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 adults.
Final Report May 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.
In particular we would like to thank Gera Nagelhout, researcher at STIVORO and Maastricht
University (CAPHRI), the Netherlands for identifying four Dutch reports on mass media campaigns
and kindly providing synopses in English.
2
Table of Contents
EXECUTIVE SUMMARY................................................................................................................ 5
1
INTRODUCTION .................................................................................................................... 10
1.1
Background ......................................................................................................................................... 10
1.2
Aims and objectives ............................................................................................................................ 12
2
METHODS ................................................................................................................................ 12
2.1
Search strategy ................................................................................................................................... 12
2.2 Study selection.................................................................................................................................... 13
Study selection process .................................................................................................................................. 13
Inclusion criteria ............................................................................................................................................. 14
Data extraction ............................................................................................................................................... 16
Quality assessment ........................................................................................................................................ 16
Data synthesis ................................................................................................................................................ 16
3
RESULTS .................................................................................................................................. 18
3.1
Introduction ........................................................................................................................................ 18
3.2 Smoking restrictions in workplaces, enclosed public places, cars and homes. ..................................... 21
3.2.1
Smoking restrictions in workplaces ................................................................................................. 24
3.2.2
Smoking restrictions in enclosed public places ................................................................................ 33
3.2.3
Smoking restrictions in cars ............................................................................................................. 54
3.3
Increases in price/tax of tobacco products .......................................................................................... 64
3.4
Controls on advertising, promotion and marketing of tobacco ........................................................... 85
3.5 Mass media campaigns ....................................................................................................................... 94
3.5.1
Mass media cessation campaigns .................................................................................................... 97
3.5.2
Mass media campaigns to promote calls to Quitlines and use of NRT .......................................... 119
3.6
Multiple policies ............................................................................................................................... 131
3.7 Settings based interventions ............................................................................................................. 136
3.7.1
Community .................................................................................................................................... 137
3.7.2
Workplace ...................................................................................................................................... 141
3.7.3
Hospitals ........................................................................................................................................ 143
3.8 Population-level cessation support interventions ............................................................................. 146
3.8.1
National Quitlines .......................................................................................................................... 146
3.8.2
UK NHS Smoking Cessation Services .............................................................................................. 146
3.8.3
New Zealand General Practice Smoking Cessation Services .......................................................... 152
4
DISCUSSION .......................................................................................................................... 154
4.1
Future research ................................................................................................................................. 165
5
CONCLUSIONS ...................................................................................................................... 166
6
REFERENCES ........................................................................................................................ 168
7
APPENDICES ......................................................................................................................... 177
3
7.1
Appendix A Search strategies: electronic searches, handsearching and searching for grey literature 177
7.2
Appendix B WHO European countries and other stage 4 countries ................................................... 189
7.3
Appendix C Inclusion/exclusion form ................................................................................................ 190
7.4
Appendix D Included studies ............................................................................................................. 192
7.5
Appendix E Excluded studies ............................................................................................................. 203
7.6
Appendix F Data extraction ............................................................................................................... 207
7.7
Appendix G Quality assessment ........................................................................................................ 426
7.8
Appendix H Equity Impact ................................................................................................................. 433
7.9
Appendix I Summary of Equity Impact .............................................................................................. 480
4
EXECUTIVE SUMMARY

Smoking is the single most important preventable cause of premature mortality in
Europe and a major cause of inequalities in health. Adult smoking prevalence in the
EU is declining but the social gradient in smoking is not. Reducing inequalities in
smoking is therefore a key public health priority.

Some progress has been made in tobacco control in many EU countries in recent
years.
However,
there
is
considerable
variation
in
the
strength
and
comprehensiveness of tobacco control policies and their implementation.

While there is good evidence on which tobacco control policies are effective in
reducing adult smoking, little is known about what is effective in reducing
inequalities in smoking.

The aim of this report was to undertake a systematic review of the effectiveness of
population-level policies and interventions to reduce socioeconomic inequalities in
smoking in adults.

The systematic review included primary studies involving adults (aged 18 years and
older), published between January 1995 and January 2013, which assessed the impact
of population-level policies and interventions by socioeconomic status (SES).

The search strategy included searches of 10 electronic databases, papers ‘in press’ in
four key journals, and contacting tobacco control experts for grey literature.

Any type of tobacco control or other policy intervention, of any length of follow-up,
with at least one smoking-related outcome was included, such as quit attempts,
intentions to quit, exposure to second-hand smoke (SHS) and social norms/attitudes,
was included.

All primary studies based in a WHO Europe country or non-European countries at
stage 4 of the tobacco epidemic were eligible. SES variables included education,
income and occupation.

A quality assessment tool was adapted to enable appraisal of the diverse range of
intervention types and study designs encompassed in the included studies. The results
are presented in the form of a narrative synthesis and according to intervention type.

The equity impact(s) of each intervention/policy on smoking-related outcomes was
assessed as either being: positive (reduced inequality), neutral (no difference by
SES), negative (increased inequality), mixed (equity impact varied by SES measure
5
and/or gender, setting, country and/or outcome measure) or unclear (not possible to
assess the equity impact).

One
hundred
and
sixteen
studies
were
included
which
evaluated
129
interventions/policies. Electronic searches produced 93 studies and 23 studies were
identified through hand-searching, grey literature, key reviews and contacting
experts.

There was considerable variation in study design and quality. More than half the
studies were carried out in the USA. Eighteen studies were carried out in the UK,
mostly assessing the impact of smokefree legislation and NHS smoking cessation
services, and eight in the Netherlands. This limited geographical coverage raises
concerns about the generalisability and potential transferability to, or relevance for,
countries in Europe with different social and cultural contexts and/or levels of
tobacco control.

The types of interventions/policies included were: smoking restrictions in cars,
homes, workplaces and other public places (44 studies); increases in the price/tax of
tobacco products (27); controls on advertising, promotion and marketing of tobacco
(9); mass media campaigns including promoting the use of quitlines and NRT (30);
multiple policy interventions (4); settings-based interventions including community,
workplace and hospital (7); and population-level cessation support interventions (8).
Eight studies included more than one type of policy/intervention.

Only one relevant study of non-tobacco control interventions and polices (e.g.
education, employment, social policy) was identified.

The equity impacts of the 129 included interventions/policies were: 33 positive, 35
neutral, 38 negative, 6 mixed and 17 unclear.

Twenty-six of the 29 neutral equity impact studies showed similar beneficial impacts
across SES groups. Three studies, all community-based, found no significant
intervention effect for any SES group.

Some trends in equity effect by type of intervention/policy emerged. Over half of the
studies of increases in the price/tax of cigarettes were associated with a positive
equity impact. More than half the smokefree policy/legislation studies (these
included voluntary and partial smokefree policies) were associated with a negative
equity impact, making up the bulk of the negative studies. There were no negative
studies for controls on advertising, marketing and promotion of tobacco products.
6
Four of the six studies of UK NHS cessation services had a positive equity impact.
There was no clear trend for the equity impact of mass media campaign studies.

Smokefree policies and legislation (44 studies) - The evidence suggests that partial,
voluntary or regional adoption of smokefree policies can increase socioeconomic
inequalities in protection from secondhand smoke (SHS) exposure. The recent
increase in smokefree policies in bars, restaurants and workplaces in Australia,
Canada, UK and USA has had a positive equity impact, reducing inequalities in
policy coverage by SES, with low SES worksites and public places catching up in
adopting total smokefree policies.
National comprehensive smokefree legislation reduces SHS exposure, increases quit
attempts and has positive population health effects. By definition such policies have a
positive equity impact in removing inequalities in policy coverage. However, only
two of the 22 studies that evaluated national smokefree legislation demonstrated an
overall positive equity impact using other outcome measures. The national smokefree
legislation in Scotland, Wales and Northern Ireland did not displace smoking into the
home. Although smoking restrictions in the car and home increased following this
legislation, there was no change in smoking-related inequality. SES differences
remained, with a greater proportion of lower SES adults smoking in the car/home.

Price and tax increases (27 studies) - The majority of studies on price/tax increases
on cigarettes were associated with a positive equity impact and had the most
consistent of all the policy results. Overall, lower SES adults appear more responsive
to price/tax increases in terms of larger price elasticities compared with higher SES
adults in respect of reducing prevalence and/or consumption. Most of the
econometric studies did not measure longer-term effects on quitting, cross-border
sales or smokers’ price reducing strategies which may differ by SES.

Controls on advertising, marketing and promotion (9 studies) - Most of the studies
were on health warnings and found that they had neutral (3) or positive (2) equity
effects. Only three studies looked at restrictions on marketing and were associated
with neutral equity impacts.

Mass media cessation campaigns (18 studies) - There was no consistent equity
impact for these studies, but only three studies had an overall positive equity impact.
A Dutch multimedia campaign targeted at smokers with an intention to quit smoking
7
and with a focus on lower educated smokers, was associated with a positive equity
impact for campaign awareness. A tobacco control paid media campaign in the US
was associated with a more rapid decline in smoking prevalence among low SES
women. The EX mass media campaign (TV element) increased cessation-related
cognitions only among those with less than a high-school education and increased
quit attempts only among those with less than a high-school education.
Different types of media messages appeared to have differential impacts by SES,
with some limited evidence that emotionally evocative, testimonial and graphic
messages were more likely to be equity positive. The media format of the campaign
and the mechanisms of engagement also varied by SES.

Mass media quitline and NRT campaigns (12 studies) - all the studies found increases
in calls to quitlines. However, the equity impact was inconsistent, though three of the
five positive equity impact studies promoted free NRT.

Multiple policies (4 studies) - The evidence suggests that different elements of
multiple policies may impact differentially by SES. For example, people with lower
incomes were more affected by cigarette tax increases, whereas people with higher
incomes may have been more affected by voluntary smokefree policies. The evidence
also suggests that, within and across different SES groups, the impact of multiple
tobacco control policies can vary by age, gender and the type of smoking-related
outcome.

Settings-based interventions (7 studies) - the types of interventions included were
very variable in approach and had inconsistent equity impacts. The only intervention
in the review to address wider social determinants of inequality (community
approach) had no impact on quitting rates.

Comprehensive smoking cessation services (8 studies) – Four of the six UK NHS
smoking cessation services studies had a positive equity impact. These studies found
that the relatively higher reach of services among low SES smokers more than
compensated for the relatively lower quit rates in low SES smokers. The UK
smoking cessation service is unique in Europe in the extent of its population
coverage. However, these findings may be relevant to increasing the positive equity
impact of cessation support in other European countries. A study of a General
Practitioner delivered smoking cessation service in New Zealand was effective in
reducing smoking prevalence, but there was no evidence of a significant impact on
8
area-based inequalities (neutral equity impact). The only quitline study produced an
unclear equity impact.

While 116 studies were identified, only limited conclusions can be drawn about
which types of tobacco control interventions are likely to reduce inequalities in
smoking. The clearest and most consistent evidence of a positive equity impact was
for price/tax increases.
9
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 a major
cause of socioeconomic inequalities in mortality in the European Union (EU). 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 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.
Since the 1990s, many European countries have intensified tobacco control policies and
introduced measures such as legislation on smokefree public places, bans on tobacco
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 20035 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)6 and form the
basis of the Framework Convention on Tobacco Control (FCTC), the first international
public health treaty.7
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
10
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,8
funded by the EU entitled: “Tackling socioeconomic inequalities in smoking: learning from
natural experiments by time trend analyses and cross-national comparisons”. The SILNE
project is a three-year European project co-ordinated by the University of Amsterdam,
Department of Public Health, Academic Medical Centre, the Netherlands, with financial
support from the European Commission Seventh 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.
Few reviews have addressed the equity impact of tobacco control measures; two key reviews
have previously been carried out on the equity impact of tobacco control interventions.9;10 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,9
focussing on population-level interventions (not individual 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.10 This study included a review of the
evidence on the efficacy of
interventions
to
reduce
adult
smoking amongst
socioeconomically deprived populations, which built on the CRD review and included
evidence published from January 2006 until November 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.11 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.
11
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. This report focuses on
the findings of the systematic review of the effectiveness of population-level policies and
interventions to reduce socio-economic inequalities in smoking among adults. Populationlevel 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’12. The report’s objectives
are to identify and review the strengths and limitations of the published evidence on the
effectiveness of policies at the population level to reduce smoking amongst
socioeconomically deprived populations as compared to higher socioeconomic groups, and
the implications for European and other countries at stage 4a of the tobacco epidemic.
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 and details
of the search strategies, including hand-searching and searching for grey literature, are in
Appendix A.
The following databases were searched:

BIOSIS

CINAHL Plus
a
The 4 stages of the tobacco epidemic are described: Stage 1, characterized by low uptake of smoking and low cessation
rates; Stage 2, characterized 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).
12

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 hand-searching 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
Three key reviews were also searched for relevant primary studies: the York review,9 the
PHRC review,10 and a report by the US Surgeon General on Preventing Tobacco Use
Among Youth and Young Adults12 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 all the databases used in the initial search to
identify studies published between May 2012 and end of December/start of January 2013. In
February 2013, the same four key journals were hand-searched to identify articles published
on the journals’ websites but not yet listed in electronic databases. See appendix A for
details.
2.2 Study selection
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
13
from MEDLINE were screened by title and abstract by two reviewers (AAb and TBc) 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 (SPd) was consulted.
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
was chosen for the youth review. However, many adult focussed 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.
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 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.
b
AA=Amanda Amos, c TB=Tamara Brown, dSP=Stephen Platt
14
Any type of tobacco control policy/intervention or other type of policy (eg social,
education), 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.
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 not written in 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 only socio-demographic data (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.
15
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).
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
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.9 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.13 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.
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.
In order to provide a simple basis for comparing the methodology of each study a typology
of study designs was devised (Table 1).
16
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
The equity impact of each population-level intervention/policy is summarised by adapting a
model used in the York review14:

