensive
smoking restrictions can reduce overall SHS exposure across all SES groups of
children. Changes in smoking restrictions in homes and cars following UK
smokefree legislation did not appear to be patterned by SES in pooled analyses,
however smoking in homes and cars remains more prevalent amongst children from
low SES families. Evidence shows that there is significant variation by SES in levels
of exposure prior to smokefree legislation with higher levels of exposure in lower
SES. Whether exposure is measured in relative or absolute terms appears to influence
the equity impact results. However, there is some evidence that smokefree legislation
can also have a neutral equity impact in terms of increasing voluntary smoking
restrictions in cars. The evidence also suggests that where there are no
comprehensive smoking restrictions in schools or where there is variable compliance
with voluntary bans; inequity in smoking will continue.

Controls on the advertising, promotion and marketing of tobacco- Two of the studies
had a negative equity impact and one had a neutral impact. The three studies were
very different with one indicating that tobacco companies marketing expenditure may
be associated with an increase in smoking initiation especially in young people with
lower levels of education. Another study found that despite an FDA buffer zone
policy to protect children from tobacco advertising, tobacco advertising was
specifically targeted at adolescents of low SES inside school buffer zones and that
this has the potential to increase inequality in smoking amongst youth. This would
indicate that banning all tobacco advertising would be particularly beneficial for low
SES children. There was also some tentative support from one study that introducing
plain packaging would have a similar impact across all SES groups.

Mass media campaigns- only one study assessed the equity impact of a mass media
campaign, the Truth campaign. The overall equity impact was difficult to assess but
there was a neutral equity impact in terms of receptivity.

Increases in price/tax of tobacco products - the majority of evidence on price/tax is
from the US, and suggests that there is variation in the equity impact of increases in
58
cigarette tax or price on youth smoking behaviour and variation in smoking
behaviour amongst youth of different ages and different SES groups. Low income
youth were not consistently more responsive to tax/price increases compared with
high income youth: youth of lower SES were not more likely to stop smoking when
cigarette prices/taxes increased. The inconsistency within the evidence could reflect a
true effect or measurement errors such as failure to capture youth behavioural
reactions in retrospective recall studies.

Controls on access to tobacco products- Reducing access to cigarettes through
increasing the minimum age of sale, including vending machines sales, may impact
on youth sales but the inconsistent evidence from the UK and US studies make it
difficult to draw conclusions about whether they also reduce youth smoking
inequalities.

School-based prevention programmes-only one study (ASSIST) had promising
findings in terms of a positive equity impact. The other studies findings were
inconsistent, varied by type of SES measure used and attenuated over time.

Multiple policy interventions- these were three very different studies (two national
and one at community level) in three different countries looking at different types of
policies which makes it difficult to draw any conclusions about the equity impact of
multiple policy interventions.