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, socioeconomic conditions, and other factors? We draw conclusions
about the strengths and weaknesses of the current evidence of the impact of tobacco control
17
and other policy interventions on reducing socioeconomic inequalities in smoking in youths
and adults (equity impact) and identify the most effective and promising interventions.
3 RESULTS
3.1 Introduction
A total of 116 studies (from 119 papers) were included in the review of adult populationlevel policies/interventions.
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, 115 were included and 171 were excluded. See Figure 1 for flow chart of study
inclusion. Eighty-three (81 studies) of the 119 papers focused on adult population-level
interventions and were included in this adult review from the initial searching of the
electronic database. In addition twenty-four papers (23 studies) were identified through
hand-searching, searching of grey literature, key reviews and contacting experts. An update
of the electronic searches were carried out in 2013 which identified a further twelve relevant
studies published up until January 2013. Appendix D contains bibliographic details for all
the included adult population-level policies/interventions including details of source. The
details of studies that were excluded at the stage of screening of full-text articles (n=51) are
listed in Appendix E with reasons for exclusion.
The findings of these 116 included studies are presented by intervention type. A summary of
studies by design and type of policy/intervention are summarised in Table 2. Populationlevel policies/interventions (which aimed to change social norms, smoking behaviour and/or
access to tobacco) included: smoking restrictions in cars, workplaces and other public places
including bars and restaurants; increases in price/tax of tobacco products; controls on
advertising, promotion and marketing of tobacco; mass media campaigns including
campaigns promoting the use of quitlines; multiple policy interventions; settings based
interventions; population-level cessation support interventions. Data extraction tables and
quality assessment, grouped by intervention type, can be found in Appendices F and G
respectively. A table of the equity impact can be found in Appendix H and a summary of the
equity impact is in Appendix I.
18
Figure 1 Study selection flow chart
Electronic search May
2012
Titles and abstracts
screened
update electronic search
January 2013
n = 12,605
titles and abstracts
n = 1309
excluded from title and
abstract
Full papers ordered
n = 287
update full papers
screened
n = 12,318
n = 44
screened
update included
n = 12*
n = 286
update excluded
n = 32
included
excluded (full-text)
n = 115
n = 171
adult policy included
n = 83
update electronic search*
n = 12
handsearch, reviews,
experts
n = 24
total number adult policy
studies
n = 116**
**119 papers for 116 studies
19
Table 2 Summary of studies by intervention type*
Intervention type
Number
of
studies
Smoking restrictions in workplaces, enclosed public places, cars and homes
44
Increases in price/tax of tobacco products
27
Controls on advertising, promotion and marketing of tobacco
9
Mass media campaigns – cessation
18
Mass media campaigns - quitlines and NRT
12
Multiple policies
Settings based interventions (community, workplace, hospitals)
Population-level cessation support interventions
4
7
8
* 8 studies were included in more than one intervention type
20
3.2 Smoking restrictions in workplaces, enclosed public places, cars
and homes.
Introduction
Studies assessing the socio-economic impact of smoking restrictions were split into three
categories. The first category (3.2.1) includes studies that looked at workplace specific
smoking restrictions and the impact on workers. The second category (3.2.2) includes studies
that looked at the impact of wider smoking restrictions in enclosed public places (including
workplaces) on the wider population (which might also have included workers). This second
category also includes studies which looked at the impact of smokefree policies on peoples
smoking restrictions and smoking behaviour in the home. The third category (3.2.3) includes
studies that looked at the impact of voluntary restrictions in cars. Smokefree vehicle laws
exist in some countries and support for such policies is increasing.
One study evaluated the socioeconomic impact of national smokefree policy15 and another
the adoption of local clean air ordinances16and both included separate results for workplace
settings and other public places. Therefore for these two studies the results for workplace
settings are included in the ‘smoking restrictions in workplaces’ section (3.2.1) and results
for non-workplace settings are included in the ‘smoking restrictions in workplaces’ section
(3.2.2).
Within the first two categories the studies have been split into two sub-sections:
(i)
Adoption and coverage of smokefree workplace policies by SES - these are
correlational studies which cover countries, states or regions where smokefree
workplace policies were either voluntary or include several states or regions some
of which had voluntary and others which had compulsory smokefree workplace
policies
(ii)
Impact of introducing smokefree policies by SES - these are intervention studies
which look at the impact of smokefree policies introduced at the national, local or
individual workplace level.
The studies within each sub-section were grouped according to a logic model of expected
outcomes associated with smoke-free legislation developed by Haw et al. which is based on
an evaluation strategy to assess the expected short-term, intermediate and long-term
outcomes of legislation on smoking in enclosed public places.17 The model (Figure 2)
21
includes eight key outcome areas; knowledge and attitudes, environmental tobacco smoke
(ETS)/SHS exposure, compliance, culture, smoking prevalence and tobacco consumption,
tobacco-related morbidity and mortality, economic impacts on the hospitality sector and
health inequalities.
22
Expected Outcomes
Short-term
0-2 mths
Implementation
of smoke-free
legislation
Increasing awareness 1
of health risks of ETS,
change in attitudes
towards ETS exposure
Enforcement of
smoke-free
legislation
Intermediate
> 2 –12 mths
Long-term
> 12 mths
Reduction in exposure to ETS
2
Reduced ETS exposure
Increasing compliance with
smoke-free legislation
3
Sustained compliance with
smoke-free legislation
Increasing support for
4
legislation and change in
smoking cultures
Sustained cultural change
Reduction in smoking prevalence and tobacco consumption
Reduction in tobacco-related morbidity and mortality
Logic Model of Expected
Outcomes Associated with
Smoke-free legislation
5
6
Reduction in costs to health
service of tobacco-related
illness
Variable economic impact on
hospitality sector
health inequalities
7
Reduction in
health inequalities
8
Figure 2 Logic model for Smoke-free legislation
23
3.2.1 Smoking restrictions in workplaces
Overall, fifteen studies were included as assessing the socio-economic impact of smoking
restrictions in the workplace; thirteen studies were set exclusively in workplaces and two
studies included workplace settings.
Thirteen studies18-30 assessed the socio-economic impact of smoking restrictions exclusively
in workplaces, the majority of studies evaluated local/regional adoption of legislation (either
enforced or voluntary) and two studies assessed the impact of national workplace smoking
bans.25;30
Studies were conducted mainly in the USA, but also Belgium,25 Scotland,23,
Sweden22 and the Netherlands.30 The SES variables used within the majority of studies were
occupation and education, although income was also used as well as poverty level (family
income divided by family size).26
Outcomes included policy adoption, implementation, coverage and enforcement; SHS/ETS
exposure (cotinine levels or self-report); smoking prevalence; and changes in smoking
behaviour including quit rates and quit attempts. Some studies evaluating SHS exposure only
included non-smokers and one study only included non-smokers that were not exposed to
SHS at home.18 Two studies included female workers only.26;28Two studies included both
workplace and home smoking restrictions.26;29
Of the thirteen workplace specific studies; four studies were single cross-sectional surveys,
eight studies used a repeat cross-sectional design, and one study included qualitative
data.23Only five of the 13 study samples were assessed as representative of the study
populations. In ten of the 13 studies it was unclear whether the observed effects were
attributable to the workplace smoking restrictions/intervention that was under investigation.
Findings from three of the studies could be generalisable on a national scale and two studies
were generalisable to the region of study.
(i) Adoption and coverage of smokefree workplace policies by SES
This section first considers studies that have looked at the adoption (i.e. diffusion) of
smokefree policies by SES, then those that have looked at the impact in terms of SHS
exposure or other smoking related variables, and finally, studies which have looked at the
relationship between workplace smokefree policy coverage and smokefree policies in the
home. The studies are ordered beginning with national studies, then regional studies and
finally, local studies.
24
A cross-sectional study using the optional tobacco module of the 2001 Behavioral Risk
Factor Surveillance System (BRFSS) examined workplace smoking policy coverage in over
44,000 indoor workers in 25 US states in 2001.19 Overall, 70.9% of respondents reported
working under a smokefree workplace policy, ranging from 60.4% (Kentucky) to 84.5%
(Alaska). Non-smokers were most likely to report a smoke-free environment (74.4%),
followed by occasional smokers (67.9%) and daily smokers (58.2%). Household income
was inversely related to the odds of working in a non-smokefree environment; the likelihood
of being protected by a smokefree work policy was significantly lower among workers who
earned less than $50,000 annually. Education, even after adjusting for all other factors
including income, was strongly associated with the absence of a smokefree workplace
policy. Workers with less than a high school education and workers with a high school
diploma or General Educational Development (GED) were 3.46 and 2.49 times more likely,
respectively, than college graduates to report working in a non-smokefree environment.
Workers in South or Midwest regions were less likely to have a smokefree work policy
compared to workers in Northeast or West, which indicates that other factors as well as SES
influenced workplace smoking policy coverage.
A study which used the Tobacco Use Supplement to the Current Population Survey
supplements (1993 to 1999) examined trends in smokefree workplace policies among
approximately 254,000 indoor workers employed in 38 major occupations in the USA, with
a particular focus on the 6.6 million workers employed in the food preparation and service
occupations.27 It should be noted that analyses were not adjusted for smoking status of
workers. Among all workers, the proportion reporting a smokefree policy increased 37%
between 1993 and 1996 but less than 9% from 1996 to 1999, suggesting a significant
slowing in the adoption rate of such policies. This trend was evident for each of the three
major occupational groups (white collar, blue collar, service workers). Blue collar and
service workers showed the largest percentage gains in smokefree policy coverage between
1993 and 1999 but continued to lag significantly behind their white collar counterparts with
barely a majority reporting a smokefree workplace policy in 1999 compared with more than
three-quarters of white collar workers. Amongst workers who reported a smokefree work
policy; non-compliance was higher among blue collar and service workers than among white
collar employees. However, only a relatively small percentage of workers in all occupational
categories reported that someone had violated their smoke-free policy during the previous
two weeks and non-compliance did not appear to be a significant issue.
25
A repeat cross-sectional study using Tobacco Use Supplements to the Current Population
Surveys (1995 to 1996 and 1998 to 1999) evaluated clean indoor air policies in nearly 6000
indoor workers in Wisconsin, USA.21The percentage of US indoor workers working under a
smokefree policy increased from 64% in 1995/1996 to 69% in 1998/1999. Smokefree
policies in Wisconsin had not progressed as much as other US states; Wisconsin was 29th
best in the USA in 1993 and 1996 but 37th in 1999. In Wisconsin the percent of indoor
workers working under a smokefree policy increased from 62% in 1995/1996 to 65% in
1998/1999. Residents with less than a high school education or with a high school diploma,
as well as residents making less than $15,000 were much more likely to work in an
environment where smoking was permitted or unregulated. Smoking prevalence was
generally higher among people in occupations with a lower percentage of workers covered
by a smokefree workplace policy. There are relatively small numbers in some of the
education and income subgroups which might make the estimates unstable.
Another repeat cross-sectional study using Tobacco Use Supplements to the Current
Population Surveys (1992 to 2002) examined trends in official workplace smoking policies
for indoor working environments in approximately 10,000 workers in North Carolina,
USA.24 North Carolina ranked 35th for the proportion of its workforce reporting a smokefree
place of employment in 2001/2002. The proportion of workers reporting a smokefree policy
doubled between 1992 and 2002. Less than a third of the state’s workforce was smokefree in
1992/1993, but by 2001/2002, slightly more than two-thirds reported this level of protection.
Blue-collar (55.6%, CI +/-5.5) and service workers (61.2%, CI +/-8.4), especially males,
were less likely to report a smokefree worksite than white-collar workers (73.4%, CI +/-2.6).
The study did not account for the smoking status of workers, which may have confounded
results. In addition, at the time of the study there was a pre-emptive state law specific to
North Carolina which might have limited the progress of smokefree policies and any impact
on equality, and limited the generalisability of the study findings to North Carolina.24 The
study authors state that in 1993, the state legislature passed a law that required statecontrolled buildings to set aside 20% of their space for smoking and prohibited local
regulatory boards from enacting stronger provisions unless the legislation was enacted
before the state law would take effect in October 1993. A total of 105 local ordinances were
in effect by the October date, 89 of which had been fast tracked to beat the deadline. A legal
challenge to one ordinance led to a subsequent ruling which invalidated almost all of the 89
26
newly enacted ordinances, forcing most communities to suspend legal enforcement of their
ordinances.
A cross-sectional study examined the pattern of, and socioeconomic factors associated with,
the adoption of clean indoor air (CIA) ordinances in 332 Appalachian communities16 with at
least 2000 residents, in 6 states; Alabama, Georgia, Kentucky, Mississippi, South Carolina,
and West Virginia. Fewer than 20% of the 322 communities had adopted a comprehensive
workplace, restaurant, or bar ordinance. Most ordinances were weak, achieving on average
only 43% of the total possible points. The percentage that completed high school was related
to the presence of workplace clean air policies in Appalachian communities outside West
Virginia. Adjusting for state and county, a 1% increase in high school completion rate was
associated with a 10% increase in both the odds of a workplace policy and the odds of at
least 1 policy (workplace or restaurant).
A cohort study using data from 2006/7 (Wave 5) and 2007/8 (Wave 6) International Tobacco
Control Four County Survey15(Australia, Canada, UK, USA) assessed socioeconomic and
national variations in the prevalence, introduction, retention, and removal of smokefree
policies in various indoor environments, including homes, worksites, bars, and restaurants
(see section 3.2.2). An important strength of this study is that it uses the same survey in four
countries and makes international comparisons.
In the period between Waves 5 and 6
comprehensive smokefree legislation (worksites, bars and restaurants) was introduced in
England, and several states in Australia either implemented or strengthened smokefree
polices in these environments.
In terms of smokefree worksite policies; overall, the proportion of current smokers who
reported that smoking was not allowed (total ban) was greatest among respondents from
Canada in Wave 5 (current: 88.2%) and the UK in Wave 6 (current: 96.1%; former: 98.2%).
The US had the lowest proportion of respondents with such a policy at both Waves (76.8%
and 75.9%). Among former smokers the proportion with a total ban at Wave 5 was highest in
the US (92.7%) but lowest at Wave 6 (83.0%). The proportion of current smokers with a
total ban increased with increasing SES in Canada and the US in Wave 5 but no trends were
apparent in Wave 6. Between Waves, the introduction of a total ban significantly increased
with decreasing SES among current smokers in Canada, the US and UK. No consistent
association was observed across all countries with regard to either the presence or
introduction of total smoking bans in workplaces.
27
Thus the study found that while current smokers with higher SES were more likely to have
total worksite smoking bans, the rate of the adoption of such bans over this one year period
was comparable by SES group. Also there was no consistent association in current or former
smokers between SES and total bans in bars and restaurants. The authors concluded that the
recent proliferation of smokefree policies in these locations had led to a reduction, indeed
removal, in disparities in coverage by SES as low SES worksites and public places were
catching up in the adoption of total smoking bans. They therefore had a positive equity
impact.
A cross-sectional study explored trends in cotinine levels in over 8000 US non-smoking
workers not exposed to SHS at home, by occupational groups, using data from the National
Health and Nutrition Examination Surveys (NHANES III) over 14 years from 1988 to
2002.18 For the overall population, there was a significant decrease in cotinine levels (0.16
ng/mL; 80% relative decrease) over time which ranged from 0.08 to 0.30 ng/mL (67% to
85% relative decrease). The largest absolute reductions in cotinine levels were in blue-collar
and service occupations; the negative slope in cotinine levels for blue-collar service and
service workers (0.21 and 0.22 ng/mL, respectively; 72% and 76% decreases) were
significantly greater than the slope for white-collar workers (0.13 ng/mL; 76%). Although
the study excluded workers exposed to SHS at home, SHS exposure from other settings such
as bars and restaurants cannot be ruled out.
A study investigated the sociodemographic distribution of workplace exposure to SHS in
Sweden, using the Scania Public Health Survey 2000 which was based on a sample of
24,922 randomly selected persons born from 1919 to 1981 and living in Scania.22 13,604
persons responded to the questionnaire, representing a 59% response rate. The prevalence of
SHS at work was higher among men (26.4%) than among women (20.8%), although regular
smoking was higher among women (21.1%) than among men (17.0 %). Regular smokers
had a higher risk of SHS exposure at work than non-smokers. The exposure to SHS at work
was highest among men in skilled manual work and women in unskilled manual work and
persisted after adjusting for age, country of origin, and smoking patterns. Male skilled
manual workers and female unskilled manual workers had higher adjusted odds ratios (OR
4.0, 95% CI: 3.1 – 5.3 and OR 3.2, 95% CI: 2.2 – 4.7, respectively) of SHS exposure than
non-manual high-level employees. The survey included only workers living in Scania, the
southernmost province of Sweden and so study results might not be generalisable to the
entire Swedish workforce.
28
A repeat cross-sectional study using Tobacco Use Supplements to the Current Population
Surveys from 1992 to 1993, estimated the impact of workplace smoking restrictions on the
prevalence and intensity of smoking among all indoor workers (approximately 98,000) and
various demographic and industry groups.20 The percentage of indoor workers subject to a
100% smokefree policy was 46.7%. Nearly 67% were subject to smoking restrictions in their
immediate work area but were allowed to smoke in some common areas. The percentage of
indoor workers subject to no work area or common area restrictions was 18.9%.
The survey results showed a consistent pattern: the more restrictive the workplace policy, the
greater the decline in smoking. Moving from no smoking restrictions to a smokefree
workplace decreased the prevalence of smoking by 5.7 percentage points (95% CI = 4.9 to
6.5) which represents a 22.8% reduction in smoking prevalence compared to the sample
mean; and reduced daily consumption among the remaining smokers by 2.67 cigarettes (95%
CI = 2.28 to 3.05) which represents nearly a 14% decrease in average daily cigarette
consumption. Maintaining work area bans but allowing smoking in common areas reduced
the impact of work area bans by half. For these workplaces, there was a 2.6 percentage point
decrease in the prevalence of smoking and a decline of 1.48 cigarettes in the average daily
consumption (95% CI = 1.08 to 1.89). Partial workplace and common area bans had no
statistically significant effects on the prevalence of smoking. However, these restrictions
decreased daily consumption among remaining smokers (those who do not quit smoking) by
0.57 cigarettes (95% CI = 0.05 to 1.08).
Indoor workers with postgraduate education had both a lower prevalence of smoking and a
lower daily consumption. Although the percentage point declines in the prevalence of
smoking in response to a smokefree environment were fairly uniform across educational
groups, as a percentage of current rate of smoking, the largest effects (percentage decline)
were for workers with a college degree (28.4% decline) and the least for high school
dropouts (13.7% decline). However, the opposite was true for the effects of the smoking ban
on average daily consumption. Those with less than a high school degree had the largest
decline, both in absolute terms (3.90 cigarettes) and as a percentage of average daily
consumption (19.4%). Those with a college degree decreased daily consumption by an
average of 1.69 cigarettes, a 9.3% decrease. The sample of indoor workers was more
educated than the sample of all workers and so the equity impact may not be generalisable to
the entire workforce.
29
Another study which used the Tobacco Use Supplement to the Current Population Survey
supplements (1998/9 and 2000/1) examined the association between workplace smoking
policies and home smoking restrictions with current smoking among approximately 80,000
working women.26 About 11.1% of women reported no workplace smoking policy.
Workplace policies were associated with distance from the poverty level; 61.5% below the
poverty level were covered by full workplace restrictions, compared to 76.6% of those
150%+ above the poverty level. 19.1% of those below the poverty level had no workplace
smoking policy, compared to just 10% of the 150%+ group. Workplace smoking policies
were not associated with a quit attempt in the past year for any of the poverty level
categories.
A study assessed differences in the likelihood of exposure to SHS at home and at work
among an ethnically diverse sample of approximately 2300 non-smoking women aged 40
and older in the United States in 1997.28 The analysis of SHS exposure and smoking
restrictions at work was further restricted to include only employed women, resulting in a
sample size of 1100. The study excluded women without a telephone at home; these women
could have been more exposed to SHS. Nearly 40% of the respondents had an annual income
of $20,000 or less. Income was excluded from the final model due to the high proportion of
missing cases (16.7%) and its collinearity with educational level.
Among employed women, 19.2% were exposed to SHS at work, and 22% were employed at
worksites that allowed smoking in some or all work areas. Exposure to SHS at work was
substantially higher for women who worked where smoking was allowed in some (adjusted
OR 15.1, 95% CI 10.2, 22.4) or all (adjusted OR 44.8, 95% CI 19.6, 102.4) work areas.
Exposure to SHS at work was higher among women with some high school education
(adjusted OR 2.8, 95% CI 1.5, 5.3) and high school graduates (adjusted OR 3.1, 95% CI 1.9,
5.1) and marginally so for those with some college (adjusted OR 1.5, 95% CI 0.9, 2.5).
A study compared how adoption and enforcement (self-reported smoke exposure) of
smokefree policies differed for Asian-American women by educational status, using the
California Tobacco Use Surveys for Chinese and Korean Americans (CCATUS and
KCATUS).29The response rate to the survey was low; 52% for Chinese Americans and 48%
for Korean Americans and included approximately 1900 women, nearly 60% had less than
$30,000 annual income. The study authors stated they aimed to assess the impact of
California’s smoke-free social norm campaign (with Asian community and in-language
30
outreach) but this was established in 1988; over a decade before the survey was conducted
(2003), making it difficult to isolate the specific impacts of this campaign.
Lower-educated and higher-educated women had similar proportions of smoke-free policies
for indoor work (90%) however; lower-educated women were more likely than highereducated women to report exposure during the past 2 weeks at an indoor workplace
(OR=2.43, 95% CI= 1.30, 4.55, p=0.005), even after controlling for ethnicity, smokefree
policy, knowledge about the health consequences of secondhand smoke exposure, and
acculturation.
(ii) Impact of introducing smokefree policies by SES
In March 1993 the Belgian Public Health Department published a Royal Decree to structure
and regulate smoking habits in the workplace. According to the Royal Decree, companies
were obliged to ‘take measures against the harmful consequences of smoking at the
worksite’. A study25 assessed the impact of this decree, through mailed questionnaires, to
evaluate the implementation of health policy recommendations to 3543 randomly selected
Belgian companies from the ‘Trends Top 20,000’ companies.
In 1990, 773 companies (22%) and in 1993, 890 companies (25%) responded to the
questionnaire. A total of 325 (9%) companies responded to both the 1990 and 1993
questionnaires. Comparison of the 1990 and 1993 dataset regarding the influence of the antismoking campaigns on smoking policy shows that despite the media attention and the
promulgation of the Royal Decree by the Public Health Department, no major changes were
observed. Only restrictions on smoking in cafeterias (p = 0.0001) and in meeting rooms (p =
0.02) were implemented. The relation between companies’ turnover and the willingness to
offer a worksite smoking cessation programme (WSCP) was not observed in 1990 but
became significant in 1993. Companies with a very high turnover reported more willingness
to offer a WSCP in 1993 (67% in 1993 versus 54% in 1990).
A significant relation was observed between the blue/white collar worker ratio and its impact
on company’s smoking policy in 1990. Companies employing mostly white collar workers
compared with companies employing mostly blue collar workers reported being more able to
offer time (p = 0.001), meeting rooms (p = 0.001) and to subsidize a WSCP (p = 0.001).
Companies employing mostly white collar workers were willing more often to offer a WSCP
31
(p = 0.02). Companies employing mostly blue collar workers had a stricter non-smoking
policy (p = 0.003).
In 1993 a significantly higher percentage of companies with a high number of white collar
compared with companies with a high number of blue collar workers were reported more
able to offer time (p = 0.00001), meeting rooms (p = 0.001), having already organised a
WSCP (p = 0.00001), to subsidize a WSCP (p = 0.00001) and to offer a WSCP (p = 0.0002).
A lower percentage of companies with a high number of blue collar compared with
companies with a high number of white collar workers tended to offer a worksite
information program (p = 0.02).
When comparing survey data from 1990 and 1993: the difference regarding a more strict
smoking policy between companies employing mostly blue collar (12% total non-smoking
policy) and companies employing mostly white collar (2% total non-smoking policy) which
was significant in 1990 has disappeared in 1993 (7% in a ‘mostly blue collar’ company
versus 4% in a ‘mostly white collar’ company).
It is unclear how comprehensive this decree was or how strictly it was enforced. The 1993
Royal Decree31 regarding smoking in workplaces issued by the Minister of Employment
states:
“[Tobacco use] must be based on mutual tolerance, respect of individual liberties, and
courtesy. If necessary, the employer must take additional technical measures [ventilation
systems] in order to eliminate the annoyance caused by environmental tobacco smoke.”
This indicates that there was likely to have been variability in adoption and enforcement of
the decree. The response rate to the questionnaire in 1990 and 1993 was related to the
companies’ turnover (12% in low to 30% in high turnover) and to the blue/white collar ratio
(13% in high ratio to 26% in low ratio). This differential response rate might invalidate study
findings. In addition, the study evaluated the impact of the new law only 3 months post
implementation which might not be sufficient time to assess impact.
A study in the Netherlands30 examined whether a national workplace partial smoking ban in
2004 reduced exposure to SHS and inequalities in SHS exposure. The ban applied to all
workplaces except the hospitality industry (employees in restaurants, pubs, bars, and
discotheques were excluded from this ban). The data source was the Continuous Survey of
Smoking Habits (CSSH) Dutch internet survey, and included over 11,000 non-smoking
32
workers. SHS exposure decreased among all employees and low-educated employees (at
higher risk before the ban); 52.2% still reported being exposed post-legislation. Lowereducated workers were twice as likely to be exposed as those workers with a higher level of
education. There were significant differences between educational subgroups and the
decrease in SHS exposure since the national smoking ban. OR between low and middle, pre
and post-legislation: 1.61 (1.23-2.10); 1.21 (1.16-1.47); OR low v high educated: 2.29 (1.743.01); 2.17 (1.91-2.45).
The authors of the study argue that the workplace smoking ban was limited because it
excluded the hospitality industry and employers were also permitted to offer designated
smoking rooms at work. The internet sample might not be representative of the general nonsmoking working population in the Netherlands. Any positive response to exposure was
coded as ‘exposed’ during the survey; dichotomising responses in such a manner could have
led to over-stating exposure. The brief period of data collection pre-ban offered less seasonal
variability compared to data collect post-ban. In addition, education is a difficult measure of
SES to compare across generations and internationally, more so for this study because there
was no definition provided for ‘low, middle, high’ education.
A study which examined the implications of moving from a voluntary smoking code to a
smoking ban at Edinburgh University, UK used a postal questionnaire which was completed
by 997 staff members (27.8% of the sample) and qualitative interviews with a purposive
sample of 30 staff members.23Across the staff groups (smoke less, smoke more, quit, no
change) the proportions were as follows: Academic and related 39 (36.8%), 3 (2.8%), 17
(16.0%), 47 (44.3%); Clerical / secretarial 30(42.2%), 1 (1.4%), 6 (8.4%), 34 (47.9%);
Technical 25 (51.0%), 2 (4.1%), 6 (12.2%), 16 (32.7%); Manual 76 (45.2%), 15 (8.9%), 7
(4.2%), 70 (41.7%). Significant differences were found in quit rates between academic and
related staff and manual staff (16.0% vs. 4.2%) and in increase in smoking between
academic and related and manual staff (2.8% vs. 8.9%). The largest response categories for
academic and related and clerical / secretarial staff was 'no change' and for technical and
manual staff was 'smoke less'.
3.2.2 Smoking restrictions in enclosed public places
A total of twenty-nine studies assessed the socio-economic impact on the wider population
(not just workers) of smoking restrictions in enclosed public places; three studies16;32;33
evaluated local/regional adoption and coverage of smokefree legislation and 24 studies
33
examined the impact of introducing smokefree policies: four studies34-37 of regional
smokefree legislation and 22 studies15;38-59 of national smokefree legislation. Six studies
evaluated national smokefree legislation alongside other types of policies.40;54-58
Studies were conducted in several countries including Australia, Canada, England, France,
Germany, Ireland, Italy, Netherlands, New Zealand, Scotland, USA and Wales. One study
used data from 18 European countries including Finland, Sweden, Denmark, England,
Ireland, Netherlands, Belgium, Germany, France, Italy, Spain, Portugal, Slovakia, Hungary,
Czech Republic, Lithuania, Latvia and Estonia.56
Settings included bars, restaurants and hospitals. SES variables used within the studies
included area deprivation, occupational class, education and household income. Outcomes
varied and included: policy adoption and coverage; compliance with smokefree legislation
and social norm data; smoking prevalence and odds ratios for smoking; SHS exposure
measured by cotinine levels and particulate matter, and self-report; smoking behaviour
including consumption and quitting; health impacts including acute myocardial infarctions
and coronary events; perceived respiratory and sensory symptoms. Qualitative data included
the impact of changes in physical spaces from smokefree legislation. Two studies evaluated
the impact of national smokefree legislation and measured children’s reports of parental
smoking behaviour in cars and in homes.46;47
Four studies were single cross-sectional surveys, sixteen studies used a repeat cross-sectional
design (one of which is classed as econometric study40 design 1.4, as price elasticities were
reported), five studies were prospective longitudinal cohorts, one study used a before-andafter design with the same participants at follow-up, and three studies were qualitative. Only
eleven of the 27 study samples were assessed as representative of the study populations; one
UK cohort reported a response rate of 72% for the original data source but applied various
exclusions to the data and excluded participants from ethnic minorities.45
Four of the five cohort studies43;45;58;59had an attrition rate of at least 30%, and three of the
cross-sectional studies had relatively small numbers within some subgroups.35;36;38For
fourteen of the studies it was not possible to be confident that the observed effects were
attributable to the intervention under investigation mainly due to other tobacco control
legislation which occurred concurrently. Findings from ten studies could be generalisable on
a national scale (one study45 might not be generalisable to ethnic minority groups within the
UK), and one study32 was generalisable to the region of study. All members of one
34
cohort43were participating in a clinical trial of aspirin in people at moderately increased risk
of cardiovascular events and so the results of the trial are specific to this trial population.
(i) Adoption and coverage of smokefree policies by SES
Three studies16;32;33 evaluated local/regional adoption of smokefree legislation and were all
cross-sectional studies based in the USA. Freestanding bars were excluded from two
studies16;33 as they were not covered by ordinances. It should be noted that the three studies
assumed that protection from SHS exposure was provided by regulations rather than
measuring the actual level of protection, however the presence of a regulation should
correlate with reduced exposure.
One study of 351 cities and towns in Massachusetts, USA examined the diffusion of
smokefree restaurant regulations.32 Over 10 years (1993 to 2004) prior to statewide ban, only
36% of the total population of Massachusetts was covered by local regulations that protected
them from SHS exposure in restaurants. The proportion of college graduates in
Massachusetts protected from SHS in restaurants in their own town was consistently
between 2 and 7 percentage points greater than the proportion of non-graduates who were
protected. Just prior to the statewide smoking ban, 40% of college graduates were protected
compared to 33% of non-graduates. There was also substantial disparity in protection from
SHS by individual poverty status; protection from SHS exposure was higher for those living
above the poverty line.
Another cross-sectional study also based in Massachusetts33 identified and quantified
differences in sociodemographic characteristics of communities relative to the strength of
351 local restaurant smoking regulations obtained from a database maintained by the
Massachusetts Tobacco Control Progam (MTCP) at one time-point in 2002. Three measures
of the strength of ordinances were developed: strong equalled smokefree, medium equalled
separate ventilated areas for smoking, and weak equalled designated smoking areas or no
restrictions. Towns with Board of Health funding by the MTCP were nearly 5 times more
likely to adopt strong regulations and more than 11 times more likely to adopt medium
regulations. In bivariate analyses, local smokefree restaurant regulations were significantly
more likely to be adopted by towns with a higher proportion of college graduates, and a
higher per capita income. Strength of regulation was not significantly related to household
income or poverty level. In multivariate analyses, education and per capita income became
insignificant. The study authors stated this might be explained by another significant
35
measure which was ‘agreeing with the 1992 ballot to create the MTCP’ which was highly
correlated with both education (r=0.90) and per capita income (r=0.74).
A cross-sectional study examined the pattern of, and socioeconomic factors associated with,
the adoption of clean indoor air (CIA) ordinances in 332 Appalachian communities16 with at
least 2000 residents, in 6 states; Alabama, Georgia, Kentucky, Mississippi, South Carolina,
and West Virginia. Appalachia is characterized by widespread poverty and, in addition,
study findings might not be generalisable to smaller Appalachian communities. Policy
coverage was evaluated in 2008 through web-based search and contacting of city halls for
CIA ordinances. Separate logistic regression models were fitted to West Virginia and
communities within the other five states because West Virginia differed from the other states
as the majority of its communities had an ordinance. The CIA strength ratings were not
adjusted to account for the state CIA laws, however the laws in these states were very weak.
Fewer than 20% of the 322 communities had adopted a comprehensive workplace,
restaurant, or bar ordinance. Most ordinances were weak, achieving on average only 43% of
the total possible points. The percentage that completed high school was related to the
presence of restaurant clean air policies in Appalachian communities outside West Virginia.
Adjusting for state and county, a 1% increase in high school completion rate was associated
with a 9% increase in the odds of a restaurant policy and a 10% increase in the odds of at
least 1 policy (workplace or restaurant).
Univariate logistic regression models revealed no associations between county
characteristics and CIA ordinances in West Virginia, with the exception of a significant
negative relationship between median income and presence of a restaurant policy (a $1000
increase in median income was associated with a 12% decrease in the odds of a restaurant
policy, likelihood ratio P=.033). A 1% increase in the percentage that completed high school
was associated with an average increase of 0.9% in points achieved for CIA strength ratings.
The analysis was repeated for the West Virginia counties, though no significant relationships
were found.
(ii) Impact of introducing smokefree policies by SES
Twenty-four studies examined the impact of introducing smokefree policies: four studies34-37
of regional/statewide smokefree legislation and 20 studies15;38-45;48-59 of national smokefree
36
legislation. Six studies evaluated national smokefree legislation alongside other types of
policies.40;54-58
A before-and-after study using International Tobacco Control Europe Surveys48 investigated
how successful national level smokefree hospitality industry legislation was in reducing
smoking in bars; assessed individual smokers predictors of smoking in bars post-ban;
examined country differences in predictors; and examined differences between education
levels. Studied countries were Ireland, France, Netherlands and Germany. While the partial
smokefree legislation in the Netherlands and Germany was effective in reducing smoking in
bars (from 88% to 34% and from 87% to 44%, respectively), the effectiveness was much
lower than the comprehensive legislation in Ireland and France which almost completely
eliminated smoking in bars (from 97% to 3% and from 84% to 3% respectively).
Smokers from Ireland and France were younger and less educated than smokers from the
Netherlands and Germany. Smokers with a low educational level were more likely than
smokers with a high educational level to smoke in bars post-ban. Highly educated smokers
from the Netherlands who were supportive of a partial ban were less likely to smoke in bars
post-ban (OR highly educated = 0.53, 95% CI = 0.26 to 1.08). Moderately educated smokers
from the Netherlands who often or sometimes thought about the harm of smoking to others
were less likely to smoke in bars (OR moderately educated = 0.54, 95% CI = 0.34 to 0.88).
Societal approval of smoking was a stronger predictor of smoking in bars among highly
educated smokers (OR highly educated = 2.87, 95% CI = 1.01 to 8.18). Low and moderately
educated smokers from Germany who very often thought about the harm of smoking to
others were borderline significantly less likely to smoke in bars (OR low educated = 0.14,
95% CI = 0.02 to 1.15; OR moderately educated = 0.23, 95% CI = 0.05 to 1.11).
A repeat cross-sectional study examined patron responses to the California smokefree bar
law in 199835 in three telephone surveys; 3-months, 8-months and 2.5 years post-law.
Approval of the law rose from 59.8% to 73.2% (OR 1.95; 95% Cl:1.58 to 2.40). Selfreported non-compliance decreased from 24.6% to 14.0% (OR 0.50; 95% CI:0.30 to 0.85).
The likelihood of visiting a bar or of not changing bar patronage after the law was
implemented increased from 86% to 91% (OR1.76: 95% CI:1.29 to 2.40). Respondents who
approved of the law were more likely to be more highly educated or have a household
income of at least $60,001. Patrons with higher income or educational attainment tended to
report they were “more likely” to visit bars or to report “no change” in their patronage.
37
Patrons with an income of at least $60,001 were less likely to perceive non-compliance.
Response rates ranged between 28 to 32% and so the study sample was not representative of
the population. Also, because of their willingness to complete the survey, the respondents
selected may be inclined to support the law.
Three studies evaluated the socio-economic impact of national comprehensive smokefree
legislation on reducing exposure to SHS. One study measured salivary cotinine levels,
another study measured particulate matter and one study used self-reported exposure.
A repeat cross-sectional study in England53 used salivary cotinine data from the Health
Survey for England that were collected in 7 of 11 annual surveys (1998 to 2008) to examine
trends in, and predictors of, SHS exposure among non-smoking adults to determine whether
exposure changed after the introduction of smokefree legislation in 2007, and whether these
changes varied by SES and by household smoking status. Exposure declined markedly from
1998 to 2008 (the proportion of participants with undetectable cotinine was 2.9 times higher
in the last 6 months of 2008 compared with the first 6 months of 1998 and geometric mean
cotinine declined by 80%). There was a significant fall in exposure after legislation was
introduced adjusting for pre-legislative downward trends and potential confounders (the odds
of having undetectable cotinine were 1.5 times higher [95% CI: 1.3, 1.8] and geometric
mean cotinine fell by 27% (95% CI:17%, 36%).
Significant reductions in SHS exposure were not, however, seen in those living in lowersocial class households or homes where smoking occurred inside on most days. Social class
was a significant determinant of SHS exposure; the odds of having undetectable cotinine
decreased with declining SES status with the lowest levels in social class IV and V [29%
lower than social class I and II, 95% CI: 21, 35] and in adults with no qualifications (19%
lower than those with a higher education qualification, 95% CI: 11, 26). Significant impacts
of the smokefree legislation were observed among those from social classes I to III. The
odds of having undetectable cotinine were 1.8 (95% CI: 1.4, 2.3) times higher among those
in social classes I and II and 1.5 (95% CI: 1.1, 1.9) times higher among those in social
classes III after the legislation, whereas geometric mean cotinine levels fell by 37% (95%
CI: 24%, 48%) and 23% (95% CI: 6%, 37%) respectively.
A repeat cross-sectional study in England, Scotland and Wales
52
evaluated the effects of
national smokefree legislation on air pollution levels in bars. The intervention included
discreet sampling of air quality in bars by researchers and also 26 personal exposure shift
38
samples for non-smoking bar workers from Scotland and England recruited to wear personal
air quality monitors. Particulate matter <2.5 mm in diameter (PM2.5) levels prior to
smokefree legislation were highest in Scotland (median 197 µg m-3), followed by Wales
(median 184 µg m-3) and England (median 92 µg m-3). All three countries experienced a
substantial reduction in PM2.5 concentrations following the introduction of the legislation
with the median reduction ranging from 84 to 93%. Personal exposure reductions were also
within this range. Bars located in more deprived postcodes had higher PM2.5 levels prior to
the legislation. Linear trend in the change in PM2.5 by deprivation category, suggested more
deprived areas experienced greater percentage reduction in PM2.5 levels up to 12 months
post-implementation when compared to more affluent areas, although there were higher
levels of PM2.5 at baseline for more deprived areas.
One study evaluated the impact of a statewide smokefree law enacted in July 2010 in
Wisconsin, USA, on smoking behaviours in and out of the home with an Annual Survey of
the Health of Wisconsin (SHOW).36 Six hundred and thirty-four adults were surveyed before
the ban and 434 after the ban. Participants who lived in an area with a workplace or complete
public smoking ban prior to the statewide ban were excluded from the analysis. Smoke-free
legislation in Wisconsin decreased reported exposure to tobacco smoke outside the home,
and at work. The smoking ban was associated with a reduction of participants reporting
exposure to smoke outside the home (from 55% to 32%; P<0.0001).
Participant exposure to tobacco smoke outside the home improved among both education
groups, and all income groups (<$30,000 per year; $30,000 to $59,000 per year; >/=$60,000
per year) but it was decreased further in the highest income group (family income >$60,000
per year). Participants being exposed to smoke at work significantly reduced only for middle
income group. Smokefree legislation not associated with change in smoking prevalence but
analyses were weakened by small sample size. The number of current smokers in the SHOW
data was only 167, a number that limits the statistical power of the study when it comes to
analysing the effects of the law on smoking prevalence and on the behaviours of current
smokers. The results of the study might be specific to the residents of Wisconsin and not
generalisable to the general population.
Ten studies (three qualitative) evaluated the socio-economic impact of national smokefree
legislation using self-reported quitting behaviour, smoker status, and/or prevalence as the
outcome measures. An interrupted time-series analyses of 11 annual cross-sectional surveys
39
(1999 to 2010) estimated the impact of the 2005 smokefree law in Italy42 which prohibited
smoking in all public place including workplaces. Changes in both smoking prevalence and
cessation were particularly marked immediately before or just after the introduction of the
2005 policy, whereas in the following years rates tended to be similar to those of the period
before the policy was introduced. Among both low and high-educated males, smoking
prevalence decreased by 2.6% (P = 0.002) and smoking cessation increased by 3.3% (P =
0.006) shortly after the ban, but both measures tended to return to pre-ban values in the
following years. The absolute difference in smoking prevalence between highly and loweducated males widened slightly over the whole time-period. Time trends in the quit ratio
mirrored those in smoking prevalence for males.
Among low-educated females, the ban was followed by a 1.6% decrease (P = 0.120) in
smoking prevalence and a 4.5% increase in quit ratios (P < 0.001). However, these
favourable trends reversed over the following years. Among high-educated females, trends
in smoking prevalence and cessation were not altered by the ban. A different pattern
emerged for the female quit ratio: the policy was associated with an immediate 2.6%
increase in quit ratio (P = 0.050), but the change in time trends (b = -0.6% per year) was not
significant at the 0.05 level. However, the immediate effect of the policy was more
favourable among low-educated females than among the higher educated, with a 4.5%
increase in quit ratios among low-educated females, p < 0.001. Long-term trends clearly
favoured the higher educated (b = 0.7% for the interaction term between education and
time). As a result, educational differences in quit ratios widened over time.
The results of this study might not be entirely attributable to the smokefree law; in Italy the
price of cigarettes rose by about 65% between 1999 and 2010, and the largest relative
increase occurred between 2003 and 2005. In addition, a national mass media anti-smoking
campaign was carried out in 2009.
A cohort of participants in an RCT of Aspirin for Asymptomatic Atherosclerosis43 were
evaluated to investigate trends in smoking cessation before and after the introduction of
smokefree legislation in Scotland which prohibited smoking in enclosed public places and
workplaces in 2006. The Scottish smokefree legislation was associated with an increase in
the rate of smoking cessation in the 3-month period immediately prior to its introduction
(5.1% quit in the 3-months prior to legislation implementation, far higher than any other 3month period). Overall quit rates in the year the legislation was introduced and the
40
subsequent year were consistent with a gradual increase in quit rates prior to the introduction
of the legislation. Odds of quitting increased annually (OR 1.09 95% CI: 1.05 to 1.12).
There was no evidence of an association between the Scottish Index of Multiple Deprivation
(SIMD) and the probability of attempting to quit, or feeling influenced to quit. However,
smokers from more affluent areas were more likely to have a positive perception of the
legislation compared with more deprived communities. The cohort was participating in a
clinical trial which might have influenced their smoking behaviour and their attitudes
towards the smokefree legislation. Therefore the findings of this study might not be
generalisable to the general population.
A repeat cross-sectional study in England44used national household surveys (2007 to 2008)
to determine the impact of smokefree legislation implemented in 2007, on quit attempts and
intentions. The smokefree legislation was associated with a significant, temporary, increase
in the percentage of smokers attempting to quit. One in five smokers who quit after the ban
said they had been influenced by the ban. There was no evidence of any significant
difference in quit attempts by social grade, but only six months of pre-legislation data were
examined.
A study45 used Millennium Cohort Study (MCS) data for parents of children born between
September 2000 and January 2002, to investigate parental smoking behaviours in England
and Scotland after Scottish smokefree legislation in 2006, and inequalities in maternal
smoking behaviour between the two countries. No smokefree legislation in England occurred
during the data collection period. Various inclusion/exclusion criteria were applied to the
MCS data; only singleton births to white British/Irish mothers who participated in all three
contacts and lived in England or Scotland at first and third contact were studied. Excluded
were mothers who were pregnant at any contact, main respondents who were not female, and
partners who were not male. Smoking behaviours among parents with young children
remained relatively stable.
There was a higher rate of smoking cessation between contact 1 (when child was 9 months
old), and contact 3 (when child was 5 years old) among mothers in England who had higher
household income, higher occupational class, or left school at an older age. There was no
significant relationship for these factors in Scotland; where quitting smoking was similar
across social groups, whether defined by occupation, education or income. The socioeconomic gradient in quitting smoking in Scotland has flattened slightly following the
41
smokefree legislation. However mothers from disadvantaged circumstances were still more
likely to smoke, start smoking or report smoking in the home. Lower SES was associated
with higher rates of maternal smoking uptake and smoking in the home in both England and
Scotland (p<0.05).
This study showed higher attrition rate among non-smokers (40% of those who only
responded at contact point 1 smoked compared to 29% who participated in the first and third
contacts), however non-response weights were included in all analyses. It should be noted
that a range of other tobacco control policies were implemented during this time. The results
may not be applicable to ethnic minority groups with England and Scotland and may be
specific to parents of young children.
A cohort study using data from 2006/7 (Wave 5) and 2007/8 (Wave 6) International Tobacco
Control Four County Survey15(Australia, Canada, UK, USA) assessed socioeconomic and
national variations in the prevalence, introduction, retention, and removal of smokefree
policies in various indoor environments, including homes, worksites (see section 3.2.1), bars,
and restaurants. An important strength of this study is that it uses the same survey in four
countries and makes international comparisons. In the period between Waves 5 and 6
comprehensive smokefree legislation (worksites, bars and restaurants) was introduced in
England, and several states in Australia either implemented or strengthened smokefree
polices in these environments.
In terms of smokefree bar policies; overall, the proportion of both current and former
smokers who reported that smoking was not allowed in any indoor area of local bars (total
ban) was greatest among respondents from Canada in Wave 5 (current: 83.6%; former:
83.0%) and those from the UK in Wave 6 (current: 97.1%; former: 95.3%). Between Waves
5 and 6, relative increases of 79.7% and 50.6% were observed in the proportion of current
smokers with a total ban in the UK and Australia, respectively. Similar increases were also
observed among former smokers in these two countries (UK: 81.1%; Australia: 45.3%). No
consistent association with SES was observed across countries with regard to either the
presence or introduction of total smoking bans in bars.
In terms of smokefree restaurant policies; overall, the proportion of both current and former
smokers who reported that smoking was not allowed in any indoor area of local restaurants
(total ban) was greatest among respondents from Canada in Wave 5 (current: 91.5%; former:
92.7%) and the UK in Wave 6 (current: 97.1%; former: 98.2%). The proportion of
42
respondents with such a policy was lowest among those from the UK in Wave 5 (current:
27.5%; former: 32.0%) and the US in Wave 6 (current: 65.0%; former: 60.9%). Between
Waves 5 and 6, relative increases of 71.7% and 67.4% were observed among current and
former smokers in the UK, respectively. No consistent association by SES was observed
across countries with regard to either the presence or introduction of total smoking bans in
bars.
Thus the study found that while current smokers with higher SES were more likely to have
total worksite smoking bans, the rate of the adoption of such bans over this period was
comparable by SES group. Also there was no consistent association in current or former
smokers between SES and total bans in bars and restaurants. The authors conclude that the
recent proliferation of smokefree policies in these locations has led to a reduction, indeed
removal, in disparities in coverage by SES as low SES worksites and public places are
catching up in the adoption of total smoking bans. They therefore had a positive equity
impact.
A national population survey assessed the effects of the implementation of a workplace
smoking ban in January 2004 in the Netherlands and the extension to the hospitality industry
in July 2008.49 The study used seven years of data from the Dutch Continuous Survey of
Smoking Habits (DCSSH), an internet-based survey (n=18,000 per year) to examine
smoking prevalence, quit attempts and successful quitting.
There was a slight, significant, decrease in smoking prevalence between 2001 and 2007
(OR=0.97, p<0.001). The workplace ban was followed by a decrease in smoking prevalence
in 2004 (OR=0.91, p<0.001), with prevalence lower in the first half of the year than the
second, suggesting some relapse. The hospitality ban had no significant influence on
smoking prevalence (OR=0.96, p=0.127). Quit attempts were higher following the
workplace ban (33% (2004) v 27.7% (2003), p<0.001), and hospitality ban (26.3% in 2008,
v 24.1% in 2007, p=0.013). Seasonal variations in quit rates also support the effectiveness of
both smokefree policies. There were significant increases in successful quit attempts
following both smokefree policies.
In terms of impact by SES; the workplace ban led to more successful quit attempts among
higher educated smokers (OR=0.35, p<0.001) than medium (OR=0.41, p<0.001) or lower
OR=0.74, p=0.052). The hospitality industry ban had a larger effect on quit attempts among
frequent bar visitors (OR = 1.48, P = 0.003) than on non-bar visitors (OR = 0.71, P = 0.014),
43
and more frequent bar visitors were more likely to be higher educated, as well as younger,
male, and employed (all p<0.001). The Dutch smoking bans were implemented in
conjunction with a tax increase and a mass media smoking cessation campaign, so it is
difficult to tease out any separate effects of the workplace ban and the hospitality industry
ban.
Three qualitative studies37;41;50;51evaluated the impact of smokefree legislation.
One study50;51 explored whether, and in what ways national smokefree legislation affected
smokers’ experience of stigma in four areas in Scotland selected to provide urban and rural,
affluent and deprived communities. The intervention included thematic analyses of semistructured interviews in two socioeconomically advantaged and two disadvantaged localities
at three time points, one pre-legislation and two post-legislation (2005 to 2007), and also
observational data recorded in public places. Smokers’ narratives in the disadvantaged
localities described more decreases in consumption and successful quitting than those in the
affluent localities. Participants’ narratives suggested that a range of factors underlay the
decreases in consumption and most of these were connected to the environmental constraints
of smokefree legislation and the nature of any newly created public social spaces for
smoking. There appears to have been a more substantial change in deprived areas, because
the advantaged areas already had reasonably comfortable accommodation for smokers
outside, and opinion changed from being opposed to the ban to accepting it and following it.
Smokers in disadvantaged areas said they abided by the law to support the licensee, and
rushed cigarettes because they were worried about their drink. These smokers might visit
public places less because of the ban. Smokers in advantaged areas said that they smoked
less, or quicker, because going outside interrupted social activity, and because of concerns
over the stigma of being seen smoking. While some described how they were able to recreate convivial social groups in the new smoking places, for example, where there was
comfortable and sheltered provision, others particularly in disadvantaged communities
described limited or no outside provision for smokers. Thus, the sense of separation was
compounded by a loss of comfort, particularly in poor weather with an implicit and real loss
of status compared with their pre-legislation position.
This qualitative study provides an in-depth analysis which showed that there might be some
unintended negative consequences of the smokefree legislation. It is unlikely that the study
44
sample was representative of the community as a whole and it is unclear whether the study
areas were typical of each urbanisation/affluence category.
Another qualitative study, also set in Scotland, explored how management, customers and
workers from across the social spectrum received and responded to the new measures
following the smokefree legislation.41 Ten bar proprietors, 16 bar workers and 44 customers
were interviewed in eight Scottish community bars in three contrasting study communities
located in one local authority area over 12 months. Bars in deprived study communities
tended to show lower compliance and less support for the legislation compared with the
relatively affluent community, but there were exceptions to this. Three factors were
particularly important in explaining variance between bars: smoking norms, management
competency and management attitudes towards the ban. Smoking norms and management
attitude were related to social disadvantage.
The small number of bars studied means that the study does not provide a representative
view of the licensed trade across Scotland. The strength of the study is derived from the
multiple perspectives offered by interviewing customers, bar workers and proprietors
operating in the same study sites. Study authors argue that the generalisability of the results
arises from the reliability of the compliance and enforcement concepts and their value to
assessment in a wider range of settings.
A Canadian qualitative study37 explored the effects of SHS policies on a purposive sample
of 47 men and women. Participants were classed as low income or non-low income
according to their self-reported combined family income before deductions. Interview and
focus group transcripts were analysed and recurring themes were identified, paying
particular attention to gendered factors and income levels. Three key themes included:
reshuffling and relocating where people smoke; SHS management and the impact on social
relations and interactions; disparities in the effect of policies and management of SHS.
The majority of participants thought that people living on a low income would be more
vulnerable to SHS, face more smoking-related challenges and be less likely to benefit from
SHS policies. Participants noted that smokers tend to be poor and have fewer resources to
afford healthier options, experience more stress and anxiety, and are more likely to use
smoking as a coping mechanism. Participants noted that some people living on a low income
use smoking to cope with mental illness, and therefore face more barriers to reducing or
quitting smoking. Participants thought that people living on a low income tend to be
45
surrounded by more smokers, and also that smoking restrictions are less likely to be
regulated. Participants thought that low income neighbourhoods or housing areas often lack
access to private outdoor space, creating challenges for those individuals trying to reduce
their smoking or SHS exposure.
The study authors recruited a small purposive sample specific to Vancouver, Canada, and
not based on smoking status. Study authors were unable to recruit men living on a low
income to attend a focus group, and only one non-low income woman turned up for a focus
group.
A cross-sectional study34 using data from the 2004 New York City Health and Nutrition
Examination Survey (NYCHANES) estimated the prevalence of smoking and SHS exposure
among 1,767 non-smoking adults in New York City (NYC) compared to a national dataset
(2003/2004 National Health and Nutrition Examination Survey), following comprehensive
smokefree workplace and enclosed public place legislation in NYC in 2003. Although the
smoking prevalence in NYC was lower than that found nationally (23.3% vs. 29.7%, p <
.05), the proportion of non-smoking adults in NYC with elevated cotinine levels was greater
than the national average (56.7% vs. 44.9%, p < .05).
Smoking prevalence in both the NYC and U.S. populations was higher in those earning less
than $20,000 per year. Nationally, those with less than a high school education had a
significantly higher smoking prevalence than those with at least a high school education. In
NYC, the effect of education on smoking prevalence did not reach statistical significance (p
< .10). However, in NYC, those with less than a high school education were 64% more
likely than those with at least a high school education to have an elevated cotinine level. The
overall NYCHANES survey response rate was only 55%, in addition, NYC residents might
face unique exposure to SHS due to the density of the urban environment, which both limit
study findings.
Three studies evaluated the impact of smokefree bans on health outcomes. One repeat crosssectional study examined Acute Myocardial Infarction (AMI) admissions to Christchurch
Public Hospital in New Zealand before and after (2003 to 2006) the implementation of the
smokefree Environments Act in 2004.38 The smokefree legislation was associated with a 5%
reduction in AMI admissions. The 55 to 74 age group recorded the greatest decrease in
admissions (9%) and this figure rose to 13% among never smokers in this group. The effects
of area deprivation increased the reduction to 21% among 55 to 74 year olds living in more
46
affluent (quintile 2) areas (RR 0.76; CI 0.59–0.97). Overall however, the statistical
association of changing levels of AMI admissions with smoking status and with deprivation
was not consistently significant. Long-term secular trends in AMI admissions might have
accounted for some of this change and new diagnostic criteria for AMI was also introduced
during the time of the study.
A repeat cross-sectional study evaluated changes in acute coronary event rates (2000 to
2005) in residents of Rome39 in relation to the 2005 ban on smoking in all indoor places. The
study included both out-of-hospital deaths and hospitalised cases. The reduction in acute
coronary events was statistically significant in 35 to 64 year-olds (11.2%, 95% CI 6.9% to
15.3%) and in 65 to 74 year-olds (7.9%, 95% CI 3.4% to 12.2%) after the smoking ban.
People aged 35 to 64 years living in low socioeconomic census blocks (socioeconomic
positions [SEP] 1 to 5, 1=low, 5=high) appeared to have the greatest reduction in acute
coronary events after the smoking ban with significantly reduced ORs for SEP 3, 4 and 5 but
not 1 and 2; but there was no evidence of a statistically significant interaction. The study did
account for several time-related potential confounders, including particulate matter air
pollution, temperature, influenza epidemics, time trends, and total hospitalization rates.
However study authors noted that the implementation of new diagnostic criteria and changes
in daily doses of statins during the study period could have partially accounted for decreases
in acute coronary events.
A cohort study before and after smokefree legislation in England and Scotland59 determined
whether workers’ attitudes towards the change in their working conditions might be linked to
the change in health they report. Data sources were the Bar workers Health and
Environmental Tobacco Smoke Exposure (BHETSE) for Scotland and the Smokefree Bars
07 for England. The study used a convenience sample of 548 bar workers in participating
bars from a random sample of bars in Glasgow, Edinburgh and Aberdeen; and small towns
in Aberdeenshire and the Borders areas of Scotland, central London and Liverpool;
Northumbria and Cumbria; and Newcastle-upon-Tyne.
There were a lower proportion of bars in England agreeing to participate compared to
Scotland (18% England; 45% Scotland) and a significantly higher proportion of bar workers
in England compared to Scotland were lost to follow-up. Analyses of reported health
symptoms were limited to 180 bar workers that did not have a cold at baseline or follow-up;
only 69 of the 253 baseline bar workers were in the low SES group (school level education).
47
There was no difference in the initial attitudes towards smokefree legislation between those
working in Scotland and England. The proportion of people reporting any symptoms was
significantly reduced from baseline to one year, in both England (76% vs. 49%) and
Scotland (81% vs. 67%), with similar patterns being evident for both countries. However,
the size of the reduction in symptom prevalence in Scotland was lower than in England.
Attitude towards smokefree legislation was not found to be related to change in reported
symptoms for bar workers in England (Respiratory, p = 0.755; Sensory, p = 0.910). In
Scotland there was suggestion of a relationship with reporting of respiratory symptoms (p =
0.042), where those who were initially more negative to smokefree legislation experienced a
greater improvement in self-reported health. For the majority of the questions, bar workers
who were educated to degree level and higher were significantly more positive towards the
smokefree legislation than those who did not continue with education after school. Level of
education did not significantly effect change in symptoms reported. There was no
association between smoking status and change in reported health. There was no evidence
that bar workers who were initially more supportive of the smokefree legislation were more
likely to report improvements in health. In summary, bar workers of all SES appeared to
benefit from smokefree legislation in terms of perceived health.
Six studies40;54-56evaluated the impact of smokefree legislation alongside other policies, and
reported the impact of smokefree legislation separately, mainly on smoking prevalence. One
study evaluated the impact of smokefree legislation in New York City (NYC)54, two
studies40;55 evaluated national smokefree legislation (one for women only55) and one study
used data on smokefree legislation from 18 European countries.56
A US study54 determined the impact of comprehensive tobacco control measures in New
York City beginning in 2002 (cigarette tax increases, Smoke-free Air Act (SFAA) 2002, free
NRT, tobacco control media campaign). During the 10 years preceding the 2002 programme,
smoking prevalence did not decline in New York City. From 2002 to 2003, smoking
prevalence among New York City adults decreased by 11% (from 21.6% to 19.2%,
(P=.0002) approximately 140000 fewer smokers). Smoking declined among all education
levels. Groups that experienced the largest declines in smoking prevalence included residents
in the lowest and highest income brackets and residents with higher educational levels.
48
The decrease was more pronounced among low-income women (an 18.1% decrease, from
21.6% to 17.8%; P=.009). Significant decreases in smoking were found among residents
with more than a high school education (a 12.4% decrease, from 19.3% to 16.9%; P=.01).
Declines were also large among residents with annual family incomes of less than $25000 (a
12.6% decrease) or $75000 or more (a 13.4% decrease). In 2003, former smokers who had
quit within the past year were more likely to have low incomes compared with former
smokers who had quit more than 1 year previously (43.6% vs 32.0%, p=.0001). Highincome residents were more likely than low-income residents to report that the SFAA
reduced their exposure to ETS (53.3% vs 41.9%, P<.0001).
A US study55 examined the association between smoking and tobacco control policies
(increase in cigarette price, tobacco control media campaigns, clean air laws) among women
of low SES, using four waves of data between 1992 and 2002 from the TUS. Clean air laws
were represented by an index of state level clean air regulations. States with ‘‘no smoking
allowed (100% smoke free)’’ were counted as 100% of the effect, with ‘‘no smoking
allowed or designated smoking areas allowed if separately ventilated’’ as a 50% effect, and
with ‘‘designated smoking areas required or allowed’’ as a 25% effect. Separate indices by
type of law were used, and an aggregate weighted index, with worksite laws weighted by
50%, restaurant laws by 30%, and laws for other public places by 20%.
Smokefree legislation (clean air laws) was associated with a marginal effect on current
smoking. Over the period 1992–2002, current smoking among low education women was
inversely related to the index of clean air laws, with an odds ratio of 0.91 (0.80, 1.03), but
was significant only in the medium education female sub-population, with an odds ratio of
0.88 (0.83, 0.94). However, only in the 2001/02 model do clean air laws seem to play a part
for the medium education female sample, although the confidence intervals around the
estimates for each survey wave overlap for this group. It should be noted that most of the
developments in clean air regulations at the state level occurred after 2001.
A US study40used data from the February 2002 panel of the Tobacco Use Supplement of the
Current Population Survey (54,024 individuals representing the US population aged 15–80)
to evaluate the effect of strong clean indoor air laws (100% ban) and cigarette prices on
smoking participation and consumption. Clean indoor air laws and cigarette prices were
independently associated with significant reductions in smoking participation and
consumption. The effect of clean indoor air laws on smoking status (OR 0.66) was larger
49
than the effect of cigarette prices over the range of prices at which they found smokers to be
price sensitive (OR 0.83 for $2.91 to $3.28). Established patterns of education and income
disparity in smoking were largely unaffected by either clean indoor air laws or price in terms
of both mean effects and variance. The study authors concluded that strong clean indoor air
laws and price increases appear to benefit all SES groups equally in terms of reducing
smoking participation and consumption and are generally neutral with regard to health
disparities.
One European study examined the extent to which tobacco control policies (increase in
cigarette price, advertising bans, public place bans, campaign spending, health warnings)
were correlated with smoking cessation, in eighteen European countries.56 Log-linear
regression analyses were used to explore the correlation between national quit ratios and
scores (total and sub scores by separate policy) on the Tobacco Control Scale (TCS). The
SES variable was the Relative Index of Inequality (RII); the RII assesses the association
between quit ratios and the relative position of each educational group, and can be
interpreted as the risk of being a former smoker at the very top of the educational hierarchy
compared to the very lowest end of the educational hierarchy.
The study found large variations in quit rate and RII between countries. Quit rates were
positively associated with TCS score; more developed tobacco control policies were
associated with higher quit rates. More educated smokers were more likely to have quit than
lower educated, for men and women. There was a larger absolute difference between high
and low educated adults for 25-39 year olds. The regression coefficient for the association
between national quit ratios and sub score for public place bans, on TCS was 0.94 (-2.43 to
5.89) for men and 0.41 (-3.84 to 5.26) for women. However, no consistent differences were
observed between higher and lower educated smokers regarding the association of quit ratios
with score on the TCS. Strong conclusions cannot be drawn because of various study
limitations; the survey was conducted before the TCS was devised, and before some were
policies enacted, so the study results might underestimate the impact of recent smoking
policies. In addition, the study only examined the association between ex-smokers and
presence of policies, rather than changes in smoking prevalence post-implementation.
A US study57 examined the impact of smokefree legislation (and cigarette excise taxes) on
tobacco use among households with children aged six to seventeen years of age. Household
tobacco use was defined as any member of the household using tobacco. Data sources
50
included the National Survey of Children’s Health 2003 (N = 67,607) and 2007 (N =
62,768). The study is a comparison of methods study in which the authors focus on causal
inference model results. A smoke-free legislation total score for each state was constructed
from the National Cancer Institute’s State Cancer Legislative Database, which measured the
scope and strength of smoke-free legislation across seven domains from zero (none) to 32
(very strong) and coded in 10 unit increments: government worksites (scoring 0–5); private
worksites (0–5); schools (0–5); childcare facilities (0–5); restaurants (0–4); retail stores (0–
4); recreational/cultural facilities (0–4). From 2001 to 2005, 18 US states strengthened
smokefree legislation with a mean increase of 13.3 (SE 1.8; range 1–28). In 2005, the mean
smokefree legislation total score was 12.0 (SE 1.3; range 0–32).
In adjusted causal inference models there was no effect of smokefree legislation on
household tobacco use. In adjusted cross-sectional models, a higher smokefree legislation
total score was associated with a lower prevalence of household tobacco use. The interaction
between smokefree legislation and household income was only significant for households at
the 100–199 % Federal poverty level but not at 0–99 % Federal poverty level or above 199%
federal poverty level. Smokefree legislation was not associated with an overall reduction in
household tobacco use. However, the measure used (household tobacco use) would not have
picked up any changes in individual household members’ smoking if one member of the
household was still using tobacco.
A cohort study58 in the Netherlands examined age and educational inequalities in smoking
cessation due to the implementation of a national smokefree hospitality industry legislation.
The study assessed three interventions which were all implemented at the same time and also
included a national tobacco tax increase and a national mass media smoking cessation
campaign. Three survey waves of the International Tobacco Control (ITC) Netherlands
Survey, 2008 (before) and 2009 and 2010 (after) were used. Dutch smokers (having smoked
at least 100 cigarettes in their lifetime and currently smoking at least once per month) aged
15 years and older were recruited from a probability-based web database and 78% responded
to the first survey. Analyses were restricted to respondents who participated in all three
survey waves, did not quit during the 2008 and 2009 surveys and answered all survey
questions.
In total, 65.6% reported having visited a drinking establishment that had some form of
smoking restriction. Higher educated smokers were more exposed to the smokefree
51
legislation. Exposure to the smokefree legislation had a significant positive association with
attempting to quit smoking in the univariate analyses, but not with successful smoking
cessation. In the multivariate analyses, the association between exposure to the smokefree
legislation with attempting to quit smoking remained significant (OR:1.11; 95% CI:1.01–
1.22; p=0.029). There were no overall age or educational differences in successful smoking
cessation after the implementation of the smokefree legislation.
The follow-up rate was 70%. However the study authors’ report that almost half of the
sample was either lost to follow-up or did not answer all questions. These respondents were
younger; less addicted and had more intention to quit smoking. Therefore, the results may
not be fully generalisable to the broader population of Dutch smokers.58However this study
did measure exposure to each policy and measured the effects of each policy.
Three studies investigated voluntary smokefree home policies by SES. 36;46;47
One study36 evaluated the impact of a statewide smokefree law enacted in July 2010 in
Wisconsin, USA, on voluntary smokefree home policies by SES.36 Six hundred and thirtyfour adults were surveyed before the ban and 434 after the ban. Participants who lived in an
area with a workplace or complete public smoking ban prior to the statewide ban were
excluded from the analysis. Smoke-free legislation in Wisconsin increased the number of
participants who reported having strict no-smoking policies in their households and
decreased reported exposure to tobacco smoke inside the home. The smoking ban was
associated with a reduction of participants reporting exposure to smoke at home (13% to 7%;
P=0.002) and an increased percentage of participants with no-smoking policies in their
households (from 74% to 80%; P=.04).
Participants being exposed to smoke at home were significantly reduced only for the highest
income group and the higher education group. Participants having a strict ban in the home
were significantly increased only for the highest income group and the higher education
group. Smokefree legislation was not associated with change in smoking prevalence but
analyses were weakened by the small sample size. Although this study is specific to the
residents of Wisconsin, it is the only included study that directly evaluated the impact of
smokefree legislation in public places on home smoking by SES. This study suggests that a
statewide smoking ban does beneficially impact voluntary home smoking policies, but only
for higher SES adults, suggesting a negative equity impact in this setting.
52
Two further studies were included which measured parental smoking in homes by proxy (via
children’s reports).
The changes in child exposure to environmental tobacco smoke (CHETS) study was
included: CHETS Wales46 and a CHETS UK study.47 The CHETs 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. In addition the CHETS Wales46 study measured
children’s estimates of adult smoking prevalence and parental smoking in cars and in homes.
The CHETS UK study47 pooled data from the Scottish, Welsh and Northern Irish CHETS
studies to examine socioeconomic patterning in children’s reports of parental restrictions on
smoking in cars and in homes.
Results for the home are included in the previous section (3.2.2) and results for cars are
reported in this section (3.2.3). Individual data from the Welsh46 study is described
separately and is also included in the pooled analyses of UK data along with data from
Scotland and Northern Ireland.47 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).47 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.
In the CHETS Wales46 study children were asked to identify whether parent figures (mother,
father, stepfather or mother’s partner, and stepmother or father’s partner) smoked in the
home. Multinomial regressions were used to assess change in home-smoking restrictions.
The CHETS Wales46 study showed that parental smoking in the home and perceived
smoking prevalence were highest among children from low SES households. In 2007 the
percentage of homes with neither parent smoking (reported by children) were 48.9% for low
SES (as measured by Family Affluence Scale), 65.5% for medium SES and 72.4% for high
SES. In 2008 the percentage of homes with neither parent smoking were 49.9% for low SES,
67.3% for medium SES and 78.1% for high SES.
Parental smoking in the home and children’s estimates of adult smoking prevalence declined
only among children from higher SES households following smokefree legislation. The
percentage of children from higher SES households perceiving that nearly all adults in Wales
53
smoked halved, while estimates remained stable for lower SES children. The study authors
report that lower SHS exposure in high-SES children following smokefree legislation might
be explained by lower levels of parental smoking in the home among higher SES parents
after smokefree legislation.
The CHETS UK study47 measured smoking restrictions in the car and home as well as
parental smoking. Children were asked whether smoking was allowed inside their home. In
all countries, and the combined data set, as SES increased, the likelihood of partial or no
home smoking restrictions (compared with full smoking restrictions), decreased significantly
even after adjustment for parental smoking. There was no change in inequality following
legislation. Following legislation, 26.3% of children scoring 1 on FAS reported living in a
fully smoke-free home, climbing to 72.0% for those scoring 9.
3.2.3 Smoking restrictions in cars
Four studies investigated voluntary smokefree car policies by SES46;47;60;61
One US study60 examined smoking behaviour in terms of imposition of smoking rules in
cars with children present, amongst smoking parents in the US, in the context of no ban. 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.
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 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
54
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).
A New Zealand observational study observed smoking prevalence in vehicles61 and
differences between high and low areas of deprivation and over time. The study evaluated
the point prevalence of smoking and of SHS exposure in moving vehicles and compared
these prevalence’s between two areas of contrasting socioeconomic status and over time. In
New Zealand, all workplace vehicles accessible by the public have been required to be
smoke-free since 1990 and during 2006 to 2008 there was a Government-funded smoke-free
vehicles media campaign.
A total of 149,886 vehicles were observed in 20 days in a high SES area (Wainuiomata,
NZDep deciles 7-9) and a low SES area Karori NZDep deciles 1-4). The mean point
prevalence of smoking in vehicles at both sites combined was 3.2% (95% CI 3.1% to 3.3%).
Of those vehicles with smoking, 4.1% had children present. Smoking point prevalence in
vehicles was 3.9 times higher in the area of high deprivation than in the area of low
deprivation (95% CI 3.6 to 4.2). The same pattern was seen for vehicles with only the driver
at 3.6 times (95% CI 3.4 to 4.0), in vehicles with other adults at 4.0 times (95% CI 3.4 to
4.7) and in vehicles with children at 10.9 times (95% CI 6.8 to 21.3), with all results adjusted
for vehicle occupancy.
Compared with data collected in the 2005 study at the same two observation sites, there was
an absolute reduction in the point prevalence of smoking in vehicles of 1.1 percentage points
(RR relative to the former 1.3, 95% CI 1.2 to 1.5). The relative reduction over time in the
area of low deprivation was 1.2 times greater than in the area of high deprivation (95% CI
1.0 to 1.6). There was an absolute reduction in the point prevalence of smoking in the
presence of others in vehicles between 2005 and 2011 of 0.2 percentage points (RR relative
to the former 1.3, 95% CI 1.1 to 1.6). The relative reduction over time of smoking in the
55
presence of others in the low-deprivation area was 1.3 times greater than that for the highdeprivation area (95% CI 0.8 to 2.1).
Inter-observer variation between observer pairs was assessed (k values were (1) 0.99 for any
smoking, (2) 0.87 for other adults in vehicles with smoking and (3) 0.80 for children in
vehicles with smoking). Occupants appearing to be aged 12 years or younger were classified
as children; otherwise they were recorded as adults and so this was a subjective judgement
made by the observers. The study sample may not be fully representative of smoking in
vehicles in the Wellington region (or for elsewhere in New Zealand). In addition, as the
author states; point prevalence of smoking might underestimate the true population
prevalence of smoking in vehicles. Although a smoke-free vehicles media campaign took
place prior to the study, the study does not evaluate the impact of this campaign on smoking
in vehicles.
Two further studies were included which measured parental smoking in cars by proxy (via
childrens reports).
The changes in child exposure to environmental tobacco smoke (CHETS) study was
included: CHETS Wales46 and a CHETS UK study.47 The CHETs 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. In addition the CHETS Wales46 study measured
children’s estimates of adult smoking prevalence and parental smoking in cars and in homes.
The CHETS UK study47 pooled data from the Scottish, Welsh and Northern Irish CHETS
studies to examine socioeconomic patterning in children’s reports of parental restrictions on
smoking in cars and in homes.
Results for the home are included in the previous section (3.2.2) and results for cars are
reported in this section (3.2.3). Individual data from the Welsh46 study is described
separately and is also included in the pooled analyses of UK data along with data from
Scotland and Northern Ireland.47 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).47 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.
56
In the CHETS Wales46 study children were asked, “While you were in a car yesterday was
anyone smoking there?”46 Binary logistic regression models examined car-based smoking.
The study showed that car-based SHS exposure was highest among children from low SES
households. The percentage of children reporting SHS exposure in a car the previous day
remained at 7% before and after the smokefree legislation.
In 2007 percentages of children reporting car-based exposure to SHS exposure was 8.8%
(n=69) for low SES (as measured by Family Affluence Scale), 6.5%% (n=79) for medium
SES and 5.4% (n=58) for high SES. Among the lower SES group, percentages of children
reporting car-based exposure increased slightly from 7.4% (n = 31) pre-legislation to 10.6%
(n = 38) post-legislation. Among the medium-SES group, exposure remained almost
unchanged, at 6.3% (n = 38) pre-legislation and 6.6% (n = 41) post-legislation. However,
among the high-SES group, exposure declined from 6.3% (n = 33) to 4.6% (n = 25). The
changes in car-based SHS exposure were not statistically significant for any of the three SES
subgroups, however the changes did increase between group differences from 1% prelegislation to 6% post-legislation.
The CHETS UK study47 measured smoking restrictions in the car and home as well as
parental smoking. Children were asked ‘Are people allowed to smoke in your car, van or
truck?’ Car-based smoking declined and reached significance in the pooled UK sample
before and after adjustment for parental smoking. There was no change in inequality
following legislation. Percentages reporting that smoking was not allowed in their car ranged
from 51.7 (least affluent) to 83.0% (most affluent). Following the smokefree legislation in
the UK, smoking restrictions in the car increased. Post-legislation changes were not
patterned by SES but socioeconomic differences remained.
3.2.4 Summary of smoking restrictions in workplaces, enclosed public places, cars and,
homes
Forty-four studies evaluated the adoption/coverage or and/or the impact of smoking
restrictions in workplaces and enclosed public places.
Summary of smoking restrictions in workplaces
Fifteen studies assessed the socioeconomic impact of smoking restrictions, 13 studies were
set exclusively in workplaces and two studies included workplace settings. The majority of
studies evaluated local or regional adoption of smoking restrictions, either enforced or
57
voluntary, within the USA. Two studies assessed the impact of national workplace smoking
restrictions in Belgium25 and in the Netherlands30, and one study assessed the impact of
moving from a voluntary to an enforced smoking ban within a UK university.23The majority
of studies were cross-sectional surveys, of which five US-based studies used the same survey
data source; the Tobacco Use Supplement to the Current Population Survey, from various
years. One study included qualitative interviews following adoption of a smoking ban within
a university.23 Findings from three of the studies could be generalisable on a national scale,
although some study findings might be specific to indoor workers and working women.
The evidence shows that, where the adoption of policies is voluntary,, significant inequalities
exist in policy coverage and SHS exposure among workers according to SES. In general, the
higher the level of income or education or occupational status, the greater the odds of
working in a smokefree environment and the stronger the workplace smoking restrictions.
The lower the level of income, education and occupation, the greater the smoking prevalence
and the greater the SHS exposure. Smoking prevalence was generally higher among workers
in occupations with a lower percentage of workers covered by smokefree workplace policy.
Stricter non-smoking policies were associated with greater declines in smoking prevalence.
One study20 found that declines in prevalence were similar across educational groups, though
the largest effects were in the highest educational groups (negative equity effect). However,
declines in consumption were greater in the low educational groups (positive equity effect).
Qualitative interviews showed that a smoking ban can contribute to and sustain social
inequalities among staff. These inequalities in adoption and coverage of workplace smoking
policies by SES was also found, in the US, to be related to inequalities in the adoption of
smokefree policies at the regional and community levels, with lower SES communities less
likely to have adopted clean air ordinances.
An ITC study of Australia, Canada, UK, and USA15 found that while current smokers with
higher SES were more likely to have total worksite smoking bans, the rate of the adoption of
such bans over a one year period (2006/7-2007/8) was comparable by SES group. The
authors conclude that the recent proliferation of smokefree policies in these locations has led
to a reduction in disparities in coverage by SES, as low SES worksites and public places are
catching up in the adoption of total smoking bans and therefore having a positive equity
impact.
58
The only study assessing the impact of a worksite smoking policy which showed positive
benefits in terms of equity of exposure to SHS, was also the only study that just included
workers that were both non-smokers and not exposed to SHS smoke at home, which means
that they are probably not representative of all workers.18 The study showed that inequalities
in SHS workforce exposure might be diminishing with the increased adoption of clean
indoor laws in the USA; measured by serum cotinine levels. Blue-collar non-smoking
workers that were not exposed to SHS at home continued to have the highest cotinine levels
but experienced the largest absolute reductions. 18
Only two studies evaluated national smokefree legistation (partial) and both studies failed to
show a reduction in inequalities in SHS exposure. Neither of the national smoking policies,
in Belgium or the Netherlands, were comprehensively implemented or enforced. Following a
national workplace smoking decree in Belgium, companies with a high blue/white collar
ratio were less likely to implement health policy recommendations. However, responses to
the study survey were significantly lower amongst companies with a low blue/white collar
ratio. Both before and after implementation of the national workplace smoking ban in the
Netherlands; lower-educated non-smoking workers were twice as likely to be exposed as