Individual cessation support- only two studies were included which evaluated
individual level smoking cessation support for youth. Both of these interventions
used text messaging. The US study showed a short-term (12 weeks) neutral equity
impact and the New Zealand study showed a short-term (12 weeks) positive equity
impact but this was not significant at 26 weeks. Their equity impacts should be
viewed with caution given that the representativeness of both study samples were
unclear: both sample participants were motivated young adults who owned a mobile
phone. However text messaging interventions have the potential to reach large
numbers of young smokers.
59
5 CONCLUSIONS
Thirty-three studies were included which evaluated the effect of policies and interventions to
prevent or stop youth smoking by SES. Only six of the 31 population level studies showed
the potential to reduce inequalities in youth smoking; including three on increasing the
price/tax of cigarettes, enforcing strong policies on age-of-sale, and one school-based
prevention study (ASSIST). There were only two individual level cessation support
interventions identified for youth which assessed smoking outcomes by SES. Both cessation
studies used text messaging. One showed a neutral equity impact and the other showed a
positive equity impact. There was variation in the equity impact of each type of tobacco
control policy/intervention.
The limited nature and extent of the evidence base considerably constrains what conclusions
can be drawn about which types of tobacco control polices/interventions are likely to reduce
inequalities in youth smoking. Very few studies have assessed the equity impact of policies
and interventions on smoking prevention or cessation in youth. There is therefore little
available evidence to inform tobacco control policy and interventions that are aimed at
reducing socioeconomic inequalities in youth smoking. There is a need to strengthen the
evidence base for the equity impact of tobacco control interventions aimed at young people.
The review provides very little evidence to suggest that any specific policies would be able
to reduce inequalities in smoking initiation.
60
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daily smokers who did not quit react? The case of students of South-Eastern France.
Drugs: Education, Prevention & Policy 2010; .17(5).
63
(40) Lipperman-Kreda S, Grube JW, Friend KB. Contextual and community factors
associated with youth access to cigarettes through commercial sources. Tobacco
Control Online First . 2012. R
(41) Widome R, Brock B, Noble P, Forster JL. The Relationship of Point-of-Sale Tobacco
Advertising and Neighborhood Characteristics to Underage Sales of Tobacco.
Evaluation and the Health Professions 2012; 35(3):September.
(42) Millett C, Lee JT, Gibbons DC, Glantz SA. Increasing the age for the legal purchase
of tobacco in England: impacts on socio-economic disparities in youth smoking.
Thorax 2011; 66(10):862-865.
(43) Schneider S, Gruber J, Yamamoto S, Weidmann C. What happens after the
implementation of electronic locking devices for adolescents at cigarette vending
machines? A natural longitudinal experiment from 2005 to 2009 in Germany.
Nicotine & Tobacco Research 2011; 13(8):732-740.
(44) Kim H, Clark PI. Cigarette smoking transition in females of low socioeconomic
status: impact of state, school, and individual factors. Journal of Epidemiology &
Community Health 2006; 60:Suppl-9.
(45) Bacon TP, Hilderbrand JA. Impact of a School-Based Drug Prevention Program on
Students' Behaviors and Risk and Protective Factors. 1-4-2001.
(46) Menrath I, Mueller-Godeffroy E, Pruessmann C, Ravens-Sieberer U, Ottova V,
Pruessmann M et al. Evaluation of school-based life skills programmes in a high-risk
sample: A controlled longitudinal multi-centre study. Journal of Public Health
(Germany) 2012; 20(2):April.
(47) West P, Sweeting H, Young R. Smoking in Scottish youths: personal income,
parental social class and the cost of smoking. Tobacco Control 16, 329-335. 2007.
(48) Helakorpi S, Martelin T, Torppa J, Vartiainen E, Uutela A, Patja K. Impact of the
1976 Tobacco Control Act in Finland on the proportion of ever daily smokers by
socioeconomic status. Preventive Medicine 2008; 46(4):340-345.
(49) White VM, Hayman J, Hill DJ. Can population-based tobacco-control policies
change smoking behaviors of adolescents from all socio-economic groups? Findings
from Australia: 1987-2005. Cancer Causes & Control 2008; 19(6):631-640.
(50) Pabayo R, O'Loughlin J, Barnett TA, Cohen JE, Gauvin L. Does Intolerance of
Smoking at School, or in Restaurants or Corner Stores Decrease Cigarette Use
Initiation in Adolescents? Nicotine Tobacco Res 2012; first published online
February 21, 2012(7).
(51) Rodgers A, Corbett T, Bramley D, Riddell T, Wills M, Lin RB et al. Do u smoke
after txt? Results of a randomised trial of smoking cessation using mobile phone text
messaging. Tobacco Control 2005; 14(4):255-261.
(52) Ybarra ML, Holtrop JS, Prescott TL, Rahbar MH, Strong D. Pilot RCT Results of
Stop My Smoking USA: A Text Messaging–Based Smoking Cessation Program for
Young Adults. Nicotine & Tobacco Research Advance Access. 2013.
64
7 APPENDICES
7.1 Appendix A Search strategies: electronic searches, handsearching
and searching for grey literature
Electronic searches
Ovid MEDLINE(R) In-Process & Other Non-Indexed Citations and Ovid MEDLINE(R) 1946 to
May 04 2012, search date 09/05/2012; also Ovid MEDLINE(R) 1946 to January week 3, 2013,
search date 23/01/2013
1. smoking/
2. smoking cessation/
3. tobacco/
4. "Tobacco Use Disorder"/
5. nicotine/
6. tobacco, smokeless/
7. tobacco use, cessation/
8. (smokers or smoker).ti,ab.
9. cigar$.mp.
10. smoking.ti,ab.
11. or/1-10
12. smoking cessation/
13. tobacco use, cessation/
14. tobacco use, cessation products/
15. smoking/pc
16. smoking/dt
17. smoking/th
18. ((smok$ or anti smok$ or tobacco or cigarette$) adj3 (ban or bans or prohibit$ or restrict$ or
discourage$)).ti,ab.
19. ((smok$ or anti smok$ or tobacco or cigarette$) adj3 (workplace or work place or work site or
worksite)).ti,ab.
20. ((smok$ or anti smok$ or tobacco or cigarette$) adj3 (public place$ or public space$ or public
area$ or office$ or school$ or institution$)).ti,ab.
21. ((smok$ or anti smok$ or tobacco or cigarette$) adj3 (legislat$ or government$ or authorit$ or
law or laws or bylaw$ or byelaw$ or bye law$ or regulation$)).ti,ab.
22. ((tobacco free or smoke free) adj3 (hospital or inpatient or outpatient or institution$)).ti,ab.
23. ((tobacco-free or smoke-free) adj3 (facilit$ or zone$ or area$ or site$ or place$ or environment$
or air)).ti,ab.
24. ((tobacco or smok$ or cigarette$) adj3 (campaign$ or advertis$ or advertiz$)).ti,ab.
25. ((billboard$ or advertis$ or advertiz$ or sale or sales or sponsor$) adj3 (restrict$ or limit$ or ban
or bans or prohibit$)).ti,ab.
26. (tobacco control adj3 (program$ or initiative$ or policy or policies or intervention$ or activity or
activities or framework)).ti,ab.
27. ((smok$ or tobacco) adj (policy or policies or program$)).ti,ab.
28. ((retailer$ or vendor$) adj3 (educat$ or surveillance$ or prosecut$ or legislat$)).ti,ab.
29. test purchas$.ti,ab.
30. voluntary agreement$.ti,ab.
31. health warning$.ti,ab.
32. ((tobacco or cigarette$) adj3 (tax or taxes or taxation or excise or duty free or duty paid or
customs)).ti,ab.
33. ((cigarette$ or tobacco) adj3 (packaging or packet$)).ti,ab.
34. ((cigarette$ or tobacco) adj3 (marketing or marketed)).ti,ab.
35. ((cigarette$ or tobacco) adj3 (price$ or pricing)).ti,ab.
36. point of sale.ti,ab.
37. vending machine$.ti,ab.
65
38. (trade adj (restrict$ or agreement$)).ti,ab.
39. (contraband$ or smuggl$ or bootleg$ or cross border shopping).ti,ab.
40. (tobacco control act or clean air or clean indoor air).ti,ab.
41. ((reduce$ or prevent$) adj3 (environmental tobacco smoke or passive smok$ or secondhand
smok$ or second hand smok$ or SHS)).ti,ab.
42. ((population level or population based or population orientated or population oriented) adj3
(intervention$ or prevention or policy or policies or program$ or project$)).ti,ab.
43. (community adj3 (intervention$ or prevention or policy or policies or program$ or
project$)).ti,ab.
44. ((sale or sales or retail$ or purchas$) adj3 (minors or teenage$ or underage$ or under-age$ or
child$)).ti,ab.
45. (youth access adj3 restrict$).ti,ab.
46. (smoking cessation or cessation support).ti,ab.
47. (smokefree or smoke-free or smoke free).ti,ab.
48. ((stop$ or quit$ or reduc$ or give up or giving up) adj3 (cigarette$ or tobacco or smoking)).ti,ab.
49. quit attempt$.ti,ab.
50. tobacco quit.ti,ab.
51. quit rate$.ti,ab.
52. (quitline$ or quit line$ or quit-line$).ti,ab.
53. ((smok$ or tobacco or nicotine or cigarette$) adj2 (abstinence or cessation)).ti,ab.
54. or/12-53
55. (socioeconomic or socio economic or socio-economic).ti,ab.
56. inequalit$.ti,ab.
57. depriv$.ti,ab.
58. disadvantage$.ti,ab.
59. educat$.ti,ab.
60. (social adj (class$ or group$ or grade$ or context$ or status)).ti,ab.
61. (employ$ or unemploy$).ti,ab.
62. income.ti,ab.
63. poverty.ti,ab.
64. SES.ti,ab.
65. demographic$.ti,ab.
66. (uninsur$ or insur$).ti,ab.
67. minorit$.ti,ab.
68. poor.ti,ab.
69. affluen$.ti,ab.
70. equity.ti,ab.
71. (underserved or under served or under-served).ti,ab.
72. occupation$.ti,ab.
73. (work site or worksite or work-site).ti,ab.
74. (work place or workplace or work-place).ti,ab.
75. (work force or workforce or work-force).ti,ab.
76. (high risk or high-risk or at risk).ti,ab.
77. (marginalised or marginalized).ti,ab.
78. (social$ adj (disadvant$ or exclusion or excluded or depriv$)).ti,ab.
79. exp socioeconomic factors/
80. exp public assistance/
81. exp social welfare/
82. vulnerable populations/
83. or/55-82
84. 11 and 54
85. 83 and 84
86. limit 85 to (abstracts and english language and yr="1990 -Current")
66
Embase; Excerpta Medica Database Guide, 1980 to 2012 Week 18, search date 09/05/2012; also
1980 to 2013 week 3, search date 23/01/2013
1. smoking/
2. smoking cessation/
3. tobacco/
4. nicotine/
5. tobacco, smokeless/
6. "smoking and smoking related phenomena"/
7. cigarette smoking/
8. cigarette smoke/
9. tobacco smoke/
10. (smokers or smoker).ti,ab.
11. cigar$.mp.
12. smoking.ti,ab.
13. or/1-12
14. smoking cessation program/
15. ((smok$ or anti smok$ or tobacco or cigarette$) adj3 (ban or bans or prohibit$ or restrict$ or
discourage$)).ti,ab.
16. ((smok$ or anti smok$ or tobacco or cigarette$) adj3 (workplace or work place or work site or
worksite)).ti,ab.
17. ((smok$ or anti smok$ or tobacco or cigarette$) adj3 (public place$ or public space$ or public
area$ or office$ or school$ or institution$)).ti,ab.
18. ((smok$ or anti smok$ or tobacco or cigarette$) adj3 (legislat$ or government$ or authorit$ or
law or laws or bylaw$ or byelaw$ or bye law$ or regulation$)).ti,ab.
19. ((tobacco free or smoke free) adj3 (hospital or inpatient or outpatient or institution$)).ti,ab.
20. ((tobacco-free or smoke-free) adj3 (facilit$ or zone$ or area$ or site$ or place$ or environment$
or air)).ti,ab.
21. ((tobacco or smok$ or cigarette$) adj3 (campaign$ or advertis$ or advertiz$)).ti,ab.
22. ((billboard$ or advertis$ or advertiz$ or sale or sales or sponsor$) adj3 (restrict$ or limit$ or ban
or bans or prohibit$)).ti,ab.
23. (tobacco control adj3 (program$ or initiative$ or policy or policies or intervention$ or activity or
activities or framework)).ti,ab.
24. ((smok$ or tobacco) adj (policy or policies or program$)).ti,ab.
25. ((retailer$ or vendor$) adj3 (educat$ or surveillance$ or prosecut$ or legislat$)).ti,ab.
26. test purchas$.ti,ab.
27. voluntary agreement$.ti,ab.
28. health warning$.ti,ab.
29. ((tobacco or cigarette$) adj3 (tax or taxes or taxation or excise or duty free or duty paid or
customs)).ti,ab.
30. ((cigarette$ or tobacco) adj3 (packaging or packet$)).ti,ab.
31. ((cigarette$ or tobacco) adj3 (marketing or marketed)).ti,ab.
32. ((cigarette$ or tobacco) adj3 (price$ or pricing)).ti,ab.
33. point of sale.ti,ab.
34. vending machine$.ti,ab.
35. (trade adj (restrict$ or agreement$)).ti,ab.
36. (contraband$ or smuggl$ or bootleg$ or cross border shopping).ti,ab.
37. (tobacco control act or clean air or clean indoor air).ti,ab.
38. ((reduce$ or prevent$) adj3 (environmental tobacco smoke or passive smok$ or secondhand
smok$ or second hand smok$ or SHS)).ti,ab.
39. ((population level or population based or population orientated or population oriented) adj3
(intervention$ or prevention or policy or policies or program$ or project$)).ti,ab.
40. (community adj3 (intervention$ or prevention or policy or policies or program$ or
project$)).ti,ab.
67
41. ((sale or sales or retail$ or purchas$) adj3 (minors or teenage$ or underage$ or under-age$ or
child$)).ti,ab.
42. (youth access adj3 restrict$).ti,ab.
43. (smoking cessation or cessation support).ti,ab.
44. (smokefree or smoke-free or smoke free).ti,ab.
45. ((stop$ or quit$ or reduc$ or give up or giving up) adj2 (cigarette$ or tobacco or smoking)).ti,ab.
46. tobacco quit.ti,ab.
47. quit attempt$.ti,ab.
48. quit rate$.ti,ab.
49. (quit line$ or quitline$ or quit-line$).ti,ab.
50. ((smok$ or tobacco or nicotine or cigarette$) adj2 (abstinence or cessation)).ti,ab.
51. or/14-50
52. (socioeconomic or socio economic or socio-economic).ti,ab.
53. inequalit$.ti,ab.
54. depriv$.ti,ab.
55. disadvantage$.ti,ab.
56. educat$.ti,ab.
57. (social adj (class$ or group$ or grade$ or context$ or status)).ti,ab.
58. (employ$ or unemploy$).ti,ab.
59. income.ti,ab.
60. poverty.ti,ab.
61. SES.ti,ab.
62. demographic$.ti,ab.
63. (uninsur$ or insur$).ti,ab.
64. minorit$.ti,ab.
65. poor.ti,ab.
66. affluen$.ti,ab.
67. equity.ti,ab.
68. (underserved or under served or under-served).ti,ab.
69. occupation$.ti,ab.
70. (work site or worksite or work-site).ti,ab.
71. (work place or workplace or work-place).ti,ab.
72. (work force or workforce or work-force).ti,ab.
73. (high risk or high-risk or at risk).ti,ab.
74. (marginalised or marginalized).ti,ab.
75. (social$ adj (disadvant$ or exclusion or excluded or depriv$)).ti,ab.
76. exp socioeconomics/
77. public assistance/
78. welfare, social/
79. exp social status/
80. social security/
81. vulnerable population/
82. or/52-81
83. 13 and 51
84. 82 and 83
85. limit 84 to (abstracts and english language and yr="1990 -Current")
68
PsycInfo (OVID) 1987 to May Week 1 2012, search date 10/05/2012; also 1987 to January week 3
2013, search date 23/01/2013
1. exp tobacco smoking/
2. exp smoking cessation/
3. nicotine/
4. tobacco, smokeless/
5. (smokers or smoker).ti,ab.
6. tobacco.ti,ab.
7. nicotine.ti,ab.
8. cigar$.mp.
9. smoking.ti,ab.
10. or/1-9
11. exp smoking cessation/
12. ((smok$ or anti smok$ or tobacco or cigarette$) adj3 (ban or bans or prohibit$ or restrict$ or
discourage$)).ti,ab.
13. ((smok$ or anti smok$ or tobacco or cigarette$) adj3 (workplace or work place or work site or
worksite)).ti,ab.
14. ((smok$ or anti smok$ or tobacco or cigarette$) adj3 (public place$ or public space$ or public
area$ or office$ or school$ or institution$)).ti,ab.
15. ((smok$ or anti smok$ or tobacco or cigarette$) adj3 (legislat$ or government$ or authorit$ or
law or laws or bylaw$ or byelaw$ or bye law$ or regulation$)).ti,ab.
16. ((tobacco free or smoke free) adj3 (hospital or inpatient or outpatient or institution$)).ti,ab.
17. ((tobacco-free or smoke-free) adj3 (facilit$ or zone$ or area$ or site$ or place$ or environment$
or air)).ti,ab.
18. ((tobacco or smok$ or cigarette$) adj3 (campaign$ or advertis$ or advertiz$)).ti,ab.
19. ((billboard$ or advertis$ or advertiz$ or sale or sales or sponsor$) adj3 (restrict$ or limit$ or ban
or bans or prohibit$)).ti,ab.
20. (tobacco control adj3 (program$ or initiative$ or policy or policies or intervention$ or activity or
activities or framework)).ti,ab.
21. ((smok$ or tobacco) adj (policy or policies or program$)).ti,ab.
22. ((retailer$ or vendor$) adj3 (educat$ or surveillance$ or prosecut$ or legislat$)).ti,ab.
23. test purchas$.ti,ab.
24. voluntary agreement$.ti,ab.
25. health warning$.ti,ab.
26. ((tobacco or cigarette$) adj3 (tax or taxes or taxation or excise or duty free or duty paid or
customs)).ti,ab.
27. ((cigarette$ or tobacco) adj3 (packaging or packet$)).ti,ab.
28. ((cigarette$ or tobacco) adj3 (marketing or marketed)).ti,ab.
29. ((cigarette$ or tobacco) adj3 (price$ or pricing)).ti,ab.
30. point of sale.ti,ab.
31. vending machine$.ti,ab.
32. (trade adj (restrict$ or agreement$)).ti,ab.
33. (contraband$ or smuggl$ or bootleg$ or cross border shopping).ti,ab.
34. (tobacco control act or clean air or clean indoor air).ti,ab.
35. ((reduce$ or prevent$) adj3 (environmental tobacco smoke or passive smok$ or secondhand
smok$ or second hand smok$ or SHS)).ti,ab.
36. ((population level or population based or population orientated or population oriented) adj3
(intervention$ or prevention or policy or policies or program$ or project$)).ti,ab.
37. (community adj3 (intervention$ or prevention or policy or policies or program$ or
project$)).ti,ab.
38. ((sale or sales or retail$ or purchas$) adj3 (minors or teenage$ or underage$ or under-age$ or
child$)).ti,ab.
39. (youth access adj3 restrict$).ti,ab.
40. (smoking cessation or cessation support).ti,ab.
69
41. (smokefree or smoke-free or smoke free).ti,ab.
42. ((stop$ or quit$ or reduc$ or give up or giving up) adj3 (cigarette$ or tobacco or smoking)).ti,ab.
43. quit attempt$.ti,ab.
44. tobacco quit.ti,ab.
45. quit rate$.ti,ab.
46. (quitline$ or quit line$ or quit-line$).ti,ab.
47. ((smok$ or tobacco or nicotine or cigarette$) adj2 (abstinence or cessation)).ti,ab.
48. or/11-47
49. (socioeconomic or socio economic or socio-economic).ti,ab.
50. inequalit$.ti,ab.
51. depriv$.ti,ab.
52. disadvantage$.ti,ab.
53. educat$.ti,ab.
54. (social adj (class$ or group$ or grade$ or context$ or status)).ti,ab.
55. (employ$ or unemploy$).ti,ab.
56. income.ti,ab.
57. poverty.ti,ab.
58. SES.ti,ab.
59. demographic$.ti,ab.
60. (uninsur$ or insur$).ti,ab.
61. minorit$.ti,ab.
62. poor.ti,ab.
63. affluen$.ti,ab.
64. equity.ti,ab.
65. (underserved or under served or under-served).ti,ab.
66. occupation$.ti,ab.
67. (work site or worksite or work-site).ti,ab.
68. (work place or workplace or work-place).ti,ab.
69. (work force or workforce or work-force).ti,ab.
70. (high risk or high-risk or at risk).ti,ab.
71. (marginalised or marginalized).ti,ab.
72. (social$ adj (disadvant$ or exclusion or excluded or depriv$)).ti,ab.
73. exp socioeconomic status/
74. poverty/
75. disadvantaged/
76. or/49-75
77. 10 and 48
78. 76 and 77
79. limit 78 to (english language and abstracts and yr="1990 - 2012")
70
Cochrane Library 2012 (Cochrane Database of Systematic Reviews; Database of Abstracts of
Reviews of Effects; Cochrane Central Register of Controlled Trials; Health Technology Assessment
Database), search date 10/05/12
#1
MeSH descriptor Smoking, this term only
#2
MeSH descriptor Tobacco Use Cessation explode all trees
#3
MeSH descriptor Tobacco explode all trees
#4
MeSH descriptor Tobacco Use Disorder, this term only
#5
MeSH descriptor Nicotine, this term only
#6
(smoking or smokers or smoker or tobacco or cigar* or nicotine)
#7
(#1 OR #2 OR #3 OR #4 OR #5 OR #6)
#8
(smok* or anti-smok* or tobacco or cigarette*) near3 (ban or bans or prohibit* or restrict* or
discourage*)
#9
(smok* or anti-smok* or tobacco or cigarette*) near3 (workplace or work place or worksite)
#10
(smok* or anti-smok* or tobacco or cigarette*) near3 (public next place*)
#11
(smok* or anti-smok* or tobacco or cigarette*) near3 (public next space)
#12
(smok* or anti-smok* or tobacco or cigarette*) near3 (public next area*)
#13
(smok* or anti-smok* or tobacco or cigarette*) near3 (office* or school* or institution*)
#14
(smok* or anti-smok* or tobacco or cigarette*) near3 (legislat* or government* or authorit*
or law or laws or bylaw* or byelaw* or bye-law* or regulation*)
#15
(tobacco-free or smoke-free) near3 (hospital* or inpatient* or outpatient* or institution*)
#16
(tobacco-free or smoke-free) near3 (facility* or zone* or area* or site* or place* or
environment* or air)
#17
(tobacco or smok* or cigarette*) near3 (campaign* or advertis* or advertiz*)
#18
(billboard* or advertis* or advertiz* or sale or sales or sponsor*) near3 (restrict* or limit* or
ban or bans or prohibit*)
#19
(tobacco next control) near3 (program* or initiative* or policy or policies or intervention* or
activity or activities or framework)
#20
(smok* or tobacco) next (policy or policies or program*)
#21
(retailer* or vendor*) near3 (educat* or surveillance or prosecut* or legslat*)
#22
test next purchas* in All Fields or (voluntary next agreement*)
#23
(sale or sales or retail* or purchas*) near3 (minors or teenage* or underage* or under-age*
or child*)
#24
(youth near3 access) near3 restrict*
#25
health next warning*
#26
(tobacco or cigarette*) near3 (tax or taxes or taxation or excise or duty-free or duty-paid or
customs)
#27
(cigarette* or tobacco) near3 (packaging or packet*)
#28
(cigarette* or tobacco) near3 (marketing or marketed)
#29
(cigarette* or tobacco) near3 (price* or pricing)
#30
"point of sale"
#31
vending next machine*
#32
trade near3 (restrict* or agreement*)
#33
contraband* or smuggl* or bootleg* or (cross-border next shopping)
#34
"tobacco control act" or "clean air" or "clean indoor air"
#35
reduce* near3 "environmental tobacco smoke" or (passive next smok*) or (secondhand next
smok*) or (second next hand next smok*) or SHS
#36
prevent* near3 "environmental tobacco smoke" or (passive next smok*) or (secondhand next
smok*) or (second next hand next smok*) or SHS
#37
(population next level) near3 (intervention* or prevention or policy or policies or program*
or project*)
#38
(population next based) near3 (intervention* or prevention or policy or policies or program*
or project*)
#39
(population next orientated) near3 (intervention* or prevention or policy or policies or
program* or project*)
71
#40
(community next level) near3 (intervention* or prevention or policy or policies or program*
or project*)
#41
(community next based) near3 (intervention* or prevention or policy or policies or program*
or project*)
#42
(community next orientated) near3 (intervention* or prevention or policy or policies or
program* or project*)
#43
(community next oriented) near3 (intervention* or prevention or policy or policies or
program* or project*)
#44
smoking next cessation or cessation next support
#45
smokefree or smoke-free or smoke next free
#46
(stop* or quit* or reduc* or give next up or giving next up) near3 (cigarette* or tobacco or
smoking)
#47
quit next attempt*
#48
tobacco next quit
#49
quit next rate*
#50
quitline* or quit-line* or quit next line*
#51
(smok* or tobacco or nicotine or cigarette*) near2 (abstinence or cessation)
#52
(#8 OR #9 OR #10 OR #11 OR #12 OR #13 OR #14 OR #15 OR #16 OR #17 OR #18 OR
#19 OR #20 OR #21 OR #22 OR #23 OR #24 OR #25 OR #26 OR #27 OR #28 OR #29 OR #30 OR
#31 OR #32 OR #33 OR #34 OR #35 OR #36 OR #37 OR #38 OR #39 OR #40 OR #41 OR #42 OR
#43 OR #44 OR #45 OR #46 OR #47 OR #48 OR #49 OR #50 OR #51)
#53
socioeconomic or socio next economic or socio-economic
#54
inequalit*
#55
depriv*
#56
disadvantage*
#57
educat*
#58
social next (class* or group* or grade* or context* or status)
#59
employ* or unemploy*
#60
income
#61
poverty
#62
SES
#63
demographic*
#64
insur* or uninsur*
#65
minorit*
#66
poor
#67
affluen*
#68
equity
#69
underserved or under next served or under-served
#70
occupation*
#71
work next site or worksite or work-site
#72
work next place or workplace or work-place
#73
work next force or workforce or work-force
#74
high next risk or high-risk or at next risk
#75
marginalised or marginalized
#76
social* next (disadvant* or exclusion or excluded or depriv*)
#77
MeSH descriptor Socioeconomic Factors explode all trees
#78
MeSH descriptor Public Assistance, this term only
#79
MeSH descriptor Social Welfare, this term only
#80
MeSH descriptor Vulnerable Populations, this term only
#81
(#53 OR #54 OR #55 OR #56 OR #57 OR #58 OR #59 OR #60 OR #61 OR #62 OR #63 OR
#64 OR #65 OR #66 OR #67 OR #68 OR #69 OR #70 OR #71 OR #72 OR #73 OR #74 OR #75 OR
#76 OR #77 OR #78 OR #79 OR #80)
#82
(#7 AND #52)
#83
(#81 and #82), from 1990 to 2012
72
Science Citation Index Expanded, Social Sciences Citation Index, Conference Proceedings Citation
Index (Science, and Social Science & Humanities), in Web of Science hosted on ISI Web of
Knowledge, search date 10/05/12
(TS=(smoking or smokers or smoker or tobacco or cigar* or nicotine) AND TS=(abstinence or
cessation or quit*) AND TS=(socioeconomic or socio economic or socio-economic)) AND
Language=(English), Timespan=1990-2012
BIOSIS Previews hosted on ISI Web of Knowledge, search date 10/05/12
(TS=(smoking or smokers or smoker or tobacco or cigar* or nicotine) AND TS=(abstinence or
cessation or quit*) AND TS=(socioeconomic or socio economic or socio-economic)) AND
Language=(English), Timespan=1990-2012
CINAHL Plus (EBSCO host) search date 10/05/12
S8 S5 AND S9, Limiters - Published Date from: 19900101-20121231
S9 S6 OR S7 OR S8
S8 TX social* W1 (disadvantage* or exclusion or excluded or depriv*)
S7 TX social W1 (class* or group* or grade* or context* or status)
S6 (MH "Socioeconomic Factors") OR "SOCIOECONOMIC" OR (MH "Poverty") OR "POVERTY"
OR "EQUITY"
S5 S1 OR S2 OR S3 OR S4
S4 TX (stop* or quit* or reduc* or give up or giving up) W3 (cigarette* or tobacco or smoking)
S3 TX Smoking W1 cessation
S2 (MH "Tobacco, Smokeless") OR (MH "Tobacco Abuse Control (Saba CCC)") OR (MH "Risk
Control: Tobacco Use (Iowa NOC)") OR (MH "Passive Smoking")
S1 (MH "Smoking Cessation Programs") OR (MH "Smoking Cessation") OR (MH "Smoking
Cessation Assistance (Iowa NIC)")
ERIC (EBSCO Host) search date 11/05/12
S10 S8 and S9
S9 S4 or S5 or S6 or S7
S8 S1 or S2 or S3
S7 AB Socioeconomic OR AB Poverty OR AB equity
S6 ((DE "Socioeconomic Background" OR DE "Socioeconomic Influences" OR DE "Socioeconomic
Status") OR (DE "Poverty")) AND (DE "Disadvantaged Environment" OR DE "Economically
Disadvantaged" OR DE "Socioeconomic Influences")
S5 TX social* W1 (disadvantage* or exclusion or excluded or depriv*)
S4 TX social W1 (class* or group* or grade* or context* or status)
S3 TX (stop* or quit* or reduc* or give up or giving up) W3 (cigarette* or tobacco or smoking)
S2 TX Smoking W1 cessation
S1 DE SMOKING
73
Handsearching:
1. Addiction 2012 volume 107 issues 1 to 8 (August 2012) and Early View, search date
31/7/12; also ‘Accepted Articles’, ‘Early View’, search date 14/2/13 and 2012 volume 107
issues 12 and S2, volume 108 issues 1 to 2 search date 18/2/13.
2. Nicotine and Tobacco Research 2012, volume 14, issues 1 to 6, search date 30/7/12; also
2013 volume 15 issues 1 to 3 and ‘Advance Access’ search date 18/2/13.
3. Social Science and Medicine 2012, volume 74 issues 1 to 12, volume 75 issues 1 to 7,
articles ‘in press’ search date 31/7/12; also 2013 volumes 74 to 82 ‘in progress’, and ‘articles
in press’, search date 18/2/13.
4. Tobacco Control 2012, volume 21, issues 1 to 4, ‘online first’ search date 31/7/12; also
volume 21 issue 6, volume 22 issues 1 to 2 and ‘online first’, search date 18/2/13.
74
Searching for grey literature
23/11/12
Dear All,
As you know, ENSP is an Associated Partner in the SILNE project
(http://www.ensp.org/node/738).
In order to support the implementation of Work Package 6: Review & Synthesis by Amanda
Amos and Tamara Brown, our colleagues from the University of Edinburgh, and help them
to identify any grey literature, we would be grateful if you could inform them of any such
literature that they may be able to include in their review, particularly government reports
that they may not have identified through their searching.
They are now at the stage where they have a complete list of included studies both for the
review of youth policies and the review of adult policies. Please see the attached
inclusion/exclusion criteria. Attached are also the reference lists of these studies.
Amanda and Tamara are specifically interested in any reports of the socio-economic impact
of policies which are written in non-English and which an English synopsis could be
provided.
Please do not hesitate to contact them should you need any further clarification:
Tamara Brown
Research Fellow
Centre for Population Health Sciences
University of Edinburgh
Teviot Place
Edinburgh
EH8 9AG
Scotland, UK
Tel: 0131 650 3237
Fax: 0131 650 6909
Email: tbrown23@staffmail.ed.ac.uk
It would be great if you could not remain simply silent. So, even if you have no available
information, a simple negative reply would be appreciated. The deadline is 31/12/12.
Thanking you in advance,
Best regards
Francis
Francis Grogna
Secretary General
ENSP - European Network for Smoking and Tobacco Prevention
75
10/12/12
To all members of SILNE,
I am pleased to tell you that the youth report for Work Package 6: Review & Synthesis is
nearly complete and the adult policy review is well under way.
Amanda and I look forward to presenting the initial results of these reviews when we all
meet in Brussels in January.
Do you know of any grey literature that we may be able to include in our review, particularly
government reports that we may not have identified through our searching? We are
specifically interested in any reports of the socio-economic impact of policies which are
written in non-English and which an English synopsis could be provided.
I attach reference lists of included studies both for the review of youth policies and the
review of adult policies. I also attach our inclusion/exclusion criteria.
Our deadline for receiving literature is 31/12/12.
Please let me know if you require any further information and I look forward to some
hopeful replies and meeting you again in January.
Very best wishes
Tamara
Tamara Brown
Research Fellow
Centre for Population Health Sciences
University of Edinburgh
Teviot Place
Edinburgh
EH8 9AG
Scotland, UK
Tel: 0131 650 3237
Fax: 0131 650 6909
Email: tbrown23@staffmail.ed.ac.uk
76
7.2 Appendix B WHO European countries and other stage 4 countries
Albania
Andorra
Armenia
Austria
Azerbaijan
Belarus
Belgium
Bosnia and Herzegovina
Bulgaria
Croatia
Cyprus
Czech Republic
Denmark
Estonia
Finland
France
Georgia
Germany
Greece
Hungary
Iceland
Ireland
Israel
Italy
Kazakhstan
Kyrgyzstan
Latvia
Lithuania
Luxembourg
Malta
Monaco
Montenegro
Netherlands
Norway
Poland
Portugal
Republic of Moldova
Romania
Russian Federation
San Marino
Serbia
Slovakia
Slovenia
Spain
Sweden
Switzerland
Tajikistan
The Former Yugoslav Republic of Macedonia
Turkey
Turkmenistan
Ukraine
United Kingdom of Great Britain and Northern Ireland
Uzbekistan
Other stage 4 countries: Australia, United States, New Zealand, Canada
77
7.3 Appendix C Inclusion/exclusion form
Ref
ID
FIRST AUTHOR
COD
E
ANSWE
R
1
YEAR
TYPE
QUESTION
population
Is the study population 11 years of age or older?
2
Is it based in a WHO European country or nonEuropean country at stage 4 of the tobacco
epidemic?
3
intervention/policy
Is it an intervention or policy to reduce adult
smoking or to prevent youth starting to smoke?
4
socio-economic
inequalities
Does it report outcomes for high vs. low socioeconomic group?*
What type of study design is it? (highlight)
 Review
 RCT
 Non-randomised controlled study
 Observational cohort
 Qualitative
 Other
What type of intervention is it? (highlight)
 taxation/pricing
 tobacco advertising and marketing bans
 smoking cessation support
 smoke free policies (public places, workplaces, home)
 school-based interventions
 mass media campaigns
 community programmes
 educational policies
 social and welfare policies
 employment policies
 multifaceted lifestyle interventions/policies (not just smoking cessation)
 other
What type of SES indicator does it report? (highlight)
 Income
 Education
 Occupational social class
 Area-level socio-economic deprivation
 Housing tenure
 Subjective social class
 Health insurance
 Proxy measures for youth, i.e. Free School Meals, Family Affluences Scale (FAS)