those with a higher level of education. There was a significant difference both for differences
between educational subgroups and the decrease in exposure since ban.
Three studies focussed on women workers only and also evaluated exposure in the home.
However, none of these studies directly evaluated the influence of workplace smoking policy
on home smoking policy by SES. These studies highlight the importance of measuring other
sources of SHS exposure, including the home, especially when the smoking in the home is
associated with quit attempts for women of all poverty levels26 but possible disparity in
enforcement of home smoking bans by SES.29
Summary of smoking restrictions in enclosed public places
The evidence relating to the socioeconomic impact on the wider population of smokefree
restrictions in enclosed public places is derived from 29 mainly cross-sectional studies.
Three studies evaluated local/regional adoption of smokefree legislation, 22 studies
evaluated national smokefree legislation and four studies evaluated the impact of
comprehensive legislation in a state or city.
59
Evidence from three studies of local/regional adoption of smokefree legislation in the USA,
showed a negative equity impact in terms of policy adoption, with lower SES communities
having significantly less policy coverage in restaurants and bars. The evidence suggests that
partial or voluntary local adoption of smokefree legislation has the potential to increase
socioeconomic disparity in terms of protection from SHS exposure.
Overall, national comprehensive smokefree legislation reduces SHS exposure, increases quit
attempts and has positive health effects within the general population. By definition,
comprehensive national smokefree legislation also has a positive equity effect in terms of
removing inequalities in policy coverage. However, only two of the 22 studies15;52 that
evaluated national smokefree legislation using other outcome measures demonstrated a
positive overall equity impact. The recent proliferation of smokefree policies in bars,
restaurants and workplaces across Australia, Canada, UK and USA have had a positive
equity impact; by reducing disparities in policy coverage by SES, as low SES worksites and
public places catch up in adopting total smoking bans.15 A study52 based in England, Wales
and Scotland, showed that bars in more deprived areas experienced a greater percentage
reduction in PM2.5 levels up to 12 months post-implementation of national comprehensive
smokefree legislation, compared to more affluent areas, although there was higher levels of
PM2.5 at baseline for the more deprived areas.
Of the 22 studies that evaluated national smokefree legislation, nine studies showed equal
effectiveness by SES (neutral equity impact) and five studies showed a negative equity
impact. In three studies the equity impact was unclear and in another study the equity impact
was mixed according to outcome. All four studies that evaluated the impact of
comprehensive legislation in a state or city showed a negative equity impact.
One of the few studies that measured SHS exposure using a biochemically validated
outcome (salivary cotinine) showed that although SHS exposure was significantly reduced
following national smokefree legislation in England; significant beneficial impacts were
observed only among those from social classes I to III.53
Support for smokefree legislation was stronger among higher SES.33;35;43 One international
study48 of the same participants before and after smokefree legislation was introduced in
Ireland, France, Germany and the Netherlands, showed that smokers with a low educational
level were more likely than smokers with a high educational level to smoke in bars post-ban.
60
The evidence on the equity impact in terms of quitting and smoking behaviour was mixed.
For example, two studies did not demonstrate a significant association between SES and the
probability of attempting to quit43;44 ie a neutral equity impact, and one study showed a
‘flattening’ of the socioeconomic gradient in quitting smoking among parents of young
children in Scotland (but not in England) following the smokefree legislation.45 However,
within the same study; lower SES was associated with higher rates of maternal smoking
uptake and smoking in the home in both Scotland where the legislation had been introduced
and in England where smokefree legislation had not been introduced during the time of the
study. In the Netherlands
49
the workplace smoking ban (2004) and the hospitality smoking
ban (2008) were associated with significant increases in quit attempts and successful quit
attempts; but this was more apparent amongst higher SES, producing a negative equity
effect.
One study evaluated the impact of a statewide smokefree law enacted in July 2010 in
Wisconsin, USA, on smoking behaviours in and out of the home with an Annual Survey of
the Health of Wisconsin (SHOW).36 Participant exposure to tobacco smoke outside the home
improved in both education groups and in all income groups but the greatest decrease was in
the highest income group (family income >$60,000 per year).
Six studies evaluated the impact of smokefree legislation alongside other types of policies.
40;54-56;57;58
A regional smokefree ban in NYC was associated with an unclear equity impact;
smoking declined among all education levels and groups that experienced the largest
declines in smoking prevalence included residents in the lowest and highest income brackets
and residents with higher educational levels.54 Another US study40 found both strong clean
indoor air laws (100% ban) and cigarette prices were independently associated with
significant reductions in smoking prevalence and consumption. Established patterns of
education and income disparity in smoking were largely unaffected by strong clean indoor
air laws. The study authors concluded that clean indoor air laws appear to benefit all SES
groups equally in terms of reducing smoking prevalence and consumption, producing a
neutral equity effect.
Another US study55 showed that smokefree legislation (clean air laws) was associated with a
marginal effect on current smoking. Over the period 1992–2002, current smoking among
low education women was inversely related to the index of clean air laws, but was
significant only in the medium education female subpopulation and varied over time. In a
61
European study56 no consistent differences were observed between higher and lower
educated smokers regarding the association of quit ratios with score on the TCS. The
regression coefficient for the association between national quit ratios and sub-score for
public place bans, on TCS was not significant and did not vary significantly between high
and low education adults.
A US study57 examined the impact of smokefree legislation (and cigarette excise taxes) on
tobacco use among households with children aged six to seventeen years of age. Two
methods of analyses resulted in inconsistent results for whether smokefree legislation was
associated with an overall reduction in household tobacco use. In addition, the interaction
between smokefree legislation and household income was only significant for households at
the 100–199 % Federal poverty level but not at 0–99 % Federal poverty level or above 199%
Federal poverty level.
A cohort study in the Netherlands58 examined age and educational inequalities in smoking
cessation due to the implementation of a national tobacco tax increase. Higher educated
smokers were more exposed to the smokefree legislation and the association between
exposure to smokefree and attempting to quit was significant but was not significant for
successful smoking cessation, so the equity impact was neutral in terms of prevalence.
The national smokefree legislation in Italy42 was associated with beneficial short-term
effects for all males and for low-educated females. However there were limited long-term
effects on inequalities in smoking behaviour. The absolute difference in smoking prevalence
between high and low-educated males widened slightly over the whole time-period. Longterm trends clearly favoured the higher educated females and educational differences in quit
ratios widened over time. Overall the Italian smokefree legislation had a negative equity
impact.
Evidence from three qualitative studies based in Scotland showed a mixed equity impact of
the national smokefree legislation; bars in deprived study communities tended to show lower
compliance and less support for the national smokefree legislation compared with the
relatively affluent community. Smoking norms were related to social disadvantage and was
one of three factors which explained variation in compliance between bars.41 Post-legislation
changes in smoking behaviour were most apparent in disadvantaged localities. Smokers’
narratives in the disadvantaged localities described more decreases in consumption and
successful quitting than those in the affluent localities.51 However, smokers from both
62
deprived and affluent communities perceived the smokefree legislation to have increased the
stigmatization of smoking.50 A small qualitative study specific to Vancouver, Canada
37
explored the perceived effects of SHS policies. The physical, social, and economic barriers
low income women and men encounter to reducing smoking and smoke exposure were
viewed as possibly reinforcing or intensifying health-related disparities.
Three studies that reported on longer-term health outcomes showed a neutral equity impact.
Evidence from two studies38;39 did not show a consistently significant association between
national smokefree legislation and SES in terms of heart health, despite statistically
significant risk reduction for certain SES area deprivation quintiles within specific age
groups. A cohort study in England and Scotland59 showed that bar workers of all SES groups
appeared to benefit from smokefree legislation in terms of perceived health. Higher SES bar
workers had more positive attitudes towards the legislation, but level of education did not
significantly effect change in respiratory or sensory symptoms reported.
Three studies of smoking in the home were included. One study 36 suggests that a statewide
smoking ban does beneficially impact voluntary home smoking policies, but only for higher
SES adults, suggesting a negative equity impact of smokefree legislation on voluntary home
smoking restrictions. The CHETS Wales46 study suggests that the smokefree legislation in
Wales benefitted only high-SES parents and was potentially associated with increased
socioeconomic disparity in terms of parental smoking in the home (negative equity). The
CHETS UK study47 showed a neutral equity impact because there was no change in
inequality in parental smoking in the home following smokefree legislation. Following the
smokefree legislation in the UK, smoking restrictions in the home increased. Post-legislation
changes were not patterned by SES and socioeconomic differences remained. The smokefree
legislation in Scotland, Wales and Northern Ireland did not appear to displace smoking into
the home.
Summary of smoking restrictions in cars
Four studies of smoking in cars were included: two investigated smoking in cars in the
context of no smokefree vehicle legislation, and two evaluated any impact of national
smokefree public places legislation on parental smoking in cars.
One study60 examined smoking behaviour in terms of imposition of smoking rules in cars
with children present, amongst smoking parents in the US, in the context of no ban. Parental
education level was not significantly associated with strictly enforced smokefree car policy
63
on its own, only significant in interaction with child age and amount smoked. College
educated parents of children aged less than one year were more likely to have strict smokefree car policies. A New Zealand study61 observed a decrease in smoking prevalence in
vehicles over time that was relatively greater in lower SES areas than in higher SES areas.
However, smoking prevalence and thus exposure to SHS within vehicles remained higher in
more deprived areas. It should be noted that it was unclear whether either of these studies60;61
had representative study samples and results which can be generalisable on a national scale,
which weakens any equity impact.
The CHETS Wales study46 suggests that the smokefree public places legislation was
associated with increased socioeconomic disparity (negative equity) in terms of parental
smoking in cars. However, this conclusion is tentative because there were relatively few
children reporting car-based exposure at both time points, with changes in percentage
exposure based on small changes. The CHETS UK study47 showed a neutral equity impact
because, although smoking restrictions in the car increased following the smokefree
legislation, there was no change in SES inequalities in parental smoking in the car. The
smokefree public places legislation in Scotland, Wales and Northern Ireland did not appear
to displace smoking into the car.
No studies were identified which evaluated the equity impact of smokefree vehicle laws.
However, support for smokefree vehicle laws is increasing and these four studies, two
studies of smoking in cars in the context of no smokefree vehicle legislation, and two studies
of national smokefree public places legislation on parental smoking in cars, provide some
evidence for inequalities in smoking in vehicles in the absence of smokefree vehicle laws.
3.3 Increases in price/tax of tobacco products
A total of twenty-seven studies40;54-58;62-82 assessed the socio-economic impact of increases in
the price and/or taxation of cigarettes. Studies were conducted mainly in the USA (n=16),
but also Canada (n=3), Australia (n=2), France (n=3), Ireland (n=1) and the Netherlands
(n=1). One study evaluated the impact of a range of tobacco control policies across 18
European countries.56 The SES variables used within the majority of studies were income
and education, although occupation and area-level deprivation were also used infrequently.
The majority of studies evaluated the effects of price/tax across the general population of
smokers. However, one study focused on people who were HIV-positive, another study
focussed on pregnant women, and one study focused on parents of children aged six to
64
seventeen years. Four of the studies54;65;74;79 included in this section evaluated elements of
the ‘New York City 5 Component Tobacco Control Programme’.
Outcomes measured were generally similar across studies and mainly included price/tax
elasticity (the change in the percentage of persons smoking relative to a 1% change in
cigarette price), smoking prevalence and consumption, but also smoking behaviour including
product-related (e.g. changing to a cheaper brand) and smoking-related changes, quit
attempts and reasons for smoking. One study79 used over-the-counter pharmacy sales of
nicotine patch and gum products and one study measured the impact of price increase on
calls to quitlines.80
Twelve of the studies included econometric modelling (study design 1.4) which combined
repeat cross-sectional (mainly) or longitudinal survey data with inflation-adjusted prices for
a packet of cigarettes to produce price elasticities. Four studies were single cross-sectional
surveys, six studies assessed repeat cross-sectional survey data, four studies used
longitudinal cohort data including pharmacy sales data collected in real time over two years,
and one study was qualitative.
Thirteen of the 27 study samples were assessed as representative of the study populations
with findings that are generalisable on a regional or national scale. The findings from three
studies were applicable to specific subpopulations only, including one study of HIV-positive
smokers, one study of pregnant women smokers and one study of parents only. The majority
of studies used credible data collection methods. In all but two studies58;76 attrition rates or
numbers of participants in each survey wave were acceptable. However in three studies some
of the SES subgroups were relatively small68;73;75In the majority of studies it was unclear
whether the observed effects were directly attributable to increases in the price and/or
taxation of cigarettes; econometric studies model potential effects of increases in price/tax
rather than directly ‘observing’ findings.
A Canadian econometric study62 used cohort data from the Canadian National Population
Health Survey to examine the impact of cigarette taxes on smoking prevalence. The higher
and middle income groups were less likely to be smokers than the low income group.
Individuals with post-secondary education were less likely to smoke than those with less
than secondary education. While the tax elasticity of the high income group (−0.202) was
larger than the low income group (−0.183), it was not statistically significant. The low
educated group were more tax sensitive than the high educated group. Tax elasticities by
65
education level were: less than secondary (−0.555), secondary (−0.218), some postsecondary (−0.018) and post-secondary (−0.042). This study showed a positive equity
impact when education was measured but a neutral equity impact when income was
measured. Pictorial warning labels were introduced during the study period and may have
influenced smoker’s behaviour and so study findings cannot be attributed solely to increases
in cigarette tax.
A US econometric study evaluated the responses in the National Health Interview Survey to
increases in cigarette prices by race/ethnicity, income and age groups and showed a positive
equity impact.65 Lower-income populations were more likely to reduce or quit smoking than
those with higher incomes. The total price elasticity was –0.29 (-0.20 prevalence, -0.09
consumption) for lower-income persons compared with –0.17 (-0.05 prevalence, -0.12
consumption) for higher income persons. This paper contained a summary report of the
study and the editor noted that smokers with family incomes equal to or below the study
sample median were more likely to respond to price increases by quitting than smokers with
family incomes above the median (e.g., 10% quitting compared with 3% quitting in response
to a 50% price increase). The analysis did not control fully for other factors unrelated to
price (e.g., differences between states in social and policy environments) that could reduce
demand and be confounded with the state’s excise tax level.
Another US econometric study examined whether cigarette taxes were progressive using
data from the Current Population Survey’s Income Supplements and Tobacco Use Survey.66
Increasing tobacco taxation had a small narrowing effect on socio-economic inequalities in
smoking. Total price elasticities were -0.37 (-0.243 prevalence, -0.127 consumption) for
low-income, -0.35 (-0.196 prevalence, -0.105 consumption) for middle-income, and -0.20 (0.115 prevalence, -0.083 consumption) for high-income groups. Higher income individuals
were less price-sensitive; however the difference was less than the standard error between
groups. A $1 rise in taxation would cause a decline of approximately 2.3 percentage points
in the low-income group, 1.7 percentage points in the middle income group and 0.8
percentage points in the high income group.
However, the study authors concluded that, higher prevalence of smoking among low
income groups meant that the benefit or taxation was outweighed by the tax burden borne by
non-quitters. The tax rise would absorb 1.9% of the median income of low income smokers,
66
and 0.7% and 0.3% for the mid and high income smokers. The disparity was even wider
once the increase in cessation was accounted for.
A US econometric study67 investigated the responsiveness of older adult smokers (45 to 59
years) to large (at least 50 cents per pack) cigarette tax rises using the Behaviour Risk Factor
Surveillance Survey. Twenty-two tax increases were included, from 18 states between 2000
and 2005. The study findings showed that a relatively large state tax increase was associated
with a large narrowing of education and income-related smoking disparities.
The tax increases were associated with greater responses among low-educated smokers. $1
increase would reduce the fraction of low-educated smokers by over 10%, and only 3%
among those with more than high school education. Price participation elasticities were -0.43
for low-educated smokers and -0.12 for higher educated smokers. A similar pattern was seen
by income. A rise of $1 would reduce fraction of low-income smokers by about 10% and
high income by 2%. Low-income individuals, defined as those living in households with
annual incomes of less than $35,000, are found to quit at a much higher rate in response to
higher taxes than their counterparts from higher income households. Price participation
elasticities were -0.39 for low-income group (<$35,000) and -0.12 for high income group
($>35,000).
A US econometric study69 evaluated the effect of cigarette price increases by pooling data
from 14 years (1976-1980, 1983, 1985, and 1987-1993) from the National Health Interview
Survey. Adults with income at or below the median income were more than four times as
price-responsive as those with income above the median; total price elasticity was significant
at -0.43 (-0.21 prevalence, -0.22 consumption) and not significant at -0.10 (0.01 prevalence,
-0.11 consumption) respectively. Study authors did not report what the actual median income
was set which makes it difficult to compare findings with other similar studies.
A US econometric study70 examined the relationship between cigarette pack price and
smoking prevalence using data from the Behavioural Risk Factor Surveillance System for
1984 through to 2004. Increased real cigarette pack price overtime was associated with a
marked decline in smoking among higher-income but not among lower-income persons.
Although the pre-Master Settlement Agreement (MSA) association between cigarette pack
price and smoking revealed a larger elasticity in the lower- versus higher-income persons (0.45 vs -0.22), the post-MSA association was not statistically significant for either income
group.
67
Although smoking declined over the 20-year period, the gaps in smoking prevalence among
the income groups have widened. The proportion of lower-income persons smoking from
1984 to 1996 was 27.7%, increasing to 28.6% from 1997 to 2004; for higher-income persons
smoking declined from 23.9% to 21.6%. The study showed no evidence that increased
cigarette prices reduced disparities in smoking prevalence, with some indication of
increasing difference in smoking prevalence between the low income group and the high
income group.
It appeared that the high income group responded to prices reaching a threshold (c.$2.50)
and had no further price responsiveness. So despite the widening of inequality the absolute
gap of smoking probability narrowed as price increased (between lowest income and other
income). Unfortunately the paper only reported price elasticities for lowest income group
against all other income groups although the figure on smoking prevalence reports
prevalence by lowest, second, third and highest income quartiles. On balance, this study
findings show a neutral equity impact.
A Canadian econometric study71 investigated the overall magnitude of the demand response
to price and also the difference in response by socioeconomic level, using Statistics
Canada/Health Canada Canadian Tobacco Use Monitoring survey (CTUMS) for years 2000
through 2005. Those with less than a completed high school education level experienced
declines in smoking that were just slightly above the average, those with completed high
school and college level experienced declines considerably below the average, and those
with university level experienced declines in excess of the average. For those with university
level education, prevalence declined by 30% while consumption declined by more than 40%.
The elasticities for high school and college graduates were approximately −0.3, while
smokers with less than high school appeared to be less responsive to price movements with a
median elasticity of −0.22. These elasticities take into account the impact of price on both
participation and quantity decisions. None of these estimates was in the region of unity, and
there was no evidence of either a declining elasticity value moving from a low to high
education group or a higher elasticity value for the lower group. Cumulative frequency
distributions for all smokers for each year showed a downward shift in these distributions
over time, indicating that continuing smokers were progressively smoking stronger
cigarettes. While the higher education group saw little change in choice of cigarette, the
68
lowest income group has, although pack choice does not necessarily translate to smoking
intensity.
A Canadian econometric study72 estimated elasticities in the context of widespread
smuggling and explored the price sensitivity of smoking by income group. Excluding
smuggling provinces and using expenditure data suggested bias from using legal prices
instead of illegal prices paid through smuggling was quite modest because elasticities were
similar (elasticity not accounting for smuggling -0.72, excluding smuggling provinces -0.47,
using data expenditure elasticity -0.45). The elasticities were based on consumption rather
than prevalence data. Using expenditure data, it appeared that almost all of the response of
consumption to price changes occurred through reductions in consumption and not through
quitting smoking (using data expenditure elasticity -0.45, and conditional expenditure was 0.43 excluding smuggling). Therefore, although this study showed a positive equity impact
for reaction to price it is based on changes in cigarette consumption and not in quitting
smoking.
Study findings showed that lower income groups spent a much larger share of their incomes
(4%) on cigarettes than higher income groups (1% for highest income quartile). There was a
pattern of much higher price elasticities for the lowest income groups than for the highest
income groups either by dividing the data using after-tax income quartiles or by
consumption quartiles, showing that the lowest income group is much more price sensitive
than higher income groups.
Divided by after-tax income quartiles, there is a much larger price elasticity of demand
among the lowest income smokers. In the bottom income quartile, there is no effect of higher
taxes on cigarette spending, with an estimated elasticity of demand close to −1. This
elasticity falls to −0.45 in the second quartile, and then to −0.31 in the third quartile before
rising again to −0.36 in the top quartile. The drop between the lowest income quartile and
the other three quartiles is a statistically significant one, whereas the differences in
elasticities within the top three quartiles are not statistically significant. Divided by
consumption quartiles the elasticity pattern is similar, except that the big drop-off is between
the second and third quartiles (this drop is statistically significant), while the difference in
elasticities between the first and second quartiles and the third and fourth quartiles are not
statistically significant.
69
An Irish study73 used retrospective cohort data to investigate the role of tobacco taxes from
1960 to 1998, in starting and quitting smoking. The data was derived from a single crosssectional 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. Higher tax levels were associated with earlier
cessation. Taxation had the strongest effect on cessation among those with the lowest
education, and an equal impact on those with other levels of education. The results were
tentative because of the potential for recall bias (going back 40 years in some cases), also
during the study period 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 tax.
A US study74 used data from the New York City (NYC) Department of Health and Mental
Hygeine survey to evaluate the impact of New York City’s April 2002 increase (13%) in the
state cigarette excise tax. Response was recorded in the survey by asking individuals “How
has the increase in cigarette prices (since April 3) affected your smoking?” The final sample
represented only 64% of eligible households and the data was collected at one time-point
shortly after the increase in tax. Response to recent taxation was only one minor part of the
survey which included detailed questions on current smoking practices, exposure to SHS and
smoking cessation practices.
Lower household income was independently predictive of current smoking. US born college
graduates were less likely to smoke than other New Yorkers. Internet purchases were more
common among those with a college education or higher compared with those with a high
school education or less (4.1% VS. 1.1%, P=.003), although this finding was not linked to
the response to the state tax increase but part of examination of smoking practices.
In response to the 13% price increase; nearly one in four smokers reported reducing their
cigarette consumption shortly after the tax increase, whereas 2.8% of smokers reported
quitting smoking. In addition, 5.6% of all recent smokers (smoked cigarettes in the past 3
months) indicated that they had thought about quitting, 4.0% tried to quit, and 2.8% quit
smoking in response to the 39-cent price increase. When asked specifically about their
response to the state tax increase, 21.9% of individuals who had smoked cigarettes in the
past 3 months reported that they had reduced the number of cigarettes they smoked in
response to price increase. This response varied by income level, from 27.2% of those with
low incomes (<$25,000) to 11.0% of those with high incomes (>$50,000) (P < .0001). Quit
70
attempts were associated with lower income although again this was not linked to the
response to the state tax increase but part of general examination of cessation practices.
Study authors conclude that tax evasion through cross-border and internet cigarette
purchases could blunt the effectiveness of local tax increases and argue for a national
cigarette tax increase.
A French study75used mixed-methods, including both national repeat cross-sectional data
and in-depth interviews, to examine the social differentiation of smoking and why lowincome smokers are less sensitive to price increases. Data was derived from six telephone
surveys conducted by the National Institute for Prevention and Health Education between
2000 and 2008 and in-depth interviews with 31 ‘poor’ smokers. Subjective social status was
used based on financial status and consistency was checked using neighbourhood sociodemographic profile and respondent’s education and occupational status. Occupational class
was also used as a measure of SES.
Study findings showed a negative equity impact; the difference in smoking prevalence by
occupational class widened; prevalence among executive managers and professionals fell
after the cigarette prices had begun to increase, whereas manual groups showed a smaller,
later, and temporary decline (prevalence increased again soon after).
‘Poor’ smokers were aware of their addiction and of its financial cost. All spoke of stressrelief, several spoke of ‘little moment of happiness’, and that smoking filled voids with
nothing else to do, and compensated for loneliness or emotional problems. Many felt it was
the only joy they had left. Concerning reactions to the cigarette price increase, about one
third of ‘poor’ smokers and ‘other’ smokers reduced their cigarette consumption, but poor
smokers were more likely to turn to cheaper or hand-rolled cigarettes (50% did so, versus
33% for other smokers). ‘Poor’ smokers were significantly more likely to smoke
automatically, less likely to smoke for social reasons, more likely to relieve stress and take
mind of worries, less to aid concentration.
The study authors concluded that smokers in low occupational groups and of low-income
were less likely to respond to tobacco control measures due to the harsh living environment
which acts to sustain their attachment to smoking, despite understanding the costs. The study
findings are only tentative, and the validity of these findings is weakened by the relatively
small sample of the manual group in most of the survey years.
71
A French cohort study also by Peretti et al76 investigated how HIV-infected smokers reacted
to a sharp increase in cigarette price and showed a negative equity impact.. In France, the
price of cigarettes doubled between 1997 and 2007 (from US$4 to US$8 approximately).
The
French
cohort
study
APROCO-COPILOTE
investigated
biomedical
and
sociobehavioural characteristics of HIV-1 positive individuals who started an antiretroviral
therapy including protease inhibitors. Participants were enrolled between 1997 and 1999 in
47 French hospital departments delivering specialized care for HIV/AIDS patients, and
prevalence data was collected over ten years (1997 to 2007).
Participants were grouped by type of transmission (infection through intravenous drug use
(IDU), homosexual intercourse, heterosexual intercourse or other). There were striking
differences across transmission groups regarding socio-demographic background and
smoking prevalence. The IDU group was characterised by a lower socioeconomic status, a
higher smoking prevalence and a smaller decrease in this prevalence over the period 1997 to
2007. The homosexual group had a higher socioeconomic status, an intermediate smoking
prevalence in 1997, and the highest rate of smoking decrease. In the dynamic multivariate
analysis, smoking remained correlated with indicators of socioeconomic disadvantage and
with infection through IDU. Aging and cigarette price increase had a negative impact on
smoking among the homosexual group, but not for the IDU group. In both univariate and
multivariate analyses, smoking remained much more prevalent among the IDU group and, to
a lesser extent among patients with a lower educational level as well as those who were
unemployed or on income support during follow-up. In multivariate analysis only, smoking
was significantly more prevalent among patients who never worked, as well as among those
with an intermediate level of occupation.
It should be noted that the smoking prevalence observed among HIV-infected patients
between 1997 and 2007 was higher than that measured in the French general population
during the same period. Study results are generalisable to HIV infected smokers having
antiretroviral therapy.
A US econometric study77 estimated how changes in state cigarette taxes affected the
smoking behaviour of pregnant women using the Natality Detail File, an annual census of
births in the US (1989 to 1995). The results indicated that highly educated pregnant women
were most responsive to changes in cigarette taxes and that increase in cigarettes tax had a
negative equity impact for this specific subpopulation. This group of pregnant women had
72
higher price elasticities than the general population; the participation price elasticity of
demand for this sample was 3 to 4 times the estimate for the general adult population.
Women at lower education levels (high school or less) had higher than-average smoking
rates for their subgroups but lower-than-average responsiveness to tax changes. Price
elasticities were ‘less than high school’ -0.30, ‘High school’ -0.49, ‘Some college’ -0.86,
‘College’ -3.39. The study authors also regressed cigarette consumption data, producing
price elasticity for consumption of 0.03; indicating that the effect of cigarette tax is mainly
on smoking participation.
An Australian econometric study78 examined the effect of price on cigarette smoking
prevalence across three income groups in the five largest cities of Australia (Sydney,
Melbourne, Brisbane, Perth, and Adelaide) and showed a positive equity impact. Data was
derived from the Roy Morgan Single Source; a weekly omnibus survey by Roy Morgan
Research, an Australian market research company.
Between January 1991 and December 2006 smoking prevalence decreased from 28.2% to
19.7%, and price increased from $3.39 to $11.60. In the beginning of the period, the ageadjusted prevalence in the low-, medium-, and high-income groups were 36.5%, 28%, and
21.5%, respectively. At the end of the study period, the prevalence had decreased to 28.4%,
21.8%, and 16.6%, respectively. Real price and prevalence were negatively associated. Price
elasticity in the lowest income group (<AU $18,000) was -0.32, but only -0.04 and -0.02 in
the medium and high income groups. One Australian dollar increase in price was associated
with a decline of 2.6%, 0.3%, and 0.2% in the prevalence of smoking among low-, medium-,
and high-income groups, respectively. There was a clear gradient in the effect of income on
prevalence that diminished at higher levels of price.
The study did include controls for several other policies enacted during the survey period;
televised antismoking advertising, the availability of nicotine patches by prescription, the
availability of nicotine replacement therapy by over-the-counter sale, the availability of
bupropion by prescription, the introduction of six bold rotating health warnings on cigarette
packs, the ban of most forms of tobacco sponsorship, and addiction (both myopic and
rational). The survey covered 61% of the adult population, but only in metropolitan areas
and so generalisability of the study findings to rural areas is unknown. The study focused on
only two cigarette brands which held 38% of the market in 2003; it is unclear if this was
sufficient to capture valid results across all cigarette brands.
73
A retrospective survey63 examined smoker’s perceptions of the impact of statewide tobacco
taxes in Massachusetts, USA. Respondents were assigned to one of three mutually exclusive
categories: (1) did not respond to taxes (2) cut costs by reducing number smoked or changed
to cheaper brand (3) considered quitting. Lower income smokers were three times more
likely than higher income smokers to report cutting the costs of smoking and twice as likely
to consider quitting as opposed to having no response to the price increase. Lower income
smokers were significantly more likely than higher income smokers to respond to an
increase in cigarette prices. The lower the household income, the greater the impact of the
price increases on the respondent’s decision to quit. Household income was not related to the
choice between cutting costs and considering quitting. There appeared to be a positive equity
impact on smoking behaviour associated with a statewide tobacco tax increase. It should be
noted that 46% of continuing smokers denied having any of the three potential reactions to
the price increase and so the study could have failed to measure an important variable.
A US cohort study (Minnesota Adult Tobacco Survey) estimated the prevalence of the use of
price-minimizing strategies in a cohort of current smokers living in Minnesota, immediately
following the federal tobacco tax increase in 2009 and showed a negative equity impact
because strategies used by participants differed according to SES.64 Overall, 78% of
participants used at least one price minimizing strategy in 2009 to save money on cigarettes.
About 53% reported buying from less expensive places, 49% used coupons or promotions,
42% purchased by the carton, and 34% changed to a cheaper brand.
The lowest income group was significantly more likely than the highest income group to
report buying cigarettes from cheaper places, buying a cheaper brand, and rolling their own
cigarettes. The middle - income groups (annual household income between $25,000 and
$75,000) were significantly more likely than the highest income group to report buying
cigarettes from cheaper places, using coupons or promotions, and buying cartons instead of
packs. Participants who reported buying cartons instead of packs to save money were less
likely to attempt to quit smoking in the following year and cut back on cigarette
consumption. Having some college education, having an annual household income between
$25,000 and $75,000 were significantly associated with higher odds of using at least one
price-minimizing strategy; having less than high school education, having annual household
income less than $75,000, were significantly associated with higher number of strategies
used. Participants who used more strategies were less likely to cut back on their cigarette
consumption.
74
An Australian study using repeat cross-sectional date from the Cancer Institute NSW’s
Tobacco Tracking Survey tracked smoker’s responses to the increasing price of cigarettes
after a tax increase in 2010 and showed a positive equity impact.
68
Overall, 47.5% of
smokers made smoking-related changes and 11.4% made product-related changes without
making smoking-related changes. The proportion of smokers making only product-related
changes decreased with time, while smoking-related changes increased with time. Low- or
moderate-income smokers (versus high-income) were more likely to make smoking-related
changes compared to no changes.
Smokers with less than high school education were more likely to have cut down, thought
about quitting or started using loose tobacco than those with a tertiary education, and those
with a high school or technical college education were also more likely to have started using
loose tobacco than those with tertiary education. Smokers with lower incomes (<$40 000)
were more likely to have cut down, changed to a lower price brand or started to use loose
tobacco than those with higher incomes, and those with a moderate income were more likely
to have changed to a lower priced brand.
A greater proportion of smokers from low SES neighbourhoods switched to lower-priced
brands than those from moderate–high SES neighbourhoods. However, these low-income,
less-education smokers were no more likely to engage in these practices without also
reporting some positive changes in their smoking-related behaviours.
Study authors
conclude that the effect of increasing cigarette prices on smoking did not appear to be
mitigated by using cheaper cigarette products or sources.
A US study80 aimed to examine the impact on 16 state quitlines, before (2008) and after
(2009) a federal cigarette excise tax increase from 39 cents to $1.01 per pack. Smokers in
participating states represented 24% of smokers in US (2009). The study also included a
seven-month follow up from four state quitlines based on random samples of quitline
participants. Tobacco control varied between states but all quitlines provided mailed support
materials, a single reactive (inbound) counselling call to all tobacco users, and three or four
additional outbound calls to select groups. Some state quitlines referred insured tobacco
users to cessation benefits offered through their health plan or employer. All but four states
offered at least some free NRT depending on the state-approved eligibility criteria.
Overall, there was a 23.5% increase in total call volume when comparing December 2007–
May 2008 (84,541 calls) to December 2008–May 2009 (104,452 calls). The tax effect on call
75
volumes had returned to the before tax levels in May 2009. Participant quit rates did not
differ significantly before versus after the tax increase (controlled for age, gender, race,
education, chronic condition, amount smoked, how heard about quitline, and state). More
quitline callers in 2009 compared with 2008 had less than a high school education (61.0% vs
58.6%, p=0.007). Quit rates at seven months did not differ before versus after tax, however
this was not reported by SES. The authors stated that more callers with the same quit rate
indicated an increase in the total number of successful quitters. The magnitude of the
differences before and after tax was small. The impact of the federal tax increase cannot be
analysed separately from other excise tax increases and other changes in state and local level
tobacco control policies. In summary, the tax increase was associated with a positive equity
impact for smokers in these 16 US states in terms of calls to the state quitlines, but quit rates
did not differ after the tax increase and whether the quit rate differed by SES is not reported.
A US study81 estimated how smoking prevalence, daily cigarette consumption, and share of
annual income spent on cigarettes varied by annual income (less than $30,000; $30,000–
$59,999; and more than $60,000), both nationally and New York. New York state had the
highest cigarette excise tax ($4.35) compared with the national average of $1.46 per pack.
The average price per pack was $7.95 in New York compared with $5.21 nationally. Data
sources were the New York Adult Tobacco Survey (NY ATS) and national Adult Tobacco
Survey (NATS) from 2010 to 2011. Participants were 7,536 adults and 1,294 smokers from
New York and 3,777 adults and 748 smokers nationally.
Overall, smoking prevalence was lower in New York (16.1%) than nationally (22.2%) and
was strongly associated with income in New York and nationally (P<0.001). Smoking
prevalence ranged from 12.2% to 33.7% nationally and from 10.1% to 24.3% from the
highest to lowest income group. The relationship between the percentage of income spent on
cigarettes and income level differed significantly between New York and the United States.
Percentage of income spent on cigarettes increased in New York over time for smokers
overall, from 6.4% in 2003–2004 to 12.0% in 2010–2011 p<0.001, as the state cigarette
excise tax increased from $1.50 to $4.35. Percentage of income spent on cigarettes more
than doubled for the lowest income category, increasing from 11.6% in 2003-2004 to 23.6%
in 2010-2011 (P<0.01) and 14.2% nationally. This percentage also increased for the middle
income group from 4.0% to 5.4% (P<0.01), but not for the highest income group. The
middle-income group spent 5.4% of their income on cigarettes in New York and 4.3%
76
nationally. Smokers in the highest income group spent 2.2% of their income on cigarettes in
New York and 2.0% nationally.
Daily cigarette consumption was not related to income either nationally or in New York. The
study also showed that self-reported daily cigarette consumption, adjusted for
underreporting, was considerably higher than taxable cigarette sales, suggesting that tax
avoidance was significant in New York State with an estimated 6.8 cigarettes per smoker per
day being purchased outside of New York’s tax jurisdiction. This might have weakened any
impact of the cigarette excise tax increase.
Smoking prevalence was lower in New York compared to national prevalence but the pattern
was the same: the prevalence of smoking was inversely related to income in New York State
and in the US, with a less pronounced relationship in New York. Lower SES smokers in
New York spent a significantly larger portion of their income on cigarettes and continued to
smoke at a higher rate than higher SES.
In summary this study showed a neutral equity impact for smoking prevalence, although
results are specific to New York. The percentage of income spent on cigarettes did not
significantly increase over time for high income smokers but did for low income. Lower
income smokers in New York State have not had a greater response to higher taxes than
smokers with higher incomes.
A French study82 evaluated persistent smokers’ retrospective reactions (n=621) to increasing
cigarette prices (persistent smokers were defined as smokers who did not quit because of
such increases). Twenty-four percent of persistent smokers did not change their smoking
habits at all, 31% only reduced the cost of smoking (they neither reduced their consumption
nor tried to quit) and 45% tried to give up smoking or reduced their consumption (they also
frequently reduced the cost of smoking). Twenty-nine percent attempted to quit smoking.
Smokers who had completed a university degree more frequently reduced only the cost of
smoking rather than attempted to quit or smoke less (OR = 1.8) and were much more likely
to have shown no reaction (OR=3.0). Wealthier smokers more frequently reported no
reaction at all to the price increase rather than attempted to quit or smoke less (OR=2.4
among those earning at least 1500 euros/month). The equity impact appeared positive in
terms of quit attempts and reduced consumption although the study only focuses on smokers
who did not quit.
77
Seven studies evaluated the impact of increases in price/tax of tobacco products alongside
other policies, and reported the impact of increases in price/tax separately.
A US study54 determined the impact of comprehensive tobacco control measures in New
York City beginning in 2002 (cigarette tax increases, Smoke-free Air Act (SFAA) 2002, free
NRT, tobacco control media campaign). During the 10 years preceding the 2002 programme,
smoking prevalence did not decline in New York City. From 2002 to 2003, smoking
prevalence among New York City adults decreased by 11% (from 21.6% to 19.2%, p =
0.0002, approximately 140000 fewer smokers). Smoking declined among all education
levels. Groups that experienced the largest declines in smoking prevalence included residents
in the lowest and highest income brackets and residents with higher educational levels.
Residents with low incomes (<$25000 per year) or with less than a high school education
were more likely than those with high incomes (>$75 000 per year) and those with a high
school education or higher to report that the tax increase reduced the number of cigarettes
they smoked (income: 26% [low] vs 13.0% [high], p = 0.0002; educational attainment:
27.5% [lower] vs 19.3% [higher], p = 0.009). However, authors reported that between 2002
and 2003 the proportion of cigarettes purchased outside New York City doubled, reducing
the effective price increase by a third.
Another study79 also assessed the impact of the same tobacco control programme in New
York City using over-the-counter pharmacy sales of nicotine patch and gum products in
approximately 30% of all pharmacies in New York City. SES tertiles based on income were
used to determine pharmacy location.
There was a 27% increase in nicotine patch sales during the week of the state tax increase
and a 50% increase during the week of the city tax increase. These percentages gradually
declined over the ensuing weeks. Sales of nicotine gum increased by 7% and 10% following
the rise in state and city cigarette taxes, respectively, but these increases generally did not
persist for a period as long as the increases in nicotine patch sales. Pharmacies in low income
areas generally had larger and more persistent increases in sales of nicotine patch and gum
products in response to tax increases than those in higher-income areas. Cigarette taxes were
associated with increased sales of nicotine patch and gum products which can be viewed as a
proxy for quit attempts, in New York City, particularly in low-income areas. It should be
noted that the tobacco control programme in New York City also included the Smoke-free
78
Air Act (SFAA) 2002, free NRT, and a tobacco control media campaign; as well as cigarette
tax increases which is the focus of this study.
A US study55 examined the association between smoking and tobacco control policies
(price, media campaigns, clean indoor air laws) among women of low SES using four waves
of data between 1992 and 2002 from the TUS. Between 1992 and 2002, smoking prevalence
declined more rapidly among low-education compared to medium and high education
women. Moreover, evidence showed that compared with higher educated women, low
education women responded with greater positive effect to certain policy measures,
particularly price.
A US study40used data from the February 2002 panel of the Tobacco Use Supplement of the
Current Population Survey (54,024 individuals representing the US population aged 15–80)
to evaluate the effect of strong clean indoor air laws (100% ban) and cigarette prices on
smoking participation and consumption. Clean indoor air laws and cigarette prices were
independently associated with significant reductions in smoking participation and
consumption. The effect of clean indoor air laws on smoking status (OR 0.66) was larger
than the effect of cigarette prices over the range of prices at which we found smokers to be
price sensitive (OR 0.83 for $2.91 to $3.28). Established patterns of education and income
disparity in smoking were largely unaffected by either clean indoor air laws or price in terms
of both mean effects and variance. Study authors concluded that clean indoor air laws and
price increases appear to benefit all SES groups equally in terms of reducing smoking
participation and consumption and are generally neutral with regard to health disparities.
A study of the impact of various tobacco control policies on education-related inequalities in
eighteen countries in Europe, including Eastern Europe and Baltic countries56 found that
price increases had a stronger association with national quit ratios than any other type of
tobacco control policy (i.e. countries with price increases had higher smoking cessation
rates). The regression coefficient for the association between national quit ratios and sub
score for price was 2.08 (-0.36 to 8.48) for men and 2.07 (-1.09 to 8.66) for women. There
was a significant positive association between quit ratio and price for high SES aged 40-59
years. However; high and low educated groups seem to benefit equally from the nationwide
tobacco control policies. No consistent differences were observed between higher and lower
educated smokers regarding the association of quit ratios with score on Tobacco Control
Scale (TCS). Strong conclusions cannot be drawn however because of various study
79
limitations; the survey was conducted before the TCS was devised, and before some policies
enacted so might underestimate the impact of recent smoking policies. In addition, the study
only examines the association between ex-smokers and presence of policies, rather than
changes in prevalence post-implementation. The study authors state that the a possible
reason for not finding a difference in impact between high and low education groups, might
be because they measured prevalence instead of consumption level; arguing that an increase
in price mainly reduces the number of cigarettes smoked rather than smoking prevalence
rates.
A US study57 examined the impact of cigarette excise taxes (and smokefree legislation) on
tobacco use among households with children aged six to seventeen years of age. Data
sources included the National Survey of Children’s Health 2003 (N = 67,607) and 2007 (N =
62,768). From 2003 to 2007, 40 states raised cigarette excise taxes with a mean increase of
54.5 cents (SE 6.4; range 7–175). In 2005, the mean tax was 84.7 cents (SE 7.9; range 5–
246). The study is a comparison of methods study in which the authors focus on causal
inference model results.
In adjusted causal inference models every $1.00 increase in cigarette excise tax between
2001 and 2005 was associated with a 4 percentage point decrease in household tobacco use
between 2003 and 2007 (p = 0.008). There was a significant interaction between cigarette
tax and household income: cigarette tax increases were associated with reductions in
household tobacco use for lower income households (100–399% of the Federal poverty
level) but not at 0–99 % Federal poverty level or 400 % Federal poverty level or greater.
A cohort study in the Netherlands58 examined age and educational inequalities in smoking
cessation due to the implementation of a national tobacco tax increase, national smokefree
hospitality industry legislation and a national mass media smoking cessation campaign, all
implemented during the same time period. Three survey waves of the International Tobacco
Control (ITC) Netherlands Survey, 2008 (before) and 2009 and 2010 (after) were used.
Dutch smokers (having smoked at least 100 cigarettes in their lifetime and currently smoking
at least once per month) aged 15 years and older were recruited from a probability-based
web database and 78% responded to the first survey. Analyses were restricted to respondents
who participated in all three survey waves, did not quit during the 2008 and 2009 surveys
and answered all survey questions.
80
Exposure to the price increase was assessed in terms of smokers reporting that they paid
more for their cigarettes in the 2009 survey than in the 2008 survey. 82.4% reported having
paid more for their cigarettes in the 2009 survey than in the 2008 survey. Higher educated
smokers were more exposed to the price increase. Exposure to the price increase was not
associated with significant increased odds of quit attempts or successful smoking cessation
in any SES group. Exposure to the price increase only predicted successful smoking
cessation among young respondents. There were no significant educational inequalities in
successful smoking cessation after the implementation of the price increase. It is worth
noting that prices only increased by eight percent. The follow-up rate was 70% however the
study authors’ report that almost half of the sample was either lost to follow-up or did not
answer all questions. These respondents were younger; less addicted and had more intention
to quit smoking. Therefore, the results may not be fully generalisable to the broader
population of Dutch smokers.58
Summary of increase in price/tax of tobacco products
Twenty-seven studies were included which evaluated the equity impact of increases in the
price or tax of cigarettes; seven of which evaluated the impact alongside other tobacco
control policies.40;54-58;79 The majority of studies evaluated the effects of price/tax across the
general population of smokers. However, one study focused on people who were HIVpositive, another study focussed on pregnant women, and one study focused on parents of
children aged six to seventeen years.
The majority of studies included income and/or education as a measure of SES. Outcomes
measured were generally similar across studies and mainly included smoking prevalence and
price/tax elasticity. Elasticity was based on smoking prevalence and/or consumption data.
One study used pharmacy sales data79 and one study measured the impact of price increase
on calls to quitlines.80
Thirteen of the 27 study samples were assessed as representative of the study populations
with findings that are generalisable on a national or regional scale. In the majority of studies
it was unclear whether the observed effects were directly attributable to increases in the price
and/or taxation of cigarettes. Econometric studies modelled the potential effects of increases
in price/tax rather than directly ‘observing’ findings. Two studies attempted to measure
actual exposure to the policy/intervention: one European study explored the correlation
between national quit ratios and scores (total and sub scores by separate policy) on the
81
Tobacco Control Scale (TCS)56; and in the other study respondents were asked how much
they paid for their cigarettes at their last purchase and increases in reported price were used
as a measure of exposure to the price increase.58
Overall, increase in the price/tax of tobacco products was associated with decreases in
smoking prevalence across the general population. The majority of studies also demonstrated
that increases in the price/tax of cigarettes are associated with larger reductions in smoking
prevalence and/or consumption of smoking for lower SES groups compared with higher SES
groups. Fourteen of the twenty-seven studies demonstrated a positive impact55;63;65-69;72-74;7880;82
on equity; six studies demonstrated a neutral equity impact,40;56;58;70;71;81 in one study the
equity impact was mixed depending on SES measure62 and in two studies the equity impact
was unclear.54;57 Four studies showed a negative impact on equity.64;75-77 However this group
of ‘negative’ equity studies included two studies of distinct population subgroups; HIVpositive adults76 and pregnant women.77
Two studies showed inconsistent equity results according to type of SES measure. One of
these studies showed that smokers living in higher neighbourhood deprivation were more
likely to report a product-related change in response to a price/tax increase but not more
likely to also report a smoking-related change, whereas smokers of lower income and lower
education were more likely to report both product and smoking-related changes compared
with higher income and higher education smokers.68 Another one of these studies showed
positive equity results when education was measured but neutral impact when income was
measured.62
There was also some inconsistency in equity results depending on the type of outcome
measure used. One study showed a neutral effect on equity in terms of price elasticity but
also suggested the gap in smoking prevalence between income groups had widened over
time.70 In the case of one econometric study
66
both relative and absolute changes were
considered; the study authors stated that the absolute change in smoking prevalence was
similar among high- and low-income consumers, which implied the relative change was
much larger among the former.
One study showed a positive equity impact in terms of increasing calls to quitlines amongst
lower SES smokers but no change in callers’ quit rates following a cigarette tax increase. 80
Another study showed a negative impact in terms of exposure to price increases but no effect
(in any SES) groups in terms of reducing smoking prevalence.58
82
Seven studies40;54-58;79 evaluated the impact of increases in price/tax of tobacco products
alongside other tobacco control policies and appeared to show either equal equity impact or
positive equity impact. In two cases the equity impact was unclear: a US study57 examined
the impact of cigarette excise taxes (and smokefree legislation) on tobacco use among
households with children aged six to seventeen years of age. An increase in excise tax was
associated with an overall reduction in household tobacco use, but this reduction was not
consistent across all income levels. There was no significant reduction in tobacco use in the
poorest households or in the least poor households. To the extent that the interaction term
(income) was significant, it is reasonable to conclude that there was some change in the
distribution of risk of tobacco use by household SES, but the equity impact is unclear
because the reduction in tobacco use was not consistent across all income levels.
In another study54 the equity impact was unclear because although smoking declined among
all education levels, groups that experienced the largest declines in smoking prevalence
included people in the lowest and highest income brackets.
A study of the impact of various tobacco control policies on education-related inequalities in
eighteen countries in Europe, including Eastern Europe and Baltic countries56 found that
price increases had a stronger association with national quit ratios than any other type of
tobacco control policy (i.e. countries with price increases had higher smoking cessation
rates). However; high and low educated groups seem to benefit equally from the nationwide
tobacco control policies; producing a neutral equity effect.
Interestingly, a US study40 evaluated the effect of strong clean indoor air laws (100% ban)
and cigarette prices on smoking participation and consumption and found both policies to be
independently associated with significant reductions in smoking participation and
consumption. The effect of clean indoor air laws on smoking status was larger than the effect
of cigarette prices over the range of prices at which we found smokers to be price sensitive.
Established patterns of education and income disparity in smoking were largely unaffected
by price in terms of both mean effects and variance and therefore appeared to have a neutral
equity impact; benefitting all SES groups equally.
A US study55 examined the association between smoking and tobacco control policies (price,
media campaigns, clean indoor air laws) among women of low SES using four waves of data
between 1992 and 2002 from the TUS. Between 1992 and 2002, smoking prevalence
declined more rapidly among low-education compared to medium and high education
83
women. Moreover, evidence showed that compared with higher educated women, low
education women responded with greater positive effect to certain policy measures,
particularly price.
A US multifaceted study79 using over the counter sales of nicotine patch and gum products
showed that pharmacies in low income areas generally had larger and more persistent
increases in response to tax increases than those in higher-income areas. However it is
uncertain how sales of nicotine products translate into actual successful quitting outcome.
A cohort study in the Netherlands58 examined age and educational inequalities in smoking
cessation due to the implementation of a national tobacco tax increase. Higher educated
smokers were more exposed to the price increase but the price increase was not effective in
reducing overall smoking prevalence and so the equity impact was neutral.
Four studies showed a ‘negative equity impact’; three of which included at least two
measures of SES, all showing negative results.64;75-77 However this group of ‘negative’
studies included two studies of distinct population subgroups; HIV-positive adults76 and
pregnant women.77 Interestingly, this group of ‘negative’ studies also included distinctly
different study designs; two cohort studies64;76 and one qualitative study.75 HIV-positive
smokers appear to be a particularly vulnerable subgroup, where smoking was significantly
more prevalent amongst the poorest adults. In the case of pregnant women; those at lower
education levels had higher than average smoking rates but lower-than-average
responsiveness to tax changes. However,, in nearly all cases, pregnant women were found to
be more responsive to higher cigarette taxes than the general adult population.77 A
qualitative study tentatively (due to small study size) concluded that low SES smokers were
less likely to respond to cigarette price increases.75 The qualitative study used subjective
social status based on financial status as the SES variable and so this is distinct from other
measures of income used in the other included studies. However, it helps to explain the
reasons why ‘poor’ smokers may be less likely to respond to price increase through quitting.
Overall, within the general population, lower SES adults appear more responsive to price/tax
increases in terms of larger price elasticities compared with high SES adults. However
smoking prevalence is greater in lower SES adults compared with higher SES adults, and the
prevalence gap in smoking disparities may be widening. Larger price elasticities amongst
lower SES adults might be capturing short-term effects which do not translate into increased
quitting amongst lower SES adults. In addition, cross-border sales or smuggling were not
84
accounted for in most econometric studies which could have biased the results. Lower SES
adults might be more likely than higher SES adults to mitigate the effects of price or tax
increases by switching to cheaper brands or bulk buying.
A panel of experts who assessed the effectiveness of tax and price policies in tobacco control
in 201083 concluded that there was sufficient evidence of the effectiveness of increased
tobacco excise taxes and prices in reducing overall tobacco consumption and prevalence of
tobacco use. The experts also concluded that there was strong but not sufficient evidence
that lower income populations are more responsive to tax and price increases compared with
higher income groups within high-income countries; and limited evidence that lower income
populations are more responsive to tax and price increases compared with higher income
groups within low- and middle-income countries. This review does not analyse the data
according to income level of country but does add to the evidence base by showing that a
majority of studies demonstrate greater responsiveness to tax/price increases in lower SES
groups, through reduced smoking prevalence and consumption.
3.4 Controls on advertising, promotion and marketing of tobacco
Nine studies were included which evaluated the effects of controls on advertising, promotion
and marketing of tobacco. Three studies examined the impact of restrictions on tobacco
advertising, promotion and marketing; including marketing restrictions84 and advertising
bans85;86. Five studies evaluated the impact of warning labels alone87-90 one of which
examined the effect of including the word “Quitline” beside the telephone number.91 One
study examined the extent to which a range of tobacco control policies (increase in cigarette
price, advertising bans, public place bans, campaign spending, health warnings) were
correlated with smoking cessation, in eighteen European countries.56
One study84 examined the effectiveness of tobacco marketing regulations in the UK, Canada,
Australia, and the USA, on exposure to different forms of product marketing, and differences
in exposure across different SES groups. The study used seven waves of data collected
between 2002 and 2008 as part of the International Tobacco Control (ITC) Four Country
Survey. Respondents lost to attrition (number not stated) were replenished at each wave and
all respondents who participated in at least one of the seven survey waves were included in
the present study, giving a total of 21,615 individuals (5251 in the UK, 5265 in Canada,
4806 in Australia, and 6293 in the US). A 35-minute telephone survey to evaluate the
psychosocial and behavioural impact of various national-level tobacco control policies on
marketing regulations was undertaken with 21,615 adult smokers (5251 in the UK, 5265 in
85
Canada, 4806 in Australia, and 6293 in the US). Since 2002, various tobacco marketing
regulations have been enacted in the United Kingdom (UK), Canada, Australia and the
United States. Self-reported exposure was assessed through salience of pro-smoking
marketing i.e. overall awareness and the total number of channels (max 15) through which
marketing was noticed.
There were differences between counties both in the type and extent of marketing
restrictions at baseline and those that were introduced during this period. Awareness was
related to the extent of restrictions, being highest in the US and lowest in Australia. In
general, the introduction and implementation of additional tobacco marketing regulations
were associated with significant reductions in smokers’ reported awareness of pro-smoking
cues, among all SES groups, and the observed reductions were greatest immediately
following the enactment of regulations with awareness reduction occurring more slowly in
subsequent years. While tobacco marketing regulations have been effective in reducing
exposure to certain types of product marketing there still remain gaps in each country,
especially with regard to in-store marketing and price promotions.
Changes in reported awareness were generally the same across different SES groups. Out of
68 possible SES differences in the four countries only 5 SES differences were statistically
significant. These exceptions included awareness of billboard advertising and arts
sponsorships in the UK reducing more sharply among those in the high SES group relative to
those in the low SES group immediately following the enactment of the Tobacco
Advertising and Promotion Act 2002.
In each of the four countries, the high SES groups experienced greater reductions in the total
number of channels through which they reported being aware of tobacco marketing
compared to the low SES groups. However, at baseline, the high SES groups in each country
were exposed to more marketing channels than were the low SES groups. The study authors
argue therefore that the significant SES group differences should not be interpreted as an
indicator that marketing regulations had differential impacts on different SES groups. By the
end of the study period there was no significant difference by SES in the number of channels
that smokers reported being aware of tobacco marketing. Therefore the introduction of
restrictions on tobacco advertising and marketing had a neutral equity effect measured by
exposure.
86
The strength of this study is the comparison between four countries; however other policy
changes within studies across the study period might have also influenced reported
awareness. For example, in the UK, national legislation prohibiting smoking in worksites,
bars, and restaurants was implemented during this time might have influenced awareness of
tobacco marketing. Also the study did not assess the extent of exposure or its effect by SES.
Single field observation85 of a random sample of 129 licensed tobacco retailers in 2010
assessed retailer compliance with Food and Drug Administration (FDA) regulations on
tobacco sales and advertising practices, including point-of-sale advertisements, in two
distinct Columbus, Ohio neighbourhood groups by income. Practices considered out of
compliance with FDA regulation were: sales of loose cigarettes, offering free items with
cigarette or smokeless tobacco (ST) purchase, and self-service access to cigarette or ST
products. No outlets were out of compliance by selling loose cigarettes or offering free items
with cigarette purchase. Less than 10% of sampled outlets were out of compliance by
offering self-service access to cigarettes, which did not differ by neighbourhood income.
While there was no significant difference between low and high income neighbourhoods
regarding the number of advertisements on site or inside shops, there were significantly
fewer advertisements on the buildings in high income areas (1.1 vs 1.9, P<0.05).
Three observational audits86 of 302 randomly selected stores (milk bars, convenience stores,
newsagents, petrol station, supermarket) evaluated compliance with legislation which
restricted cigarette displays in retail outlets, including a point-of-sale display ban, and
assessed prevalence of pro- and anti-tobacco elements in stores pre- and post-legislation
(October 2010 and December 2011) in Melbourne, Australia by Socio-Economic Indexes for
Areas (SEIFA) index of disadvantage. Overall, the prevalence of anti-tobacco signage
increased and pro-tobacco features decreased between audits for every store type and
neighbourhood SES. Mid-SES stores had consistently lower scores than low- and high-SES
stores for non-mandated anti-tobacco signage but not mandated signage.
A European study examined the extent to which tobacco control policies (increase in
cigarette price, advertising bans, public place bans, campaign spending, health warnings)
were correlated with smoking cessation, in eighteen European countries.56 Log-linear
regression analyses were used to explore the correlation between national quit ratios and
scores (total and sub scores by separate policy) on the Tobacco Control Scale (TCS). The
SES variable was the Relative Index of Inequality (RII); the RII assesses the association
87
between quit ratios and the relative position of each educational group, and can be
interpreted as the risk of being a former smoker at the very top of the educational hierarchy
compared to the very lowest end of the educational hierarchy.
The study found large variations in quit rate and RII between countries. Quit rates were
positively associated with TCS score; more developed tobacco control policies were
associated with higher quit rates. More educated smokers were more likely to have quit than
lower educated, for men and women. There was a larger absolute difference between high
and low educated adults for 25-39 year olds. The regression coefficient for the association
between national quit ratios and sub-score for advertising bans, on TCS was 1.33 (1.11 to
8.02) for men and 1.59 (1.39 to 8.67) for women.
No consistent differences were observed between higher and lower educated smokers
regarding the association of quit ratios with score on the TCS. A comprehensive advertising
ban showed the next strongest associations with quit ratios (after price) in most subgroups
(not low SES aged 40-59 or low SES women aged 25-39 years). Strong conclusions cannot
be drawn because of various study limitations; the survey was conducted before the TCS was
devised, and before some were policies enacted, so the study results might underestimate the
impact of recent smoking policies. In addition, the study only examined the association
between ex-smokers and presence of policies, rather than changes in smoking prevalence
post-implementation.
Warning labels
An internet-based study in the Netherlands90 examined the self-reported perceived impact of
the effect of health warnings on cigarette packs and to determine whether these effects
differed for subgroups of smokers, using cross-sectional data from the Continuous Survey of
Smoking Habits (June 2002 to June 2003). 3,937 (31%) of the original sample were
smokers, and 3318 (84.3%) had noticed a change to health warnings and were asked further
questions. An EU Directive meant that as of 30 September 2002, the front of cigarette
packets in EU countries were required to have one of two health warnings, covering 30% of
the surface. The back of the packet must contain one of 14 different health warnings,
covering 40% of the surface. On 1 May 2002 the new health warning labels came into effect
in The Netherlands.
Across the survey period, 3318 (84.3%) said they had noticed changes to the health
warnings. This percentage was higher in the 3 months directly after the introduction (90%)
88
compared with the months April to June of 2003 (81% p<0.001). Of all smokers, 14%
indicated they were less inclined to purchase cigarettes as a result of the new warnings;
31.8% said they prefer to buy packets without the new warnings; and 10.3% said they
smoked less because of the new warnings. A strong dose-response relationship was
observed, e.g. the higher the intention the greater the impact of the warnings. 17.9% reported
that warnings made them more motivated to quit; multivariate analysis showed that those
intending to quit smoking within one month had a higher change of reporting that they
smoked less because of new warnings (OR 7.89), independent of other variables.
There were no significant differences in level of education for respondents in reported
change in smoking behaviour. More respondents with medium level of education (19.4%)
reported being more motivated to quit than those of high (18.3%) or low levels (15.8%)
p<0.001). More respondents with a higher level of education (35.5%) reported a preference
for buying packs without the new warning compared to those of low (28%%) or medium
levels 31%. There was no significant difference between education levels in inclination to
buy the new packs. As the study only surveyed smokers who had noticed the new health
warning labels, this sample might be more motivated to change their smoking behaviour
compared to the overall general population. In addition it was unclear in this internet-based
survey was representative of the general population in the Netherlands.
A European study examined the extent to which tobacco control policies (increase in
cigarette price, advertising bans, public place bans, campaign spending, and health warnings)
were correlated with smoking cessation, in eighteen European countries.56 The regression
coefficient for health warnings was -0.40 (-7.32 to 2.31) for men and -0.42 (-9.51 to 3.43) for
women.
A cohort study in New Zealand91 examined how recognition of a national quitline number
changed after new health warnings were required on tobacco packaging. The study used data
from the New Zealand ‘arm’ of the International Tobacco Control Policy Evaluation Survey
which differed somewhat from other ITC samples as the smokers involved were New
Zealand Health Survey (NZHS) participants. NZHS respondents were invited at end of
NZHS to participate in this study. Wave 1 (March 2007 and February 2008) respondents
were exposed to text-based warnings with a quitline number but no wording to indicate that
it was the “Quitline” number. Wave 2 (March 2008 and February 2009) respondents were
exposed to pictorial health warnings (PHWs) that included the word “Quitline” beside the
89
number as well as a cessation message featuring the Quitline number and repeating the word
“Quitline.”
The introduction of the new PHWs was associated with a 24 absolute percentage point
between-wave increase in Quitline number recognition (from 37% to 61%, p < .001) and a
matched odds ratio of 3.31, 95% CI = 2.63 to 4.21. A majority (range 58.0%–65.5%) of all
five quintiles of socioeconomic deprivation using a small area measure recognized the
Quitline number in Wave 2. The increase between the waves was lowest in the most
deprived quintile (p < .001), though this group had the highest level of recognition at
baseline. For individual deprivation, the increase was highest in the second-to-least deprived
group and lowest in the most deprived group. For area and individual-level deprivation, the
most deprived had the highest level of recognition in Wave 1 and the lowest level of
recognition at Wave 2 (though in the latter, the differences were not significantly different).
Recognition increased from a minority of respondents to a majority for all deprivation levels
(using small area and individual measures), and financial stress (unable to pay any important
bills on time and not spending on household essentials). The overall response rate for this
study was 32.6% and the attrition was 32.9%, therefore results might not be representative or
generalisable to the overall general population of New Zealand.
Two studies evaluated the impact of the new pictorial health warnings for tobacco packages
which were among the first regulations following the introduction of the Family Smoking
Prevention and Tobacco Control Act in 2009 which granted the Food and Drug
Administration (FDA) authority to regulate tobacco products. Cigarette packages are
required to display one of nine colour graphic (i.e., pictorial) warnings on the top 50% of the
“front” and “back” of cigarette packages. Both studies used online research panels and
although the pictorial warnings replicated the new FDA warning the intervention conditions
did not mirror real life exposure to cigarette packaging.
A web-based RCT87 evaluated the potential impact of the nine new pictorial warning labels
compared with text-only labels using a purposive sample of U.S. adult smokers from diverse
racial/ethnic and socioeconomic subgroups in 2011. The U.S. Family Smoking Prevention
and Tobacco Control Act of 2009 required updating of the existing text-only health warning
labels (HWLs) on tobacco packaging with nine new warning statements accompanied by
pictorial images. 1,665 participants assigned to the control condition were exposed to one of
nine text-only HWLs, and 1,706 participants in the experimental condition were exposed to
90
one of nine pictorial HWL with the same text messages as in the control condition.
Participants viewed the labels and reported their reactions.
There were significantly stronger reactions for the pictorial condition for each outcome:
salience (b = 0.62, p<.001); perceived impact (b = 0.44, p<.001); credibility (OR = 1.41,
95% CI = 1.22-1.62), and intention to quit (OR = 1.30, 95% CI = 1.10-1.53). Individuals
with a high school education or less compared with higher educated individuals had stronger
responses for perceived impact and salience. There were no significant differences in
reactions across income categories. No significant results were found for interactions
between condition and education or income. The only exception concerned the intention to
quit outcome, where the condition-by-education interaction was nearly significant (p =
0.057). There was a stronger effect for the pictorial condition versus the text-only condition
among individuals with moderate education compared with higher educated groups. The
study sample was unlikely to be representative of the study population because the
recruitment rate and survey completion rates were low. In addition, there were significant
differences between intervention groups at baseline for SES and smoking behaviour.
Another web-based quasi-randomised trial88 evaluated the efficacy of the 36 proposed FDA
warnings for each of the nine “statements” or health effects specified in the Act.
Respondents rated each warning while the image appeared on screen, one at a time, and then
ranked the warnings within a set on overall effectiveness. Comparisons on specific elements
indicated that warnings were perceived as more effective if they were: full colour (vs. black
and white), featured real people (vs. comic book style), contained graphic images (vs. nongraphic), and included a quitline number or personal information. Association between
index ratings scores and both education and income were not significant. The most effective
ratings performed equally well across SES groups. Due to a technical flaw in the program,
the second set of health warnings assigned to respondents was not assigned at random and so
the number of participants who viewed each set of warnings not balanced. There were
relatively few (less than 200) participants in the low SES sub-groups (income and
education).
A European study89 examined the effectiveness of text only health warnings among daily
cigarette smokers in France (n = 1,532), Germany (n = 1,305), the Netherlands (n = 1,788)
and the UK (n = 1,788. The International Tobacco Control Policy Evaluation Project
produced data from single survey waves in each of the four countries between 2007 and
91
2008. At the time of the study the European Commission required tobacco products sold in
the EU to display standardized text health warnings. Smokers rated the health warnings on
warning salience, thoughts of harm and quitting and forgoing cigarettes; and a labels impact
index (LII) was used to score results. Scores on the LII differed significantly across
countries. Scores were highest in France, lower in the UK, and lowest in Germany and the
Netherlands. Impact tended to be highest in countries with more comprehensive tobacco
control programmes.
Across all countries, scores were significantly higher among low income smokers (i.e. rated
warnings more effective), with no significant interaction between country and income. There
was a main effect of education, as well as a country by education interaction. Although
scores on the LII tended to be higher among smokers with low to moderate education in
France, Germany and the Netherlands, the opposite trend was observed in the UK. The
impact of the health warnings was highest among smokers with lower incomes and smokers
with low to moderate education (except the UK in the case of education) suggests that health
warnings could be more effective among low SES groups. This European study was
representative and enables cross-country comparisons. However, France and the UK now
have pictorial health warnings rather than text-only warnings.
Summary of controls on advertising, promotion and marketing of tobacco
Of the nine studies which evaluated the effects of controls on advertising, promotion and
marketing of tobacco, five studies evaluated the impact of warning labels alone. The effects
of controls on advertising, promotion and marketing of tobacco were equally effective in
seven studies (neutral equity impact) and had a positive equity impact in two studies
including EU text-only health warnings and the addition of quitline number to new pictorial
health warnings. The representativeness of the majority of the study samples is unclear and
limits the generalisability of the results which may weaken the potential equity impact.
In general, tobacco marketing regulations were associated with significant reductions in
smokers’ reported awareness of pro-smoking cues, among all SES groups in nationally
representative samples from the UK, Canada, Australia, and the USA.84 The observed
reductions were greatest immediately following the enactment of regulations, with
awareness reducting more slowly in subsequent years. Changes in reported awareness were
generally the same across different SES groups. The introduction of restrictions on tobacco
advertising and marketing had a neutral equity effect measured by exposure. It is unknown
92
whether the extent of exposure differed by SES or whether there were any differences by
SES in the impact of change in exposure. While tobacco marketing regulations have been
effective in reducing exposure to certain types of product marketing there still remain gaps in
coverage, especially with regard to in-store marketing and price promotions. It is unclear
whether these gaps have a differential impact by SES.
It is unclear how change in ‘intermediate’ outcomes, such as awareness, recognition,
motivation and preferences, translate into change in smoking prevalence and the impact of
such longer-term changes on equity. Compliance with restrictions on sales and general and
point-of-sale advertising was associated with a neutral equity impact as there was no
significant difference in compliance by SES. However this evidence was derived from two
regional studies85;86 and it is unclear whether this outcome is generalisable to other regions
and how this outcome impacts on smoking prevalence. A European study56 found that
comprehensive advertising bans had the next strongest association with quit ratios (after
price) in most subgroups (not low SES aged 40-59 or low SES women aged 25-39 years).
Pictorial health warnings were associated with greater impact than text only warnings and
were equally effective across SES groups, with two studies suggesting a neutral equity
impact. There were two studies which evaluated EU text only warning labels. Findings from
a Netherlands study of EU text only warning labels showed neutral equity impact and a
European study showed positive equity impact. There were no significant differences in
changes in smoking behaviour by education level, following new EU text health warnings,
amongst an internet-based sample of smokers motivated to quit in the Netherlands. A
European study showed variation in impact of EU text only health warnings across countries
depending on type of SES measure used. Overall there was a positive equity with the impact
highest among smokers with lower incomes and smokers with low to moderate education
(except the UK in the case of education), suggesting that text only health warnings could be
more effective among low SES groups. However, France and the UK now have pictorial
health warnings. Another European study which evaluated a range of tobacco control
policies including health warnings showed a lack of significant effect for health warnings.
Quitline number recognition included with new pictorial health warnings, increased across
all SES groups in New Zealand, and the gap in quitline number recognition between the least
and most deprived groups narrowed, indicating a positive equity effect. It is unclear how
quitline number recognition translates into quitting.
93
3.5 Mass media campaigns
Introduction
Mass media interventions in tobacco control encompass a range of different types of media,
sources and messages. These include paid advertising, earned media (e.g. through advocacy),
press releases and events such as no smoking days, and direct marketing through television,
radio, newspapers, magazines, cinema, billboards, posters, leaflets, internet and other digital
media (e.g. texts, viral marketing).
Mass media campaigns aim to impact directly on
smoking behaviour (e.g. increase unaided quit attempts, increase call to quitlines) and/or
changing social norms relating to smoking (e.g. to support policy action, reduce the
desirability and acceptability of smoking).
Niederdeppe et al92 undertook a systematic review which compared media campaign
effectiveness by SES. In order to understand how, and at what point, media campaigns
might differ in effect by SES, the study authors adapted a logic framework (Figure 3).
According to the logic framework, differences in effect between SES groups can occur
during exposure to a media campaign, in motivational response, and finally, in longer-term
behavioural response to a media campaign. Therefore, when interpreting the data from
studies of media campaigns, we group results in terms of message recall/awareness, seeking
information/treatment, attempting to quit, and, finally, sustained quitting.
Studies showing lower levels of exposure or response or abstinence/quitting in lower SES
compared with higher SES are summarised as likely to increase inequality (negative equity
impact).
Studies
showing
equivalent
levels
of
exposure
and
response
and
abstinence/quitting, between low SES compared with higher SES groups, are summarised as
maintaining inequality (neutral equity impact). Studies showing higher levels in at least one
stage (exposure or response or abstinence/quitting) without lower levels at another stage,
between low and high SES groups, are summarised as reducing inequalities (positive equity
effect).
Twenty-nine studies were identified and included interventions using multiple media
formats, television campaigns, unpaid for media and the internet. Eighteen studies evaluated
a range of mass media campaigns, nine studies focused specifically on mass media to
promote the use of quitlines and three studies used mass media to promote the use of NRT.
One study was included in both the ‘mass media’ section and the subsection ‘mass media to
increase the use of NRT because the study included both a concurrent Quit & Win contest
94
and NRT giveaway.93 Studies of quitline campaigns were only included if they reported on
the impact of the mass media element in terms of reach and/or impact at the population level.
95
Figure 3 Logic framework for Mass Media Campaigns
96
3.5.1 Mass media cessation campaigns
Fifteen studies55;58;93-105 were included which evaluated the effects of mass media cessation
campaigns. In addition four Dutch reports106-109 were included that were obtained through
grey literature searching and English synopses are provided separately. The results of one
Dutch report107 are discussed alongside a published paper of the same study.58 Therefore in
total, eighteen studies were included that evaluated mass media cessation campaigns. The
findings from one study, the EX campaign, were reported in two papers.101;102 Studies were
conducted mainly in the USA, but one study was set in Croatia97 and one in Russia.94 All the
studies used education as a measure of SES and some studies also used income.
The types of mass media used varied between studies: three studies used multiple media
formats. This included a Croatian national ‘smoke out day’ media campaign on the first day
of Lent.97 A cohort study in the Netherlands examined age and educational inequalities in
smoking cessation due to the implementation of a national tobacco tax increase; national
smokefree hospitality industry legislation and a national mass media smoking cessation
campaign, all implemented during the same time period.58 One study evaluated the impact of
paid media campaigns alongside cigarette prices and clean air regulations and the types of
media campaigns are not detailed within the paper; states were included as having a media
campaign if the state ‘spent more than 70% of the CDC goals in 2001 and 2002’.55
Four studies assessed Quit & Win campaigns using multiple media formats including press,
television and radio: a Russian-based ‘Quit & Win’ campaign,94 a Canadian Quit & Win
incentive-based intervention95 plus a ‘Quit Kit’, a Dutch Quit & Win campaign in the
Netherlands110 and a US concurrent Quit & Win contest and NRT giveaway.93
Seven studies used mainly TV advertisements: a television-based anti-tobacco media
campaign using graphic imagery of the health effects of smoking,96
a comparison of
different types of anti-tobacco television adverts in Massachusetts,98 television smoking
cessation adverts in Wisconsin,100 EX, a US-based branded national smoking cessation
media campaign designed to promote cessation in the USA,101;102 an Australian study103
sought to identify modifiable factors that increased the efficiency of antismoking TV
advertisements in terms of reach and recall, a US study104 assessed the impact of emotional
and/or graphic antismoking TV advertisements on quit attempts, and a New York Media
Tracking Survey Online
105
examined SES variation in response to different types of
television smoking cessation advertisements.
97
One study used online internet advertising to promote a web-based cessation programme,99.
Outcomes measured were generally similar across studies and included uptake of the
campaign, smoking prevalence, smoking abstinence, quit attempts, campaign awareness,
recall and interest, recruitment, and cessation-related cognitions.
One study compared different interventions (Quit & Win, NRT or both), eight studies were
prospective cohorts, one study used single cross-sectional data and five studies used repeat
cross-sectional data. Only four of the fifteen study samples were assessed as representative
of the study populations, with findings that are generalisable on a regional or national scale.
The majority of studies used credible data collection methods. In seven studies the attrition
rates were either low or unclear. In four studies it was unclear whether the observed effects
were directly attributable to the mass media campaigns, either because the mass media
campaign was an element of a broader tobacco control programme or the study validity was
compromised in some other way.
Multiple media formats
A study based in Croatia97 evaluated the impact on smokers behaviour of ‘Smoke out day’
using cross-sectional data from anonymous surveys carried out over one week, in people’s
homes. Over 2000 participants aged 15 years and over, were selected from radio and
television subscribers in the Republic of Croatia. This was the first national ‘smoke out day’
media campaign, carried out on the first day of Lent as part of the ‘Say yes to no smoking’
campaign. The activity was connected with an event of cultural and religious significance for
the majority of the Croatian people (88% of the population are Roman Catholic) and was
also supported by other religious communities, governmental, and non-governmental
associations. Various strategies were used (intense media campaign, round tables, stands,
public events at main town squares, activities in nurseries, schools, and work places). The
aim of these simultaneous activities was to reach the target population, i.e. smokers, in the
phase of contemplation about quitting smoking regardless of age, gender, or duration of
smoking.
Nearly 93% of selected listeners and viewers responded and were interviewed. In the total
analysed sample 1,822 (85.0%) had heard of the activity and 1,608 (75.0%) knew the exact
date of the “Smoke out day.” Among smokers, 27% had given up smoking on that day and
16% declared they would not smoke during Lent. Among smokers, 141 (15.6%) participants
98
had primary school education, 579 (64.1%) had secondary school education, 71 (7.9%) had
university education, and 112 (12.4%) were students. The analysis of abstainers according to
the level of education showed that the largest group of abstainers (abstinence for one day)
was those with secondary school education (59.1%), followed by primary school educated
(20.4%) and those with university education (16.8%). However, the study did not compare
the quit rates by SES group or provide details of relative uptake by SES. The summary
equity impact was therefore unclear.
A US study55 evaluated the impact of paid media campaigns alongside cigarette prices and
clean air regulations. The types of media campaigns are not detailed within the paper; states
were included as having a media campaign if the state ‘spent more than 70% of the CDC
goals in 2001 and 2002’. The study examined the association between smoking and media
campaigns among women of low SES using four waves of data between 1992 and 2002 from
the TUS. Between 1992 and 2002, smoking prevalence declined more rapidly among loweducation compared to medium and high education women. Moreover, evidence showed that
compared with higher educated women, low education women responded with greater
positive effect to certain policy measures, including mass media. The authors concluded that
media campaigns may reduce prevalence among women with low education. In a state with
a media campaign, low education women’s odds ratio for smoking was 0.86 for women of
low education, 0.89 for women with medium education and 0.93 (non-significant) for
women with high education. Generally, the association between the media variable and
smoking prevalence declined in the more recent survey waves.
The mass media campaign appeared effective for lower SES women, however the study is
limited because exposure to mass media campaigns was based on whether a state of
residence funded a comprehensive tobacco control programme with a significant media
component (there was no examination of individual level exposure). There was no
description of the types of media campaigns involved, and which were the most effective
(either the mode of intervention or locations). The positive effects might not be due to the
mass media component and may even be the consequence of changing social norms. In
addition, there were a number of tobacco control policies that were introduced during this
period which may have influenced the results.
A cohort study in the Netherlands examined age and educational inequalities in smoking
cessation due to the implementation of a national tobacco tax increase; national smokefree
99
hospitality industry legislation and a national mass media smoking cessation campaign, all
implemented during the same time period.58 Three survey waves of the International
Tobacco Control (ITC) Netherlands Survey, 2008 (before) and 2009 and 2010 (after) were
used. Dutch smokers (having smoked at least 100 cigarettes in their lifetime and currently
smoking at least once per month) aged 15 years and older were recruited from a probabilitybased web database and 78% responded to the first survey. Analyses were restricted to
respondents who participated in all three survey waves, did not quit during the 2008 and
2009 surveys and answered all survey questions (n=962).
From April 2008 until January 2009, a mass media smoking cessation campaign ‘There is a
quitter in every smoker’ ran on television, radio, print and internet. This campaign was
designed to stimulate smokers to quit smoking and focussed on smokers with low to
moderate educational levels aged 20–50 years. 83.1% of participants reported having
experienced one or more parts of the national mass media smoking cessation campaign.
Smokers from different educational levels were reached equally (no difference in levels of
exposure) by the mass media smoking cessation campaign (the campaign did not reach low
to moderate educated smokers more than high educated smokers). Exposure to the cessation
campaign had a significant positive association with attempting to quit smoking in the
univariate analyses, but not with successful smoking cessation and was not significant in the
multivariate analyses. There were no overall educational differences in successful quitting
after the implementation of the national mass media smoking cessation campaign.
The follow-up rate was 70%. However, the study authors’ report that almost half of the
sample was either lost to follow-up or did not answer all questions. These respondents were
younger; less addicted and had more intention to quit smoking. Therefore the results may not
be fully generalisable to the broader population of Dutch smokers.58However this study did
measure exposure to each policy and measure the effects of each policy. In summary, a
Dutch, targeted multi-media campaign had equal reach by SES, but was not effective in
reducing prevalence (in any SES subgroup).
An evaluation report of the same Dutch multimedia campaign (‘There is a quitter in every
smoker’) was identified through contacting experts and an English synopsis was provided. A
larger sample size (n=1,573) was analysed in the report107 than in the published paper.
58
The report also assesses a sponsored television show that was part of the campaign called ‘Ik
wed dat ik het kan’ (‘I bet I can do it’). In the television show, groups of smokers were
100
followed in their attempts to quit smoking successfully. The campaign was designed to
stimulate smokers to quit smoking and had a special focus on smokers with low to moderate
education levels, aged 20 to 50 years. Low education included primary education, lower
vocational education; ‘middle education group’ included general secondary education and
secondary vocational education; ‘high education group’ included general and higher
education, higher professional education and university education (bachelor), and university
education (doctoral). The evaluation report showed that the ‘There is a quitter in every
smoker’ campaign had positive effects on communication about smoking cessation, but only
among higher educated smokers. The ‘I bet I can do it’ television show had positive effects
on quit intention among low educated smokers.
English synopsis of three Dutch mass media campaigns using multiple media formats
(grey literature)
Three Dutch mass media campaigns, all using multiple media formats were included which
evaluated SES differences in campaign effects. The campaigns are reported in chronological
order beginning with the earliest campaign.
A mass media campaign109 on television, radio, and the internet; entitled ‘Nederland start
met stoppen / Nederland gaat door met stoppen’ (‘The Netherlands starts quitting / The
Netherlands continues with quitting’) ran from November 2003 to the beginning of 2004. A
representative sample of smokers aged 16 to 70 years old participated in a longitudinal webbased survey with eight survey waves between September 2003 and May 2005. In the first
survey, 3,411 respondents participated. Of this group, 1,305 respondents participated also in
the last survey (62% attrition rate). There was also a concurrent workplace campaign and a
‘children copy’ (the behaviour of parents) campaign.
The aim of the campaign was to stimulate smokers to attempt to quit smoking as a New
Year’s Resolution. The campaign consisted of sponsored amusement programs and short
communications within existing amusement programmes and informative programmes. The
‘higher education’ group included (hoger algemeen voortgezet onderwijs (HAVO) meaning
higher general secondary education, voortgezet wetenschappelijk onderwijs (VWO) meaning
secondary science education; college and university education), the ‘middle education
group’ included vocational training and the ‘low education group’ included secondary
school, lower vocational education, and primary education.
101
There was no differential effect of the campaign on several psychosocial determinants of
smoking cessation between lower and higher educated smokers. There were positive effects
of the campaign for quit intention, attitude towards smoking cessation, social norms, and
interpersonal communication about smoking cessation. The study examined both quit
attempts and successful quitting, but positive effects of the campaign were only found for
successful quitting. Successful quitting was self-reported and it was not specified how long
people should be quit. Adults with lower education were less likely to successfully quit. This
Dutch multimedia campaign109was associated with an unclear equity impact because
although positive effects were reported for several psychosocial determinants of smoking
cessation between lower and higher educated smokers, adults with lower education were less
likely to successfully quit.
A mass media campaign108 called ‘Rokers verdienen ‘n beloning’, de 24-uur-niet-rokenactie
(‘Smokers deserve an award’, the 24-hour-no-smoking intervention) ran in 2006 in the
Netherlands. The intervention was announced on posters, flyers, local newspapers, banners
on websites, with press releases, and radio spots. It included a web-based survey with one
questionnaire after the intervention was performed among a representative group of smokers.
2,800 smokers were asked to participate and 2,140 answered the survey (76% response rate).
There was also a web based survey of 920 intervention respondents. Smokers were
encouraged to stop smoking for 24 hours and to register for participation. Participants filled
in a web-based survey, on which they immediately got personalised feedback aimed at
increasing self-efficacy and intention to quit. Participants were rewarded with a magazine of
their choice and the chance to win a television.
People with lower school or lager beroepsonderwijs (LBO) meaning junior secondary
education are classified in the ‘lower wealth group’. Persons with middelbaar algemeen
voortgezet onderwijs (MAVO) meaning secondary school education; HAVO meaning higher
secondary general education; middelbaar beroepsonderwijs (MBO) meaning middle-level
applied (vocational) education; or pre-university education; are classified in the ‘middle
wealth group’. Persons with college or university education were classified in the ‘highest
wealth group’.
The 24 hour no-smoking intervention had greater reach in the higher socioeconomic groups
which was measured using awareness of the campaign. The middle SES group had the
highest rate of registration for participation in the 24-hour no-smoking day. Effects on
102
smoking cessation were not studied, only on willingness to quit. There was no significant
difference between the low and high SES groups on willingness to stop smoking by
awareness of the campaign and by participation. The 24 hour no-smoking intervention108
which included a web-based survey and personalised feedback aimed at increasing selfefficacy and intention to quit, was associated with a negative equity impact for campaign
reach.
A Dutch mass media campaign106 ran from December 15, 2010 until March 2011 and was
called ‘Echt stoppen met roken kan met de juiste hulp’ (‘Really quitting smoking can be
done with the right help’). There was a television and radio commercial, banners, social
media, posters and flyers, and messages in newspapers and magazines. The target group was
smokers with an intention to quit smoking in the future, with a focus on lower educated
smokers. The goal of the mass media campaign was to make smokers aware of the fact that
smoking cessation is more successful with the right cessation aids and that the combination
of pharmacotherapy and behavioral therapy is reimbursed as of January 2011.
A representative sample of smokers aged 18 years and older participated in a longitudinal
web-based survey, with two waves before the campaign and two surveys after the campaign.
The first survey was sent in September 2010 to 4,338 potential respondents, of which 2,763
participated in the survey (64% response rate). The second survey was in December 2010, in
which 1,811 respondents of the first survey participated (34% attrition rate). The third survey
was in March 2011 and 1,694 respondents participated (39% attrition rate). The fourth
survey was in June 2011 and 1,429 respondents participated (48% attrition rate).
Smokers with low (lower education, lower vocational and MAVO meaning secondary school
education) and secondary (HAVO meaning higher secondary general education and
vocational) education belonged to the group of ‘less educated’ and smokers who had
completed college or university training among the ‘highly educated’ group. Lower educated
smokers reported more often that they had heard from the campaign than higher educated
smokers. This Dutch multimedia campaign106 targeted at smokers with an intention to quit
smoking in the future, with a focus on lower educated smokers, was associated with a
positive equity impact for campaign awareness.
103
Mass media Quit & Win campaigns
Four studies evaluated Quit & Win campaigns, one in Russia, one in Canada and one in the
Netherlands. A US study93 examined a concurrent Quit & Win contest plus NRT.
A Russian study94 examined the sociodemographic and motivation of participants in the
Novosibirsk Quit and Win Campaign, organised by the Institute of Internal Medicine in
Russia since 1994. Registered participants were interviewed a year after each campaign from
1998 to 2004. The Quit and Win Campaign is an international antismoking campaign
initiated by the WHO. Any adult aged 18 years or older who smoked at least one cigarette a
day during the previous year and who wanted to quit could participate. The Quit and Win
Campaign is conducted at same time in each country, all participants are asked to abstain
from 1st May to 29th May and the campaign ends on International Non-Smoking Day which
is the 31st May. Abstinence is biochemically confirmed and participants who did not smoke
may take part in the drawing of the prize. The international prize is 10,000 US$ and there are
also six regional prizes (2,500 US$) which were raffled between winners from participating
countries.
Overall, 90% did not smoke during the month of campaign and 40% did not smoke in the
following year. The number of people intending to stop smoking completely increased from
year to year. Follow-up questionnaires were used to measure participants intentions before
the campaign; participant’s intentions to quit entirely, were 77% in 1996 and 87% in 2002.
In 1998, 32% of participants had higher education, compared with 43% in 2000, and 30% in
2002. In 1998, 28% of participants had secondary professional education, compared with
27% in 2000, and 27% in 2002. In 1998, 15% of participants had secondary school
education, compared with 16% in 2000, and 13% in 2002. In 1998, 2000 and 2002 about
10% had primary education. The majority of participants were men; 84% were men in 1996
and 76% were men in 2002. In 2002 only 3% of participants were supported by medical
professionals in their quit attempt and 90% reported that they did not use any nicotine
replacement therapies. These findings are likely to be different from other countries. The
study only analysed uptake of the campaign by educational level, and did not analyse
abstinence by educational level nor make any comparisons with the SES of smokers in the
general population. Campaign uptake by SES appeared stable across time; the higher the
education level the higher the participation, and so in terms of uptake of the campaign the
equity impact appears negative.
104
A Canadian study95 evaluated the impact of a Quit & Win incentive-based intervention plus
a ‘Quit Kit’ that was developed to help daily smokers to quit smoking. Quit & Win
Challenge participants were 231 adult daily smokers (minimum average of 10 cigarettes per
day) residents from two of the four Eastern Ontario counties (Frontenac, Lennox &
Addington) who entered the Quit and Win contest in January 1995. A cohort group of
comparison adult daily smokers were selected by random telephone survey (n = 385) from
the same regions as well as two neighbouring counties (Hastings, Prince Edward). Both
cohorts were followed up for one year.
Enrolled adult smokers pledged to quit smoking for a designated period of time. In
exchange, they were entered into a lottery with a cash prize of $1,000 and secondary prizes
of lesser values. The initiative was promoted through the local print and radio media, as well
as through the distribution of leaflets. A contest winner, who was required to be smokefree
in the month leading up to the prize ceremony, was selected by random draw approximately
three months after the contest was initiated. The winner was asked to provide the name of a
"buddy" to be contacted to verify smokefree status. Those who enrolled in the contest were
also given the educational Quit Kit, which contained a letter of encouragement, information
on cessation methods, a list of local cessation programmes, tips on maintaining a smoke-free
status and a refrigerator magnet with the telephone number of a health unit information line.
After one year, 19.5% of Quit & Win participants reported that they were smokefree (selfreported 6 months continuous abstinence), whereas less than 1% of the random comparison
group had quit. A participation rate of 0.83% combined with the cessation rate produced an
impact rate of 0.17% (extrapolates to 1 in 8 smokers led to quit due to Quit & Win contest).
Compared with the random survey group, Quit and Win participants tended to be more
educated at baseline. There was no significant association between level of education or
occupation and cessation at one year. In summary, lower SES smokers were not reached as
well by the Quit & Win campaign but there were no differences in cessation by education
level at one year, leading to a negative equity impact. The response rates and the one-year
follow-up rates in both groups were high, however the results may be specific to this region
of Canada. In addition 87% of Quit & Win participants were actively trying to quit at
baseline (and were more likely to have quit at one year) so the results may be relevant only
to a highly motivated subpopulation.
105
A Quit and Win campaign in the Netherlands110 took place in May 2005 and the main
objective was to encourage respondents to abstain from smoking for at least one month.
Recruitment of participants was promoted on a national as well as regional level using radio,
newspapers, campaign posters and brochures.
In total, five supportive e-mail messages were sent to the participants. Participants were
offered the opportunity to receive computer-tailored cessation advice, support from a
telephonic coach, and they could enrol in an e-mail counselling programme, all of which
were provided by the Dutch Foundation on Smoking and Health (STIVORO). Participants
were also asked to name a buddy, whom they could call upon for support during their
cessation attempt. Other cessation support included NRT and bupropion. After one month,
prize winners (first prize: €1.000 and 11 regional prizes of €450) were randomly selected
from a pool of successful quitters and were obliged to undergo biochemical verification of
smoking abstinence.
Quit & Win contestants were significantly more likely to be from medium and high educated
groups than the control group of non-contestants. At one month abstinence rates were 35.4%
in Quit & Win contestants and 10.9% in control participants (OR 4.70; 95% CI:3.02 to 7.31)
when all non-respondents were classed as smokers. At 12 months abstinence rates were
11.9% in Quit & Win contestants and 2.9% in control participants (OR 2.46; 95% CI:1.64 to
3.68). One-month abstinence was significantly predicted by use of buddy support and Quit
and Win e-mail messages. Quit and Win e-mail messages remained a significant predictor
for continuous abstinence at 12 months. Participants with a higher education were more
likely to maintain their quit attempt for the entire contest month. Higher education was a
significant predictor of cessation at one month (OR = 1.199; 95% CI: 1.032 to 1.393) but did
not predict continuous abstinence at 12 months (OR=1.109; 95% CI: 0.895 to 1.374). There
were no analyses of recruitment method, use of buddy system or other types of cessation
support by SES. In summary, the Netherlands Quit & Win contest was associated with a
negative equity impact based on reach and short-term quit rates.
A US study93 examined a concurrent Quit & Win contest and NRT giveaway in Erie and
Niagara counties in the western New York region. Smokers could enrol in both or either
programme (combined group). Daily smokers (at least 10 cigarettes per day) were offered
the opportunity to win prizes including $1000 if they stopped smoking for the month of
January 2003 with a quit date of 1st January. NRT vouchers were redeemable at pharmacies
106
for a 2-week supply of nicotine gum or patch. Media coverage included a press conference,
newspaper and television coverage. $35,000 was spent on radio advertisements aired on 6
local radio stations. The focus was mainly on the Quit & Win contest – people were
informed of free NRT giveaway when they telephoned the New York State Quitline. Both
interventions were marketed to minority populations (African American and Latino) using
newspaper, churches and community sites.
Random samples of 341 Quit & Win participants (40%) and 314 (46%) NRT voucher and
230 (100%) combination group were selected for follow-up at 4 to 7 months from the 1st
January 2003, by telephone survey. Follow-up rates were 60-64%, with 204, 179 and 143
participants follow-up for Quit & Win, NRT and combination groups, respectively. The 3
intervention groups were compared with smokers in the same region using Erie-Niagara
Tobacco Use Survey (ENTUS), to determine reach. At follow-up the self-reported quit rates
were similar across the three intervention groups: 25 to 30%. Compared with smokers in
region, those enrolled in the three interventions had significantly more years of formal
education. However there was no significant difference in 7-day point prevalence of
smoking by education group. It was unclear how representative the regional cohort of
smokers was in the ENTUS survey, and in addition, smokers in all three intervention groups
were heavier smokers than in general population (20-21 vs 17 cigarettes per day). In
summary, the Quit & Win contest and concurrent NRT giveaway had lower reach among
less educated smokers in two regions in the US, all 3 interventions were associated with a
25-30% quit rate which did not differ by educational level.
Television advertisements
A US study96 assessed the effect of two mass media campaigns (2006) on smoking
prevalence among New York City (NYC) residents, using data from the NYC Department of
Health and Mental Hygiene (DOHMH) annual health surveys from 2002 to 2006. Gross
ratings points (GRPs) were used to measure exposure to the campaign; GRPs are an
industry-specific standardized measure of the broadcast frequency and audience reach of a
campaign. For example, 100 GRPs are equal to one exposure in the given period. An
extensive, television-based anti-tobacco media campaign using graphic imagery of the health
effects of smoking focused on increasing smokers’ motivation to quit. Advertisements
included testimonials from sick and dying smokers and graphic images of the effects of
smoking on the lungs, arteries, and brains of smokers. Advertisements included diverse
messages in both English and Spanish. The television campaign broadcast for 23 of 40
107
weeks during January through to October 2006, with 100 to 600 GRPs per week, for a total
of approximately 6,500 GRPs. The New York State Department of Health also aired a
separate, simultaneous statewide television-based anti-tobacco media campaign that included
NYC. The campaign included advertisements featuring graphic images of the effects of
smoking and emphasizing the effects of SHS on children. The broadcasts equated to
approximately 4,400 GRPs in NYC from January through December 2006. Thus, in total,
New York City adult smokers were exposed to nearly 11,000 GRPs during this 1-year
period, equating to the average viewer in NYC seeing an advertisement approximately 110
times over the year.
The smoking prevalence among NYC residents decreased significantly from 21.5% in 2002
to 18.4% in 2004 (p<0.001). From 2004 to 2005, smoking prevalence did not change
significantly among NYC residents overall. In 2006, the year during which television
advertisements were aired, smoking prevalence did not change significantly among NYC
residents overall (17.5% in 2006 compared with 18.9% in 2005, p=0.055). The total decrease
associated with NYC’s comprehensive programme from 2002 to 2006 was 19%, an average
annual decrease of 5%. From 2002 to 2004 decreases in prevalence were demonstrated in all
education subgroups. The smoking prevalence among those with less than a college
education was higher than among those with more education and the percentage change in
smoking prevalence from 2002 to 2006 was significantly higher in those with more
education compared with those with less than a college education. From 2005 to 2006, no
significant changes occurred within education subgroups.
The 2006 DOHMH media campaign was part of a tobacco-control programme which
consisted of increased taxation in 2002, establishment of smoke-free workplaces in 2003,
public and health-care–provider education, cessation services, and rigorous evaluation.
Therefore it is difficult to tease out the specific contribution of the media campaign impact
on smoking prevalence. In terms of equity impact, in 2006, the year the television adverts
were aired, smoking prevalence did not change significantly overall or between educational
subgroups, the equity impact is summarised as neutral.
A US cohort study98 assessed which types of mass media messages might reduce disparities
in smoking prevalence among disadvantaged population subgroups. The study used a
cumulative measure of SES: high school education or lower and household income of
$50,000 or less was classed as ‘low SES’. More than $50,000 household income and at least
108
college education was classed as ‘high SES’ and all others as ‘medium SES’. Data source
was the first two waves of UMass Tobacco Study, a longitudinal survey of Massachusetts
adults designed to investigate responses to the Massachusetts Tobacco Control Program.
Television adverts of varying intensity were aired in the two years prior to data collection in
2003/2004. 20.2% were highly evocative personal testimonials, 13.4% emotional but not
testimonials, 11.2% testimonials but not highly emotional and 53.7% not highly emotional or
testimonials.
On average, smokers were exposed to more than 200 antismoking ads during the 2-year
period, as estimated by televised gross ratings points (GRPs). The odds of having quit at
follow-up increased by 11% with each 10 additional potential ad exposures (per 1000 points,
odds ratio [OR]=1.11; 95% confidence interval [CI]=1.00, 1.23; P<.05). Greater exposure to
ads that contained highly emotional elements or personal stories drove this effect (OR=1.14;
95% CI 1.02, 1.29; P<.05), comparison ads show no significant effect (OR=0.93).
The study authors reported no significant variation in exposure to the advertisements by
SES. At follow-up (approximately 26 months from baseline), 12.9% of low SES smokers
had quit compared to 18.2% of mid and 19.2% of high SES smokers. The likelihood of
quitting for each 10 additional potential exposures to an emotionally evocative or personal
testimonial ad, adjusting for all co-variates, increased for respondents in the low-SES group,
the mid-SES group (highest increase), and the undetermined-SES group. By contrast,
smokers in the high-SES group showed a decreased likelihood of quitting with each 10
additional potential exposures to these types of ads.
The TV advertisements overall appeared to have a neutral equity impact in terms of exposure
but a negative equity impact in terms of quit rates as the odds of quitting were higher in the
mid and high SES groups compared to the low SES group. However, the highly emotional or
personal testimonial advertisements were more effective with the low, mid and undetermined
SES groups compared to the high SES groups for increasing the likelihood of quitting
smoking. The authors argue that using such advertisements may contribute to reducing
socioeconomic disparities in smoking. However the role of the ‘underdetermined’ SES group
might have undermined the significance of the intervention impact. Response rates and
attrition were relatively low (response rate 46%, follow up rate 56%) which might have
reduced the representativeness of the study sample and the generalisability of the study
findings.
109
A US study100 examined whether the impact of a televised smoking cessation advertising
campaign differed by education or income levels. The campaign formed part of the
Wisconsin Tobacco Control and Prevention Programme. Televised smoking cessation
advertisements were aired most weeks between May 2002 and December 2003. The
advertisements highlighted the dangers of SHS and included personal testimonials, or keep
trying to quit messages (KTQ), and aimed to promote Quitline calls. Subsets of both types of
adverts were targeted at low SES groups. Data were collected before and after the media
campaign a statewide sample of 452 adult smokers who were interviewed in 2003 to 2004
and followed up 1 year later in the Wisconsin Behavioural Health Survey.
At one year, 42% had made a quit attempt and 13% were abstinent. Overall, neither KTQ
nor secondhand smoke ad recall was associated with quit attempts or smoking abstinence at
one year. KTQ ads were significantly more effective in promoting quit attempts among
higher- versus lower-educated populations. There was a positive relationship between KTQ
advert recall and quit attempts for the higher educated group (college degree), but a negative
relationship for the lower educated group (high school diploma or less). There was no
relationship between KTQ recall and income. No differences were observed for SHS ads by
the smokers' education or income levels.
The equity impact overall was unclear for this study, there was potentially neutral equity
impact in terms of smoking abstinence at one year and negative equity impact in terms of
quit attempts related to the KTQ ad. However results can only be tentative because the type
of ad message appeared to have a differential impact and the impact also appeared to vary
depending on type of SES outcome measure. There was a small initial sample size, plus a
low rate of enrolment (29%) into the study, and a greater loss to follow up among the less
educated.
Two papers evaluated the EX national media campaign, one examined the association
between awareness and quit attempts and the other evaluated cessation-related cognitions
and quit attempts. 101;102 Both papers use survey data from the first six-months of the national
campaign. The survey had an overall response rate of 48% among known eligible
households and a 73% follow-up rate. The summary equity impact for the EX campaign was
positive.
The EX campaign was a branded mass media campaign to promote cessation among lower
income and blue collar smokers of diverse race/ethnicity, aged 25 to 49 years, who were
110
interested in quitting. The campaign was based on behaviour change theory, and included
formative research with the target audience. Using an empathic tone, the EX campaign
encourages smokers to "relearn" life without cigarettes. Smokers are asked to identify their
personal smoking triggers (e.g. drinking coffee, or driving a car) and work to disassociate
smoking from these daily activities. EX advertising is delivered through television, radio, the
Internet, and other channels. Television advertising was placed during programming popular
with smokers and aired during different times of the day to increase exposure among shift
workers, (large segment of the target audience). Advertising was also aired to match the high
interest of smokers in sports events. Radio advertisements were aired during AfricanAmerican and Hispanic programming (small proportion in Spanish language), as well as on
country and classic rock stations.
One paper101 examined whether changes in cessation-related cognitions mediated the relationship between awareness of a national mass-media smoking cessation campaign, the EX
campaign, and quit attempts in 3,571 current smokers in 2008. A majority of respondents
were seriously thinking of quitting at baseline, with 15.6% expressing an intention to quit
within 30 days and 51.6% within six months. 85% of the sample was aged between 25 and
49 years. At the six-month follow-up, 46.5% had confirmed awareness of the EX campaign
(measured by awareness of TV adverts). The direct effect of EX awareness on quit attempts
was 0.031 (SE = 0.01), which indicated that EX awareness increased the probability of
reporting a quit attempt at follow-up by approximately 3%. Altogether, the model explained
approximately 18% of the variance in quit attempts at follow-up. Data suggested that there
were both a direct effect of confirmed awareness of EX on quit attempts as well as an indirect effect mediated by positive changes in cessation-related cognitions. Only respondents
with less than a high-school education showed a statistically significant effect of EX
awareness on quit attempts, and this effect was both direct (0.082, SE = 0.04) and indirect
(0.017, SE = 0.01), therefore showing a positive equity effect.
The study author’s hypothesis was that EX awareness manifested in changes in quit
behaviour through initial modification of cessation-related cognitions. The data, however,
did not fully support this hypothesis. While there was a statistically significant effect of EX
awareness on quit attempts mediated through cessation-related cognitions, the larger effect
of EX awareness on quit behaviour was not mediated through cessation related cognitions.
Furthermore, the mechanism underlying how EX awareness promotes quit attempts differed
across education subgroups.
111
Another linked paper102 assessed the effectiveness of the EX campaign, focussing on TV
advertising only, across racial/ethnic and educational subgroups of 4067 current smokers in
2008. EX campaign awareness differed significantly by education, with higher awareness
observed among those with higher educational attainment (41.0% weighted estimate for
college degree vs. 30.2% for less than high school diploma, summary p value = .002). EX
was significantly related to a higher cognitions index score at 6-month follow-up only
among respondents who had achieved less than a high school education (OR = 2.6, p =
.037). Baseline cognition index score was consistently predictive of follow-up cognition
index score for all educational strata at the p < .000 level. A statistically significant
relationship between confirmed awareness of EX and having made a quit attempt at followup was observed among those with less than high school education (OR = 2.1, p = .016).
Among smokers with less than a high school education, confirmed awareness of the EX
campaign more than doubled their odds of having more favourable cognitions about quitting
smoking at 6-month follow-up, and doubled their odds of having made a quit attempt during
the study period.
The Cancer Institute New South Wale’s Tobacco Tracking Survey103 (CITTS) sought to
identify modifiable factors that increased the efficiency of anti-smoking TV advertisements
in terms of reach and recall. Over 13,000 adult smokers and recent quitters were interviewed
between 2005 and 2010. Income and education variables were combined into dummy
variables indicating low, middle or high SES. Postcodes were used with the Socio-Economic
Indices for Areas (SEIFA) to indicate neighbourhood SES.
TV advertisements broadcast more at higher levels or in more recent weeks were more likely
to be recalled. Advertisements were more likely to be recalled in their launch phase than in
following periods. Controlling for broadcasting parameters, advertisements higher in
emotional intensity were more likely to be recalled than those low in emotion. Also
emotionally intense advertisements required fewer GRPs to achieve high levels of recall than
lower emotion advertisements. There was some evidence for a diminishing effect of
increased GRPs on recall.
Neighbourhood SES was not significant in univariate analyses. In order to ascertain if the
effects of broadcasting parameters on recall were moderated by advertisement type, the
multivariate models were run with interaction terms between advertisement type (low
emotion, high emotion graphic imagery and high emotion narrative) and broadcasting
112
parameters (GRPs, broadcasting recency, launch phase). High SES but not moderate SES
had increased OR for recall compared to low SES (OR 1.11, 95% CI: 1.04 to 1.18, p=0.001).
High SES and moderate SES had decreased OR for recall compared to low SES (OR 0.90,
95%CI: 0.84 to 0.97, p=0.001; and OR 0.89 95% CI: 0.83 to 0.96, p=0.002 respectively.
The individual composite measure of SES (income and education) but not neighbourhood
measure of SES showed significant associations with recall and recognition. The impact of
TV advertisements on recall was in the opposite direction to the impact of recognition and
also recall and recognition outcomes differed between high and moderate SES (compared to
low SES). High SES adult smokers/recent quitters were more likely to readily recall TV antismoking advertisements from memory than low SES. High and moderate SES adult
smokers/recent quitters were less likely to recognise specific advertisements currently or
recently on air (last 4 weeks) compared to low SES. This inconsistency between outcomes
means any equity impact of these TV advertisements is unclear.103The study analyses do not
inform as to whether the type of advertisements varied in impact between SES groups.
A US study104 assessed the impact of emotional and/or graphic anti-smoking TV
advertisements on quit attempts in the past 12 months among 8780 adult smokers in New
York State. Smokers saw an average of three emotional and/or graphic (defined as such by
interrater agreement 0.81 to 1.00) and three comparison advertisements (defined as not
emotional and/or graphic) per month across the study period (2003 to 2010). Of the 142
study advertisements, 98 (69%) were comparison and 44 (31%) were emotional and/or
graphic.
The overall response rate to the survey was 40% which limits generalisability of the study
results. Exposure to emotional and/or graphic advertisements was positively associated with
making quit attempts among smokers overall. Exposure to advertisements without strong
negative emotions or graphic images had no effect. Recalling at least one emotional or
graphic advertisement recently was associated with a 29% increase in the odds of making a
quit attempt (p<0.05), whereas each additional 5000 GRPs of exposure to emotional and/or
graphic advertisements in the past year was associated with a 38% increase in the odds of
making a quit attempt (p<0.01). Education was not a predictor of quit attempts, income was
marginally signifıcant in the confırmed recall model.
Exposure to all types of advertisements and to emotional and/or graphic advertisements was
positively associated with making quit attempts by income and education. Smokers with
113
incomes of >/=$30,000, and smokers with some college education or beyond were more
likely to make a quit attempt if they reported recall of advertisements (all types). Recall of
emotional and/or graphic advertisements was associated with making a quit attempt for
smokers with incomes <$30,000 and those with a high-school degree or less (p<0.05).
Exposure to the comparison advertisements, as measured by past year GRPs and confırmed
recall, was not associated with quitting for any group of smokers.
A New York Media Tracking Survey Online105 examined SES variation in response to
different types of television smoking cessation advertisements in adult smokers in five waves
over two years (2007 to 2009). Participants included adult smokers who resided in either
New York or media markets within New Jersey where the New York Tobacco Control
Program purchased advertising time. A key feature of the survey included exposing
participants to videos of a random selection of specific anti-smoking advertisements via
online multimedia tools. Participants were showed a number of ads from five main
categories: (1) Why-Graphic (10 ads), (2) Why-Testimonial (15 ads), (3) How (7 ads, only
one of which used a personal testimonial), (4) Anti-Industry (4 ads), and (5) Secondhand
Smoke (9 ads). Secondhand Smoke advertisements were excluded from analyses. Outcomes
included aided advertisements recall and perceived advertisement effectiveness.
Participants recalled Why-Testimonial advertisements at higher rates than advertisements
using the other three themes. Participants perceived Why-Graphic advertisements as more
effective than the three other advertisement themes. In terms of recall there was a significant
interaction between How advertisements (vs. Why-Testimonial) and income; and significant
interactions between both Why-Graphic and How advertisements (vs. Why-Testimonial) and
education. The interactions between How advertisements and income/education were not
robust to the inclusion of both interaction terms. Stage of change did not interact with
advertisement theme: did not change the size or significance of the coefficients for the
interaction between Why-Graphic advertisements or How advertisements (vs. WhyTestimonial) and education on aided ad recall. Why-Testimonial advertisements had the
highest and How advertisements had the lowest ad recall across all levels of education. This
difference was greatest at low levels of education. For example, among those with 10 years
of education, the model predicted 71% recall of Why-Testimonial advertisements vs. 33%
recall of How advertisements. Among those with 20 years of education, the model predicts
67% recall of Why-Testimonial advertisements vs. 40% recall of How advertisements.
114
In terms of effectiveness there was significant interactions between How advertisements (vs.
Why-Graphic advertisements) and income, and How advertisements (vs. Why-Graphic
advertisements) and education, respectively. How advertisements (vs. Why-Graphic) and
income was not robust to the inclusion of interactions with education. There were significant
interaction between How advertisements and the contemplation stage, although in the
opposite direction of what would be expected based on the theory. The inclusion of
interactions between advertisement theme and stage of change did not substantially alter the
size or significance of the interaction between How advertisements and education. WhyGraphic advertisements had the highest level of perceived effectiveness. This value was
higher than How advertisements across all levels of education. Once again, however, the
difference was most pronounced at low levels of education. It should be noted that the New
York survey sample was not representative of the broader population of smokers in New
York, New Jersey or elsewhere because the internet-based sample was skewed toward
White, affluent and educated smokers.
Internet advertisements
A US feasibility study99 examined the potential of online advertising compared with
traditional advertising, to recruit smokers to cessation treatments. Online advertisements
were placed on national and local websites and search engines between December 2004 and
October 2006 to promote QuitNet’s web-based cessation program and state run telephone
quitlines in Minnesota and New Jersey. The advertising campaigns were managed by
Healthways QuitNet, including negotiation of contracts with online advertising partners.
The advertisements invited the user to click to receive more information. Clicking on the ad
took the user to a landing page where he or she read a brief description of three cessation
treatment options: (1) 24/7 online support, (2) telephone counselling, or (3) telephone and
online support. If users selected the first option, they were taken immediately to the statesponsored QuitNet website where they were prompted to register and begin using the
website. If the individuals selected the second or third option, they were asked to fill out an
online quitline referral form, which provided a quitline counsellor with basic contact
information; individuals selecting option three were then directed to the state-sponsored
QuitNet website to register. As a comparison group, registration were extracted data on all
individuals who joined QuitNet during the study period in response to all other forms of
advertising (ie, not an online ad), such as billboards, TV and radio ads, outdoor ads (e.g. bus
shelters), direct mail and physician referrals.
115
A total of 130,214 individuals responded to advertising during the study period: 23,923
(18.4%) responded to traditional recruitment approaches and 106,291 (81.6%) to online ads.
Of those who clicked on an online ad, 9655 (9.1%) registered for cessation treatment: 6.8%
(n = 7268) for Web only, 1.1% (n = 1119) for phone only, and 1.2% (n = 1268) for Web and
phone. Online ads recruited more men, young people and those with a high school degree or
less (24.6% v 23.2%, p<0.02) than traditional media. Banner adverts, rather than actively
searching for cessation assistance, was a source of significantly more smokers with high
school education or less (26.3% vs 23.9%, P = .03). Compared to traditional media,
humorous online ads were significantly more likely to recruit those with a high school
degree or less (26.8%, p<0.01). Humorous ads were also the only creative approach that was
effective in recruiting smokers with lower levels of education.
This feasibility study shows the potential of online advertising on uptake and recruitment of
lower SES groups, with banner ads driving much of the effect and effectiveness limited to
one type of advertisement (humorous). Although engagement was not analysed by SES, the
subsequent level of engagement with the advertised cessation website was significantly
lower (although relatively small difference) among those recruited online, compared with
traditional media responders, but the authors argued that this was such a small difference that
it would be clinically insignificant.
Summary of Mass Media Cessation Campaigns
Fifteen mass media campaigns were included which evaluated the effectiveness by SES, plus
three Dutch grey literature reports, totalling eighteen studies.
Three studies showed a positive equity impact, including one Dutch study106 found from
searching the grey literature. This Dutch multimedia campaign106 targeted at smokers with
an intention to quit smoking in the future, with a focus on lower educated smokers, was
associated with a positive equity impact for campaign awareness. A tobacco control paid
media campaign in the US was associated with a more rapid decline in smoking prevalence
among low SES women. One campaign (the EX campaign) showed a positive equity impact.
The EX mass media campaign (TV element) increased cessation-related cognitions only
among those with less than a high-school education and increased quit attempts only among
those with less than a high-school education.
116
Two studies showed equal effectiveness by SES, a television-based anti-tobacco media
campaign in the US was associated with decreased smoking prevalence across all SES
groups. A mass media smoking cessation campaign in the Netherlands called ‘There is a
quitter in every smoker’ which ran on television, radio, print and internet showed equal reach
by SES and no significant educational inequalities in successful smoking cessation.
Five studies demonstrated a negative equity impact, including four Quit & Win campaigns
and a Dutch 24 hour no-smoking intervention. A Quit & Win campaign in Russia only
reported uptake by SES, which appeared stable across time, the higher the education levels
the higher the participation. The study did not report abstinence by SES nor make any
comparisons with the SES of smokers in the general population. Lower SES Canadian
smokers were not reached as well by a Quit & Win campaign but there were no differences
in cessation by education level at one year, leading to a negative equity impact. A Dutch
Quit & Win campaign including behavioural support and pharmacotherapy significantly
increased abstinence rates at one month and 12 months compared to control. Non-contestants
were more likely to be lower educated than contestants. Higher education was a significant
predictor of cessation at one month but did not predict continuous abstinence at 12 months.
In summary, the Netherlands Quit & Win contest was associated with a negative equity
impact based on reach and short-term quit rates.
A Quit & Win contest and concurrent NRT giveaway had lower reach among less educated
smokers in two regions in the US, and all three interventions (including a combined group)
were associated with a 25-30% quit rate which did not differ by educational level. A Dutch
24 hour no-smoking intervention108 which included a web-based survey and personalised
feedback aimed at increasing self-efficacy and intention to quit, was associated with a
negative equity impact for campaign reach.
Equity impact was unclear in six studies due to the following reasons: type of outcome
reported (i.e. uptake by SES); measure of exposure; where impact was more pronounced in a
‘middle’ SES group; where there was inconsistency between outcome measures; where
outcome differed between SES groups even despite similar exposure to the policy; or where
differences in effect were more pronounced although the effect was similar across all SES
groups. One Dutch multimedia campaign109was associated with an unclear equity impact
because although positive effects were reported for several psychosocial determinants of
smoking cessation between lower and higher educated smokers, adults with lower education
117
were less likely to successfully quit. These issues were also impacted by the lack of
representativeness of most of the study samples and also in some cases low attrition.
Two US studies98;104 found that the equity impact varied depending on which types of
messages were used and these two studies were classed as ‘mixed’ equity impact. Highly
emotional and personal testimony ads were more effective with low SES groups in one
study98 and emotional or graphic ads with low SES smokers in the other study.104
Mass media campaigns targeted at low SES smokers did not show consistently more
beneficial results for low SES compared with campaigns targeted at the general population.
The type of outcomes measured varied, but were mainly stage one and stage two outcomes
according to the logic framework; such as campaign awareness, recall and interest (stage 1)
and recruitment, quit attempts and one-day abstinence (stage 2). Some studies reported the
impact of mass media campaigns in terms of longer term outcomes, including smoking
prevalence and abstinence and there was no apparent pattern of effectiveness according to
stage or type of outcome reported. It is unclear how short or intermediate outcomes translate
into reduction in smoking prevalence and other health outcomes, and the impact of such
longer term changes on equity.
Different types of media messages appear to have differential impact by SES, and multiple
media formats may lead to equity benefit. A Dutch study105 showed that all smokers
(particularly those with low education) recalled advertisements on ‘how to quit’ less often,
and perceived them as less effective, than advertisements using graphic imagery or personal
testimonials on ‘why quit’. Differences in readiness to quit between higher and lower
educated populations did not explain why thematic differences in recall and response were
more pronounced among smokers with the lowest levels of education. A study exploring
differences in smokers’ perceptions of the effectiveness of cessation media messages 111
found that advertisements using a ‘why quit’ message with either graphic images or personal
testimonials were perceived as more effective than the other advertisement categories (how
to quit and anti-industry).
This review adds to the evidence included in the Niederdeppe review100and suggests that the
type of media message, the media format of the campaign and the mechanisms of
engagement vary by SES.
118
3.5.2 Mass media campaigns to promote calls to Quitlines and use of
NRT
Mass media campaigns to promote calls to Quitlines
Nine studies91;112-119 were included which evaluated the effects of mass media campaigns to
promote the use of quitlines.
Four studies were based in the USA112;113;115;118 one in
England,116 one in Canada,119 one in New Zealand,91 and two studies114;117 assessed callers
to the same quitline in Victoria, Australia across different time periods. One of these
studies113 evaluated the use of free nicotine patches rather than using paid media to increase
the use of a Quitline in Oregon. Another study used TV, radio and newspapers to launch a
programme of 2-weeks free NRT.115 In both studies NRT was accessed through calling a
quitline and so these two studies are assessed in ‘mass media campaigns to promote the use
of quitlines’. A Canadian study119examined the reach and effectiveness of free 5 weeks
mailed NRT (patches or gum) via a quitline and included brief telephone advice among the
first 14,000 eligible Ontario residents who were smokers motivated to quit and who called a
toll-free quitline. A cohort study in New Zealand91 examined how recognition of a national
quitline number changed after new health warnings were required on tobacco packaging.
Three studies evaluated mass media advertising targeted at specific sub-populations; one
media campaign was targeted at low-income Latino smokers112 one at young smokers in
England116 and one at lower SES smokers in Australia.114 Two studies of the Victorian
quitline in Australia114;117 focused on the impact of television advertising alone, whereas the
majority of the other studies assessed the impact of multimedia campaigns to promote the
use of quitlines including billboards, radio, magazine and cinema advertising, one study also
used unpaid media.
All studies reported characteristics of the quitline callers and four studies reported
quitting/abstinence.112;115;116;119 One study112 assessed television gross rating points but did
not directly measure the association between campaign exposure and quitline calls. The two
studies of the Victorian quitline in Australia114;117 directly measured exposure to ads and
calls to quitline adjusting for covariates, using Target Audience Rating Points.
Four studies used educational level as the SES variable and two of these studies also
included income.118;119Two studies114;117 based on data from the same quitline in Australia
used an area level indicator of SES as did the New York study;115 and the English study116
119
used occupational social class as a measure of SES. One study used small area deprivation,
individual deprivation, and financial stress as measures of SES.91
Four studies used cross-sectional data one of which used repeat cross-sectional data. Two
studies used cohort data91;116, one study compared free NRT plus brief advice through a
quitline to a no-intervention control cohort (study design 2.3), and two studies used quasiexperimental designs.112;115 Only one of the studies was assessed as representative of the
study populations with findings that are generalisable on a regional scale; which is surprising
given these are national quitlines.
Four of the studies could be assessed for attrition rates/numbers in each survey wave, of
which one study had low response rates 44.1% and 50.4% among pre and post-campaign
Latinos.112 Another study116 randomly selected only 905 of 6038 for 2-month recall survey
and only 473 (of 905) interviews were achieved at 11 months post-baseline. A fresh sample
(n = 951) was randomly drawn from the 5133 baseline log sheets with telephone numbers
that had not been used for the two month recall study. This provided an additional 257
respondents. Thus a total of 730 respondents were interviewed one year after their initial call
to Quitline which represented a relatively small number of the initial sample. In another two
studies attrition was low.91;119 In another study113 there were 920 in the baseline sample but
less than 200 in the educational subgroups. In the majority of studies the observed effects
were directly attributable to the mass media campaigns, either because the calls to the
quitlines were evaluated before and after the campaign or because exposure to the campaign
was directly measured.
Multimedia formats
One study used a quasi-experimental design to evaluate the impact of a media campaign for
the Colorado Quitline targeting Spanish-speaking smokers.112 Advertisements in Spanish
were aired on Spanish-language television channels, radio and at cinemas in majority-Latino
neighbourhoods. The advertisements delivered ‘positive, supportive and encouraging’
messages and modelling of quitting through actors portraying key family members (relating
to the important cultural value of familismo). Although there was no direct measure of
campaign exposure, it was estimated that 79.8% of households were exposed to campaign
messages, an average of 12 times each. Quitline calls among Latino smokers increased by
57.6% over the three month campaign period, with Latino callers significantly more likely to
be younger, uninsured and of lower education status. 42.5% of callers during the intervention
120
had less than high school education, compared to 22.2% pre-intervention. 56.0% uninsured,
compared to 40.5% pre-intervention. Callers during the campaign were also significantly
more likely to report remaining abstinent at 6-month follow up (18.8% post-intervention,
9.6% preintervention, p=0.04). Quit rates by SES are not reported.
Although the survey response rates increased pre and post campaign for Latinos, the rates
were still relatively low; 44.1% and 50.4% among pre and post-campaign Latinos, and
54.3% and 52.7% among pre and post-intervention non-Latinos. Individuals lost to follow up
were typically younger and uninsured, less likely to have completed the program, and less
likely to have requested a second NRT shipment. The media intervention had a positive
equity impact on calls to the quitline but the impact on overall quit rates is not known.
A quasi-experimental study set in New York City (NYC)115 assessed the effectiveness of a
programme of free NRT to improve smoking cessation. In 2003, the New York City
Department of Health and Mental Hygiene (NYC DOHMH), announced the availability of
free six-week courses of NRT patches to the first 35 000 eligible smokers to call the New
York State Smokers’ Quitline. All major metropolitan newspapers and television and radio
stations reported the programme launch. Neighbourhood-specific media and promotional
efforts were used to reach populations with the highest prevalence of heavy smokers. Six
months after treatment, smoking status was assessed in 1305 randomly sampled NRT
recipients and a non-randomly selected comparison group of eligible smokers who, because
of mailing errors, did not receive the treatment.
An estimated 5% of all adults in New York City who smoked ten cigarettes or more daily
received NRT; most (64%) recipients were non-white, foreign-born, or resided in a lowincome neighbourhood. Of individuals contacted at six months, more NRT recipients than
comparison group members successfully quit smoking (33% vs 6%, p<0·0001), and this
difference remained significant after adjustment for demographic factors and amount
smoked (odds ratio 8·8, 95% CI 4·4–17·8). NRT recipients who received counselling calls
were more likely to stop (246 [38%] vs 189 [29%], adjusted odds ratio 1·5; 95% CI, 1·1–
1·9) than those who did not. Similar proportions of NYC heavy smokers and NRT recipients
resided in low-income neighbourhoods. Neighbourhood income level and educational
attainment were not associated with quit success.
Of the people in the random sample, about 60% of NRT recipients participated in the 6month follow-up survey, compared to a 31% response rate for the non-random comparison
121
group (eligible callers who did not receive NRT). New York City implemented this
programme at a time when new smoke-free workplace legislation and increased taxation on
cigarettes focused public attention on cessation. However, the mass media promotion
campaign appeared equally effective across all SES.
A Canadian study119examined the reach and effectiveness of free 5 weeks mailed NRT
(patches or gum) via a quitline and included brief telephone advice among the first 14,000
eligible Ontario residents who called a toll-free quitline, who smoked at least 10 cigarettes
per day and were willing to make a quit attempt within 30 days. The Smoking Treatment for
Ontario Patients (STOP) Study was compared with population-based estimates of smoker
characteristics from a concurrent Ontario Tobacco Survey (OTS) study of smokers from the
same general population. A sub cohort of the OTS was matched to STOP participants to
assess effectiveness. The STOP study was launched in January 2006. Region-specific media
promotion was used to increase the reach in more remote regions of the province with a high
prevalence of smoking. The response rate for STOP was 48% (n=5261) and 42% had
complete follow-up data and were assessed.
The percentage of STOP participants reporting abstinence after 6 months was 21.4%,
relative to 11.6% in the no-intervention cohort (rate ratio of 1.84;95% CI 1.79 to 1.89), with
30-day point prevalence of 17.8% and 9.8% for the intervention and nointervention cohorts,
respectively (rate ratio 1.81; CI 1.75 to 1.87). Compared with all adult Ontario smokers
STOP participants were more likely to have less than high school education. The lowest
income group was associated with a lower percentage of self-reported quit at the time of
interview in bivariate analyses. In multivariate analyses neither education nor income was
significantly related to self-report at least one serious quit attempt within 6 months, being
quit at the time of interview, or 30-day quit point prevalence. In summary, mailed NRT
showed a positive equity impact in terms of reach, was equally effective in significantly
increasing quit rates across all SES groups and therefore had an overall positive equity
effect.
An English study116 evaluated the impact of a 3-month TV and advertising campaign
supported by advertorials (adverts that look like editorial) in women's magazines. The
television advertisements were targeted at young smokers (aged 16-24 years) and aimed to
challenge their reasons for smoking and provide them with reasons to quit. In contrast to
previous campaigns, the TV adverts adopted a hard hitting testimonial approach. The radio
122
and magazine adverts were aimed at a slightly wider audience and were intended to provide
support and encouragement to those who want to quit. All adverts included the freephone
Quitline number.
The study evaluated the impact of a telephone helpline (Quitline) with additional support
(written information) on callers who used the service during a mass media campaign. 3019
of 18,873 log sheets were randomly selected and compared with all smokers in the general
population in England; callers were more likely to be women, to be in the age groups 25-34
or 35-44 years, to come from households with children under the age of 16 years, and to be
heavy smokers (smoke 20 or more cigarettes a day). Of 6038 callers who had left telephone
numbers to be contacted, 730 were follow-up at one year (12%). Compared with callers at
baseline, women, those aged 35 and over, those with moderate consumption levels (10-19
cigarettes a day), and more long term smokers were overrepresented in the one year recall
sample. Quitline received around half a million calls in the course of one year, representing
4.2% of the total population of adult smokers in England.
At one year the social class profile of callers to the helpline reflected the social class profile
of all adult smokers; 63% of the sample were of manual occupations or unemployed
compared with 61% of the adult smoker population. At one year 22% (95% CI; 18.4% to
25.6%) of smokers reported that they had stopped smoking. Assuming that those who refuse
to take part in the one year follow up were continuing smokers and a further 20% of reported
successes would fail biochemical validation, this yielded an adjusted quit rate of 15.6%
(95% CI 12.7% to 18.9%) at one year. 25% (17.05 to 32.95) of social classes ABC1 and
21% (13.52 to 28.48) social classes C2DE stopped smoking at one year; manual and
unemployed ex-smokers were more likely to relapse at one year compared with non-manual
ex-smokers. Information on social class was not available at baseline and so it is not possible
to conclude about the reach of the mass media campaign, although the difference in relapse
suggest the campaign was less effective in the long-term in lower SES smokers.
A US study118 compared characteristics of new callers to a national reactive telephone
helpline with those in a control population of adult current smokers in the US (2002)
National Behavioral Risk Factor Surveillance Study and the 1999-2001 National Health
Interview Study. Mass media advertising campaigns using health consequences messages
directed homogeneously across all population segments were used to boost helpline usage.
Based upon an independent survey report of 432 callers, billboards were noted to be the most
123
common method (49.6%) for the users to learn about the helpline, followed by radio
(12.5%), television (10.6%), and word of mouth (7.6%).
A convenience sample of 890 eligible adult smokers participated (98.9%), mostly from the
Midwestern and Southern states who called the helpline during January 2003 and October
2005. There was significant overrepresentation of poorer and less educated smokers who
used this national reactive telephone helpline, when compared with the general adult
population of smokers across the United States.
There were issues with study validity; the study findings were based on a convenience
sample not sampled by a stratified design across the entire United States. Participants were
mostly from the Midwestern and Southern states so results may not be generalisable across
US. Further, all comparisons between the two populations were based on crude or
unadjusted prevalence rates. The study did not take into account the secular trends in
smoking behaviour during the period 1999 to 2005. In addition, helpline callers were more
likely to represent the contemplation stage of behavioural change than the general population
of smokers. The study did not directly measure TV advertising exposure amongst callers to
the helpline.
Television advertisements
An Australian study114 examined the efficacy of 13 different types of mass media
advertisements in driving lower SES smokers aged 18 to 39 years, to utilise quitlines over
two years (2006 to 2008). Each person within the target population was exposed 88.39 times,
and rates of exposure were similar across ad types. After all significant covariates were
included, (including the introduction of smokefree pubs and clubs legislation) increases in
anti-smoking advertising TARPs were significantly associated with the number of quitline
calls (Rate Ratio = 1.070, 95% CI 1.020 to 1.122, P = 0.005). Higher emotion narrative ad
exposure had the strongest association with quitline calls, increasing call rates by 13% for
every additional ad exposure per week (per 100 points, rate ratio = 1.132, P = 0.001).
The Victorian quitline received a significantly higher rate of calls from high SES (RR =
4.177, P < 0.001) and mid-high SES (RR = 1.804, P < 0.001) smokers compared with those
from the low SES group, but call rates from mid low SES smokers (RR = 0.869, P < 0.001)
were significantly lower than those from the low SES smokers. There was no interaction
between TARPs and SES group (P = 0.223). There were greater increases in calls to the
124
quitline from lower SES groups when higher emotion narrative ads were on air compared
with when other ad types were on air. In summary, there was a neutral equity impact,
although there was an over-representation of Quitline calls from the high SES group,
Quitline calls increased by the same degree across each SES group. Higher emotion narrative
anti-smoking ads may potentially contribute to reducing socio-economic disparities in calls
to the quitline through maximizing the responses of the lower SES smokers.
An Australian antismoking TV media campaign117 assessed the impact of anti-tobacco
television advertising on call rates to a Quitline in Victoria, and socioeconomic variations in
call rates. The TV campaign predominantly featured hard-hitting advertisements on the
health risks of smoking, and promotion of a telephone Quitline. Adverts were shown
irregularly over 169 week period; in 88 weeks there were no adverts, in 42 weeks there was a
‘medium’ volume of adverts, and in 39 weeks there was a ‘ high’ volume of adverts aired.
Attempts were made to tailor adverts to low SES groups, including placement and content.
Study participants were television viewer in Victoria who responded to the TV
advertisements by calling the Quitline and requesting a Quit Pack. Quitline calls were
tracked between January 2001 and March 2004 and linked to callers postcodes; SES
quintiles were derived from the Index of Socioeconomic Disadvantage.
Exposure to TV adverts led to higher Quitline call-rates across all five SES quintiles. Call
rates increased almost universally by 2.5-2.7 times in all five quintiles. SES and call rates
were inversely associated; the adjusted call rate was 57% (95% CI 45% to 69%) higher in
the highest than the lowest SES quintile. The call rates gradient appeared to be very similar
across SES groups. The trend in calls appeared to be very similar across SES categories,
indicating no interaction between TARPs and SES in their effect on the volume of calls.
There was no evidence of an interaction of time with SES, suggesting that SES differentials
in call rates were stable in the study period.
The study showed that TV advertising of a Quitline can have an equal effect in terms of
prompting people of all SES levels to seek help by calling a Quitline. However, an equal
increased response rate meant that there was no reduction in the relatively lower rates of
calls in the lower SES quintiles and so the summary equity impact is neutral.
125
Earned media
A US study113 evaluated the use of free nicotine patches rather than using paid media to
increase the use of a Quitline in Oregon. The study evaluated whether a multicomponent
campaign which promoted the Oregon Free Patch Initiative (FPI) in 2004, could generate
and sustain incoming call volumes to the Oregon Tobacco Quitline, (ORQL) more
efficiently than paid media advertising. Twelve of the 22 health plans contacted, agree to
promote the Free Patch Initiative (FPI) and included health maintenance organizations (both
Medicaid and non-Medicaid), preferred provider organizations, and indemnity-based plans.
The promotional plan, utilizing Roger’s Diffusion of Innovation theory, targeted health
plans, local policy makers, media sources, and referral sources, such as healthcare providers.
Word-of-mouth advertising was also encouraged using a free patch card, which could be
handed out to tobacco users. Six weeks prior to the public launch, information about the
initiative was disseminated by e-mailing and sending letters to public and private sector
partners. The ORQL paid for media (TV commercials) during the preinitiative period, but
not during the initiative.
A sample, six months prior to the launch, was utilized as the comparison group. In three
months, the FPI achieved free news media coverage, generated a 12-fold increase in calls to
the ORQL, sustained a two-fold increase in calls for 5 months after the FPI, and reached
1.3% of all Oregon smokers in 3 months. If these volumes were sustained, the annualized
reach would be 5.2%. Between October and December 2004, the top two specific sources of
hearing about the ORQL identified were TV news (17.1%) and family or friends (16.2%). In
the pre-initiative sample, the two top sources of hearing about the ORQL identified at
registration were TV/commercial (19.3%) and a Medicaid letter (17.9%).
The pre- and post-launch cohorts differed on major demographic characteristics including
education; 56.2% ‘high school or less education’ vs 54.2% after launch; 36% ‘some college’
before and 35.3% after; ‘college graduate or more’ 7.8% before and 10.5% after. The media
campaign increased calls from ‘college graduate or more’ but not ‘some college’ nor ‘high
school or less’. The study does not provide details of the relative uptake by SES. In terms of
equity based on caller educational level, the media campaign was associated with a negative
equity impact. Within 6 months of the FPI, 2 of the 22 health plans decided to add tobacco
cessation phone counselling as a member benefit. These Health Plan system changes that
occurred during the initiative may have influenced call rates.
126
Quitline number on cigarette packets
A cohort study in New Zealand91 examined how recognition of a national quitline number
changed after new health warnings were required on tobacco packaging. The study used data
from the New Zealand ‘arm’ of the International Tobacco Control Policy Evaluation Survey
which differed somewhat from other ITC samples as the smokers involved were New
Zealand Health Survey (NZHS) participants. NZHS respondents were invited at end of
NZHS to participate in this study. Wave 1 (March 2007 and February 2008) respondents
were exposed to text-based warnings with a quitline number but no wording to indicate that
it was the “Quitline” number. Wave 2 (March 2008 and February 2009) respondents were
exposed to pictorial health warnings (PHWs) that included the word “Quitline” beside the
number as well as a cessation message featuring the Quitline number and repeating the word
“Quitline.”
Quitline number recognition increased across all SES groups and the gap in quitline number
recognition between the least and most deprived groups narrowed. The overall response rate
for this study was 32.6% and the attrition was 32.9%, therefore results might not be
representative or generalisable to the overall general population of New Zealand.
Mass media campaigns to promote use of NRT
Three US studies93;120;121
were included which evaluated the effects of mass media
campaigns to promote the use of NRT.
The 2008 Nicotine Patch and Gum Program (NPGP) was a 16-day programme which used
geographic information system (GIS) analyses to monitor the large scale distribution of
nicotine replacement therapy (NRT) in New York City (NYC).120 The intake data were
analysed in two ways, as the percent of NYC current smokers enrolled (through intake
reporting) and the geographic density of enrolment (through mapping). Population estimates
for current smokers were based on self-reported data from the Community Health Survey.
All campaign messages directed interested smokers to call 3-1-1 during the publicised dates.
Applicants were notified of programme eligibility by letter; eligible callers received the
appropriate NRT package (determined by the number of cigarettes smoked per day), while
ineligible callers received a letter with a referral to other cessation services. Two days before
the end of the NPGP, the NYC Department of Health and Mental Hygiene issued a press
release announcing that there was only 48 hours left to call for NRT. The complete intake
127
data were electronically passed from 3-1-1 to the NYC DOHMH daily for analysis,
reporting, and mapping.
In 2006 the adult smoking prevalence in NYC was 17.5%, representing 1,065,000 smokers.
More than 32,000 smokers applied for the 2008 NPGP and almost 30,000 (92.1%) were
found eligible. Almost all of the applicants and enrollees (99.6%) had geocodable addresses.
The primary sources of referral reported by all NPGP enrollees were TV commercials
(66.5%), followed by recruitment letters (11.2%), word of mouth (9.5%), and radio
commercials (5.2%). Overall, 2.8% of NYC smokers enrolled in the programme. Low
income adults had high enrolment percentages: 3.3% of NYC current smokers enrolled
compared to 2.5% from middle income neighbourhoods and 2.6% from high income
neighbourhoods. Adults with less than a high school education had high enrolment: 3.6% of
NYC smokers compared to 2.7% for high school graduates; 2.7% for ‘some college’ and
1.2% for college graduates. Neighbourhoods varied in the percentage of smokers enrolled,
ranging from 1.2 to 5.1%, with the low and medium income neighbourhoods having more
enrollees compared to high income neighbourhoods. This study of a large scale distribution
of NRT programme showed a positive impact in terms of reach and uptake by low SES
smokers. GIS provided near real-time assessment of participation patterns and the impact of
media and outreach strategies and it is one of the few studies to assess reach of an NRT
programme. However results might be specific to NYC neighbourhoods.
A US study93 examined a concurrent Quit & Win contest and NRT giveaway in Erie and
Niagara counties in the western New York region. Smokers could enrol in both or either
programme (combined group). Daily smokers (at least 10 cigarettes per day) were offered
the opportunity to win prizes including $1000 if they stopped smoking for the month of
January 2003 with a quit date of 1st January. NRT vouchers were redeemable at pharmacies
for a 2-week supply of nicotine gum or patch. Media coverage included a press conference,
newspaper and television coverage. $35,000 was spent on radio advertisements aired on 6
local radio stations. The focus was mainly on the Quit & Win contest – people were
informed of free NRT giveaway when they telephoned the New York State Quitline. Both
interventions were marketed to minority populations (African American and Latino) using
newspaper, churches and community sites.
Random samples of 341 Quit & Win participants (40%) and 314 (46%) NRT voucher and
230 (100%) combination group were selected for follow-up at 4 to 7 months from the 1st
128
January 2003, by telephone survey. Follow-up rates were 60-64%, with 204, 179 and 143
participants follow-up for Quit & Win, NRT and combination groups, respectively. The 3
intervention groups were compared with smokers in the same region using Erie-Niagara
Tobacco Use Survey (ENTUS), to determine reach. At follow-up the self-reported quit rates
were similar across the three intervention groups: 25 to 30%. Compared with smokers in
region, those enrolled in the three interventions had significantly more years of formal
education. However there was no significant difference in 7-day point prevalence of
smoking by education group. It was unclear how representative the regional cohort of
smokers was in the ENTUS survey, and in addition, smokers in all three intervention groups
were heavier smokers than in general population (20-21 vs 17 cigarettes per day). In
summary, the Quit & Win contest and concurrent NRT giveaway had lower reach among
less educated smokers in two regions in the US, all 3 interventions were associated with a
25-30% quit rate which did not differ by educational level.
A US study121 evaluated the impact of a multimedia campaign to promote a Nicotine
Replacement Therapy (NRT) giveaway between May 3rd and June 6th 2006 in New York
City (NYC). Smokers could enrol via a free non-emergency government information line
and eligible callers received four weeks of NRT patches. The Nicotine Patch Program (NPP)
was advertised via a multimedia campaign (TV/radio/print in English & Spanish) from
January to October 2006, including testimonials from dying/sick smokers, and graphic
images of smoking’s impact. The NPP was assessed by random telephone survey of adult
smokers in NYC (n=1000) conducted in 2006 in English or Spanish. The study aimed to
aimed to improve understanding of: (1) awareness of the 2006 Nicotine Patch Program
(NPP) among New York City (NYC) smokers; (2) differences in sociodemographic
characteristics among those who reported a desire to participate compared to those who did
not; (3) perceived barriers and reasons for not wanting to participate; and (4) suggested
outreach methods for future giveaways and media campaigns.
Programme awareness was 60% overall, with most awareness coming from TV advertising
(62%) followed by word-of mouth (19%) and radio advertisements (14%). Interest among
those who hadn’t heard of the programme was 54%. Reported awareness was significantly
lower for the highest income group ($75,000 or more) and for the highest education (college
graduate) group. Populations with lower levels of income and education expressed more
interest in the programme compared to groups with higher levels of income and education.
Compared to 37% of respondents with an annual income of $75,000 or more, 56% of
129
respondents each earning less than $25,000 (p=0.04) and $25,000 to less than $50,000
(p=0.03) reported program interest. Sixty-three percent of those with less than a high school
education (p=0.04) and 67% of high school graduates (p<0.001) reported program interest,
compared to 43% of college graduates.
Summary equity impact for awareness and interest in the programme was positive however,
there was no SES evaluation of the other research questions (3) perceived barriers and
reasons for not wanting to participate; and (4) suggested outreach methods for future
giveaways and media campaigns. Response and co-operation rates were low; 14% screening
response rate to the survey and 56% (n=602) completed the survey. The study extrapolated
data from a very small population to make assertions about a huge, diverse city. There was
no assessment of the representativeness of the sample of either smokers or NYC as a whole.
The study was likely to over-estimate the number of potential users given the hypothetical
question on interest (those reporting interest would significantly outweigh the number of
actual users). Programme awareness estimates might also be overestimates, because study
authors note that the NPP was tied to a larger social marketing campaign around quitting
smoking.
Summary of mass media campaign to promote the use of quitlines and use of NRT
Nine studies used mass media to promote the use of quitlines and three studies used mass
media to promote use of NRT. In general, the evidence of effectiveness of mass media
campaigns to promote the use of quitlines in terms of equity was inconsistent.
Mass media smoking cessation advertising campaigns to promote the use of quitlines were
associated with increases in calls to telephone helplines for quitting smoking. Three of the
nine studies showed greater effectiveness for lower SES smokers compared with higher SES
smokers.91;112;118;119. One US study found higher calls to quitlines (motivational response,
stage 2) and a New Zealand study found greater recognition of a quitline number on cigarette
packs (recall, stage 1). It is unclear how quitline number recognition might translate into
quitting. A Canadian study of a mass media campaign and provision of free NRT by mail
following a brief telephone intervention showed a positive equity impact in terms of reach,
was equally effective in significantly increasing quit rates across all SES groups and
therefore had an overall positive equity impact.
130
Three studies showed equal effectiveness (neutral impact) in terms of calls to quitlines by
SES114;117and in quit rates.
115
Higher emotion narrative anti-smoking ads may potentially
contribute to reducing socio-economic disparities in calls to quitlines through maximizing
the responses of the lower SES smokers. Two studies showed lower effectiveness for low
SES groups, in terms of calls to quitlines113and smoking relapse.116 An English study116
evaluated the impact of a 3-month TV and advertising campaign, showed that manual and
unemployed ex-smokers were more likely to relapse at one year compared with non-manual
ex-smokers.116 It was not possible to conclude about the reach of the mass media campaign,
although the difference in relapse rates, suggests the campaign was less effective in the longterm in lower SES smokers.
Three US studies93;120;121
were included which evaluated the effects of mass media
campaigns to promote the use of NRT. A multimedia campaign to promote awareness of a
nicotine patch giveaway was associated with a positive equity impact: there was significantly
lower reported awareness of the nicotine patch giveaway for the highest income and
education groups.121 Another study (by the same first author) of a large-scale distribution of
NRT showed a positive impact in terms of reach: low income and low education smokers
had higher participation rates. Among neighbourhoods with high smoking prevalence, lower
income neighbourhoods had higher enrolment compared to higher income neighbourhoods.
Geographic information system analyses provided near real-time assessment of participation
patterns and the impact of media and outreach strategies and it is one of the few studies to
assess reach of an NRT programme. However the results from this study might be specific
to NYC neighbourhoods. A US Quit & Win contest with a concurrent NRT giveaway had
lower reach among less educated smokers in two regions in the US, all 3 interventions were
associated with a 25-30% quit rate which did not differ by educational level.
3.6 Multiple policies
Four studies54;56;122;123 which examined the impact of multifaceted policies were included,
two54;56 of which also reported results for separate policies and are reported in the relevant
sections of this review.
Three studies used repeat cross-sectional data, one study used USA data54 and two studies
were set in the Netherlands.122;123 One study used single cross-sectional data from 18
European countries.56 The two Dutch studies had large study samples and used the same
internet-based survey source. All four studies used education as an SES variable; one study
131
used the relative index of inequality (RII)56 and one Dutch study122 also used household
income.
All studies examined the impact of multifaceted tobacco control policies; including
smokefree workplace and enclosed public places legislation, increases in price/tax of
cigarettes, tobacco control campaign spending, advertising bans, health warnings, and mass
media smoking cessation campaigns. Outcomes included smoking prevalence, self-reported
behavioural responses to policies, smoking consumption, smoking initiation ratios, quit
attempts, and quit ratios. Most of the studies examined trends in data; the study in 18
European countries56 used log-linear regression analyses to explore the correlation between
national quit ratios and scores (both total and sub scores by individual policy) on the
Tobacco Control Scale (TCS).
A US study54 determined the impact of comprehensive tobacco control measures in New
York City (NYC) beginning in 2002 (cigarette tax increases, Smoke-free Air Act (SFAA)
2002, free NRT, tobacco control media campaign). During the 10 years preceding the 2002
programme, smoking prevalence did not decline in NYC. From 2002 to 2003, smoking
prevalence among NYC adults decreased by 11% (from 21.6% to 19.2%, (P =.0002)
approximately 140000 fewer smokers). Smoking declined among all education levels.
Groups that experienced the largest declines in smoking prevalence included residents in the
lowest and highest income brackets and residents with higher educational levels.
High-income people were more likely than low-income people to report that the SFAA
reduced their exposure to ETS (53.3% vs 41.9%, P<.0001). Residents with low incomes
(<$25000 per year) or with less than a high school education were more likely than those
with high incomes (>$75 000 per year) and those with a high school education or higher to
report that the tax increase reduced the number of cigarettes they smoked (income: 26%
[low] vs 13.0% [high], P=.0002; educational attainment: 27.5% [lower] vs 19.3% [higher],
P=.009). The authors concluded that the data suggest that people with lower incomes may
have been more affected by the increase in taxation, whereas people with higher incomes
may have been more affected by greater awareness of the dangers of SHS and smokefree
legislation.
A Dutch study123 explored how the combination of a workplace smoking ban and two tax
increases influenced the smoking behaviour of the general population (>32,000) using repeat
cross-sectional survey data from the internet-based Dutch Continuous Survey of Smoking
132
Habits. Survey respondents were grouped into those who had paid work and those that
didn’t, in order to control for exposure to the workplace smoking ban.
There were no significant changes in the percentage of quit attempts among those with or
without paid work. For respondents with paid work, the combination of a smoking ban and 2
tax increases led to a decrease in the number of cigarettes per day and in the prevalence of
daily smoking. For respondents without paid work, there was no significant effect on any of
the outcome parameters.
For paid workers, there was no significant change (OR: 0.87) in the likelihood of daily
smoking among the respondents interviewed in the one month (January 2004) in which the
ban without additional tax increases was in force, although the OR was similar to the other
interventions. The effects of the first (OR: 0.86) and second tax increase (OR: 0.85) after the
ban on daily smoking were significant and in the expected direction. Among those without
paid work, the tax increases had no significant effect on the likelihood of daily smoking.
However, in terms of effect size, there was little difference between those with and without
paid work in the effect of the first (OR: 0.86 vs. OR: 0.87) and second (OR: 0.85 vs. OR:
0.94) tax increase. In both paid and unpaid groups, there was no evidence that the effect of
the measures on smoking was moderated by the respondent’s level of education.
Study authors argue that lack of significant effect for the workplace smoking ban amongst
paid workers, despite a relatively strong effect, might have been due to lack of statistical
power, and that due to the short time span in which the effect of the workplace smoking ban
alone could be measured (1 month); the influence of the workplace-smoking ban is likely to
be incorporated in the effects found for the first and second tax increase and so the individual
policy elements should not be teased out, but evaluated in combination. There is the
possibility that the study sample was not representative, particularly of those not in paid
work.
Another Dutch study122 examined trends in socioeconomic inequalities in smoking
prevalence, consumption, initiation, and cessation between 2001 and 2008, also using repeat
cross-sectional survey data from the internet-based Dutch Continuous Survey of Smoking
Habits. Several tobacco control policies were implemented; in 2002 text warning labels for
cigarette packages were introduced, in 2002 there was a tobacco advertising ban, in 2003 a
youth access law, in 2004 smoke-free workplace legislation was implemented which was
extended in 2008 to include the hospitality industry. Tax increases were implemented in
133
2001, 2004, and 2008. Intensive national mass media smoking cessation campaigns ran in
2003, 2004, and 2008.
While inequalities in smoking prevalence were stable among Dutch men, they increased
among women, due to widening inequalities in both smoking cessation and initiation.
Among men, educational inequalities widened significantly between 2001 and 2008 for
smoking consumption only.
Lower educated respondents were significantly more likely to be smokers, smoked more
cigarettes per day, had higher initiation ratios, and had lower quit ratios than higher educated
respondents. Income inequalities were smaller than educational inequalities and were not all
significant, but were in the same direction as educational inequalities. Among women,
educational inequalities widened significantly between 2001 and 2008 for smoking
prevalence, smoking initiation, and smoking cessation. Among low educated women,
smoking prevalence remained stable between 2001 and 2008 because both the initiation and
quit ratio increased significantly. Among moderate and high educated women, smoking
prevalence decreased significantly because initiation ratios remained constant, while quit
ratios increased significantly. It should be noted that there was evidence of an increase in
respondents to the survey with higher incomes over time.
One study examined the extent to which tobacco control policies (increase in cigarette price,
advertising bans, public place bans, campaign spending, health warnings) were correlated
with smoking cessation, in eighteen European countries.56 Log-linear regression analyses
were used to explore the correlation between national quit ratios and scores (total and sub
scores by separate policy) on the TCS.
The study found large variations in quit ratios (ratio of the number of ex-smokers divided by
the number of ever-smokers (current + former smokers)) and RII between countries. Quit
ratios were positively associated with TCS score; more developed tobacco control policies
were associated with higher quit ratios. More educated smokers were more likely to have
quit than lower educated, for men and women. There was a larger absolute difference
between high and low educated adults for 25-39 year olds. Policies related to cigarette price
showed the strongest association with quit ratios, a comprehensive advertising ban showed
the next strongest association with quit ratios and health warnings were negatively associated
with quit ratios.
134
There was significant positive association between quit ratio and price for high SES men and
women aged 40-59 years. There was significant positive association between quit ratio and
advertising bans for high SES men and women across both age groups and low SES men
aged 25-39 years. However, no consistent differences were observed between higher and
lower educated smokers regarding the association of quit ratios with score on the TCS.
Strong conclusions cannot be drawn because of various study limitations; the survey was
conducted before the TCS was devised, and before some were policies enacted, so the study
results might underestimate the impact of recent smoking policies. In addition, the study
only examined the association between ex-smokers and presence of policies, rather than
changes in smoking prevalence post-implementation.
Summary of multiple policies
Four cross-sectional studies54;56;122;123 examined the equity impact of multiple tobacco
control policies; including smokefree workplace and enclosed public places legislation,