What type of outcomes does it report? (highlight)
 quit rates
 initiation rates
 changes in initiation/cessation or abstinence rates
 uptake and reach
78
 use of quitting aids/services
 smoking status (self-reported/validated)
 number of quit attempts
 exposure
 prevalence
 changing attitudes
 passive smoking
 policy reach/awareness/comprehensiveness
 attitude/social norms
 intentions to smoke
 sources (i.e. vending machines)
 second hand smoke exposure
 other
What is the length of follow up? (highlight)
<3 months
3 months
6 months
12 months
Other
Is the intervention
Youth or adult or both? (highlight)
Individual support or population/policy or both? (highlight)
What is the type of analyses?
Population-level or individual level or both? (highlight)
*INCLUDE? YES/NO/UNCLEAR (highlight)
*To be included a paper must be rated as YES to 1 + 2 + 3 + 4
REVIEWER COMMENTS
79
7.4 Appendix D Included studies-Youth
Reference
Akhtar PC, Haw SJ, Levin KA, Currie DB, Zachary R, Currie CE.
Socioeconomic differences in second-hand smoke exposure among
children in Scotland after introduction of the smoke-free legislation.
Journal of Epidemiology & Community Health 2010; 64(4):341-346.
Source
MEDLINE
Bacon TP, Hilderbrand JA. Impact of a School-Based Drug Prevention
Program on Students' Behaviors and Risk and Protective Factors. Paper
presented at the Annual Conference of the American Educational
Research Association (Seattle, WA, April 10-14, 2001).
ERIC
Biener L, Aseltine RH, Jr., Cohen B, Anderka M. Reactions of adult and
teenaged smokers to the Massachusetts tobacco tax. American Journal of
Public Health 1998; 88(9):1389-1391.
MEDLINE
*Campbell R, Starkey F, Holliday J, Audrey S, Bloor M, Parry-Langdon
N et al. An informal school-based peer-led intervention for smoking
prevention in adolescence (ASSIST): a cluster randomised trial. Lancet
2008; 371:1595-1602.
Mercken 2012
*Crone MR, Reijneveld SA, Willemsen MC, van Leerdam FJ, Spruijt
RD, Sing RA. Prevention of smoking in adolescents with lower
education: a school based intervention study. Journal of Epidemiology &
Community Health 2003; 57(9):675-680.
Mercken 2012
*de Vries H, Dijk F, Wetzels J, Mudde A, Kremers S, Ariza C et al. The
European Smoking prevention Framework Approach (ESFA): effects
after 24 and 30 months. Health Education Research 2006; 21(1):116-132.
Mercken 2012
Galan I, Diez-Ganan L, Mata N, Gandarillas A, Cantero JL, Durban M.
Individual and contextual factors associated to smoking on school
premises. Nicotine and Tobacco Research 2012; 14(4):2012.
HAND
SEARCH
Gilpin EA, Pierce JP. Trends in adolescent smoking initiation in the
United States: is tobacco marketing an influence? Tobacco Control 1997;
6(2):122-127.
MEDLINE
Glied S. Youth tobacco control: reconciling theory and empirical
evidence. Journal of Health Economics 2000; 21:117-135.
YORK
REVIEW
Gruber J. Youth smoking in the US:Prices and policies, working paper
7506. 2000. Cambridge, MA. National Bureau of Economic Research
(NBER) Working Paper Series.
YORK
REVIEW
Hammond DDJDSB-TM. Impact of Female-Oriented Cigarette
Packaging in the United States. Nicotine & Tobacco Research 2011;
13(7):579-588.
EXPERT
Helakorpi S, Martelin T, Torppa J, Vartiainen E, Uutela A, Patja K.
Impact of the 1976 Tobacco Control Act in Finland on the proportion of
ever daily smokers by socioeconomic status. Preventive Medicine 2008;
46(4):340-345.
MEDLINE
80
Kim H, Clark PI. Cigarette smoking transition in females of low
socioeconomic status: impact of state, school, and individual factors.
Journal of Epidemiology & Community Health 2006; 60:(Suppl II):ii13ii19.
MEDLINE
Lipperman-Kreda S, Grube JW, Friend KB. Contextual and community
factors associated with youth access to cigarettes through
commercial sources. Tobacco Control Online First. 2012.
HANDSEARC
H
Menrath I, Mueller-Godeffroy E, Pruessmann C, Ravens-Sieberer U,
Ottova V, Pruessmann M et al. Evaluation of school-based life skills
programmes in a high-risk sample: A controlled longitudinal multi-centre
study. Journal of Public Health (Germany) 2012; 20(2):159-170.
EXPERT
Madden D. Tobacco taxes and starting and quitting smoking: does the
effect differ by education? Applied Economics 2007; 39:613-627.
PHRC
REVIEW
Mackay D, Haw S, Ayres JG, Fischbacher C, Pell JP. Smoke-free
legislation and hospitalizations for childhood asthma. New England
Journal of Medicine 2010; 363(12):1139-1145.
MEDLINE
*Mercken L, Moore L, Crone MR, de VH, De Bourdeaudhuij I, Lien N et
al. The effectiveness of school-based smoking prevention interventions
among low- and high-SES European teenagers. Health Education
Research 2012; 27(3):459-469.
EXPERT
Millett C, Lee JT, Gibbons DC, Glantz SA. Increasing the age for the
legal purchase of tobacco in England: impacts on socio-economic
disparities in youth smoking. Thorax 2011; 66(10):862-865.
MEDLINE
Millett C, Lee JT, Laverty AA, Glantz SA, Majeed A. Hospital
admissions for childhood asthma after smoke-free legislation in England.
Pediatrics 2013; 131(2):e495-e501.
EXPERT
Moore GF, Currie D, Gilmore G, Holliday JC, Moore L. Socioeconomic
inequalities in childhood exposure to secondhand smoke before and after
smoke-free legislation in three UK countries. Journal of Public Health
2012; 34(4):599-608.
EXPERT
Moore GF, Holliday JC, Moore LA. Socioeconomic patterning in changes
in child exposure to secondhand smoke after implementation of smokefree legislation in Wales. Nicotine & Tobacco Research 2011;
13(10):903-910.
MEDLINE
Nabi-Burza E, Regan S, Drehmer J, Ossip D, Rigotti N, Hipple B et al.
Parents smoking in their cars with children present. Pediatrics 2012;
130(6):e1471.
EMBASE
Noach MB, Steinberg DM, Rier DA, Goldsmith R, Shimony T, Rosen LJ.
Ethnic Differences in Patterns of Secondhand Smoke Exposure Among
Adolescents in Israel. Nicotine & Tobacco Research 2012; 14(6):648656.
HAND
SEARCH
Pabayo R, O'Loughlin J, Barnett TA, Cohen JE, Gauvin L. Does
intolerance of smoking at school, or in restaurants or corner stores
HAND
SEARCH
81
decrease cigarette use initiation in adolescents? Nicotine & Tobacco
Research 2012; first published online February 21, 2012(7).
Peretti-Watel P, Guagliardo V, Combes J-B, Obadia Y, Verger P. Young
smokers' adaptation to higher cigarette prices: How did those daily
smokers who did not quit react? The case of students of South-Eastern
France. Drugs: Education, Prevention & Policy 2010; 17(5): 632-640.
PsycINFO
Pucci LG, Joseph HM, Jr., Siegel M. Outdoor tobacco advertising in six
Boston neighborhoods. Evaluating youth exposure. American Journal of
Preventive Medicine 1998; 15(2):155-159.
MEDLINE
Rodgers A, Corbett T, Bramley D, Riddell T, Wills M, Lin RB et al. Do u
smoke after txt? Results of a randomised trial of smoking cessation using
mobile phone text messaging. Tobacco Control 2005; 14(4):255-261.
MEDLINE
Schneider S, Gruber J, Yamamoto S, Weidmann C. What happens after
the implementation of electronic locking devices for adolescents at
cigarette vending machines? A natural longitudinal experiment from 2005
to 2009 in Germany. Nicotine & Tobacco Research 2011; 13(8):732-740.
MEDLINE
Vallone DM, Allen JA, Xiao H. Is socioeconomic status associated with
awareness of and receptivity to the truth campaign? Drug & Alcohol
Dependence 2009; 104:Suppl-20:S15-S20.
MEDLINE
White VM, Hayman J, Hill DJ. Can population-based tobacco-control
policies change smoking behaviors of adolescents from all socioeconomic groups? Findings from Australia: 1987-2005. Cancer Causes &
Control 2008; 19(6):631-640.
MEDLINE
Widome R, Brock B, Noble P, Forster JL. The relationship of point-ofsale tobacco advertising and neighborhood characteristics to underage
sales of tobacco. Evaluation and the Health Professions 2012; 35(3):331345.
EMBASE
Woodruff SI. Effect of an eight week smoking ban on women at US Navy
recruit training command. Tobacco Control 2009; 9:40-46.
Ybarra ML, Holtrop JS, Prescott TL, Rahbar MH, Strong D. Pilot RCT
results of Stop My Smoking USA: a text messaging–based smoking
cessation program for young adults. Nicotine & Tobacco Research
Advance Access. 2013.
PsycINFO
HANDSEARC
H
*Mercken 2012 is a secondary analysis paper of Campbell 2008, Crone 2003 and de Vries 2006.
82
7.5 Appendix E Excluded studies-Youth
Reference
Alwan N, Siddiqi K, Thomson H, Cameron I. Children's exposure
to second-hand smoke in the home: a household survey in the
North of England. Health & Social Care in the Community 2010;
18(3):257-263.
Reason for exclusion
Not an intervention or
policy to reduce adult
smoking or to prevent
youth starting to smoke
Centers for Disease Control and Prevention (CDC). Response to
increases in cigarette prices by race/ethnicity, income, and age
groups--United States, 1976-1993. MMWR - Morbidity &
Mortality Weekly Report 1998; 47(29):605-609.
Does not report
outcomes for high
versus low socioeconomic group (for
youth)
El Ansari W, Stock C. Factors associated with smoking, quit
attempts and attitudes towards total smoking bans at university: a
survey of seven universities in England, Wales and Northern
Ireland. Asian Pacific Journal of Cancer Prevention 2012;
13(2):2012.
Not an intervention or
policy to reduce adult
smoking or to prevent
youth starting to smoke
– attitudes towards
possible total smoking
ban
Fardy PS, White RE, Clark LT, Amodio G, Hurster MH,
McDermott KJ et al. Health promotion in minority adolescents: a
Healthy People 2000 pilot study. Journal of Cardiopulmonary
Rehabilitation 1995; 15(1):65-72.
Does not report
outcomes for high
versus low socioeconomic group
Flynn BS, Worden JK, Secker-Walker RH, Pirie PL, Badger GJ,
Carpenter JH. Long-term responses of higher and lower risk
youths to smoking prevention interventions. Preventive Medicine
1997; 26(3):389-394.
Does not report
outcomes for high
versus low socioeconomic group
Hamilton G, Cross D, Resnicow K, Hall M. A school-based harm Does not report
minimization smoking intervention trial: outcome results. outcomes for high
Addiction 2005; 100(5):689-700.
versus low socioeconomic group
Hawkins SS, Chandra A, Berkman L. The impact of tobacco
control policies on disparities in children's secondhand smoke
exposure: a comparison of methods. Maternal and Child Health
Journal 2012; 16:S70-77.
Included in adult policy
review – examines
tobacco use among
households with schoolage children and
adolescents
Herbert RJ, Gagnon AJ, O'Loughlin JL, Rennick JE. Testing an
empowerment intervention to help parents make homes smokefree: a randomized controlled trial. Journal of Community Health
2011; 36(4):650-657.
Does not report
outcomes for high
versus low socioeconomic group
Hublet A, Schmid H, Clays E, Godeau E, Gabhainn SN, Joossens
L et al. Association between tobacco control policies and
smoking behaviour among adolescents in 29 European countries.
Addiction 2009; 104(11):1918-1926.
Does not report
outcomes for high
versus low socioeconomic group
Jensen R, Lleras-Muney A. Does staying in school (and not Not based in a WHO
working) prevent teen smoking and drinking? Journal of Health European country or
non-European country at
83
Economics 2012; 31(4):644-657.
stage 4 of the tobacco
epidemic – Dominican
Republic.
Linetzky B, Mejia R, Ferrante D, De Maio FG, Diez Roux AV.
Socioeconomic status and tobacco consumption among
adolescents: A multilevel analysis of Argentina's global youth
Tobacco survey. Nicotine and Tobacco Research 2012;
14(9):1092-1099.
Not based in a WHO
European country or
non-European country at
stage 4 of the tobacco
epidemic - Argentina.
Mata HJ. Development and evaluation of a personalized
normative feedback intervention for Hispanic youth at high risk
of smoking. Dissertation Abstracts International Section A:
Humanities and Social Sciences 73[4-A], 1295. 2012.
Does not report
outcomes for high
versus low socioeconomic group
Poulin CC. School smoking bans: do they help/do they harm? Does not report
Drug & Alcohol Review 2007; 26(6):615-624.
outcomes for high
versus low socioeconomic group
Schmitt CL. The effect of decision heuristics and ethnicity on
cigarette sales to minor girls. Dissertation Abstracts
International: Section B: The Sciences and Engineering 2002;
.62(9-B).
Not an intervention or
policy to reduce adult
smoking or to prevent
youth starting to smoke
Sims M, Bauld L, Gilmore A. England's legislation on smoking in Does not report
indoor public places and work-places: Impact on the most outcomes for high
exposed children. Addiction 2012;107(11): 2009-2016.
versus low socioeconomic group regression analyses
adjust for SES
Straub DM, Hills NK, Thompson PJ, Moscicki AB. Effects of
pro- and anti-tobacco advertising on non-smoking adolescents'
intentions to smoke. Journal of Adolescent Health 2003;
32(1):36-43.
Does not report
outcomes for high
versus low socioeconomic group
Tangari AH, Tangari AH, Burton S, Andrews JC, Netemeyer RG.
How do anti-tobacco campaign advertising and smoking status
affect beliefs and intentions? Some similarities and differences
between adults and adolescents. Journal of Public Policy &
Marketing 2007; .26(1):60-74.
Does not report
outcomes for high
versus low socioeconomic group
Veldwijk J, Hoving C, van Gelder BM, Feenstra TL. Potential
reach of effective smoking prevention programmes in vocational
schools: Determinants of school directors' intention to adopt these
programmes. Public Health 2012; 126(4):338-342.
Not an intervention or
policy to reduce adult
smoking or to prevent
youth starting to smoke
- about theoretical
intention to adopt a
schools programme
Weinman ML, Weinman ML. A comparison of three groups of Does not report
young fathers and program outcomes. School Social Work outcomes for high
Journal 2007; .32(1):1-13.
versus low socioeconomic group
Wildey MB, Clapp EJ, Woodruff SI, Kenney EM. Retailer Does not report
84
education to reduce the availability of single cigarettes. Journal of outcomes for high
Health Education 1995; 26(5):297-302.
versus low socioeconomic group
85
7.6 Appendix F Data extraction - Youth
Details
Method
Results
Comments
Data sources
Two surveys of 11 year olds, January
2006 and January 2007
General population impact
After legislation cotinine levels fell across
all groups
Participant selection
11 year olds, final year of primary
school. 2006 n=2559 (86%) 2007
n=2424 (85%), 116/170 (68%)
schools participated at baseline and
111/170 (65%) schools at follow up
Impact by SES variable
The greatest absolute decline in cotinine
levels was among the lowest SEC and FAS
groups even after adjusting for parental
smokers (e.g. 0.10ng/ml in SEC1 v
0.28ng/ml in SEC4).
However a linear regression model
suggests that relative inequality between
groups has widened. SHS exposure
declined among children from lower SES
households, higher in absolute terms but
lower in relative terms than among children
from higher SES households.
Internal validity
FAS and SEC determined
using child’s answers, including
parental occupation and
material affluence although
questions on family affluence
seem fairly simple, so should
lead to few being incorrectly
categorised.
Biochemical measure of
smoking.
Smoking restriction in cars, workplaces, schools and other public places
Author, year
Akhtar, 2010
Age (years)
11
Study design
Repeat cross-sectional surveys in
same schools before and after
legislation
Objective
Explore socioeconomic differences in
child exposure to environmental
tobacco smoke (CHETS) after
Scottish smoke-free legislation
Setting
Primary schools, Scotland
Intervention
Smoke-free public and workplaces
SES variables used
Self-reported family socioeconomic
classification (SEC) and family
affluence scale (FAS)
Study analysis
Participant characteristics
% low/medium/high FAS divided
evenly. SEC mostly SEC1 and 2.
FAS score for 96.6% of pupils in
2006 and 94.5% in 2007, and
meaningful family SEC (family SEC
1-4) 79.1% in 2006 and 76.7% in
2007
Intervention details
Smoking prohibited in almost all
public and work places in Scotland
from March 2006.
Outcomes measured
Parental smoking status
Pupil’s smoking status
Salivary cotinine levels
Author’s conclusion of SES impact
Smoke-free legislation has reduced
exposure to SHS among all children.
Although the greatest absolute reduction in
cotinine is observed in the lowest SEC/FAS
group, cotinine levels remain highest for
this group and there is a suggestion of
possible increases in inequalities, which
may warrant longer-term monitoring
External validity
No bias detected in nonparticipation rates. Students
absent from school on day of
data collection were not
included, though these
represent a small proportion.
Ignores those excluded from
school, most likely to be low
SES.
Narrow age group limits
generalisability.
Same linear analyses as
CHETS Wales (Moore 2011).
Average cotinine
concentrations among children
in the Scottish CHETS were
substantially higher than in
Wales and children’s SHS
86
Details
Method
Smoking restriction in cars, workplaces, schools and other public places
Analysis of variance and linear
regression analyses, accounts for
cluster and stratification. All results
based on confirmed non-smoking
pupils
Results
Comments
exposure outside of the home
was perhaps greater in
Scotland, with impacts of
legislation therefore greater
overall than in Wales and
distributed among all groups
Validity of author’s conclusion
Valid. Reviewer ratio
calculations using reported
mean concentrations also
suggest a widening of relative
inequality by FAS, but not by
SEC.
The impact of comprehensive
smoking bans may differ
depending on the pre-ban level
of exposure and the balance
between sources of exposure
i.e. public places v home.
87
Details
Method
Results
Comments
Smoking restriction in cars, workplaces, schools and other public places
Author, year
Galan 2012
Age (years)
15-16
Setting
79 secondary schools, Madrid, Spain
Study design
Cross-sectional study
Objective
To evaluate the relationship of
contextual factors with smoking on
school premises
SES variables used
School-level:
Socioeconomic status of the census
tracts in which the school is located,
estimated from an index based on
aggregate data (unemployment,
temporary workers, manual workers,
and low educational level among the
overall adult [age >15 years] and
young adult [age 16–29 years]
populations).
Individual variables:
Educational attainment of parents
Data sources
Surveillance System of Risk
Factors associated with noncommunicable diseases
targeting the adolescent
population in the fourth year
of compulsory secondary
education in the Madrid region
(15–16 years), 2004-2005.
Participant selection
Two-stage cluster sampling
with stratification in the
selection of schools according
to area and type (public or
private). Overall response rate
(schools and students) was
83.1%.
Participant characteristics
15-16 year olds in fourth year
of compulsory education,
N=1179
Outcomes measured
Probability of smoking in
school
Intervention details
Survey of smoking behaviour
and individual and schoollevel contextual variables
General population impact
Among smokers, 50.6% had smoked on
school premises during the last thirty
days with significant variability (0% to
100%) between schools
Impact by SES variable
Model with school-level and individuallevel variables: a lower probability of
smoking on school premises was found
among adolescents whose fathers had a
university education (OR 0.43, 95% CI:
0.19 to 0.96) or among those who did not
know the level of studies of their father
(OR 0.39, 95% CI: 0.16 to 0.94)
compared with those with fathers who
had a very low level of educational
attainment.
Adolescents with low academic
achievement showed an OR of 1.51
(95% CI: 1.00–2.29).
Employment status of either parent or
educational level of mother was not
significant. SES of the census tracts of
the school was not significant, nor was
written reference to smoking control
policy or educational activities about
smoking prevention. A lower probability
of smoking on school premises was
found for state subsidized private schools
(odds ratio [OR]: 0.20; 95% CI: 0.11–
0.35) and nonsubsidized private schools
(OR: 0.30; 95% CI: 0.14–0.62) when
Internal validity
The self-completed questionnaire was
filled out in the classroom in the
presence of previously trained staff.
Smoking variable previously validated
but potential for response bias. Some
subgroups are not sufficiently powered.
SES measured by census tracts of the
school rather than the location of the
home of the student so may not be
accurate.
External validity
Should be representative and
generalisable to other secondary
schools in Spain and other similar
countries. However, presence or
absence of smoking policy did not
include an evaluation of whether policy
was implemented which limits
applicability of this study.
Validity of author’s conclusion
Agreed, census tract of school may not
be sensitive to school-level SES
88
Details
Method
Results
Comments
Smoking restriction in cars, workplaces, schools and other public places
Employment status of parents
compared with that for public schools
Study analysis
Multilevel logistic regression models
of smoking population
(n=1,179=32.6% analyses on
1,116=94.7% of sample of smokers)
Author’s conclusion of SES impact
A higher probability of smoking on school
premises was found among adolescents
whose fathers had a lower level of
educational attainment. However, at the
contextual level, no relationship was
found with socioeconomic status
89
Details
Method
Results
Comments
General population impact
Before the legislation was
implemented, admissions for asthma
were increasing at a mean rate of
5.2% per year (95% confidence
interval [CI], 3.9 to 6.6). After
implementation of the legislation,
there was a reduction in the annual
rate of 18.2% relative to the rate on
March 26, 2006 (95% CI, 14.7 to
21.8; P<0.001), resulting in a net
reduction in asthma admissions after
implementation of the legislation of
13.0% per year (95% CI, 10.4 to
15.6).
After adjustment for the potential
confounding effects of sex, age
group, urban or rural residence, and
quintile of socioeconomic status,
admissions for asthma before
implementation of the legislation
increased by a mean of 4.4% per
year (95% CI, 3.3 to 5.5) relative to
the rate in January 2000. After
implementation of the legislation,
there was a reduction of 19.5% (95%
CI, 16.5 to 22.4; P<0.001) relative to
the rate on March 26, 2006, resulting
in a net reduction in admissions for
asthma of 15.1% per year (95% CI,
12.9 to 17.2).
The trends before the legislation
varied according to age group, with a
mean annual increase of 9.1%
Internal validity
Also accounts for deaths the decrease in
admissions was not due to
an increase in the
incidence of deaths before
arrival at the hospital.
Smoking restriction in cars, workplaces, schools and other public places
Author, year
MacKay 2010
Age (years)
Less than 15 years: 0 to 4 and 5 to
14 years
Setting
Hospitals, Scotland
Study design
Repeat cross-sectional (before and
after)
Objective
to determine whether the risk of a
hospital admission for childhood
asthma has changed since the
introduction of comprehensive
smoke-free legislation in Scotland.
SES variables used
area deprivation score: quintiles 1 to
5 Index of Multiple Deprivation 2006
Study analysis
negative binomial regression
Data sources
Scottish Morbidity Record (SMR01) collects
information on all admissions to acute care
hospitals in Scotland, General Register Office for
Scotland collects death-certificate data on all
deaths that occur in Scotland. The admission
and death databases are linked at an individual
level so that records relating to the same person
can be identified. Combined SMR01 and deathcertificate data to identify all hospital admissions
and deaths before arrival at the hospital that
occurred from January 2000 through October
2009
Participant selection
Emergency hospital admissions (plus deaths
occurring before arrival at hospital) for childhood
(0-14 years) asthma, from January 2000 through
October 2009
Participant characteristics
21,415 hospital admissions: 11,796 (55.1%)
occurred among preschool children and 9619
(44.9%) among school-age children.
Outcomes measured
admission rate,
adjusted admission rate
Intervention details
National smokefree legislation in Scotland
March 2006
External validity
Comparable with English
study on childhood
asthma admissions.
Validity of author’s
conclusion
Cannot determine the
extent to which the
observed reduction in
asthma was due to
reduced exposure to
environmental tobacco
smoke in the home,
reduced exposure to
environmental tobacco
smoke in public places, or
a reduction in active
smoking among schoolage children. Cannot rule
out impact of change in
asthma treatments.
90
Details
Method
Results
Comments
Smoking restriction in cars, workplaces, schools and other public places
among preschool children, as
compared with no significant change
over time among school-age
children. However, the change after
legislation was similar in the two
groups, with a reduction of 18.4%
among preschool children and 20.8%
among school-age children relative to
the rate on March 26, 2006
Very similar results based on
admissions alone as few deaths.
Impact by SES variable
There were no significant interactions
between hospital admissions for
asthma and quintile of SES. All SES
subgroups associated with significant
reduction in admissions.
Author’s conclusion of SES impact
The additional change after
implementation of the legislation was
significant in all subgroups
91
Details
Method
Results
Comments
General population impact
Before the implementation of the
legislation, the admission rate for
childhood asthma was increasing by
2.2% per year (adjusted rate ratio
1.02; 95% confidence interval [CI]:
1.02–1.03). After implementation of
the legislation, there was a significant
immediate change in the admission
rate of -8.9% (adjusted rate ratio
0.91; 95% CI: 0.89–0.93) and change
in time trend of -3.4% per year
(adjusted rate ratio 0.97; 95% CI:
0.96–0.98). Overall, the legislation
was associated with a net 12.3%
reduction of hospital admissions for
childhood asthma in the first year.
This change was equivalent to 6802
fewer hospital admissions in the first
3 years after implementation.
Internal validity
ITS - estimates both the
immediate change and
change in time trend after
policy implementation.
Changes in diagnostic
coding over the study
period, may have
underestimated the effect
of smoke-free legislation if
coding of childhood
asthma admissions
improved over the study
period.
Smoking restriction in cars, workplaces, schools and other public places
Author, year
Millett 2013
Age (years)
preschool (0–4 years) and school
age (5–14 years)
Setting
Hospitals, England
Study design
Interrupted time series (before and
after legislation)
Objective
To assess whether the
implementation of English smokefree
legislation in July 2007 was
associated with a reduction in
hospital admissions for childhood
asthma.
SES variables used
area deprivation score: quintiles 1 to
5 Index of Multiple Deprivation
Study analysis
negative binomial regression,
multivariate
Data sources
Hospital Episode Statistics (HES): national
administrative database for hospital activity in
England
Participant selection
Nonplanned (emergency) hospital admissions
for childhood (0-14 years) asthma, from April 1,
2002 and November 30, 2010 (8.5 years)
Participant characteristics
217 381 hospital admissions for childhood
asthma, evenly distributed between preschool
(50.1%) and school age children (49.9%). The
number of admissions was higher in boys
(63.4%) than girls (36.6%). Most admissions
occurred in children living in urban locations
(86.5%), and there were a higher number of
admissions in children living in the most
deprived areas.
Outcomes measured
Admission rate,
Adjusted admission rate ratio, (ratio of the actual
admission rate in relation to the rate projected
by the underlying trend)
Intervention details
National smokefree legislation in England July
2007
Impact by SES variable
During the study period there were a
higher number of admissions in
children living in the most deprived
areas.
There were similar reductions in
asthma admission rates among
children from different SES groups.
External validity
Comparable with Scottish
study on childhood
asthma admissions.
Validity of author’s
conclusion
One of few studies to
report longer-term
outcomes for children but
does not measure SHS
exposure. Cannot rule out
impact of change in
asthma treatments.
Author’s conclusion of SES impact
The findings suggest immediate as
well as cumulative benefits over time
92
Details
Method
Results
Comments
Smoking restriction in cars, workplaces, schools and other public places
applying across SES.
93
Details
Method
Results
Comments
General population impact
There was no significant increase in
inequality in the relative likelihood of a
child’s sample containing a high level of
cotinine (RRR = 1.03; 95% CI = 0.91–
1.17).
Internal validity
Biochemical measure of
smoking. No significant
differences between
characteristics of pre- and
post-legislation samples, nor
were there significant
differences between those
providing useable saliva
samples and those providing
only questionnaire responses.
Required imputation of random
values for 47% of cases which
limits reliability.
Smoking restriction in cars, workplaces, schools and other public places
Author , year
Moore 2011
Data sources
CHETS Wales study
Age (years)
11
Participant selection
In 2007, 1,611 pupils of an eligible
1,761 pupils within 75 schools
completed the smoking questionnaire
(91.5%), compared with 1,605 of an
eligible 1,775 children within the
same 75 schools in 2008 (90.4%). In
total, 1,447 children pre-legislation
(82.2% of those eligible) and 1,461
children post-legislation (82.3% of
those eligible) from 71 schools
provided useable saliva samples
Setting
Primary schools, Wales
Study design
Repeat cross-sectional surveys of
10-11 year old children in same
schools before and after legislation
Objective
To assess socioeconomic patterning
in changes in salivary cotinine
concentrations, reports of parental
smoking in the home and car and
estimates of population-level
smoking prevalence following
introduction of smoke-free legislation
Intervention
Smoke-free legislation in Wales
SES variables
Family Affluence Scale (bedroom
occupancy, car ownership, holidays,
computer ownership)
Participant characteristics
Mean age 11 years. Pre-legislation,
422 (27.1%), 606 (39.0%), and 527
(33.9%) of children were assigned to
low-, medium-, and high-SES tertiles,
respectively. Post-legislation, a
slightly smaller proportion of children
were assigned to the low-SES group
(n = 360, 23.6%), with 621 (40.6%)
and 547 (35.8%) assigned to
medium- and high-SES groups,
respectively.
Outcomes
Salivary cotinine levels
Parental smoking in the home
Impact by SES variable
The likelihood of providing a sample
containing an undetectable level of cotinine
increased significantly after legislation
among children from high [relative risk ratio
(RRR) = 1.44, 95% CI = 1.04–2.00,p=0.03]
and medium SES households (RRR =
1.66, 95% CI = 1.20–2.30, p<0.01), while
exposure among children from lower SES
households remained unchanged
(RRR=0.93, 95% CI=0.62-1.40, p=0.72).
Parental smoking in the home, car-based
SHS exposure, and perceived smoking
prevalence were highest among children
from low SES households. Parental
smoking in the home and children’s
estimates of adult smoking prevalence
declined only among children from higher
SES households.
Author’s conclusion of SES impact
Post-legislation reductions in SHS
exposure were limited to children from
higher SES households. Children from
lower SES households continue to have
External validity
Generalisability limited by
narrow age group and
analyses restricted to children
attending school and living with
parents, a parent and stepparent or a single parent.
Same linear analyses as
CHETS Scotland (Akhtar
2010).
Average cotinine
concentrations among children
in the Scottish CHETS