increases in price/tax of cigarettes, tobacco control campaign spending, advertising bans,
health warnings, and mass media smoking cessation campaigns.
On the whole, these multifaceted tobacco control policies were associated with a neutral
equity impact. High and low SES groups seem to benefit equally from nationwide tobacco
control policies. In one European-wide study, more developed tobacco control policies were
associated with higher quit rates. Policies related to cigarette price showed the strongest
association with quit ratios; significant associations with price were found for high education
males and females aged 40-59 years. A comprehensive advertising ban showed the next
strongest association with quit ratios; the association was stronger in the higher educated
group compared to the lower educated group in most age/sex groups.
Evidence suggests that different elements of these multiple policies may impact
differentially by SES. For example, people with lower incomes were more affected by the
cigarette tax increase, whereas people with higher incomes may have been more affected by
greater awareness of the dangers of SHS and smokefree legislation.
Evidence also suggests that within and across different SES groups; impact of multiple
tobacco control policies varies by age, gender, and according to the type of smoking-related
outcome that is measured. One Dutch study showed that initiation ratios (ratio of ever
smokers to all respondents) amongst low SES women increased and amongst moderate/high
135
educated women initiation rates did not change. Quit ratios (ratio of former smokers to ever
smokers) increased in all SES groups but overall, educational inequalities widened amongst
women for smoking prevalence due to the differences in initiation ratios between SES
groups.
3.7 Settings based interventions
Seven studies124-130 were included which evaluated the impact of settings based
interventions.
Four studies126-129 did not focus on smoking alone, but on broader inequalities related to
lifestyle (diet, physical activity, and smoking) and the wider environment (unemployment,
education, crime and the physical environment). Two studies were cancer prevention
initiatives (diet and smoking) set in manufacturing worksites in Massachusetts, USA;
WellWorks and WellWorks-2 which were developed by the same research group.126;127
WellWorks-2 integrated health promotion with occupational health and safety issues. The
New Deal for Communities (NDC) in England128 aimed to improve conditions in some of
most deprived neighbourhoods in the country. The Hartslag Limburg Intervention129 was a
five year community cardiovascular risk reduction lifestyle intervention programme in the
Netherlands.
Two community-based studies focussed on reducing smoking; one targeting AfricanAmerican smokers in low income and moderate income areas in four sites in the northeastern and south-eastern parts of the United States124 and one study targeting women,
particularly low-income women of childbearing age in two rural counties in Vermont and
New Hampshire, USA.125
One study looked at the association between tobacco control policy and quit rates and the
influence of education level, within alcohol-addicted hospital in-patients in Germany.130
Measures of SES included education, income-level of areas, household income; and
occupation for the two worksite studies. The two worksite studies and the NDC study
reported an equity focus although both smoking interventions targeted lower-income adults
(African-American and American women of childbearing age). All studies except one
reported quit or abstinence rates, one study also reported smoking initiation rates129 and one
study reported smoking prevalence and quit attempts.124
136
Six studies compared results with a control group and two125;129 of these studies were
assessed as having comparable groups at baseline. One study used repeat cross-sectional
samples to observe changes in behaviour125 and two studies observed changes within a
cohort compared to an external comparison cohort128;129 One study was quasi-experimental
in design124and two studies were RCTs of worksite health promotion interventions ‘WellWorks’ and ‘WellWorks-2’ - that included stopping smoking.126;127 However both of
these RCTs were not assessed according to an intention to treat (ITT) method. A seventh
study did not have a control group and applied a pre-post design with parallel cross-sectional
assessments.130
In the WellWorks126 study a random sample of workers were selected both at baseline and at
follow-up and completion rate of the surveys was 61% and 62% respectively, however the
paper focuses on those workers who responded to both surveys. In WellWorks-2127 15 out of
41 eligible worksites agreed to participate; the response rate of workers was 80% (range 64
to 92%) at baseline and 65% (range 31 to 89%) at follow-up. The study used both crosssectional data and an embedded cohort of respondents for analyses. In both RCTs126;127 it
was unclear how representative the study samples were of the study population, whether the
intervention and control groups were comparable, and if the attrition rates were acceptable.
Only one125 of the seven study samples were assessed as representative of the study
populations, with findings that are generalisable on a regional scale. The majority of studies
used credible data collection methods. The two worksite studies and the hospital-based study
did not have acceptable levels of attrition. With the exception of the NDC initiative (where
there was overlap between intervention and comparator sites) and the hospital-based study, it
is likely that the observed effects were directly attributable to the community-based
intervention.
3.7.1 Community
Two broad health inequalities studies set in the community included the New Deal for
Communities (NDC) in England128 and the Hartslag Limburg Intervention in the
Netherlands.129
The New Deal for Communities (NDC) area-based initiative128 aimed to improve conditions
in some of the most deprived neighbourhoods in England and reduce the gap between them
and the rest of the country. There were 39 NDC areas, each with a budget of approximately
£50 million with which to address five specific outcome areas (health, unemployment,
137
education, crime and the physical environment) over 10 years. It was unique in this review in
targeting a broad range of social determinants of inequality. A longitudinal survey of 10 390
residents in NDC areas and 977 residents in comparator areas was undertaken with followup at two years (2002 to 2004).
Small overall improvements were seen on all domains in NDC areas but similar
improvements were also seen in comparator areas. More than 10% of residents quit smoking
in NDC areas. At baseline there were large differences by education for smoking between
the intervention and control sites, and these differences widened over the two-year followup. In NDC areas, higher educational groups were more likely to stop smoking. NVQ1 is up
to general certificate of secondary education (GCSE) level and NVQ4 is up to degree level.
The odds ratio for quitting smoking in the NDC areas for NVQ 1-2 was 1.14 (95% CI: 0.86
to 1.50) and for NVQ 3-5 was 1.49 (95% CI: 1.14 to 1.95). The odds ratio for quitting
smoking in the comparator areas for NVQ 1-2 was 0.55 (95% CI: 0.23 to 1.32) and for NVQ
3-5 was 1.48 (95% CI: 0.57 to 3.87). In summary, adults with higher education were more
likely to quit smoking within NDC group but there was no significant difference between
NDC areas and comparator areas, so in terms of equity there was no intervention effect.
The attrition rate was 27% in the intervention group and 28% in the comparator group at two
years. The comparator areas had a slightly lower proportion of residents with no educational
qualifications (33% versus 39%) which may indicate that the comparator areas were slightly
less deprived than their NDC counterparts. There was considerable overlap of area-based
initiatives in NDC areas and it is likely that interventions were underway in some of the
similarly deprived comparator areas.
The Hartslag Limburg Intervention in the Netherlands129 was a five year community
cardiovascular risk factor reduction lifestyle intervention programme, encouraging people to
reduce their fat intake, be physically active, and stop smoking. It was an umbrella project
with two strategies, one at population level and the other targeted at deprived communities.
790 interventions were implemented (9 were anti-smoking interventions). Almost 50% of the
interventions took place in deprived areas. Examples of interventions were nutrition parties;
debt assistance (people with debts are taught to cook a healthy meal on a small budget);
printed guides showing walking and cycling routes; a daily TV guided aerobics programme,
including information about the health advantages of exercising; and anti-smoking
campaigns using billboards, posters, and leaflets.
138
To evaluate the programme, a longitudinal survey was undertaken with follow-up at five
years (1998 to 2003) of 2356 participants in experimental area (Maastricht), and 758 in
control area (Doetinchem). The participants in the intervention were involved in a previous
health monitoring study, and so were likely to be more health conscious than the general
population. Follow-up rate was over 80% in both intervention and comparator areas. At five
years, 6.5% of men and 5.8% women in the intervention group quit smoking compared to
5.8% men and 5.9% women in the control group. Initiation of smoking was 3.2% men and
3.3% women in the intervention group, and 2.3% men and 3.2% women in the control
group. All changes were significant for within group changes and there were no significant
differences between intervention and control groups. Smoking quit rates by low versus
median/high education was 6.2% vs 6.1% in the intervention group and 5.8% vs 5.9% in the
control group. Smoking initiation by low versus median/high education was 2.2% vs 4.3% in
the intervention group and 2.0% vs 3.7% in the control group. There were no significant
between intervention and control by educational level.
Two community-based studies focussed on reducing smoking; one targeting AfricanAmerican smokers in low income and moderate income areas124 and one study targeting
low-income American women of childbearing age.125
A community-based intervention124 targeted 2,644 black smoking households in four sites in
the north-eastern and south-eastern parts of the United States. A sample of 520 smokers was
randomly drawn from the baseline cohort for the six-month follow-up. For the twelve-month
follow-up a random sample of 490 smokers were selected from the original cohort
(excluding those individuals who had participated in the six-month follow-up). At the
eighteen-month follow-up survey (1989 to 1990), 2096 members of the original cohort left
were followed up. The community as a whole (both the active and the passive areas) were
exposed to a mass media campaign designed to promote readiness to quit smoking. The
active intervention included area-based educational interventions to reduce smoking. The
community-based intervention was centred on the health belief and diffusion of innovation
models.
At 18 months, there was a 41.5% greater point prevalence rate of non-smoking in the active
versus the passive intervention areas which was statistically significant. At 18 months, 1344
baseline smokers were re-interviewed in the active intervention groups combined, and the
point prevalence of non-smoking was 16.7% while it was 11.8% in the passive groups
139
combined, an absolute difference of 4.9 percent. Significant beneficial changes were also
observed for the intervention for quit attempts in the previous six months, number of
smokefree days and number of cigarettes smoked. The moderate income areas tended to
show a smaller percentage change in smoking outcomes in the intervention versus control
groups, than did the lower income areas, although the differences were not significant. The
exception to this was the greater percentage reduction in the number of cigarettes smoked.
Education was not significantly related to outcome variables. Within the paper there was no
specific outcome data by income area and income areas were not defined in any detail and so
it is difficult to ascertain what the impact of the intervention was by area SES.
One community-based intervention ‘Breathe Easy’ aimed to reduce the prevalence of
cigarette smoking among women with special emphasis on lower-income women of
childbearing age, among whom smoking was most prevalent.125 Two counties in Vermont
and two counties in New Hampshire, USA were assessed pre-intervention and postintervention using random-digit-dialled telephone surveys over four years (1989 to 1994).
Social cognitive theory, the transtheoretical model of behaviour change, diffusion of
innovation theory, and communications theory guided the intervention. Community
organization approaches to create coalitions and task forces to develop and implement a
multicomponent intervention with a special focus on providing support to help women quit
smoking. A community coordinator formed a local planning group, each county's planning
group formed a coalition, and each coalition recruited volunteers to serve on 5 working
groups: support systems, health professionals, educators, worksites, and mass media.
In the intervention counties, compared with the comparison counties, the odds of a woman
being a smoker after 4 years of programme activities were 0.88 (95% CI = 0.78, 1.00,
p=0.02); women smokers' perceptions of community norms about women smoking were
significantly more negative and the quit rate in the past 5 years was significantly greater
(25.4% vs 21.4%; P=0.002). Quit rates were significantly higher in the intervention counties
among women with household annual incomes of $25 000 or less (14.6±2.0) compared with
control counties (22.6±2.3), p<0.01. There was no significant difference in 5 year quit rates
between intervention and control with household income >$25,000.
The response rates were 79.1% for the baseline survey and 89.9% for the year 5 survey of
eligible households. The mass media campaign was used in the context of a comprehensive
community programme including telephone counselling, support groups, primary care
140
interventions, cessation classes, workplace initiatives, health fairs and public events – and so
it is difficult to tease out independent effects of any separate component of the intervention.
3.7.2 Workplace
Two ‘linked’ RCTs evaluated worksite cancer prevention initiatives ‘WellWorks’126 and
‘WellWorks-2’127 which targeted behavioural risk factors including smoking in workers in
worksites in Massachusetts, USA. In the earlier trial (WellWorks) one worksite in each
matched pair was randomly assigned to the intervention and the other to the control group.
61% of worksites completed surveys at baseline (range by worksite was 36 to 99%), and
62% completed surveys at follow-up (range by worksite was 43 to 92%). The three
occupation groups were; ‘skilled and unskilled labourer (blue collar workers)’ ‘office work’
and ‘professional, managerial and administrative work’.
The intervention consisted of a whole worksite cancer prevention initiative, particularly
tailored for blue-collar workers, targeting behavioural risk factors (diet and smoking) and
exposure to job-related hazards in 2386 workers in 24 predominantly manufacturing
worksites. Three key intervention elements targeted health behaviour change: (1) joint
worker management participation in programme planning and implementation (2)
consultation with management on work-site environmental change (3) health education
programmes. The study length was 5 years (1989 to 1994) and the smoking outcome was 6month self-reported abstinence.
No significant effects were observed for smoking cessation; six-month smoking abstinence
rates were 15% in the intervention worksites and 9% in control worksites controlling for
worksites (p=0.123). When worksite was removed from the model, the OR for the
intervention effect was 1.83 (p=0.04). The intervention impact by job category was not
significant, though there was a trend with 6-month abstinence rate for skilled and unskilled
labourers 17.9% in the intervention sites and 9.0% in the control sites. For office workers
abstinence was 5.1% in control sites vs 2.5% in intervention sites, for professionals and
managers abstinence was 18.6% in control and 14.2% in intervention sites (abstinence rates
higher in control). Thus the intervention had no significant impact and no equity effect
(neutral equity impact).
It should be noted that this study focuses on the cohort of workers who completed both
baseline and follow-up surveys (62%) and that there were a differentially low proportion of
smokers and office workers which may have impacted on the abstinence results. Compared
141
with those responding only at baseline; the cohort had higher percentage of skilled and
unskilled labourers (49 vs 43%) and lower smoking prevalence (23% vs 26%). Members of
the cohort were less likely to have college degrees (26% vs 30%) but more likely to have
some college education (37% vs 32%).
The later study (WellWorks-2), similarly tailored to address needs of blue collar workers
consisted of a worksite health promotion integrated with an occupational health and safety
intervention (HP/OHS Group; seven worksites) compared with a worksite health promotion
only intervention (HP Group; eight worksites). It included interventions at the individual,
organisational, and environmental levels of influence and was conducted between 1997 and
1999. Worksites ranged in size from 424 workers to 1585 workers (mean: 741 per site).
Types of manufacturing at the worksites included adhesives, food, technology, jewellery,
motor controls, paper products, newspaper, abrasives, automobile parts, and metal
fabrication. 5156 workers responded to both the baseline and final survey; there was an
‘embedded cohort’ of 880 smokers at baseline who responded to the final survey.
‘Hourly wage earners’ were classified as blue collar workers and ‘paid on salary’ as white
collar workers. The primary smoking outcome was self-reported abstinence for six months
prior to the survey. Current smokers were defined as having smoked at least 100 cigarettes in
their lives and defined themselves as current smokers. For all smokers the quit rates were
higher in the HP/OHS condition compared to the HP group, but the difference was not
statistically significant; 11.3% vs 7.5% respectively, p=0.17. Smoking quit rates among
hourly workers in the HP/OHS condition more than double those in the HP condition (11.8%
vs. 5.9%; p=0.04). There were no differences in quit rates between intervention groups for
salaried workers. Smoking quit rates among salaried workers in the HP/OHS condition was
9.9% vs 12.7% in the HP condition p=0.63. Thus the intervention appeared to have a
positive equity impact.
In WellWork-2 the unit of randomization and intervention was the worksite, while the unit
of measurement was the employee. Of 41 eligible worksites, 15 agreed to participate which
is a 37% response rate. Response rate to the baseline cross-sectional survey was 80%, the
response rate to the final survey was 65%. It was unclear how many smokers at baseline in
the ‘embedded cohort’ did not respond to the follow-up survey. It was also unclear which
differences in baseline characteristics between groups were adjusted for in analyses. The
142
measure of blue and white collar workers used in the WellWorks-2 study might not transfer
to other types of business.
Although both WellWorks and WellWorks-2 were RCTs; quit rates were not assessed in all
smokers randomised to each intervention. In addition, participating worksites might not be
representative of general population of worksites of this size and type of business.
3.7.3 Hospitals
One study looked at the association between tobacco control policy and quit rates and the
influence of education level, within alcohol-addicted in-patients in Germany.130 The study
explored the influence of tobacco control policies in German in-patient substance abuse
treatment centres on the smoking status of alcohol-addicted patients at discharge. Patients
were recruited consecutively in a 6-month period starting June 2005, 774 (65.7%) alcoholaddicted in-patient smokers were followed up in 37 treatment centres. The mean duration of
treatment was 12.9 weeks. The majority of the centres were located in the western part of
Germany. One fourth of the recruited patients were female, the mean age of the patients was
42 years. The majority of the patients were not employed and had an education of less than
12 years. The mean smoking prevalence of patients at admission was 84% varying between
65% and 100%.
The Institutional tobacco control policy contained seven elements regarding Restrictions,
Enforcement, Assessment of smokers, Smoking cessation offers, Non-smoker protection,
Activities, and Training of Employees. The questionnaire consisted of scores up to an
optimal 100, for seven policy areas and was developed using published material and piloted.
Retest reliability was acceptable in 5 of 7 areas (r=0.61 to r=0.81) and in 2 areas the retest
reliability was ≤0.5. The tobacco control policy questionnaire was anonymous and answered
by the director of each treatment centre.
There was a small but significant effect of centres’ tobacco control policy on patients’
smoking cessation. A total of 39/774 in-patients that were smokers at admission (N=774)
were non-smokers (7-day prevalence) at discharge. This equals an abstinence rate of 3.3%
(intent-to-treat-analysis) respectively 5.0% (exclusion of drop outs). Abstinence rates varied
between centres within the range of 0% to 23%. Lower tobacco dependency predicted nonsmoking status at discharge (OR=0.84, 95% CI= 0.71 to 0.99). Comprehensiveness of
smoking restrictions (OR=1.03, 95% CI=1.00 to 1.07) and intensity of smoking-related
training of employees (OR=1.02, 95%CI=1.00 to 1.03) were significant predictors for the
143
variance in quit rates between the centres. Significant individual predictors for quitting
included educational status (OR=1.86, 95%CI=1.25 to 2.75), with higher education
predicting non-smoking status at discharge.
The study sample was a very specific population of smokers whose quit rates were relatively
low and the effects of the tobacco control policy were small. It was unclear how
representative the study sample was; compared with the general German population the
education of the sample was lower and the unemployment higher. There might have been
some selection bias as the majority of the treatment centres were self-selected and was only
one-fifth of all German in-patient substance abuse treatment centres. In addition attrition rate
was relatively high; 34% of the smokers dropped out of the study.
Summary of settings based interventions
There were seven settings based interventions: four community, two workplace and one
hospital based intervention. Two of the community based and both workplace interventions
focused on broader inequalities related to lifestyle and the wider environment.
Two studies demonstrated positive equity impacts; a workplace intervention integrating
health promotion with occupational health and safety efforts significantly improved smoking
quit rates among blue-collar manufacturing workers compared to health promotion alone, in
Massachusetts, USA. The ‘Breathe Easy’ community intervention which targeted lowerincome women produced higher quit rates amongst these women after four years.
Three interventions showed neutral effects for SES; a cancer prevention workplace
intervention showed that job category was significantly associated with smoking but there
were no significant effects of the intervention for smoking cessation, and intervention by job
category interaction was not significant. A community-based intervention targeting AfricanAmerican smokers showed that education was not significantly related to smoking outcomes
at 18 months. The community-based Hartslag Limburg Intervention did not reduce smoking
or prevent starting smoking in the general population or among low SES adults in the
Netherlands.
Two studies showed a negative equity impact. The NDC initiative in England, which was the
only intervention in the whole review to address the wider social determinants of inequality,
showed differences by education for smoking widened over the two-year follow-up. The
initiative did not demonstrate a beneficial effect, either overall or for lower SES. Residents
144
with lower education experienced the least favourable health profiles at baseline and the
smallest improvements. In a hospital-based study of alcohol addicted patients, at a time
when Germany did not have comprehensive smokefree hospitals; tobacco control policy
within substance-abuse treatment centres was likely to have had a negative equity impact,
with higher education predicting non-smoking status at discharge. There were two predictive
areas of tobacco control policy (restrictions and employee training) while an overall
effectiveness of the tobacco control policy could not be proven.
145
3.8 Population-level cessation support interventions
3.8.1 National Quitlines
A New Zealand study131 evaluated reach of a quitline using repeat cross-sectional data from
the New Zealand Health Survey (NZHS) as part of The International Tobacco Control Policy
Evaluation Survey (ITC Project). It should be noted that another study91 is included within
this review (which examined the effect of including the word “Quitline” and the telephone
number to new pictorial health warning labels of cigarette packets) that uses the same
participant data.
A complex sample design included systematic boosted sampling of the Māori, Pacific, and
Asian populations. The initial wave (2007 to 2008) included 2,438 adult participants,
between-wave attrition of 32.9% resulted in 923 respondents in wave 2 (2008 to 2009).
Quitline use in the last 12 months rose from 8.1% (95% CI = 6.3%–9.8%) in Wave 1 to
11.2% (95% CI = 8.4% to 14.0%) at Wave 2. There was higher usage with increasing small
area deprivation (p = .04 for trend) and for higher ratings in one of the two measures of
financial stress “not spending on household essentials”. The overall response rate was
32.6%, and results were weighted to adjust for the complex study design and high level of
non-response. The weighting process may not have fully adjusted for nonresponse bias,
potentially affecting the generalizability of the findings to all NZ smokers.
In summary, one study was identified which evaluated reach of a national Quitline, and
found that SES was not significantly associated with Quitline usage. The equity impact was
unclear because of inconsistency of outcome between SES measures, uncertainty about how
quitline calls translates to smoking prevalence, and lack of representativeness of study
sample.
3.8.2 UK NHS Smoking Cessation Services
The UK is the only country in the world to have established comprehensive local smoking
cessation services which are available to smokers free as part of NHS. This state-reimbursed
stop smoking service provides behavioural support and pharmacotherapy. Thus, while
services are delivered at the individual level (either one-to-one or in groups), because of their
national comprehensive coverage they can also be regarded as a population-level policy
intervention.
146
Six studies of UK NHS stop smoking services (SSSs) which reported the reach of these
services were included. Articles were only included if they reported on the impact of the
SSSs in terms of reach and/or impact at the population level. An early study of NHS
SSS’s132aimed to evaluate the reach of the service and quit rates at four weeks in 76 of 99
health authorities in England during 2000/2001. One cross-sectional study examined the
reach of NHS SSSs in Spearhead (deprived) areas and impact on inequalities in smoking in
England.133 Another cross-sectional study evaluated the prevalence of smoking status,
provision of advice and referral to NHS SSSs and whether trends differed by deprivation
group across the UK.134 Another study135 examined the impact of an NHS SSS rolling-group
drop-in service in a cohort of clients in Liverpool and Knowsley (England) over a year.
Another cross-sectional study136 assessed the impact of the Quality and Outcomes
Framework (QOF) on the recording of smoking targets in primary care medical records in
the UK. A ‘grey literature’ report evaluated the NHS SSSs in Scotland.137
A study of NHS SSS’s132aimed to evaluate the reach of the service and quit rates at four
weeks in 76 of 99 health authorities in England during 2000/2001 when the service was
relatively new. There was considerable variation in outcomes across the health authorities
including those sampled and not sampled.
A wide range of service characteristics (individual sessions, stronger service relationships,
service operating at full capacity, smoking cessation co-ordinator hours, location of service)
were significantly associated with the outcome measures: reach, absolute success, cessation
rate, and loss to follow up. A number of area characteristics were also significantly
associated with outcome measures. Area characteristics accounted for a large proportion of
the variation in reach (81%) and the absolute number of successful self-reported four week
quits (79%). Study authors argue this is due to the service being more developed and better
funded in HAZ areas. Service characteristics were substantially more important in
accounting for the cessation rate (78%) and loss to follow up (98%).
Cessation services based in health action zones (HAZ, areas of high deprivation) reached
140% more smokers compared to other more affluent areas, and the number of people who
reported quitting at four weeks was 90% greater in HAZ areas. However, there was an
inverse relationship between reach and cessation rates (the number of smokers who reported
quitting at four weeks as a percentage of those setting a quit date). Cessation rates were
lower in deprived areas compared with more advantaged areas. Typically the cessation rate
147
in an area with an upper quartile deprivation score was 6% lower than that in an area in the
lower quartile. Services operating in deprived areas were more likely to lose clients between
setting a quit date and reporting outcomes at four weeks. The study did not assess the overall
equity impact of the services (ie whether the higher reach in deprived areas compensated for
lower quit rates). Therefore the equity impact is unclear.
One study133 examined the impact of NHS SSSs in Spearhead areas which are officially
designated as the most disadvantaged local authority areas in England and account for about
30% of the adult population. Estimates of smoking prevalence were compared with national
monitoring data from the NHS SSSs to evaluate reach of services and impact on inequalities.
Self-reported 4-week quit rates were lower in disadvantaged areas (52.6%) than elsewhere
(57.9%) (p<0.001), but the proportion of smokers being treated was higher (16.7% compared
with 13.4%) (p<0.001). Overall, the proportion of all smokers who were estimated to have
quit at 4 week and 52 week follow up was higher in the Spearhead areas (8.8% and 2.2%)
than elsewhere (7.8% and 1.9%) (p<0.001). Assuming 75% of 4 week quitters would relapse
(across all areas) within one year, the absolute and relative rate gaps in smoking prevalence
between Spearhead areas and others were estimated to fall by small but statistically
significant amounts from 5.2 and 1.215 (CIs: 1.216 to 1.213) to 5.0 and 1.212 (CIs: 1.213 to
1.210) between 2003-4 and 2005-6. The study found that although disadvantaged groups had
proportionately lower quitting success rates than their more affluent neighbours, services
were treating many more clients in disadvantaged communities. Overall, therefore, the net
effect of service intervention was to achieve a greater proportion of quitters among smokers
living in the most disadvantaged areas. In summary, NHS SSSs were having a slight
narrowing i.e. positive effect on inequalities in smoking prevalence.133
One study134 investigated smoking prevalence, provision of advice and referral to NHS
SSSs within the UK and whether trends differed by deprivation group. In April 2004, a
General Medical Services contract was introduced into UK primary health care that included
financial incentives to record smoking status and to provide smoking cessation support. The
study134 used the QRESEARCH database to confirm a recent acceleration in smoking
reduction found using survey data, and also describe the recording of smoking status,
provision of smoking advice, and referral to SSSs in patients registered in primary care in the
UK. It also aimed to investigate whether these trends differed between sex, age, and
deprivation groups. Data sources were cross-sectional samples from 2001/2 and 2006/7 of
2.7 million patients from 525 general practices.
148
The proportion of people with smoking status recorded increased by 32.9% (2001/2002:
46.6% to 2006/2007: 79.5%). A large overall increase in the provision of smoking cessation
advice (2001/2002: 43.6% to 2006/2007: 84.0%) and referral to SSSs (2001/2002: 1.0% to
2006/2007: 6.6%) was also observed. The proportion of people who smoked (with a
recorded smoking status) reduced by 6.0% (2001/2002: 28.4% to 2006/2007: 22.4%). The
decrease in the proportion of people who smoked was greatest among patients in the most
deprived areas (7.2%) and the youngest patients (16–25 years: 7.1%). In 2006/2007, more
than twice as many patients in deprived areas smoked as those in affluent areas (most
deprived: 33.8%; most affluent: 14.1%).
In 2001/2002, patients in deprived areas (who had been recorded as smokers in the last 12
months) received the most smoking cessation advice (P<0.001). However, in 2006/2007,
similar proportions from the most affluent and most deprived groups were provided with
smoking cessation advice. In 2001/2002, patients in deprived areas were more likely to be
referred to SSSs (P<0.001). In 2006/2007, those living in the most deprived areas were most
likely to be referred. Large increases in the number of patients referred to SSSs were also
found (P<0.001), most particularly among those in the most deprived areas.
In summary, a greater proportion of lower SES smokers were more likely to be referred to a
SSS and this has increased over time. The absolute gap between low and high SES in terms
of smoking prevalence appeared to be increasing whilst the relative gap was getting smaller.
The study used a large representative dataset of UK adults. There were a larger number of
non-smokers being recorded over time which could have overestimated decreases in the
prevalence of smokers but it is unlikely that any potential overestimation varied across SES
groups. During the time period of the study there was a range of smoking cessation
initiatives introduced as part of a multifaceted government policy to reduce inequalities in
smoking. These initiatives included mass media campaigns, increases in cigarette tax,
increased action to reduce tobacco smuggling and the Tobacco Advertising and Promotion
Act 2002. The study authors do not attribute any specific intervention to the observed
effects.
An English study135 assessed long term outcomes of a drop-in rolling-group model of
behavioural support for smoking cessation: the Roy Castle Lung Cancer Foundation Fag
Ends NHS Stop Smoking Service in Liverpool and Knowsley, UK. ‘Fag Ends’ is an
alternative intervention approach with support centred on drop-in rolling groups. Quit date
149
can be different for attendees and can be determined by the client. There are no waiting lists,
no appointments and no requirement to be referred by a third party, although referral systems
are in place. Weekly sessions run continuously. Clients can attend as many sessions as they
wish and can continue to attend even if they relapse.
The study collected data from clients who accessed the service during a ten week period in
2009. In terms of reach, the study sample135 was particularly disadvantaged, 68% resided in
the most deprived decile of the English Index of Multiple Deprivation (positive equity). ‘Fag
Ends’ clients were drawn from particularly disadvantaged groups when compared to the
general population. Only 20% had finished their education after age 16, whereas in England
49% had qualifications obtained after age 16 in 2009. Nearly two-thirds were eligible for
free prescriptions, whereas 50% of the general population were eligible. A third were longterm unemployed, whereas the General Lifestyle Survey 2008 estimate for UK over-16s
unemployment was 4.2%.
In terms of effectiveness, in general, more affluent clients were significantly more likely to
be quitters at 12 months (negative equity impact). The study135 was only able to
biochemically validate quit status of approximately two-thirds of the clients. A composite
measure of affluence in the multivariate analysis found that affluent smokers had
significantly higher quit rates (OR 1.33 p<0.001). In the bivariate analysis quit rates were
significantly higher in those living in affluent areas, those who owned their home and those
who were not entitled to free prescriptions. However, there was no significant difference by
educational status and there was no clear pattern by occupational status. The overall equity
impact was therefore ‘mixed’.
The Liverpool and Knowsley region has high economic and social disadvantage, Liverpool
is the most disadvantaged local authority in England. Rolling-group drop-in services are
attended by approximately 3% of NHS SSS clients who set a quit date138 and so although
this type of NHS SSS might be particularly effective at reaching lower SES (positive equity
impact), it is a relatively small proportion of services users who access this particular type of
NHS SSS.
Another UK study136 assessed the impact of the QOF (April 2004) on the recording of
smoking targets in primary care medical records. The data source was the Health
Improvement Network (THIN) database which included over six million patients’ records
from 446 practices throughout the UK. The introduction of the QOF was associated with a
150
significant increase in the recording of smoking status and cessation advice. There was a
greater recording of smoking status and cessation advice with advancing Townsend score
(greater deprivation). Multivariate analyses for 2008 showed that more deprived patients
were 35% more likely to have their smoking status recorded (OR 1.35, 95% CI 1.21-1.49,
p<0.001) and 20% more likely to have cessation advice recorded (OR 1.20, 95% CI 1.101.30, p<0.001), than those least deprived.
The smokefree legislation was introduced around the same time as the QOF which may have
confounded study results. The study reports intermediate outcomes for smoking (recording
status and advice) which do not show how the intervention impacts on smoking prevalence.
Other studies have found that lower SES smokers are less likely to be successful when they
attempt to quit smoking, even after accessing support from a SSS.
The report of NHS Smoking Cessation Service Statistics (Scotland)137 1st January to 31st
December 2011 provides an analysis of Scottish NHS SSSs uptake and outcomes during
2011. This is the sixth annual release of statistics from the minimum dataset monitoring in
Scotland, produced by Information Services Division (ISD) Scotland. For the first time, the
2012 annual report included statistics on successful ‘self-reported’ one month quits by
Scottish Index of Multiple Deprivation (SIMD) and also as a percentage of total estimated
adult smokers.
Those living in the most deprived communities (equivalent to SIMD 1-2) account for an
estimated 31% of adult smokers in Scotland and for 37% of quit attempts made in NHS
SSSs in 2011. One month quit outcomes by SIMD reveal that the lowest quit rates were in
the most deprived areas (1-2) and the highest quit rates in the least deprived areas (9-10).
However, in terms of overall numbers of quitters the most deprived areas (1-2) still
accounted for the largest numbers of quitters of all the deprivation deciles.
Most importantly, combining reach (of all smokers in an area) with quit rates at one month,
showed that the percentage of successful quitters was greater in the most deprived SIMD
area 1 (4.2%) compared with least deprived SIMD area 10 (3.4%). This report therefore
shows a positive equity impact of the SSSs in Scotland. However there is the possibility of
systematic bias in the results, there was a greater percentage of ‘lost to follow-up/smoking
status unknown’ in the more deprived SIMD areas than the least deprived SIMD areas.
151
3.8.3 New Zealand General Practice Smoking Cessation Services
A New Zealand study139 evaluated the impact of a behavioural and pharmacological smoking
cessation programme “Preparation Education Giving up and Staying smoke free’’ (PEGS)
which targeted more deprived areas and was delivered by General Practitioners to 11,000
patients over six years who resided in the Christchurch urban area. PEGS is an educational
smoking cessation intervention with different types of counselling and literature based on
patients level of readiness to quit. The ‘most ready’ participants are also offered NRT and to
nominate a quit date. The delivery of the programme is not consistent across practices but in
general, face-to-face support was given when the patient collected NRT from the practice
every one or two weeks. The NRT was heavily subsidised by the Ministry of Health for up
to three months. Enrolees were followed up by their GP six months after their enrolment.
There was little difference in utilisation of the programme between the highest and lowest
deprivation areas as a proportion of the city’s smoking population (22.0% for least deprived
quintile and 20.7% for most deprived quintile). However, the quit rate for the least deprived
neighbourhoods was 36.1% compared to 25.6% for the most deprived areas. Assuming those
lost to follow-up were smokers the quit rate was 25.2% in the least deprived areas compared
with 17.5% in the most deprived areas.
The study estimated that the actual gap in smoking prevalence between the most and least
affluent neighbourhoods was reduced by 0.2 percentage points (15.6% to 15.4%), but
relative gap widened from 2.81 to 2.84 OR due to the PEGS programme. The populationlevel effect was small and non-significant. Although the programme was effective in
reducing smoking prevalence, there was no evidence of a significant impact on area
inequalities (neutral equity impact).
Summary of population-level cessation support interventions
UK NHS SSSs appear to be reaching relatively more disadvantaged than advantaged
smokers and, although low SES service users have lower quit rates, the higher reach is more
than compensating for this. Thus, the net overall effect is a narrowing of relative inequality
in terms of smoking prevalence between adults of the lowest and highest SES, i.e. a positive
equity effect. The one study to assess the equity impact of a behavioural and
pharmacological smoking cessation programme (PEGS) delivered by General Practitioners
and targeted at more deprived areas ,was effective in reducing smoking prevalence however
there was no evidence of a significant impact on area inequalities (neutral equity impact).
152
The one study to assess the equity impact of a national quitline, in New Zealand, produced
unclear findings.
153
4 DISCUSSION
The review presented in this report has systematically assessed the available evidence on the
impact of population-level tobacco control and other policy interventions on socioeconomic
inequalities in adult smoking. One hundred and sixteen studies were included which have
evaluated the impact of population-level policies/interventions, on smoking-related
outcomes in adults by SES, measured by a range of indicators including income, occupation,
education and area deprivation. 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 as well as ‘grey
literature’. The search included searching key reviews, handsearching to identify ‘in press’
articles from four key journals, and contacting European tobacco control experts and asking
them to provide any other relevant peer reviewed articles (non-English language) or grey
literature. 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. In addition a pragmatic decision was taken to exclude studies published prior to
1995.
The inclusion criteria for the systematic review were intentionally wide in order to gather the
broadest possible range of evidence that could inform equity-orientated policies. Any type
of tobacco control or other policy intervention, of any length of follow-up, with a relvant
smoking-related outcome was included. Thus, this review goes beyond the previous CRD
and PHRC reviews in searching for non-tobacco control interventions and polices (e.g.
education, social policy) which assessed any smoking-related equity impacts. 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 and use of quitting services. Studies were included
which did or did not have a specific equity focus. In order to include as much relevant
evidence as possible, many of the primary studies included in this review would not meet the
criteria used by other systematic reviews. However, ‘pure’ experimental designs are often
either not feasible or inappropriate for evaluating certain types of tobacco control policies
and interventions, such as smokefree legislation and national media campaigns.
154
A further inclusion criterion was that a measure of SES had to be reported within the abstract
of a paper. It is possible that papers which undertook analyses by SES were not included
because these analyses were not mentioned in their abstract. An example of this is
econometric studies where an outcome is elasticity (i.e. affordability according to income).
All potentially relevant econometric studies might not have been identified as the abstracts
might not have reported a measure of SES, although by their very nature these econometric
studies are relevant to this review. It was not feasible to include all papers which report SES
anywhere in the main body of the paper in such a broad encompassing review as this.
However, such as search might be worth undertaking in future reviews in respect of a small
number of topic/policy areas to see if any more relevant evidence is captured and whether
this differs from that found in the original review.
Socioeconomic variables included income, education, occupational social class, area-level
socio-economic deprivation and subjective social status. These SES variables do not
encompass all disadvantaged people, who might have been captured by including other
measures of SES, such as ethnicity. In addition, the socioeconomic conditions captured by
SES measures, such as income, education and occupation, can vary widely between
countries across Europe.
Studies targeted at low SES sub-populations that did not report differential smoking-related
outcomes for at least two socio-economic groups were excluded because, although they can
potentially provide useful information about uptake and impact within specific lower SES
groups, they cannot provide information about any equity impact.
We developed a new quality assessment tool, an adapted version of previously used tools,
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. Given the variations in
study methodologies, intervention types and outcome measures, the results were presented in
the form of a narrative synthesis and according to intervention type. In order to provide a
simple basis for comparing the methodology of each study, a typology of study designs was
devised.
We also adapted a model to assess the equity impact of each intervention/policy. A study
was classed as associated with a positive equity impact when low SES groups, such as lower
occupational groups, those with a lower level of educational attainment, the less affluent or
those living in more deprived areas, were more responsive to the intervention/policy. A
study was classed as associated with a neutral equity impact when there was no social
155
gradient in the effectiveness of the intervention/policy as measured by SES. This could mean
that both lower and higher SES groups benefitted equally from the intervention/policy or that
the intervention/policy was not effective in any SES group. A study was classed as
associated with a negative equity impact when high SES groups were more responsive to the
intervention/policy.
The equity impact of each study policy/intervention was derived ‘on balance’, taking into
account quality issues, such as internal and external validity, generalisability and
transferability.
4.2 Strengths and limitations of the available evidence
A relatively large number of studies were identified and included within this systematic
review. The majority of the evidence concerns the effectiveness of smoking restrictions in
enclosed public places (44), increases in price/tax of tobacco products (27) and mass media
campaigns (30). A relatively small number of studies were included for other types of
interventions/policies including the effects of controls on advertising, promotion and
marketing of tobacco (9); multiple policies (4); settings-based interventions (7) and
population-level cessation support interventions (8). Despite searching for non-tobacco
control interventions and polices (e.g. education, social policy) which assessed any smokingrelated equity impacts, only one study (community approach) was identified.
There was considerable variation in the type of designs and quality of the studies. A large
proportion of the studies were from the USA, 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. In
addition, there was a lack of consistency in respect of the reported outcome measures and
length of follow-up within most policy or intervention types.
The summary of the equity impact of policies/interventions was derived ‘on balance’.
Assessing the overall equity impact of different types of interventions/policies was
complicated by some studies having multiple outcomes or multiple measures of SES which
varied in equity impact. In other cases the same SES measure or outcome varied by gender,
setting or country. In these cases the equity impact was classed as ‘mixed’. In some cases it
was not possible to assess the equity impact and these types of studies were classed as
156
‘unclear’. Whether exposure was measured in relative or absolute terms could also influence
the equity impact results.
4.3 Main findings and conclusions
There were 116 studies which reported smoking-related outcomes by SES included in the
review. The initial electronic search produced 12,605 references, of which 81 studies met
the inclusion criteria. A further twenty-three studies were identified through hand-searching,
searching of grey literature, key reviews and contacting experts. An update of the electronic
searches and journal handsearching was carried out in January 2013 which identified a
further twelve relevant studies.
The literature was international, with more than half the studies being carried out in the
USA. Eighteen studies were carried out in the UK and eight in the Netherlands. A few
studies were based in multiple countries. Other study countries included Australia, Belgium,
Canada, Croatia, France, Germany, Italy, New Zealand, Sweden and Russia. Most of the
British studies assessed the impact of smokefree legislation and the NHS smoking cessation
services.
The types of interventions/policies included were: smoking restrictions in cars, homes,
workplaces and other public places (44); increases in the price/tax of tobacco products (27);
controls on advertising, promotion and marketing of tobacco (9); mass media campaigns
including call to promote the use of quitlines and NRT (30); multiple policy interventions
(4); settings-based interventions including community, workplace and hospitals (7); and
population-level cessation support interventions (8). Eight studies were included in more
than one type of policies/intervention category.
4.3.1 Equity impact
Out of the 116 included studies there were 129 different types of policies that were evaluated
and the equity impact was as follows: 33 ‘positive’ policies, 35 ‘neutral’ policies, 38
‘negative’ policies, 6 ‘mixed’ policies and 17 ‘unclear’ policies (Appendix I). It is important
to point out that the 35 ‘neutral’ policies indicate that these policies have benefits for adults
across all SES groups. Only three of these ‘neutral’ policies showed no significant effect of
the intervention for any SES group and these three studies were community-based.
157
Thirty-three policies showed the potential to produce a positive equity impact i.e. to reduce
inequalities in adult smoking. These ‘positive’ policies included one study of smokefree
workplace legislation, two studies of national smokefree legislation in enclosed public
places, fourteen studies of increasing the price/tax of tobacco products, two studies of
controls on advertising, promotion and marketing of tobacco, three studies of anti-tobacco
mass media campaigns, five studies of mass media smoking cessation advertising campaigns
to promote the use of quitlines, two settings-based interventions (community, workplace)
and four studies of the UK NHS smoking cessation services. One of these ‘positive’ policies
91
was included in both the ‘mass media’ section and the ‘mass media to promote the use of
quitlines’. One study had a positive equity impact for mass media and price policies but an
unclear equity impact for smokefree legislation.55
Some trends in equity effect by type of tobacco control intervention/policy emerged from the
data. More than half of the studies of smokefree legislation were associated with a negative
equity impact and make up the bulk of the ‘negative’ studies. However, these include a large
number of studies that looked at the equity impact of voluntary policies. The majority of the
studies of policies to increase the price/tax of cigarettes were associated with a positive
equity impact. There were no ‘negative’ studies for controls of advertising, marketing and
promotion of tobacco products. The mass media campaigns were associated with
inconsistent equity impacts. Four of the six studies of NHS smoking cessation services had a
positive equity impact.
4.3.2 Equity impact by type of tobacco control policy/intervention
Smoking restrictions in workplaces, enclosed public places, cars and homes
The 44 studies which assessed the equity impact of smoking restrictions and smokefree
policies varied considerably in terms of the scope, setting and comprehensiveness of the
policies being assessed. These ranged from voluntary workplace and/or public places
smoking polices to partial national legislation covering workplaces to comprehensive
smokefree national legislation covering all enclosed public places. The evidence shows that,
irrespective of the country, where the adoption of smokefree policies is voluntary, there are
significant inequalities in policy coverage and SHS exposure among workers according to
SES. In general, the higher the level of income or education or occupational status, the
greater the odds of working in a smokefree environment and the stronger the workplace
158
smoking restrictions. The lower the level of income, education and occupation, the greater
the smoking prevalence and the greater the SHS exposure in the workplace. The evidence
also suggests that partial or voluntary local adoption of smokefree legislation has the
potential to increase socioeconomic inequalities in terms of protection from SHS exposure.
Statewide/regional rather than national comprehensive legislation also has the potential to
increase socioeconomic inequality. For example, several US studies found that more
deprived communities were slower in adopting smokefree polices for public places than
more affluent communities.
Only one of fifteen studies assessing the impact of voluntary worksite smoking policies
demonstrated a positive equity impact in terms of exposure to SHS. This study included
workers who were both non-smokers and not exposed to SHS smoke at home, which means
that they are probably not representative of all workers.18 The study showed that inequalities
in SHS workforce exposure (measured by serum cotinine levels) might be diminishing with
the increased adoption of clean indoor laws in the USA. Blue-collar non-smoking workers
who were not exposed to SHS at home continued to have the highest cotinine levels but
experienced the largest absolute reductions.18
Overall, national comprehensive smokefree legislation was found to reduce SHS exposure,
increases quit attempts and have positive health effects within the general population. By
definition such legislation is equity positive as it removes the inequalities in protection from
SHS found in studies which looked at voluntary policies. However, in terms of equity impact
on other smoking-related outcomes, only two of the 22 studies15;52 that evaluated national
smokefree legislation demonstrated an overall positive equity impact. Nine studies showed a
neutral equity impact and five showed a negative equity impact. In three studies the equity
impact was unclear and in another study the equity impact was mixed according to outcome.
The recent proliferation of smokefree policies in bars, restaurants and workplaces across
Australia, Canada, UK and USA has had a positive equity impact by reducing disparities in
policy coverage by SES, as low SES worksites and public places catch up in adopting total
smoking bans.15 A study52 based in England, Wales and Scotland, showed that bars in more
deprived areas experienced a greater percentage reduction in PM2.5 levels up to 12 months
post-implementation of national comprehensive smokefree legislation, compared to more
affluent areas, although there were higher levels of PM2.5 at baseline for the more deprived
areas.
159
The comprehensive smokefree legislation in Scotland, Wales and Northern Ireland did not
appear to displace smoking into the car or the home and was not patterned by SES in pooled
analyses. Two of the three studies on the impact of public places smoking legislation on
voluntary home smoking restrictions found a negative impact and one was associated with a
neutral impact. The CHETS UK study47, for example, showed that although smoking
restrictions in the car and in the home increased following the smokefree legislation, there
was no change in inequalities in parental smoking in the car or in the home (socioeconomic
differences remained).
No studies which evaluated the equity impact of smokefree vehicle laws were identified.
However, support for smokefree vehicle laws is increasing and this review provides some
evidence of inequalities smoking in vehicles in the absence of smokefree vehicle laws.
Increases in price/tax of tobacco products
Overall, increase in the price/tax of tobacco products was associated with decreases in
smoking prevalence across the general population. Fourteen of the twenty-seven
studies55;63;65-69;72-74;78-80;82 of increases in the price/tax of cigarettes were associated with
larger reductions in smoking prevalence and/or consumption for lower SES groups
compared with higher SES groups, demonstrating a positive equity impact. Six studies
demonstrated a neutral equity impact,40;56;58;70;71;81 in one study the equity impact was mixed
depending on SES measure62 and in two studies the equity impact was unclear.54;57 Four
studies showed a negative impact on equity.64;75-77 However this group of ‘negative’ equity
studies included two studies of distinct population subgroups: HIV-positive adults76 and
pregnant women.77 In addition, most of these studies were from the US.
Overall, within the general population, lower SES adults appear more responsive to price/tax
increases in terms of larger price elasticities compared with high SES adults. However,
larger price elasticities amongst lower SES adults might be capturing short-term effects
which do not translate into increased sustained quitting amongst lower SES adults.
In addition, cross-border or black-market sales were not accounted for in most econometric
studies which could have biased the results. Cross-border sales may be patterned by SES
and issues of cross-border sales may have more relevance to some European countries than
others. Included studies suggest that lower SES adults might be more likely than higher SES
adults to mitigate the effects of price or tax increases by switching to cheaper or stronger
160
brands or bulk buying. A recent study140 examining socioeconomic and country variations in
cross-border cigarette purchasing among adult smokers showed that cross-border cigarette
purchasing was more often reported by smokers with higher education and income.
Furthermore, cross-border cigarette purchasing is more common in European regions
bordering countries with lower cigarette prices.
A panel of experts who assessed the effectiveness of tax and price policies in tobacco control
in 201083 concluded that there was sufficient evidence of the effectiveness of increased
tobacco excise taxes and prices in reducing overall tobacco consumption and prevalence of
tobacco use. They also concluded that there was strong but not sufficient evidence in highincome countries that lower income populations are more responsive to tax and price
increases compared with higher income groups. Our review adds to the evidence base by
showing that a majority of studies demonstrate greater responsiveness to tax/price increases
in lower SES groups, through reduced smoking prevalence and consumption.
Controls on the advertising, promotion and marketing of tobacco
Few studies have looked at the equity impact of wider restrictions and bans on advertising
and promotion. Of the nine studies which assessed the effects of controls on advertising,
promotion and marketing of tobacco, five looked only at the impact of health warning on
packets. Seven studies found a neutral equity impact (i.e. were equally effective in all SES
groups). The two studies with a positive equity impact were on EU text-only health warnings
and the addition of a quitline number to new pictorial health warnings.
A European study showed variation in impact of EU text only health warnings across
countries depending on type of SES measure used. Overall there was a positive equity with
the impact highest among smokers with lower incomes and smokers with low to moderate
education (except the UK in the case of education), suggesting that text only health warnings
could be more effective among low SES groups. However, France and the UK now have
pictorial health warnings. Quitline number recognition included with new pictorial health
warnings, increased across all SES groups in New Zealand, and the gap in quitline number
recognition between the least and most deprived groups narrowed, indicating a positive
equity effect. It is unclear how change in ‘intermediate’ outcomes (reported in most of these
studies), such as awareness, recognition, motivation and preferences, translate into change in
smoking prevalence and the equity impact of any such longer term changes.
Mass media campaigns including campaigns to promote the use of Quitlines and NRT
161
There was no consistent equity impact for either mass media cessation campaigns or
campaigns promoting quitlines or free NRT. Three studies of mass media cessation
campaigns showed a positive equity impact. A tobacco control paid media campaign55 in the
US was associated with a more rapid decline in smoking prevalence among low SES
women. The EX mass media campaign (TV element) increased cessation-related cognitions
only among those with less than a high-school education and increased quit attempts only
among those with less than a high-school education. A Dutch multimedia campaign106
targeted at smokers with an intention to quit smoking in the future, with a focus on lower
educated smokers, was associated with a positive equity impact for campaign awareness.
The equity impact was unclear in six studies due to the following reasons: type of outcome
reported; measure of exposure; where impact was more pronounced in a ‘middle’ SES
group; where there was inconsistency between outcome measures; where outcome differed
between SES groups even despite similar exposure to the policy; or where differences in
effect were more pronounced although the effect was similar across all SES groups. These
issues were also impacted by the lack of representativeness of most of the study samples and
in some cases also low attrition. Five studies demonstrated a negative equity impact,
including four Quit & Win competitions and a Dutch 24 hour no-smoking intervention.
The type of outcomes measured varied, but were mainly stage one and stage two outcomes
according to the logic framework; such as campaign awareness, recall and interest (stage 1)
and recruitment, quit attempts and one-day abstinence (stage 2). Some studies reported the
impact of mass media campaigns in terms of longer-term outcomes, including smoking
prevalence and abstinence and there was no apparent pattern of effectiveness according to
stage or type of outcome reported. It is unclear how short or intermediate outcomes translate
into reduction in smoking prevalence and other health outcomes, and the impact of such
longer-term changes on equity.
Different types of media messages appear to have differential impact by SES and multiple
media formats may lead to equity benefit. A Dutch study105 showed that all smokers
(particularly those with low education) recalled advertisements focused on how to quit less
often, and perceived them as less effective, than advertisements using graphic imagery or
personal testimonials to convey why to quit. A study exploring differences in smokers’
perceptions of the effectiveness of cessation media messages111 found that advertisements
using a ‘why to quit’ strategy with either graphic images or personal testimonials were
162
perceived as more effective than the other advertisement categories (how to quit and antiindustry). A further US study of paid media campaigns98 showed that highly emotional or
personal testimonial advertisements were more effective with the low, mid and undetermined
SES groups compared to the high SES groups for increasing the likelihood of quitting
smoking.
Mass media campaigns to promote the use of quitlines were associated with increases in
calls. However, only two of the nine studies found a positive equity effect91;112 in terms of
calls to quitlines and recognition of a quitline number on cigarette packs. Promoting free
NRT had more consistent positive equity effects. A Canadian study119 of a mass media
campaign and free NRT showed a positive equity impact in terms of reach and was equally
effective in increasing quit rates across all SES groups. Two of the three studies of mass
media to promote the use of NRT showed positive equity impacts in terms of awareness or
reach.120;121
This review adds to the evidence included in the Niederdeppe review100and suggests that the
type of media message, the media format of the campaign and the mechanisms of
engagement vary by SES. A mass media campaign using multiple media formats, targeted at
lower SES groups, as part of an overall comprehensive tobacco control programme, has the
potential to impact positively on smoking inequalities.
Multiple policies
Four studies54;56;122;123 examined the equity impact of multiple tobacco control policies;
including smokefree workplace and enclosed public places legislation, increases in price/tax
of cigarettes, tobacco control campaign spending, advertising bans, health warnings, and
mass media smoking cessation campaigns. On the whole, these multifaceted tobacco control
policies were associated with a neutral equity impact. High and low SES groups seem to
benefit equally from nationwide tobacco control policies. In one European-wide study, more
developed tobacco control policies were associated with higher quit rates. Policies related to
cigarette price showed the strongest association with quit ratios and this mirrors the results
found from studies of individual interventions/policies.
Evidence suggests that different elements of these multiple policies may impact
differentially by SES. For example, people with lower incomes were more affected by
cigarette tax increases, whereas people with higher incomes may have been more affected by
163
greater awareness of the dangers of SHS and smokefree legislation. Evidence also suggests
that, within and across different SES groups,, the impact of multiple tobacco control policies
can vary by age, gender and the type of smoking-related outcome that is measured.
Settings based interventions
There were seven settings based interventions: four community-based, two workplace and
one hospital based intervention. The types of interventions included in these studies varied
considerably in their scope and approach; thus, the observed inconsistency in equity impact
is perhaps unsurprising. The evidence for any specific setting was insufficient to be able to
draw firm conclusions. The only intervention in the whole review to address wider social
determinants of inequality, the New Deal for Communities (NDC) in England128 had no
impact on the smoking outcome (quitting rates). The other community based intervention in
the Netherlands.129 also found no impact on smoking across all SES groups.
Two studies demonstrated positive equity impacts. A workplace intervention126 integrating
health promotion with occupational health and safety efforts significantly improved smoking
quit rates among blue-collar manufacturing workers compared to health promotion alone, in
Massachusetts, USA. The US ‘Breathe Easy’ community intervention125 which targeted
lower-income women produced higher quit rates amongst these women after four years.
Population-level cessation support interventions
The UK is the only country to have established comprehensive local smoking cessation
services which are free to smokers. This state-reimbursed stop smoking service provides
behavioural support and pharmacotherapy. Because of their national comprehensive
coverage these services can be regarded as a population-level policy intervention. The
services are particularly targeted at disadvantaged communities. Four of the five relevant
studies found a positive equity impact. These services are reaching relatively more
disadvantaged (than advantaged) smokers and, although these low SES service users have
lower quit rates, the higher reach more than compensates for this. Thus, the net overall effect
is a narrowing of relative inequality in terms of smoking prevalence between adults of the
lowest and highest SES, i.e. a positive equity effect.
One New Zealand study assessed the equity impact of a behavioural and pharmacological
smoking cessation programme (PEGS) delivered by General Practitioners, targeted at more
164
deprived areas, which was effective in reducing smoking prevalence. However there was no
evidence of a significant impact on area inequalities (neutral equity impact).
The only study to evaluate the reach of a national Quitline found that SES was not associated
with Quitline use. The equity impact was unclear because of inconsistency of outcome
between SES measures, uncertainty about how quitline calls translates to smoking
prevalence, and lack of representativeness of the study sample.
4.1 Future research
It was not feasible to include in this review all papers which reported impact by SES
anywhere in the main body of the paper. However, a wider-ranging search might be worth
undertaking in a future study in respect of a small number of topic/policy areas, in order to
ascertain whether any more relevant evidence is captured and how this differs from the
evidence found in this review.
Studies targeted at low SES sub-populations that did not report differential smoking-related
outcomes for at least two socio-economic groups were excluded because, although they can
potentially provide useful information about uptake and impact within specific lower SES
groups, they cannot provide information about any equity impact. However, these types of
studies could increase understanding about the mechanisms of change and how more
effectively to target/tailor policies and interventions.
Given the relatively small number of identified studies that included equity analyses, another
potentially fruitful way to develop the evidence base would be to perform secondary
analyses of relevant datasets where SES data have been collected but not reported within
published papers. Consideration might be given to studies evaluating wider non-tobacco
control public policies, such as Spearhead and Sure Start in the UK, as well as tobacco
control policies. Another option would be to explore in cessation studies intermediate
outcome measures along the path to quitting, such as reduction in consumption.
A final suggestion would be to investigate whether findings are sensitive to different
measures of SES within and across studies included within this systematic review. This
might help us to increase our understanding of mechanisms of change.
165
5 CONCLUSIONS
One hundred and sixteen studies were included in this systematic review of the effectiveness
of population-level policies and interventions to reduce socio-economic inequalities in
smoking among adults. Despite searching for non-tobacco control interventions and polices
(e.g. education, employment, social policy) which assessed any smoking-related equity
impacts, only one relevant study was identified.
Over a third of the studies assessed
smoking restrictions and smokefree polices, with approximately a quarter focusing on mass
media campaigns and a quarter on increases in the price/tax of tobacco products.
There was considerable variation in the type of designs and quality of the studies. A large
proportion of the studies were from the USA, 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.
Among the included policies, 26% had a positive equity impact, 27% had a neutral equity
impact and 29% had a negative equity impact. It is important to point out that most of the
policies/interventions associated with a neutral equity effect had equal benefits for all SES
groups. Only three of these ‘neutral’ studies showed no significant effect of the intervention
for any SES group.
Limited conclusions can be drawn from these 116 studies about which types of tobacco
control interventions are likely to reduce inequalities in smoking. While the evidence base
has increased significantly since the previous PHRC review10 particularly in relation to
smokefree policies, no substantially new or significantly different findings or conclusions
have emerged.
The most consistent policy/intervention in terms of positive impact on reducing smoking
inequalities was price/tax rises. Overall, national comprehensive smokefree legislation
reduces SHS exposure, increases quit attempts and has positive health effects within the
general population. While comprehensive national smokefree polices remove inequalities in
protection from SHS in the workplace and enclosed public places, only two studies found a
positive equity impact on other smoking-related outcomes. This may be due to a lag effect in
terms of the impact on smoking behaviour (e.g. through changing social norms, which are a
long-term process) and the increased relative importance of SHS exposure in the home and
car, which is higher among low SES groups. Mass media campaigns had inconsistent effects,
166
which is perhaps to be expected given the diversity of messages, media formats and levels of
exposure in the studies. However, there is some emerging evidence that certain types of mass
media messages are more effective in low SES groups. The provision of free NRT might
also be more effective in low SES groups. A mass media campaign using multiple media
formats, with emotionally engaging or graphic messages, targeted at lower SES groups, as
part of an overall comprehensive tobacco control programme, appears to have the potential
to positively impact on smoking inequalities. Evidence from the UK NHS smoking cessation
services also indicates that cessation services effectively targeted at low income smokers can
have a positive equity impact by more than compensating for the lower quit rates in low SES
groups. This is an important finding: the previous PHRC review found that all types of nontargeted cessation support have a negative equity effect as low SES smokers using such
support have lower quit rates than high SES smokers.
Given these previous findings, it is not surprising that the evidence suggests that different
elements of multiple policies (e.g. tax, smokefree) may impact differentially by SES. The
impact of multiple tobacco control policies also may vary by age, gender and the type of
smoking-related outcome.
167
6
REFERENCES
(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
(10)
(11)
(12)
(13)
(14)
(15)
(16)
Lopez AD, Collishaw NE, Piha T. A descriptive model of the cigarette epidemic in
developed countries. Tobacco Control 1994; 3: 242-247.
Amos A, Greaves L, Nichter M, Bloch M. Women and tobacco: A call for including
gender in tobacco control research, policy and practice. Tobacco Control 2012;
21:236-243.
Hiscock R, Bauld L, Amos A, Fidler JA, Munafo M. Socioeconomic status and
smoking: a review. Annals of the New York Academy of Sciences 2012; 1248:107123.
Hiscock R, Bauld L, Amos A, Platt S. Smoking and socioeconomic status in
England: the rise of the never smoker and the disadvantaged smoker. Journal of
Public Health 2012; 34:390-396.
Joosens L, Raw M. The Tobacco Control Scale: a new scale to measure country
activity. Tobacco Control 2006; 15:247-253.
World Health Organisation. MPOWER: Six Policies to Reverse the Tobacco
Epidemic.WHO report on the global tobacco epidemic, 2008. Geneva, World Health
Organisation.
Conference of the Parties to the WHO FCTC. WHO Framework Convention on
Tobacco Control, 2003. Geneva, World Health Organisation.
SILNE consortium. Project: SILNE – Tackling socio-economic inequalities in
smoking: learning from natural experiments by time trend analyses and crossnational comparisons. 2012.
Fayter D, Main C, Misso K, Ogilvie D, Petticrew M, Sowden A et al. Population
tobacco control interventions and their effects on social inequalities in smoking.
York: Centre for Reviews and Dissemination 2008;322.
Public Health Research Consortium. A9-10R: Tobacco control, inequalities in health
and action at the local level in England. 2011.
Joosens L, Raw M. The Tobacco Control Scale 2010 in Europe. 2011. Chaussée de
Louvain 479, B-1030 Brussels, Belgium, Association of the European Cancer
Leagues.
U.S.Department of Health and Human Services. Preventing Tobacco Use Among
Youth and Young Adults: A Report of the Surgeon General. 2012. Atlanta,GA, U.S.
Department of Health and Human Services, Centers for Disease Control and
Prevention, National Center for Chronic Disease Prevention and Health Promotion,
Office on Smoking and Health.
Thomas H. Quality assessment tool for quantitative studies. 2003. Hamilton,
Ontario, Effective Public Health Practice Project.
Thomas S, Fayter D, Misso K, Ogilvie D, Petticrew M, Sowden A et al. Population
tobacco control interventions and their effects on social inequalities in smoking:
systematic review. Tobacco Control 2008; 17(4):230-237.
King BA, Hyland AJ, Borland R, McNeill A, Cummings KM. Socioeconomic
variation in the prevalence, introduction, retention, and removal of smoke-free
policies among smokers: findings from the International Tobacco Control (ITC) Four
Country Survey. International Journal of Environmental Research & Public Health
2011; 8(2):411-434.
Ferketich AK, Liber A, Pennell M, Nealy D, Hammer J, Berman M. Clean indoor air
ordinance coverage in the Appalachian region of the United States. American Journal
of Public Health 2010; 100(7):1313-1318.
168
(17) Haw SJ, Gruer L, Amos A, Currie C, Fischbacher C, Fong GT et al. Legislation on
smoking in enclosed public places in Scotland: how will we evaluate the impact?
Journal of Public Health 2006; 28 (1): 24-30.
(18) Arheart KL, Lee DJ, Dietz NA, Wilkinson JD, Clark JD, III, LeBlanc WG et al.
Declining trends in serum cotinine levels in US worker groups: the power of policy.
Journal of Occupational & Environmental Medicine 2008; 50(1):57-63.
(19) Delnevo CD, Hrywna M, Lewis MJ. Predictors of smoke-free workplaces by
employee characteristics: who is left unprotected? American Journal of Industrial
Medicine 2004; 46(2):196-202.
(20) Farrelly MC, Evans WN, Sfekas AE. The impact of workplace smoking bans: results
from a national survey. Tobacco Control 1999; 8(3):272-277.
(21) Guse CE, Marbella AM, Layde PM, Christiansen A, Remington P. Clean indoor air
policies in Wisconsin workplaces. Wisconsin Medical Journal 2004; 103(4):27-31.
(22) Moussa KM, Lindstrom M, Ostergren P-O. Socioeconomic and demographic
differences in exposure to environmental tobacco smoke at work: the Scania Public
Health Survey 2000. Scandinavian Journal of Punlic Health 2004; 32(3):194-202.
(23) Parry O, Platt S. Smokers at risk: implications of an institutionally bordered riskreduced environment. Health & Place 2000; 6(2):117-123.
(24) Plescia M, Malek SH, Shopland DR, Anderson CM, Burns DM. Protecting workers
from secondhand smoke in North Carolina. North Carolina Medical Journal 2005;
66(3):186-191.
(25) Razavi D, Vandecasteele H, Primo C, Bodo M, Debrier F, Verbist H et al. Improving
cancer prevention at the worksite: how are Belgian companies dealing with smoking
regulations? Psycho-Oncology 1997; 6(3):204-211.
(26) Shavers VL, Fagan P, Alexander LA, Clayton R, Doucet J, Baezconde-Garbanati L.
Workplace and home smoking restrictions and racial/ethnic variation in the
prevalence and intensity of current cigarette smoking among women by poverty
status, TUS-CPS 1998-1999 and 2001-2002. Journal of Epidemiolgoy and Public
Health 2006; 60:Suppl-2:34-43.
(27) Shopland DR, Anderson CM, Burns DM, Gerlach KK. Disparities in Smoke-Free
Workplace Policies among Food Service Workers. Journal of Occupational and
Environmental Medicine 2004; 46(4):347-356.
(28) Stamatakis KA, Brownson RC, Luke DA. Risk factors for exposure to environmental
tobacco smoke among ethnically diverse women in the United States. Journal of
Womens Health & Gender-Based Medicine 2002; 11(1):45-51.
(29) Tong EK, Tang H, Tsoh J, Wong C, Chen MS, Jr. Smoke-free policies among AsianAmerican women: comparisons by education status. American Journal of Preventive
Medicine 2009; 37(2:Suppl):S144–S150.
(30) Verdonk-Kleinjan WMI, Knibbe RA, Tan FES, Willemsen MC, de Groot HN, de
VH. Does the workplace-smoking ban eliminate differences in risk for environmental
tobacco smoke exposure at work? Health Policy 2009; 92(2-3):197-202.
(31) Dearlove JV, Bialous SA, Glantz SA. Tobacco industry manipulation of the
hospitality industry to maintain smoking in public places. Tobacco Control 2002;11:
94-104.
(32) Deverell M, Randolph C, Albers A, Hamilton W, Siegel M. Diffusion of local
restaurant smoking regulations in Massachusetts: identifying disparities in health
protection for population subgroups. Journal of Public Health Management and
Practice 2006; 12(3):262-269.
(33) Skeer M, George S, Hamilton WL, Cheng DM, Siegel M. Town-level characteristics
and smoking policy adoption in Massachusetts: are local restaurant smoking
169
(34)
(35)
(36)
(37)
(38)
(39)
(40)
(41)
(42)
(43)
(44)
(45)
(46)
(47)
(48)
(49)
regulations fostering disparities in health protection? American Journal fo Public
Health 2004; 94(2):286-292.
Ellis JA, Gwynn C, Garg RK, Philburn R, Aldous KM, Perl SB et al. Secondhand
smoke exposure among nonsmokers nationally and in New York City. Nicotine and
Tobacco Research 2009; 11(4):362-370.
Tang H, Cowling DWLJCRTKKLSCMBDG. Changes of Attitudes and Patronage
Behaviors in Response to a Smoke-Free Bar Law. American Journal of Public Health
2003; 93:611-617.
Guzman A, Walsh MC, Smith SS, Malecki KC, Nieto JF. Evaluating effects of
statewide smoking regulations on smoking behaviors among participants in the
survey of the health of Wisconsin. Wisconsin Medical Journal 2012; 111(4):2012.
Hemsing N, Greaves L, Poole N, Bottorff J. Reshuffling and relocating: the gendered
and income-related differential effects of restricting smoking locations. Journal of
environmental and public health 2012; Article ID 907832.
Barnett R, Pearce J, Moon G, Elliott J, Barnett P. Assessing the effects of the
introduction of the New Zealand Smokefree Environment Act 2003 on acute
myocardial infarction hospital admissions in Christchurch, New Zealand. Austrlian
and New Zealand Journal of Public Health 2009; 33(6):515-520.
Cesaroni G, Forastiere F, Agabiti N, Valente P, Zuccaro P, Perucci CA. Effect of the
Italian smoking ban on population rates of acute coronary events. Circulation 2008;
117(9):1183-1188.
Dinno A, Glantz S. Tobacco control policies are egalitarian: a vulnerabilities
perspective on clean indoor air laws, cigarette prices, and tobacco use disparities.
Social Science and Medicine 2009; 68(8):1439-1447.
Eadie D, Heim D, MacAskill S, Ross A, Hastings G, Davies J. A qualitative analysis
of compliance with smoke-free legislation in community bars in Scotland:
implications for public health. Addiction 2008; 103(6):1019-1026.
Federico B, Mackenbach JP, Eikemo TA. Kunst AE. Impact of the 2005 smoke-free
policy in Italy on prevalence, cessation and intensity of smoking in the overall
population and by educational group. Addiction 2012. doi:10.1111/j.13600443.2012.03853.x
Fowkes FJI, Stewart MCW, Fowkes FGR, Amos A, Price JF. Scottish smoke-free
legislation and trends in smoking cessation. Addiction 2008; 103(11):1888–1895.
Hackshaw L, McEwen A, West R, Bauld L. Quit attempts in response to smoke-free
legislation in England. Tobacco Control 2010; 19(2):160-164.
Hawkins SS, Cole TJ, Law C. Examining smoking behaviours among parents from
the UK Millennium Cohort Study after the smoke-free legislation in Scotland.
Tobacco Control 2011; 20(2):112-118.
Moore GF, Holliday JC, Moore LA. Socioeconomic patterning in changes in child
exposure to secondhand smoke after implementation of smoke-free legislation in
Wales. Nicotine & Tobacco Research 2011; 13(10):903-910.
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.
Nagelhout GE, Mons U, Allwright S, Guignard R, Beck F, Fong GT et al. Prevalence
and predictors of smoking in "smoke-free" bars. Findings from the International
Tobacco Control (ITC) Europe Surveys. Social Science and Medicine 2011;
72(10):1643-1651.
Nagelhout GE, Willemsen MC, de VH. The population impact of smoke-free
workplace and hospitality industry legislation on smoking behaviour. Findings from
a national population survey. Addiction 2011; 106(4):816-823.
170
(50) Ritchie D, Amos A, Martin C. "But it just has that sort of feel about it, a leper"-stigma, smoke-free legislation and public health. Nicotine and Tobacco Research
2010; 12(6):622-629.
(51) Ritchie D, Amos A, Martin C. Public places after smoke-free--a qualitative
exploration of the changes in smoking behaviour. Health and Place 2010; 16(3):461469.
(52) Semple S, van TM, Galea KS, MacCalman L, Gee I, Parry O et al. UK smoke-free
legislation: changes in PM2.5 concentrations in bars in Scotland, England, and
Wales. Annals of Occupational Hygiene 2010; 54(3):272-280.
(53) Sims M, Mindell JS, Jarvis MJ, Feyerabend C, Wardle H, Gilmore A. Did smokefree
legislation in England reduce exposure to secondhand smoke among nonsmoking
adults? Cotinine analysis from the Health Survey for England. Environmental Health
Perspectives 2012; 120(3):425–430.
(54) Frieden TR, Mostashari F, Kerker BD, Miller N, Hajat A, Frankel M. Adult tobacco
use levels after intensive tobacco control measures: New York City, 2002-2003.
American Journal of Public Health 2005; 95(6):1016-1023.
(55) Levy DT, Mumford EA, Compton C. Tobacco control policies and smoking in a
population of low education women, 1992-2002. Journal of Epidemiology and
Community Health 2006; 60(Suppl II):ii20–ii26.
(56) Schaap MM, Kunst AE, Leinsalu M, Regidor E, Ekholm O, Dzurova D et al. Effect
of nationwide tobacco control policies on smoking cessation in high and low
educated groups in 18 European countries. Tobacco Control 2008; 17(4):248-255.
(57) 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.
(58) Nagelhout GE, Crone MR, van den Putte B, Willemsen MC, Fong GT, de VH. Age
and educational inequalities in smoking cessation due to three population-level
tobacco control interventions: findings from the International Tobacco Control (ITC)
Netherlands Survey. Health Education Research 2013; 28(1):83-91.
(59) MacCalman L, Semple S, Galea KS, van TM, Dempsey S, Hilton S et al. The
relationship between workers' self-reported changes in health and their attitudes
towards a workplace intervention: lessons from smoke-free legislation across the UK
hospitality industry. BMC Public Health 2012; 12:324.
(60)
(61)
(62)
(63)
(64)
(65)
(66)
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-e1478.
Patel VTGWN. Objective measurement of area differences in 'private' smoking behaviour:
observing smoking in vehicles. Tobacco Control 2011; Online First, published on December
1, 2011 as 10.1136/tobaccocontrol-2011-050119.
Azagba S, Sharaf M. Cigarette taxes and smoking participation: evidence from recent tax
increases in Canada. International Journal of Environmental Research & Public Health 2011;
8(5):1583-1600.
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.
Choi KHDFJSCAW. Use of Price-Minimizing Strategies by Smokers and Their Effects on
Subsequent Smoking Behaviors. Nicotine and Tobacco Research 2012; 14(7):864-870.
Centers for Disease Control and Prevention (CDC). Response to increases in cigarette prices
by race/ethnicity, income, and age groups-United States, 1976-1993. Morbidity & Mortality
Weekly Report 1998; 47(29):605-609.
Colman GJ. Vertical equity consequences of very high cigarette tax increases: If the poor are
the ones smoking, how could cigarette tax increases be progressive? Journal of Policy
Analysis and Management 2008; 27(2).
171
(67) DeCicca P, McLeod L. Cigarette taxes and older adult smoking: evidence from recent large
tax increases. Journal of Health Economics 2008; 27(4):918-929.
(68) Dunlop SM, Perez D, Cotter T. Australian smokers' and recent quitters' responses to the
increasing price of cigarettes in the context of a tobacco tax increase. Addiction 2011;
106(9):1687-1695.
(69) Farrelly MC, Bray JWPTWT. Response by Adults to Increases in Cigarette Prices by
Sociodemographic Characteristics. Southern Economic Journal 2001; 68(1):156-165.
(70) Franks P, Jerant AF, Leigh JP, Lee D, Chiem A, Lewis I et al. Cigarette prices, smoking, and
the poor: implications of recent trends. American Journal of Publci Health 2007;
97(10):1873-1877.
(71) Gospodinov N, Irvine I. Tobacco taxes and regressivity. Journal of Health Economics 2009;
28(2):375-384.
(72) Gruber J, Sen A, Stabile M. Estimating price elasticities when there is smuggling: the
sensitivity of smoking to price in Canada. Journal of Health Economics 2003; 22(5):821-842.
(73) Madden D. Tobacco taxes and starting and quitting smoking: does the effect differ by
education? Applied Economics 2007; 39:613-627.
(74) Mostashari F, Kerker BD, Hajat A, Miller N, Frieden TR. Smoking practices in New York
City: the use of a population-based survey to guide policy-making and programming. Journal
of Urban Health 2005; 82(1):58-70.
(75) Peretti-Watel P, Constance J. "It's all we got left". Why poor smokers are less sensitive to
cigarette price increases. International Journal of Environmental Research & Public Health
2009; 6(2):608-621.
(76) Peretti-Watel P, Villes V, Duval X, Collin F, Reynes J, Sobel A et al. How do HIV-infected
smokers react to cigarette price increases? Evidence from the APROCO-COPILOTE-ANRS
CO8 Cohort. Current HIV Research 2009; 7(4):462-467.
(77) Ringel JS, Evans WN. Cigarette taxes and smoking during pregnancy. American Journal of
Public Health 2001; 91(11):1851-1856.
(78) Siahpush M, Wakefield MA, Spittal MJ, Durkin SJ, Scollo MM. Taxation reduces social
disparities in adult smoking prevalence. American Journal of Preventive Medicine 2009;
36(4):285-291.
(79) Metzger KB, Mostashari F, Kerker BD. Use of pharmacy data to evaluate smoking
regulations' impact on sales of nicotine replacement therapies in New York City. American
Journal of Public Health 2005; 95(6):1050-1055.
(80) Bush T, Zbikowski S, Mahoney L, Deprey M, Mowery PD, Magnusson B. The 2009 US
federal cigarette tax increase and quitline utilization in 16 states. Journal of environmental
and public health 2012; Article ID 314740, 9 pages
(81) Farrelly MC, Nonnemaker JM, Watson KA. The Consequences of High Cigarette Excise
Taxes for Low-Income Smokers. PLoS ONE 2012; 7(9):e43838.
(82) Peretti-Watel P, L'haridon O, Seror V. Responses to increasing cigarette prices in France:
How did persistent smokers react? Health Policy 2012; 106(2):169-176.
(83) Chaloupka FJ, Straif K, Leon ME, Working Group IAfRoC. Effectiveness of tax and price
policies in tobacco control. Tobacco Control 2011; 20(3):235-238.
(84) Kasza KA, Hyland AJ, Brown A, Siahpush M, Yong HH, McNeill AD et al. The
effectiveness of tobacco marketing regulations on reducing smokers' exposure to advertising
and promotion: findings from the International Tobacco Control (ITC) Four Country Survey.
International Journal of Environmental Research & Public Health 2011; 8(2):321-340.
(85) Frick RG, Klein EG, Ferketich AK, Wewers ME. Tobacco advertising and sales practices in
licensed retail outlets after the Food and Drug Administration regulations. [References].
Journal of Community Health: The Publication for Health Promotion and Disease Prevention
37[5], 963-967. 2012.
(86) Zacher M, Germain D, Durkin S, Hayes L, Scollo M, Wakefield M. A Store Cohort Study of
Compliance With a Point-of-Sale Cigarette Display Ban in Melbourne, Australia. Nicotine
and Tobacco Research 2013;15(2): 444-449.
(87)
Cantrell J, Vallone DM, Thrasher JF, Nagler RH, Feirman SP, Muenz LR et al.
Impact of Tobacco-Related Health Warning Labels across Socioeconomic, Race and
172
(88)
(89)
(90)
(91)
(92)
(93)
(94)
(95)
(96)
(97)
(98)
(99)
(100)
Ethnic Groups: Results from a Randomized Web-Based Experiment. PLoS ONE
2013; 8(1):e52206.
Hammond D, Reid JL, Driezen P, Boudreau C. Pictorial health warnings on cigarette
packs in the united states: An experimental evaluation of the proposed FDA
warnings. Nicotine and Tobacco Research 2013; 15(1):93–102.
Hitchman SC, Mons U, Nagelhout GE, Guignard R, McNeill A, Willemsen MC et al.
Effectiveness of the European Union text-only cigarette health warnings: findings
from four countries. European Journal of Public Health 2012; 22(5):693-699.
Willemsen MC. The new EU cigarette health warnings benefit smokers who want to
quit the habit: results from the Dutch Continuous Survey of Smoking Habits.
European Journal of Public Health 2005; 15(4):389-392.
Wilson N, Weerasekera D, Hoek J, Li J, Edwards R. Increased smoker recognition of
a national quitline number following introduction of improved pack warnings: ITC
Project New Zealand. Nicotine and Tobacco Research 2010; 12:Suppl-7.
Niederdeppe J, Kuang X, Crock B, Skelton A. Media campaigns to promote smoking
cessation among socioeconomically disadvantaged populations: what do we know,
what do we need to learn, and what should we do now?. Social Science and Medicine
2008; 67(9):1343-1355.
Hawk LW, Jr., Higbee C, Hyland A, Alford T, O'Connor R, Cummings KM.
Concurrent quit & win and nicotine replacement therapy voucher giveaway
programs: participant characteristics and predictors of smoking abstinence. Journal of
Public Health Management and Practice 2006; 12(1):52-59.
Alekseeva NV, Alekseev OL, Chukhrova MG. Some psychosocial aspects of
smoking: 10-year experience in "Quit & Win" campaigns in Novosibirsk. Alaska
Medicine 2007; 49(2:Suppl):71-74.
Bains N, Pickett W, Laundry B, Mercredy D. Predictors of smoking cessation in an
incentive-based community intervention. Chronic Diseases in Canada 2000;
21(2):54-61.
Centers for Disease Control and Prevention (CDC). Decline in smoking prevalence-New York City, 2002-2006. Morbidity & Mortality Weekly Report 2007;
56(24):604-608.
Civljak M, Ulovec Z, Soldo D, Posavec M, Oreskovic S. Why choose Lent for a
"smoke out day?" Changing smoking behavior in Croatia. Croatian Medical Journal
2005; 46(1):132-136.
Durkin SJ, Biener L, Wakefield MA. Effects of different types of antismoking ads on
reducing disparities in smoking cessation among socioeconomic subgroups.
American Journal of Public Health 2009; 99(12):2217-2223.
Graham AL, Milner P, Saul JE, Pfaff L. Online advertising as a public health and
recruitment tool: comparison of different media campaigns to increase demand for
smoking cessation interventions. Journal of Medical Internet Research 2008;
10(5):e50.
Niederdeppe J, Fiore MC, Baker TB, Smith SS. Smoking-cessation media campaigns
and their effectiveness among socioeconomically advantaged and disadvantaged
populations. American Journal of Public Health 2008; 98(5):916-924.
(101) Richardson A, Cullen J, Mowery P, McCausland K, Vallone DE-MA, Richardson Aao. The
path to quit: How awareness of a large-scale mass-media smoking cessation campaign
promotes quit attempts. Nicotine and Tobacco Research 2011; 13(11):1098–1105.
(102) Vallone DM, Niederdeppe J, Richardson AK, Patwardhan P, Niaura R, Cullen J. A national
mass media smoking cessation campaign: effects by race/ethnicity and education. American
Journal of Health Promotion 2011; 25(5:Suppl):S38-S50.
173
(103) Dunlop SM, Perez D, Cotter T. The natural history of antismoking advertising recall: the
influence of broadcasting parameters, emotional intensity and executional features. Tobacco
Control Online First . 2012.
(104) Farrelly MC, Duke JC, Davis KC, Nonnemaker JM, Kamyab K, Willett JG et al. Promotion
of smoking cessation with emotional and/or graphic antismoking advertising. American
Journal of Preventive Medicine 2012; 43(5):475– 482.
(105) Niederdeppe J, Farrelly MC, Nonnemaker J, Davis KC, Wagner L. Socioeconomic variation
in recall and perceived effectiveness of campaign advertisements to promote smoking
cessation. Social Science and Medicine 2011; 72(5):773-780.
(106) Willems RA, Willemsen MC, Nagelhout GE, Smit ES, Janssen E, van den Putte B et al.
Evaluatie van de 'Echt stoppen met roken kan met de juiste hulp' campagne. 2012.
Maastricht, Universiteit Maastricht.
(107) Nagelhout GE, Willemsen MC, van den Putte B, Crone MR, de VH. International Tobacco
Control (ITC) policy evaluation project. Evaluatie 'In iedere roker zit een stopper' campagne.
Tweede nameting. 2009. Den Haag, the Foundation for Public Health and Smoking
STIVORO.
(108) Wiebing MA, Bot SM, Willemsen MC. Rokers verdienen 'n beloning', de 24-uur-nietrokenactie. Blootstelling, deelname en effect op stopbereidheid bij hoge en lage
welstandsgroepen. Tijdschrift voor Gezondheidswetenschappen 2010; 88:435-441.
(109)van den Putte B, Yzer MC, Ten Berg BM, Steevels RMA. Nederlands Start Met Stoppen /
Nederlands Gaat Door Met Stoppen. Evaluatie van de STIVORO campagnes rondom de
jaarwisseling 2003-2004. 2005. Amsterdam, Universiteit van Amsterdam.
(110)van Osch L., Lechner L, Reubsaet A, Steenstra M, Wigger S, de VH. Optimizing the efficacy of
smoking cessation contests: an exploration of determinants of successful quitting. Health
Education Research 2009; 24(1):54-63.
(111) Davis KC, Nonnemaker JM, Farrelly MC, Niederdeppe J. Exploring differences in smokers'
perceptions of the effectiveness of cessation media messages. Tobacco Control 2011; 20: 2633.
(112) Burns EK, Levinson AH. Reaching Spanish-speaking smokers: state-level evidence of
(113)
(114)
(115)
(116)
(117)
(118)
(119)
(120)
untapped potential for QuitLine utilization. American Journal of Public Health 2010;
100:S165–S170.
Deprey M, McAfee T, Bush T, McClure JB, Zbikowski S, Mahoney L. Using free
patches to improve reach of the Oregon Quit Line. Journal of Public Health
Management and Practice 2009; 15(5):401-408.
Durkin SJ, Wakefield MA, Spittal MJ. Which types of televised anti-tobacco
campaigns prompt more quitline calls from disadvantaged groups? Health Education
Research 2011; 26(6):998-1009.
Miller N, Frieden TR, Liu SY, Matte TD, Mostashari F, Deitcher DR et al.
Effectiveness of a large-scale distribution programme of free nicotine patches: a
prospective evaluation. Lancet 2005; 365(9474):1849-1854.
Owen L. Impact of a telephone helpline for smokers who called during a mass media
campaign. Tobacco Control 2000; 9(2):148-154.
Siahpush M, Wakefield M, Spittal M, Durkin S. Antismoking television advertising
and socioeconomic variations in calls to Quitline. Journal of Epidemiology and
Community Health 2007; 61(4):298-301.
Sood A, Andoh J, Rajoli N, Hopkins-Price P, Verhulst SJ. Characteristics of smokers
calling a national reactive telephone helpline. American Journal of Health Promotion
2008; 22(3):176-179.
Zawertailo L, Dragonetti R, Bondy SJ, Victor C, Selby P. Reach and effectiveness of
mailed nicotine replacement therapy for smokers: 6-month outcomes in a naturalistic
exploratory study. Tobacco Control Online First 2012.
Czarnecki KD, Goranson C, Ellis JA, Vichinsky LE, Coady MH, Perl SB. Using
geographic information system analyses to monitor large-scale distribution of
174
(121)
(122)
(123)
(124)
(125)
(126)
(127)
(128)
(129)
(130)
(131)
(132)
(133)
(134)
nicotine replacement therapy in New York City. Preventive Medicine 2010; 50(56):288-296.
Czarnecki KD, Vichinsky LE, Ellis JA, Perl SB. Media campaign effectiveness in
promoting a smoking-cessation program. American Journal of Preventive Medicine
2010; 38(3:Suppl): S333–S342.
Nagelhout GE, de Korte-de Boer D, Kunst AE, van der Meer RM, de Vries H, van
Gelder BM, Willemsen MC. Trends in socioeconomic inequalities in smoking
prevalence, consumption, initiation, and cessation between 2001 and 2008 in the
Netherlands. Findings from a national population survey. BMC Public Health 2012;
303.
Verdonk-Kleinjan WMI, Verdonk-Kleinjan WMI. Effects of a workplace-smoking
ban in combination with tax increases on smoking in the Dutch population. Nicotine
and Tobacco Research 2011; 13(6): 412-418.
Darity WA, Chen TT, Tuthill RW, Buchanan DR, Winder AE, Stanek E et al. A
multi-city community based smoking research intervention project in the AfricanAmerican population. International Quarterley of Community Health Education
2006; 26(4):323-336.
Secker-Walker RH, Flynn BS, Solomon LJ, Skelly JM, Dorwaldt AL, Ashikaga T.
Helping women quit smoking: results of a community intervention program.
American Journal of Public Health 2000; 90(6):940-946.
Sorensen G, Stoddard A, Hunt MK, Hebert JR, Ockene JK, Avrunin JS et al. The
effects of a health promotion-health protection intervention on behavior change: the
WellWorks Study. American Journal of Public Health 1998; 88(11):1685-1690.
Sorensen G, Stoddard AM, LaMontagne AD, Emmons K, Hunt MK, Youngstrom R
et al. A comprehensive worksite cancer prevention intervention: behavior change
results from a randomized controlled trial (United States). Journal of Public Health
Policy 2003; 24(1):5-25.
Stafford M, Nazroo J, Popay JM, Whitehead M. Tackling inequalities in health:
evaluating the New Deal for Communities initiative. Journal of Epidemiology and
Community Health 2008; 62(4):298-304.
Wendel-Vos GCW, Dutman AE, Verschuren WMM, Ronckers ET, Ament A, van
AP et al. Lifestyle Factors of a Five-Year Community-Intervention Program. The
Hartslag Limburg Intervention. American Journal of Preventive Medicine 2009;
37(1):50-56.
Donath C, Metz K, Chmitorz A, Gradl S, Piontek D, Floter S et al. Prediction of
alcohol addicted patients' smoking status through hospital tobacco control policy: A
multi-level-analysis. Drugs: Education, Prevention & Policy 2009; 16(1):53-70.
Wilson N, Weerasekera D, Borland R, Edwards R, Bullen C, Li J. Use of a national
quitline and variation in use by smoker characteristics: ITC Project New Zealand.
Nicotine and Tobacco Research 2010; 12:Suppl 1:78-84.
Bauld L, Chesterman J, Judge K, Pound E, Coleman T, English Evaluation of
Smoking Cessation Services (EESCS). Impact of UK National Health Service
smoking cessation services: variations in outcomes in England. Tobacco Control
2003; 12(3):296-301.
Bauld L, Judge K, Platt S. Assessing the impact of smoking cessation services on
reducing health inequalities in England: observational study. Tobacco Control 2007;
16(6):400-404.
Simpson CR, Hippisley-Cox J, Sheikh A. Trends in the epidemiology of smoking
recorded in UK general practice. British Journal of General Practice 2010;
60(572):e121-e127.
175
(135) Bauld L, Ferguson J, McEwen A, Hiscock R. Evaluation of a drop-in rolling-group
model of support to stop smoking. Addiction 2012. doi:10.1111/j.13600443.2012.03861.x
(136) Taggar JS, Coleman T, Lewis S, Szatkowski L. The impact of the Quality and
Outcomes Framework (QOF) on the recording of smoking targets in primary care
medical records: cross-sectional analyses from The Health Improvement Network
(THIN) database. BMC Public Health 2012; 12:329.
(137) Galbraith L, Hecht G (ISD Scotland). NHS Smoking Cessation Service Statistics
(Scotland) 1st January to 31st December 2011. 1-40. 2012. ScotPHO.
(138) The Health and Social Care Information Centre. Statistics on NHS Stop Smoking
Services: England, April 2011 – March 2012. 2012.
(139) Hiscock R, Pearce J, Barnett R, Moon G, Daley V. Do smoking cessation
programmes influence geographical inequalities in health? An evaluation of the
impact of the PEGS programme in Christchurch, New Zealand. Tobacco Control
2009; 18(5):371-376.
(140) Nagelhout G, van den Putte BAS, Mons U, McNeill A, Guignard Real.
Socioeconomic and country variations in cross-border cigarette purchasing as
tobacco tax avoidance strategy. Findings from the ITC Europe Surveys. Tobacco
Control Online First 2013; published on May 3, 2013.
176
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.
177
37. vending machine$.ti,ab.
38. (trade adj (restrict$ 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$)).ti,ab.
79. exp socioeconomic factors/
80. exp public assistance/
81. exp social welfare/
82. vulnerable populations/
83. or/55-82
84. 11 and 54
85. 83 and 84
86. limit 85 to (abstracts and english language and yr="1990 -Current")
178
Embase; Excerpta Medica Database Guide, 1980 to 2012 Week 18, search date 09/05/2012; also
1980 to 2013 week 3, search date 23/01/2013
1. smoking/
2. smoking cessation/
3. tobacco/
4. nicotine/
5. tobacco, smokeless/
6. "smoking and smoking related phenomena"/
7. cigarette smoking/
8. cigarette smoke/
9. tobacco smoke/
10. (smokers or smoker).ti,ab.
11. cigar$.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$)).ti,ab.
179
41. ((sale or sales or retail$ 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$)).ti,ab.
76. exp socioeconomics/
77. public assistance/
78. welfare, social/
79. exp social status/
80. social security/
81. vulnerable population/
82. or/52-81
83. 13 and 51
84. 82 and 83
85. limit 84 to (abstracts and english language and yr="1990 -Current")
180
PsycInfo (OVID) 1987 to May Week 1 2012, search date 10/05/2012; also 1987 to January week 3
2013, search date 23/01/2013
1. exp tobacco smoking/
2. exp smoking cessation/
3. nicotine/
4. tobacco, smokeless/
5. (smokers or smoker).ti,ab.
6. tobacco.ti,ab.
7. nicotine.ti,ab.
8. cigar$.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.
181
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")
182
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; also January 2012 to December 2012, search date 29/04/13.
#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*)
183
#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
184
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; also 1st May 2012 to 31st December 2012, search date 29/04/13.
(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; also January 2012 to December 2012, search date
29/04/13.
CINAHL Plus (EBSCO host) search date 10/05/12; also 1st May 2012 to 31st December 2012, search
date 29/04/13.
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; also 1st May 2012 to 31st December 2012, search date
29/04/13.
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
185
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.
186
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
187
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
188
7.2 Appendix B WHO European countries and other stage 4 countries
Albania
AndorraArmeniaAustriaAzerbaijanBelarusBelgiumBosnia
and
HerzegovinaBulgariaCroatiaCyprusCzech
RepublicDenmarkEstoniaFinlandFranceGeorgiaGermanyGreeceHungaryIceland
IrelandIsraelItalyKazakhstanKyrgyzstanLatviaLithuaniaLuxembourgMaltaMonacoMontenegroNethe
rlandsNorwayPolandPortugalRepublic
of
MoldovaRomaniaRussian
FederationSan
MarinoSerbiaSlovakiaSloveniaSpainSwedenSwitzerlandTajikistanThe Former Yugoslav Republic of
MacedoniaTurkeyTurkmenistanUkraineUnited Kingdom of Great Britain and Northern
IrelandUzbekistanOther stage 4 countries: Australia, United States, New Zealand, Canada
189
7.3 Appendix C Inclusion/exclusion form
Ref ID FIRST AUTHOR
YEAR
CODE ANSWER TYPE
QUESTION
1
Is the study population 11 years of age or older?
population
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
 use of quitting aids/services
 smoking status (self-reported/validated)
 number of quit attempts
190
 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
191
7.4 Appendix D Included studies
Reference
Source
Alekseeva NV, Alekseev OL, Chukhrova MG. Some psychosocial MEDLINE
aspects of smoking: 10-year experience in "Quit & Win" campaigns in
Novosibirsk. Alaska Medicine 2007; 49(2:Suppl):Suppl-4.
Arheart KL, Lee DJ, Dietz NA, Wilkinson JD, Clark JD, III, LeBlanc MEDLINE
WG et al. Declining trends in serum cotinine levels in US worker
groups: the power of policy. Journal of Occupational & Environmental
Medicine 2008; 50(1):57-63.
Azagba S, Sharaf M. Cigarette taxes and smoking participation: MEDLINE
evidence from recent tax increases in Canada. International Journal of
Environmental Research & Public Health 2011; 8(5):1583-1600.
Bains N, Pickett W, Laundry B, Mercredy D. Predictors of smoking MEDLINE
cessation in an incentive-based community intervention. Chronic
Diseases in Canada 2000; 21(2):54-61.
Barnett R, Pearce J, Moon G, Elliott J, Barnett P. Assessing the effects MEDLINE
of the introduction of the New Zealand Smokefree Environment Act
2003 on acute myocardial infarction hospital admissions in
Christchurch, New Zealand. Australian & New Zealand Journal of
Public Health 2009; 33(6):515-520.
Bauld L, Chesterman J, Judge K, Pound E, Coleman T, English PHRC
Evaluation of Smoking Cessation Services (EESCS). Impact of UK
National Health Service smoking cessation services: variations in
outcomes in England. Tobacco Control 2003; 12(3):296-301.
Bauld L, Judge K, Platt S. Assessing the impact of smoking cessation MEDLINE
services on reducing health inequalities in England: observational study.
Tobacco Control 2007; 16(6):400-404.
Bauld L, Ferguson J, McEwen A, Hiscock R. Evaluation of a drop-in HANDSEARCH
rolling-group model of support to stop smoking. Addiction 2012.
Biener L, Aseltine RH, Jr., Cohen B, Anderka M. Reactions of adult and MEDLINE
teenaged smokers to the Massachusetts tobacco tax. American Journal
of Public Health 1998; 88(9):1389-1391.
Burns EK, Levinson AH. Reaching Spanish-speaking smokers: state- MEDLINE
level evidence of untapped potential for QuitLine utilization. American
Journal of Public Health 2010; 100:Suppl-710.
Bush T, Zbikowski S, Mahoney L, Deprey M, Mowery PD, Magnusson EMBASE
B. The 2009 US federal cigarette tax increase and quitline utilization in
16 states. Journal of environmental and public health 2012; Article ID
314740, doi:10.1155/2012/314740.
Cantrell J, Vallone DM, Thrasher JF, Nagler RH, Feirman SP, Muenz EXPERT
LR et al. Impact of Tobacco-Related Health Warning Labels across
Socioeconomic, Race and Ethnic Groups: Results from a Randomized
Web-Based Experiment. PLoS ONE 2013; 8(1):e52206.
192
Centers for Disease Control and Prevention (CDC). Response to MEDLINE
increases in cigarette prices by race/ethnicity, income, and age groups-United States, 1976-1993. Morbidity & Mortality Weekly Report 1998;
47(29):605-609.
Centers for Disease Control and Prevention (CDC). Decline in smoking MEDLINE
prevalence--New York City, 2002-2006. Morbidity & Mortality Weekly
Report 2007; 56(24):604-608.
Cesaroni G, Forastiere F, Agabiti N, Valente P, Zuccaro P, Perucci CA. MEDLINE
Effect of the Italian smoking ban on population rates of acute coronary
events. Circulation 2008; 117(9):1183-1188.
Choi K, Hennrikus D, Forster J, St Claire AW. Use of Price-Minimizing HANDSEARCH
Strategies by Smokers and Their Effects on Subsequent Smoking
Behaviors. Nicotine & Tobacco Research 212; 14(7):864-870.
Civljak M, Ulovec Z, Soldo D, Posavec M, Oreskovic S. Why choose
Lent for a "smoke out day?" Changing smoking behavior in Croatia.
Croatian Medical Journal 2005; 46(1):132-136.
MEDLINE
Colman GJ. Vertical equity consequences of very high cigarette tax PSYCINFO
increases: If the poor are the ones smoking, how could cigarette tax
increases be progressive? Journal of Policy Analysis and Management
2008; 27(2).
Czarnecki KD, Goranson C, Ellis JA, Vichinsky LE, Coady MH, Perl MEDLINE
SB. Using geographic information system analyses to monitor largescale distribution of nicotine replacement therapy in New York City.
Preventive Medicine 2010; 50(5-6):288-296.
Czarnecki KD, Vichinsky LE, Ellis JA, Perl SB. Media campaign MEDLINE
effectiveness in promoting a smoking-cessation program. American
Journal of Preventive Medicine 2010; 38(Suppl 3):S333–S342.
Darity WA, Chen TT, Tuthill RW, Buchanan DR, Winder AE, Stanek E MEDLINE
et al. A multi-city community based smoking research intervention
project in the African-American population. International Quarterly
Community Health Education 2006; 26(4):323-336.
DeCicca P, McLeod L. Cigarette taxes and older adult smoking: MEDLINE
evidence from recent large tax increases. Journal of Health Economics
2008; 27(4):918-929.
Delnevo CD, Hrywna M, Lewis MJ. Predictors of smoke-free MEDLINE
workplaces by employee characteristics: who is left unprotected?
American Journal of Industrial Medicine 2004; 46(2):196-202.
Deprey M, McAfee T, Bush T, McClure JB, Zbikowski S, Mahoney L. MEDLINE
Using free patches to improve reach of the Oregon Quit Line. Journal of
Public Health Management Practice 2009; 15(5):401-408.
Deverell M, Randolph C, Albers A, Hamilton W, Siegel M. Diffusion of MEDLINE
local restaurant smoking regulations in Massachusetts: identifying
disparities in health protection for population subgroups. Journal of
193
Public Health Management Practice 2006; 12(3):262-269.
Dinno A, Glantz S. Tobacco control policies are egalitarian: a MEDLINE
vulnerabilities perspective on clean indoor air laws, cigarette prices, and
tobacco use disparities. Social Science Medicine 2009; 68(8):14391447.
Donath C, Metz K, Chmitorz A, Gradl S, Piontek D, Floter S et al. PSYCINFO
Prediction of alcohol addicted patients' smoking status through hospital
tobacco control policy: A multi-level-analysis. Drugs: Education,
Prevention & Policy 2009; 16(1): 53-70.
Dunlop SM, Perez D, Cotter T. Australian smokers' and recent quitters' MEDLINE
responses to the increasing price of cigarettes in the context of a tobacco
tax increase. Addiction 2011; 106(9):1687-1695.
Dunlop SM, Perez D, Cotter T. The natural history of antismoking HANDSEARCH
advertising recall: the influence of broadcasting parameters, emotional
intensity and executional features . Tobacco Control Online First. 2012.
Durkin SJ, Biener L, Wakefield MA. Effects of different types of MEDLINE
antismoking ads on reducing disparities in smoking cessation among
socioeconomic subgroups. American Journal of Public Health 2009;
99(12):2217-2223.
Durkin SJ, Wakefield MA, Spittal MJ. Which types of televised anti- MEDLINE
tobacco campaigns prompt more quitline calls from disadvantaged
groups? Health Education Research 2011; 26(6):998-1009.
Eadie D, Heim D, MacAskill S, Ross A, Hastings G, Davies J. A MEDLINE
qualitative analysis of compliance with smoke-free legislation in
community bars in Scotland: implications for public health. Addiction
2008; 103(6):1019-1026.
Ellis JA, Gwynn C, Garg RK, Philburn R, Aldous KM, Perl SB et al. MEDLINE
Secondhand smoke exposure among nonsmokers nationally and in New
York City. Nicotine & Tobacco Research 2009; 11(4):362-370.
Farrelly MC, Evans WN, Sfekas AE. The impact of workplace smoking MEDLINE
bans: results from a national survey. Tobacco Control 1999; 8(3):272277.
Farrelly MC, Bray JWPTWT. Response by Adults to Increases in YORK
Cigarette Prices by Sociodemographic Characteristics. Southern
Economic Journal 2001; 68(1):156-165.
Farrelly MC, Duke JC, Davis KC, Nonnemaker JM, Kamyab K, Willett EMBASE
JG et al. Promotion of smoking cessation with emotional and/or graphic
antismoking advertising. American Journal of Preventive Medicine
2012; 43(5): 475– 482.
Farrelly MC, Nonnemaker JM, Watson KA. The Consequences of High EMBASE
Cigarette Excise Taxes for Low-Income Smokers. PLoS ONE 2012;
7(9):e43838.
194
Federico B, Mackenbach JP, Eikemo TA, Kunst AE. Impact of the 2005 HANDSEARCH
smoke-free policy in Italy on prevalence, cessation and intensity of
smoking in the overall population and by educational group. Addiction
2012.
Ferketich AK, Liber A, Pennell M, Nealy D, Hammer J, Berman M.
Clean indoor air ordinance coverage in the Appalachian region of the
United States. American Journal of Public Health 2010; 100(7):13131318.
EBSCO HOST
Fowkes FJI, Stewart MCW, Fowkes FGR, Amos A, Price JF. Scottish EMBASE
smoke-free legislation and trends in smoking cessation. Addiction 2008;
103(11): 1888–1895.
Franks P, Jerant AF, Leigh JP, Lee D, Chiem A, Lewis I et al. Cigarette
prices, smoking, and the poor: implications of recent trends. American
Journal of Public Health 2007; 97(10):1873-1877.
MEDLINE
Frick RG, Klein EG, Ferketich AK, Wewers ME. Tobacco advertising PSYCINFO
and sales practices in licensed retail outlets after the Food and Drug
Administration regulations. Journal of Community Health: The
Publication for Health Promotion and Disease Prevention 2012; 37[5]:
963-967.
Frieden TR, Mostashari F, Kerker BD, Miller N, Hajat A, Frankel M. MEDLINE
Adult tobacco use levels after intensive tobacco control measures: New
York City, 2002-2003. American Journal of Public Health 2005;
95(6):1016-1023.
Gospodinov N, Irvine I. Tobacco taxes and regressivity. Journal of MEDLINE
Health Economics 2009; 28(2):375-384.
Graham AL, Milner P, Saul JE, Pfaff L. Online advertising as a public MEDLINE
health and recruitment tool: comparison of different media campaigns to
increase demand for smoking cessation interventions. Journal of
Medical Internet Research 2008; 10(5):e50.
Gruber J, Sen A, Stabile M. Estimating price elasticities when there is MEDLINE
smuggling: the sensitivity of smoking to price in Canada. Journal of
Health Economics 2003; 22(5):821-842.
Guse CE, Marbella AM, Layde PM, Christiansen A, Remington P. MEDLINE
Clean indoor air policies in Wisconsin workplaces. Wisconsin Medical
Journal 2004; 103(4):27-31.
Guzman A, Walsh MC, Smith SS, Malecki KC, Nieto JF. Evaluating EMBASE
effects of statewide smoking regulations on smoking behaviors among
participants in the survey of the health of Wisconsin. Wisconsin
Medical Journal 2012; 111(4):2012.
Hackshaw L, McEwen A, West R, Bauld L. Quit attempts in response to MEDLINE
smoke-free legislation in England. Tobacco Control 2010; 19(2):160164.
195
Hammond D, Reid JL, Driezen P, Boudreau C. Pictorial health EMBASE
warnings on cigarette packs in the united states: An experimental
evaluation of the proposed FDA warnings. Nicotine and Tobacco
Research 2013; 15(1): 93–102.
Hawk LW, Jr., Higbee C, Hyland A, Alford T, O'Connor R, Cummings MEDLINE
KM. Concurrent quit & win and nicotine replacement therapy voucher
giveaway programs: participant characteristics and predictors of
smoking abstinence. Journal of Public Health Management & Practice
2006; 12(1):52-59.
Hawkins SS, Cole TJ, Law C. Examining smoking behaviours among MEDLINE
parents from the UK Millennium Cohort Study after the smoke-free
legislation in Scotland. Tobacco Control 2011; 20(2):112-118.
Hawkins SS, Chandra A, Berkman L. The impact of tobacco control EMBASE
policies on disparities in children's secondhand smoke exposure: a
comparison of methods. Maternal and child health journal 2012; 16:
S70-77).
Hemsing N, Greaves L, Poole N, Bottorff J. Reshuffling and relocating: EMBASE
the gendered and income-related differential effects of restricting
smoking locations. Journal of environmental and public health 2012;
Article ID 907832, doi:10.1155/2012/907832.
Hiscock R, Pearce J, Barnett R, Moon G, Daley V. Do smoking PHRC
cessation programmes influence geographical inequalities in health? An
evaluation of the impact of the PEGS programme in Christchurch, New
Zealand. Tobacco Control 2009; 18(5):371-376.
Hitchman SC, Mons U, Nagelhout GE, Guignard R, McNeill A, MEDLINE
Willemsen MC et al. Effectiveness of the European Union text-only
cigarette health warnings: findings from four countries. European
Journal of Public Health 2012; 22(5):693-699.
Kasza KA, Hyland AJ, Brown A, Siahpush M, Yong HH, McNeill AD MEDLINE
et al. The effectiveness of tobacco marketing regulations on reducing
smokers' exposure to advertising and promotion: findings from the
International Tobacco Control (ITC) Four Country Survey. International
Journal of Environmental Research & Public Health 2011; 8(2):321340.
King BA, Hyland AJ, Borland R, McNeill A, Cummings KM. MEDLINE
Socioeconomic variation in the prevalence, introduction, retention, and
removal of smoke-free policies among smokers: findings from the
International Tobacco Control (ITC) Four Country Survey. International
Journal of Environmental Research & Public Health 2011; 8(2):411434.
Levy DT, Mumford EA, Compton C. Tobacco control policies and MEDLINE
smoking in a population of low education women, 1992-2002. Journal
of Epidemiology & Community Health 2006; 60:Suppl-6.
Linsey Galbraith GHIS. NHS Smoking Cessation Service Statistics
GREY
196
(Scotland) 1st January to 31st December 2011. 1-40. 2012. ScotPHO.
LITERATURE
MacCalman L, Semple S, Galea KS, van TM, Dempsey S, Hilton S et EMBASE
al. The relationship between workers' self-reported changes in health
and their attitudes towards a workplace intervention: lessons from
smoke-free legislation across the UK hospitality industry. BMC Public
Health 2012; 12:324.
Madden D. Tobacco taxes and starting and quitting smoking: does the PHRC REVIEW
effect differ by education? Applied Economics 2007; 39:613-627.
Metzger KB, Mostashari F, Kerker BD. Use of pharmacy data to MEDLINE
evaluate smoking regulations' impact on sales of nicotine replacement
therapies in New York City. American Journal of Public Health 2005;
95(6):1050-1055.
Miller N, Frieden TR, Liu SY, Matte TD, Mostashari F, Deitcher DR et MEDLINE
al. Effectiveness of a large-scale distribution programme of free nicotine
patches: a prospective evaluation. Lancet 2005; 365(9474):1849-1854.
Moore GF, Currie D, Gilmore G, Holliday JC, Moore L. Socioeconomic EXPERT
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.
Moore GF, Holliday JC, Moore LA. Socioeconomic patterning in MEDLINE
changes in child exposure to secondhand smoke after implementation of
smoke-free legislation in Wales. Nicotine & Tobacco Research 2011;
13(10):903-910.
Mostashari F, Kerker BD, Hajat A, Miller N, Frieden TR. Smoking MEDLINE
practices in New York City: the use of a population-based survey to
guide policy-making and programming. Journal of Urban Health 2005;
82(1):58-70.
Moussa KM, Lindstr+Âm M, +ûstergren P. Socioeconomic and EBSCO HOST
demographic differences in exposure to environmental tobacco smoke at
work:
the
Scania
Public
Health
Survey
2000
823. Scandinavian Journal of Public Health 2004; 32(3):194-202.
Nabi-Burza E, Regan S, Drehmer J, Ossip D, Rigotti N, Hipple B et al. EMBASE
Parents smoking in their cars with children present. Pediatrics 2012;
130(6):e1471.
*Nagelhout GE, Willemsen MC, van den Putte B, Crone MR, de VH. GREY
International Tobacco Control (ITC) policy evaluation project. LITERATURE
Evaluatie 'In iedere roker zit een stopper' campagne. Tweede nameting.
2009. Den Haag, the Foundation for Public Health and Smoking
STIVORO.
Nagelhout GE, Willemsen MC, de VH. The population impact of MEDLINE
smoke-free workplace and hospitality industry legislation on smoking
behaviour. Findings from a national population survey. Addiction 2011;
106(4):816-823.
197
Nagelhout GE, Mons U, Allwright S, Guignard R, Beck F, Fong GT et MEDLINE
al. Prevalence and predictors of smoking in "smoke-free" bars. Findings
from the International Tobacco Control (ITC) Europe Surveys. Social
Science & Medicine 2011; 72(10):1643-1651.
Nagelhout GE, de Korte-de Boer D, Kunst AE, van der Meer RM, de EXPERT
Vries H, van Gelder BM, Willemsen MC. Trends in socioeconomic
inequalities in smoking prevalence, consumption, initiation, and
cessation between 2001 and 2008 in the Netherlands. Findings from a
national population survey. BMC Public Health 2012; 303.
*Nagelhout GE, Crone MR, van den Putte B, Willemsen MC, Fong GT, EXPERT
de VH. Age and educational inequalities in smoking cessation due to
three population-level tobacco control interventions: findings from the
International Tobacco Control (ITC) Netherlands Survey. Health
Education Research 2013; 28(1):83-91.
Niederdeppe J, Fiore MC, Baker TB, Smith SS. Smoking-cessation MEDLINE
media campaigns and their effectiveness among socioeconomically
advantaged and disadvantaged populations. American Journal of Public
Health 2008; 98(5):916-924.
Niederdeppe J, Farrelly MC, Nonnemaker J, Davis KC, Wagner L. MEDLINE
Socioeconomic variation in recall and perceived effectiveness of
campaign advertisements to promote smoking cessation. Social Science
& Medicine 2011; 72(5):773-780.
Owen L. Impact of a telephone helpline for smokers who called during a MEDLINE
mass media campaign. Tobacco Control 2000; 9(2):148-154.
Parry O, Platt S. Smokers at risk: implications of an institutionally MEDLINE
bordered risk-reduced environment. Health & Place 2000; 6(2):117-123.
Patel V, Thomson G, Wilson N. Objective measurement of area HANDSEARCH
differences in 'private' smoking behaviour: observing smoking in
vehicles. Tobacco Control 2011; Online First, published on December
1, 2011 as 10.1136/tobaccocontrol-2011-050119.
Peretti-Watel P, Constance J. "It's all we got left". Why poor smokers MEDLINE
are less sensitive to cigarette price increases. International Journal of
Environmental Research & Public Health 2009; 6(2):608-621.
Peretti-Watel P, Villes V, Duval X, Collin F, Reynes J, Sobel A et al. MEDLINE
How do HIV-infected smokers react to cigarette price increases?
Evidence from the APROCO-COPILOTE-ANRS CO8 Cohort. Current
HIV Research 2009; 7(4):462-467.
Peretti-Watel P, L'haridon O, Seror V. Responses to increasing cigarette EXPERT
prices in France: How did persistent smokers react? Health Policy 2012;
106(2):169-176.
Plescia M, Malek SH, Shopland DR, Anderson CM, Burns DM. MEDLINE
Protecting workers from secondhand smoke in North Carolina. North
Carolina Medical Journal 2005; 66(3):186-191.
198
Razavi D, Vandecasteele H, Primo C, Bodo M, Debrier F, Verbist H et MEDLINE
al. Improving cancer prevention at the worksite: how are Belgian
companies dealing with smoking regulations? Psycho-Oncology 1997;
6(3):204-211.
**Richardson A, Cullen J, Mowery P, McCausland K, Vallone DE-MA, PSYCINFO
Richardson Aao. The path to quit: How awareness of a large-scale
mass-media smoking cessation campaign promotes quit attempts.
Nicotine & Tobacco Research 2011; .13(11).
Ringel JS, Evans WN. Cigarette taxes and smoking during pregnancy.
American Journal of Public Health 2001; 91(11):1851-1856.
MEDLINE
***Ritchie D, Amos A, Martin C. "But it just has that sort of feel about MEDLINE
it, a leper"--stigma, smoke-free legislation and public health. Nicotine &
Tobacco Research 2010; 12(6):622-629.
***Ritchie D, Amos A, Martin C. Public places after smoke-free--a MEDLINE
qualitative exploration of the changes in smoking behaviour. Health &
Place 2010; 16(3):461-469.
Schaap MM, Kunst AE, Leinsalu M, Regidor E, Ekholm O, Dzurova D MEDLINE
et al. Effect of nationwide tobacco control policies on smoking cessation
in high and low educated groups in 18 European countries. Tobacco
Control 2008; 17(4):248-255.
Secker-Walker RH, Flynn BS, Solomon LJ, Skelly JM, Dorwaldt AL, MEDLINE
Ashikaga T. Helping women quit smoking: results of a community
intervention program. American Journal of Public Health 2000;
90(6):940-946.
Semple S, van TM, Galea KS, MacCalman L, Gee I, Parry O et al. UK MEDLINE
smoke-free legislation: changes in PM2.5 concentrations in bars in
Scotland, England, and Wales. Annals of Occupational Hygiene 2010;
54(3):272-280.
Shavers VL, Fagan P, Alexander LA, Clayton R, Doucet J, Baezconde- MEDLINE
Garbanati L. Workplace and home smoking restrictions and
racial/ethnic variation in the prevalence and intensity of current cigarette
smoking among women by poverty status, TUS-CPS 1998-1999 and
2001-2002. Journal of Epidemiology and Community Health 2006;
60(Suppl II):ii34–ii43
Shopland DR, Anderson CM, Burns DM, Gerlach KK. Disparities in EMBASE
Smoke-Free Workplace Policies among Food Service Workers. Journal
of Occupational and Environmental Medicine 2004; 46(4):347-356.
Siahpush M, Wakefield M, Spittal M, Durkin S. Antismoking television MEDLINE
advertising and socioeconomic variations in calls to Quitline. Journal of
Epidemiology and Community Health 2007; 61(4):298-301.
Siahpush M, Wakefield MA, Spittal MJ, Durkin SJ, Scollo MM. MEDLINE
Taxation reduces social disparities in adult smoking prevalence.
American Journal of Preventive Medicine 2009; 36(4):285-291.
199
Simpson CR, Hippisley-Cox J, Sheikh A. Trends in the epidemiology of MEDLINE
smoking recorded in UK general practice. British Journal of General
Practice 2010; 60(572):e121-e127.
Sims M, Mindell JS, Jarvis MJ, Feyerabend C, Wardle H, Gilmore A. EMBASE
Did smokefree legislation in England reduce exposure to secondhand
smoke among nonsmoking adults? Cotinine analysis from the Health
Survey for England. Environmental Health Perspectives 2012;
120(3):425–430.
Skeer M, George S, Hamilton WL, Cheng DM, Siegel M. Town-level MEDLINE
characteristics and smoking policy adoption in Massachusetts: are local
restaurant smoking regulations fostering disparities in health protection?
AM J PUBLIC HEALTH 2004; 94(2):286-292.
Sood A, Andoh J, Rajoli N, Hopkins-Price P, Verhulst SJ. MEDLINE
Characteristics of smokers calling a national reactive telephone helpline.
American Journal of Health Promotion 2008; 22(3):176-179.
Sorensen G, Stoddard A, Hunt MK, Hebert JR, Ockene JK, Avrunin JS MEDLINE
et al. The effects of a health promotion-health protection intervention on
behavior change: the WellWorks Study. American Journal of Public
Health 1998; 88(11):1685-1690.
Sorensen G, Stoddard AM, LaMontagne AD, Emmons K, Hunt MK, MEDLINE
Youngstrom R et al. A comprehensive worksite cancer prevention
intervention: behavior change results from a randomized controlled trial
(United States). Journal of Public Health Policy 2003; 24(1):5-25.
Stafford M, Nazroo J, Popay JM, Whitehead M. Tackling inequalities in MEDLINE
health: evaluating the New Deal for Communities initiative. Journal of
Epidemiology and Community Health 2008; 62(4):298-304.
Stamatakis KA, Brownson RC, Luke DA. Risk factors for exposure to MEDLINE
environmental tobacco smoke among ethnically diverse women in the
United States. Journal of Womens Health & Gender-Based Medicine
2002; 11(1):45-51.
Taggar JS, Coleman T, Lewis S, Szatkowski L. The impact of the EMBASE
Quality and Outcomes Framework (QOF) on the recording of smoking
targets in primary care medical records: cross-sectional analyses from
The Health Improvement Network (THIN) database. BMC Public
Health 2012; 12:329.
Tang H, Cowling DW, Lloyd JC, Rogers T, Koumjian KL, Stevens CM, YORK REVIEW
Bal DG. Changes of Attitudes and Patronage Behaviors in Response to
a Smoke-Free Bar Law. American Journal of Public Health 2003;
93:611-617.
Tong EK, Tang H, Tsoh J, Wong C, Chen MS, Jr. Smoke-free policies MEDLINE
among Asian-American women: comparisons by education status.
American Journal of Preventive Medicine 2009; 37(2S):S144–S150.
**Vallone DM, Niederdeppe J, Richardson AK, Patwardhan P, Niaura MEDLINE
R, Cullen J. A national mass media smoking cessation campaign: effects
200
by race/ethnicity and education. American Journal of Health Promotion
2011; 25(5): S38-S50.
Van den Putte B, Yzer MC, Ten Berg BM, Steevels RMA. Nederlands GREY
Start Met Stoppen / Nederlands Gaat Door Met Stoppen. Evaluatie van LITERATURE
de STIVORO campagnes rondom de jaarwisseling 2003-2004. 2005.
Amsterdam, Universiteit van Amsterdam.
Van Osch L, Lechner L, Reubsaet A, Steenstra M, Wigger S, de Vries PHRC
H. Optimizing the efficacy of smoking cessation contests: an
exploration of determinants of successful quitting. Health Education
Research 2009;24(1):54-63.
Verdonk-Kleinjan WMI, Knibbe RA, Tan FES, Willemsen MC, de EMBASE
Groot HN, de VH. Does the workplace-smoking ban eliminate
differences in risk for environmental tobacco smoke exposure at work?
Health Policy 2009; 92(2-3):197–202.
Verdonk-Kleinjan WMI, Verdonk-Kleinjan WMI. Effects of a PSYCINFO
workplace-smoking ban in combination with tax increases on smoking
in the Dutch population. Nicotine & Tobacco Research 2011;13(6):412418.
Wendel-Vos GCW, Dutman AE, Verschuren WMM, Ronckers ET, EMBASE
Ament A, van AP et al. Lifestyle Factors of a Five-Year CommunityIntervention Program. The Hartslag Limburg Intervention. American
Journal of Preventive Medicine 2009; 37(1):50-56.
Wiebing MA, Bot SM, Willemsen MC. Rokers verdienen 'n beloning', GREY
de 24-uur-niet-rokenactie. Blootstelling, deelname en effect op LITERATURE
stopbereidheid bij hoge en lage welstandsgroepen. Tijdschrift voor
Gezondheidswetenschappen 2010; 88:435-441.
Willems RA, Willemsen MC, Nagelhout GE, Smit ES, Janssen E, van GREY
den Putte B et al. Evaluatie van de 'Echt stoppen met roken kan met de LITERATURE
juiste hulp' campagne. 2012. Maastricht, Universiteit Maastricht.
Willemsen MC. The new EU cigarette health warnings benefit smokers YORK REVIEW
who want to quit the habit: results from the Dutch Continuous Survey of
Smoking Habits. European Journal of Public Health 2005; 15(4):389392.
Wilson N, Weerasekera D, Borland R, Edwards R, Bullen C, Li J. Use MEDLINE
of a national quitline and variation in use by smoker characteristics: ITC
Project New Zealand. Nicotine & Tobacco Research 2010;12 (Suppl84):S78-S84.
Wilson N, Weerasekera D, Hoek J, Li J, Edwards R. Increased smoker MEDLINE
recognition of a national quitline number following introduction of
improved pack warnings: ITC Project New Zealand. Nicotine &
Tobacco Research 2010; 12 (Suppl-1): S72–S77.
Zacher M, Germain D, Durkin S, Hayes L, Scollo M, Wakefield M. A HANDSEARCH
Store
Cohort
Study
of
Compliance
With
a
Point-of-Sale
Cigarette
Display
Ban
in
Melbourne, Australia. Nicotine and Tobacco Research 2013; 15(2):
201
444-449.
Zawertailo L, Dragonetti R, Bondy SJ, Victor C, Selby P. Reach and HANDSEARCH
effectiveness of mailed nicotine replacement therapy for smokers: 6month outcomes in a naturalistic exploratory study. Tobacco Control
Online First 2012.
202
7.5 Appendix E Excluded studies
Reference
Ahrens D, Uebelher P, Remington PL. Evaluation of community and
organizational characteristics of smoke-free ordinance campaigns in
15 Wisconsin cities. Preventing Chronic Disease 2005; 2(3):1-9.
Alexander LA, Crawford T, Mendiondo MS. Occupational status,
work-site cessation programs and policies and menthol smoking on
quitting behaviors of US smokers. Addiction 2010; 105(Suppl-1):
95–104.
Anger S, Kvasnicka M, Siedler T. One last puff? Public smoking
bans and smoking behavior. Journal of Health Economics 2011;
30(3):591-601.
Brenner H, Born J, Novak P, Wanek V. Smoking behavior and
attitude toward smoking regulations and passive smoking in the
workplace. A study among 974 employees in the German metal
industry. Preventive Medicine 1997; 26(1):138-143.
Burns EK, Levinson AH, Deaton EA. Factors in Nonadherence to
Quitline Services: Smoker Characteristics Explain Little
68. Health Education & Behavior 2012; 39(5):596-602.
Centers for Disease Control and Prevention (CDC). State-specific
prevalence of current cigarette smoking among adults and the
proportion of adults who work in a smoke-free environment--United
States, 1999. Morbidity & Mortality Weekly Report 2000;
49(43):978-982.
Deason LM, Adhikari SB, Clopton TM, Oches B, Jensen C. The
Ohio Cross-Cultural Tobacco Control Alliance: understanding and
eliminating tobacco-related disparities through the integration of
science, practice, and policy. American Journal of Public Health
2010; 100:(Suppl-5): S240–S245.
Delnevo CD, Hrywna M, Foulds J, Steinberg MB. Cigar use before
and after a cigarette excise tax increase in New Jersey. Addictive
Behavior 2004; 29(9):1799-1807.
Eek F, Ostergren PO, Diderichsen F, Rasmussen NK, Andersen I,
Moussa K et al. Differences in socioeconomic and gender
inequalities in tobacco smoking in Denmark and Sweden; a cross
sectional comparison of the equity effect of different public health
policies. BMC Public Health 2010; 10:9.
Emmelin M, Weinehall L, Stenlund H, Wall S, Dahlgren L. To be
seen, confirmed and involved--a ten year follow-up of perceived
health and cardiovascular risk factors in a Swedish community
intervention programme. BMC Public Health 2007; 7:190.
Fujishiro K, Stukovsky KDH, Roux AD, Landsbergis P, Burchfiel C.
Occupational gradients in smoking behavior and exposure to
workplace environmental tobacco smoke: The multi-ethnic study of
atherosclerosis. Journal of Occupational and Environmental
Medicine 2012; 54(2):136–145.
Germain D, Durkin S, Scollo M, Wakefield M. The long-term
decline of adult tobacco use in Victoria: changes in smoking
initiation and quitting over a quarter of a century of tobacco control.
Australian & New Zealand Journal of Public Health 2012; 36(1):1723.
Gilpin EA, Pierce JP. The California Tobacco Control Program and
potential harm reduction through reduced cigarette consumption in
continuing smokers. Nicotine & Tobacco Research 2002; 4:Suppl66.
Hunt MK, Lederman R, Stoddard AM, LaMontagne AD, McLellan
D, Combe C et al. Process evaluation of an integrated health
promotion/occupational health model in WellWorks-2. Health
Reason for exclusion
Not an intervention or policy to
reduce adult smoking or to prevent
youth starting to smoke
Not an intervention or policy to
reduce adult smoking or to prevent
youth starting to smoke
Does not report outcomes for high
versus low socio-economic group
Not an intervention or policy to
reduce adult smoking or to prevent
youth starting to smoke
Did not report reach by SES
Not an intervention or policy to
reduce adult smoking or to prevent
youth starting to smoke
Not an intervention or policy to
reduce adult smoking or to prevent
youth starting to smoke
Not an intervention or policy to
reduce adult smoking or to prevent
youth starting to smoke – focus is
cigar use
Not an intervention or policy to
reduce adult smoking or to prevent
youth starting to smoke
Does not report outcomes for high
versus low socio-economic group
– for smoking outcomes
Not an intervention or policy to
reduce adult smoking or to prevent
youth starting to smoke
Does not link with specific
intervention/policy. Does not
report outcomes for high versus
low socio-economic group
on/policy, did not report.
Reports changes in daily
prevalence by SES but no analysis
or discussion by policy
Does not report outcomes for high
versus low socio-economic group
203
Education & Behavior 2005; 32(1):10-26.
Hyland A, Higbee C, Travers MJ, Van DA, Bansal-Travers M, King
B et al. Smoke-free homes and smoking cessation and relapse in a
longitudinal population of adults. Nicotine & Tobacco Research
2009; 11(6):614-618.
Kaplan GA, Siefert K, Ranjit N, Raghunathan TE, Young EA, Tran
D et al. The health of poor women under welfare reform. American
Journal of Public Health 2005; 95(7):1252-1258.
Keller PA, Christiansen B, Kim SY, Piper ME, Redmond L, Adsit R
et al. Increasing consumer demand among Medicaid enrollees for
tobacco dependence treatment: the Wisconsin "Medicaid covers it"
campaign. American Journal of Health Promotion 2011; 25(6):392395.
Lando HA, Pechacek TF, Pirie PL, Murray DM, Mittelmark MB,
Lichtenstein E et al. Changes in adult cigarette smoking in the
Minnesota Heart Health Program. American Journal of Public Health
1995; 85(2):201-208.
Levy DT, Romano E, Mumford E. The relationship of smoking
cessation to sociodemographic characteristics, smoking intensity,
and tobacco control policies. Nicotine & Tobacco Research 2005;
7(3):387-396.
Licht A, Hyland A, O'Connor R, Chaloupka F, Borland R, Fong T et
al. The impact of socio-economic status and price minimizing
behaviors on smoking cessation: Findings from the international
tobacco control (ITC) four country survey. American Journal of
Epidemiology Conference: 3rd North American Congress of
Epidemiology Montreal, QC Canada 2011; 173(pp S285):01.
Lock K, Adams E, Pilkington P, Duckett K, Gilmore A, Marston C.
Evaluating social and behavioural impacts of English smoke-free
legislation in different ethnic and age groups: implications for
reducing smoking-related health inequalities. Tobacco Control 2010;
19(5):391-397.
Luk R, Cohen JE, Ferrence R, McDonald PW, Schwartz R, Bondy
SJ. Prevalence and correlates of purchasing contraband cigarettes on
First Nations reserves in Ontario, Canada. Addiction 2009;
104(3):488-495.
Martinez-Sanchez JM, Gallus S, Zuccaro P, Colombo P, Fernandez
E, Manzari M et al. Exposure to secondhand smoke in Italian nonsmokers 5 years after the Italian smoking ban. European journal of
public health 2012; 22(5):707-712.
McLellan DL. Intended and unintended consequences: Effects of
state cigarette price on smoking and current, binge, and heavy
drinking by demographic group. Dissertation Abstracts International
Section A: Humanities and Social Sciences 2012; 72(8-A): 2991.
Mindell JS, Wardle H. Using the Health Survey for England to
monitor the effect on non-smokers and on inequalities of smokefree
legislation. European Journal of Cardiovascular Prevention and
Rehabilitation Conference: EuroPRevent 2010 Prague Czech
Republic 2010; 17(pp S4):May.
Minov J, Karadzinska-Bislimovska J, Vasilevska K, Nelovska Z,
Risteska-Kuc S, Stoleski S et al. Smoking among macedonian
workers five years after the anti-smoking campaign. Arhiv za
Higijenu Rada i Toksikologiju 2012; 63(2):01.
Monteiro CA, Cavalcante TM, Moura EC, Claro RM, Szwarcwald
CL. Population-based evidence of a strong decline in the prevalence
of smokers in Brazil (1989-2003). Bulletin of the World Health
Organization 2007; 85(7):527-534.
Moore K, Borland R, Yong HH, Siahpush M, Cummings KM,
Thrasher JF et al. Support for tobacco control interventions: Do
country of origin and socioeconomic status make a difference?
Not an intervention or policy to
reduce adult smoking or to prevent
youth starting to smoke
Not an intervention or policy to
reduce adult smoking or to prevent
youth starting to smoke
Does not report outcomes for high
versus low socio-economic group
Does not report outcomes for high
versus low socio-economic group
Does not report outcomes for high
versus low socio-economic group
Not an intervention or policy to
reduce adult smoking or to prevent
youth starting to smoke
Does not report outcomes for high
versus low socio-economic group
Not based in a WHO European
country or non-European country
at stage 4 of the tobacco epidemic
– specific to First Nations reserves
No baseline comparison (prior to
ban).
Abstract focuses on tobacco
control impacts on alcohol
behaviour rather than smoking
Conference abstract only
Does not link with specific
intervention/policy.
Not based in a WHO European
country or non-European country
at stage 4 of the tobacco epidemic
- Brazil
Cessation survey related to
attitudes to tobacco control.
204
[References]. International Journal of Public Health 2012;57(5):777786.
Nierkens V, Kunst AE, Vries HD, Voorham TAJ, Stronks K. Reach
and effectiveness of a community program to reduce smoking among
ethnic Turkish residents in Rotterdam, the Netherlands: A quasiexperimental design. Nicotine and Tobacco Research 2013;
15(1):112-120.
Okechukwu C, Bacic J, Cheng K-W, Catalano R. Smoking among
construction workers: The nonlinear influence of the economy,
cigarette prices, and antismoking sentiment. Social Science and
Medicine 2012; 75(8):1379-1386.
Osypuk TL, Subramanian SV, Kawachi I, Acevedo-Garcia D. Is
workplace smoking policy equally prevalent and equally effective
among immigrants? Journal of Epidemiology & Community Health
2009; 63(10):784-791.
Paulik E, Maroti-Nagy A, Nagymajtenyi L, Rogers T, Easterling D.
Support for population level tobacco control policies in Hungary.
Central European Journal of Public Health 2012; 20(1):Mar.
Peng L, Ross H. The impact of cigarette taxes and advertising on the
demand for cigarettes in Ukraine. Central European Journal of Public
Health 2009; 17(2):93-98.
Pereira A, Sa E Sousa, Morais De AM, Filipe AL, Carvalho R,
Todo-Bom A et al. The Portuguese national asthma surveyprevalence of tobacco smoke and tobacco smoke exposure at home
in the general Portuguese population. Allergy: European Journal of
Allergy and Clinical Immunology Conference: 30th Congress of the
European Academy of Allergy and Clinical Immunology Istanbul
Turkey 2011; 66(pp 82):June.
Phillips G, Renton A, Moore DG, Bottomley C, Schmidt E, Lais S et
al. The Well London program - a cluster randomized trial of
community engagement for improving health behaviors and mental
wellbeing: baseline survey results. Trials 2012; 13.
Pierce JP, Gilpin EA, Farkas AJ. Can strategies used by statewide
tobacco control programs help smokers make progress in quitting?
Cancer Epidemiology, Biomarkers & Prevention 1998; 7(6):459464.
Pisinger C, Vestbo J, Borch-Johnsen K, Jorgensen T. Smoking
cessation intervention in a large randomised population-based study.
The Inter99 study. Preventive Medicine 2005; 40(3):285-292.
Regidor E, Pascual C, Gutierrez-Fisac JL. Increasing the price of
tobacco: economically regressive today and probably ineffective
tomorrow. European Journal of Cancer Prevention 2007; 16(4):380384.
Reid JL, Hammond D, Driezen P. Socio-economic status and
smoking in Canada, 1999-2006: has there been any progress on
disparities in tobacco use? Canadian Journal of Public Health Revue
Canadienne de Sante Publique 2010; 101(1):73-78.
Schopfer DW, Whooley MA, Stamos TD. Hospital compliance with
performance measures and 30-day outcomes in patients with heart
failure. American Heart Journal 2012; 164(1):80-86.
Smit ES, Hoving C, Cox VC, de vH. Influence of recruitment
strategy on the reach and effect of a web-based multiple tailored
smoking cessation intervention among Dutch adult smokers
493. Health education research 2012; 27(2):191-199.
Szatkowski L, Coleman T, McNeill A, Lewis S. The impact of the
introduction of smoke-free legislation on prescribing of stopsmoking medications in England. Addiction 2011; 106(10):18271834.
Szilagyi T. Higher cigarette taxes--healthier people, wealthier state:
Neither participation nor outcome
analysed by SES.
Analysis does not compare by
education level (un/employment).
Does not report outcomes for high
versus low socio-economic group
Cross-sectional data related to
attitudes to Tobacco Control, no
intervention
Does not report outcomes for high
vs. low socio-economic group
Not an intervention or policy to
reduce adult smoking or to prevent
youth starting to smoke
Only baseline data, no
intervention.
Does not report outcomes for high
versus low socio-economic group
Not an intervention or policy to
reduce adult smoking or to prevent
youth starting to smoke
Not an intervention or policy to
reduce adult smoking or to prevent
youth starting to smoke
Not an intervention or policy to
reduce adult smoking or to prevent
youth starting to smoke
Uses composite measures so
cannot disentangle effect on
smoking.
Does not compare reach of either
recruitment strategy with
smokers in general population.
Does not report outcomes by
intervention group, by SES.
Not an intervention or policy to
reduce adult smoking or to prevent
youth starting to smoke - focus on
tobacco replacement products
Does not report outcomes for high
205
the Hungarian experience. Central European Journal of Public Health
2007; 15(3):122-126.
Tangari AH, Tangari AH, Burton Ssue, Andrews JCc, Netemeyer
RG. How do antitobacco 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.
Tzelepis F, Paul CL, Walsh RA, Wiggers J, Knight J, Lecathelinais
C et al. Telephone recruitment into a randomized controlled trial of
quitline support. American Journal of Preventive Medicine 2009;
37(4):324-329.
Veeranki S, Mamudu H, Johnson T. Epidemiology of smoke free
policies in the United States. American Journal of Epidemiology
Conference: 3rd North American Congress of Epidemiology
Montreal, QC Canada 2011; 173(S330):01.
Verkleij SP, Adriaanse MC, Verschuren WM, Ruland EC, WendelVos GC, Schuit AJ. Five-year effect of community-based
intervention Hartslag Limburg on quality of life: a longitudinal
cohort study. Health & Quality of Life Outcomes 2011; 9:11.
Voigt K. Nonsmoker and "Nonnicotine" Hiring Policies: The
Implications of Employment Restrictions for Tobacco Control
83. American Journal of Public Health 2012; 102(11):2013-2018.
versus low socio-economic group
Wehby GL, Courtemanche CJ. The heterogeneity of the cigarette
price effect on body mass index. Journal of Health Economics 2012;
31(5):719-729.
Widome R, Jacobs DR, Jr., Schreiner PJ, Iribarren C. Passive smoke
exposure trends and workplace policy in the Coronary Artery Risk
Development in Young Adults (CARDIA) study (1985-2001).
Preventive Medicine 2007; 44(6):490-495.
Woodall AA, Woodall AA. The partial smoking ban in licensed
establishments and health inequalities in England: Modelling study.
British Medical Journal 2005; .331(7515).
Focuses on impact on BMI not
smoking.
Does not report outcomes for high
versus low socio-economic group
Not population-level cessation
support
Conference abstract only
Does not report outcomes for high
versus low socio-economic group
No specific employment
restriction policy is evaluated
Not an intervention or policy to
reduce adult smoking or to prevent
youth starting to smoke
Does not report outcomes for high
versus low socio-economic group
206
7.6
Appendix F Data extraction
Details
Method
Results
Comments
Smoking restrictions in cars, homes, workplaces and enclosed public places
Author, year
Arheart 2008
Country
USA
Design
Cross-sectional survey
Objective
To explore trends in cotinine levels in US
workers by occupational/industrial and
race/ethnicity-gender sub-groups.
SES variables
Occupational
status
using
both
categories from the National Centre for
Health Statistics (NCHS) and National
Occupational Research Agenda at the
National Institute on Occupational Safety
and Health (NIOSH):
Analyses
regression
Data sources
The National Health and Nutrition
Examination Surveys (NHANES III); 1988
to 1991, 1991 to 1994, 1999 to 2000,
2001 to 2002.
Participant selection
complex sampling strategy, randomly
selected households, NHANES sampling
scheme was not based on occupational
category
Participant characteristics
8105 non-smoking workers (confirmed by
cotinine levels) and reported not exposed
to SHS at home and 18 years of age and
older across the four survey periods
Intervention
smoke-free workplace policies
Length of study
14 years; 1988 to 2002
Outcomes
cotinine levels
General population
For the entire sample, there was a significant
decrease in cotinine levels (0.16 ng/mL; 80%
relative decrease) over time. Decreases from
1988 to 2002 ranged from 0.08 to 0.30 ng/mL
(67% to 85% relative decrease).
SES
Largest absolute reductions in: blue-collar and
service occupations; construction/manufacturing
industrial sectors.
NCHS occupational groups: The decline in
cotinine levels ranged from 0.10 to 0.22 ng/mL
(71% to 76% relative decrease). The negative
slope in cotinine levels for blue-collar service
and service workers (0.21 and 0.22 ng/mL,
respectively; 72% and 76% decreases) were
significantly greater than the slope for White
collar workers (0.13 ng/mL; 76%). All reductions
were significant (except for farm workers which
had a small subgroup sample size (n = 81)).
NIOSH industrial sector groups: the decrease in
cotinine levels ranged from 0.09 to 0.23 ng/mL
(73% to 85% relative decrease). The negative
slope in cotinine levels for the Construction
sector (0.23 ng/mL; 77% decrease) was
significantly greater than the slope for
Agriculture (0.09 ng/ml; 75%), health care , and
Service sectors. The Manufacturing sector (0.22
ng/mL; 85% decrease) had a larger negative
slope than Health care (0.11 ng/mL;73%) and
Service
sectors
(0.13
ng/ml;76%).
Transportation=0.19 ng/mL; 76%)
Author’s conclusion of SES impact
All worker groups had declining serum cotinine
levels. Most dramatic reductions occurred in
sub-groups with the highest before cotinine
Internal validity
an unknown proportion of the
NHANES participants had not
worked the day before they
provided blood samples for
cotinine
analysis,
therefore
reported levels may underestimate
the amount of occupational
exposure to SHS. NHANES did
not include questions about other
forms of SHS exposure such as
visiting bars and restaurants,
where smoking may still be still
permitted; this might lead to an
over-estimate of occupational SHS
exposure.
External validity
Validity of author’s conclusion
The use of cotinine levels and selfreported no SHS exposure in the
home makes it more likely that the
observed effects were a result of
smokefree workplace policies but
SHS exposure from other settings
cannot be ruled out.
207
Details
Method
Results
Comments
Smoking restrictions in cars, homes, workplaces and enclosed public places
levels, thus disparities in SHS workforce
exposure are diminishing with increased
adoption of clean indoor laws. large differences
in cotinine levels in worker subgroups persist;
including those employed in the construction
sector, and blue-collar workers who continue to
have the highest cotinine levels.
208
Details
Method
Results
Comments
Smoking restrictions in cars, homes, workplaces and enclosed public places
Author, year
Barnett 2009
Country
New Zealand
Design
Before and after study (different
participants)
Objective
to examine Acute Myocardial Infarction
(AMI) admissions in Christchurch, New
Zealand
before
and
after
the
implementation
of
the
smokefree
legislation in 2004
SES variables
Neighbourhood social deprivation; the
socio-economic profile of each
Census Area Unit (CAU) was identified
using the 2006 New Zealand Deprivation
Index and on this basis the CAUs were
classified according to their quintile
ranking on the index.
Analyses
Poisson regression was used to calculate
rate ratios by comparing for AMI rates
of hospital admissions
Data sources
AMI hospital admissions to Christchurch
Public Hospital and census data
Participant selection
first admissions for AMI within the study
timeframe originating in Christchurch City
Participant characteristics
3,079/6928
Intervention
New Zealand Smokefree Environments
Act 2003 implemented in Dec 2004
Length of study
3 years – Jan 2003 to Dec 2006
Outcomes
AMI hospital admissions
General population
The introduction of the smokefree legislation
was associated with a 5% reduction in AMI
admissions. The 55 to 74 age group recorded
the greatest decrease in admissions (9%) and
this figure rose to 13% among never smokers in
this group. Reductions were more marked for
men.
SES
Adding the effects of area deprivation increased
the reduction to 21% among 55 to 74 year olds
living in more affluent (quintile 2) areas. Only
among the 55 to 74 year age group does the RR
analysis give a hint that admissions may be
falling in less deprived areas with quintile 2
being statistically significant (RR 0.76; CI 0.59–
0.97).
Overall
however,
the
statistical
association of changing levels of AMI
admissions with smoking status and with
deprivation was not consistently significant.
Author’s conclusion of SES impact
At this early stage following the smokefree
legislation, there are hints emerging of a positive
impact on AMI admissions but these
suggestions cannot yet be treated with certainty.
Internal validity
External validity
Unclear if data from one hospital
can be generalisable to rest of the
country
Validity of author’s conclusion
Authors discuss other potential
influences as well as smokefree
legislation including possible longterm secular trends and new
diagnostic criteria for AMI
209
Details
Method
Results
Comments
Smoking restrictions in cars, homes, workplaces and enclosed public places
Author, year
Cesaroni 2008
Country
Rome, Italy
Design
Repeat cross-sectional
Objective
To evaluate changes in acute coronary
event rates in residents of Rome in
relation to the smoking ban
SES variables
small-area
index
of
deprivation
(education, occupation, home ownership,
family composition, and nationality) to
create
a
composite
index
of
socioeconomic position (SEP), distributed
in quintiles.
Analyses
computed annual standardized rates and
estimated rate ratios by comparing the
data from prelegislation and post
legislation
Data sources
Residents of Rome between 35 and 84
years of age
Participant selection
out-of-hospital deaths and hospitalized
cases; hospitalizations for acute coronary
events from all discharge reports of
residents of Rome (35 to 84 years of age)
between 2000 and 2005 that listed a
principal diagnosis of “acute myocardial
infarction” (as subsequently defined) and
“other acute and subacute forms of
ischemic heart disease”.
Participant characteristics
See participant selection
Intervention
Ban on smoking in all indoor public
places January 2005
Length of study
5 years, 2000 to 2004 and 2005
Outcomes
Acute coronary events
General population
The prevalence of smoking decreased from
34.9% to 30.5% in men and from 20.6% to
20.4% in women. Cigarette sales also
decreased in Rome in 2005 compared with
2004 (-5.5%). The average concentrations of
PM10 decreased (from 46 _g/m3 in 2000 to 39
_g/m3 in 2005), as did the number of days per
year that PM10 rose above 50 _g/m3 (144 days
in 2000 versus 73 in 2005).
The reduction in acute coronary events was
statistically significant in 35- to 64-year-olds
(11.2%, 95% CI 6.9% to 15.3%) and in 65- to
74-year-olds (7.9%, 95% CI 3.4% to 12.2%)
after the smoking ban. No evidence was found
of an effect among the very elderly.
SES
people aged 35 to 64 years living in low
socioeconomic census blocks appeared to have
the greatest reduction in acute coronary events
after the smoking ban with significantly reduced
ORs for SEP 3,4 and 5 but not 1and 2. There
was no evidence of a statistically significant
interaction between SEP and smokefree
legislation.
Author’s conclusion of SES impact
Evidence indicates that a comprehensive ban
could contribute effectively to the reduction of
inequalities in health.
Internal validity
Took into account several timerelated potential confounders,
including particulate matter air
pollution, temperature, influenza
epidemics, time trends, and total
hospitalization rates.
External validity
Validity of author’s conclusion
Implementation of new diagnostic
criteria and changes in daily doses
of statins during study period could
partially account for decreases in
acute coronary events observed in
this study.
210
Details
Method
Results
Comments
Smoking restrictions in cars, homes, workplaces and enclosed public places
Author, year
Delnevo 2004
Country
25 states, USA
Design
Cross-sectional
Objective
To examine recent data from 25 states
regarding
workers’
protection
via
workplace smoking policies and focuses
particularly on predictors of which
workers are at risk of ETS exposure at
the worksite.
SES variables
Education, household income
Analyses
Logistic regression
Data sources
The optional tobacco module on the
2001
Behavioral
Risk
Factor
Surveillance System (BRFSS) was
administered by 25 states.
Participant selection
BRFSS is a state-based random digit dial
telephone survey of the adult population.
The data from the 25 states were pooled.
Across all 25 states, the median
response rate was 51.3% and ranged
from 33.3 to 70.8%
Participant characteristics
44,357 adults who reported that they are
employed for wages and work indoors
most
of
the
time.
Intervention
Smokefree workplace policy; defined a
smoke-free policy as a policy that
prohibited smoking in the common,
public, and work areas of the workplace.
Length of study
2001 only
Outcomes
Policy coverage
General population
Overall, 70.9% of respondents reported working
under a smoke-free workplace policy. ranging
from 60.4 (Kentucky) to 84.5% (Alaska).
SES
Household income was inversely related to the
odds of working in a non smoke-free
environment.
Education, even after adjusting for all other
factors including income, was strongly
associated with the absence of a smokefree
workplace smoking policy. Workers with less
than a high school education and workers with a
high school diploma or GED were 3.46 and 2.49
times more likely, respectively, than college
graduates to report working in a non smoke-free
environment.
Author’s conclusion of SES impact
The likelihood of being protected by a smokefree workplace policy was significantly lower
among workers who earned less than $50,000
annually, or had a high school education or less
Internal validity
working
in
a
smoke-free
environment was associated with a
worker’s
smoking
status;
nonsmokers were most likely to
report a smoke-free environment
(74.4%), followed by occasional
smokers (67.9%) and everyday
smokers (58.2%). Absence of a
smokefree policy by education
level was controlled for income
race and gender but not smoking
status?
External validity
Workers in South or Midwest or
less likely to have a smokefree
work policy compared to workers
in Northeast.
Data from only 25 states: Data
reported by region may not
capture
all
states
normally
considered to be part of a region
and may not be representative of
the entire US workforce.
Validity of author’s conclusion
211
Details
Method
Results
Comments
Smoking restrictions in cars, homes, workplaces and enclosed public places
Author, year
Deverell 2006
Country
351 cities and towns in Massachusetts,
USA
Design
Repeat cross-sectional
Objective
To examine the diffusion of smokefree
restaurant regulations and identify
socioeconomic
and
racial/ethnic
disparities
in
SHS
exposure
in
restaurants
SES variables
Town-level SEP as measured by
percentage of towns adult population with
a college degree and living below the
poverty line
Analyses
Proportion of population protected
divided
by
total
population
of
Massachusetts, bivariate
Data sources
Local smokefree ordinances, classified
into strong=no smoking and other =
restricted smoking, and the US census
Participant selection
n/a
Participant characteristics
6,349,097 adults
Intervention
Decade of transition from no 100%
smokefree restaurant regulations to
statewide ban on smoking in restaurants
and bars
Length of study
10 years, January 1993 to July 2004
Outcomes
Local regulation adoption of smokefree
regulation
General population
Over 10 years prior to statewide ban, only 36%
of total population was covered by local
regulations that protected them from SHS
exposure in restaurants
SES
The proportion of college graduates in
Massachusetts protected from SHS in
restaurants in their own town was consistently
between 2 and 7 percentage points greater than
the proportion of nongraduates who were
protected. Just prior to the statewide smoking
ban 40% of college graduates were protected
compared to 33% of nongraduates. There was
also substantial disparity in protection from SHS
by individuals poverty status (protection higher
for those living above poverty line)
Author’s conclusion of SES impact
Prior to the statewide ban there was substantial
disparity in protection against SHS exposure
based on educational status.
Internal validity
Bivariate analyses makes it difficult
to tease out which SES is most
important (measured education,
poverty, rural area, race/ethnicity)
External validity
Validity of author’s conclusion
Study addresses a theoretical level
of protection from SHS exposure
provided by regulations rather than
actual level of protection but
presence of regulation should
correlate with reduced exposure.
Towns with higher proportion of
college educated were more likely
to support legislation.
212
Details
Method
Result
Comments
General population
Clean indoor air laws and cigarette prices
are independently associated with
reductions in smoking.
Independent associations of strong clean
indoor air laws were found for current
smoker status (OR 0.66, 95% CI 0.60,
0.73), and consumption among current
smokers (-2.36 cigarettes/day, 95% CI 2.43, -2.29).
Cigarette price was found to have
independent associations with both
smoking and consumption, an effect that
saturated at higher prices. The odds ratio
for smoking for the highest versus lowest
price over the range where there was a
price effect, was 0.83. Average
consumption
declined
(-1.16
cigarettes/day) over the range of effect of
price on consumption.
The effect of clean indoor air laws on
smoking status (OR 0.66) was larger than
the effect of cigarette prices over the
range of prices at which we found
smokers to be price sensitive (OR 0.83
for $2.91 to $3.28).
SES
Established patterns of education,
income, and race/ethnic disparity in
smoking are largely unaffected by either
clean indoor air laws or price in terms of
both mean effects and variance.
Author’s conclusion of SES impact
Clean indoor air laws and price increases
appear to benefit all SES groups equally
in terms of reducing smoking participation
and consumption and are generally
neutral with regard to health disparities.
Internal validity
The household response rate for the
February 2002 CPS was 93%.
External validity
One of few studies to look at separate
impact of smokefree legislation and price
Validity of author’s conclusion
valid
Smoking restrictions in cars, homes, workplaces and enclosed public places
Author, year
Dinno 2009
Country
USA
Design
Single cross-sectional
Objective
To consider disparities in tobacco control
both by evaluating possible differences in
the effects of clean indoor air laws and
cigarette prices by different social
circumstances, and by establishing
whether vulnerabilities exist for smoking
participation and consumption and, if so,
whether these vulnerabilities covary with
tobacco control policies.
SES variables
Education, household income
Analyses
Multilevel modelling
Data sources
February 2002 panel of the Tobacco Use
Supplement of the Current Population
Survey (54,024 individuals representing
the US population aged 15–80). Data on
strong clean indoor air laws in effect at
time of interview were obtained from the
American Lung Association’s State of
Tobacco Control 2002 and local
ordinances
from
the
American
Nonsmokers’ Rights Foundation Local
Tobacco Control Ordinance database;
price from the average state cigarette
prices per pack from The Tax Burden on
Tobacco
Participant selection
Non-institutionalized civilian individuals in
266 counties in 50 states plus the District
of Columbia.
Participant characteristics
54,024 self-respondents aged 15 to 18
years
Intervention
Strong clean indoor air laws and cigarette
prices.
Strong clean indoor air laws include
100% prohibition without exception of
smoking in public and private workplaces
(including non-hospitality work sites like
manufacturing and office sites among
others), restaurants (with and without
attached bars), and bars and taverns.
Length of study
February 2002
Outcomes
Smoker status
Consumption
Smoking elasticities
213
Details
Method
Results
Comments
Smoking restrictions in cars, homes, workplaces and enclosed public places
Author, year
Eadie 2008
Country
Scotland
Design
Before and after qualitative study
Objective
to explore how management, customers
and workers from across the social
spectrum received and responded to the
new measures during the 12 months
following the ban
SES variables
Social grade based on the occupation of
the household’s chief wage-earner
Analyses
Ethnographic case study combining
unobtrusive semi-structured observation
and in-depth interviews (minimal cueing).
Interviews were recorded digitally and
audio-files transcribed for thematic
analysis.
Data sources
Eight Scottish community bars in three
contrasting study communities located in
one local authority area
Participant selection
In two areas, all the community bars in
the study area were recruited to take
part, while in the third covert visits were
made to all licensed premises in the area
to identify those with a local customer
base. Bar customers were recruited doorto-door from within the local community
and interviews conducted in the
customer’s home. Sample stratified to
broadly represent the smoking and
gender profile of each study bar using
baseline observation data as a guide.
Participant characteristics
Ten bar proprietors, 16 bar workers and
44 customers
Intervention
Individual and paired interviews were
conducted with a cohort of bar customers
and bar staff (proprietors and bar
workers) over two and three stages,
respectively,
to
provide
multiple
perspectives on compliance, enforcement
and acceptance of the smokefree
legislation
Length of study
12 months
Outcomes
Compliance with ban
General population
All eight study bars endeavoured to enforce the
ban, but with varying enthusiasm. Compliance
varied, with violations more prevalent in those
bars serving deprived communities. Most
violations occurred in peripheral areas and
generally went unchallenged. Six bars reported
some form of complicit behaviour with staff and
customers smoking together, either in the
entrance area or during ‘lock-ins’ when access
to the bar was restricted to regular customers.
SES
Bars in deprived study communities tended to
show lower compliance and less support for the
legislation compared with the relatively affluent
community, but there were exceptions to this.
Three factors were particularly important in
explaining variance between bars: smoking
norms,
management
competency
and
management attitudes towards the ban.
Smoking norms and management attitude were
related to social disadvantage
Author’s conclusion of SES impact
Evidence suggests a need for targeted support
for bars serving deprived communities where a
pro-smoking culture remains entrenched, to help
ensure that the major gains already achieved
are retained and built upon
Internal validity
Strength
in
the
multiple
perspectives
offered
by
interviewing
customers,
bar
workers and proprietors operating
in the same study sites.
Data collection restricted in one of
the eight bars (refusal by
proprietor to participate in post-ban
follow-up stages and to facilitate
access to staff)
External validity
The small number of bars involved
means that the study does not
provide a representative view of
the licensed trade across Scotland
Validity of author’s conclusion
authors
argue
that
the
generalizability of the results
arises not from the sample’s
representativeness, but from the
reliability of the compliance and
enforcement concepts and their
value to assessment in a wider
range of settings
214
Details
Method
Results
Comments
Smoking restrictions in cars, homes, workplaces and enclosed public places
Author, year
Ellis 2009
Country
New York City, USA
Design
cross-sectional survey with control
comparison
Objective
To estimate prevalence of smoking and
SHS exposure among non-smoking
adults in New York City
SES variables
Education and income
Analyses
multivariate logistic regression
Data sources
2004 NYC Health and Nutrition
Examination Survey and the 2003 to
2004 National Health and Nutrition
Examination Survey
Participant selection
NYCHANES:
three-stage
cluster
sampling
Participant characteristics
adult non-smokers; NYCHANES: ( n =
1,767 adults aged 20 years or older);
NHANES: ( n = 4,476 adults aged 20
years or older)
Intervention
comprehensive smokefree workplace
legislation 2003
Length of study
12 months
Outcomes
Smoking prevalence
Secondhand smoke exposure (cotinine)
General population
Compared with national adult population
characteristics (as reported in NHANES), more
NYC adults were foreign born (51.3% vs.
15.2%), had less than a high school education
(26.6% vs. 18.2%), and had an annual income
of less than US$20,000 (32.4% vs. 23.6%).
Although the smoking prevalence in NYC was
lower than that found nationally (23.3% vs.
29.7%, p < .05), the proportion of nonsmoking
adults in NYC with elevated cotinine levels was
greater than the national average overall (56.7%
vs. 44.9%, p < .05) and was higher for most
demographic subgroups.
SES
Smoking prevalence by population subgroups
demonstrated a generally consistent pattern:
smoking prevalence in both the NYC and U.S.
populations was higher in those earning less
than $20,000 per year. Nationally, those with
less than a high school education had a
significantly higher smoking prevalence than
those with at least a high school education. In
NYC, the effect of education did not reach
statistical significance ( p < .10).
In general, NYC nonsmokers were significantly
more likely to have elevated cotinine levels than
their U.S. counterparts, except for adults aged
60 years or older, White females, Black males,
and those with an annual income below
$20,000. In NYC, those with less than a high
school education were 64% more likely than
those with at least a high school education to
have an elevated cotinine level.
Author’s conclusion of SES impact
In summary, we found, unexpectedly, that a
greater proportion of NYC adults are exposed to
SHS than are adults nationally, despite lower
levels
of
smoking.
Sociodemographic
Internal validity
NHANES: overall response rate
was 69% (4,742/6,916),
NYCHANES:
overall
survey
response rate of 55%. Thus,
reported estimates may be biased.
However, all data reported were
weighted using information on age,
gender, race/ethnicity, income,
education, language spoken at
home, and household size to
correct for bias related to these
factors.
Study strength is that it is an
assessment of SHS exposure
conducted at the community level
using a biologically measured
indicator.
External validity
NYC residents might face unique
exposure to SHS due to the
density of the urban environment
which limits study findings to NYC
Validity of author’s conclusion
valid
215
Details
Method
Results
Comments
Smoking restrictions in cars, homes, workplaces and enclosed public places
differences in the NYC population account only
partially for the observed higher prevalence of
SHS exposure. The higher prevalence across
racial/ethnic and socioeconomic strata in NYC
compared with nationally suggests that SHS
exposure in dense, urban settings may be
elevated, although the concentration of the SHS
exposure may be lower than that found
nationally.
216
Details
Method
Results
Comments
Smoking restrictions in cars, homes, workplaces and enclosed public places
Author, year
Farrelly 1999
Country
USA
Design
Repeat cross-sectional
Objective
To estimate the impact of workplace
smoking restrictions on the prevalence
and intensity of smoking among all indoor
workers and various demographic and
industry groups.
SES variables
Education, industry
Analyses
Multivariate probit models (prevalence),
ordinary
least
squares
models
(consumption)
Data sources
Tobacco use supplements to the
September 1992, January 1993, and May
1993 Current Population Surveys of
97,882 indoor workers who were not selfemployed.
Participant selection
Sample of indoor workers n=97,882
Participant characteristics
The indoor sample was roughly the same
age, was more educated, had a higher
percentage of females, and had a lower
fraction of minorities than the sample of
all workers. In all, 24 471 indoor workers
(25.0%) smoked at the time of the
survey, and smokers reported smoking
19.2 cigarettes a day. These numbers
are only slightly lower than the estimates
for the full workforce.
Intervention
Workplace smoking policies; four main
types of workplace programme were
defined:
(1)
100%
smoke-free
environments, (2) work area bans in
which smoking is allowed in some
common areas, (3) bans in some but not
all work and common areas, and (4)
minimal or no restrictions
Length of study
September 1992 to May 1993
Outcomes
Smoking prevalence
consumption
General population
46.7% of workers were subject to a 100%
smoke-free policy, nearly 67% were subject to
smoking restrictions in their immediate work
area but were allowed to smoke in some
common areas. The percentage of indoor
workers subject to no work area or common
area restrictions was 18.9%.
Moving from no smoking restrictions to a
smoke-free
workplace
decreased
the
prevalence of smoking by 5.7 percentage points
(95% CI = 4.9 to 6.5) and reduced daily
consumption among the remaining smokers by
2.67 cigarettes (95% CI = 2.28 to 3.05). The
former result is a 22.8% reduction in smoking
prevalence compared to the sample mean,
while the latter represents a nearly 14%
decrease
in
average
daily
cigarette
consumption.
Maintaining work area bans but allowing
smoking in common areas reduced the impact
of work area bans by half. For these
workplaces, we observed a 2.6 percentage point
decrease in the prevalence of smoking and a
decline of 1.48 cigarettes in the average daily
consumption (95% CI = 1.08 to 1.89). Partial
workplace and common area bans had no
statistically significant effects on the prevalence
of smoking. However, these restrictions
decreased daily consumption among remaining
smokers (those who do not quit smoking) by a
modest 0.57 cigarettes (95% CI = 0.05 to1.08).
These results show a consistent pattern: the
more restrictive the workplace policy, the
greater the decline in smoking.
SES
Those with postgraduate education had both a
Internal validity
Education sample was limited
workers aged 25 and older, when
many have completed their
education.
External validity
The indoor sample was more
educated than the sample of all
workers.
Validity of author’s conclusion
valid
217
lower prevalence of smoking and a lower daily
consumption. Although the percentage point
declines in the prevalence of smoking in
response to a smoke-free environment were
fairly uniform across educational groups, as a
percentage of current rate of smoking, the
largest effects (percentage decline) were for
workers with a college degree (28.4% decline)
and the least for high school dropouts (13.7%
decline). However, the opposite is true for the
effects of the smoking ban on average daily
consumption (19.4%). Those with less than a
high school degree had the largest decline both
in absolute terms (3.90 cigarettes) and as a
percentage of average daily consumption
(19.4%). Those with a college degree
decreased daily consumption by an average of
1.69 cigarettes, a 9.3% decrease.
Author’s conclusion of SES impact
Smoke-free workplace policies reduce the
prevalence
and
intensity
of
smoking.
Furthermore, we found these policies to be an
effective tool for reducing smoking among more
and less educated people.
218
Details
Method
Results
Comments
Smoking restrictions in enclosed public places
Author, year
Federico 2012
Country
Italy
Design
Interrupted Time-Series of 11 crosssectional surveys
Objective
To estimate the immediate as well as the
longer-term impact of the 2005 smokefree law in Italy on the smoking behaviour
of adult subjects, and to assess if the
impact differed by educational group.
SES variables
Education; highly educated subjects were
those who held at least a high school
degree (level 3 of the International
Standard Classification of Education),
while the remaining subjects were
classified as low-educated.
Analyses
segmented linear regression
Data sources
11 multi-purpose yearly surveys ‘Aspects
of everyday life’, carried out by the
National Institute of Statistics
Participant selection
For bigger municipalities cluster sampling
was used, with households being the
primary sampling units. A two-stage
sampling
was
used
for
smaller
municipalities.
Participant characteristics
29,000 to 36,000 subjects each year,
aged 20–64 years
Intervention
10th January 2005 Italian smoke-free law
prohibited smoking in all public and workplaces
Length of study
12 years; 1999 to 2010 except 2004
Outcomes
Quit ratios
General population
The prevalence of current smoking in the overall
population decreased over time, while the quit
ratio increased. Changes in both prevalence
and cessation of smoking were particularly
marked immediately before or just after the
introduction of the 2005 policy, whereas in the
following years values tended to be similar to
those of the period before the policy was
introduced. A clear decline over the whole timeperiod is observed for the number of cigarettes
smoked daily, from 15.0 in 1999 to 13.1 in 2010.
SES
Among both low and high educated males,
smoking prevalence decreased by 2.6% (P =
0.002) and smoking cessation increased by
3.3% (P = 0.006) shortly after the ban, but both
measures tended to return to pre-ban values in
the following years. The absolute difference in
smoking prevalence between highly and loweducated males widened slightly over the whole
time-period. Time trends in the quit ratio mirror
those in smoking prevalence for males.
Among low-educated females, the ban was
followed by a 1.6% decrease (P = 0.120) in
smoking prevalence and a 4.5% increase in quit
ratios (P < 0.001). However, these favourable
trends reversed over the following years. Among
highly educated females, trends in smoking
prevalence and cessation were not altered by
the ban.
A different pattern emerged for the female quit
ratio: the policy was associated with an
immediate increase in quit ratio (b = 2.6%, p =
0.050), but the change in time trends (b = -0.6%
per year) was not significant at the 0.05 level.
However, the immediate effect of the policy was
Internal validity
Data for 2004, which were used
only to obtain descriptive statistics,
were derived from a different
survey.
External validity
Excludes
institutionalised
population.
Validity of author’s conclusion
Results may not be entirely
attributable to smokefree law. In
Italy the price of cigarettes rose by
about 65% between 1999 and
2010, and the largest relative
increase occurred between 2003
and 2005. In addition national
mass
media
anti-smoking
campaign carried out in 2009.
Authors state reduced compliance
or adaptation to the ban may have
contributed to reduced social
pressure to quit smoking among
current smokers as well as to
smoking relapse among former
smokers.
219
more favourable among low-educated females
than among the higher educated, with a 4.5%
increase in quit ratios among low-educated
females, p < 0.001. Long-term trends clearly
favoured the higher educated (b = 0.7% for the
interaction term between education and time).
As a result, educational differences in quit ratios
widened over time.
Author’s conclusion of SES impact
The impact of the Italian smoke-free policy on
smoking and inequalities in smoking was shortterm. Smoke-free policies may not achieve the
secondary effect
of
reducing smoking
prevalence in the long term, and they may have
limited effects on inequalities in smoking.
220
Details
Method
Results
Comments
Smoking restrictions in cars, homes, workplaces and enclosed public places
Author, year
Ferketich 2010
Country
Appalachia, USA
Design
Cross-sectional
Objective
to examine the pattern of, and
socioeconomic factors associated with,
adoption of clean indoor air ordinances in
Appalachia.
SES variables
Percentage completed high school
education, per capita income, median
income,
percentage
poverty,
and
unemployment rate (average of yearly
percentage reported between 1998 and
2007).
Analyses
mixed-effects logistic regression
Data sources
Web-based search and contacting of city
halls for CIA ordinances. US Census
Bureau and the US Bureau of Labor
Statistics.
Participant selection
Participant characteristics
332 Appalachian communities with at
least 2000 residents, in 6 states;
Alabama, Georgia, Kentucky, Mississippi,
South Carolina, and West Virginia.
Intervention
Clean indoor air (CIA) ordinances; in all 6
states, there are weak statewide CIA
laws in place that do not prohibit smoking
in restaurants, bars, and many other
workplaces. However, the statewide CIA
laws in these states also do not prohibit
local communities from passing stronger
CIA ordinances. Revised rating system
for CIA local ordinances developed by
local authorities could range from 0 to 13.
Length of study
June through August of 2008
Outcomes
Policy
coverage
in
workplaces,
restaurants and bars
General population
Fewer than 20% of the 322 communities had
adopted
a
comprehensive
workplace,
restaurant, or bar ordinance. Most ordinances
were weak, achieving on average only 43% of
the total possible points.
SES
Both the percentage who completed high school
and unemployment rate were related to the
presence of workplace and restaurant clean air
policies in Appalachian communities outside
West Virginia. Adjusting for state and county, a
1% increase in high school completion rate was
associated with a 9% increase in the odds of a
restaurant policy and a 10% increase in both the
odds of a workplace policy and the odds of at
least 1 policy (workplace or restaurant).
By contrast, we observed a negative
relationship between the presence of an
ordinance and unemployment rate: a 1%
increase in unemployment rate was associated
with an approximate 50% decrease in the odds
of a restaurant policy, or either a workplace or
restaurant policy. We observed the same
relationship for workplace policies, though it was
not significant at the .05 level. Univariate logistic
regression models revealed no associations
between county characteristics and CIA
ordinances in West Virginia, with the exception
of a significant negative relationship between
median income and presence of a restaurant
policy (a $1000 increase in median income was
associated with a 12% decrease in the odds of a
restaurant policy, likelihood ratio P=.033).
A 1% increase in the percentage who completed
high school was associated with an average
increase of 0.9% in points achieved for strength
Internal validity
Fitted separate logistic regression
models to West Virginia and
communities within other 5 states
because West Virginia differed
from the other states as majority of
its communities had an ordinance.
Did not adjust the ratings to
account for the state CIA laws.
However the laws in these states
were very weak, achieving only
26% of the total possible points.
Freestanding bars were excluded
as not covered by ordinances.
External validity
Appalachia is characterized by
widespread poverty. Census data
used might have been outdated for
use in this study. Might not be
generalisable
to
smaller
Appalachian communities.
Validity of author’s conclusion
221
ratings, and a 1% increase in unemployment
corresponded to an average decrease of 10.5%
after adjustment for state. The analysis was
repeated for the West Virginia counties, though
no significant relationships were found.
Author’s conclusion of SES impact
CIA efforts in these states should be statewide,
because, clearly, leaving the effort to local
communities does not result in a large number
of strong local CIA ordinances. Communities
with a higher unemployment rate were less
likely and those with a higher education level
were more likely to have a strong ordinance.
222
Details
Method
Result
Comments
General population
The Scottish smoke-free legislation was
associated with an increase in the rate of
smoking cessation in the 3-month period
immediately prior to its introduction. Overall quit
rates in the year the legislation was introduced
and the subsequent year were consistent with a
gradual increase in quit rates prior to
introduction of the legislation.
Odds of quitting increased annually (OR 1.09
95% CI: 1.05 to 1.12). 5.1% quit in 3 months
prior to legislation implementation, far higher
than any other 3-month period.
In the subgroup completing the questionnaire (n
= 474); 57 (12%) quit following between June
2005 and May 2007and 43.9% of these said that
the smoke-free legislation had helped them to
quit.
Bi-modal perceptions of the legislation’s impact
on their decision to quit (20% rated influence as
between 2 and 8/10), 56% rated the legislation’s
as having between 0 and 4/10 influence. 22.5%
tried to quit following legislation, 66% of whom
were influenced to do so by the ban. 70% of
current smokers considered the ban to be
positive.
SES
No association between area of residence or
SIMD with the probability of attempting to quit, or
feeling influenced to quit. Smokers from more
affluent areas more likely to have a positive
perception of the legislation compared with more
deprived communities (p=0.01).
Author’s conclusion of SES impact
Socio-economic status was not related to
smoking cessation, but individuals from more
affluent communities were more positive about
the legislation.
Internal validity
Geographic measure of SES can be
misleading.
Reliance on patient recall of date they
quit/began smoking.
Small sample size.
External validity
Based on participants in an existing
trial – therefore sample already more
health-literate and more likely to
respond positively to legislation? Also
participation in the trial might have
influence smoking behaviour
Validity of author’s conclusion
Data on socio-economic impact of
smoking status not presented, but
assumed to be accurate.
Smoking restrictions in cars, homes, workplaces and enclosed public places
Author , year
Fowkes, 2008
Country
Scotland
Design
Cohort
Objective
To investigate trends in smoking
cessation before and after the
introduction of Scottish smoke-free
legislation and to assess the
perceived influence of the legislation
on giving up smoking and
perceptions of the legislation in
smokers.
SES variables
Scottish Index of Multiple
Deprivation (Cat 1=high, Cat 5=low)
Analyses
Logistic regression
Data sources
Participants of Aspirin for Asymptomatic
Atherosclerosis RCT
Participant selection
1087 current smokers and 54 who
restarted during study period (n=1141 out
of 3350). Also subgroup of 474 of 631
(75.1%) current smokers the year prior to
legislation completed questionnaire about
the legislation’s impact (no sig differences
to original study population).
Participant characteristics
50-75 year olds from central Scotland at
moderately increased risk of
cardiovascular events. 33% male, mean
age 60.9, SIMD1-5 = 13%, 11%, 15%,
25%, 36%
Intervention
Smoke-free legislation in Scotland
prohibiting smoking in almost all enclosed
public places and work places (26th March
2006).
Length of study
April 1998 to December 2007
Outcomes
Cessation (three month abstinence).
Perception of legislation and its impact
measured on an 11-point scale.
223
Details
Method
Results
Comments
Smoking restrictions in cars, homes, workplaces and enclosed public places
Author, year
Frieden 2005
Country
New York City, USA
Design
Repeat cross-sectional
Objective
to
determine
the
Impact
of
comprehensive
tobacco
control
measures in New York City
SES variables
education
Analyses
Univariate and multivariate
Data sources
Annual New York State Behavioral Risk
Factor Surveillance System (BRFSS),
New York City Department of Health and
Mental Hygiene (DOHMH) conducted a
population-based, random-digit dialed
telephone community health survey
Participant selection
randomly selected
Participant characteristics
adult New York City resident
Intervention
1. April and July 2002 state and city tax
increases raised the cost of a pack
of cigarettes by approximately 32%,
to a retail price of approximately
$6.85
2. 2002 Smoke-Free Air Act (SFAA)
became effective in March 2003
eliminated existing exemptions to
make virtually all indoor workplaces,
including restaurants and bars,
smokefree.
3. April 2003 nicotine-patch distribution
program began providing free 6week courses (coupled with brief
telephone counseling) to 34 000 of
the city's heavy smokers
4. Expansion of educational efforts
such as publications and
advertisements in broadcast and
print media, emphasized the health
risks of environmental tobacco
smoke and the benefits of quitting.
There was also extensive media
coverage of the debate regarding
smoke-free workplace legislation.
Length of study
General population
During the 10 years preceding the 2002
program, smoking prevalence did not decline in
New York City; within a year of implementation
of the new policies, a large, statistically
significant decrease occurred. From 2002 to
2003, smoking prevalence among New York
City adults decreased by 11% (from 21.6% to
19.2%, (P=.0002) approximately 140000 fewer
smokers).
Increased taxation appeared to account for the
largest proportion of the decrease; however,
between 2002 and 2003 the proportion of
cigarettes purchased outside New York City
doubled, reducing the effective price increase by
a third.
SES
Smoking declined among all education levels.
The decrease was more pronounced among
low-income women (an 18.1% decrease, from
21.6% to 17.8%; P=.OO9). Significant
decreases in smoking were found among
people with more than a high school education
(a 12.4% decrease, from 19.3% to 16.9%;
P=.O1). Declines were also large among people
with annual family incomes of less than $25000
(a 12.6% decrease) or $75000 or more (a
13.4% decrease).
In 2003, former smokers who had quit within the
past year were more likely to have low incomes
compared with former smokers who had quit
more than 1 year previously (43.6% vs 32.0%,
p=.0001).
Residents with low incomes (<$25000 per year)
or with less than a high school education were
more likely than those with high incomes (>$75
000 per year) and those with a high school
education or higher to report that the tax
increase reduced the number of cigarettes they
Internal validity
Response rates per wave among
contacted households were 64%,
59%, and 64% respectively for
three waves of data collection
2002 to 2003.
ORs significantly reduced for
smoking, only for people in income
<$25,000 and ‘some college’