were substantially higher than
in Wales (Holliday et al., 2009)
and children’s SHS exposure
outside of the home was
perhaps greater in
94
Details
Method
Smoking restriction in cars, workplaces, schools and other public places
Study analysis
Car-based SHS exposure
Multinomial logistic regression
analysis accounting for clustering
Intervention details
and adjusted for age, year and time
Questionnaire plus cotinine assay
of data collection.
Analyses are limited to children living
with parents, a parent and stepparent or a single parent, and who
completed the FAS (smoking
questionnaire n = 1,555/1,528;
salivary cotinine n = 1,397/1,390
pre/post-legislation). Cotinine
analyses are limited to children
classified as non-smokers [i.e., who
both reported being a non-smoker
and provided saliva with a cotinine
concentration <15 ng/ml (n =
1,362/1,364)].
Results
Comments
high levels of exposure, particularly in
homes and cars, and to perceive that
smoking is the norm among adults.
Children’s SHS exposure did not worsen
for any SES subgroup after introduction of
legislation in Wales. However, the
unanticipated reductions in children’s SHS
exposure following legislation appear
limited to children from more affluent
households in Wales, whose exposure was
already significantly lower prior to
legislation, leading to increased
socioeconomic disparity.
Scotland, with impacts of
legislation therefore greater
overall than in Wales and
distributed among all groups.
Validity of author’s conclusion
The impact of comprehensive
smoking bans may differ
depending on the pre-ban level
of exposure and the balance
between sources of exposure
i.e. public places v home.
95
Details
Method
Results
Comments
General population impact
Relative risk of children’s samples
containing no detectable cotinine increased
significantly following legislation.
Percentages of children with undetectable
concentrations increased from 31.0 (n =
1715) to 41.0% (n = 2251) following
legislation overall, and from 20.1 to 34.2,
44.9 to 51.0 and from 38.6 to 42.9% in
Scotland, Wales and NI, respectively.
Relative risk of providing a sample
containing a ‘high’ cotinine concentration
also increased significantly.
Internal validity
Biochemical measure of
smoking. Children reported on
smoking restrictions in homes
and cars.
SES varied significantly
between survey years
(affluence higher at follow-up).
Smoking restriction in cars, workplaces, schools and other public places
Author , year
Moore 2012
Age (years)
11.2
Setting
Primary schools, Scotland, Northern
Ireland, Wales
Study design
Repeat cross-sectional surveys of
children in same primary schools
before and after legislation
Objective
To pool data from 3 countries in
order to assess socioeconomic
patterning in SHS exposure and
parental restrictions on smoking in
homes and cars before and after
smokefree legislation
Intervention
Smoke-free legislation in Scotland,
Northern Ireland, Wales
SES variables
Family Affluence Scale (bedroom
occupancy, car ownership, holidays,
computer ownership)
Data sources
CHETS Scotland, Northern Ireland
and Wales studies, questionnaire
plus cotinine assay
Participant selection
Of 586 schools approached, 320/304
(54/51%) participated at
baseline/follow-up.
Participant characteristics
10 867 non-smokers (self-reported
nonsmokers providing saliva samples
containing <15 ng/ml cotinine) in their
final year at 304 primary schools in
Scotland (n = 111), Wales (n = 71)
and NI (n = 122).
Outcomes
Salivary cotinine levels
Smoking restrictions in the home
Smoking restrictions in the car
Intervention details
National smokefree legislation
prohibiting smoking in enclosed
public places and
workplaces (Scotland March 2006,
Wales March 2007, Northern Ireland
(NI) April 2007
Impact by SES variable
Relative risk of children’s samples
containing no detectable cotinine increased
significantly as SES increased, whilst the
relative risk of samples containing a ‘high’
cotinine concentration fell. These
associations were almost identical in all
countries, remaining significant after entry
of terms for parental smoking and private
smoking restrictions.
This inequality appears to have widened
following legislation (in the combined data
set and trend in individual countries), with
percentages of samples above the limit of
detection ranging from 96.9 to 38.2% for
the least and most affluent children,
respectively, after legislation. Gradients for
higher exposure levels remained relatively
unchanged.
External validity
Generalisability limited by
narrow age group and
analyses restricted to children
attending school and living with
parents, a parent and stepparent or a single parent.
However pools data from 3
CHETS studies.
Validity of author’s conclusion
Valid. Impact may differ
between individual countries
because baseline cotinine
concentrations differed
between countries. Difficult to
compare results by SES
pertaining to individual
countries with other CHETS
papers because analyses are
different.
96
Details
Method
Results
Comments
Smoking restriction in cars, workplaces, schools and other public places
Study analysis
Multinomial logistic regression
analysis accounting for clustering
and adjusted for age and country.
Binomial logistic regression for carbased smoking.
In all countries, and the combined data set,
as SES increased, the likelihood of partial
or no home smoking restrictions (rather
than full smoking restrictions), decreased
significantly, whilst the odds of smoking
being allowed inside the family car also
decreased significantly. These trends
remained after adjustment for parental
smoking No change in inequality following
legislation for home and car-based
smoking restrictions (socioeconomic
patterning remained stable).
Author’s conclusion of SES impact
Socioeconomic inequality in the likelihood
of a child’s sample containing detectable
traces of cotinine increased. Hence,
declines in exposure occurred
predominantly among children with low
exposure before legislation, and from more
affluent families. Substantial
socioeconomic gradients in proportions of
children with higher SHS exposure levels
remained unchanged. Post-legislation
changes in smoking restrictions in cars or
homes were not patterned by
socioeconomic status.
97
Details
Method
Results
Comments
Smoking restriction in cars, workplaces, schools and other public places
Author , year
Nabi-Burza 2012
Age (years)
26% (n=214) aged less than
1 year;
35% (n=288) aged 1 to 4
years;
19% (n=158) aged 5 to 9
years);
18% (n=147) aged 10 years
or over
Setting
Paediatric clinics in 8 US
states
Study design
Cross-sectional study
Objective
To determine prevalence
and factors associated with
strictly enforced smoke-free
car policies among smoking
parents.
SES variable
education (high school
or less versus some college
or college
Data sources
Baseline data collected at paediatric
practices enrolled in the control arm of a
cluster, randomized controlled trial, Clinical
Effort Against Secondhand Smoke Exposure.
Participant selection
Participants were eligible to enrol in the study
if they had accompanied a child to the office
visit, had smoked at least a puff of a cigarette
in the past 7 days, were the parent or legal
guardian of the child seen that day, were at
least 18 years old, and spoke English.
Enrolled parents received $5 in cash for
completing the baseline enrolment survey.
Screening continued until 100 eligible
parents were enrolled at each practice.
Participant characteristics
817/981 parents reported having a car. The
majority (70%) of the parents were in the age
group 25 to 44 years, 77% were females,
mostly mothers (98% vs 2% legal guardians),
and 68% were non-Hispanic whites. Many
parents (42%) had only a high school degree,
and 16% had completed college. Most of the
children (60%) were covered by Medicaid
Outcomes
Smokefree car policy
Intervention details
General population impact
Of 795 parents, 73% reported that
someone had smoked in their car in
the past 3 months. Less than 1 in 3
parents who had a smoke-free car
policy reported that it was violated
in the past 3 months. Of the 562
parents who did not report having a
smoke-free car policy, 48%
reported that smoking occurred with
children present in the car.
Approximately one-fifth of all
enrolled parents reported being
asked by a paediatric health care
provider about their smoking status.
Only 14% of smoking parents
reported being asked if they had a
smoke-free car, and 12% reported
being advised to have a smoke-free
car policy by a paediatric health
care provider.
Internal validity
Unable to ascertain how representative
the study sample was. Self-reported
outcome data.
External validity
Sample excludes non-car owners.
Sample is derived from 8 US states.
Validity of author’s conclusion
Educated was not significantly
associated with smokefree car policy
on its own, only significant in
interaction with child age and amount
smoked.
Impact by SES variable
No association between parent’s
age, race and ethnicity, education,
and intention to quit smoking with
having a strictly enforced
smokefree car policy.
Exploratory analyses assessed
possible interactions between the 4
parent demographic variables (age,
gender, race, and education) and
the 3 significant predictors of car
policy (child’s age, number of
98
Details
Method
Results
Comments
Smoking restriction in cars, workplaces, schools and other public places
graduates)
Questionnaire of smoking behaviour in cars
cigarettes smoked per day by the
and home
parent, and having another smoker
at home). Parent gender and
Study analysis
education interacted
Logistic regression
with child’s age: parents of children
aged <1 year were more likely to
have strict smoke-free car policies if
they were female (OR: 3.00 [95%
CI: 1.22–
7.38], P = .016) or college educated
(OR:2.42 [95% CI: 1.21–4.83], P =
.013). Strict smoke-free car policies
were more common when parents
were both light smokers (smoked
10 or less cigarettes per day) and
college educated (OR: 2.88 [95%
CI: 1.24–6.66], P = .013).
Author’s conclusion of SES impact
College educated parents of
children aged <1 year were more
likely to have strict smoke-free car
policies.
99
Details
Method
Results
Comments
Smoking restriction in cars, workplaces, schools and other public places
Author , year
Noach 2012
Age (years)
15
Setting
Schools, Israel
Study design
Cross-sectional
study
Objective
To examine
determinant of SHS
exposure in Israeli
adolescents
SES variable
Maternal and
paternal education
(<12 years, 12
years, College or
University, other
degree)
Study analysis
Logistic regression
models
Data sources
Israel National Health and Nutrition Youth
survey among 7-12th grade, 2003-2004
Participant selection
Israel Ministry of Education provided list of
approximately 1,000 schools from the statesponsored educational system. Sample
stratified by population group (Jewish, Arab +
Bedouin, Druze), stream (state, state religious),
school level (7–9, 10–12), and SES (defined by
the Ministry of Education as related to the
school, as low, high). For each school chosen
as a primary sampling unit, the grade level and
then the class within each grade level were
randomly selected. Response rates were high
(school: 91.8%, child: 87.9%), with 6,274
participants.
Participant characteristics
Average age was 15 years (11–19 years).
N=6,274 students: 55.7% girls, 44.3% boys;
70% Jews, 30% non-Jews (18% Moslem Arab,
4% Christian Arab, 6% Druze, and 1%
Christian).
Outcomes
Correlates of exposure to SHS at home, school,
entertainment, ‘other’ places
General population impact
Most Israeli adolescents were exposed to SHS
(total: 85.6%; home: 40%; school: 31.4%;
entertainment: 73.3%; other: 16.3%).
Impact by SES variable
Parental education is not a significant
determinant of smoking in school
Home:
Teenagers whose fathers had less than 12
years of education (OR = 1.48; CI: 1.09, 1.99; p
= .0111) were more exposed than were
teenagers whose fathers had a degree from a
university or college. Teenagers with lesseducated mothers (OR = 1.39; CI: 1.02, 1.90; p
= .0366) were more exposed than teenagers
with mothers with degrees from a university or
college.
Author’s conclusion of SES impact
The high levels of SHS exposure among Israeli
adolescents were characterized by different
patterns of exposure among different
population groups
Internal validity
The smoking question in the
survey has not been validated by
biochemical measures in Israel.
Main aim of the survey was to
assess nutritional status and so
smoking question is basic yes/no.
External validity
Schools from the ultraorthodox
Jewish, independent and private
sectors were excluded, as were
boarding schools.
Israel is heterogeneous with broad
range of ethnic, religious and
socioeconomic populations and is
not generalisable to other WHO
European or stage 4 countries.
Validity of author’s conclusion
No comprehensive smokefree
bans at time of survey so survey is
not assessing impact of specific
policy implementation but lending
support to National Tobacco
Control plan recently approved by
Israeli government
Intervention details
Survey
100
Details
Method
Results
Comments
General population impact
Among the 4393 recruits who provided
entry and graduation survey data, 41.4% (n
= 1819) reported being smokers at entry
(that is, reported any smoking in the 30
days before entering). Twenty five per cent
(n = 1110) of all women recruits reported
being a smoker at graduation, a significant
reduction from the 41% smoking rate at
entry into RTC (McNemar ÷2 = 665.7, p <
0.001).
Slightly over two thirds (n = 724) of
“smokers” who responded to the follow up
survey had resumed smoking three months
after graduation, and 32% (n = 340)
reported not smoking. Among past month
smokers at entry to RTC, the relapse rate
at the three month follow up was 81%.
Daily smokers at entry had the highest
relapse rate (89%)=11% follow-up
cessation rate
Internal validity
Response bias is present; low
response rate at 3 month
follow-up, nonrespondents had
a slightly higher past 30 day
smoking rate at baseline than
did respondents.
Definition of ‘smoker’ differed
at graduation (post 8 weeks)
from baseline and 3 month
follow-up. Group of smokers
assessed for relapse was
broadly defined and included
daily smokers, occasional
smokers, experimenters, or
former smokers.
Impact by SES variable
Education did not significantly predict
relapse
Validity of author’s conclusion
Study did not aim to assess
differential impact by SES.
Smoking restriction in cars, workplaces, schools and other public places
Author, year
Woodruff 2000
Data sources
Intervention study
Age (years)
19
Participant selection
5505/5197=93% response amongst
recruits who volunteered to take part;
86% response rate among 5129
eligibles, n=4411/5129, eversmokers at entry=2820/4411, 39%
response rate for 3 month follow-up,
n=1077/2748 (72 left Navy before
follow-up); volunteers entering
Recruit Training Command Illinois
March 1996-March 1997
Setting
Recruit Training Command, US
Study design
Before and after experimental study
Objective
To examine the effect of a US Navy
smoking ban in female recruits
Intervention
Organisational smoking ban for 8
weeks, unique as 24-hour ban with
‘live-in’ recruits
SES variable
Education (less than a high school
education, high school, and greater
than a high school education);
Study analysis
Predictors of changes in perceptions
of being a smoker: stepwise logistic
regression to determine the
Participant characteristics
All female. The mean (SD) age was
19 (2.75) years. The majority (94.5%)
had at least a high school education.
Recruits were ethnically diverse, with
42% belonging to ethnic groups other
than white non-Hispanic.
Outcomes
Perceived smoking status
Smoking relapse
Intervention details
8-week 24-hour smoking ban
External validity
Not generalizable to civilian
population or setting. All
female.
Author’s conclusion of SES impact
None- Study did not aim to assess
differential impact by SES
101
independent correlates of graduation
smoking status.
Predictors of relapse at 3 month
follow-up: multivariate logistic
analysis
102
Details
Method
Results
Comments
General population impact
1979 to 1984 adolescent initiation rates
decreased but increased thereafter
Internal validity
Respondents are asked about
how old they were when they
started smoking (retrospective
so potential for recall bias and
underreporting)
Controls on advertising, promotion and marketing of tobacco
Author, year
Gilpin & Pierce 1997
Age (years)
14-21 in 1979 to 1989
Setting
US
Study design
Cross-sectional study
Objective
To investigate the possible
association between increased
tobacco marketing and increased
smoking initiation by adolescents
Intervention
Examines trends in smoking initiation
by inflation-adjusted cigarette prices
and tobacco industry budget for
marketing
SES variables used
Education (less than 12 years, 12
years with no college education,
more than 12 years with some
college education as adults)
Data sources
Combined data from 3 Current
Population Surveys (September
1993, January 1993, May 1993) that
contained special supplement on
tobacco use. One quarter=in person
interviews and ¾ = telephone
interviews. Tobacco Institute for
weighted average pack prices, US
Federal Trade Commission for
marketing expenditure; adjusted to
1989 dollars using Consumer Price
Index
Participant selection
Civilian non-institutionalised
population aged 15 years+, surveyed
about 56,000 households per month
Participant characteristics
Analysis restricted to respondents
17-38(n=140,975) that would have
been 14-21 in 1979 to 1989
Impact by SES variable
Initiation rates highest among high school
dropouts and lowest amongst those who
eventually attended college. Only quadratic
model significant for dropouts (p=0.035).
Neither model was significant for highschool graduates and both models were
significant for ‘some college’ (p=0.081
linear, p=0.014 quadratic).
In 1988 initiation rate was 9.9% for those
who did not graduate from high school,
6.9% for high-school graduates reporting
no college and 3.7% for those reporting at
least some college.
Author’s conclusion of SES impact
External validity
Initiation rates are for decade
1979 to 1989 so relatively older
study which limits its
generalisability to current youth
Validity of author’s conclusion
Tentative because study links
overall initiation rates by
marketing budget but doesn’t
assess marketing budget
impact on initiation rates by
education level
Marketing expenditure may be associated with
an increase in smoking initiation especially in
young people with lower levels of education.
Outcomes measured
Initiation rates by education (rate
calculated as number in an age
group who reported starting smoking
regularly in a year, divided by
number of never-smokers at start of
the year)
Study analysis
103
Details
Method
Results
Comments
Controls on advertising, promotion and marketing of tobacco
Linear or quadratic models fitted to
Intervention details
initiation rates
Examines trends in smoking initiation
by inflation-adjusted cigarette prices
and tobacco industry budget for
marketing
104
Details
Method
Results
Comments
General population impact
Fully branded female packs were rated
significantly more appealing than the same
packs without descriptors, “plain” packs,
and non – female- branded packs. Femalebranded packs were associated with a
greater number of positive attributes
including glamour, slimness, and
attractiveness and were more likely to be
perceived as less harmful. Approximately
40% of smokers and non-smokers
requested a pack at the end of the study;
female- branded packs were 3 times more
likely to be selected than plain packs.
Internal validity
Reports significant
sociodemographic predictors
only, convenience sample
Education varied by condition,
with the highest level of
education in the standard
condition ( χ 2 = 18.0, p = .04),
and number of smoked
cigarettes per day was
significantly higher in the plain
condition ( M =10.6) compared
with the standard condition ( M
= 7.7, B = −0.14, p = .046)
among current smokers
Controls on advertising, promotion and marketing of tobacco
Author, year
Hammond 2011
Age (years)
18-19
Setting
US
Study design
Randomised controlled trial
Objective
To examine the impact of cigarette
pack design among young women
Intervention
Short online survey intervention
looking at brand appeal of tobacco
packaging
SES variables
Education level categorized as “low ”
(grade school or some high school), “
medium ” (high school, technical
school , or community college), and “
high ” (university).
Income
Study analysis
Data sources
Online survey of 18-19 year old
women in US in February 2010
Participant selection
Convenience sample of 826 female
smokers and non-smokers aged 1819 years, recruited via email from a
consumer panel through Global
Market Insite Inc. (panel reach 2.8
million) participants received
approximately $2USD for completing
the survey. Randomised to four
experimental conditions after
ascertaining smoking status
Participant characteristics
18-19 year old women, education
varied by condition, with the highest
level of education in the standard
condition ( χ 2 = 18.0, p = .04),
Outcomes measured
Packs rated by participants on
measures of appeal and health risk,
also behavioural pack selection task
Intervention details
Online survey intervention.
Participants viewed eight cigarette
packages, one at a time, displayed in
a random order. Packages were
Impact by SES variable
Participants in the high- income (B = 0 .11,
p = .004) and high education (B = 0 .08, p
= .05) categories endorsed a greater
number of positive smoker traits
(female/male, glamorous/not glamorous,
cool/not cool, popular/not popular,
attractive/unattractive, slim/overweight, and
sophisticated/not sophisticated) than those
in the low- income and low education
categories.
High- income respondents were more likely
to endorse smoking and weight control
beliefs compared with respondents
reporting low ( OR = 1.70, 95% CI = 1.12 –
2.60) and medium income ( OR = 1.73,
95% CI = 1.09 – 2.73) and those who did
not state their income ( OR = 2.17, 95% CI
External validity
Young women only limit
generalisability.
Validity of author’s conclusion
The reactions to/perceptions of
the different types of packs
was the same by SES for
nearly all the measures. Thus,
very tentatively, plain
packaging might have a neutral
equity effect for young women.
Equity impact was not a main
aim of the study.
105
Details
Method
Controls on advertising, promotion and marketing of tobacco
Regression models were used to
displayed according to each
examine the effect of experimental
of the four experimental conditions:
condition for three primary outcomes: ( 1) female-oriented packages
pack ratings, smoker image ratings,
(standard condition); ( 2) femaleand beliefs about smoking. For each
oriented packages with brand
outcome, regression models were
imagery, including colours and
conducted in two steps. In Step 1,
graphics, but with descriptors (i.e.,
the model included only the
slims) removed; ( 3) female-oriented
“condition” variable. In Step 2 of the
packages without brand imagery
model, the following variables were
and descriptors (i.e., plain packages);
entered as covariates: age,
and (4) popular U.S. brands of “
education, income, ethnicity, smoking
regular ” or non – female- oriented
status, and weight concerns. In Step
packages
3, all two-way interactions with the
“condition” variable were tested by
entering each interaction term into
the model one at a time.
Results
Comments
= 1.29 – 3.65).
No significant differences in pack selection
were observed for smoking status, age,
income, education, ethnicity, or weight
concerns
Author’s conclusion of SES impact
Not stated
106
Details
Method
Results
Comments
General population impact
The greatest number of sites for any
neighbourhood was 22 in Roxbury, with
Mattapan (21) second and East
Boston (16) third. These three
neighbourhoods also shared the top three
positions for number of units: Mattapan
(169), Roxbury (124), and East Boston
(113).
The overall advertising density for schools
in all neighbourhoods combined was higher
for middle (10.1) and high schools (9.9)
than for elementary schools (6.3)
Internal validity
Uses actual observations of
tobacco density and links to
buffer zones. However study
does not include point-ofpurchase advertising,
advertising inside stores that is
seen from the street, or
advertising on taxis and buses.
Controls on advertising, promotion and marketing of tobacco
Author , year
Pucci 1998
Age (years)
5-14, 15-19
Setting
Boston, US
Study design
Cross-sectional study
Objective
To determine the prevalence, type
and proximity to public schools of all
stationary outdoor tobacco
advertising in 6 Boston
neighbourhoods
Intervention
Youth exposure to tobacco
advertising density within FDA 1,000
foot buffer zones around schools
SES variable
Neighbourhoods defined by median
income per household from Boston
Neighborhood Health Status
Report
Data sources
field survey using single observations
in 1996. Six Boston
neighbourhoods—two with the
highest, two with middle, and two
with the lowest median household
incomes—were selected. July to
August 1996, four observer teams
(one adult and two to three youth),
recruited from Boston summer youthemployment programs, participated
in 2-day training. Observations made
by the teams were validated by
randomly selecting 8 sites. An
independent observer who had
attended the team training conducted
follow- up observations within a week
of the original observations.
Participant selection
The neighbourhoods, as defined in
the Boston Neighborhood Health
Status Report, are (from highest to
lowest median income) Beacon Hill
($38,816), West Roxbury, Mattapan,
North End, East Boston, Roxbury
($19,351).
Impact by SES variable
East Boston and Roxbury, the two
neighbourhoods with the lowest median
incomes, showed the highest number of
advertising sites inside the buffer zones, 16
and 18, respectively
External validity
Unable to assess
generalisability of these 6
Boston neighbourhoods as no
details provided.
Validity of author’s conclusion
Valid but probably
underestimates density.
Author’s conclusion of SES impact
The majority of outdoor tobacco advertising
was in the neighbourhoods with the lowest
median household incomes
Participant characteristics
580 advertising units at the 94 sites
Outcomes
Advertising density by school level
107
Details
Method
Results
Comments
Controls on advertising, promotion and marketing of tobacco
Study analysis
and neighbourhood
Advertising sites plotted using
MapInfo, density calculated by
Intervention details
dividing number of advertising units
Observational survey identifying
by area of buffer zone
advertising sites
108
Details
Method
Results
Comments
Data sources
Seven waves of Legacy Media
Tracking Survey data (telephone
survey), collected from September
2000 through January 2004. The
LMTS was developed to track
awareness of, and receptivity to,
American Legacy Foundation’s
truth® campaign.
General population impact
N/A
Internal validity
Appends SES proxy measures
(zip codes) to data as LMTS
did not measure SES.
Intervention methods differed
over time: proportion of
campaign broadcast on cable
increased over time.
Survey developed specifically
for this campaign but repeated
over 7 waves and 4 years.
Mass media campaigns
Author , year
Vallone 2009
Age (years)
12-17
Setting
US
Study design
Cross-sectional study
Objective
To determine whether SES is
associated with awareness of and
receptivity to the truth® campaign
among youth aged 12–17.
Intervention
The truth® campaign is a branded
countermarketing campaign
SES variable
Median household income and
median household education at the
zip code level.
Study analysis
This receptivity analysis using
bivariable and multivariable analyses
is limited to participants who
Participant selection
Response rates for the LMTS ranged
from 60% to 30% per wave, with a
general pattern of decline over time.
The samples for each survey wave
were generated by a combination of
random digit dial (RDD) and
supplementary lists. Listed sample
was used to achieve target numbers
within geographic and racial/ethnic
populations. African American,
Hispanic and Asian youth and young
adults were oversampled in each
survey wave in an effort to generate
sufficient sample sizes among
racial/ethnic groups. To evaluate
the campaign, oversamples were
also drawn in some survey waves
from within three sentinel sites, from
within states which had strong
tobacco countermarketing
campaigns, and those with variation
across truth® gross ratings points
Impact by SES variable
Youth who lived in zip codes in which the
median household income was less than or
equal to US$ 35,000 had a lower level of
confirmed awareness than respondents in
each of the other income categories (p <
0.05). There were no statistically significant
differences in confirmed awareness by
median level of education, though there
was a pattern in which the proportion of
confirmed awareness increased with
education. Similarly, there were no
differences in receptivity by median
household income or median household
education, though there was a pattern of
increasing receptivity with greater income
and education
Author’s conclusion of SES impact
From 2000 to 2004, both female and male
youth living in lower education zip codes
had lower odds of having confirmed
awareness of truth® as compared with
youth living in more highly educated zip
codes. Zip code level median household
income was not associated with confirmed
awareness. However, there were no
differences in receptivity to the campaign
by zip code level income or education.
External validity
Generalisability may be limited
due to response rates; which
ranged from 60% to
30% per wave, with a general
pattern of decline over time. An
examination of the sample
demographics across the
seven survey waves indicates
that there are some statistically
significant differences across
waves over time; however,
further analyses revealed no
systematic bias with regard to
demographic characteristics by
response rate.
Could such a huge, lengthy
and expensive campaign be
applied outside the US? Only
national organisations are likely
to run similar mass-media
109
Details
Mass media campaigns
demonstrated confirmed awareness
of the campaign. Zip codes were
appended to the data
files by one of two means: (1) for the
listed sample, zip codes were linked
to street addresses; (2) for the RDD
sample, the most probable zip code
associated with that telephone
exchange was selected.
Method
(GRPs).
Participant characteristics
30,512, including 15,335 female and
15,177 male respondents.
By age group, 51.5% age 12–14 and
48.5% age 15–17. 57.19% identified
as white, 20.0% as Hispanic, 15.0%
as African American and 7.9% as
Asian American. Most of the sample
had never smoked (76.3%); however,
16.1% were former smokers and
7.6% were current smokers. Youth
watched a mean of 3.3 h of TV
per day, and 80.9% had cable
access. The median household
income distribution by zip code was
as follows: 25.0% of respondents
lived in zip codes in which the
median household income was less
than or equal to US$ 35K per year;
26.0% lived in US$ 35–45K zip
codes, 24.2% lived in US$ 45–60K
zip codes and 24.9% lived in
wealthier zip codes. The median
household education distribution by
zip code was as follows: 17.8% of
respondents lived in zip codes in
which the median household
education was less than or equal to
12 years; 39.7% lived in zip codes in
which the median household
education was 13 years, 30.5% lived
Results
Comments
campaigns due to prohibitive
cost
Validity of author’s conclusion
Valid but awareness and
receptivity do not inform us of
changes in smoking behaviour.
Difference in results between
awareness according to
income or education, and
between awareness and
receptivity outcomes, may
indicate measurement issues
of how or what study is
measuring?
110
Details
Method
Results
Comments