education.
External validity
Analyses of education level were
restricted to adults aged 25 years
and older
Validity of author’s conclusion
Valid, but respondents' attribution
of the impact of various control
measures on their smoking
behaviour may not be accurate.
224
Details
Method
Results
Comments
Smoking restrictions in cars, homes, workplaces and enclosed public places
May 2002 to November 2003; The 2002
community health survey was considered
to be the preintervention sample, and the
2 surveys conducted in 2003 were
combined
and
treated
as
the
postintervention sample.
Outcomes
Smoking prevalence
OR for smoking
Response to tax increase
Response to workplace smoking ban
smoked (income: 26% [low] vs 13.0% [high],
P=.0002; educational attainment: 27.5% [lower]
vs 19.3% [higher], P=.OO9).
High-income people were more likely than lowincome people to report that the SFAA reduced
their exposure to ETS (53.3% vs 41.9%,
P<.0001).
Author’s conclusion of SES impact
Groups that experienced the largest declines in
smoking prevalence included people in the
lowest and highest income brackets and people
with higher educational levels.
Our data suggest that people with lower
incomes may have been more heavily affected
by the increase in taxation, whereas people with
higher incomes may have been more affected
by greater awareness of the dangers of
environmental tobacco smoke and expansion of
smoke-free workplace legislation.
225
Details
Method
Smoking restrictions in cars, homes, workplaces and enclosed public places
Author, year
Data sources
Guse 2004
Current Population Survey tobacco
Country
supplements; 25% in person
Wisconsin, USA
interviews,
75%
telephone
Design
interviews
Repeat cross-sectional
Participant selection
Objective
No details
To describe the nature and extent of Participant characteristics
workplace
ETS
exposures
in 5933 (1995 to 1996) and 5674 (1998
Wisconsin
to 1999) aged 16 years+
SES variables
Intervention
Education, income, occupation
Workplace clean indoor air policies
Analyses
Length of study
Bivariate regression
1995 to 1996 and 1998 to 1999
surveys
Outcomes
Smoking prevalence
Workplace policy coverage
Results
Comments
General population
% US indoor workers working under a
smokefree policy increased from 64% in
1995 to 1996 to 69% in 1998 to 1999. In
Wisconsin the percent of indoor workers
working under a smokefree policy
increased from 62% in 1995 to 1996 to
65% in 1998 to 1999.
SES
Residents with less than a high school
education or with a high school diploma as
well as residents making less than $15,000
are much more likely to work in an
environment where smoking is permitted
or unregulated.
Smoking prevalence was generally higher
among people in occupations with a lower
percentage of workers covered by
smokefree workplace policy.
About 80% of indoor workers working
under a smokefree policy work are in
professional
specialities,
protective
services and technicians, compared to 22%
of farmers and 50% machine operators
and assemblers.
Author’s conclusion of SES impact
There are socioeconomic differences in
exposure to SHS in terms of occupation,
income and education.
Internal validity
Small numbers in some
subgroups make estimates
unstable
External validity
Survey represents civilian noninstitutionalised population.
Smokefree
policies
in
Wisconsin have not progressed
as much as other US states –
29th best in country in 1993
and 1996but 37th in 1999.
Validity of author’s conclusion
226
Details
Methods
Results
Smoking restrictions in cars, homes, workplaces and enclosed public places
Author , year
Data sources
General population
Guzman 2012
Annual Survey of the Health of Smoke-free legislation in Wisconsin
Country
Wisconsin (SHOW).
increased the number of participants who
Participant selection
Wisconsin, USA
reported having strict no-smoking policies
Design
Randomly selected, 2-stage cluster in their households and decreased reported
Repeat cross-sectional (before and sampling
exposure to tobacco smoke outside the
Participant characteristics
after)
home, inside the home, and at work.
Objective
N = 1341 aged 21-74 years, 20.4% The smoking ban was associated with a
To evaluate the impact of smokefree excluded from analyses (exposed to reduction of participants reporting exposure
legislation on smoking behaviours in ban prior to statewide ban), 634 to smoke outside the home (from 55% to
and out of the home
surveyed before ban and 434 after 32%; P<0.0001) and at home (13% to 7%;
SES variables
ban
P=0.002). The new legislation was
Education
level:
high
school Intervention
associated with an increased percentage of
education or level; some college 2009 Wisconsin Act, a statewide participants with no-smoking policies in
education or higher). Family income: smoke-free law enacted in July 2010
their households (from 74% to 80%;
(<$30,000 per year; $30,000 to Length of study
P=.04).
$59,000 per year; >/=$60,000 per 2008 to 2010
Smokefree legislation not associated with
year).
Outcomes
change in smoking prevalence but
Analyses
Being current smoker,
analyses weakened by small sample size.
Chi-square tests were used to
Participants being exposed to smoke SES
compare proportions and two-tailed t
outside home,
The results were stronger among
tests were used for comparison of
Participants
being
exposed
to
smoke
participants who were wealthier, and more
means.
Appropriate
sample
at
work,
educated.
weighting was applied based on
Income
Participants
being
exposed
to
smoke
survey strata and cluster structure.
at
home,
Logistic regression models were
Participant exposure to tobacco smoke
used to estimate crude and adjusted Participants having a strict ban in the outside the home improved among all
odds ratios of exposure to smoking home,
income groups but it was decreased further
variables
comparing
SHOW
in the highest income group (family income
participants recruited after and before
>$60,000 per year). Participants being
the state smoking ban.
exposed to smoke at home was
significantly reduced only for highest
income group. Participants having a strict
ban in the home was significantly increased
only for the highest income group.
Comments
Internal validity
Participants who lived in an
area with a workplace or
complete public smoking ban
prior to the statewide ban were
excluded from the analysis.
The number of current smokers
in the SHOW data was only
167, a number that limits the
statistical power of the study
when it comes to analysing the
effects of the law on smoking
prevalence
and
on
the
behaviours of current smokers.
External validity
Specific
to
Wisconsin
residents.
Validity
of
author’s
conclusion
One of very few (if any) studies
to look at impact of smokefree
on home smoking by SES.
227
Details
Methods
Results
Comments
Smoking restrictions in cars, homes, workplaces and enclosed public places
Participants being exposed to smoke at
work significantly reduced only for middle
income group.
Education
Both
education
groups
significantly
reduced exposure to smoke outside the
home. Participants being exposed to
smoke at home was significantly reduced
only
for
higher
education
group.
Participants having a strict ban in the home
was significantly increased only for the
higher education group.
Author’s conclusion of SES impact
Participants with a family income greater
than $60,000 per year also reported the
largest reduction in exposure to smoke
outside and inside the home, while the
middle income group ($30,000-$59,999 per
year) reported the largest reduction in
exposure to smoke at work. The reduction
in exposure to smoke outside the home
and at work was about the same in both
education groups but a larger reduction
was seen in exposure to smoke at home in
the group with a college education or
higher. Those in the higher education
group were also more likely to have a strict
no-smoking ban in the home.
228
Details
Method
Result
Comments
General population
8.6% quit attempts in Jul/Aug-07, (5.7%
equivalent period in 2008). Partially offset by fewer quitters in Sep/Nov-07.
2007 also shows significantly higher
percentage of smokers making quit
attempts in Jan/Mar-07.
March-07 saw a significant increase in
intention to quit before the ban, which fell
by June (18% in March, 7% in June).
Coincided with a significant rise in those
planning to quit once the ban had been
enforced (7% in March to 16% in June).
One in five who quit after the ban said
they’d been influenced by the ban.
SES
No significant difference in quit attempts
by social grade. Intention to quit not
discussed by social grade.
Author’s conclusion of SES impact
Smoke-free legislation was associated
with a significant, temporary, increase in
the percentage of smokers attempting to
quit. This was true across all social
grades. May not necessarily lead to a
reduction in smoking-related health
inequalities, but did not widen them.
Internal validity
Non-response rate not discussed.
Self-reported quit attempts likely to be
higher than actual – no indication of
attempts turning in to short-term
cessation.
Other tobacco control policies within the
time period may have influenced the
outcomes, only No Smoking Day
discussed.
Only examine six months of prelegislation data, unclear whether quit
attempts around the ban are different
from the equivalent months in 2006.
External validity
Large national household survey
Validity of author’s conclusion
Quit attempts are generally more
successful in more advantaged social
groups, so although the influence has
been equal across groups it is likely that
the net outcome is a widening of
inequality.
Smoking restrictions in cars, homes, workplaces and enclosed public places
Author , year
Hackshaw, 2010
Country
England, UK
Design
Repeat cross-sectional
Objective
To determine the impact of smokefree
legislation on quit attempts and
intentions.
SES variables
Occupational class
Analyses
SPSS version 13.1; categorical and
continuous data were analysed using x2
tests and t tests, respectively.
Data sources
National household surveys, Smoking
Toolkit study (monthly, face-to-face,
computer-assisted, interviews).
Participant selection
Random location sampling method for
over 16yrs. The sample was weighted to
match census data on demographics.
Subsample for current smokers, or have
smoked in the last year (n=10560)
Participant characteristics
Mean age 41, 52% male. Average
cigarette consumption – 13.45cpd.
Occupational grades: AB=16.3%, C1
25%, C2 24.1%, D 22.5%, E 12.1%.
Authors report there were no statistically
significant differences between
respondents to the 2007 and to the 2008
surveys according to gender, age, social
grade and daily cigarette consumption.
Intervention
National smoke free legislation enforced
in July 2007.
Length of study
January 2007 to December 2008
Outcomes
Intention to quit
Influence of the ban on quit attempts.
229
Details
Method
Result
Comments
General population
No significant differences between
countries in parental smoking or smoking
in the home at 5 years, when adjusted for
smoking at 9 months.
Light smoking parents less likely to quit in
Scotland than in England, no difference
for heavy smokers.
After adjusting for socio-demographics
mothers in Scotland were less likely to
start smoking by the child’s 5th birthday
than in England (6.2% vs 7.3%
respectively).
SES
Higher rate of smoking cessation
between contact 1 and contact 3 among
mothers in England who have higher
household income, higher occupational
class, left school at an older age, or gave
birth later. No significant relationship for
these factors in Scotland.
Lower SES associated with higher rates
of maternal smoking uptake and smoking
in the home in both countries (p<0.05).
Author’s conclusion of SES impact
Smoking behaviours among parents with
young children have remained relatively
stable. In England quitting was also
socially
patterned, but socio-economic gradient in
quitting smoking in Scotland has flattened
slightly following the smokefree
legislation. Smokefree legislation appears
to encourage quitting across all
socioeconomic groups, and does not
appear to widen health inequalities.
Internal validity
Initial data point several years before the
introduction of legislation, during a period
of continual change in tobacco control
policy, difficult to isolate the impact of
smokefree legislation.
45% of respondents in Scotland were
surveyed within six months of the
legislation.
Self-reported smoking behaviour,
possible differences in misreporting due
to differences in smoking stigma.
Higher attrition rate among non-smokers
(40% of those who only responded at
contact point 1 smoked compared to 29%
who participated in the first and third
contacts).Non-response weights were
included in all analyses.
No apparent threshold to define a
smoker, e.g. smoked at least 100
cigarettes in lifetime, or regular smoker
rather than occasional.
External validity
Results may not be applicable to ethnic
minority groups.
Validity of author’s conclusion
Difficult to attribute any of the findings to
smokefree legislation, given the range of
other tobacco control policies
implemented between the two data
collection points.
Smoking restrictions in cars, homes, workplaces and enclosed public places
Author, year
Hawkins 2011
Country
England and Scotland
Design
Cohort
Objective
To investigate parental smoking
behaviours in England and Scotland after
Scottish smokefree legislation, and
inequalities in maternal smoking
behaviour between the two countries.
SES variables
Occupational class, household income,
education
Analyses
Logistic regression
Data sources
Millennium Cohort Study (MCS) data for
parents of children born between Sep-00
and Jan-02. First contact when child was
9 months old, third contact at 5 years old,
99.6% of these in Scotland took place
post-legislation. 72% response rate to
MCS.
Participant selection
Only studied singleton births to white
British/Irish mothers who participated in
all three contacts and lived in England or
Scotland at first and third contact.
Excluded if mother was pregnant at any
contact, main respondent was not
female, or partner was not male. In the
final sample (4661), 3757 fathers were
resident in England and 904 in Scotland.
Participant characteristics
Socio-demographic variables from first
contact used. 32% of mothers held
managerial or professional jobs, 49% left
education at or before age of 16, 13%
lone parents, 60% employed, mean age
at birth 29, no sig differences between
England and Scotland. One quarter had
income of £33k or higher, sig more
English households had income above
£22k (56% v 50%, p=0.03)
Intervention
Smokefree public places introduced in
Scotland on March 26th 2006. No
smokefree legislation in England during
data collection period.
Length of study
2000 to 2007
Outcomes
Smoking behaviour at child’s age 9
months and 5 years.
230
Smoking in the home measured from
‘Does anyone smoke in the same room
as [Cohort child] nowadays?’
Smoking one cigarette per day classified
as smoker, 10 or more per day classified
as heavy smoking.
231
Details
Method
Result
Comments
General population
In adjusted causal inference models
every $1.00 increase in cigarette excise
tax between 2001 and 2005 was
associated with a 4 percentage point
decrease in household tobacco use
between 2003 and 2007 (p = 0.008);
however, there was no effect of smokefree legislation on household tobacco
use.
In adjusted cross-sectional models, a
higher smoke-free legislation total score
was associated with a lower prevalence
of household tobacco use.
SES
Cigarette
tax increases but
not
smokefree legislation total score, were
associated with reductions in household
tobacco use for lower income households
(100–399 % of the federal poverty level)
using casual inference techniques.
Cigarette tax increases and smokefree
were associated with reductions in
household tobacco use for lower income
households.
Author’s conclusion of SES impact
Stronger
tobacco
control
policies
decreased
tobacco
use
among
households with school-age children and
adolescents; however, which policy
reduced parental smoking depended on
the modelling approach used. In causal
inference models we found that stronger
cigarette
excise
taxes
decreased
household tobacco use, particularly for
families with children from lower income
groups, but smoke-free legislation did not
change tobacco use. In cross-sectional
models we showed that a higher smoke-
Internal validity
Household tobacco use as a proxy for
children’s secondhand smoke exposure.
Two year lag between tax and smokefree
policies and outcomes.
External validity
National survey data used which should
be generalisable to US parents
Validity of author’s conclusion
This is a comparison of methods study in
which authors focus on causal inference
model results. Aim of increasing cigarette
tax is to reduce prevalence of smoking
and aim of smokefree legislation is to
protect from SHS exposure.
Smoking restrictions in cars, homes, workplaces and enclosed public places
Author, year
Hawkins 2012
Country
USA
Design
Repeat cross-sectional
Objective
To examine the impact of cigarette excise
taxes and smoke-free legislation on
tobacco use among households with
school-age children and adolescents as
well
as
disparities
in
children’s
secondhand smoke exposure.
SES variables
Total combined family income during the
past calendar year before taxes. A
household’s percentage of the federal
poverty level was calculated from
household size and income. Highest level
of education in the household was
constructed by comparing education of
the mother and father: less than/high
school graduate or more than high school
graduate
Analyses
compared the results from models using
causal inference techniques (differences
in differences) to those from crosssectional models using ordinal least
squares regressions models
Data sources
National Survey of Children’s Health,
state-level cigarette excise taxes, smokefree legislation total score (0 [none]–32
[very strong]) in 2001 and 2005 (National
Cancer
Institute’s
State
Cancer
Legislative Database).
Participant selection
Not stated
Participant characteristics
families of 6–17-year-olds from the 2003
(N = 67,607) and 2007 (N = 62,768)
Intervention
Cigarette excise taxes and smoke-free
legislation.
From 2003 to 2007 40 states raised
cigarette excise taxes with a mean
increase of 54.5 cents (SE 6.4; range 7–
175). In 2005, the mean tax was 84.7
cents (SE 7.9; range 5–246). From 2001–
2005, 18 states strengthened smoke-free
legislation with a mean increase of 13.3
(SE 1.8; range 1–28). In 2005, the mean
smoke-free legislation total score was
12.0 (SE 1.3; range 0–32).
Length of study
January 2003 – July 2004 and repeated
separate sample April 2007 – July 2008.
Outcomes
Household tobacco use
232
free legislation total score, indicating
stronger policies or a greater coverage of
policies, was associated with a lower
prevalence of household tobacco use.
Results suggest that increasing cigarette
excise taxes may help reduce disparities
by
influencing
parental
smoking
behaviours for the most at-risk children.
233
Details
Method
Results
Smoking restrictions in cars, homes, workplaces and enclosed public places
Author , year
Data sources
General population
Hemsing 2012
Telephone interview with 21 women N/A
Country
(9 low income) and 19 men (9 low SES
Vancouver, Canada
income), and focus groups with one The majority of participants thought that
Design
group of 3 low income women, one people living on a low income would be
qualitative
group of 3 non-low-income men, and more vulnerable to SHS, face more
Objective
one non-low-income woman
smoking-related challenges and be less
To explore the effects of SHS Participant selection
likely to benefit from SHS policies.
policies on diverse group of men and
Recruited via advertisements in Participants noted that smokers tend to be
women
universities, coffee shops, hospitals, poor and have fewer resources to afford
SES variables
local media, and Craigslist (a free healthier options, experience more stress
low income or not low income online classified advertisement). and anxiety and are more likely to use
according to their self-reported Purposive sample,
smoking as a coping mechanism. Some
combined family income before
people living on a low income use smoking
Participant characteristics
deductions, using the Low-Income
N=47, exposed to SHS daily or to cope with mental illness, and therefore
Cut-Offs (LICOs) from Statistics almost daily and who were 19 years face more barriers to reducing or quitting
Canada for 2004, and based on and older
smoking.
Vancouver
population
size Intervention
Participants thought that people living on a
(500,000+)
Smokefree legislation, interviews and low income tend to be surrounded by more
Analyses
focus groups were semi-structured smokers, and also that smoking restrictions
Qualitative analysis (NVivo 8) conducted by a trained female are less likely to be regulated. Low income
software was utilized to analyse interviewer over the phone, and the neighbourhoods or housing areas often
interview and focus group transcripts. focus groups by a trained, female lack access to private outdoor space,
Recurring themes were identified, facilitator in a meeting room at BC creating challenges for those individuals
paying
particular
attention
to Women’s Hospital (transportation trying to reduce their smoking or SHS
gendered factors and differences vouchers
and
child
care exposure.
between women and men, and reimbursement
were
offered). Author’s conclusion of SES impact
income levels. Data associated with Participants received gift cards to Women and men living on a low income
each specific theme were organized local retailers as honorarium for their are more likely to live in more crowded
under each code. Preliminary themes participation, in the amount of $20 for areas, with more smokers and less safe,
were discussed and reviewed in a the phone interviews and $40 for the open spaces. These physical constraints
team meeting, and themes further focus groups. All interviews and limit opportunities to avoid SHS exposure
refined
groups
were
recorded
and in spite of increasing restrictions. The
transcribed,
physical, social, and economic barriers low
Comments
Internal validity
Unable to recruit men living on
a low income to attend a focus
group, and only met with one
non-low-income woman for a
focus group.
Unequal number of smokers
and non-smokers - sampling
was not performed based on
smoking status
External validity
Small study sample specific to
Vancouver.
Validity
of
author’s
conclusion
234
Details
Method
Results
Comments
Smoking restrictions in cars, homes, workplaces and enclosed public places
Length of study
income women and men encounter to
reducing smoking and smoke exposure
March 2010 and February 2011
may reinforce or intensify health-related
Outcomes
disparities. Smoking in low-income areas
3 key themes:
Reshuffling and Relocating Where may be normalized, smoking restrictions
less enforced, and individuals experiencing
People Smoke;
the many stresses associated with living on
SHS management and the impact on
a low income may find it difficult to quit
social relations and interactions;
Disparities in the effect of policies
and management of SHS.
235
Details
Method
Results
Comments
Smoking restrictions in cars, homes, workplaces and enclosed public places
Author, year
King 2011
Country
Canada, the United States, the United
Kingdom, and Australia
Design
Prospective cohort study
Objective
To assess socioeconomic and national
variations in the prevalence, introduction,
retention, and removal of smoke-free
policies in various indoor environments,
including homes, worksites, bars, and
restaurants. A secondary objective was
to identify sociodemographic predictors of
these
policy-related
indicators
by
environment type.
SES variables
Self-reported education and annual
household income were used to create
composite measure of SES.
Analyses
Bivariate analyses, multiple logistic
regression.
Data sources
2006 and 2007 Waves 5 and 6 of the
International Tobacco Control Four
Country Survey
Participant selection
Recruited
by
probability
sampling
methods in each of the four countries. In
subsequent follow-up surveys of the
cohort, recruited samples are replenished
after attrition to ensure a sample size of
at least 2,000 per country at each Wave.
Participants
were
identified
using
stratified random digit dialling and
interviews
were
conducted
using
computer assisted telephone interview
(CATI) software by multiple research
firms.
Participant characteristics
8,245 current and former adult smokers
who were interviewed as part of Wave 5
of the ITC-4 survey between October
2006 and February 2007 (Canada, n =
2,023; the US, n = 2,034; the UK, n =
2,019; and Australia, n = 2,169).
Intervention
Telephone interviews with current smoker
(reported smoking daily, weekly, or
monthly at the time of survey) and former
adult smokers (either remained quit since
the time of last survey Wave completion
or who made an attempt to stop smoking
since the time of last survey Wave
completion and was also quit for a month
or more at the time of current survey
Wave).
Length of study
General population
Smokefree bar policies:
Overall, the proportion of both current and
former smokers who reported that smoking was
not allowed in any indoor area of local bars
(total ban) was greatest among respondents
from Canada in Wave 5 (current: 83.6%; former:
83.0%) and those from the UK, where a national
ban on smoking in indoor public places was
implemented between Waves, in Wave 6
(current: 97.1%; former: 95.3%). Between
Waves 5 and 6, relative increases of 79.7% and
50.6% were observed in the proportion of
current smokers with a total ban in the UK and
Australia, respectively. Similar increases were
also observed among former smokers in these
two countries (UK: 81.1%; Australia: 45.3%).
Smokefree restaurant policies:
Overall, the proportion of both current and
former smokers who reported that smoking was
not allowed in any indoor area of local
restaurants (total ban) was greatest among
respondents from Canada in Wave 5 (current:
91.5%; former: 92.7%) and the UK, where a
national ban on smoking in indoor public places
was implemented between Waves, in Wave 6
(current: 97.1%; former: 98.2%). In contrast, the
proportion of respondents with such a policy
was lowest among those from the UK in Wave 5
(current: 27.5%; former: 32.0%) and the US in
Wave 6 (current: 65.0%; former: 60.9%).
Between Waves 5 and 6, relative increases of
71.7% and 67.4% were observed among current
and former smokers in the UK, respectively.
Smokefree worksite policies:
Overall, the proportion of current smokers who
reported that smoking was not allowed in any
Internal validity
Between September 2007 and
February 2008, a total of 5,866 of
these participants (71.1%) were
successfully
re-interviewed
in
Wave 6 (Canada, n = 1,459,
72.1%; the US, n = 1,291, 63.5%;
the UK, n = 1,484, 73.5%; and
Australia, n = 1,632, 75.2%). In
addition, another 2,329 individuals
were recruited as part of the Wave
6 replenishment sample (Canada,
n = 556; the US, n = 711; the UK,
n = 523; and Australia, n = 539).
External validity
Findings from each of the four
countries can be compared as
same survey used.
Validity of author’s conclusion
In the UK, national legislation
prohibiting smoking in worksites,
bars,
and
restaurants
was
implemented
between
data
collection waves which may have
influenced results.
236
12 months
Outcomes
presence, introduction, and removal of
smoke-free policies in homes, worksites,
bars, and restaurants
indoor area of their worksite (total ban) was
greatest among respondents from Canada in
Wave 5 (88.2%) and those from the UK, where
a national ban on smoking in indoor public areas
was implemented between Waves, in Wave 6
(96.1%). The US had the lowest proportion at
both Waves (Wave 5: 76.8%; Wave 6: 75.9%).
Among former smokers, the proportion of
respondents with such a policy in Wave 5 was
the greatest in the US (92.7%), but lowest in
Wave 6 (83.0%). Following stratification by SES,
the proportion of current smokers with a total
smoking ban in the worksite increased with
increasing SES in Canada and the U.S. in Wave
5, but no significant trends were apparent in
Wave 6. In the UK, the proportion of former
smokers with a total smoking ban in the worksite
increased with increasing SES in Wave 5.
Between Waves, the introduction of a total ban
among
continuing
smokers
significantly
decreased with increasing SES in Canada, the
U.S. and the U.K.
SES
No consistent association was observed
between SES and the presence or introduction
of bans in worksites, bars, or restaurants.
Current smokers with higher SES were more
likely to have a total smoking ban in the
workplace; however, the rate of smoke-free
policy adoption in the workplace was
comparable by SES group.
Author’s conclusion of SES impact
The lack of socioeconomic differences in public
workplace, bar, and restaurant smoke-free
policies suggest these measures are now
equitably distributed in these four countries.
although
smoke-free
workplaces
have
previously been more common in high SES
occupations, this disparity appears to have
disappeared. On balance, the evidence
indicates that smoke-free policies in public
237
places are not being implemented differentially
by the socioeconomic status of smokers.
Details
Method
Result
Comments
Smoking restrictions in cars, homes, workplaces and enclosed public places
Author, year
Levy, 2006
Country
USA
Design
Repeat cross-sectional
Objective
To
examine
association
between smoking and tobacco
control policies among women
of low SES.
SES variables
Not completed high school or
no high school degree or GED
Analyses
multivariate logistic models,
Data sources
Tobacco Use Supplement, four waves
between 1992 and 2002. Sample nationally
representative of non-institutionalised civilian
population over the age of 15.
Participant selection
Females grouped by education level (less
than high school, high school or higher,
bachelor’s degree). Low education males
included as a reference population. Sample
varies between 176,452 and 228,552.
Participant characteristics
Majority white, with increasing Hispanic
proportion in later surveys. Majority 25 year
olds or over. Over 40% from the South,
approx. 20% each from the Midwest,
Northeast and West.
Low educated female constitutes between
21.6 and 26.6% of each survey, mideducated 19.3-22.4%, high educated are 7.3
to 9.2%
Intervention
cigarette prices, clean air regulations, and
tobacco control media campaigns,
Clean air laws were represented by an index
of state level clean air regulations. States
with ‘‘no smoking allowed (100% smoke
free)’’ were counted as 100% of the effect,
with ‘‘no smoking allowed or designated
smoking areas allowed if separately
ventilated’’ as a 50% effect, and with
‘‘designated smoking areas required or
allowed’’ as a 25% effect. We used separate
indices by type of law, and settled on an
aggregate weighted index, with worksite laws
weighted by 50%, restaurant laws by 30%,
and laws for other public places by 20%.
General population impact
Smoking prevalence declining across all
categories.
SES
Price:
As price increased the OR of low-education
female smoking fell, but influence varies
over survey waves. Only lower than 1 in
1992-3 and 2001-02. Med-higher educated
groups less responsive.
Media:
In a state with a media campaign low
education women’s OR=0.86, medium
education = 0.89, high = 0.93 (non sig).
Low education men also significantly less
likely to smoke (0.92) Generally, the
association of the media variable and
smoking prevalence declines in the more
recent survey waves.
Smokefree legislation
Marginal effect on current smoking. Over
the period 1992–2002, current smoking
among low education women is inversely
related to the index of clean air laws with
an odds ratio of 0.91 (0.80, 1.03), but is
significant only in the medium education
female subpopulation, with an odds ratio of
0.88 (0.83, 0.94). However, only in the
2001/02 model do clean air laws seem to
play a part for the medium education
female sample, although the confidence
intervals around the estimates for each
survey wave overlap for this group.
Author’s conclusion of SES impact
Low
education
women
particularly
responsive to media and price increases
especially in comparison with high
Internal validity
No before and after, simply tracks the
association between policy and prevalence.
Fail to adjust for confounding individual
characteristics.
Small sample sizes at some state levels.
External validity
Most of the developments in clean air
regulations at the state level occurred after
2001.
A number of tobacco control policies were
introduced during this period as well as
changing social norms and increasing
awareness, all of which may have influenced
the results. Data is now one, in some cases
nearly two, decades out of date. Covers a
substantial Hispanic population that wouldn’t
exist in the UK.
No description of the types of media
campaigns involved, and which were the most
effective (either the mode of intervention or
locations) in order to replicate the study.
Validity of author’s conclusion
No examination of individual level exposure, or
whether media campaigns were actively
influencing people to change their smoking
behaviour. Outcome may simply be the
consequence of changing social norms in
these populations.
238
Media campaign exposure measured at the
state level rather than individual, and youth
campaigns coded as half a media campaign.
Length of study
1992 to 2002
Outcomes
Individual use, attitudes towards smoking
and clean air laws, and smoking bans at
home or work.
education women. Tax increases can play
an important role. Tax increases and media
messages may reduce prevalence among
women with low education. Health-SES
relationship not irreversible.
239
Details
Method
Results
Smoking restrictions in cars, homes, workplaces and enclosed public places
Author , year
Data sources
General population
MacCalman 2012
Bar
workers
Health
and There was no difference in the initial
Country
Environmental Tobacco Smoke attitudes towards SFL between those
England and Scotland
Exposure – BHETSE (Scotland), and working in Scotland and England.
Design
Smokefree Bars 07 (England)
The proportion of people reporting any
Cohort, before and after SFL
Participant selection
symptoms was significantly reduced from
Objective
Random sample of bars from baseline to 1 year, in both England (76%
To determine whether workers’ Glasgow, Edinburgh and Aberdeen; vs. 49%) and Scotland (67% vs. 87%), with
attitudes towards the change in their and small towns in Aberdeenshire similar patterns being evident for both
working conditions (SFL) may be and the Borders areas of Scotland, countries. However, the size of the
linked to the change in health they central London and Liverpool; reduction in symptom prevalence in
report.
Northumbria
and
Cumbria; Scotland was lower than in England.
SES variables
Newcastle-upon-Tyne.
Attitude towards SFL was not found to be
Highest attained education (School, Convenience sample of bar workers related to change in reported symptoms for
college, university or postgraduate)
bar workers in England (Respiratory, p =
in participating bars.
0.755; Sensory, p = 0.910). In Scotland
Analyses
Participant characteristics
there was suggestion of a relationship with
Regression
N=548, bar workers
reporting of respiratory symptoms (p =
Intervention
0.042), where those who were initially more
UK smokefree legislation (SFL)
negative to SFL experienced a greater
Length of study
improvement in self-reported health.
1 year,
SES
Outcomes
attitudes towards SFL and the For the majority of the questions bar
presence of respiratory and sensory workers who were educated to degree level
symptoms
and higher were significantly more positive
towards the legislation than those who did
not continue with education after school.
Education did not significantly effect
change in symptoms reported.
Author’s conclusion of SES impact
Initial attitude did not have an effect on the
change in symptoms reported by those in
England.
There
was,
however,
a
relationship between the change in
Comments
Internal validity
72/159 bars agreed to participate
in Scotland (45%) and 46/253
(18%) in England.
Same
questionnaire used for both the
Scottish and English studies. A
higher proportion of bar
workers in England were lost to
follow-up (p<0.001), especially
those
from
London
and
Newcastle while there was a
slightly lower proportion of
those from Aberdeen lost to
follow-up. 295/548 lost to
follow-up
(54%,
65%
in
England and 49% in Scotland).
Analyses of reported health
symptoms limited to 180 bar
workers (did not have a cold at
baseline or follow-up. Only 138
bar workers in low SES group
(school level education).
External validity
lower proportion of bars in
England agreeing to participate
(18% England; 45% Scotland),
Validity
of
author’s
conclusion
Valid – no association between
smoking status and change in
reported health. No evidence
that bar workers who were
initially more supportive of SFL
were more likely to report
240
Details
Method
Results
Smoking restrictions in cars, homes, workplaces and enclosed public places
reported respiratory symptoms and initial
attitude
in
Scotland.
The
biggest
improvement in respiratory symptoms, from
baseline to year 1, was reported by those
who were initially negative towards the
SFL.
Initial attitude is more likely to be
associated with the symptoms reported
initially, with those who were initially more
positive towards the legislation being more
likely to report no symptoms than those
who had a negative attitude.
Comments
improvements in health. So no
evidence of this type of
selection bias, and all bar
workers of all SES likely to
benefit from SFL in terms of
perceived health.
241
Details
Method
Results
Comments
General population
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).
SES
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).
In 2007 the percentage of homes with
neither parent smoking (reported by
children) were 48.9% for low SES, 65.5%
for medium SES and 72.4% for high SES.
In 2008 the percentage of homes with
neither parent smoking were 49.9% for low
SES, 67.3% for medium SES and 78.1%
for high SES.
The percentage of children reporting SHS
exposure in a car the previous day
remained at 7% before and after the
smokefree legislation.
In 2007 percentages of children reporting
car-based exposure to SHS exposure was
8.8% (n=69) for low SES, 6.5%% (n=79)
for medium SES and 5.4% (n=58) for high
SES. Among the lower SES group,
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.
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.
Childrens reports of parental
smoking in the home and in the
car are only proxy measures.
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.
Smoking restriction in cars, homes, workplaces and other public places
Author, year
Moore 2011
Country
Primary schools, Wales
Design
Repeat cross-sectional
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
SES variables
Family Affluence Scale (bedroom
occupancy, car ownership, holidays,
computer ownership)
Analysis
Multinomial logistic regression
analysis accounting for clustering
and adjusted for age, year and time
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
Data sources
CHETS Wales study
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
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.
Intervention
National smokefree legislation
Length of study
1 year
Outcomes
Salivary cotinine levels
Parental smoking in the home
242
Details
Method
Smoking restriction in cars, homes, workplaces and other public places
and provided saliva with a cotinine
Car-based SHS exposure
concentration <15 ng/ml (n =
1,362/1,364)].
Intervention details
Questionnaire plus cotinine assay
Results
Comments
percentages of children reporting carbased exposure increased slightly from
7.4% (n = 31) pre-legislation to 10.6% (n =
38) post-legislation. Among the mediumSES group, exposure remained almost
unchanged, at 6.3% (n = 38) pre-legislation
and 6.6% (n = 41) post-legislation.
However, among the high-SES group,
exposure declined from 6.3% (n = 33) to
4.6% (n = 25). The changes in car-based
SHS exposure were not statistically
significant for any of the three SES
subgroups, however the changes did
increase between group differences from
1% pre-legislation to 6% post-legislation.
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
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
243
Details
Method
Results
Comments
Smoking restriction in cars, homes, workplaces and other public places
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.
244
Details
Method
Results
Comments
General population
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.
SES
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.
In all countries, and the combined data set,
as SES increased, the likelihood of partial
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).
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.
Childrens reports of parental
restrictions in the home and in
the car are only proxy
measures.
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.
Smoking restriction in cars, homes, workplaces and other public places
Author, year
Moore 2012
Country
Primary schools, Scotland, Northern
Ireland, Wales
Design
Repeat cross-sectional
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
SES variables
Family Affluence Scale (bedroom
occupancy, car ownership, holidays,
computer ownership)
Analysis
Multinomial logistic regression
analysis accounting for clustering
and adjusted for age and country.
Binomial logistic regression for carbased smoking.
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).
Intervention
National smokefree legislation
prohibiting smoking in enclosed
public places and workplaces
(Scotland March 2006, Wales March
2007, Northern Ireland (NI) April
2007
Length of study
One year
Outcomes
Salivary cotinine levels
Smoking restrictions in the home
Smoking restrictions in the car
245
Details
Method
Results
Comments
Smoking restriction in cars, homes, workplaces and other public places
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.
Following legislation, 26.3% of children
scoring 1 on FAS reported living in a fully
smoke-free home, climbing to 72.0% for
those scoring 9.
Percentages reporting that smoking was
not allowed in their car ranged from 51.7
(least affluent) to 83.0% (most affluent).
These trends remained after adjustment for
parental smoking No change in inequality
following legislation for home and carbased 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.
246
Details
Method
Results
Comments
Smoking restrictions in cars, homes, workplaces and enclosed public places
Author, year
Moussa 2004
Country
Scania, Sweden
Design
Cross-sectional
Objective
To investigate the sociodemographic
distribution of workplace exposure to ETS
in a Swedish working population sample
in order to assess the potential
contribution of ETS exposure to health
inequalities.
SES variables
Occupation;
High-level
non-manual
employees, medium-level non-manual
employees,
low-level
non-manual
employees, skilled manual workers,
unskilled manual workers, self-employed
persons (a very heterogeneous group),
and students.
Analyses
multivariable regression
Data sources
Scania Public Health Survey 2000 was
based on a sample of 24,922 randomly
selected persons born from 1919 to 1981
and living in Scania (population 1.14
million), the southernmost province of
Sweden.
Participant selection
13,604 persons responded to the
questionnaire, representing 59% of those
contacted for the study.
Participant characteristics
8,270 working individuals
Intervention
Workplace ETS
Length of study
November 1999 to February 2000.
Outcomes
ETS exposure
General population
The prevalence of ETS at work was higher
among men (26.4%) than among women (20.8
%), although regular smoking was higher among
women (21.1%) than among men (17.0 %).
Regular smokers had a higher risk of ETS
exposure at work than non-smokers.
SES
The exposure to ETS at work was highest
among men in skilled manual work and women
in unskilled manual work. The higher risk of
exposure
among
individuals
in
the
aforementioned groups persisted after adjusting
for age, country of origin, and smoking patterns.
Male skilled manual workers and female
unskilled manual workers had higher adjusted
odds ratios (OR 4.0, 95% CI: 3.1 – 5.3 and OR
3.2, 95% CI: 2.2 – 4.7, respectively) of ETS
exposure
than
non-manual
high-level
employees.
Author’s conclusion of SES impact
Individuals in lower socioeconomic groups
experienced a higher risk of ETS exposure at
work than other such groups. ETS should be
recognized as a factor contributing to health
inequalities.
Internal validity
Age and smoking habits were
adjusted for in analyses.
External validity
Sample is from Scania only and
may not be generalisable to whole
of Sweden.
Validity of author’s conclusion
Valid
247
Details
Method
Results
Comments
Smoking restrictions in cars, homes, workplaces and enclosed 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
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.
Objective
To determine prevalence and
factors associated with strictly
enforced
smoke-free
car
policies
among
smoking
parents.
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
SES variable
education (high school
or less versus some college or
college
graduates)
Outcomes
Smokefree car policy
Study analysis
Logistic regression
Intervention details
Questionnaire of smoking behaviour in cars and
home
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 cigarettes
smoked per day by the parent, and
having another smoker at home).
Parent gender and education interacted
with child’s age: parents of children
aged <1 year were more likely to have
strict smoke-free car policies if they
248
Details
Method
Results
Comments
Smoking restrictions in cars, homes, workplaces and enclosed public places
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.
249
Details
Method
Results
Comments
Smoking restrictions in cars, homes, workplaces and enclosed public places
Author, year
Nagelhout 2011a
Country
Ireland,
France,
the
Netherlands,
Germany
Design
Before
and
after
study
(same
participants)
Objective
to investigate how successful the smokefree hospitality industry legislation was in
reducing smoking in bars; assess
individual smokers predictors of smoking
in bars post-ban; to examine country
differences in predictors; to examine
differences between education levels.
SES variables
education
Analyses
multivariate
regression
mediation
analyses
Data sources
International Tobacco Control (ITC)
Europe Surveys
Participant selection
Probability sampling methods with fixed
line telephone numbers selected at
random from the population of each
country. The Netherlands sample differed
in that most respondents were surveyed
using web interviewing (n = 1668 of
baseline sample of 2072) instead of
telephone interviewing. The Dutch web
sample was drawn from a large
probability-based
database
with
respondents who had indicated their
willingness to participate in research on a
regular basis.
Participant characteristics
3147 adult smokers (Ireland n = 573,
France n = 820, the Netherlands n =
1034 (telephone n = 185, web n = 849),
Germany n = 720).
Intervention
smoke-free hospitality industry legislation
Length of study
Varied between countries, approx. 12-24
months
Outcomes
Prevalence, predictors of smoking in bars
General population
while the partial smoke-free legislation in the
Netherlands and Germany was effective in
reducing smoking in bars (from 88% to 34% and
from 87% to 44%, respectively), the
effectiveness was much lower than the
comprehensive legislation in Ireland and
France which almost completely eliminated
smoking in bars (from 97% to 3% and from 84%
to 3% respectively).
Smokers, who were more supportive of the ban,
were more aware of the harm of SHS, and who
had negative opinions of smoking were less
likely to smoke in bars post-ban. Support for the
ban was a stronger predictor in Germany.
SES
Smokers from Ireland and France were younger
and less educated than smokers from the
Netherlands and Germany. Smokers with a low
educational level were more likely than smokers
with a high educational level to smoke in bars
post-ban.
Highly educated smokers from the Netherlands
who were supportive of a partial ban were less
likely to smoke in bars post-ban (OR highly
educated = 0.53, 95% CI = 0.26 to 1.08).
Moderately educated smokers from the
Netherlands who often or sometimes thought
about the harm of smoking to others were less
likely to smoke in bars (OR moderately
educated = 0.54, 95% CI = 0.34 to 0.88).
Societal approval of smoking was a stronger
predictor of smoking in bars among highly
educated smokers (OR highly educated = 2.87,
95% CI = 1.01 to 8.18). Low and moderately
educated smokers from Germany who very
often thought about the harm of smoking to
Internal validity
Respondents who did not visit bars
after the implementation (n = 985)
and respondents who had quit
smoking (n = 606) were excluded
from analysis.
Younger smokers had lower
follow-up rates. Since younger
smokers were more likely to
smoke in bars post-ban, this could
have led to an underestimation of
the point estimates of smoking in
bars post-ban.
72.5% follow-up - rates were
considerably
higher
for
the
Netherlands web survey (80.1%)
than the Netherlands telephone
survey (73.7%) and the telephone
surveys in the other countries
(Ireland 71.8%, France 71.0%,
Germany 66.1%).
The survey months and years and
the time intervals between waves
and between the ban and post-ban
waves were different between
countries, there were demographic
differences between countries and
the interviewing methods were
different for the ITC Netherlands
survey.
External validity
Findings from each of the four
countries can be compared as
same survey used.
Validity of author’s conclusion
valid
250
others were borderline significantly less likely to
smoke in bars (OR low educated = 0.14, 95% CI
= 0.02 to 1.15; OR moderately educated = 0.23,
95% CI = 0.05 to 1.11).
Author’s conclusion of SES impact
SHS harm awareness was a stronger predictor
among less educated smokers in the
Netherlands and Germany. This suggests that
smoking in bars post-ban can be decreased
among lower SES smokers by communicating
about the harm of smoking to others. This is
especially urgent for the Netherlands, where
only 1 percent of low educated smokers thinks
very often about the harm of their smoking to
others (compared to 19% of Irish, 17% of
French, and 9% of German low educated
smokers).
251
Details
Method
Smoking restrictions in cars, homes, workplaces and enclosed public places
Author, year
Data sources
Nagelhout 2011b
Dutch Continuous Survey of Smoking
Country
Habits (DCSSH), a continuous crossThe Netherlands
sectional population survey, running
Design
from 2001-2008. The DCSSH is
Cross-sectional
conducted
by
TNS
NIPO
Objective
(Amsterdam, the Netherlands) for
To study the impact of implementing the Dutch expert centre on tobacco
smoke-free
workplace
and control (STIVORO)
hospitality industry legislation on Participant selection
smoking behaviour.
Aged 15 or over, randomly selected
SES variables
from regular participants in internetEducation (low: primary and lower based research, 18,000 surveyed
secondary, medium: mid-secondary each year (total=144733).
and secondary vocational, high: Participant characteristics
senior secondary school, (pre- No significant differences between
)university and higher professional). years or pre/post 2008 hospitality
Employment (employed or ‘not ban.
employed for at least two days a Weighted by age, gender, education,
week’)
working hours, region, urbanisation
Analyses
and household size to make the
Multivariate logistic regression
sample representative of Dutch
population over 15 years old.
21% of responses contained no
information on income.
Intervention
Workplace smoking ban in the
Netherlands, introduced in 2004,
and a hospitality industry smoking
ban introduced in 2008.
Result
Comments
General population
There was a slight, significant,
decrease in prevalence between
2001 and 2007 (OR=0.97, p<0.001).
Workplace ban was followed by a
decrease in smoking prevalence in
2004 (OR=0.91, p<0.001), with
prevalence lower in the first half of
the year than the second, suggesting
some relapse.
Hospitality ban had no significant
influence on prevalence (OR=0.96,
p=0.127).
Quit attempts higher following the
workplace ban (33% (2004) v 27.7%
(2003), p<0.001), and hospitality ban
(26.3% in 2008, v 24.1% in 2007,
p=0.013). Seasonal variations in quit
rates also support effectiveness of
both smokefree policies.
Significant increases in successful
quit attempts following both
policies.
SES
Workplace ban led to more
successful quit attempts among
higher educated smokers (OR=0.35,
p<0.001) than medium (OR=0.41,
p<0.001)
or
lower
OR=0.74,
p=0.052).
Internal validity
Unable to infer causality from crosssectional data.
All data is self-reported.
Do not disclose the characteristics of
the surveyed population from which
the weighted study data was
extrapolated.
External validity
Population exposed to a number of
concurrent tobacco control policies
during study period, including three
tax rises, national media campaigns,
warning labels, advertising ban and a
youth access law.
Similar population structure to
England, with similar recent history
in
tobacco
control
policies.
Legislation poorly enforced in some
areas.
Validity of author’s conclusion
Disagree with the equal impact of
the smokefree hospitality legislation.
There is no significant difference in
quit attempts pre-ban, but post-ban
higher educated smokers are more
likely to attempt to quit than low
educated smokers (p=0.022).
252
Length of study
No variation in impact of hospitality
2001 to 2008
ban by SES.
Outcomes
The hospitality industry ban had a
Smoking prevalence, quit attempts larger effect on quit attempts among
(and success).
frequent bar visitors (OR = 1.48, P =
0.003) than on non-bar visitors (OR =
0.71, P = 0.014). More frequent bar
visitors more likely to be higher
educated, as well as younger, male,
and employed (all p<0.001).
Author’s conclusion of SES impact
Workplace smoking ban had a
greater
impact
on
smoking
behaviour than a hospitality industry
ban. The latter only appeared to
increase quit attempts rather than
change smoking prevalence.
Hospitality industry bans have the
potential to increase cessation in all
socio-economic groups.
253
Details
Method
Results
Smoking restrictions in cars, homes, workplaces and enclosed public places
Author , year
Data sources
General population
Nagelhout 2013
Three
survey waves
of
the Cessation:
Country
International Tobacco Control (ITC) 281 out of 962 respondents (29.3%) had
The Netherlands
Netherlands Survey, 2008 (before) tried to quit smoking between the 2009 and
Design
and 2009 and 2010 (after)
2010 surveys. At the 2010 survey, 86 out
Cohort
Participant selection
of
962
respondents
(8.9%)
had
Objective
Recruited from a probability-based successfully quit smoking. There were no
To examine age and educational web database
significant age inequalities in successful
inequalities in smoking cessation due
smoking cessation. Smokers aged 15–39
Participant characteristics
to the implementation of a tobacco
years were more likely to attempt to quit
tax increase, smoke-free legislation N=1820/2331 (78.1%) in first survey, smoking.
1447 in second survey and 1275 in
and a cessation campaign.
third survey. Analyses restricted to Exposure:
SES variables
respondents who participated in all In total, 82.4% reported having paid more
Education, low (primary education three survey waves (n=1176). And for their cigarettes in the 2009 survey than
and lower pre-vocational secondary excluded 128 who had quit during in the 2008 survey, 65.6% reported having
education), moderate (middle pre- 2008 and 2009 surveys, n=1048 and visited a drinking establishment that had
vocational secondary education and then answered all questions, n=962.
some form of smoking restriction and
secondary vocational education) and
Dutch smokers (having smoked at 83.1% reported having experienced one or
high [senior general secondary
least 100 cigarettes in their lifetime more parts of the campaign. Smokers aged
education, (pre-) university education
and currently smoking at least once 15–24 years were more exposed to the
and higher professional education].
smoke-free legislation, whereas smokers
per month) aged 15 years and older
Analyses
aged 25–39 years were more exposed to
Intervention
the cessation campaign.
Univariate and multivariate logistic
Tobacco tax increase, smoke-free
regression. All analyses were
Exposure to the smoke-free legislation and
hospitality industry legislation and
weighted by age and gender to be
to the cessation campaign had a significant
mass media cessation campaign (all
representative of the adult smoker
positive association with attempting to quit
at national level) implemented during
population in the Netherlands.
smoking in the univariate analyses, but not
the same time period in the
with successful smoking cessation. In the
Netherlands in 2008. The Dutch
multivariate analyses, only the association
cessation campaign focused on
between exposure to the smoke-free
smokers with low to moderate
legislation with attempting to quit smoking
educational levels.
remained significant [odds ratio (OR)=1.11,
Length of study
95% confidence interval (95% CI)=1.01–
2008 – 2010
1.22, P=0.029]. Exposure to the price
Comments
Internal validity
70% follow-up rate
External validity
Prices increased by only 8%.
Smokefree legislation was
weak, not well implemented
and issues with compliance.
Study authors report that
almost half of the sample was
either lost to follow-up or did
not answer all questions.
These
respondents
were
younger, less addicted and had
more intention to quit smoking.
Therefore, our results may not
be fully generalizable to the
broader population of Dutch
smokers.
Validity
of
author’s
conclusion
Smokefree, price, mass media
campaigns
were
not
associated with reduction in
prevalence of smoking.
254
Details
Method
Results
Comments
Smoking restrictions in cars, homes, workplaces and enclosed public places
Outcomes
increase only predicted successful smoking
Exposure,
cessation among young respondents.
Quit attempts,
SES
7-day point prevalence (successful Exposure: Higher educated smokers were
quitters)
more exposed to the price increase and the
smoke-free legislation.
Smokers from different educational levels
were reached equally by the mass media
campaign.
Cessation: There were no significant
educational inequalities in successful
smoking cessation.
Author’s conclusion of SES impact
There were no overall ages or educational
differences
in
successful
smoking
cessation after the implementation of the
three interventions.
255
Details
Method
Results
Comments
Smoking restrictions in cars, homes, workplaces and enclosed public places
Author, year
Parry 2000
Country
Edinburgh University, Scotland
Design
Qualitative and cross-sectional sample
Objective
To examine the implications of a smoking
ban at the university
SES variables
Occupation
Analyses
Qualitative data – from questionnaires
and interviews – were transcribed, then
thematically explored and analysed.
Data sources
Postal survey and qualitative work was
undertaken as part of an evaluation of the
smoking ban commissioned by the
University. It included analysis of policy
documentation,
a
questionnaire,
qualitative interviews and participant
observation.
Participant selection
Questionnaire – Respondents were
identified from the January 1998 salary
register. Questionnaires were personally
addressed to respondents and sent
through the University internal mail
system. Each respondent received a
preaddressed envelope and instructions
to return completed questionnaires via
the University internal mail service.
997 people (27.8% of achieved sample)
wrote comments on the blank page of the
questionnaires. Qualitative interviews – a
purposive sample of 30 staff members
pre- and post-implementation of the
policy.
Participant characteristics
Postal survey: Number:= 3531,
Gender: 1675M (46.6%), 1898F(52.8%),
19
Unknown
(<1%)
Occupation:
Academic (1355), Academic related
(419), Clerical / secretarial (825),
Technical(469), Manual (524) Significant
differences in reported smoking between
the different occupational groups within
the University: Academic 188 of
1765(10.7%), Clerical / secretarial 134 of
802 (16.7%), Technical 67 of 457
(14.7%), Manual 223 of 507 (44%),
Missing data 61. There was a significant
variation in smoking prevalence by
General population
Of 151 (15.5%) indicated that they smoked
during the working day prior to the ban, 51
(5.2%) smoked but not during the day and 775
(79.3%) were non-smokers. No information on
smoking was available for 20 respondents.
Day time smoking
Do not smoke now 36 (9.1%), Smoke less 170
(43.1%), Smoke more 21 (5.3%), No change
167(42.4%)
Overall pattern of smoking
Do not smoke now 21 (6.5%), Smoke less 77
(23.8%), Smoke more 45 (13.9%), No change
180 (55.7%)
Smoking outside work
Do not smoke now 19 (5.9%), Smoke less 35
(10.9%), Smoke more 70 (21.7%), No change
198 (61.5%) Of those still smoking during the
working day 35(8.2%) had reduced smoking
outside work since the ban. 70(16.4%) smoked
more and 198(46.5%) had not changed.
Relocation of smoking
2648 of 3448 (76.8%) of respondents reported
an increase of smoking on University property
outside buildings. 2756 of 3435 (80.29%) noted
an increase in smoking specifically on entrances
and steps to University buildings.
Quality of air
No change, 2419 of 3529 (68.5%), Improvement
1069 of 3529(30.3%), Deterioration 41 of 3529
(1.2%). Data on quality of air by smoking status
not extracted.
Change in working patterns
3278 (91.3%) reported no change in the amount
of time spent in the main work area before the
Internal validity
External validity
Differences between the University
sample and national samples are
discussed.
Validity of author’s conclusion
restrictions
on
smoking
in
workplaces may be more effective
for staff in higher occupational
grades.
„official‟ beginning of the work day,
3226(89.8%) reported no change in working
late, 3124(87.5%) no change at lunch times and
3254 (90.6%) no change during actual working
256
Details
Method
Results
Comments
Smoking restrictions in cars, homes, workplaces and enclosed public places
gender (Males 225 of 1653 (15.4%) vs.
Females 354 of 1862 (19.0%), p= 0.005).
Smoking rates did not differ by age.
Interviewees: included members of the
University court, those involved in the
process
of
implementation,
union
officials, student representatives and
attendees at support and implementation
classes.
Intervention
Workplace smoking ban: Prior to the
intervention smoking at the University
was guided by a voluntary code
discouraging smoking in communal
areas. Those with their own offices were
allowed to smoke provided they kept their
doors shut and those sharing offices
were expected to respect the wishes of
their colleagues. Reserved smoking
areas were provided in some restaurant
facilities and designated smoking rooms
were provided at the discretion of heads
of department.
The smoking policy, banning smoking in
University buildings and University
vehicles was introduced on 1 October
1997. The smoking policy applies to all
staff, students, outside contractors and
visitors to the University of Edinburgh.
The policy is supported by University
disciplinary procedures for staff and
through
faculty
representation
for
students. Three exceptions to the ban are
licensed premises, some selected
residential accommodation for students
and
University
grounds
(provided
entrances
to
buildings
are
not
obstructed). The decision to move from a
voluntary code to a smoking ban was
hours. 76 (17.8%) of smokers stated that they
spent less time in their work area during working
hours since the ban was introduced compared
to 6 (0.2%) of non-smokers. 122 (32.2%) of
smokers and 14 (0.5%) of non-smokers
indicated they spent less time in their main work
area at lunch time since the ban. 84 (19.7%)
smokers and 4(0.1%) nonsmokers claimed to
spend less time at work before the official start
to the day and 70 (16.7%) smokers and 8
(0.3%) non-smokers stayed late less often than
before the ban. When data on respondents who
used to smoke during the day but subsequent to
the ban claimed to be nonsmokers were
excluded the level of reported change in the
amount of time spent in the main work area rose
further (data not extracted).
Desire to quit
Of the 358 respondents (84.0%) who still
smoked during the day 43 (12.0%) expressed
an interest in changing smoking behaviour
through the uptake of support from the
University or elsewhere.
Perception of rule breaking
445 (15.2%) of non-smokers felt that the ban
was only partially working or not working at all in
personal offices. Of the non-smokers 724
(24.8%) claimed the ban was not wholly
effective in corridors and foyers.
Attitudes to smoking
3125/3947 (89.4%) agreed it was important for
the University to have a policy on smoking.
223/405 (55.1%) of those who had smoked
during the day prior to the ban, 135/178 (75.8%)
of those smoking outside the working day prior
to the ban and 2720/2862 (95.0%) of nonsmokers were in favour of a policy (chi-squared
= 664.4, df=4, p<0.001). 1919/3516 (54.6%) felt
that a University smoking policy should allow for
257
Details
Method
Results
Comments
Smoking restrictions in cars, homes, workplaces and enclosed public places
taken by the University Court without
prior consultation with staff or students.
Two years' warning was given during
which time the University devised a
programme of publicity, education and
the provision of support for smokers. No
smoking classes were held during work
hours and run by a smoking consultant
commissioned by the University.
Length of study
March and April 1998
Outcomes
Relocation of smoking (Survey)
Quality of air (Survey)
Change in working patterns (Survey)
Desire to quit (Survey)
Perception of rule breaking (Survey)
Attitudes to smoking (Survey)
designated smoking areas within University
buildings. There were significant differences in
opinion according to smoking status
Qualitative: The high visibility of smokers
following the ban raised awareness about the
problems faced by smokers among nonsmoking staff members. Smoking bans can be
divisive in pitching non-smoker against smoker
at work.‟
SES
OCCUPATION
426 of 612 (69.6%) respondents who smoked
did so during the day before the ban. At six
months 170 smoked less, 21 smoked more, 36
had quit and for 167 there had been no change,
32 had missing data. Across the staff groups
(smoke less, smoke more, quit, no change) the
proportions were as follows: Academic and
related 39 (36.8%), 3 (2.8%), 17 (16.0%), 47
(44.3%); Clerical / secretarial 30(42.2%), 1
(1.4%), 6 (8.4%), 34 (47.9%); Technical 25
(51.0%), 2 (4.1%), 6 (12.2%), 16 (32.7%);
Manual 76 (45.2%), 15 (8.9%), 7 (4.2%), 70
(41.7%). Significant differences were found in
quit rates between academic and related staff
and manual staff (16.0% vs. 4.2%) and in
increase in smoking between academic and
related and manual staff (2.8% vs. 8.9%). The
largest response categories for academic and
related and clerical / secretarial staff was 'no
change' and for technical and manual staff was
'smoke less' (p values not reported).
Author’s conclusion of SES impact
The University smoking policy did not impact
equally upon all members of the organisation
and was experienced as divisive contributing
towards and sustaining social inequalities
among staff.
258
Details
Method
Results
Comments
Smoking restrictions in cars, homes, workplaces and enclosed public places
Method
Results
Details
Comments
Smoking restrictions in cars, homes, workplaces and enclosed public places
Author, year
Patel 2011
Country
Wellington, New Zealand
Design
single-observer data collection
Objective
to (a) refine and use methods to measure
the point prevalence of smoking and of
secondhand smoke exposure in moving
vehicles and (b) compare these
prevalence’s (1) between two areas of
contrasting socioeconomic status and (2)
over time
SES variables
The two observation sites represented
high and low areas of socioeconomic
deprivation (small area deprivation
index).
Analyses
Monte Carlo simulations
Data sources
observational
Participant selection
Site selection criteria included high traffic
flows, low traffic speeds and good
visibility of vehicle occupants (at both
sites, observers were approximately only
1-2 meters distance from the passing
vehicles). The average flow was 935
vehicles per hour over the observation
periods.
Participant characteristics
149 886 vehicles, Wainuiomata NZDep
deciles 7-9 (high SED) and Karori deciles
1-4 (low SED)
Intervention
Solo observers on the roadside observed
vehicles at two sites in the Wellington
region over 15 km apart by road.
Observations at both sites were made
during high traffic periods (7:30-9:30 and
16:00-18:00) on 20 weekdays during
February to April 2011 that were not in
school holidays. Two consecutive pairs of
observers were used, one for 9 days and
one for 11 days. Observers held a
mechanical counter in one hand to count
the total number of vehicles that fitted the
sample frame (regardless of whether
smoking was observed or not). For each
vehicle with observed smoking, the
observer recorded on a pre-formatted
data sheet: the presence of smoking, the
presence of other adults than the smoker
and the presence of children. Observers
General population
A total of 149 886 vehicles were observed in 20
days. The mean point prevalence of smoking in
vehicles at both sites combined was 3.2% (95%
CI 3.1% to 3.3%). Of those vehicles with
smoking, 4.1% had children present.
SES
Smoking point prevalence in vehicles was 3.9
times higher in the area of high deprivation than
in the area of low deprivation (95% CI 3.6 to
4.2). The same pattern was seen for vehicles
with only the driver at 3.6 times (95% CI 3.4 to
4.0), in vehicles with other adults at 4.0 times
(95% CI 3.4 to 4.7) and in vehicles with children
at 10.9 times (95% CI 6.8 to 21.3), with all
results adjusted for vehicle occupancy.
Compared with data collected in the 2005 study
at the same two observation sites, there was an
absolute reduction in the point prevalence of
smoking in vehicles of 1.1 percentage points
(RR relative to the former 1.3, 95% CI 1.2 to
1.5). The relative reduction over time in the area
of low deprivation was 1.2 times greater than in
the area of high deprivation (95% CI 1.0 to 1.6).
There was an absolute reduction in the point
prevalence of smoking in the presence of others
in vehicles between 2005 and 2011 of 0.2
percentage points (RR relative to the former 1.3,
95% CI 1.1 to 1.6). The relative reduction over
time of smoking in the presence of others in the
low-deprivation area was 1.3 times greater than
that for the high-deprivation area (95% CI 0.8 to
2.1).
Author’s conclusion of SES impact
Adults and children from high deprivation areas
Internal validity
Inter-observer variation between
observer pairs was assessed (k
values were (1) 0.99 for any
smoking, (2) 0.87 for other adults
in vehicles with smoking and (3)
0.80 for children in vehicles with
smoking).
Occupants appearing to be aged
12 years or younger were
classified as children; otherwise
they were recorded as adults. This
is a subjective judgement made by
the observers.
External validity
Compares results with similar
study with smaller sample size
(16055) conducted in 2005 but the
2005 study is not referenced.
Results may not be fully
representative of smoking in
vehicles in the Wellington region
(or for elsewhere in New Zealand).
Validity of author’s conclusion
As
author
states
–
point
prevalence may underestimate
true population prevalence of
smoking in vehicle trips.
Government-funded
smoke-free
vehicles media campaign during
2006 to 2008 and all workplace
vehicles accessible by the public
have been required to be smokefree since 1990.
259
Details
Method
Results
Comments
Smoking restrictions in cars, homes, workplaces and enclosed public places
swapped observation points every 2
days.
Length of study
February to April 2011
Outcomes
observed point prevalence of smoking in
vehicles
are much more likely to be exposed to
secondhand smoke.
260
Details
Method
Results
Comments
Smoking restrictions in cars, homes, workplaces and enclosed public places
Author, year
Plescia 2005
Country
North Carolina, USA
Design
Repeat cross-sectional
Objective
To examine trends in official workplace
smoking policies for indoor working
environments in North Carolina
SES variables
Occupational status
Analyses
Trends in the state are compared with
trends nationally and among select
surrounding states.
Data sources
40-item Tobacco Use Supplement to the
Census Bureau’s Current Population
Survey. The Supplement was conducted
over four time periods, 1992-1993, 19951996, 1998-1999, 2001-2002.
Participant selection
Monthly CPS sample consists of
approximately 56,000 eligible housing
units in 792 sampling areas.
Participant characteristics
10,773 15 years of age or older and (1)
employed either full- or part-time at the
time of interview, (2) employed outside
the home but not self-employed, (3) not
working outdoors or in a motor vehicle,
(4) not traveling to different buildings or
sites, and (5) not working in someone
else’s home.
Intervention
Smokefree workplace policies
Length of study
10 years, 1992 to 2002
Outcomes
Smokefree workplace coverage
General population
North Carolina ranks 35th in the proportion of its
workforce reporting a smoke-free place of
employment. The proportion of workers
reporting such a policy doubled between 1992
and 2002. Less than a third of the state’s
workforce was smoke-free in 1992-1993, but by
2001-2002, slightly more than two thirds were
reporting this level of protection.
SES
Blue-collar (55.6%, CI +/-5.5) and service
workers (61.2%, CI +/-8.4), especially males,
were less likely to report a smoke-free worksite
than white-collar workers (73.4%, CI +/-2.6).
Author’s conclusion of SES impact
While some progress has been made in North
Carolina to protect workers from secondhand
smoke, significant disparities exist.
Internal validity
Response rates to the NCI
Tobacco Use Supplement are
between 85-89%. Multivariate
analyses would have provided
evidence of any independent
variables
associated
with
workplace smoking policy. Study
does not account for smoking
status of workers which may have
confounded results.
External validity
Trends in the state are compared
with trends nationally and among
select surrounding states.
Validity of author’s conclusion
opportunities to protect North
Carolina workers from the health
effects of SHS are limited by a preemptive state law specific to North
Carolina
261
Details
Method
Results
Comments
Smoking restrictions in cars, homes, workplaces and enclosed public places
Author, year
Razavi 1997
Country
Belgium
Design
Repeat cross-sectional
Objective
To assess changes in attitudes and in
policies towards smoking in Belgian
companies between October 1990 and
June 1993, in order to evaluate the
impact due to the media inputs and to the
promulgation of this decree.
SES variables
Occupation; blue and white collar
Analyses
Changes in the companies’ attitudes
between 1990 and 1993 were analysed
using the McNemar test for paired data
Data sources
Trends Top 20,000, a dataset containing
information about the economic and
financial situation of the most important
Belgian companies.
Mailed questionnaire to 3543 Belgian
companies
Participant selection
Out of the 20,000, 3543 companies were
randomly selected using stratified
method.
In 1990, 773 companies (22%) and in
1993, 890 companies (25%) responded
to the questionnaire. A total of 325 (9%)
companies responded to the 1990 and
1993 questionnaires.
Participant characteristics
Questionnaire received by personnel
manager
and
general
manager
Intervention
In March 1993 the Belgian Public Health
Department published a Royal Decree to
structure and regulate smoking habits in
the workplace, in order to reduce the
health risks due to passive smoking.
Length of study
3 years, October 1990 and June 1993
Outcomes
designation of smoke free areas (SFA);
willingness to offer a worksite information
program (WIP); willingness to offer a
worksite smoking cessation program
(WSCP); willingness to subsidize a
WSCP; willingness to offer a WSCP
during working hours; willingness to offer
a meeting room for a WSCP and actual
General population
Comparison of the 1990 and 1993 dataset
regarding the influence of the antismoking
campaigns on smoking policy, shows that
despite the media attention and the
promulgation of the Royal Decree by the Public
Health Department, no major changes are
observed. Apparently only restriction of smoking
in the cafeteria (p = 0.0001) and in meeting
room (p = 0.02) have been implemented.
Moreover the organization of WSCP has been
more frequently reported.
The relation between companies’ turnover and
the willingness to offer a WSCP which was not
observed in 1990 became significant in 1993.
Companies with a very high turnover reported
more willing to offer a WSCP in 1993 (67% in
1993 versus 54% in 1990).
SES
1990: A significant relation is observed between
the blue/white collar worker ratio and its impact
on company’s smoking policy. Companies
employing mostly white collar workers
compared with companies employing mostly
blue collar workers reported being more able to
offer time (p = 0.001), meeting rooms (p =
0.001) and to subsidize a WSCP (p = 0.001).
Companies employing mostly blue collar
workers have a stricter non-smoking policy (p =
0.003). Companies employing mostly white
collar workers are willing more often to offer a
WSCP (p = 0.02).
1993: A significantly higher percentage of
companies with a high number of white collar
compared with companies with a high number of
blue collar workers are reported more able to
offer time (p = 0.00001), meeting rooms (p =
0.001), having already organized a WSCP (p =
Internal validity
The response rate to the
questionnaire in 1990 and 1993 is
related to the companies’ turnover
(12% in low to 30% in high
turnover) and to the blue/white
collar ratio (13% in high ratio to
26% in low ratio).
External validity
Evaluated impact of new law only
3 months post implementation –
may not be sufficient time to
assess impact.
Validity of author’s conclusion
Differential response rates may
invalidate conclusions?
262
Details
Method
Results
Comments
Smoking restrictions in cars, homes, workplaces and enclosed public places
organization of a WSCP.
0.00001), to subsidize a WSCP (p = 0.00001)
and to offer a WSCP (p = 0.0002). A lower
percentage of companies with a high number of
blue collar compared with companies with a
high number of white collar workers tend to offer
a WIP (p = 0.02).
Comparison between 1990 and 1993:
The difference regarding a more strict smoking
policy between companies employing mostly
blue collar (12% total non smoking policy) and
companies employing mostly white collar (2%
total non smoking policy) which was significant
in 1990 has disappeared in 1993 (7% in a
‘mostly blue collar’ company versus 4% in a
‘mostly white collar’ company (Table 2). In 1993
companies with mostly white collar employees
reported being more likely to have already
organized a WSCP compared with 1990.
Author’s conclusion of SES impact
Small companies and companies with a high
blue/white collar ratio were less able to
implement health policy recommendations.
There was a tendency towards a recommended
smoking policy in companies with a low
blue/white collar ratio.
263
Details
Method
Results
Comments
Smoking restrictions in cars, homes, workplaces and enclosed public places
Author, year
Ritchie 2010a
Ritchie 2010b
Country
4 localities in Scotland
Design
qualitative longitudinal case studies using
semi-structured
interviews
in
2
socioeconomically advantaged and 2
disadvantaged localities at three time
points, one pre-legislation and two post
legislation.
Objective
to explore whether and in what ways the
smoke-free legislation affected smokers’
experience of stigma
SES variables
range of indices, including SES and
smoking rates among adults and during
pregnancy
Analyses
thematic analysis of narrative accounts
Data sources
Interviews in four contrasting locales
between October 2005 and March 2007,
and observational data recorded in public
places.
Participant selection
Four areas selected to provide both
urban and rural, affluent and deprived
communities.Purposively sampled panel
recruited within the localities by trained
interviewers using a variety of methods
including door knocking, opportunistic
street recruitment, and visiting community
venues. Predefined quotas were used,
based on three primary criteria (smoking
status, age, and gender) and three
secondary criteria (children younger than
12 years in the household, use of
licensed premises, and employment
outside the home).
Participant characteristics
20 male and 20 female current and
recent ex-smokers (quit in the previous
12 months) aged 18 years and older.
Urban Disadv (D1) Mostly social grade E,
Adult smoking rate 50.7%
Suburban Adv (A1) 48.1% A-B, 18.8%
Semi-rural Disadv (D2) 23% E, 38%
Semi-rural Adv (A2) 30.5% AB, 21%
Intervention
National
smokefree
legislation
in
Scotland. Smoking was banned in
enclosed public places, including pubs
and restaurants in Scotland in March
2006.
The interviews used topic guides that
General population
Pre-legislation there are more outdoor facilities
for smokers and a lower rate of smoking in
pubs, some already smokefree. Disadvantaged
communities less supportive of the ban, some
hoped that it would help them quit.
Smokers perceived the smoke-free legislation to
have increased the stigmatization of smoking.
By separating, albeit temporarily, those who
were smoking from those who were not had led
to increased felt stigma. This had led to a social
milieu that fostered self-labeling and selfstigmatization by smokers of their own smoking
behaviour, even when they were not smoking.
While there was little reported direct
discrimination, there was a loss of social status
in public places. Smokers attempted to
ameliorate stigmatization by not smoking
outside, reducing going out socially, joining in
the stigmatization of other smokers, and/or
acknowledging the benefits of smokefree
environments.
SES
Smokers in disadvantaged areas say they abide
by the law to support the licensee, and rush
cigarettes because they’re worried about their
drink. Also may visit public places less because
of the ban.
Smokers in advantaged areas say that they
smoke less, or quicker, because going outside
interrupts social activity, and because of
concerns over the stigma of being seen
smoking.
While some described how they were able to recreate convivial social groups in the new
smoking places, for example, where there was
comfortable and sheltered provision, others
Internal validity
88% follow-up rate
External validity
Recruited interviewees to fill quota,
unlikely to be representative of the
community as a whole.
No indication of whether the
localities are typical of each
urbanisation/affluence category.
Validity of author’s conclusion
Appears to have been a more
substantial change in deprived
areas, because the advantaged
areas already had reasonably
comfortable accommodation for
smokers outside, and opinion
changed from being opposed to
the ban to accepting it and
following it.
264
explored participants’ smoking behaviour
and/or exposure within the context of
their daily lives; their beliefs and
understandings of second hand smoke;
regulation of smoking within the home;
awareness,
understandings,
and
attitudes toward the legislation; and any
changes in smoking patterns and
consumption. Participants described their
smoking behaviour in a typical 24-hr
period using an adapted version of the
“life grid,” which annotated the number of
cigarettes smoked over the course of a
day in terms of when, where, and in what
social context smoking occurred. All
interviews
were
recorded
and
transcribed. Participants received £15 for
each interview.
Length of study
Maximum 15 months
Outcomes
Changes in smoking behaviour and
changes in physical spaces
particularly in disadvantaged communities
described limited or no outside provision for
smokers. Thus, the sense of separation was
compounded by a loss of comfort, particularly in
poor weather with an implicit and real loss of
status compared with their prelegislation
position.
Author’s conclusion of SES impact
Behavioural changes in localities were shaped
by environmental constraints as well as the
social context.
There are unintended negative consequences of
smokefree legislation for some which suggest
that tobacco control strategies need to consider
how smokers who experience increased stigma
are supported by public health to address their
smoking while continuing to create smoke-free
environments.
265
Details
Method
Smoking restrictions in cars, homes, workplaces and enclosed public places
Result
Comments
Author, year
Schaap, 2008
Country
18 European countries; Finland, Sweden,
Denmark, England, Ireland, Netherlands,
Belgium, Germany, France, Italy, Spain,
Portugal, Slovakia, Hungary, Czech Rep.,
Lithuania, Latvia, Estonia
Design
Cross-sectional
Objective
To examine the extent to which tobacco
control policies are correlated with
smoking cessation, especially among
lower education groups
SES variables
Education; relative index of inequality
(RII). The RII assesses the association
between quit ratios and the relative
position of each educational group, can
be interpreted as the risk of being a
former smoker at the very top of the
educational hierarchy compared to the
very lowest end of the educational
hierarchy
Analyses
Log-linear regression analyses to explore
the correlation between national quit
ratios and the national score on the
Tobacco Control Scale (TCS).
General population
Large variations in quit rate and RII
between countries.
Quit rates positively associated with
tobacco control scale score. Policies
related to cigarette price showed the
strongest association with quit ratios. A
comprehensive advertising ban showed
the next strongest associations with quit
ratios in most subgroups. Health
warnings negatively associated with quit
rates.
Regression coefficient 2.08 (-0.36 to
8.48) for men and 2.07 (-1.09 to 8.66) for
women for price.
Regression coefficient 1.33 (1.11 to 8.02)
for men and 1.59 (1.39 to 8.67) for
women for advertising bans.
Regression coefficient 0.94 (-2.43 to
5.89) for men and 0.41 (-3.84 to 5.26) for
women for public place bans.
Regression coefficient 0.54 (-3.05 to
6.17) for men and 0.54 (-3.52 to 6.41) for
women for campaign spending.
Regression coefficient -0.40 (-7.32 to
2.31) for men and -0.42 (-9.51 to 3.43) for
women for health warnings.
A ‘stripped’ analysis focusing on price,
health warnings and treatment (excluding
recent policy developments) supported
the main findings.
SES
Quit rates positively associated with
tobacco control scale score. More
educated smokers more likely to have
quit than lower educated, for men and
women. Larger absolute difference
between high and low educated for 25-39
year olds. However no consistent
Internal validity
Non-response percentages ranged from
about 15% in Italy and Spain up to 49%
in Slovakia, while percentages in most
other countries were between 20% and
35%.
Survey conducted before tobacco control
scale devised, and before some policies
enacted so may underestimate the
impact of recent policies.
Difficult to draw conclusions about
causality as study only examines the
association between ex-smokers and
presence of policies, rather than changes
in prevalence post-implementation.
Occasional smokers excluded from all
analyses.
External validity
Included data from Eastern Europe and
Baltic countries. Limited analyses to the
adult population aged 25–59 years.
Difficulty in drawing conclusions from
multiple nations with varying average
standards of education, definition of
‘highly educated’ likely to vary for some
nations.
Validity of author’s conclusion
Conclusion is consistent with the data
presented; however it’s difficult to draw
strong conclusions about the impact of
any
one
intervention
given
the
methodological limitations discussed
above.
Data sources
National
health
surveys.
100,893
respondents over 18 countries.
Participant selection
Selection process varies. Non-response
rate between 13.4 and 49% depending
on country.
Participant characteristics
Ireland has most developed tobacco
control policy, Latvia least.
Intervention
Joosens and Raw’s tobacco control scale
used as a proxy, with some analysis by
individual policies including:
Price, advertising bans, public place
bans, campaign spending, health
warnings
Length of study
Year 2000, except Germany and Portugal
= year 1998-9.
Outcomes
Quit ratios
266
differences were found between quit
ratios in high and low educated groups
and tobacco control scale score.
Policies related to cigarette price showed
the strongest association with quit ratios.
Significant positive association between
quit ratio and price for high SES aged 4059 years.
A
comprehensive
advertising
ban
showed the next strongest associations
with quit ratios in most subgroups (not
low SES aged 40-59 or low SES women
aged 25-39 years.
Health warnings negatively associated
with quit rates.
Author’s conclusion of SES impact
High and low educated groups seem to
benefit equally from nationwide tobacco
control policies. More developed tobacco
control policies are associated with
higher quit rates.
267
Details
Method
Results
Comments
Smoking restrictions in cars, homes, workplaces and enclosed public places
Author, year
Semple 2010
Country
Scotland, England, Wales
Design
Before and after study
Objective
To evaluate the effect of smokefree
legislation on air pollution levels in bars
SES variables
Postcode data of bar location – area level
deprivation scores
Analyses
Regression
analysis
of
PM2.5
concentrations measured discreetly for at
least 30 minutes in >300 bars
Data sources
Random selection of bars using a
database of bars generated from online
business directories from selected
regions and urban areas in each country.
Participant selection
n/a
Participant characteristics
n/a
Intervention
Discreet sampling of air quality in bars by
researchers and also 26 personal
exposure shift samples for non-smoking
bar workers from Scotland and England
recruited to wear TSI SidePak AM510
Personal Aerosol Monitors
Length of study
Up to 12 months post implementation
Outcomes
particulate matter <2.5 mm in diameter
(PM2.5)
General population
PM2.5 levels prior to smoke-free legislation
were highest in Scotland (median 197
µg m-3), followed by Wales (median 184 µg m-3)
and England (median 92 µg m-3). All three
countries experienced a substantial reduction in
PM2.5 concentrations following the introduction
of the legislation with the median reduction
ranging from 84 to 93%. Personal exposure
reductions were also within this range.
SES
Bars located in more deprived postcodes had
higher PM2.5 levels prior to the legislation.
Linear trend in the change in PM2.5 by
deprivation category, which suggests more
deprived areas experienced greater percentage
reduction in PM2.5 levels up to 12 months postimplementation when compared to more affluent
areas, although higher levels of PM2.5 at
baseline for more deprived areas.
Author’s conclusion of SES impact
Legislation in all three countries produced
improvements in indoor air quality.
Internal validity
Variation in number, location and
timing of visits to bars across the
three projects.
External validity
common protocol for air sampling
across studies and large data set.
Validity of author’s conclusion
The amount of variability in the
percentage reduction in PM2.5
concentrations that was explained
by deprivation category was low
this could either be due to the SES
measure used or SES had no
significant influence on legislative
changes.
268
Details
Method
Results
Comments
Smoking restrictions in cars, homes, workplaces and enclosed public places
Author, year
Shavers 2006
Country
USA
Design
Repeat cross-sectional
Objective
To examine the association between
workplace smoking policies and home
smoking restrictions with current smoking
among women
SES variables
Poverty level: at or below the poverty
line, 100-124% of the poverty level,
125-149% of the poverty level, 150%
or more above the poverty level.
Analyses
Multivariate logistic regression
Data sources
Tobacco Use Supplement to the Current
Population Survey supplements
Participant selection
Response rate approx. 80%, multistage
probability sampling design. Employed
women aged 18-64, based on nationally
representative survey data. Proxy
respondents and respondents missing
smoking-related survey data excluded.
Participant characteristics
N=82966, Majority white, education and
income vary significantly by ethnicity.
African
Americans,
American
Indians/Alaskans, and Hispanics all
significantly more likely to live in poverty
(16.8-19.6%), 7.1% overall. White
females most likely to be smokers
(22.7%).
Intervention
Workplace and home smoking policies
Length of study
1998-9 and 2000-1
Outcomes
Policy coverage/restrictions,
Quit attempts
Workplace:
Not permitted in any area, permitted in
common areas only, permitted in work
area only, permitted in all areas, no
policy, other.
Home:
Not
permitted
anywhere,
permitted
in
some
places/times,
permitted anywhere at any time.
General population
Almost 66% prohibit smoking anywhere in the
home.
11.1% report no workplace smoking policy.
Current smoking and heavy smoking (20+
cigarettes per day) significantly associated with
permitting smoking anywhere in the home for all
poverty levels.
Lower adjusted odds ratio for quit attempts
among those who permit smoking anywhere in
the home for all poverty level categories except
for women who were 125%–149% of the
poverty level. In contrast, workplace smoking
policies were not associated with a quit attempt
in the past year for any of the poverty level
categories.
SES
Workplace policies are associated with distance
from the poverty level, 61.5% below the poverty
level are covered by full workplace restrictions,
compared to 76.6% of those 150%+ above the
poverty level. 19.1% of those below the poverty
level have no workplace smoking policy,
compared to just 10% of the 150%+ group.
Home smoking policies show the same trend:
56.3% of people below the poverty line don’t
permit smoking anywhere, and 21.3% allow
smoking anywhere; compared to 67.3% and
14.8% of the most advantaged group.
Author’s conclusion of SES impact
Variance in exposure to ETS among employed
women; those further from the poverty line more
likely to be covered by restrictions on smoking in
the workplace and home. Home smoking
policies were more consistently associated with
a lower prevalence of current smoking
irrespective of poverty status or race/ethnicity
Internal validity
Cross-sectional data, unable to
infer any causal relationship.
External validity
Working women only.
Validity of author’s conclusion
Valid
269
Details
Method
Results
Comments
Smoking restrictions in cars, homes, workplaces and enclosed public places
than workplace policies.
270
Details
Method
Results
Comments
Smoking restrictions in cars, homes, workplaces and enclosed public places
Author, year
Shopland 2004
Country
USA
Design
Repeat cross-sectional
Objective
To examine recent trends in smoke-free
workplace policies among the major
occupational groups in the United States
with a particular focus on the 6.6 million
workers employed in the food preparation
and service occupations.
SES variables
Occupational class; white collar, blue
collar, service workers.
Analyses
Standard errors, which were used in
computing the 95% confidence intervals
(CI), were produced using the CPS
design effect adjustments developed by
the Bureau of the Census.
Data sources
Census Bureau’s Current Population
Survey Tobacco Use Supplement
September 1992, January 1993, and May
1993 and repeated the same months in
1995–1996 and 1998–1999.
Participant selection
The monthly CPS sample consists of
approximately 56,000 eligible housing
units in 792 sampling areas. Response
rates to the CPS labor force core
questionnaire are approximately 95% and
84% to 89% for the NCI Supplements.
Participant characteristics
254,059 indoor workers employed in 38
major occupations. Individuals must have
been 18 years of age or older and 1)
employed either full- or part-time at the
time of the interview, 2) employed outside
the home but not self-employed, 3) not
working outdoors or in a motor vehicle, 4)
not traveling to different buildings or sites,
and 5) not working in someone else’s
home.
Intervention
smoke-free workplace policies
Length of study
6 years; 1993 to 1999
Outcomes
Policy coverage
Prevalence
General population
Among all workers, the proportion reporting a
smoke-free policy increased 37% between 1993
and 1996 but less than 9% from 1996 to 1999,
suggesting a significant slowing in the adoption
rate of such policies. This trend was evident for
each of the 3 major occupational groups.
SES
Blue collar and service workers showed the
largest percentage gains in smoke-free policy
coverage between 1993 and 1999 but continued
to lag significantly behind their white collar
counterparts with barely a majority reporting a
smoke-free workplace policy in 1999 compared