Mass media campaigns
in zip codes in which the median
household education was 14 years
and 12.0% lived in more educated
zip codes.
Outcomes
Confirmed awareness and receptivity
Intervention details
The truth® campaign is a branded
countermarketing campaign
designed to prevent smoking among
at-risk youth, primarily through edgy
television advertisements with an
anti-tobacco industry theme
111
Details
Method
Results
Comments
General population impact
26% (10.4,42.0) cut costs, 21% (9.3,31.9)
considered quitting, 53% (36.8, 69.6) no
response
Internal validity
53% of the teenagers who
continued to smoke denied
having had any of the 3
potential reactions to price
increase. Analysis restricted to
small sample.
Increases in price/tax of tobacco products
Author, year
Biener 1998
Age (years)
12-17
Setting
Massachussetts, US
Study design
Cross-sectional study
Objective
Examines smokers perceptions of
the impact of new tobacco taxes
Intervention
Statewide (Massachusetts) tobacco
control programme
SES variables used
household income is dichotomised at
the median, for
teenagers=$50,000/y, obtained from
the report of an adult household
resident
Data sources
Telephone interviews from sample
from random-digit-dialling, 1993-1994
Participant selection
Screening interviews for 78% of
sampled households (random-digit
dialling), 75% response rate for
youths=1606 youth interviews
Participant characteristics
Analysis restricted to 216 current
teenage smokers who reported
having ever bought cigarettes
Outcomes measured
Smoking behaviour
Intervention details
Survey retrospectively assessing
reactions to 1993 tax increase
Impact by SES variable
Teenaged smokers from low income
households were much more likely to cut
costs of their smoking in response to the
price increase, rather than do nothing (OR
7.57, 95%CI 1.55,36.98) or cut costs rather
than consider quitting (OR 14.72, 95%CI
2.55,84.95), household income was
unrelated to the choice between
considering quitting and doing nothing (OR
0.51, 95% CI 0.13,2.77), these significant
bivariate effects are still significant in
multivariate model
External validity
No further details of teenager
demographics although reports
that age and sex not
significantly related to reported
response to price increase
Validity of author’s conclusion
Possible that study failed to
measure an important variable.
Author’s conclusion of SES impact
Low-income teenagers more likely than
more affluent teens to cut costs by cutting
down on smoking or (less often) by
switching to cheaper brands. Young lowincome smokers were not more likely than
wealthier teenagers to consider quitting
Study analysis
Multinomial logistic regression using
bivariate and multivariate models
112
Details
Method
Results
Comments
General population impact
1979 to 1984 adolescent initiation rates
decreased but increased thereafter
Internal validity
Respondents are asked about
how old they were when they
started smoking (retrospective
so potential for recall bias and
underreporting)
Increases in price/tax of tobacco products
Author, year
Gilpin & Pierce 1997
Age (years)
14-21 in 1979 to 1989
Setting
US
Study design
Cross-sectional study
Objective
To investigate the possible
association between increased
tobacco marketing and increased
smoking initiation by adolescents
Intervention
Examines trends in smoking initiation
by inflation-adjusted cigarette prices
and tobacco industry budget for
marketing
SES variables used
Education (less than 12 years, 12
years with no college education,
more than 12 years with some
college education as adults)
Data sources
Combined data from 3 Current
Population Surveys (September
1993, January 1993, May 1993) that
contained special supplement on
tobacco use. One quarter=in person
interviews and ¾ telephone
interviews. Tobacco Institute for
weighted average pack prices, US
Federal Trade Commission for
marketing expenditure; adjusted to
1989 dollars using Consumer Price
Index
Participant selection
Civilian non-institutionalised
population aged 15 years+, surveyed
about 56,000 households per month
Participant characteristics
Analysis restricted to respondents
17-38(n=140,975) that would have
been 14-21 in 1979 to 1989
Impact by SES variable
Initiation rates highest among high school
dropouts and lowest amongst those who
eventually attended college. Only quadratic
model significant for dropouts (p=0.035).
Neither model was significant for highschool graduates nor both models were
significant for ‘some college’ (p=0.081
linear, p=0.014 quadratic).
In 1988 initiation rate was 9.9% for those
who did not graduate from high school,
6.9% for high-school graduates reporting
no college and 3.7% for those reporting at
least some college.
Author’s conclusion of SES impact
Increase in cigarette taxes did not reduce
smoking initiation rates.
External validity
Initiation rates are for decade
1979 to 1989 so relatively older
study which limits its
generalisability to current youth
Validity of author’s conclusion
Tentative because study links
overall initiation rates by
marketing budget but doesn’t
assess marketing budget
impact on initiation rates by
education level
Outcomes measured
Initiation rates by education (rate
calculated as number in an age
group who reported starting smoking
regularly in a year, divided by
number of never-smokers at start of
the year)
Study analysis
113
Linear or quadratic models fitted to
initiation rates
Intervention details
Examines trends in smoking initiation
by inflation-adjusted cigarette prices
and tobacco industry budget for
marketing
114
Details
Method
Results
Comments
General population impact
Longitudinal data: Taxes at age 14 had a
significant negative impact on later
smoking behaviour (elasticity -0.66,
p<0.05) although this effect reduced over
time. This result was confirmed by the fixed
effect analysis.
Cross-sectional data: Taxes at age 14 had
a significant negative impact on current
smoking at ages 19-28 (elasticity -0.96,
p<0.01) and late initiation (p<0.10), but no
effect on quitting.
Internal validity
Longitudinal data and crosssectional data appear to be
similar and similar for general
population and for low-income
population
Increases in price/tax of tobacco products
Author, year
Glied 2002
Age (years)
14-23 in 1979
Setting
US
Study design
Prospective longitudinal cohort study
with cross-sectional analysis
(econometric)
Objective
To test the assumption that
policies targeting youth to
reduce smoking initiation will
reduce lifetime smoking
propensities
Intervention
Estimates the effect of cigarette
taxes at age 14 on future overall
smoking behaviour, quitting and
initiation
SES variables used
Family income in 1979 below the
sample median (about $12,000 in
Data sources
Smoking data from the National
Longitudinal Survey of Youth (1979,
84, 92 and 94). Cigarette tax rates
and tax policies from the Tobacco
Institute 1996
Participant selection
No details
Participant characteristics
N=7,605; Sixty percent
had tried cigarettes by age 16, mean
(SD): age 17.5 (2.2), age began
smoking 13.6 (3.4); 53% female;
30% black; 18% Hispanic; mean
(SD) family income in 1979 $18,270
($11,747)
Outcomes measured
Smoking participation, quitting,
initiation
Intervention details
Assesses relationship (price
elasticity) between tax and smoking
behaviour over time and across time
Impact by SES variable
Longitudinal data
Low income (< $12,000 median in 1979)
-0.65, p<0.10 (at age 14)
-0.33 (at age 24)
-0.01 (at age 34)
0.15 (at age 39)
Tax at age 14 had a statistically significant
negative effect on current smoking overall,
for low income people.
Elasticities declined over time for low
income people indicating that by age 39 the
effect of taxes at age 14 has largely
disappeared.
Cross-sectional data
Current smoking at age 19 to 28
-1.00, p<0.05 (low income)
Taxes at age 14 had most effect on low
income people at ages 19-28 although this
External validity
Not clear if National
Longitudinal Survey of Youth
was representative as
minorities were oversampled,
and the analysis was restricted
to only those surveyed in 1979,
84, 92 and 94.
Validity of author’s conclusion
Valid.
115
Details
Method
Increases in price/tax of tobacco products
1979)
Study analysis
Model: using longitudinal data: (1)
probit model including the effects of
time and how taxes change over
time, with adjustment for clustering
within an individual; (2) ordinary least
squares regression using individual
fixed effects with an interaction term
between tax at and time since age
14.
Using cross-sectional data (analysing
1984, 92 and 94 separately) to
estimate the effect of taxes at age 14
on overall smoking behaviour,
quitting and initiation.
Results
Comments
reduced and was no longer significant in
later years.
Quitting
Taxes at age 14 had a positive but not
significant effect on quitting by the age of
27 to 37 for low income people.
Late initiation (starting after age 16)
Taxes at age 14 did not have a significant
effect on late initiation for low income
people.
Author’s conclusion of SES impact
These results suggest that reducing
smoking among teens through tax policy
may not be sufficient to substantially
reduce smoking in adulthood
116
Details
Method
Results
Comments
General population impact
N/A – all results stratified by age
There is no public policy (clean air or
access) variable other than price which is
significant for either age group in all three
data sets, or even in both the data sets
representing the full teen population (MTF
and YRBS).
Internal validity
Parental education is used as a
proxy for income.
Increases in price/tax of tobacco products
Author, year
Gruber 2000
Age (years)
13-18
Setting
US
Study design
Cross-sectional study (econometric)
Objective
To provide a comprehensive
analysis of the impact of prices
and other public policies on
youth smoking in the 1990s
Intervention
State-level measures of prices,
clean air regulations and youth
access restrictions
SES variable
Parental education
Study analysis
Econometric analysis
Model: linear regression models with
standard errors corrected for within
Data sources
Monitoring the Future (MTF:
University of Michigan) providing
smoking behaviour, race, age, sex
and state data for 8th, 10th, 12th
graders (1991-97); Youth Behaviour
Risk Survey (YBRS) data (CDC) for
1991, 3, 5, and 7 for 9th-12th
graders; Vital Statistics Natality Detail
Files from 1989 onwards providing
smoking behaviour of women during
pregnancy.
Participant selection
Participant characteristics
Number=641,759 (MTF); 106,556
(YBRS); 3,970 (Natality, aged 13-18)
Outcomes
Smoking participation
Smoking intensity
Intervention details
Econometric analysis using repeated
cross-sectional data
Impact by SES variable
Parental education (YRBS data only)
For seniors the elasticity of participation
was -4.39* for those whose parents were
high school dropouts or graduates and -.24
for parents with some college education.
For smoking intensity this trend was
reversed with elasticities of -0.40 for high
school and -2.39* for college education.
There was no pattern for younger
teenagers, although participation elasticity
was positive and statistically significant for
high school educated parents (2.72*). [*
p<0.05]
External validity
No information on high-school
dropouts who may be
differentially price sensitive.
State by year dropout rates
were controlled for in
regression analysis which
suggests no selection bias due
to dropout related to tax.
Validity of author’s conclusion
In cross-sectional data it is
impossible to disentangle price
and policy impacts from other
underlying long-run
determinants of smoking
attitudes. Sensitivity to price
suggests cross-elasticity
between price and income
Author’s conclusion of SES impact
These results suggest that the single
greatest policy determinant of youth
smoking is the price of cigarettes.
Older teenagers are more sensitive to
prices with a central elasticity estimate of 0.67. This price sensitivity rises for more
socioeconomically disadvantaged
117
Details
Method
Increases in price/tax of tobacco products
state-year correlation (to account for
variation across states and years).
Separate models built for each
dataset. (MTF, YBRS, Natality)
Outcome variables: smoking
participation (any smoking
over past months); conditional
intensity (quantity smoked)
Explanatory variables: price per
pack (including taxes); clean air
regulations (private workplace, public
workplace, restaurants, schools,
other e.g. public transport); youth
access index (score across 9
categories including minimum
purchase age, vending machine
availability, which is added to create
a total index with high scores
indicating more restrictions); state
and year (as fixed effects to account
for between state and between year
price differences).
Results
Comments
groups such as blacks or those with less
educated parents.
118
Details
Method
Result
Comments
General population
Higher tax levels are associated with
later initiation and earlier cessation.
SES
Taxation has a stronger effect to
prevent or delay initiation among
those with intermediate education,
and weakest among those with the
lowest education.
Taxation has the strongest effect on
cessation among those with the
lowest education, an equal impact on
those with other levels of education.
Author’s conclusion of SES impact
Results are extremely tentative, but it
appears that the greater impact is
among those with intermediate
education. Greatest effect on quitting
for the lowest levels of education.
Internal validity
Potential for recall bias, going back
up to 40 years in some cases.
Doesn’t capture failed attempts to
quit.
External validity
Revenue Commissioners does not
break down the tax component into
excise and VAT for the period up to
1973. Thus, authors have taken the
total tax component of the retail price
and deflated it by the personal
consumption deflator to arrive at a
real tax on tobacco.
Tax was relatively low through the
study period, unclear whether the
relationship would continue with
further increases from current levels
of taxation.
Potential quitters had less cessation
support available.
Only covers Irish females.
Covers a period of increasing
awareness of the impact of smoking,
unclear whether cessation was linked
to taxation or increased awareness.
Validity of author’s conclusion
Results are extremely tentative
Increases in price/tax of tobacco products
Author, year
Madden, 2007
Age
19 (when started smoking)
Country
Ireland
Design
Single cross-sectional survey
containing retrospective cohort data
Objective
To investigate the role of tobacco
taxes in starting and quitting smoking
and explores how tax effect differs by
education
SES variables
Education (primary, junior (age 16),
secondary (age 18), University)
Analyses
Duration analyses – various
parametric duration models
Data sources
Retrospective data from a survey on
women’s knowledge, understanding
and awareness of lifetime health
needs (Saffron Survey, 1998).
Participant selection
All survey respondents who were
born after 1950 (so that sample’s
exposure matches price data).
Participant characteristics
N=703. Average age 34, ex-smokers
slightly older. 10% primary education,
27% junior education, 40%
secondary, 21% university. Eversmokers and current smokers more
likely to have lower levels of
education. 55% employment rate,
47.5% among current smokers.
Intervention
Tobacco taxation from 1960
onwards.
Length of study
1960 to 1998
Outcomes
Ever smoked, age of initiation, and
cessation.
119
Details
Method
Results
Comments
General population impact
32% did not react to price increase, 33%
reduced costs of smoking(purchasing in
foreign countries/smuggling, cheaper
brand, hand-rolled), 35% reduced
consumption or tried to quit
Internal validity
Student’s report of parent’s
educational level may be prone
to bias. Study was powered for
a response rate of 70% but
small sample size for this
analysis with statistical
significance threshold of 10%.
Retrospective questions after
price increase.
Increases in price/tax of tobacco products
Author , year
Perretti-Watel 2010
Age (years)
19.5
Setting
South-Eastern France
Study design
Cross-sectional study
Objective
To investigate young smokers
retrospective reactions to an increase
in cigarette prices
Intervention
Price increase on tobacco
SES variable
Students report of parental education
Study analysis
Restricted to 427 daily smokers,
Data sources
Survey on Provencal Students’
Health conducted by The Southeastern Health Regional Observatory
between November 2005 and June
2006 (unpublished). random sample
of 2455 students stratified by
university and
academic department
Participant selection
Response rate 71%, n=1753,
excluded another 30 due to
incomplete survey, n=1723
Participant characteristics
First year University students in 6
Universities, 58% were girls and 42%
were boys (mean age: 19.5 years
old,). 32% current smokers (daily
smokers: 25%, occasional smokers:
7%), and 6% were former smokers.
Outcomes
Smoking behaviour: no reaction,
cheaper smoking, smoking less
Impact by SES variable
Daily smokers with low-educated parents
were less likely to react to the price
increase, daily smokers who had at least
one parent that completed high school
were more prone to react to higher
cigarette price (OR=2.5, 95% CI=1.6,4.0 for
cheaper smoking vs no reaction; and
OR=2.1, 95% CI 1.4,3.3 for smoking less
vs no reaction; in multivariate analysis, p <
0.001 and p< 0.01, respectively)
Students who reported difficulties in
financing their studies were significantly
more likely to purchase cheaper cigarettes
(OR=1.9,95% CI=1.0,3.7; p< 0.1).
External validity
Regional not national survey so
may not be generalisable to
whole of France; also reactions
to price increase are only
relevant to daily smokers who
did not quit.
Validity of author’s conclusion
Valid but small specific sample
Author’s conclusion of SES impact
Young smokers with a lower socioeconomic status were less likely to react to
the price increase
Intervention details
Survey
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Details
Method
Results
Comments
General population impact
N/A
Internal validity
Study is longitudinal but 7 year
gap in data used to assess
transition from adolescence to
young adulthood may have
missed other important
mediators. Missing values for
family income were imputed.
We don’t know how
demographic characteristics at
each wave compare.
Controls on access to tobacco products
Author, year
Kim 2006
Age (years)
15
Setting
US
Study design
Prospective cohort study
Objective
To examine whether young
especially low SES females are
influenced by tobacco control policies
in terms of smoking initiation and
transition
Intervention
State level tobacco control policies
and state cigarette excise tax
SES variables
Parents level of education and
income (parents questionnaire)
Study analysis
multilevel logistic regressions
comparing initiators to never smokers
Data sources
State level tobacco policy scores
developed by US National Cancer
Institute, evaluating 9 items for each
state each year= statewide
enforcement, random inspections,
graduated penalties, photo
identification, free distribution,
minimum age, packaging, vending
machines, and clerk intervention.
Dataset, the national longitudinal
study of adolescent health (Add
Health), is a school based survey of
the health related behaviours of
adolescents.
Participant selection
Add Health surveys individual
adolescents from 132 schools,
grades 7 to 12, using a sampling
frame stratified by region, level of
urbanisation, school type, school
size, and by school racial
compositions. In 1994–5
(wave 1), data from 18 924
adolescents were collected; in
1996 (wave 2) and in 2001–2 (wave
3), follow up in-home surveys were
conducted to interview again 15 197
of the respondents from wave 1
about their health behaviours and life
experience as young adults.
Impact by SES variable
Stronger state level tobacco policies were
associated with lower likelihood of smoking
initiation and adverse transition among low
SES women, although the effect sizes were
small. The positive policy effects for
initiation were strongest for low SES
females, whose odds ratio was 0.95 (0.98
for middle SES, 1.00 for high SES). For
initiation, school level smoking rates did not
vary substantially across low, middle, and
high SES groups (OR=1.01, 0.99 and 1.00,
respectively. For statewide enforcement,
the odds ratios of initiation were
significantly lower for the low (0.89) and
middle (0.91) SES female groups; on the
other hand, the policy had no effect on the
high SES female group (OR=1.00). For
random inspections the odds ratios of
initiation were significantly lower for low
(0.88) and middle (0.90) SES female
groups. Photo identification had a
significant positive effect on the low SES
female group (OR=0.85), but not on the
middle SES female group (OR=0.95, NS)
and on high SES females (OR=1.10, NS).
other policies had a pattern similar to the
significant ones
External validity
2697 females only-no further
information on how
representative this sample is.
Study adopted a measure of
comprehensive state tobacco
control efforts based on a
score developed by the
National Cancer Institute
evaluating nine items for each
state each year; enables future
studies to use similar rating
scores for policy.
Validity of author’s conclusion
Valid but effect size is small.
Author’s conclusion of SES impact
121
Details
Method
Controls on access to tobacco products
Participant characteristics
Restricted to female adolescents
younger than 18 at baseline=2697
females from 33 states,126 schools
Sample sizes were 1245 for low
SES, 812 for middle SES, and
640 for high SES female
adolescents.
Outcomes measured
Smoking initiation and transition
Results
Comments
Tobacco control policies have the biggest
impact on reducing the likelihood of
smoking initiation in low SES females, less
of an impact on the likelihood of middle
SES female group, and the least impact on
high SES females. Stronger tobacco
control policies are positively related to
lower likelihood of adverse transition in
smoking, especially for the low SES female
group
Intervention details
National longitudinal school-based
survey ‘Add Health’ of individual
adolescents about their health
behaviours and life experience as
young adults
122
Details
Method
Results
Comments
General population impact
Overall rate of retailer non-compliance with
underage tobacco sales laws in the 997
selected outlets was 14.3%. Buyer’s actual
age, a male clerk and asking young buyers
about their age were related to successful
cigarette purchases. Buyer’s actual age
and minimum age signs increased the
likelihood that clerks will request
identification (ID).
Internal validity
There were no significant
differences between the
sampled and the unsampled
cities in relation to population
size, ethnic diversity,
household size and median
household incomes.
Controls on access to tobacco products
Author, year
Lipperman-Kreda 2012
Data sources
Access surveys
Age (years)
Underage tobacco sales – 4
confederate buyers (2 men and 2
women), who were over 18 years of
age, but judged to appear younger by
an independent panel, mean age 19
years.
Participant selection
purposive geographic sample
Setting
997 Tobacco outlets in 50 mid-sized
California cities, USA
Study design
Cross-sectional
Objective
To examine contextual and
community-level characteristics
associated with youth access to
tobacco through commercial sources
Intervention
underage tobacco sales laws
SES variables
Median family income, % population
with college education (city level
n=50)
Participant characteristics
997 Tobacco outlets in 50 mid-sized
California cities, USA
Outcomes measured
Retailer compliance with underage
tobacco sales laws
Intervention details
Purchase attempts were made at 997
tobacco outlets in 50 mid-sized
California cities by a team of two
buyers. At each outlet a single buyer
attempted to purchase a pack of
Marlboro or Newport cigarettes,
which are the most popular cigarette
brands among high school-aged
students. Each buyer asked for
Marlboro in one outlet and Newport
in the next one. If asked about their
age they stated that they were over
18 years old, and if asked for an age
ID they indicated they had none. If a
sale was refused, the buyers left
without attempting to pressure the
clerk.
Impact by SES variable
Retailer compliance with underage tobacco
sales laws: at the community level, a
greater percentage of residents with at
least a college degree were associated
with increased likelihood of noncompliance.
Predictors of clerks requesting ID: at the
community level, lower percentage of
residents with at least a college degree
was associated with retailers asking for an
ID. Asking young buyers about their age
was positively associated with successful
purchases.
Predictors of cigarette pack prices: higher
cigarette prices of Marlboro but not
Newport, were associated with higher
median household income.
External validity
Only 2 buyers conducted the
surveys in each city which
limits ability to consider
characteristics of the buyers
other than gender and age.
Also limited to 2 brands.
Validity of author’s conclusion
Higher education was a
significant predictor of
underage tobacco sales.
So stricter enforcement of laws
would not reduce gap between
low and high SES in terms of
smoking prevalence? Unclear
how access to tobacco
translates into smoking
prevalence.
Author’s conclusion of SES impact
Youth in communities with higher
educational levels may have easier access
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Details
Method
Results
Comments
Controls on access to tobacco products
Study analysis
Multilevel logistic and linear
regression
to cigarettes from retail stores. The
relationships between community
characteristics and cigarette prices varied
by cigarette brand. Higher median
household income was associated with
higher prices of Marlboros.
124
Details
Method
Results
Comments
Students receiving FSM were more likely to
smoke (adjusted OR for FSM: 1.87,
p<0.001).
Internal validity
Pupil records with missing
values (e.g., not answering) for
outcome variables and
covariates were removed
(10.4%).
Baseline differences in age,
gender and ethnicity but
controlled for in analyses.
Self-report smoking status but
reported within schools rather
than at home.
Cross-sectional but response
bias is likely to be low because
the pupil response rate to the
survey was very high (88% in
2008) in participating schools.
Sample size was sufficient to
detect a 10% relative reduction
in smoking prevalence in the
non-FSM group compared with
the FMS group (at 80% power
at the 5% level of significance).
However, the sample size did
not permit examination of
whether the legislation reduced
the volume of cigarettes
smoked.
Controls on access to tobacco products
Author, year
Millett 2011
Age (years)
13
Setting
Secondary schools, England
Study design
Repeat cross-sectional surveys of
children in same schools before and
after legislation
Objective
To determine whether the law had a
differential impact on the likelihood of
regular smoking depending on FSM
status among youth in England
Intervention
Legislation in England, Scotland and
Wales increasing minimum age for
legal purchase of tobacco from 16 to
18 years, October 2007
SES variables
Free school meals (FSM) (eligibility
assessed on basis of parental
employment and status and income
level)
Data sources
Smoking, Drinking and Drug Use
Among Young People in England
(SDDU) annual survey of 11-15 year
olds, by National Centre for Social
Research and the National
Foundation for Educational
Research, National Foundation for
Educational Research database
Participant selection
In 2008, 264 schools agreed to take
part (response rate 58%) and within
these schools 7798 pupils aged
between 11 and 15 years completed
the survey (response rate 88%).
Participant characteristics
FSM group was significantly younger
(mean age: 13.1 vs 13.2 years,
p=0.002), more likely to be female
(53% vs 49%,P=0.042) and
contained significantly more pupils
from ethnic minorities (22% vs 13%
non-white, p<0.001) than the nonFSM group in 2008.
Outcomes measured
Regular smoking status
Usual source of tobacco
Ease of tobacco purchase
General population impact
Increasing the minimum age for purchase
was associated with a significant reduction
in regular smoking among youth (adjusted
OR 0.67; 95% CI 0.55 to 0.81,
P=0.0005).
Impact by SES variable
Regular smoking was not significantly
different in pupils eligible for FSM
compared with those that were not
(adjusted OR 1.29; 95% CI 0.95 to 1.76,
p=0.10).
Percentage of regular smokers who usually
bought cigarettes from a vending machine
decreased significantly in the non-FSM but
not in the FSM group.
Percentage of regular smokers who usually
bought cigarettes from friends and relatives
or from other people increased significantly
in the non-FSM but not the FSM group
after the introduction of age restriction.
Regular smokers eligible for FSM were
significantly more likely to be given
cigarettes by their parents in 2006
External validity
Although the response rate for
schools was only 58% in 2008,
the sampling frame ensured
125
Details
Method
Controls on access to tobacco products
Intervention details
Study analysis
Data used from 2003 to 2008
excluding 2007.
Multivariate logistic regression
analysis adjusted for previous time
trends, age, gender, ethnicity, alcohol
and drug use
Results
Comments
(p<0.001) but this was no longer the case
in 2008 (p=0.42).
Percentage of pupils who stated that they
found it difficult to buy cigarettes from a
shop did not increase in those eligible for
FSM (25.2% to 33.3%; p=0.21) but did
increase significantly in others (21.2% to
36.9%; p<0.01) between 2006 and 2008.
that schools participating in the
survey closely reflect the
composition of schools in
England generally.
The survey did not include 16
and 17 year olds who were
most directly affected by the
increase in age for the legal
purchase of tobacco.
Percentage of regular smokers who were
successful in buying cigarettes from a shop
during their latest attempt decreased
significantly in the non-FSM but not the
FSM group between 2006 and 2008.
Validity of author’s conclusion
Smokefree ban and alcohol
restrictions also introduced
during this time which may
confound these results.
No differences in ease of purchase were
found between pupils eligible for FSM and
those not before or after the legislation
(2006: p=0.34, 2008: p=0.55).
Author’s conclusion of SES impact
Increasing the minimum age for the
purchase of tobacco in England was
associated with a significant reduction in
youth smoking and was neutral with regard
to disparities.
126
Details
Method
Results
Comments
General population impact
Number of commercial sources declined by
12% from 2005 to 2009 resulting mainly
from removal of 44% of outdoor cigarette
vending machines (indoor machines
decreased by 5%). Convenience cigarette
sources reduced by only 0.9%,
supermarket and drug stores +2.6%.
Internal validity
Potential for limited interrater
reliability between 3 geocoders
Controls on access to tobacco products
Author , year
Schneider 2011
Age (years)
17.6% aged 0-20 years
Setting
Cologne, Germany
Study design
Before and after observational study
Objective
To compare number of vending
machines and other commercial
sources before and after new
legislation and to examine
association between commercial
cigarette sources and area SES
Intervention
Electronic locking devices on vending
machines to prevent underage (<16
years) purchasing
SES variable
Income
Unemployment
Social welfare
Low-qualifying schools
Data sources
German Sources of Tobacco for
Pupils (STOP) study, observational
Participant selection
Cologne selected because had
existing sociogeographical data
Participant characteristics
17.6% aged 0-20 years
Outcomes
Density of sources before and after
legislation according to SES of each
district
Impact by SES variable
The lower the income level in a district, the
higher the availability of cigarettes
(Pearson’s r = .595; p = .009). The same
occurred for the alternative indicators such
as youth unemployment (Pearson’s r =
.548; p = .019), the percentage of people
receiving social welfare (Pearson’s r =
.485; p = .041), and the percentage of
pupils attending low-qualifying schools
(Pearson’s r = .473; p = .048).
In 2005 as well as in 2009, we found
significantly fewer commercial cigarette
sources in districts with above-average
SES than in districts with below-average
SES. This can be seen in terms of absolute
as well as relative numbers. The density of
commercial cigarette sources in 2005 in
districts with above-average SES was 3.20
per 1,000 inhabitants and 4.84 per 1,000
inhabitants in the districts with belowaverage SES. In 2009, the numbers were
2.63 per 1,000 inhabitants and 4.44. per
1,000 inhabitants, respectively. The
differences between socially advantaged
and disadvantaged districts appeared to be
External validity
‘natural experiment’ design is
real life, but limited to one city
so not representative of all
German cities but appears
comparable with Germany as a
whole
Validity of author’s conclusion
Valid
127
Details
Method
Controls on access to tobacco products
Study analysis
Inventory of commercial cigarette
sources in 2005 and 2007 and 2009
and mapped using Geographic
Information System
Results
Comments
significant in both years (2005: t(15) =
9.017, p < .001 and 2009: t(17) = 6.915, p
< .001).
Author’s conclusion of SES impact
In districts with above-average SES, the
supply density was lower than in districts
with below-average SES, even at the
beginning of the study. Decreases in the
number of cigarette sources were reflected
more sharply in regions of higher SES,
which also emphasizes the social
inequalities between these two areas.
128
Details
Method
Results
Comments
General population impact
No association found between tobacco
point-of-sale marketing and compliance
check failure.
Of a total of 467 stores, 48 failed
compliance check. Tobacco shops were
most likely to fail compliance checks (44%).
Supermarkets were least likely to fail (3%).
Internal validity
Completion of a full store
assessment was not
significantly associated with
whether stores passed their
compliance check (p = .931).
Each store assessed by one
assessor.
Impact by SES variable
Poverty of stores block group was not
associated with compliance failure of
stores. Stores in block groups with greater
percentage of people living in poverty were
not more likely to fail compliance check.
External validity
Authors report that Minnesota
has less racial/ethnic diversity
compared to other urban
centres.
Compliance checks may not be
a very valid measure of
commercial tobacco
accessibility for minors.
Only vendors with a current
license can sell tobacco in
state of Minnesota but this is
not the case across all US
states.
Also stores who repeatedly
violate youth access laws have
license rescinded.
Study was cross-sectional so
cannot assess whether change
in advertising leads to change
in compliance check failure.
Controls on access to tobacco products
Author , year
Widome 2012
Age (years)
Minors aged 15-18 years used for
compliance checks
Setting
Minnesota, US
Study design
Cross-sectional
Objective
To test the association between
point-of-sale advertising intensity and
likelihood that a store would fail a
compliance check
Intervention
Age-of-sale tobacco checks
SES variable
Poverty (below 150% poverty level)
Study analysis
Description of compliance check
failure proportions for various types
of stores and by census block group
demographics. Failure proportions
calculated. Chi-square tests to test
Data sources
(1) Observations of the advertising
environment in establishments (2) a
record of age-of-sale tobacco checks
where an undercover minor working
with law enforcement attempts to
purchase tobacco (3) Demographic
data from the Year 2000 U.S.
census.
Participant selection
655 licensed tobacco vendors, both
interior and exterior assessments
were completed on 485
establishments (74.0%). Analyses
conducted on 467 establishments
that had complete assessments.
Participant characteristics
Outcomes
Compliance -failure defined as the
sale of tobacco to a youth, regardless
of whether the store clerk examined
the minor’s ID.
Author’s conclusion of SES impact
There was no association between store
advertising characteristics or poverty and
stores’ compliance check failure. The
relationship between advertising and real
youth sales may be more nuanced as
compliance checks do not perfectly
simulate the way youth attempt to purchase
cigarettes.
Validity of author’s conclusion
Valid as considers weakness of
129
Details
Method
Controls on access to tobacco products
whether failure was associated with a
store being situated in a block group
that was in the top decile of each
demographic item. Top decile used
as a cut-off to examine more extreme
examples of census block groups
that had relatively high proportions of
certain demographics, and t tests to
examine whether the percentage of
people in a block group for each
demographic item was associated
with compliance check failure. X2
tests to examine whether specific
advertising practices were associated
with failure.
Results
Comments
the compliance check
measure.
130
Details
Method
Results
Comments
Data sources
General population impact
8% 48/588 in intervention group indicated
greater likelihood of actual tobacco use at
end of programme compared to 12%
(45/375) in control, p=0.04. No statistically
significant difference between groups at 20
weeks follow-up.
Internal validity
Confounding influences of
other interventions were not
observed; 16-17% attrition; test
of equivalence of attrition rates
by treatment condition did not
show attrition bias for students
predisposition towards future
tobacco use behaviours
School-based prevention
Author, year
Bacon 2001
Age (years)
11 (6th grade)
Setting
6 middle schools in Florida, US
Study design
Cluster randomised controlled trial
Objective
To examine effectiveness of ‘Too
Good for Drugs II’ (TGFD II)
programme
Intervention
9 week prevention curriculum and
follow-up after further 20 weeks,
school-based curriculum and also
involves community partners and
parents; theoretical basis includes
Social Learning Theory, Problem
Behaviour Theory and Social
Development Theory.
SES variables used
free/reduced lunch status
Participant selection
Randomly selected
Participant characteristics
1318 sixth grade students, 52%
female, 48% white, 33% AfricanAmerican, 13% Hispanic, 6% Asian;
51% in receipt of free or reduced
school lunches; 84% participated in
20-week follow-up
Outcomes measured
Intentions, attitudes and perceptions
towards tobacco use
Intervention details
9 lesson units (40 minutes each) at
each grade by trained classroom
teacher or TGFD II instructor; social
and emotional competencies,
reducing risk factors and building
protective factors; emphasise
cooperative learning activities, roleplay and skills building methods;
Impact by SES variable
The overall findings of the comparison of
change scores for treatment students
indicates the programme was similarly
effective in impacting students risk and
protective factors regardless of economic
status (perception of peer resistance skills;
positive attitudes toward non-drug use,
perceptions of peer normative substance
use, perceptions of peer disapproval of
substance use, association with prosocial
peers, perceptions of locus of control selfefficacy)
Student scores at end of programme and at
20 weeks follow-up showed significant
multivariate overall effects for SES (before
and after intervention).
External validity
Impact by SES only relates to
scores for substance use not
just tobacco use which limits
comparability
Validity of author’s conclusion
Equity impact unclear
Author’s conclusion of SES impact
The findings suggest the programme was
equally effective for students regardless of
SES
Study analysis - RCT
131
Details
Method
Results
Comments
Data sources
RCT A Stop Smoking in Schools Trial
(ASSIST)
General population impact
At 1-year follow-up, the odds ratio of being
a smoker in intervention compared with
control group was 0·77 (95% CI 0·59–
0·99). At
2-year follow-up, the corresponding odds
ratio of 0·85 (0·72–1·01) was not significant
(p=0·067) which suggests an attenuation of
this intervention effect over time. For the
high-risk group (occasional, experimental,
or ex-smokers at baseline), the odds ratios
at 1-year follow-up of 0·75 (0·56–0·99) and
at 2-year follow-up of 0·85 (0·70–1·02).
In a three-tier multi-level model using data
from all three follow-ups (immediately after
the intervention (N = 10047), after 1 year
(N = 9909) and after 2 years (N = 9666))
the odds of being a smoker in the
intervention group compared with the
control group was 0.78 (95% CI = 0.64–
0.96)
Internal validity
A slightly larger proportion of
students in control schools
came from less affluent
backgrounds and did not have
a family car than did those in
intervention schools Saliva
cotinine levels obtained which
minimised reporting bias.
Results may depend on the
SES indicator used.
School-based prevention
Mercken 2012
Author, year
Campbell 2008 (from Mercken 2012)
Age (years)
12-13
Setting
59 secondary schools in England &
Wales
Study design
RCT
Objective
To assess the effectiveness of a
peer-led intervention that aimed to
prevent smoking uptake in secondary
schools
Intervention
school-based, peer-led – influential
students trained to act as peer
supporters outside of the classroom
SES variables used
FAS and FSM (above 19% and
equal or below 19%), area
deprivation
Participant selection
Schools were randomly assigned to
the control group to continue their
usual smoking education (29 schools
with 5372 adolescents) and
intervention group (30 schools with
5358 adolescents) by stratified block
randomization.
Participant characteristics
Not reported
Outcomes measured
smoking behaviour in the past week
Intervention details
Training influential students to act as
peer supporters during informal
interactions outside the classroom to
encourage peers not to smoke.
During the 10-week intervention
period, peer supporters undertook
informal conversations about
smoking with their peers when
travelling to and from school, in
External validity
Results are specific to study
interventions
Validity of author’s conclusion
Valid
Impact by SES variable
Reported in primary study: subgroup
analyses showed no evidence of
intervention having differential effect
according to deprivation measured by FSM
(0·99 [0·65–1·51]). However, the
intervention does seem to have had a more
pronounced effect in schools located in
132
Details
Method
Results
breaks, at lunchtime and after school
in their free time. Peer supporters
logged a record of all conversations
in a diary. Trainers visited schools
four times to meet with peer
supporters to provide support, trouble
shooting and monitoring of peer
supporters’ diaries
south Wales valleys (0·58 [0·36–0·93].
Comments
School-based prevention
Mercken 2012
Study analysis
Data of the assist trial were
reanalysed according to methods
reported in the ASSIST study.
Multilevel modelling was used to
explore intervention effects on
adolescent smoking in different SES
categories. Data from the three
follow-up periods were modelled
using a using a three-level multilevel
model with schools at Level 3,
students at Level 2 and follow-up
measurements at Level 1. Models
were estimated using the RIGLS
estimation procedure combined with
first-order penalized quasi-likelihood
within MLWin 2.10 beta. Separate
analyses were conducted for
adolescents in the low, medium and
high categories of the included SES
indicators.
Reported in secondary analyses: A
significant main effect of intervention was
found among adolescents scoring low (chisquare (df = 1) =5.97, P < 0.05, OR = 0.71,
95% CI = 0.54–0.93) and high (chi-square
(df = 1) = 7.28, P < 0.05, OR = 0.68, 95%
CI = 0.52–0.90) on the FAS. No significant
main effects of the intervention on
adolescent smoking behaviour were found
in either group. However, a trend is visible
among adolescents in schools with a low
free school meal entitlement (chi-square (df
= 1) = 3.56, P = 0.06, OR = 0.80, 95% CI =
0.63–1.01). The intervention was significant
among adolescents in schools located in
the valleys which can be considered to be
a more deprived area (chi-square (df = 1) =
5.68, P < 0.05, OR = 0.53, 95% CI = 0.32–
0.89) but not among adolescents in schools
on other locations. Among adolescents in
Valley schools, the intervention was also
effective among those with low FAS scores
(chi-square (df = 1) = 5.97, P < 0.05, OR =
0.71, 95% CI = 0.54–0.93). The additional
analyses stratified by SES and gender
showed that the ASSIST intervention was
mostly effective among lower SES girls.
Author’s conclusion of SES impact
The results were mixed depending on the
specific SES indicator used. The ASSIST
133
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Method
Results
Comments
School-based prevention
Mercken 2012
study showed the strongest results for
adolescents in the Valley schools, located
in a deprived area. Social network
approach allowing youngsters to deliver the
intervention themselves seems promising
in preventing the uptake of smoking in
deprived adolescents.
134
Details
Method
Results
Comments
Author, year
Crone 2003 (from Mercken 2012)
Data sources
RCT
Age (years)
13
Participant selection
Schools were ranked by size,
stratified by use of a national drug
education programme and
subsequently randomly assigned to
the control and intervention group. At
baseline, a sample of 2562
adolescents participated
General population impact
9.6% of the nonsmokers started to smoke
in the intervention group, whereas 14.2%
started to smoke in the control group (N =
1388, OR = 0.61, 95% CI = 0.41–0.90).
After 1-year follow-up, the effect was no
longer significant.
Internal validity
The percentage of boys in the
control group was higher than
in the intervention group at
baseline but this was adjusted
for in analyses.
Nonresponse was higher
among smokers, especially in
the control group but selective
dropout was assessed using
ITT under 3 different
assumptions.
Results may depend on the
indicator used
School-based prevention
Mercken 2012
Setting
26 junior secondary education
schools in the Netherlands
Study design
RCT (an independent person tossed
a coin)
Objective
To investigate whether a peer group
pressure and social influence
intervention reduced the percentage
of adolescents who start to smoke
Intervention
school-based social influence and
peer group pressure to prevent
smoking with a class-based
competition
SES variables used
parental education
Study analysis
Participant characteristics
Not reported
Outcomes measured
experimenting with smoking or
smoking daily or weekly
Intervention details
Three lessons on knowledge,
attitudes and social influence,
followed by a class agreement not to
start smoking or to stop smoking for
the next 5 months. Video lessons on
smoking and social influence were
available as an optional extra during
these 5 months. Classes having
fewer than 10% smokers after 5
months were entered in the
competition. The final activity of the
Impact by SES variable
At 5 months, smoking behaviour was
significantly lower in adolescents who
indicated that their parents had mid to high
completed educations (chi-square (df = 1)
= 4.21, P < 0.05, OR = 0.35, 95% CI =
0.13–0.95). The intervention did not result
in smoking fewer cigarettes among
adolescents who indicated that their
parents had lower education (chi-square (df
= 1) = 0.33, P > 0.05, OR = 0.80, 95% CI =
0.37–1.72). All significant intervention
effects disappeared at 12 months followup. The additional analyses stratified by
gender and SES furthermore showed that
the intervention was only effective at 5
months follow-up among boys with higher
parental educational levels (chi-square (df
= 1) = 5.56, P < 0.05, OR = 0.24, 95% CI =
0.07–0.79).
External validity
Results are specific to study
interventions.
Validity of author’s conclusion
Valid.
Author’s conclusion of SES impact
The Dutch class competition study only had
a significant effect among higher SES
135
Details
Method
Results
class was to make a photo
expressing the idea of a non-smoking
class. There were competition prizes
for six classes with less than 10%
smokers and a photo best expressing
a non-smoking class
adolescents and appeared to widen the
inequalities
Comments
School-based prevention
Mercken 2012
Data from follow-up at 5 and 12
months were modelled using threelevel multilevel models with school at
Level 3, class at Level 2 and
adolescent at Level 1. Models were
estimated using the restricted
iterative generalized least squares
(RIGLS) estimation procedure
combined with first-order penalized
quasi-likelihood within MLWin 2.10
beta. The multilevel model was
tested separately for adolescents in
each of the categories of the two
included SES indicators.
136
Details
Method
Results
Comments
Data sources
RCT - the European Smoking
Prevention Framework (ESFA) study
General population impact
At 24 months significantly fewer eversmokers were found in the Portuguese
experimental group (33.8%) than the
control group (41.5%) (OR=0.73, 95% CI =
0.57–0.94).
At 30 months 41.8% of the never smokers
started to smoke 30 months later in the
intervention group, whereas 53.8% of the
never smokers in the control group (N =
1304, OR = 0.62, 95% CI = 0.48–0.80)
In terms of non-smokers becoming weekly
smokers in experimental vs control groups;
7.3% vs 9.1% respectively at 24 months
(OR = 0.74, 95% CI = 0.41–1.34) and 7.9%
vs 12.4% at 30 months (OR = 0.56, 95% CI
= 0.37–0.84).
Internal validity
Response rates differed
between experimental and
control groups; 41.7% vs
39.1% respectively.
May not be a strong
association between indicators
such as adolescents’ pocket
money and household income.
‘mid to high’ spending money
subgroup relatively small
(n=182) which explains wide
CI’s and probably why result
not significant – so intervention
might not decrease inequalities
in smoking
School-based prevention
Mercken 2012
Author, year
De Vries 2006 (from Mercken 2012)
Age (years)
13.5
Setting
25 schools in 2 regions of Portugal
Study design
RCT
Objective
Not stated
Intervention
Social influence intervention which
was school-based with wider
community. Interventions were
developed for four levels: the
individual adolescent level, the
school level, the parental level and
the out-of-school level.
SES variables used
spending money
Study analysis
Multilevel modelling techniques were
used to test for intervention effects
Participant selection
Two regions, consisting of 14 and 11
schools, respectively, were randomly
assigned to the experimental and
control condition. At baseline, 3102
adolescents participated in the
intervention study in Portugal
Participant characteristics
Not reported
Outcomes measured
ever smoking/never smoking
Intervention details
Lessons on effects of tobacco,
reasons for (not) smoking, social
influence processes, refusal skills
and decision making and a smokefree competition.
Teachers received 48 hours of
teacher training, manual and
smoking cessation materials.
Schools received the ESFA nosmoking policy manual and nonsmoking posters. To the parents,
information was offered on how to
Impact by SES variable
The intervention was significant in reducing
smoking uptake among adolescents who
indicated to have no to only a low amount
of spending money (chi-square (df = 1) =
9.85, P < 0.01, OR = 0.62, 95% CI = 0.46–
0.84). This effect was not seen among
adolescents reporting to receive mid to
high amounts of spending money (chisquare (df = 1) = 3.51, P > 0.05, OR =
0.57, 95% CI = 0.32–1.03). Additional
analyses stratified by gender and SES
showed that the intervention was mostly
effective among girls.
External validity
Process evaluation included
pupil report of exposure to
each element of the
intervention and showed it
reasonably likely that the
observed effects were
attributable to the school-based
elements of the intervention.
Interventions differed between
countries and Portugal
received the most intensive
teacher training and
pharmacists of smoking
137
Details
Method
Results
Comments
School-based prevention
Mercken 2012
on smoking behaviour in different
SES categories. Data from follow-up
at 30 months were modelled using
three-level multilevel models with
region at Level 3, school at Level 2
and adolescent at Level 1. Models
were estimated using the RIGLS
estimation procedure combined with
first-order penalized quasi-likelihood
within MLWin 2.10 beta. The
multilevel model was tested
separately for adolescents in each of
the categories of the three included
SES indicators.
discuss non-smoking with their
adolescents. Pharmacists
furthermore offered cessation
courses for 150 parents. At the
community level, the Portuguese
Health Minister and mayor of the
community introduced the ESFA
study on the national no smoking day
Author’s conclusion of SES impact
The results were mixed depending on the
specific SES indicator used. When using
spending money as a SES indicator, the
intervention did appear to decrease
inequalities in smoking.
cessation support for 150
parents; so results may only be
generalisable to that type of
intervention in that country.
Validity of author’s conclusion
Valid
Comments
The ESFA study was a
community-based intervention
that took place in six European
countries. In Finland, Denmark,
UK and Portugal schools or
regions were randomly
assigned. In Spain and The
Netherlands it was quasirandomisation.
Due to the fact that peer-led
programmes were uncommon
in the ESFA countries,
programmes
were teacher-led.
Since the strongest and
significant long-term effects
after 24 and 30 months were
found in the Portuguese
sample, only data of the ESFA
study in Portugal were
reanalysed on the impact by
SES (Mercken 2012) and so
only results for Portugal are
138
Details
Method
Results
Comments
School-based prevention
Mercken 2012
extracted here.
Details
Method
Results
Comments
Data sources
General population impact
In the EGC analysis the effect of the
intervention was observed with regard to
smoking (cigarettes per week and 30-day
smoking prevalence). In the ITT analysis
only the effect on the 30-day smoking
prevalence was significant.
Internal validity
Over 50% of the schools
eligible for the study initially
agreed to participate.
Authors report did ITT analysis
and analysis of classes with
60% programme participation
(EGC analysis).
The intervention group
included significantly more
pupils who reported a higher
SES.
Loss to follow-up was 23%.
Schools in the intervention
group were asked to conduct
one of the two programmes in
classes 5 or 6.
School-based prevention
Author, year
Menrath 2012
Age (years)
12
Setting
53 public secondary general schools
in Northern Germany (rural federal
state of Schleswig-Holstein)
Study design
Quasi randomised multicentre trial (6
schools included without
randomisation to intervention group)
Objective
To evaluate the effects of two
validated school-based life skills
programmes (Fit and Strong for Life
and Lions Quest) in a high-risk
sample of socially disadvantaged
pupils.
SES variables
Family Affluence Scale
Participant selection
Oversampled pupils with low SES by
only including secondary general
schools. 2/102 classes lost to followup at end of school year and 7 more
lost to follow-up at six months
Participant characteristics
102 classes with a total of
1,561 pupils. 25% of the
pupils had a low SES
Outcomes measured
Self-report cigarettes smoked per
week
30-day smoking prevalence
Intervention details
“Fit and Strong for Life” and “Lions
Quest”. Both programmes foster life
skills and self-efficacy and include
the prevention of substance abuse
(cigarettes, alcohol, and drug
consumption). Fit and Strong for Life
is a modular life skills programme for
Impact by SES variable
ANOVA with SES as a factor revealed no
influence of SES on the effect of the
intervention (SES* time*group).
Author’s conclusion of SES impact
School-based life skills programmes have a
positive effect on smoking prevention
regardless of socioeconomic status.
Socially disadvantaged children benefit
from such programmes to a similar extent
as other pupils.
External validity
Analyses do not appear to
account for specific life skills
programmes (“Fit and Strong
for Life” and “Lions Quest”.)
Validity of author’s conclusion
Does not report data for results
by SES and does not assess
effects of each life skills
139
Details
Method
Results
Comments
School-based prevention
Mercken 2012
Study analysis
Repeated standardised interviews
before and after school year and at 6
months follow-up, repeated
measures analyses of variance
primary and secondary schools.
Each module covers the following six
topics: (1) self-esteem and empathy,
(2) coping with stress and negative
emotions, (3) communication skills,
(4) resistance skills and critical
thinking, (5) problem solving and
decision making, (6) health-related
knowledge. The consecutive
modules are not interdependent and
may start at any grade regardless of
whether the pupils have participated
in the programme before or not. In
this study we used the module for
grades 5 and 6.
Lions Quest has a comparable
curriculum. It may be used in
secondary schools from class 5 to
10. Based on the life skills approach
it consists of seven major content
areas: (1) behaviour in
classes/groups, (2) self-esteem, (3)
coping with emotions, (4) peerrelationships, (5) family-relationships,
(6) decision making and (7) selfefficacy. In our study both
programmes Fit and Strong for Life
and Lions Quest were carried out by
classroom teachers. Beforehand all
teachers had to attend a one- or twoday training workshop.
programme separately so
difficult to assess equity impact
of each specific programme.
140
Details
Method
Results
Comments
Data sources
National Public Health Institute
annual cross-sectional postal surveys
from 1978 to 2002. Unique personal
identification codes were used to link
information on socioeconomic group
from population censuses (every fifth
year starting 1970 except 1985)
General population
Among men the secular cohort trend in
smoking declined only in upper white collar
workers, whereas in other socioeconomic
groups the secular cohort trend was nonsignificant. A clear decline in the
prevalence of male ever daily smokers
concurrent with the TCA was found in all
socioeconomic groups except farmers. The
differences between the three largest
socioeconomic groups in the effect of the
TCA were statistically significant (p=0.007
for the interaction between SES and the
TCA) among men. Smoking decline
corresponding to the 1976 TCA was most
marked among white collar employees. In
the three largest socioeconomic groups,
the secular cohort trend remained
unchanged after TCA (p=0.60 for the
cohort trend after TCA, controlling for the
general secular cohort trend) and there
was no difference between the three
largest socioeconomic groups in this
respect (p=0.64 for the interaction between
SES and cohort trend after the TCA).
Among women an increasing secular
cohort trend in ever daily smoking was
found in each socioeconomic group before
the impact of the 1976 TCA (birth cohorts
born in 1926–1962). A reversal of the
female ever daily smoking trend concurrent
with the introduction of the 1976 TCA was
found in each examined socioeconomic
group. The impact of the legislation was
Internal validity
Average response rate 1978–
2002 was 70% among men
and 79% among women.
Multiple policy interventions
Author, year
Helakorpi 2008
Age
Range for smoking initiation defined
as 13 - 20 years
Setting
Finland
Study design
Repeat cross-sectional
Objective
To assess the impact of the 1976
Tobacco Control Act (TCA) on
smoking initiation across
socioeconomic groups.
Intervention
1976 Tobacco Control Act
SES variables
Upper white collar workers (upper
level employees), lower white collar
workers (lower level employees),
blue collar workers (manual workers),
farmers and entrepreneurs (other
self-employed persons than farmers).
Analyses
Participant selection
Each year an independent random
sample (n=5000) of the population
aged 15–64 years was drawn from
the National Population Register.
Participant characteristics
33,080 adults aged 25 to 64 years
born between 1926 and 1975
Intervention
The 1976 TCA prohibited smoking in
most public places, including public
transport, and the sale of tobacco
products to those below 16 years of
age, and required obligatory health
warnings on packages
Length of study
14 years – 1978 to 2002
Outcomes
Smoking prevalence (ever
External validity
The response rate has
declined over the past 25 years
in both genders and all age
groups. The decline has been
faster among men than
women, and in younger than
older age groups – this may
have biased the results.
Validity of author’s conclusion
There have been two major
steps in Finnish tobacco
control policy: the 1976 TCA,
supplemented by a total
tobacco advertising ban in
1978, and the environmental
tobacco smoke amendment of
the TCA in 1995. A significant
rise in the price of tobacco
products almost coincided with
the 1976 TCA; tobacco prices
rose substantially (real price
increase 27%) in 1975–1976,
(but since then annual
increases have been either
modest or negligible) and could
explain some of the variability
141
Details
Method
Results
Comments
Multiple policy interventions
Logistic regression
smoked daily for at least a year)
even in the three largest socioeconomic
groups (p=0.14 for the interaction between
SES and the TCA). Moreover, the general
cohort trend after the TCA differed from the
secular cohort trend before TCA (p<0.001)
and there were differences between the
three largest SES groups in this respect
(p=0.002 for the interaction between SES
and the cohort trend after the TCA).
in results by SES.
SES
In cohorts reaching the smoking initiation
age after the TCA, the prevalence of ever
smoking remained relatively stable among
white collar female workers but tended to
decline among blue collar female workers
(odds ratio=0.88, 95% confidence interval
0.72 to 1.02), in contrast to the sharply
increasing trend in older cohorts.
Author’s conclusion of SES impact
Among men, whose prevalence of ever
smoking was potentially influenced by the
1976 TCA (those born in 1956 or later) the
1976 TCA appears to have had the
greatest impact on male white collar
employees. Among women, the apparent
effect was very pronounced in all
socioeconomic groups and among blue
collar female workers the cohort trend
tended to decline.
142
Details
Method
Results
Comments
Data sources
‘The Natural History of Nicotine
Dependence in Teens Study’. Selfreport questionnaires administered in
classroom, every 3 months from
1999 to 2005 in 1, 293 grade 7, age
12-13, students in 10 secondary
schools. 7 English and 3 French
language secondary public schools,
General population impact
Students in smoking-intolerant schools
(access and restrictions) were less likely to
initiate smoking than students in smokingtolerant schools (Hazard ratio [HR] = 0.83,
0.68, 1.01); attending schools located in
neighbourhoods with smoking intolerant
restaurants, HR=0.85 (0.68, 1.07). There
was no association between corner store
smoking intolerance and smoking initiation
Internal validity
25% (219/868) lost to follow-up
over 5 years, more likely to
attend a low SES school (OR
1.7, 95% CI 1.2, 2.4; p<0.01)
Multiple policy interventions
Author , year
Pabayo 2012
Age (years)
12.7
Setting
Montreal, Canada
Study design
Prospective cohort study
Objective
To describe the association between
smoking intolerance in schools,
restaurants and corner stores near
schools and the initiation of smoking
in adolescents
SES variable
Parental education
Schools classified as
low/medium/high SES based on
mean household income
Participant selection
Convenience sample, 54.5% student
response
Participant characteristics
Mean age 12.7 (SD 0.5), range 1116; 51% male
Outcomes
Smoking initiation
Impact by SES variable
HR for cigarette use initiation for low SES
school, in schools=1.11 (0.88, 1.36),
p=0.40; in restaurants=1.04
(0.83,1.31)p=0.74; in corner stores=1.10
(0.88, 1.37) p=0.59
External validity
Convenience sample limits
generalisability of this study
Validity of author’s conclusion
Study did not aim to assess
differential impact by SES.
Author’s conclusion of SES impact
Not stated
Intervention details
Longitudinal cohort and direct
observation
Study analysis
Cox proportional hazards modelling,
limited to n=868 never smokers at
baseline
143
Details
Method
Results
Comments
Data sources
Random sample students aged 1217 years from each Australian state
and territory and three main
education sectors, questions on
smoking were part of a larger survey
assessing use of alcohol and illicit
drugs, 1987-2005, 19,000-22,000
students sampled each year
General population impact
There was a significant and substantial
reduction in the likelihood of smoking
among all SES groups for older (16-17)
and younger students (12-15) between
1987 and 2005 (all p <0.01).
Internal validity
Over the study period, Year 12
retention rates increased from
53% in 1987 to 75% in 2002
and 2005 so the characteristics
of the student sample in Years
11 and 12 are likely to differ
systematically across survey
years.
Individual students SES may
not match the area IRSD.
Self-reported smoking status
so potential for bias
Multiple policy interventions
Author, year
White 2008
Age (years)
12-17
Setting
Australia
Study design
Cross-sectional study
Objective
To examine whether SES was
associated with changes in smoking
prevalence among Australian
adolescents during 3 phases of
tobacco control activity between
1987 and 2005
Intervention
3 periods of tobacco control activity:
low tobacco-control funding (19921996), high tobacco-control activity
(1984-1991, and 1997-2005) which
included smoking restrictions and
increased tax
SES variable
Index of relative socio-economic
disadvantage (IRSD) associated with
Participant selection
School acceptance rate has
decreased over time but has stayed
around 65% since 1999, Variation in
school participation rates did not
systematically co-vary with smoking
prevalence
Participant characteristics
students aged 12-17 years
Outcomes
Self-reported smoking prevalence
Intervention details
Self-report anonymous surveys of
cigarette use administered at school
Impact by SES variable
For younger students the reductions
differed by SES (interactions p <0.01), with
reductions in all smoking behaviours,
greater for students from higher SES
groups. Among older students, only the
reductions in committed smoking differed
across SES groups (interaction p < 0.01),
and again reductions were greater among
students from higher SES groups.
Between 1990 and 1996 the proportion of
younger and older students involved with
smoking increased significantly. Among
younger students, the increase in monthly
and weekly smoking was greater among
lower SES students (interactions p < 0.05).
Between 1996 and 2005 the prevalence of
monthly and weekly smoking decreased
significantly among both younger and older
students, and these decreases were
consistent across SES groups. For
committed smoking, the interaction
between year and SES was of borderline
significance for students from both age
groups, suggesting that the decrease may
not be consistent across SES groups.
External validity
Co-operation rate of schools
was 85% in 1987 and 63% in
2005
Validity of author’s conclusion
Unclear because changing
prevalence estimates may be
the result of different survey
samples
144
Details
Multiple policy interventions
residential postcode
Study analysis
Logistic regression analysis,
controlled for sex, age and state and
weighted to reduce the influence of
under- or over-sampling of any state,
education sector, age, or sex
grouping
Method
Results
Comments
Author’s conclusion of SES impact
The magnitude of the decreases in
smoking prevalence between 1996 and
2005 did not differ significantly between
SES groups for most indicators of tobacco
involvement. These findings suggest that
the tobacco-control policies adopted in the
late 1990s and early 2000s were effective
in reducing smoking among Australian
secondary students from all SES groups.
145
Details
Method
Results
Comments
General population impact
Not smoking in past week:
RR at 6 weeks = 2.20 (1.79 to 2.70)
RR at 12 weeks = 1.55 (1.30 to 1.84)
RR at 26 weeks = 1.07 (0.91 to 1.26)
All participants with missing status are
assumed to be smoking.
Current non-smoking at 6 weeks = 28.1%
vs 12.8%;assuming rate of true quitters is
same as sample assessed for cotinine then
current non-smoking at 6 weeks = 13.9%
vs 6.2%; absolute difference in quit rates at
6 weeks is reduced to 7.7% from 15.3%;
Internal validity
Random sampling for salivary
cotinine showed over-reporting
of quit rates but not different
between active and control
group; 74% (n=1265) follow-up
rate at 26 weeks which was
different between groups (69%
in intervention group vs 79% in
control group), meant there
was some uncertainty about
between group differences at
26 weeks; for example
reported quit rates increased
amongst control group from
13% at 6 weeks to 24% at 26
weeks (this would have led to
underestimating of treatment
effects);
Individual smoking cessation support
Author, year
Rodgers 2005
Data sources
RCT
Age (years)
Mean=25, median = 22 (IQR 19-30)
Included persons from 16 years
Participant selection
Recruited from adverts on websites,
media, email and text messaging
mailing lists and posters at tertiary
education institutions
Setting
New Zealand
Study design
RCT
Objective
To determine the effectiveness of a
mobile phone text messaging
smoking cessation programme
Intervention
Regular personalised text messages
providing smoking cessation advice,
support, distraction
SES variable
Income
Study analysis
Logistic regression
Participant characteristics
1705 smokers who wanted to quit,
58% female, mean number cigarettes
smoked per day = 15 average
previous quit attempts=2 per person;
Outcomes
Self-reported smoking status
Biochemically verified abstinence on
random selection
Intervention details
Free five text messages per day for
week prior to negotiated quit date
and for four weeks after quit date.
Control group received free month of
text messaging if participated until 26
weeks.
Impact by SES variable
Effect was consistent across income level
Author’s conclusion of SES impact
Text messaging can double quit rates and
this effect was consistent across major
subgroups including income level
External validity
Participants had to be in the
contemplative stage of change
to be included; participants
could use other smoking
cessation strategies and were
informed of quitline and
government subsidy for NRT at
baseline; participants had to
own a mobile phone
Validity of author’s conclusion
valid
146
Details
Method
Results
Comments
General population impact
40% of the participants in the intervention
arm had a verified quit status compared
with 30% in the control arm at 3 months
post quit. The observed difference was not
statistically significant (OR = 1.62, 95%
CI:0.82, 3.21).
Participants in the intervention were
significantly more likely to have quit at 4
weeks post quit (39%) than those in the
control group (21%; aOR = 3.33, 95% CI:
1.48, 7.45); this was true also for 7-day
point prevalence (44% vs. 27%; aOR =
2.55, 95% CI: 1.22, 5.30).
Cessation rate among intervention
participants was stable between 4 weeks
and 12 weeks, but increased among
control participants
Internal validity
Feasibility sample – small
sample size so not sufficiently
powered particularly for
subgroup results.
Imbalance in the minimum
number of participants
intended for each study arm
within each subgroup (e.g.,
male heavy smokers). As a
result, allocation concealment
was broken for the last eight
participants enrolled. To rectify
the imbalance, these
participants were manually
assigned to the arm subgroup
that required additional
participants to become
balanced.
Eighty-seven percent of
participants responded at 4
weeks post quit and 80% at 3
months post quit. Differential
follow-up between the
intervention and control groups
was not observed at either
follow-up time.
Employment status differed
between groups at baseline –
does not add up to 100% in
control group in Table 2.
Study reports that allocation
Individual smoking cessation support
Author, year
Ybarra 2013
Data sources
RCT
Age (years)
18-25
Participant selection
Purposefully targeted a diversity of
communities. Recruited nationally
through online advertisements (e.g.,
Craigslist) between May 3, 2011 and
August 4, 2011. Eligibility criteria
included the following: being between
the ages of 18–25, able to read and
write in English, owning cell phone,
being cognizant of how to send and
receive text messages, being
currently enrolled or intending to
enrol in an unlimited text messaging
plan, smoking 24 cigarettes or more
per week (at least four per day on at
least 6 days/week), seriously thinking
about quitting in the next 30 days,
and agreeing to smoking cessation
status verification by a significant
other (e.g., family member, friend).
Setting
National, text-based, USA
Study design
Pilot Quasi RCT
Objective
To address the lack of smoking
cessation programs available to
young adults, Stop My Smoking
(SMS) USA, a text messaging–based
smoking cessation program, was
developed and pilot tested
Intervention
6-week text messaging intervention
SES variable
Income (<$35,000 vs. higher);
Education (enrolled/not enrolled in
higher education)
Study analysis
Participant characteristics
1,916 people expressed interest in
participating, 585 (31%) of whom
appeared eligible based upon the
online screener form. Of these 585,
contact was not made with 49% (n =
284 ‘passive refusals’). Fifteen
percent (n = 90) declined to
Impact by SES variable
The intervention appeared to be helpful for
young adults not currently enrolled in
higher education settings (45% vs. 26%
control had quit at 3 months; p = .07).
Enrolment in higher education settings was
an effect modifier within the context of
other potentially influential characteristics
(arm assignment × school status; aOR =
4.7, 95% CI: 1.01, 22.3).
Author’s conclusion of SES impact
147
Details
Method
Individual smoking cessation support
Logistic regression
participate.
n = 211 consented to participate and
were randomized into the study. Final
sample n = 164 (47 did not complete
online baseline survey following
randomisation): 101 in the
intervention and 63 in the control
groups.
Mean age 22, daily smokers, 44%
female, 84-90% low income
(<$35,000)
Outcomes
3-month continuous abstinence
(reported smoking five or fewer
cigarettes since their quit date and
verified by phone with significant
other),
smoking five or fewer cigarettes
since quit day at 4 weeks post quit
(verified by a significant other);
7-day point prevalence abstinence at
4 weeks;
Acceptability
Intervention details
Tailored to young adult smokers
based on quitting stage.
2 weeks of Pre-Quit messages aimed
at encouraging them to clarify
reasons for quitting and to
understand their smoking patterns
and tempting
Results
Comments
The intervention appeared to be more
influential for intervention participants not
enrolled in higher education compared with
control participants not enrolled in higher
education aOR of verified quit at 3 months
=2.7, 95% CI: (1.0, 7.4).
‘unknown’ for 47 participants
who did not complete baseline
survey but looking at numbers
in each group it is possible that
majority of these participants
were from control group
although all participants were
blinded to treatment
External validity
Participants had to be seriously
thinking about quitting in next
30 days – motivated sample.
Financial incentives for
completing follow-up surveys.
Sample classed as ‘low
income’ and low income
defined as <$35,000! However,
43% report an annual
household income of less than
$15,000. Majority were male
which is unusual.
Having this type of control
group suggests content of text
messages is important.
Validity of author’s conclusion
Overall significant increased
quit rates in intervention group
vs control group at 6-weeks
were not sustained at 3
months. Tailored text
messaging appears to benefit
148
Details
Method
Individual smoking cessation support
situations/triggers/urges. Early Quit
messages, sent on Quit Day and
through the first week post quit,
talked about common difficulties and
discomforts associated with quitting
and emphasized the use of coping
strategies. Late Quit messages
encouraged participants to recognize
relapse in a different way (e.g.,
situations, confidence) and provided
actionable information about how to
deal with issues that arise as a nonsmoker (e.g., stress, moods).
Text message at Post-Quit Day 2
and 7 that asked their smoking
status. At either time point, if
participants reported smoking, they
were pathed to Relapse messages
that focused on helping them get
back on track and to recommit to
quitting. If participants were smoking
at both days, they were pathed to an
Encouragement arm that focused on
norms for quitting and suggested that
participants try quitting again at later
time.
Participants received four messages
per day during the 2-week Pre-Quit
stage, with the exception of Day 1
and Day 14 when they received five
and six messages, respectively. In
the Early Quit stage, participants
received nine messages on both Quit
Day and Post-Quit Day 2, eight
messages on the third day, and then
Results
Comments
youth not enrolled in higher
education.
149
Details
Method
Results
Comments
Individual smoking cessation support
one fewer message each day until
the last day of the week when four
messages were received. In Late
Quit, participants received two
messages per day for 2 weeks and
then one message per day during the
final week. Participants in Relapse
received two messages per day;
those in Encouragement received
one message per day for 4 days.
Intervention group participants had
access to two program components
first used in the STOMP NZ program
(Rodgers et al., 2005): (a) Text
Buddy (another person in the
program that a participant was
assigned to so they could text one
another for support anonymously
during the program; assignment was
sequential so that buddies would be
in similar stages during the quitting
process); (b) Text Crave (immediate,
on-demand messages aimed at
helping the participant through a
craving). A project Web site
(StopMySmoking.com) provided
additional quitting resources,
technical support, and a discussion
forum.
Control group received similar
number of text messages, message
content was aimed at improving
sleep and exercise habits within the
context of how it would help the
participant quit smoking. Messages
150
Details
Method
Results
Comments
Individual smoking cessation support
were not tailored based on quitting
stage nor were Text Buddy and Text
Crave components available
151
7.7 Appendix G Quality assessment
Generalisability+
to
Attributability
intervention†††
Attrition rate††
Credibility of
collection
instruments†
Comparability***
data
Quality of execution##
Randomisation**
Study
design#
Representativeness*
Study
Smoking restriction in schools, workplaces, and other public places
Akhtar 2010
1.2
yes
n/a
n/a
yes
yes
Galan 2012
1.1
yes
n/a
n/a
yes
n/a
regional
MacKay 2010
1.2
yes
n/a
n/a
yes
yes
national
Millett 2013
1.2
yes
n/a
n/a
yes
yes
national
Moore 2011
1.2
yes
n/a
n/a
yes
yes
yes
national
Moore 2012
1.2
yes
n/a
n/a
yes
yes
yes
national
Nabi-Burza 2012
1.1
n/a
n/a
yes
n/a
Noach 2012
1.1
n/a
n/a
yes
n/a
Woodruff 2000
2.1
n/a
n/a
yes
national
yes
yes
national
Controls on advertising, promotion and marketing of tobacco
Gilpin & Pierce 1997
1.1
yes
n/a
Hammond 2011
3.1
yes
Pucci 1998
1.1
n/a
n/a
yes
n/a
yes
n/a
n/a
yes
n/a
n/a
n/a
yes
yes
national
yes
Mass media campaigns
Vallone 2009
1.2
Increases in price/tax of tobacco products
Biener 1998
1.1
yes
n/a
n/a
Gilpin & Pierce 1997
1.1
yes
n/a
n/a
Glied 2002
1.4
n/a
Gruber 2000
1.4
Madden 2007
1.3
Perretti-Watel 2010
1.1
yes
yes
n/a
regional
yes
n/a
national
n/a
yes
yes
n/a
n/a
yes
yes
n/a
n/a
yes
n/a
n/a
n/a
regional
n/a
n/a
yes
yes
national
n/a
n/a
yes
n/a
n/a
n/a
yes
yes
n/a
n/a
yes
n/a
n/a
n/a
yes
n/a
yes
yes
yes
yes
yes
yes
national
Controls on access to tobacco products
Kim 2006
1.3
Lipperman-Kreda
2012
1.1
Millett 2011
1.2
Schneider 2011
1.2
Widome 2012
1.1
yes
yes
yes
yes
national
yes
regional
School-based prevention
Bacon 2001
3.1
yes
Campbell 2008++
3.1
yes
yes
Crone 2003++
3.1
yes
yes
yes
152
Generalisability+
to
yes
Attributability
intervention†††
yes
Attrition rate††
3.3
data
Menrath 2012
yes
Credibility of
collection
instruments†
3.1
Comparability***
De Vries 2006++
Quality of execution##
Randomisation**
Study
design#
Representativeness*
Study
yes
yes
yes
yes
Multiple policy interventions
Helakorpi 2008
1.2
Pabayo 2012
1.3
White 2008
1.2
yes
yes
n/a
n/a
yes
yes
n/a
n/a
yes
yes
n/a
n/a
yes
yes
national
yes
national
Individual smoking cessation support
Rodgers 2005
3.1
Ybarra 2013
3.3
yes
yes
yes
yes
yes
++study identified in Mercken 2012
#Study designs see Table 1
## Quality of execution
*Representativeness: Were the study samples randomly recruited from the study population with a
response rate of at least 60% or were they otherwise shown to be representative of the study
population?
**Randomisation: Were participants, groups or areas randomly allocated to receive the intervention
or control condition?
***Comparability: Were the baseline characteristics of the comparison groups comparable or if there
were important differences in potential confounders were these appropriately adjusted for in the
analysis? If there is no comparison group this criterion cannot be met.
†Credibility of data collection instruments: Were data collection tools shown to be credible, e.g.
shown to be valid and reliable in published research or in a pilot study, or taken from a published
national survey, or recognized as an acceptable measure (such as biochemical measures of smoking).
††Attrition Rate: Were outcomes studied in a panel of respondents with an attrition rate of less than
30% or were results based on a cross-sectional design with at least 200 participants included in
analysis in each wave?
†††Attributability to intervention: Is it reasonably likely that the observed effects were attributable to
the intervention under investigation? This criterion cannot be met if there is evidence of
contamination of a control group in a controlled study. Equally, in all types of study, if there is
evidence of a concurrent intervention that could also have explained the observed effects and was not
adjusted for in analysis, this criterion cannot be met.
+ Generalisability: Is the study generalisable at National, State/Regional, or Local level?
Randomisation and comparability are not applicable (N/A) for all study designs except controlled
trials coded 3.1, 3.2 or 3.3. Attrition rate is N/A to cross-sectional studies coded 1.1.
153
7.8 Appendix H Summary of equity impact of youth polices/interventions
Author,
year
Age
Study design
Setting,
country
SES variable
policy/intervention
outcome
Equity impact
Smoking restriction in schools, workplaces and other public places
Akhtar
2010
11
Repeat crosssectional
Primary
schools,
Scotland
SEC, FAS
Smokefree
national legislation
SHS exposure
Greatest absolute reduction for low
SES, but relative inequalities may
have widened
Galan
2012
15-16
Crosssectional
Secondary
schools,
Spain
Census tract
of school, parental
education
Voluntary
compliance
Smoking
on
school premises
A higher probability of smoking on
school premises among adolescents
whose fathers had a lower level of
educational attainment. However, at
the school level there was no
significant impact
MacKay
2010
0-14
Repeat crosssectional
Hospitals,
Scotland
Area deprivation
score (IMD)
Smokefree national
legislation
Admission rates
There
were
no
significant
interactions
between
hospital
admissions for asthma and quintile
of SES. All SES subgroups
associated with significant reduction
in admissions
Millett 2013
0-14
Interrupted
time series
Hospitals,
England
Area deprivation
score (IMD)
Smokefree national
legislation
Admission rates
Significant and similar reductions in
asthma admission rates among
children from different SES groups
Moore
2011
11
Repeat crosssectional
Primary
schools,
Wales
FAS
Smokefree national
legislation
SHS exposure
Reductions limited to children from
more affluent households, whose
exposure was already significantly
lower prior to legislation, leading to
increased socioeconomic disparity
Moore
2012
11.2
Repeat crosssectional
Primary
schools,
Scotland,
Northern
Ireland,
Wales
FAS
Smokefree national
legislation
SHS exposure
Smoking
restrictions
in
the home and
car
Declines in exposure occurred
predominantly among children with
low exposure before legislation, and
from
more
affluent
families.
Substantial socioeconomic gradients
in proportions of children with higher
154
Author,
year
Age
Study design
Setting,
country
SES variable
policy/intervention
outcome
Equity impact
SHS exposure levels remained
unchanged.
No change in inequality following
legislation for home and car-based
smoking restrictions (socioeconomic
patterning remained stable).
Nabi-Burza
2012
0-18?
Single crosssectional
Paediatric
practices,
USA
Parental education
Noach
2012
15
Crosssectional
Secondary
schools,
Israel
Parental education
Woodruff
2000
19
Before
and
after
experimental
study
US
Navy
recruitment
centre,
females only
Education
Voluntary
smokefree
policy
smoking
behaviour
in
cars and home
Parental education level was not
significantly associated with strictly
enforced smokefree car policy on its
own, only significant in interaction
with child age and amount smoked.
College educated parents of children
aged <1 year were more likely to
have strict smoke-free car policies.
Voluntary
compliance
SHS exposure
Parental education was a significant
predictor of smoking in the home but
not at school, exposure was
significantly
greater
amongst
adolescents whose parents had less
education
8-week
24-hour
smoking ban
Smoking
relapse
Education did not predict smoking
relapse
car
Controls on advertising, promotion and marketing of tobacco
Gilpin
Pierce
1997
&
Hammond
2011
14-21
in
197989
Crosssectional
US
population
surveys
Education
Tobacco
marketing
Smoking
initiation
Level of education impacted on
initiation rates with initiation rates
highest among high school dropouts
and lowest amongst those who
eventually attended college
18-19
RCT,
convenience
US
online
survey,
Education
Cigarette
packaging
Brand appeal
Reactions to/perceptions of different
types of packs was the same by
155
Author,
year
Age
Pucci 1998
5-14
15-19
Study design
SES variable
sample
Setting,
country
females only
policy/intervention
outcome
Equity impact
Crosssectional
US
field
observation
Median
income
household
Advertising buffer
zones
around
schools
Advertising
density
Neighbourhoods with the lowest
median household incomes showed
highest advertising density inside
school buffer zones
US
population
survey
Median household
income,
median
household
education at zip
code level
American Legacy
Foundation’s
truth® campaign
Awareness,
receptivity to the
campaign
Youth who lived in zip codes in
which the median household income
was less than or equal to US$
35,000 had a lower level of
confirmed
awareness
than
respondents
in
other
income
categories. Zip code level median
household
income
was
not
associated
with
confirmed
awareness and there were no
differences in receptivity by zip code
level income or education
SES for nearly all the measures
Mass media campaigns
Vallone
2009
12-17
Crosssectional
Increases in price/tax of tobacco products
Biener
1998
Gilpin
Pierce
1997
&
Glied 2002
12-17
Crosssectional
US statewide
survey
Household income
Cigarette
increase
tax
Smoking
behaviour
Low-income teenagers more likely
than more affluent teens to cut costs
by cutting down on smoking or (less
often) by switching to cheaper
brands. Young low-income smokers
were not more likely than wealthier
teenagers to consider quitting
14-21
in
19791989
Crosssectional
US
population
surveys
Education
Cigarette
increase
tax
Smoking
initiation
Level of education impacted on
initiation rates with initiation rates
highest among high school dropouts
and lowest amongst those who
eventually attended college
14-23
in 1979
Cohort
with
longitudinal
and
cross-
US
population
Family income
Cigarette
increase
tax
Smoking
behaviour
Tax at age 14 had a statistically
significant negative effect on current
smoking including initiation for low
156
Author,
year
Age
Study design
sectional data
Setting,
country
survey
SES variable
Parental education
Cigarette
prices,
clean air, access
Price elasticity
Price is the most important
determinant of smoking by teens
aged 16-18 years but not younger
teenagers. Sensitivity to prices
increases for those with less
educated parents, sensitivity to price
intensity increased for those with
more educated parents
Education
Cigarette taxes
Smoking
initiation
Increased cigarette prices were
associated with later initiation among
those
with
an
intermediate
education, but not those with only a
primary education.
Parental education
Tobacco
increase
price
Smoking
behaviour
Smokers with a lower SES were less
likely to react to the price increase
Gruber
2000
13-18
Crosssectional,
econometric
US surveys
Madden
2007
19
Retrospective
longitudinal
Ireland,
survey
women
PerrettiWatel 2010
19.5
Crosssectional
France,
regional
survey,
university
students
policy/intervention
outcome
Equity impact
income people. Elasticities declined
over time for low income people. By
age 39 the effect of taxes at age 14
has largely disappeared.
of
Controls on access to tobacco products
Kim 2006
15
Cohort
US schoolbased
survey,
females only
Parental
education,
parental income
Statewide tobacco
control
policies,
statewide cigarette
excise tax
Smoking
behaviour
Stronger state level tobacco policies
on age of sale were associated with
lower likelihood of smoking initiation
and adverse transition among low
SES girls, although the effect sizes
were small.
LippermanKreda-2012
19
Crosssectional
Tobacco
retailers,
California,
USA
percentage
of
population with a
college education,
median household
Underage tobacco
sales laws
Compliance
Higher education was a significant
predictor of underage tobacco sales.
157
Author,
year
Age
Study design
Setting,
country
SES variable
policy/intervention
outcome
Equity impact
Significant reduction in regular
smoking among youth, regular
smoking was not significantly
different in pupils eligible for FSM
compared with those that were not.
Higher access reported for other
sources by FSM eligible pupils.
Following increase in age of sale
significant reduction in access in
non-FSM but not FSM.
income
Millett 2011
13
Repeat crosssectional
Secondary
schools,
England
Free school meals
Legislation
in
England, Scotland
and
Wales
increasing
minimum age for
legal purchase of
tobacco from 16 to
18 years
Smoking
behaviour
Schneider
2011
17.6%
aged 020
Before & after
City-wide
(Cologne),
Germany,
observational
Income,
unemployment,
social
welfare,
low-qualifying
schools
Electronic locking
devices on vending
machines
to
prevent underage
(<16
years)
purchasing
Density
vending
machines
Widome
2012
15-18
Crosssectional
Licensed
tobacco
vendors,
Minnesota,
US
Below
150%
poverty level
Age-of-sale
tobacco checks
Compliance
There was no association between
store advertising characteristics or
poverty and stores’ compliance
check failure.
Free/reduced
lunch status
‘Too
Good
Drugs II’
for
Intentions,
attitudes
and
perceptions
towards tobacco
use
Programme was similarly effective in
impacting
students
risk
and
protective factors regardless of SES
FAS, FSM
Peer-led
network
smoking
prevention
social
based
uptake
Smoking in past
week
The results were mixed depending
on the specific SES indicator used.
The intervention was most effective
for adolescents in the Valley
schools, located in a deprived area,
particularly low SES girls.
of
The lower the income level in a
district, the higher the availability of
cigarettes, significant difference both
before and after locking devices
School-based prevention
Bacon
2001
11
Cluster RCT
Middle
schools,
Florida, US
Campbell
2008*
12-13
RCT
England
Wales
&
158
Author,
year
Age
Study design
Setting,
country
SES variable
policy/intervention
outcome
Equity impact
Crone
2003*
13
RCT
Netherlands
Parental education
Anti-smoking classbased intervention
Experimenting
with smoking or
smoking daily or
weekly
The intervention had a significant
effect
among
higher
SES
adolescents and appeared to widen
the inequalities in the short-term. All
significant
intervention
effects
disappeared at 12 months follow-up.
De
Vries
2006*
13.5
RCT
Portugal
Spending money
Smoking prevention
school
policies,
also parents and
community
Ever/never
smoking
The results were mixed depending
on the SES indicator used. When
using spending money as a SES
indicator, the intervention appeared
to decrease inequalities in smoking
but results unclear due to small
number in ‘mid to high’ spending
money subgroup and use of
‘spending money’ as proxy measure
of SES.
Menrath
2012
12
Quasi
randomised
Public
secondary
general
schools,
Northern
Germany
FAS
Two validated life
skills programmes
including element
of
smoking
prevention
Self-report
cigarettes
smoked
per
week,
30-day smoking
prevalence
The two school-based life skills
programmes had a positive effect on
smoking prevention and benefitted
children of all SES equally.
Multiple policy interventions
Helakorpi
2008
13-20
Repeat crosssectional
Finland,
national
postal survey
Occupation
1976
Tobacco
Control
Act
(smokefree, age of
sale,
health
warnings)
Smoking
prevalence (ever
smoked daily for
at least one
year)
1976 TCA appears to have had the
greatest impact on male white collar
employees. Among women, the
apparent
effect
was
very
pronounced in all socioeconomic
groups and among blue collar
female workers the cohort trend
tended to decline.
Pabayo
2012
12.7
Cohort,
convenience
Canada,
school-based
Household income
Smoking
intolerance
Smoking
initiation
No significant impact on smoking
initiation by SES for smoking
in
159
Author,
year
Age
Study design
sample
White 2008
12-17
Crosssectional
Setting,
country
observational
study
SES variable
policy/intervention
outcome
Australia,
school-based
survey
Area-based Index
of Relative SocioEconomic
Disadvantage
(IRSD)
3
periods
of
tobacco
control
activity:
low
tobacco-control
funding
(19921996),
high
tobacco-control
activity (1984-1991,
and
1997-2005)
which
included
smoking restrictions
and increased tax
Smoking
prevalence
The magnitude of the decreases in
smoking prevalence between 1996
and 2005 did not differ significantly
between SES groups for most
indicators of smoking behaviour.
Less impact on younger low SES in
period of low tobacco control
funding.
schools,
restaurants
and
corner stores near
schools
Equity impact
intolerance in schools, restaurants or
corner stores
Individual smoking cessation support
Rodgers
2005
25
(mean)
RCT
New
Zealand, any
setting, any
location
Income level
Text-messaging
Smoking
cessation
Text messaging doubled quit rates
and this effect was consistent across
major subgroups including income
level
Ybarra
2013
22
(mean)
RCT
USA,
national
Enrolment
in
higher education
Text-messaging
Continuous
abstinence,
7-day
point
prevalence
Significant increase in quit rates in
intervention group vs control group
at 6-weeks were not sustained at 3
months. Tailored text messaging
appeared to benefit youth not
enrolled in higher education.
*study identified in Mercken 2012
160
7.9 Appendix I Equity impact model of youth policies/interventions by
SES measure
First author
Income
pos
neu
neg
Area-level deprivation
Education
pos
pos
neu
neg
neu
Occupation
neg
pos
neu
neg































Smoking restriction in cars, schools, workplaces and other public places

Akhtar 2010



Galan 2012
MacKay 2010
Millett 2013



Moore 2011
Moore 2012
Nabi-Burza 2012



Noach 2012
Woodruff 2000
Controls on advertising, promotion and marketing of tobacco
Gilpin 1997

Hammond 2011

Pucci 1998
Mass media campaigns

Vallone 2009

Increases in price/tax of tobacco products
Biener 1998

Gilpin 1997
Glied 2002



Gruber 2000
Madden 2007
Perretti-Watel 2010

Controls on access to tobacco products
Kim 2006
Lipperman-Kreda
2012
Millett 2011







Schneider 2011
Widome 2012

School-based prevention
Bacon 2001

Campbell 2008**
Crone 2003**
DeVries 2006**
Menrath 2012








Multiple policy interventions
Helakorpi 2008
Pabayo 2012


White 2008


Individual smoking cessation support
161

First author
Income
pos
Rodgers 2005
Ybarra 2013
**Study identified in Mercken 2012
neu


neg
Area-level deprivation
Education
pos
pos
neu


neg
neu
Occupation
neg
pos
neu

This equity impact model of youth studies should be read in conjunction with the text in
Section 2.2.5
This matrix is based upon a hypothesis-testing model adapted from a model used in the York
review16:



The null hypothesis of a neutral equity impact that for any given socio-economic
characteristic related to education, occupation or income, there is no social gradient in
the effectiveness of the intervention.
The hypothesis of a positive equity impact defined as evidence that groups such as
lower occupational groups, those with a lower level of educational attainment, the less
affluent, those living in more deprived areas, are more responsive to the intervention.
The hypothesis of a negative equity impact defined as evidence that groups such as
higher occupational groups, those with a higher level of educational attainment, the
more affluent, or those who live in more affluent areas are more responsive to the
intervention.
Key to symbol colour
= “hard outcome” such as smoking prevalence or consumption;
= “intermediate outcome” such as beliefs and attitudes
Neu = evidence supports null hypothesis i.e. neutral equity impact
Pos = evidence supports hypothesis of positive equity impact
Neg = evidence supports hypothesis of negative equity impact
162
neg