with more than three fourths of white collar
workers.
Trends in Smoke-Free Workplace Policy
Coverage Among Indoor U.S. Workers, by Type
of Worker and
Percent Increase in Coverage Between 1993
and 1999:
All U.S. workers 46.5 (+/-0.4) 1993; 63.7 (+/0.5) 1996; 69.3 (+/-0.4) 1999; 49% increase
White collar workers 54.1 (+/-0.5) 1993; 71.7
(+/-0.5) 1996; 76.3 (+/-0.4) 1999; 41% increase
Blue collar workers 28.3 (+/-1.0) 1993; 45.4 (+/1.1) 1996; 52.2 (+/-1.0) 1999; 84% increase
Service workers 35.5 (+/-1.1) 1993; 51.5 (+/-1.2)
1996; 57.5 (+/-1.2) 1999; 62% increase
Internal validity
Few details of analysis of data.
External validity
Large nationally representative
dataset.
Validity of author’s conclusion
Valid but doesn’t take into account
smoking status of participants?
Food service workers reported
smoking prevalence rates that are
almost double those of white collar
workers and these rates did not
change over the 6-year time period,
1993 to 1999. In contrast, smoking
prevalence declined by 8.2% among
white collar workers and by nearly
271
Details
Method
Results
Comments
Smoking restrictions in cars, homes, workplaces and enclosed public places
10% among all workers
Trends in Smoking prevalence among various
occupational groups of indoor workers and
Percent change in prevalence Between 1993
and 1999:
Non-food service White collar workers 20.5 (+/0.4) 1993; 19.5 (+/-0.4) 1996; 18.8 (+/-0.4)
1999; -8.2%
Non-food service Blue collar workers 34.7 (+/1.0) 1993; 32.7 (+/-0.8) 1996; 31.5 (+/-0.9)
1999; -9.2%
Non-food service Service workers 32.9 (+/-1.2)
1993; 32.0 (+/-1.1) 1996; 30.4 (+/-1.0) 1999; 7.5%
Author’s conclusion of SES impact
Protection for workers is increasing, but those in
food preparation and service occupations are
significantly less protected than others.
272
Details
Method
Results
Comments
Smoking restrictions in cars, homes, workplaces and enclosed public places
Author, year
Sims 2012
Country
England
Design
Repeat cross-sectional
Objective
To examine trends in and predictors of
SHS exposure among non-smoking
adults to determine whether exposure
changed after the introduction of
smokefree legislation and whether these
changes varied by SES and by
household smoking status.
SES variables
Social class households
Analyses
Multivariate regression
Data sources
salivary cotinine data from the Health
Survey for England that were collected
in 7 of 11 annual surveys;
Participant selection
Data collection involves an interviewer
visit, in which all adults ≥ 16 years of age
and up to two children in each household
are eligible to be interviewed, followed by
a nurse visit.
Participant characteristics
Non-smoking adults
Intervention
1 July 2007, smokefree legislation was
implemented in England, which made
virtually all enclosed public places and
workplaces smokefree.
Length of study
11 years; 1998 to 2008
Outcomes
SHS exposure
General population
Secondhand smoke exposure was higher
among those exposed at home and among
lower-SES groups. Exposure declined markedly
from 1998 to 2008 (the proportion of participants
with undetectable cotinine was 2.9 times higher
in the last 6 months of 2008 compared with the
first 6 months of 1998 and geometric mean
cotinine declined by 80%). We observed a
significant fall in exposure after legislation was
introduced—the odds of having undetectable
cotinine were 1.5 times higher [95% confidence
interval (CI): 1.3, 1.8] and geometric mean
cotinine fell by 27% (95% CI:17%, 36%) after
adjusting for the prelegislative trend and
potential confounders.
SES
Determinants of secondhand smoke exposure
the odds of having undetectable cotinine
decreased with declining SES status with the
lowest levels in social class IV and V [29% lower
than social class I and II, 95% confidence
interval (CI): 21, 35] and in adults with no
qualifications (19% lower than those with a
higher education qualification, 95% CI: 11, 26).
Variation in the estimated impact of the
smokefree legislation by social class
Significant impacts were observed only among
those from social classes I to III. The odds of
having undetectable cotinine were 1.8 (95%
CI:1.4, 2.3) times higher among those in social
classes I and II and 1.5 (95% CI: 1.1, 1.9) times
higher among those in social classes III after the
legislation, whereas geometric mean cotinine
levels fell by 37% (95% CI: 24%, 48%) and 23%
(95% CI: 6%, 37%) respectively. By contrast, no
significant impact was seen in social classes IV
Internal validity
Impact
adjusted
for
the
prelegislative downward trend in
exposure observed between 1998
and 2008 however no cotinine
data from 2004 to 2006.
External validity
Survey includes only individuals
living in private households in
England.
lower levels of prelegislative
exposure compared with Scotland
Validity of author’s conclusion
Valid – large representative
sample
using
biomarker
to
validate.
273
and V when measured using either the OR of
undetectable cotinine [0.38 (95% CI: 0.12, 1.2)
and 1.00 (95% CI: 0.64,1.6) respectively], or
multiplicative change in geometric cotinine [1.5
(95% CI: 0.89, 2.5) and 1.0 (95% CI: 0.7, 1.4)
respectively].
Author’s conclusion of SES impact
Non-smokers from lower social classes appear
not to have benefitted significantly from the
legislation.
274
Details
Method
Results
Comments
Smoking restrictions in cars, homes, workplaces and enclosed public places
Author, year
Skeer 2004
Country
Massachusetts, USA
Design
Cross-sectional
Objective
To identify and quantify differences in
sociodemographic
characteristics
of
communities relative to the strength of
local restaurant smoking regulations
SES variables
Town-level SES
Analyses
Multinomial logistic regression
Data sources
Database
of
restaurant
smoking
regulations by town maintained by
Massachusetts Tobacco Control Progam
(MTCP)
Participant selection
n/a
Participant characteristics
351 local restaurant smoking regulations
in Massachusetts
Intervention
3 measures of strength of ordinances:
strong=smokefree,
medium=separate
ventilated
areas
for
smoking,
weak=designated smoking areas or no
restrictions
Length of study
One time-point; June 2002
Outcomes
Town-level policy coverage
General population
Towns with board of health funding by the
MTCP were nearly 5 times more likely to adopt
strong regulations and more than 11 times more
likely to adopt medium regulations.
SES
Bivariate: local smokefree restaurant regulations
were significantly more likely to be adopted by
towns with a higher proportion of college
graduates, a higher per capita income. Strength
of regulation was not significantly related to
household income or poverty level.
Multivariate: education and per capita income
became insignificant (authors state may be
explained by other significant measure which
was agreeing with the 1992 ballot to create the
MTCP which was highly correlated with both
education (r=0.90) and per capita income
(r=0.74).
Author’s conclusion of SES impact
Education and income were significantly related
to the strength of protection from ETS exposure
in restaurants. Current policy of smokefree
enactment is fostering disparities in health
protection.
Internal validity
education and per capita income
became insignificant in multivariate
analysis
External validity
‘Free standing bars’ not included
as
defined
as
separate
establishments by the regulations.
Town-level SES may not translate
to individual-level SES.
Validity of author’s conclusion
Study addresses a theoretical level
of protection from SHS exposure
provided by regulations rather than
actual level of protection but
presence of regulation should
correlate with reduced exposure.
275
Details
Method
Results
Comments
Smoking restrictions in cars, homes, workplaces and enclosed public places
Author, year
Stamatakis 2002
Country
USA
Design
Cross-sectional
Objective
To assess differences in the likelihood of
exposure to ETS at home and at work
among an ethnically diverse sample of
women age 40 and older in the United
States.
SES variables
education
Analyses
unadjusted OR and adjusted (aOR) for
exposure to ETS at home and at work,
where each risk factor was adjusted for
all sociodemographic variables (race,
age, education, location, and having
children in the home) using logistic
regression.
Data sources
U.S. Women’s Determinants Study
Participant selection
Phone numbers were selected from zip
codes with more than 20% of one of the
following groups: African American,
American Indian/Alaska Native, Asian
American/Pacific Islander, and Hispanic.
Only women of these racial/ethnic
backgrounds who lived in selected zip
codes and met the criterion of being 40
years
or
older
were
surveyed.
Proportional-to size sampling was
conducted to ensure that the sample had
a proportionality similar to that of the total
population.
White women of the same age group
were surveyed using standard BRFSS
random-digit dialing techniques.
Participant characteristics
non-smoking (defined as former and
never smokers) women (n=2326). The
analysis of ETS exposure and smoking
restrictions at work was further restricted
to include only employed women,
resulting in a sample size of 1100.
The proportion of women in the lowest
education group, having achieved only an
eighth grade or less education, was
13.2%, and nearly 40% of the
respondents had an annual income of
$20,000 or less. A majority of the
respondents were married (58.7%), lived
in nonrural areas (60.6%), and had no
children living in the home (66.6%).
Intervention
Workplace smoking policy
General population
Among employed women, 19.2% were exposed
to ETS at work, and 22% were employed at
worksites that allowed smoking in some or all
work areas.
Exposure to ETS at work substantially higher for
women who worked where smoking was
allowed in some (adjusted OR 15.1, 95% CI
10.2, 22.4) or all (adjusted OR 44.8, 95% CI
19.6, 102.4) work areas.
SES
Exposure to ETS at work was higher among
women with some high school education
(adjusted OR 2.8, 95% CI 1.5, 5.3) and high
school graduates (adjusted OR 3.1, 95% CI 1.9,
5.1) and marginally so for those with some
college (aOR 1.5, 95% CI 0.9, 2.5).
An eighth grade or less education level was
associated with about twice the risk of home
ETS exposure (aOR 2.1, 95% CI 1.3, 3.6), as
was having a high school education (aOR 2.2,
95% CI 1.4, 3.3) compared with college
graduates.
Author’s conclusion of SES impact
Among individual risk factors, lower education
level was most strongly related to ETS exposure
at work.
Internal validity
Asian/Pacific Islanders were not
included in the final sample
because of a prohibitively low
response rate in this group.
Income was excluded from the
final model due to the high
proportion of missing cases
(16.7%) and its collinearity with
educational level.
results of the test-retest study
indicated that overall reliability was
very good for exposure to ETS at
work (kappa = 0.82)
External validity
Excluded women without a
telephone at home – these women
could have been more exposed to
ETS
Validity of author’s conclusion
276
Details
Method
Results
Comments
Smoking restrictions in cars, homes, workplaces and enclosed public places
Length of study
1996 to 1997
Outcomes
exposure to ETS
277
Details
Method
Results
Comments
Smoking restrictions in cars, homes, workplaces and enclosed public places
Author, year
Tang 2003
Country
California, USA
Design
Repeat cross-sectional
Objective
To examine patron responses to a
California smoke-free bar law
SES variables
Education, income
Analyses
Bivariate
and
multivariate
logistic
regression
Data sources
3 cross-sectional telephone surveys.
Survey 1: March 1998, 3 months post
implementation of law; Survey 2: August
1998, 8 months post intervention; Survey
3: June 2000 2.5yrs post intervention.
Participant selection
Random-digit dialling, each household
identified a respondent aged 21 or older.
The first eligible respondent who had
visited a bar at least once in the past year
was asked for an interview.
Participant characteristics
Sample size: Survey 1 – 1001; 2: 1020;
3: 1000.
Intervention
On 1 January 1998 – law came into effect
banning smoking in “practically all bars”.
In 1998 California Tobacco Control
program launched campaign to introduce
new law, focused on changing social
norms regarding tobacco use through
media and other educational efforts.
Length of study
2.5 years; March 1998 to June 2000
Outcomes
Approval of the law
Likelihood of visiting a bar
compliance with the law
General population
Approval of the law rose from 59.8% to 73.2%
(odds ratio [0R] = 1.95; 95% confidence interval
[Cl] = 1.58. 2.40). Self-reported noncompliance
decreased from 24.6% to 14.0% (OR = 0.50;
95% Cl = 0.30, 0.85). Likelihood of visiting a bar
or of not changing bar patronage after the law
was implemented increased from 86% to 91%
(OR = 1.76: 95% Cl = 1.29, 2.40).
SES
Approval of the law
All results are reported as OR (95% CI);
*p<0.05;**p<0.01; ***p<0.001;
Respondents who approved of the law were
more likely to be more highly educated.
Educational level: ≥ college graduate 1.34 (1.11
to 1.62)** compared to ≤High school;
Household income $: ≥60,001 1.22 (1.00 to
1.47)* compared to ≤20,000;
More likely or no difference of bar visiting
Patrons with higher income, educational
attainment (data not reported) tended to report
they were “more likely” to visit bars or to report
“no change” in their patronage.
Education – OR not reported
Income: ≥$60,001 1.37 (1.04 to 1.81)*
compared to ≤20,000;
Perceived non-compliance with the law
Patrons with an income =/>60,000, or visiting
restaurant/hotel bar were less likely to perceive
non-compliance.
Income: ≥$60,001 0.77 (0.63 to 0.95)*
compared to ≤20,000;
Author’s conclusion of SES impact
No conclusion reported by SES not
Internal validity
Response rates for each wave
were 28% (March 1998), 32%
(August 1998), and 30% (June
2000).
Education level was the only
statistically
significant
demographic variable across the
different surveys. In the third
survey
(June
2000),
the
percentage
of
respondents
reporting both lowest and highest
education levels rose slightly,
compared with the first and second
surveys (25.7%, 22.5%, 22.4%,
respectively, for lowest level;
41.9%,
39.2%.
39.5%,
respectively, for highest level).
External validity
In 1994 California legislature
passed a Bill banning smoking in
“virtually” all indoor workplaces.
Because of their willingness to
complete
the
survey,
the
respondents selected may be
inclined to support the law.
Validity of author’s conclusion
278
Details
Method
Results
Smoking restrictions in cars, homes, workplaces and enclosed public places
Details
Method
Result
Comments
Comments
Smoking restrictions in cars, homes, workplaces and enclosed public places
Author , year
Tong, 2009
Country
California, USA
Design
cross-sectional
Objective
To compare how adoption and
enforcement of smokefree policies
differed for Asian-American women by
educational status
SES variables
Education
Analyses
Multivariate logistic regression
Data sources
California Tobacco Use Surveys for
Chinese and Korean Americans
(CCATUS and KCATUS)
Participant selection
18+years, Chinese or Korean or Mixed
ethnicity, matched and weighted to the
2000 census characteristics for Chinese
and Korean populations.
Response rates: 52% Chinese 48%
Korea
n=879 for Chinese, 1023 Korean.
Participant characteristics
Low education = 795, high 1082.
High education mostly 25-44 year olds.
Mostly low income – 59.4% less than
$30k.
Intervention
Linguistically and culturally-adapted
version of California’s smoke-free social
norm campaign, established in 1988.
Length of study
Data from 2003 survey, analyses
conducted in 2008
Outcomes
Smokefree policy adoption and
enforcement.
Self-report exposure (none, <=30mins,
30-120mins, >120mins per week)
General population
Lower-educated and higher-educated
women had similar proportions of smokefree policies at home (58%) or indoor
work (90%).
SES
Lower education women as likely as
higher educated to report a smoke-free
house, and to have equivalent knowledge
about the health impacts of second hand
smoke. However more likely to have
been exposed at home, and not to be in
control of home smoking regulations.
Also more likely to be exposed at work.
Lower-educated women were more likely
than higher-educated women to report
anyone ever smoking at home (OR=1.62,
95% CI=1.06, 2.48, p=0.03) and
exposure during the past 2 weeks at an
indoor workplace (OR=2.43, 95% CI=
1.30, 4.55, p=0.005), even after
controlling for ethnicity, smoke-free
policy, knowledge about the health
consequences of secondhand smoke
exposure, and acculturation.
Author’s conclusion of SES impact
Despite similar rates of knowledge and
adoption low educated Asian-American
women suffer higher exposure to
secondhand smoke in the home.
Similar rates of smokefree policies at
work and at home but disparity in
enforcement by educational status with
lower educated Asian-American women
reporting greater SHS exposure.
Internal validity
Hard to capture knowledge of SHS based
on a Likert scale.
Self-report exposure data.
External validity
Could be difficult to translate and adapt
policy to different ethnic sub-groups and
expensive in areas with less dense
minority ethnic populations.
Research was built upon a 15 year old
policy, so effectiveness is difficult to
isolate.
Response rate low
Validity of author’s conclusion
Valid
279
Details
Method
Result
Comments
General population
ETS exposure decreased among all
employees and subgroups that were at
higher risk before the ban (male and loweducated). 52.2% still reported being
exposed post-legislation.
SES
Lower-educated workers twice as likely to
be exposed as those with higher level of
education.
% exposed, before + after.
Low: 79.7% - 61.5%
Mid: 71.0% - 53.6%
High: 63.5% - 41.7%
Sig diff @ p<0.001 both for differences
between subgroups and the decrease
since intervention.
OR between low and middle, pre and
post-legislation: 1.61 (1.23-2.10); 1.21
(1.16-1.47)
OR Low v high educated: 2.29 (1.743.01; 2.17 (1.91-2.45)
Author’s conclusion of SES impact
Ban has not abolished inequalities in
exposure. Both before and after
implementation of the ban, males and
lower educated employees were about
two times more likely to be exposed to
ETS.
Internal validity
Dichotomising responses could be overstating exposure (‘sometimes’ could be
almost insignificant).
Could be including exposure while
entering/leaving the building as exposure.
Brief period of data collection pre-ban,
offered less seasonal variability.
External validity
Education a difficult measure of SES to
compare
across
generations
and
internationally, more so here as no
definition is provided for ‘low, middle,
high’.
Internet
sample
may
not
be
representative
Validity of author’s conclusion
Accurate, least educated still significantly
more exposed than middle or high
educated groups.
Smoking restrictions in cars, homes, workplaces and enclosed public places
Author , year
Verdonk-Kleinjan, 2009
Country
The Netherlands
Design
Repeat cross-sectional
Objective
To examine whether a workplace
smoking ban reduced exposure and
inequalities
SES variables
Education
Analyses
Logistic regression
Data sources
Continuous Survey of Smoking Habits
(CSSH) Dutch internet survey. Sample
weighted to be nationally representative.
200 respondents selected randomly each
week. Any positive response coded as
exposed.
Participant selection
11,291 non-smoking, working (15+
hours/week) respondents between 16-65
years old.
Participant characteristics
56% male, mostly 30-49 years, 84% nonGovernment employees, 63.9% working
35+ hours per week. 39.2% middle
education, 34.3% high.
Intervention
Workplace
smoking
ban
in
the
Netherlands 2004; full ban of smoking in
workplaces except bars, cafes and
restaurants, designated smoking rooms
allowed.
Length of study
July 2003 to July 2005
Outcomes
Exposure to ETS among non-smokers
280
Details
Method
Results
Comments
General population
The decreased proportion of Canadian smokers
is larger for most of the selected groups
between the years 2000 and 2002 and average
real cigarette tax went up during this period.
The tax elasticity estimate for the whole
population is −0.227. This result implies that if
there is a 10% increase in taxes then smoking
participation will fall by about 2.3%.
SES
The higher and middle income groups are less
likely to be smokers than the low income group.
Individuals with post-secondary education are
less likely to smoke than those with less than
secondary education.
While the participation tax elasticity of the high
income group (−0.202) is larger than the low
income group (−0.183), it is not statistically
significant.
The low education group are more tax sensitive
than the high educated group. Tax elasticities by
education level are: less secondary (−0.555),
secondary (−0.218), some post-secondary
(−0.018) and post-secondary (−0.042).
Author’s conclusion of SES impact
Evidence of a heterogeneous response to
cigarette taxes among different groups of
smokers. The differential response of low
income/education
smokers
versus
high
income/education smokers raises the debate
about the distributional impact of such taxes.
Internal validity
Due to the small sample size of
the low income group, income was
grouped into two categories: low
income category = low/middle
income household and high
income group = high income
household.
Education levels split in two
categories and also into four
categories.
External validity
The survey excludes those living
on Indian Reserves and Crown
Lands, full-time members of the
Canadian Forces Bases and some
remote areas of Ontario and
Quebec.
Average real taxes varied by
province but this is accounted for
in the analyses.
Graphic pictorial warning labels
were introduced during period
2000 to 2002.
Validity of author’s conclusion
Pictorial warning labels may have
influenced smokers as well as
increases in cigarette tax.
Increases in price/tax of tobacco products
Author, year
Azagba & Sharaf 2011
Country
Canada
Design
Longitudinal cohort data - econometric
Objective
To examine the impact of cigarette taxes
on smoking participation
SES variables
Household income, education
Analyses
Historical tax data are obtained from the
respective provincial tax offices. The tax
rates
are
matched
with
each
respondent‘s province of residence and
date of interview available in the NPHS.
To obtain the real cigarette tax per
carton, both the federal and provincial
consumer price index obtained from
CANSIM are used to deflate each of the
nominal tax components .The sum of the
deflated taxes is the real exercise tax in
2000 dollars.
Data sources
Canadian National Population Health
Survey and tax data
Participant selection
No details
Participant characteristics
Aged 12 to 65 years, >50,000 for income
and education subgroups
Intervention
Cigarette tax increases
Length of study
1998/9 to 2008/9 (cycles 3 to 8), followup every 2 years
Outcomes
Smoking prevalence, tax elasticity
281
Details
Method
Results
Comments
Increases in price/tax of tobacco products
Author, year
Biener 1998
Country
Massachusetts, USA
Design
Cross-sectional study
Objective
To examine smokers perceptions of the
impact of new tobacco taxes.
SES variables
household income
Analyses
Multinomial logistic regression using
bivariate and multivariate models
Data sources
Telephone
interviews
(retrospective
survey)
Participant selection
random-digit-dialling on the basis of
household
enumeration;
response
rate=78%
Participant characteristics
N=4733 adults, 1657 current adult
smokers and 126 posttax quitters
Intervention
1993 tobacco excise tax increase of 25
cents per cigarette pack (=15% increase)
on January 1st 1993.
Length of study
October 1993 to March 1994
Outcomes
Smoking behaviour; respondents were
assigned to one of three mutually
exclusive categories: (1) did not respond
to taxes (2) cut costs by reducing number
smoked or changed to cheaper brand (3)
considered quitting
General population
35% considered quitting, 28% changed to
cheaper brand, 17% reduced number smoked.
8% of adult who had been smokers before tax
increase reported quitting after price increase.
On a 4-point rating scale, 56% of these quitters
said that price increase had no effect at all on
their decision to quit and 44% said it had at least
some effect.
SES
Among adult smokers those with lower incomes
were 3 times as likely as those with higher
incomes to report cutting costs of smoking and
twice as likely to consider quitting as opposed to
having no response to the price increase
(significant in both bivariate and multivariate
models). Household income was not related to
choice between cutting costs and considering
quitting.
The only individual predictor that reached
significance was income in terms of impact on
quitting; the lower the household income, the
greater the impact of the price increase on the
respondent’s decision to quit.
Author’s conclusion of SES impact
Lower income smokers are significantly more
likely than higher income smokers to respond to
an increase in cigarette prices. Low income
adults were more likely to cut costs or consider
quitting rather than not react to a price increase.
Internal validity
46% continuing smokers denied
having any of the 3 potential
reactions to the price increase.
External validity
No further details of sample
demographics
compared
to
general
population;
limits
generalisability
Validity of author’s conclusion
Possible that study failed to
measure an important variable.
282
Details
Method
Results
Comments
Increases in price/tax of tobacco products
Author, year
Bush 2012
Country
16 states including Alaska, Connecticut,
Georgia,
Hawaii,
Indiana,
Maine,
Maryland, Missouri, North Carolina,
Oklahoma, Oregon, South Carolina,
Utah,
Virginia,
Washington
and
Wisconsin, USA
Design
Repeat cross-sectional (before and after)
plus 7-month follow-up of random sample
Objective
to (1) describe call volumes to 16 state
quitlines before and after the tax
increase; (2) examine the characteristics
of tobacco users who enrolled with
quitlines before and after the tax increase
and (3) examine the outcomes (quit
rates) of tobacco users who enrolled with
state quitlines before and after the tax
increase.
SES variables
Education level
Analyses
Chi-square and t-test statistics to
compare characteristics of callers during
2009 tax increase and for the same
months in the prior year and included
state as fixed variable to account for the
variability in services provided across
quitlines.
For the four states with data from the
seven-month
follow-up,
multivariate
logistic regression analyses were used.
Outcomes were reported in two ways:
Data sources
Administrative data from the Free & Clear
database for 16 of 17 state tobacco
quitlines. Seven-month follow up from
four state quitlines based on random
samples of quitline participants.
Participant selection
Random sample
Participant characteristics
N= 29,674 (before tax increase) and
50,254 after tax increase, mean age 41,
59% female
Intervention
April 1, 2009, federal cigarette excise tax
increase from 39 cents to $1.01 per pack.
Tobacco control varied between states
but all quitlines provided mailed support
materials, a single reactive (inbound)
counselling call to all tobacco users, and
three or four additional outbound calls to
select groups. Some state quitlines refer
insured tobacco users to cessation
benefits offered through their health plan
or employer. All but four states offered at
least some free NRT depending on the
state-approved eligibility criteria.
Length of study
March-May 2008 and March-May 2009
Outcomes
Monthly call volume,
Daily call volume,
Seven day point prevalence,
30-day point prevalence
General population
Overall, there was a 23.5% increase in total call
volume when comparing December 2007–May
2008 (84,541 calls) to December 2008–May
2009 (104,452 calls). The tax effect on call
volumes had returned to the before tax levels in
May. Tobacco users who enrolled with the
quitline before and after the announcement and
implementation of the April 2009 federal tax
increase: age of callers was slightly younger
(41.9 versus 41.2), fewer callers were aged 18–
24 years (11.5% after tax versus 13.6% before
tax). Although fewer callers enrolled in the
multicall program (4-5 counselling calls) after
tax, they completed slightly more counselling
sessions compared with those who enrolled for
the multiple calls before tax (1.9 versus 2.2,
respectively, P < 0.0001). Participant quit rates
did not differ significantly before versus after the
tax (controlled for age, gender, race, education,
chronic condition, amount smoked, how heard
about quitline, and state). Callers after the tax
increase were more likely to report that friends
and family told them about the quitline than
those who called before the tax increase.
SES
More callers in 2009 (compared with the prior
year) had less than a high school education:
58.6% vs 61.0%, p=0.007. Magnitude of the
differences before and after tax was small.
Author’s conclusion of SES impact
Calls to the quitlines increased by 23.5% in
2009 and more smokers with less education
called after (versus before) the tax.
Internal validity
Seven-month response rate N =
645/1651 (39.1%)
All participating states used same
data collection methods and
questionnaire
to
collect
demographic and tobacco use
data at intake and follow-up.
External validity
Smokers in participating states
represented 24% of smokers in
US 2009.
Other tobacco control policies
occurred during study period that
are not accounted for.
Validity of author’s conclusion
Valid and reports that cannot
estimate impact of federal tax
increase separately from other
excise tax increases and other
changes in state and local level
tobacco control policies.
283
first among those who completed the
survey (respondent analysis) and second
using the “intent-to-treat” (ITT) analysis
whereby persons with missing outcomes
data are assumed to be smoking.
284
Details
Method
Results
Comments
General population
Overall, 78% of participants used at least one
price minimizing strategy in 2009 to save money
on cigarettes. About 53% reported buying from
less expensive places, 49% used coupons or
promotions, 42% purchased by the carton, and
34% changed to a cheaper brand. Participants’
characteristics differed somewhat by strategy.
Participants who reported buying by the carton
were less likely to attempt to quit smoking and
cut
back
on
cigarette
consumption
subsequently; those who used more strategies
were less likely to cut back on their cigarette
consumption.
SES
The lowest income group was more likely than
the highest income group to report buying
cigarettes from cheaper places, buying a
cheaper brand, and rolling their own cigarettes (
p < .05). The middle - income groups (i.e., those
who reported annual household income
between $25,000 and $75,000) were more likely
than the highest income group to report buying
cigarettes from cheaper places, using coupons
or promotions, and buying cartons instead of
packs ( p < .05).
Having some college education, having an
annual household income between $25,000 and
$ 75,000 were associated with higher odds of
using at least one price-minimizing strategy ( p
< .05); having less than high school education,
having annual household income less than
$75,000, were associated with higher number of
strategies used ( p < .05).
Author’s conclusion of SES impact
No specific conclusions regarding SES impact.
Internal validity
Additional analysis showed that
smokers who were lost to followup between 2009 and 2010 were
more likely to be younger and
have someone close to them who
smokes or uses tobacco (p < .05).
External validity
State-specific sample, which limits
the generalizability of findings to
the adult smokers in the United
States.
Validity of author’s conclusion
Valid but small regional sample?
Increases in price/tax of tobacco products
Author, year
Choi 2012
Country
Minnesota, USA
Design
Longitudinal cohort
Objective
To estimate the prevalence of the use of
price-minimizing strategies in a cohort of
current smokers immediately following
the federal tobacco tax increase in 2009
and to examine the demographic and
social characteristics of those who use
price minimizing strategies.
SES variables
Education (categorized into less than
high school, high school graduate, some
college, and college graduate or above);
Annual
household
income
was
categorized into less than $25,000,
$25,000 – $ 50,000, $50,000 – $ 75,000,
and more than $75,000.
Analyses
Multivariate logistic regression
Data sources
Minnesota Adult Tobacco Survey (MATS)
Cohort Study
Participant selection
The sample was drawn from the 12,580
MATS 2007 participants randomly
selected from the Minnesota adult
population (n = 7,532) and Blue Cross
Blue Shield members (n = 5,048). Of
those eligible for MATS, 2,436 (77%)
agreed to participate in MATS.
Participant characteristics
718 current smokers in 2009 (reported
smoking at least 1 day in the previous 30
days) and 602 resurveyed in 2010 = 84%
follow-up rate
Intervention
federal tobacco tax increase 2009
Length of study
2009 to 2010
Outcomes
Six cigarette price-minimizing strategies;
(a) bought a cheaper brand of cigarettes,
(b) rolled their own cigarettes, (c) used a
form of tobacco other than cigarettes, (d)
used coupons, rebates, or promotions
(e.g., buy-one-get-one free, in-store
discount), (e) purchased cartons instead
of individual packs, and (f) found less
expensive places to buy cigarettes.
Quit
Quit attempts
Cigarette consumption?
285
Details
Method
Effects of increases in price/tax of tobacco products
Author, year
Data sources
CDC 1998
National Health Interview Survey (NHIS)
Country
Participant selection
USA
Multistage probability sample, response
Design
rate 80% to smoking history supplement.
Participant characteristics
Repeat cross-sectional - econometric
Objective
Noninstitutionalised civilian population 18
To evaluate the responses to increases years+, the 14 cross-sections of the NHIS
in cigarette prices by race/ethnicity, have 367,106 respondents; of these,
income and age groups
355,246 respondents had complete
SES variables
demographic
and
price
data
Family incomes; respondents with (approximately 24,000 respondents per
incomes equal to or below the median year).
were compared with those above the Intervention
median income ($33,106 in 1997 dollars). Survey of smoking behaviour, Current
Analysis
smokers were persons who reported
A probit (limited dependent variable) having smoked at least 100 cigarettes
model, an ordinary least squares model,
during their lifetimes and who currently
smoked cigarettes.
Length of study
1976 to 1993
Outcomes
Prevalence price elasticity
Consumption price elasticity
Total price elasticity
Results
Comments
General population
For all respondents, the models estimated a
prevalence price elasticity of –0.15 and a
consumption price elasticity of –0.10, yielding a
total price elasticity estimate of –0.25.
Therefore, a 50% price increase could cause a
12.5% reduction in the total U.S. cigarette
consumption (i.e., 50% X –0.25=–12.5%)
SES
Lower-income populations were more likely to
reduce or quit smoking than those with higher
incomes. The total price elasticity was –0.29 for
lower-income persons compared with –0.17 for
higher income persons
Editorial note: Smokers with family incomes
equal to or below the study sample median were
more likely to respond to price increases by
quitting than smokers with family incomes above
the median (e.g., 10% quitting compared with
3% quitting in response to a 50% price increase)
Author’s conclusion of SES impact
Editorial note: indicates that lower income
smokers would be more likely than other
smokers to be encouraged to quit in response to
a price increase.
Internal validity
Not all respondents for whom price
data was available reported family
income
External validity
Analysis does not control fully for
other factors unrelated to price
(e.g., differences between states in
social and policy environments)
that could reduce demand and be
confounded with the state’s excise
tax level. This is a summary report.
Validity of author’s conclusion
Valid
286
Details
Method
Increase in price/tax of tobacco products
Author , year
Data sources
Colman, 2008
Current Population Survey’s Income
Country
Supplements and Tobacco Use Survey,
Participant selection
USA
Design
Excluded those without matching data
Repeat cross-sectional - Econometric
across surveys, under 18 years, those
Objective
replying through proxies and those with
To examine whether cigarette taxes are missing values.
Participant characteristics
progressive
SES variables
N=294693. Smoking prevalence higher
Income
among the low income group at all time
Analyses
points. Low income more likely to be an
Econometric
ethnic minority, and not in the labour
force. Low income group more likely to
have high school education or lower, high
income group more likely to have college
or post-graduate qualification.
Intervention
Real cigarette price rose by over 70%
during study period.
Estimated the
impact of a further $1 increase on 2003
prices.
Length of study
Cross-sectional data from 1993, 96, 99,
2001, 2002 and 2003.
Outcomes
Current smoking, either every day or
some days.
Result
Comments
General population
N/A
SES
Higher income individuals are less pricesensitive; however the difference is less
than the standard error between groups.
A $1 rise in taxation would cause a
decline of approximately 2.3 percentage
points in the low-income group, 1.7
percentage points in the middle income
group and 0.8 percentage points in the
high income group.
The tax rise would absorb 1.9% of the
median income of low income smokers,
and 0.7% and 0.3% for the mid and high
income smokers. Disparity even wider
once the above increase in cessation is
accounted for.
Author’s conclusion of SES impact
Higher prevalence of smoking among low
income groups means that the benefit of
taxation is outweighed by the tax burden
borne by non-quitters. Taxes may be
progressive for a small section of
smokers
under
some behavioural
models.
Internal validity
External validity
English population would have more
cessation support services available to
them than were available in USA during
the data collection period.
Validity of author’s conclusion
Increasing tobacco taxation had a small
narrowing effect on socio-economic
inequalities in smoking.
287
Details
Method
Increase in price/tax of tobacco products
Author, year
Data sources
De Cicca, 2008
Behaviour Risk Factor Surveillance
Country
Survey, an annual survey of US adults.
Participant selection
USA
Design
Individuals between the ages of 45-59
Repeat cross-sectional - econometric
with state of residence data selected.
Objective
Participant characteristics
To investigate the responsiveness of No discussed, but survey described as
older adult smokers to large cigarette tax state-representative.
Intervention
rises
SES variables
Increases in state tax of at least 50c per
Education (high school diploma or pack of 20 cigarettes, introduced
equivalent, or lower) and income between 2000 and 2005. Price increases
(household income <$35,000).
ranged from 50c to $1, with resulting
taxes ranging from 70c to $2.46. 22 tax
increases are included, from 18 states
(Michigan, Montana, New Jersey and
Washington introduced two tax increases
during the study period).
Length of study
2000 to 2005
Outcomes
Smoking
prevalence
(self-reported
smoking every day or some days).
Result
Comments
General population
Daily smokers fell from 19.6% to 17.9%, with
almost all decrease coming after 2003 (2003:
19.4%, 2004: 17.9%), after the larger tax
increases started. Some days smokers follow
similar patterns.
Estimate that a $1 increase in state cigarette tax
reduces daily smoking by 1.4 percentage points
(approx. 8% overall). Price participation elasticity
(PPE) of -0.29 to -0.31.
SES
Greater impact among low-educated smokers. $1
increase would reduce the fraction of loweducated smokers by over 10%, and only 3%
among those with more than a high school
education. Price participation elasticities of -0.43
and -0.12 respectively. If low education is only
those with less than a high school degree, the
PPE is -0.9.
A similar pattern is seen by income. Low-income
individuals, defined as those living in households
with annual incomes of less than $35,000, are
found to quit at a much higher rate in response to
higher taxes than their counterparts from higher
income households. Price participation elasticities
were -0.39 for low-income (<$35,000) and -0.12
for high income ($>35,000). A rise of $1 would
reduce fraction of low-income smokers by about
10% and high income by 2%.
Author’s conclusion of SES impact
Smokers with low education and income showed
greater reduction in smoking participation
following large tax increases. Relative response
would need to be far more significant for tax
increases to be considered a progressive policy
option.
Internal validity
Other tobacco control initiatives
are controlled for, but still not
necessarily
evidence
that
smokers are quitting in response
to the tax increase.
External validity
Studied taxes arising from a
relatively low starting point.
Unclear whether further tax rises
on top of high English prices
would have the same impact.
Validity of author’s conclusion
Associated
with
a
large
narrowing of the education and
income-related
smoking
disparities.
288
Details
Method
Result
Comments
General population
Clean indoor air laws and cigarette prices
are independently associated with
reductions in smoking.
Independent associations of strong clean
indoor air laws were found for current
smoker status (OR 0.66, 95% CI 0.60,
0.73), and consumption among current
smokers (-2.36 cigarettes/day, 95% CI 2.43, -2.29).
Cigarette price was found to have
independent associations with both
smoking and consumption, an effect that
saturated at higher prices. The odds ratio
for smoking for the highest versus lowest
price over the range where there was a
price effect, was 0.83. Average
consumption
declined
(-1.16
cigarettes/day) over the range of effect of
price on consumption.
The effect of clean indoor air laws on
smoking status (OR 0.66) was larger than
the effect of cigarette prices over the
range of prices at which we found
smokers to be price sensitive (OR 0.83
for $2.91 to $3.28).
SES
Established patterns of education,
income, and race/ethnic disparity in
smoking are largely unaffected by either
clean indoor air laws or price in terms of
both mean effects and variance.
Author’s conclusion of SES impact
Clean indoor air laws and price increases
appear to benefit all SES groups equally
in terms of reducing smoking participation
and consumption and are generally
neutral with regard to health disparities.
Internal validity
The household response rate for the
February 2002 CPS was 93%.
External validity
One of few studies to look at separate
impact of smokefree legislation and price
Validity of author’s conclusion
valid
Increases in price/tax of tobacco products
Author, year
Dinno 2009
Country
USA
Design
Single cross-sectional
Objective
To consider disparities in tobacco control
both by evaluating possible differences in
the effects of clean indoor air laws and
cigarette prices by different social
circumstances, and by establishing
whether vulnerabilities exist for smoking
participation and consumption and, if so,
whether these vulnerabilities covary with
tobacco control policies.
SES variables
Education, household income
Analyses
Non-linear gression models
Data sources
February 2002 panel of the Tobacco Use
Supplement of the Current Population
Survey (54,024 individuals representing
the US population aged 15–80). Data on
strong clean indoor air laws in effect at
time of interview were obtained from the
American Lung Association’s State of
Tobacco Control 2002 and local
ordinances
from
the
American
Nonsmokers’ Rights Foundation Local
Tobacco Control Ordinance database;
price from the average state cigarette
prices per pack from The Tax Burden on
Tobacco
Participant selection
Non-institutionalized civilian individuals in
266 counties in 50 states plus the District
of Columbia.
Participant characteristics
54,024 self-respondents aged 15 to 18
years
Intervention
Strong clean indoor air laws and cigarette
prices.
Strong clean indoor air laws include
100% prohibition without exception of
smoking in public and private workplaces
(including non-hospitality work sites like
manufacturing and office sites among
others), restaurants (with and without
attached bars), and bars and taverns.
Length of study
February 2002
Outcomes
Smoker status
Consumption
Smoking elasticities
289
Details
Method
Results
Comments
General population
47.5% of smokers made smoking-related
changes and 11.4% made product-related
changes without making smoking-related
changes. The proportion of smokers making
only product-related changes decreased with
time, while smoking-related changes increased.
Recent quitters who quit after the tax increase
(versus before) were more likely to report that
price influenced them.
SES
Low- or moderate-income smokers (versus
high-income) were more likely to make smokingrelated changes compared to no changes.
Smokers with less than high school education
were more likely to have cut down, thought
about quitting or started using loose tobacco
than those with a tertiary education, and those
with a high school or technical college education
were also more likely to have started using
loose tobacco than those with tertiary education.
Smokers with lower incomes (<$40 000) were
more likely to have cut down, changed to a
lower price brand or started to use loose
tobacco than those with higher incomes, and
those with a moderate income were more likely
to have changed to a lower priced brand.
A greater proportion of smokers from low SES
neighbourhoods switched to lower-priced
brands than those from moderate–high SES
neighbourhoods.
Author’s conclusion of SES impact
The effect of increasing cigarette prices on
smoking does not appear to be mitigated by
using cheaper cigarette products or sources.
Internal validity
Increases in price/tax of tobacco products
Author, year
Dunlop 2011
Country
New South Wales, Australia
Design
Repeat cross-sectional
Objective
To track smokers responses to the
increasing price of cigarettes after a tax
increase and assess socio-demographic
differences in responses
SES variables
Income, education and Socio-Economic
Indices for Areas (SEIFA)
Analyses
Multinomial logistic regressions
Data sources
The Cancer Institute NSW’s Tobacco
Tracking Survey (CITTS) is a continuous
tracking telephone survey. 50 interviews
per week are conducted across most
weeks of the year.
Participant selection
Households are recruited to the
telephone survey using random digit
dialling and participants are recruited
using a random selection procedure. An
overall response rate of 30% was
achieved, with a cooperation rate of 67%
among eligible respondents.
Participant characteristics
834 smokers and 163 recent quitters (quit
in last 12 months)
Intervention
Smokers were asked what effect, if any,
the increasing price of cigarettes had on
them when: (a) they tried to quit; (b) cut
down; (c) thought about quitting; (d)
changed to lower-priced cigarette brands;
(e) started using ‘roll your own’ or other
loose tobacco, such as ‘chop chop’; or (f)
bought in bulk. Multiple responses were
allowed.
Length of study
May to September 2010
Outcomes
Smoking related and product related
changes to cigarette price increases
External validity
Prior to the tax increase, cigarette
prices had been increasing
incrementally from approximately
AU$11.00 per pack in 2005 to
AU$14.00 in April 2010.Study did
not relate the price increase
questions directly to the 30 April
tax increase.
.
Validity of author’s conclusion
290
Details
Method
Results
Comments
General population
Elasticity [* p<0.10]
-0.13 (participation)
-0.15 (amount smoked)
-0.28 (total).
SES
Adults with a lower income are more
price-responsive than those with a
high income.
Elasticity [* p<0.10]
Stratified results
Elasticity [* p<0.10]
Family income less or equal to median
(median value was not reported)
-0.21* (participation)
-0.22* (amount smoked)
-0.43 (total)
Family income above median
0.01 (participation)
-0.11 (amount smoked)
-0.10 (total, not significant)
Author’s conclusion of SES impact
Adults with income at or below the median are
more than four times as price-responsive as
those with income above the median
Internal validity
controlled for within-state variation
in the models
External validity
Median income not reported
Validity of author’s conclusion
Valid but comparisons with other
econometric
studies
unclear
because did not report median
income
Increases in price/tax of tobacco products
Author, year
Farrelly 2001
Country
USA
Design
Repeat cross-sectional - econometric
Objective
To evaluate the effect of cigarette price
increases by gender, income, age and
race or ethnicity with a nationally
representative sample of more than
350,000 adults
SES variables
Family income
Analyses
Econometric. Two-part model of demand:
firstly a probit model of the decision to
smoke (participation); followed by linear
regression (ordinary least squares) of the
amount smoked by smokers.
Data sources
National
Health
Interview Survey;
multistage probability sample of the
civilian,
noninstitutionalized
U.S.
population age 18 and older
Participant selection
N=367,106 (all respondents); 354,228
(those with complete sociodemographic
and price data)
Participant characteristics
53% female; mean (SD) age 44 (17.7);
10% African-American/non-Hispanic; 6%
Hispanic; 26% high school dropout; 38%
high school graduate; 18% some college;
10% college graduate; 7% postgraduate;
mean (SD) family income $25,784
($18,670)
Intervention
Cigarette price increases
Length of study
14 years (1976-1980, 1983, 1985, and
1987-1993)
Outcomes
Price elasticities
291
Details
Method
Results
Comments
General population
Overall, smoking prevalence is lower in New
York (16.1%) than nationally (22.2%) and is
strongly associated with income in New York
and nationally (P<.001). 6.8 cigarettes per
smoker per day are purchased outside of New
York’s tax jurisdiction.
SES
Smoking prevalence ranges from 12.2% to
33.7% nationally and from 10.1% to 24.3% from
the highest to lowest income group.
In 2010–2011, the lowest income group spent
23.6% of annual household income on
cigarettes in New York (up from 11.6% in 2003–
2004) and 14.2% nationally. The middle-income
group spent 5.4% of their income on cigarettes
in New York and 4.3% nationally. Smokers in
the highest income group spent 2.2% of their
income on cigarettes in New York and 2.0%
nationally. The relationship between the
percentage of income spent on cigarettes and
income level differs significantly between New
York and the United States (P<.05).
Percentage of income spent on cigarettes
increased in New York over time for smokers
overall, from 6.4% in 2003–2004 to 12.0% in
2010–2011 p<0.001, as the state cigarette
excise tax increased from $1.50 to $4.35.
Percentage of income spent on cigarettes more
than doubled for the lowest income category,
increasing from 11.6% to 23.6% (P<0.01). This
percentage also increased for the middle
income group from 4.0% to 5.4% (P<0.01), but
not for the highest income group.
Daily cigarette consumption is not related to
income either nationally or in New York.
Author’s conclusion of SES impact
Internal validity
Self-reported cigarette price and
household income could be
misreported and this could vary by
income level and bias results.
External validity
Results specific to New York
State.
Validity of author’s conclusion
Valid.
Increases in price/tax of tobacco products
Author, year
Farrelly 2012
Country
USA
Design
Repeat cross-sectional and comparison
group
Objective
To analyse differences in smoking
prevalence and consumption overall and
by three income levels nationally and in
the state with the highest cigarette excise
tax ($4.35), New York.
SES variables
Annual household income, less than
$30,000; $30,000 to $59,999; and
$60,000 or more.
Analyses
Adjusted Wald tests, logistic regression,
linear regression, imputed missing
income
Data sources
New York Adult Tobacco Survey (NY
ATS) and a National Adult Tobacco
Survey (NATS)
Participant selection
Not reported
Participant characteristics
7,536 adults and 1,294 smokers from
New York and 3,777 adults and 748
smokers nationally.
Intervention
New York state had the highest cigarette
excise tax ($4.35) compared with the
national average of $1.46 per pack. The
average price per pack was $7.95 in New
York compared with $5.21 nationally.
Length of study
2010 to 2011, amount spent by smokers
on cigarettes annually as a share of
household income for 2003–2004 and
2010–2011 (adjusted for underreporting).
Outcomes
Smoking prevalence,
Daily cigarette consumption,
Share of annual income spent on
cigarettes,
292
Details
Method
Results
Comments
Increases in price/tax of tobacco products
High cigarette taxes reduce cigarette smoking
but impose a significant financial burden on lowincome smokers in New York State. Lower
income smokers in New York State have not
had a greater response to higher taxes than
smokers with higher incomes.
293
Details
Method
Increases in price/tax of tobacco products
Result
Comments
Author , year
Franks, 2007
Country
USA
Design
Repeat cross-sectional - econometric
Objective
To examine the relationship between
cigarette pack price and smoking
participation to inform future tobacco
control policy aimed at lessening incomebased disparities in smoking
SES variables
Income group (<25th percentile vs >25th
percentile)
Analyses
Fixed effects logistic regression
General population
Pack price increased throughout the
study period, and smoking decreased
overall
SES
Increased real cigarette-pack price
overtime was associated with a marked
decline in smoking among higher-income
but not among lower-income persons.
Lowest income group have stayed fairly
constant (~30% to 28%), whereas middle
groups have shown a downward trend
(both 30% to 25+22%). Highest income
saw substantial decline between 19901993, stable since (c.24% to 16%). –
derived from figure in paper
1984 to 1996: The association between
price and smoking is significant for both
income groups, with a larger elasticity in
the lower-income group (-0.45 vs -0.22
for the higher-income group).
In the later time period, the relationship
between price and smoking was not
statistically significant in the lower income
group or in the higher-income group
Author’s conclusion of SES impact
No significant contribution to reducing
smoking disparities. Income related
smoking disparities have increased, and
may impose a disproportionate burden on
poor smokers. Further price rises likely to
exacerbate inequalities due to the burden
of tax placed on low income groups.
Internal validity
Only reports lowest income against all
other, although figure of smoking
prevalence reports data for four income
categories..
External validity
BRFSS only included all states from 1995
onwards (after the large fall in high
income smoking). Excludes people
without telephones.
Validity of author’s conclusion
Appears that high income group have
responded to prices reaching a threshold
(c.$2.50) and have no further price
responsiveness. So despite the widening
of inequality the absolute gap of smoking
probability narrows as price increases
(between lowest and others). – derived
from figure in paper.
Data sources
Behavioural Risk Factor Surveillance
System (BRFSS), telephone survey, The
Tax Burden on Tobacco,'' an annual
compendium that includes cigarette tax
and price data
Participant selection
Multistage cluster design based on
random-digit dialling across all states.
Non-institutionalised adults (18+), 13.6%
missing outcome data were excluded.
State participation in the BRFSS
increased from 15 states in 1984 to all
states in 1995; the total sample included
more than 2.6 million respondents. The
data sets included weights to adjust for
nonresponse (which varied by state and
year) and selection criteria to enable
nationally representative estimates of
parameters of interest
Participant characteristics
Nationally representative sample of
adults
Intervention
Cigarette price increases adjusted for
inflation to 2004 levels.
Length of study
1984 to 2004
Outcomes
Smoking prevalence, price elasticity
294
Details
Method
Results
Comments
General population
During the 10 years preceding the 2002
program, smoking prevalence did not decline in
New York City; within a year of implementation
of the new policies, a large, statistically
significant decrease occurred. From 2002 to
2003, smoking prevalence among New York
City adults decreased by 11% (from 21.6% to
19.2%, (P=.0002) approximately 140000 fewer
smokers).
Increased taxation appeared to account for the
largest proportion of the decrease; however,
between 2002 and 2003 the proportion of
cigarettes purchased outside New York City
doubled, reducing the effective price increase by
a third.
SES
Smoking declined among all education levels.
The decrease was more pronounced among
low-income women (an 18.1% decrease, from
21.6% to 17.8%; P=.OO9). Significant
decreases in smoking were found among
people with more than a high school education
(a 12.4% decrease, from 19.3% to 16.9%;
P=.O1). Declines were also large among people
with annual family incomes of less than $25000
(a 12.6% decrease) or $75000 or more (a
13.4% decrease).
In 2003, former smokers who had quit within the
past year were more likely to have low incomes
compared with former smokers who had quit
more than 1 year previously (43.6% vs 32.0%,
p=.0001).
Residents with low incomes (<$25000 per year)
or with less than a high school education were
more likely than those with high incomes (>$75
000 per year) and those with a high school
education or higher to report that the tax
increase reduced the number of cigarettes they
Internal validity
Response rates per wave among
contacted households were 64%,
59%, and 64% respectively for
three waves of data collection
2002 to 2003.
ORs significantly reduced for
smoking, only for people in income
<$25,000 and ‘some college’
education.
External validity
Analyses of education level were
restricted to adults aged 25 years
and older
Validity of author’s conclusion
Valid, but respondents' attribution
of the impact of various control
measures on their smoking
behaviour may not be accurate.
Increases in price/tax of tobacco products
Author, year
Frieden 2005
Country
New York City, USA
Design
Repeat cross-sectional
Objective
to
determine
the
Impact
of
comprehensive
tobacco
control
measures in New York City
SES variables
education
Analyses
Univariate and multivariate
Data sources
Annual New York State Behavioral Risk
Factor Surveillance System (BRFSS),
New York City Department of Health and
Mental Hygiene (DOHMH) conducted a
population-based, random-digit dialed
telephone community health survey
Participant selection
randomly selected
Participant characteristics
adult New York City resident
Intervention
5. April and July 2002 state and city tax
increases raised the cost of a pack
of cigarettes by approximately 32%,
to a retail price of approximately
$6.85
6. 2002 Smoke-Free Air Act (SFAA)
became effective in March 2003
eliminated existing exemptions to
make virtually all indoor workplaces,
including restaurants and bars,
smokefree.
7. April 2003 nicotine-patch distribution
program began providing free 6week courses (coupled with brief
telephone counseling) to 34 000 of
the city's heavy smokers
8. Expansion of educational efforts
such as publications and
advertisements in broadcast and
print media, emphasized the health
risks of environmental tobacco
smoke and the benefits of quitting.
There was also extensive media
coverage of the debate regarding
smoke-free workplace legislation.
Length of study
295
Details
Method
Results
Comments
Increases in price/tax of tobacco products
May 2002 to November 2003; The 2002
community health survey was considered
to be the preintervention sample, and the
2 surveys conducted in 2003 were
combined
and
treated
as
the
postintervention sample.
Outcomes
Smoking prevalence
OR for smoking
Response to tax increase
Response to workplace smoking ban
smoked (income: 26% [low] vs 13.0% [high],
P=.0002; educational attainment: 27.5% [lower]
vs 19.3% [higher], P=.OO9).
High-income people were more likely than lowincome people to report that the SFAA reduced
their exposure to ETS (53.3% vs 41.9%,
P<.0001).
Author’s conclusion of SES impact
Groups that experienced the largest declines in
smoking prevalence included people in the
lowest and highest income brackets and people
with higher educational levels.
Our data suggest that people with lower
incomes may have been more heavily affected
by the increase in taxation, whereas people with
higher incomes may have been more affected
by greater awareness of the dangers of
environmental tobacco smoke and expansion of
smoke-free workplace legislation.
296
Details
Method
Results
Comments
Increases in price/tax of tobacco products
Author, year
Gospodinov & Irvine 2009
Country
Canada
Design
Repeat cross-sectional - Econometric
Objective
To investigate the overall magnitude of
the demand response to price and also
the
difference
in
response
by
socioeconomic level
SES variables
Education
Analyses
Econometric - estimates price elasticities
for different socioeconomic groups using
recent Canadian survey data for a period
during which prices rose to a level of
about $7 per pack.
Data sources
Statistics
Canada/Health
Canada
Canadian Tobacco Use Monitoring
survey (CTUMS) for years 2000 through
2005. The dollar price series is
constructed for tobacco products from the
monthly tobacco-price index for each
province from Canadian Socioeconomic
Information
Management
system
(CANSIM) and dollar prices for cigarettes
for November 2001 from the Department
of Finance
Participant selection
n/a
Participant characteristics
90,850 individuals aged 20+ years, of
whom 69,215 (76.2%) are non-smokers
Intervention
Cigarette price increases
Length of study
5 years – 2000 to 2005
Outcomes
Smoking prevalence
Weekly consumption per person
Price elasticity
Type of cigarette smoked
General population
Prevalence and number of cigarettes smoked
per person each declined by about one third.
Smokers tend to mitigate the impact of tobacco
taxes by switching towards brands that have
higher nicotine levels. That is, they move along
the ultralight—regular spectrum, in an effort to
get more nicotine for their dollar.
Aggregate price elasticity lies in the range −0.28
to −0.3 depending on whether it is estimated at
the median or mean
SES
Those with less than a completed high school
education level experienced declines that were
just slightly above the average, those with
completed high school and college level
experienced declines considerably below the
average, and those with university level
experienced declines in excess of the average.
For this last group participation declined by 30%
while quantity declined by more than 40%.
The elasticities for high school and college
graduates are approximately −0.3, while
smokers with less than high school appear to be
less responsive to price movements with a
median elasticity of −0.22. None of these
estimates is in the region of unity, and there is
no evidence of either a declining elasticity value
as we move from a low to high education group
or a higher elasticity value for the lower group.
Cumulative frequency distributions for all
smokers for each year in our data show a
downward shift in these distributions over time
indicating that continuing smokers are
progressively smoking stronger cigarettes while
the higher education group has seen little
change in its choice of cigarette, the lowest
Internal validity
Due to the low participation rate
and the large proportion of
occasional smokers (with 5 or less
cigarettes per week) for the group
with university degree, its effective
sample size becomes very small
and this education group was
excluded from the subsequent
analysis.
External validity
Does not account for illegal
products and cross-border sales.
Estimates are based on data
where prices are closer to what
might reasonably considered an
‘optimal’ range.
Validity of author’s conclusion
Study looks at data on pack choice
but not the intensity with which
high and low socioeconomic
groups smoke their cigarettes, nor
how such intensity patterns may
have changed in response to the
major tax increases of the period
2002 and 2003.
297
income group has. This distributional shift on the
part of the lowest income group may reflect the
tendency of quitters to be ‘light/mild’ smokers
and for non-quitters to be ‘regular’ smokers.
Author’s conclusion of SES impact
Little hope that such tax increases may really
benefit
low
socioeconomic
groups,
or
disadvantage them to a lesser degree than high
socioeconomic groups
298
Details
Method
Results
Comments
Increases in price/tax of tobacco products
Author, year
Gruber 2003
Country
Canada
Design
Repeat cross-sectional - econometric
Objective
To provide a framework for estimating
elasticities in the context of widespread
Smuggling and to explore the price
sensitivity of smoking by income group
SES variables
After-tax
income
quartiles
and
expenditure quartiles
Analyses
estimate demand models for Canada that
attempt to correct for the smuggling
problem in two different ways:
1. use legal sales data, and
exclude the regions and years
where the smuggling problem
was the worst
2. use household level expenditure
data on smoking.
Data sources
Cigarette prices ffrom Statistics Canada,
legal sales from National Clearinghouse
on Tobacco and Health Program,
household cigarette expenditure from
Canadian Survey of Family Expenditure
(FAMEX), renamed the Survey of
Household Spending after 1996.
Participant selection
n/a
Participant characteristics
The resulting FAMEX data set consists
of 81,479 observations across eight
survey years.
Intervention
Econometric estimation of
sensitivity of smoking to price
Length of study
n/a
Outcomes
elasticity
General population
Elasticity not accounting for smuggling is -0.72.
Excluding smuggling provinces elasticity is 0.47.
Using expenditure data elasticity is -0.45. there
is only a small and insignificant effect of prices
on the presence of any tobacco expenditure in
the family. But there is a large elasticity of
conditional expenditures of −0.41. Thus, it
appears that almost all of the response of
consumption to price changes occurs through
reductions in consumption and not quitting
smoking. Excluding smuggling provinces and
using expenditure data suggests bias from using
legal prices instead of illegal prices paid through
smuggling is quite modest because elasticities
are similar.
SES
Lower income groups spend a much larger
share of their incomes on cigarettes than do
higher income groups.
there is a pattern of much higher elasticities for
the lowest income groups than for the highest
income groups showing that the lowest income
group is much more price sensitive than higher
income groups.
After-tax income quartiles: there is a much
larger price elasticity of demand among the
lowest income smokers. In the bottom income
quartile, there is no effect of higher taxes on
cigarette spending, with an estimated elasticity
of demand close to −1. This elasticity falls to
−0.45 in the second quartile, and then to −0.31
in the third quartile before rising again to −0.36
in the top quartile. The drop between the lowest
income quartile and the other three quartiles is a
statistically significant one, whereas the
Internal validity
External validity
Widespread smuggling is only
relevant to certain countries
Validity of author’s conclusion
This paper accounts for smuggling
(which biases the response legal
cigarette sales to price) and by
doing so might produce a more
‘true’ price elasticity estimate.
299
differences in elasticities within the top three
quartiles are not statistically significant.
Expenditure quartiles: elasticity pattern is
similar, except that the big drop-off is between
the second and third quartiles (this drop is
statistically significant), while the difference in
elasticities between the first and second
quartiles and the third and fourth quartiles are
not statistically significant.
Author’s conclusion of SES impact
cigarette taxes may not be as regressive as
previously suggested
300
Details
Method
Result
Comments
General population
In adjusted causal inference models
every $1.00 increase in cigarette excise
tax between 2001 and 2005 was
associated with a 4 percentage point
decrease in household tobacco use
between 2003 and 2007 (p = 0.008);
however, there was no effect of smokefree legislation on household tobacco
use.
In adjusted cross-sectional models, a
higher smoke-free legislation total score
was associated with a lower prevalence
of household tobacco use.
SES
Cigarette
tax increases but
not
smokefree legislation total score, were
associated with reductions in household
tobacco use for lower income households
(100–399 % of the federal poverty level)
using casual inference techniques.
Cigarette tax increases and smokefree
were associated with reductions in
household tobacco use for lower income
households.
Author’s conclusion of SES impact
Stronger
tobacco
control
policies
decreased
tobacco
use
among
households with school-age children and
adolescents; however, which policy
reduced parental smoking depended on
the modelling approach used. In causal
inference models we found that stronger
cigarette
excise
taxes
decreased
household tobacco use, particularly for
families with children from lower income
groups, but smoke-free legislation did not
change tobacco use. In cross-sectional
models we showed that a higher smoke-
Internal validity
Household tobacco use as a proxy for
children’s secondhand smoke exposure.
Two year lag between tax and smokefree
policies and outcomes.
External validity
National survey data used which should
be generalisable to US parents
Validity of author’s conclusion
This is a comparison of methods study in
which authors focus on causal inference
model results. Aim of increasing cigarette
tax is to reduce prevalence of smoking
and aim of smokefree legislation is to
protect from SHS exposure.
Increases in price/tax of tobacco products
Author, year
Hawkins 2012
Country
USA
Design
Repeat cross-sectional
Objective
To examine the impact of cigarette excise
taxes and smoke-free legislation on
tobacco use among households with
school-age children and adolescents as
well
as
disparities
in
children’s
secondhand smoke exposure.
SES variables
Total combined family income during the
past calendar year before taxes. A
household’s percentage of the federal
poverty level was calculated from
household size and income. Highest level
of education in the household was
constructed by comparing education of
the mother and father: less than/high
school graduate or more than high school
graduate
Analyses
compared the results from models using
causal inference techniques (differences
in differences) to those from crosssectional models using ordinal least
squares regressions models
Data sources
National Survey of Children’s Health,
state-level cigarette excise taxes, smokefree legislation total score (0 [none]–32
[very strong]) in 2001 and 2005 (National
Cancer
Institute’s
State
Cancer
Legislative Database).
Participant selection
Not stated
Participant characteristics
families of 6–17-year-olds from the 2003
(N = 67,607) and 2007 (N = 62,768)
Intervention
Cigarette excise taxes and smoke-free
legislation.
From 2003 to 2007 40 states raised
cigarette excise taxes with a mean
increase of 54.5 cents (SE 6.4; range 7–
175). In 2005, the mean tax was 84.7
cents (SE 7.9; range 5–246). From 2001–
2005, 18 states strengthened smoke-free
legislation with a mean increase of 13.3
(SE 1.8; range 1–28). In 2005, the mean
smoke-free legislation total score was
12.0 (SE 1.3; range 0–32).
Length of study
January 2003 – July 2004 and repeated
separate sample April 2007 – July 2008.
Outcomes
Household tobacco use
301
free legislation total score, indicating
stronger policies or a greater coverage of
policies, was associated with a lower
prevalence of household tobacco use.
Results suggest that increasing cigarette
excise taxes may help reduce disparities
by
influencing
parental
smoking
behaviours for the most at-risk children.
302
Details
Method
Increases in price/tax of tobacco products
Result
Comments
Author, year
Levy, 2006
Country
USA
Design
Repeat cross-sectional
Objective
To
examine
association
between smoking and tobacco
control policies among women
of low SES.
SES variables
Not completed high school or
no high school degree or GED
Analyses
multivariate logistic models,
General population impact
Smoking prevalence declining across all
categories.
SES
Price:
As price increased the OR of low-education
female smoking fell, but influence varies
over survey waves. Only lower than 1 in
1992-3 and 2001-02. Med-higher educated
groups less responsive.
Media:
In a state with a media campaign low
education women’s OR=0.86, medium
education = 0.89, high = 0.93 (non sig).
Low education men also significantly less
likely to smoke (0.92) Generally, the
association of the media variable and
smoking prevalence declines in the more
recent survey waves.
Smokefree legislation
Marginal effect on current smoking. Over
the period 1992–2002, current smoking
among low education women is inversely
related to the index of clean air laws with
an odds ratio of 0.91 (0.80, 1.03), but is
significant only in the medium education
female subpopulation, with an odds ratio of
0.88 (0.83, 0.94). However, only in the
2001/02 model do clean air laws seem to
play a part for the medium education
female sample, although the confidence
intervals around the estimates for each
survey wave overlap for this group.
Author’s conclusion of SES impact
Low
education
women
particularly
responsive to media and price increases
especially in comparison with high
education women. Tax increases can play
an important role. Tax increases and media
messages may reduce prevalence among
Internal validity
No before and after, simply tracks the
association between policy and prevalence.
Fail to adjust for confounding individual
characteristics.
Small sample sizes at some state levels.
External validity
Most of the developments in clean air
regulations at the state level occurred after
2001.
A number of tobacco control policies were
introduced during this period as well as
changing social norms and increasing
awareness, all of which may have influenced
the results. Data is now one, in some cases
nearly two, decades out of date. Covers a
substantial Hispanic population that wouldn’t
exist in the UK.
No description of the types of media
campaigns involved, and which were the most
effective (either the mode of intervention or
locations) in order to replicate the study.
Validity of author’s conclusion
No examination of individual level exposure, or
whether media campaigns were actively
influencing people to change their smoking
behaviour. Outcome may simply be the
consequence of changing social norms in
these populations.
Data sources
Tobacco Use Supplement, four waves
between 1992 and 2002. Sample nationally
representative of non-institutionalised civilian
population over the age of 15.
Participant selection
Females grouped by education level (less
than high school, high school or higher,
bachelor’s degree). Low education males
included as a reference population. Sample
varies between 176,452 and 228,552.
Participant characteristics
Majority white, with increasing Hispanic
proportion in later surveys. Majority 25 year
olds or over. Over 40% from the South,
approx. 20% each from the Midwest,
Northeast and West.
Low educated female constitutes between
21.6 and 26.6% of each survey, mideducated 19.3-22.4%, high educated are 7.3
to 9.2%
Intervention
cigarette prices, clean air regulations, and
tobacco control media campaigns,
Clean air laws were represented by an index
of state level clean air regulations. States
with ‘‘no smoking allowed (100% smoke
free)’’ were counted as 100% of the effect,
with ‘‘no smoking allowed or designated
smoking areas allowed if separately
ventilated’’ as a 50% effect, and with
‘‘designated smoking areas required or
allowed’’ as a 25% effect. We used separate
indices by type of law, and settled on an
aggregate weighted index, with worksite laws
weighted by 50%, restaurant laws by 30%,
and laws for other public places by 20%.
Media campaign exposure measured at the
state level rather than individual, and youth
campaigns coded as half a media campaign.
303
Length of study
1992 to 2002
Outcomes
Individual use, attitudes towards smoking
and clean air laws, and smoking bans at
home or work.
women with low education. Health-SES
relationship not irreversible.
304
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
Country
Ireland
Design
Single cross-sectional survey containing
retrospective cohort data - econometric
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. Ever-smokers 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.
305
Details
Method
Results
Comments
General population
We found a 27% increase in nicotine patch
sales during the week of the state tax increase
and a 50% increase during the week of the city
tax increase. These percentages gradually
declined over the ensuing weeks. Sales of
nicotine gum increased by 7% and 10%
following the rise in state and city cigarette
taxes, respectively, but these increases
generally did not persist for a period as long as
the increases in nicotine patch sales.
The week of the implementation of the SHAA
was associated with a 31% increase in nicotine
patch sales and an 8% increase in nicotine gum
sales, even though the free patch program
began the same week. Sales of the patch, but
not the gum declined during the subsequent
weeks, corresponding with the duration of the 6
week free patch program. Gum sales increased
by 11% during the fourth week after the SFAA
was enacted, coinciding with the beginning of
the act's enforcement.
SES
Pharmacies in low income areas generally had
larger and more persistent increases in
response to tax increases than those in higherincome areas.
Author’s conclusion of SES impact
Cigarette tax increases and smoke-free
workplace regulations were associated with
increased smoking cessation attempts in New
York City, particularly in low-income areas.
Internal validity
166/200 pharmacies provided data
at follow-up.
The model controlled for temporal
and seasonal patterns, included
major holidays, the World Trade
Center attack (September 11,
2001), and the Northeast blackout
(August 14, 2003).
Study conducted an analysis of
over-the-counter
sales
of
analgesic products to act as a
control.
External validity
Pharmacy sales of NRT are a
proxy measure for smoking
cessation attempts.
Validity of author’s conclusion
Valid but only a proxy measure.
Increases in price/tax of tobacco products
Author, year
Metzger 2005
Country
New York City, USA
Design
Prospective
longitudinal
cohort
of
pharmacies with repeat cross-sectional
data
Objective
To assess the impact of an increase in
cigarette excise tax and a smokefree
workplace law on smoking cessation
SES variables
Tertiles based on income for pharmacy
location
Analyses
repeated-measures analysis with Poisson
generalized estimating equations
Data sources
Data on over-the-counter pharmacy sales
are collected daily from more than 200
store locations in New York City,
representing approximately 30% of all
pharmacies in New York City
Participant selection
166/200 pharmacies
Participant characteristics
n/a
Intervention
State tax increase (implemented April 3,
2002),
the
city
tax
increase
(implemented July 2, 2002), and the
Smoke-Free Air Act (SFAA. the New
York City smoke-free workplace law,
enacted March 30, 2003). New York
City's free patch program (April 2, 2003,
to May 14. 2003), during which almost
35000 free courses of the nicotine patch
were distributed to heavy smokers,
defined as those who smoked more than
10 cigarettes per day living in New York
City.
Length of study
2 years; 2002 to 2004
Outcomes
Pharmacy specific weekly over-thecounter sales of 12 brand-name and
generic nicotine patch and nicotine gum
products
306
Details
Method
Results
Comments
Increases in price/tax of tobacco products
Author, year
Mostashari 2005
Country
New York City, USA
Design
Cross-sectional at one time-point
Objective
To inform New York City’s (NYC’s)
tobacco control program
SES variables
Education and income
Analyses
Bivariate and multivariate
Data sources
NYC Department of Health and
Mental Hygiene (DOHMH) random digitdialed telephone survey
Participant selection
Randomly
selected;
To
provide
neighbourhood estimates, a quota of 300
interviews was set for each of 33
neighbourhood strata defined by zip code
aggregation.
Participant characteristics
9,674
New
York
City
adults
Intervention
New York City’s April 2002 increase in
the state cigarette excise tax. Response
to the April 2002 increase in the state
cigarette excise tax was recorded by
asking individuals “How has the increase
in cigarette prices (since April 3) affected
your smoking?”
Length of study
May to July 2002
Outcomes
Prevalence of smoking
Exposure to SHS
Response of smokers to state tax
increase
Cessation practices
General population
Even after controlling for sociodemographic
factors (age, race/ethnicity, income, education,
marital status, employment status, and foreignborn status) smoking rates were highest in
Central Harlem and in the South Bronx.
Sixteen percent of nonsmokers reported
frequent exposure to second-hand smoke at
home or in a workplace. More than one fifth of
smokers reported reducing the number of
cigarettes they smoked in response to the state
tax increase. Of current smokers who tried to
quit, 65% used no cessation aid.
Purchases from sales channels outside of NYC
included 4.6% who reported buying cigarettes
elsewhere within New York State, 7.3% in other
states, and 1.9% on the Internet.
Response to the 13% price increase; nearly one
in four smokers reported reducing their cigarette
consumption shortly after the tax increase,
whereas 2.8% of smokers reported quitting
smoking. In addition, 5.6% of all recent smokers
indicated that they had thought about quitting,
4.0% tried to quit, and 2.8% quit smoking in
response to the 39-cent price increase.
SES
Lower household income was independently
predictive of current smoking. US born college
graduates were less likely to smoke than other
New Yorkers.
among nonsmokers lower education was a
significant predictor of exposures to SHS
Internet purchases were more common among
those with a college education or higher
compared with those with a high school
education or less (4.1% VS. 1.1%, P=.003).
Internal validity
Final sample represented 64% of
the eligible households contacted.
External validity
The survey represents only
noninstitutionalized NYC adults
with
working
residential
telephones.
Validity of author’s conclusion
Data only collected at one timepoint shortly after increase in state
cigarette excise tax
307
21.9% of individuals who had smoked cigarettes
in the past 3 months reported that they had
reduced the number of cigarettes they smoked
in response to price increase. This response
varied by income level, from 27.2% of those with
low incomes (<$25,000) to 11.0% of those with
high incomes (>$50,000) (P < .0001).
Quit attempts were associated with lower
income.
Author’s conclusion of SES impact
Tax evasion through cross-border and Internet
cigarette
purchases
could
blunt
the
effectiveness of local tax increases and argue
for a national cigarette tax increase.
308
Details
Method
Results
Increases in price/tax of tobacco products
Author , year
Data sources
Nagelhout 2013
Three
survey waves
of
the
Country
International Tobacco Control (ITC)
The Netherlands
Netherlands Survey, 2008 (before)
Design
and 2009 and 2010 (after)
Cohort
Participant selection
Objective
Recruited from a probability-based
To examine age and educational web database
inequalities in smoking cessation due
Participant characteristics
to the implementation of a tobacco
tax increase, smoke-free legislation N=1820/2331 (78.1%) in first survey,
1447 in second survey and 1275 in
and a cessation campaign.
third survey. Analyses restricted to
SES variables
respondents who participated in all
Education, low (primary education three survey waves (n=1176). And
and lower pre-vocational secondary excluded 128 who had quit during
education), moderate (middle pre- 2008 and 2009 surveys, n=1048 and
vocational secondary education and then answered all questions, n=962.
secondary vocational education) and
Dutch smokers (having smoked at
high [senior general secondary
least 100 cigarettes in their lifetime
education, (pre-) university education
and currently smoking at least once
and higher professional education].
per month) aged 15 years and older
Analyses
Intervention
Univariate and multivariate logistic
Tobacco tax increase, smoke-free
regression. All analyses were
hospitality industry legislation and
weighted by age and gender to be
mass media cessation campaign (all
representative of the adult smoker
at national level) implemented during
population in the Netherlands.
the same time period in the
Netherlands in 2008. The Dutch
cessation campaign focused on
smokers with low to moderate
educational levels.
Length of study
2008 – 2010
Comments
General population
Cessation:
281 out of 962 respondents (29.3%) had
tried to quit smoking between the 2009 and
2010 surveys. At the 2010 survey, 86 out
of
962
respondents
(8.9%)
had
successfully quit smoking. There were no
significant age inequalities in successful
smoking cessation. Smokers aged 15–39
years were more likely to attempt to quit
smoking.
Exposure:
In total, 82.4% reported having paid more
for their cigarettes in the 2009 survey than
in the 2008 survey, 65.6% reported having
visited a drinking establishment that had
some form of smoking restriction and
83.1% reported having experienced one or
more parts of the campaign. Smokers aged
15–24 years were more exposed to the
smoke-free legislation, whereas smokers
aged 25–39 years were more exposed to
the cessation campaign.
Exposure to the smoke-free legislation and
to the cessation campaign had a significant
positive association with attempting to quit
smoking in the univariate analyses, but not
with successful smoking cessation. In the
multivariate analyses, only the association
between exposure to the smoke-free
legislation with attempting to quit smoking
remained significant [odds ratio (OR)=1.11,
95% confidence interval (95% CI)=1.01–
1.22, P=0.029]. Exposure to the price
Internal validity
70% follow-up rate
External validity
Prices increased by only 8%.
Smokefree legislation was
weak, not well implemented
and issues with compliance.
Study authors report that
almost half of the sample was
either lost to follow-up or did
not answer all questions.
These
respondents
were
younger, less addicted and had
more intention to quit smoking.
Therefore, our results may not
be fully generalizable to the
broader population of Dutch
smokers.
Validity
of
author’s
conclusion
Smokefree, price, mass media
campaigns
were
not
associated with reduction in
prevalence of smoking.
309
Outcomes
Exposure,
Quit attempts,
7-day point prevalence (successful
quitters)
increase only predicted successful smoking
cessation among young respondents.
SES
Exposure: Higher educated smokers were
more exposed to the price increase and the
smoke-free legislation.
Smokers from different educational levels
were reached equally by the mass media
campaign.
Cessation: There were no significant
educational inequalities in successful
smoking cessation.
Author’s conclusion of SES impact
There were no overall ages or educational
differences
in
successful
smoking
cessation after the implementation of the
three interventions.
310
Details
Method
Result
Comments
General population
N/A
SES
Difference in prevalence by occupational class has widened (from
36% EM&P v 44&45% to 29% v 43&50%).
Smoking prevalence among executive managers and professionals
fell after the cigarette prices had begun to increase, whereas
manual groups showed a smaller, later, and temporary decline
(prevalence increased again soon after).
Reasons for smoking
Were aware of addiction and of its financial cost. All spoke of stressrelief, several spoke of ‘little moment of happiness’, and it filled voids
with nothing else to do, compensate for loneliness or emotional
problems. Many felt it was the only joy they had left.
Quantitative data –
Concerning reactions to the cigarette price increase, about one third
of poor smokers and other smokers reduced their cigarette
consumption, but poor smokers were more likely to turn to cheaper
or hand-rolled cigarettes (50% did so, versus 33% for other
smokers).
Significantly more likely to smoke automatically, less likely to smoke
for social reasons, more likely to relieve stress and take mind of
worries, less to aid concentration.
Author’s conclusion of SES impact
Smokers in low occupational groups and of low-income are less
likely to respond to tobacco control measures due to the harsh living
environment acts to sustain their attachment to smoking, despite
understanding the costs. Acknowledging the functional aspects of
smoking helps understand why price is unlikely to deter many poor
smokers.
Internal validity
Subjective
measure
of
wealth, influenced by peers’
as much as personal wealth?
Use two different measures
of
poverty
between
quantitative and qualitative
data analyses.
Validity of these findings is
weakened by the relatively
small sample of the manual
group in most of the survey
years. Size of occupational
groups is not provided, but
lower groups are only 30%
and 10% respectively for the
one
year
that
they’re
mentioned.
Increases in price/tax of tobacco products
Author , year
Peretti-Watel, 2009
Country
France
Design
mixed-methods, included both
national repeat cross-sectional
data and in-depth interviews
Objective
To
study
the
social
differentiation
of
smoking
between 2000 and 2008, and
why low-income smokers are
less sensitive to price increases.
SES variables
Subjective social status
Low-income,
subjective:
Wealthy, satisfying, on short
side = Other. Hard to make
ends meet OR we had to get
into debt = ‘poor’. Consistency
checked using neighbourhood
socio-demographic profile and
respondent’s education and
occupational status
Occupation:
executive
managers and professional
occupations, manual workers,
unemployed (for prevalence
trend)
Data sources
6 telephone surveys conducted by
the National Institute for Prevention
and Health Education (INPES)
between 2000 and 2008 (N varied
from 2000 to 30,000)
Participant selection
‘Next birthday’ method. Motivation
studied through data extracted from
the 2008 survey (poor n=115, other
=506, response rate 71%). in-depth
interviews with 31 ‘poor’ smokers
Participant characteristics
Poor smokers more likely to be
female, manual worker/clerk, less
than HS education, single parent
compared to ‘other smokers’.
31 qualitative interviews: The 31
participants were 13 women and 18
men, seven aged 30 or less, 12
aged 30 to 50, 12 aged 51 to 60. All
participants
reported
financial
and/or housing problems, and 25
were currently unemployed.
Intervention
Tobacco price increase between
2000 and 2008. Increase from
€3.20, €3.35, €3.60, €4.60, €5(3y)
to €5.30(2y)
Length of study
2000 to 2008 for prevalence data,
2008 only for motivation data
Outcomes
Approaches to smoking
External validity
Qualitative interviews with 31
smokers who were based in
South-Eastern France – may
be region specific
Validity
of
author’s
conclusion
Tentative, based on small
sample sizes
311
Variations in self-reported smoking
status (smoking, non-smoker, never
smoker)
312
Details
Method
Results
Comments
Increases in price/tax of tobacco products
Author, year
Peretti-Watel 2009
Country
France
Design
Longitudinal cohort study
Objective
to investigate how HIV-infected smokers
reacted to a sharp increase in cigarette
price
SES variables
Education, income support
Analyses
Univariate and multivariate analyses,
generalised estimating equations
Data sources
French
cohort
study
APROCOCOPILOTE investigated biomedical and
sociobehavioural characteristics of HIV-1
positive individuals who started an
antiretroviral therapy including protease
inhibitors. Monthly data on cigarette
prices were provided by the French
Monitoring Centre for Drugs and Drug
Addiction). They corresponded to the
price of a pack of cigarette of the
bestselling brand in France.
Participant selection
Subjects were enrolled between May
1997 and June 1999 in 47 French
hospital
departments
delivering
specialized care for HIV/AIDS patients.
Participant characteristics
1,146 HIV-infected smokers; sociodemographic background of seropositive
patients varied greatly across the
transmission groups. Patients infected
through IDU had a lower SES, especially
when compared to those infected through
homosexual intercourse: only 6% had
graduated from university (versus 15%
and 31% in the heterosexual and
homosexual groups respectively), 44%
were clerks or manual workers (versus
34% and 21% respectively), and 63%
were unemployed or on income support
at baseline, month 28 or month 52
(versus 34% and 29% respectively).
Intervention
In France, the price of cigarettes doubled
between 1997 and 2007 (from US$4 to
US$8 approximately).
Length of study
General population
n/a – grouped by transmission group (infection
through
intravenous
drug
use
(IDU),
homosexual
intercourse,
heterosexual
intercourse or other
SES
We
found
striking
differences
across
transmission
groups
regarding
sociodemographic
background
and
smoking
prevalence. The IDU group was characterised
by a lower socioeconomic status, a higher
smoking prevalence and a smaller decrease in
this prevalence over the period 1997-2007. The
homosexual group had a higher socioeconomic
status, an intermediate smoking prevalence in
1997, and the highest rate of smoking decrease.
In the dynamic multivariate analysis, smoking
remained correlated with indicators of
socioeconomic disadvantage and with infection
through IDU. Aging and cigarette price increase
had a negative impact on smoking among the
homosexual group, but not for the IDU group. In
both univariate and multivariate analyses,
smoking remained much more prevalent among
the IDU group and, to a lesser extent among
patients with a lower educational level as well as
those who were unemployed or on income
support during follow-up. In multivariate analysis
only, smoking was significantly more prevalent
among patients who never worked, as well as
among those with an intermediate level of
occupation.
Author’s conclusion of SES impact
Among seropositive people, just as for the
general population, poor smokers are poor
quitters.
Internal validity
attrition rate: 69% after 9 years but
attrition
not
correlated
with
smoking status
External validity
In this study, the smoking
prevalence observed among HIVinfected patients between 1997
and 2007 was higher than that
measured in the French general
population during the same period.
Study results are generalisable to
HIV infected smokers only having
antiretroviral therapy.
Validity of author’s conclusion
Between
1997
and
2007,
increasing the excise taxes on
tobacco products was the main
instrument of French tobacco
control policy (the ban on smoking
in public places was only
introduced
in
2008),
so
conclusions valid.
313
10 years (1997 to 2007) Data regarding
respondents’
smoking
status
was
collected every 8 months over the first 5
years, and every 12 months thereafter.
Outcomes
prevalence
314
Details
Method
Result
Comments
Data sources
National
telephone
survey
conducted by the French Institute
for Health Promotion and Health
Education (INPES)
Participant selection
Random digit dialling methods were
used to obtain listed and unlisted
telephone
numbers
(including
mobile phone numbers). The
corresponding households were
notified about the survey by mail. A
professional interviewer selected
one person age 18–75 in each
household at random to be
interviewed. Overall, 71% of the
households contacted agreed to
participate, giving a sample of 2000
respondents.
Participant characteristics
Current smokers, n=621, 54% male,
mean age 37.7%.
<below high-school graduation (N =
351) 57%
high-school completed (N = 121)
19%
University degree (N = 149) 24%
Financial
resources
of
the
household
<1500D/month (N = 122) 20%
≥1500D/month (N = 499) 80%
Intervention
Cigarette price increase. Questions
about
smokers’
reactions
to
increasing cigarette prices, as well
General population
24% of persistent smokers did not change their smoking habits at
all, 31% only reduced the cost of smoking (they neither reduced
their consumption nor tried to quit) and 45% tried to give up smoking
or reduced their consumption (they also frequently reduced the cost
of smoking). Quit attempt = 29%.
SES
The more highly educated smokers more frequently reduce only the
cost of smoking rather than quit attempt or smoke less (OR = 1.8
among those who had completed a university degree) and were
much more likely to have shown no reaction (OR=3.0)
Wealthier smokers more frequently reported no reaction at all to
price increase rather than quit attempt or smoke less (OR=2.4
among those earning at least 1500 euros/month
Author’s conclusion of SES impact
More educated smokers and wealthier smokers more frequently
reported no reaction at all to price increase.
Internal validity
Refusal
rate
=
29%.
Retrospective
self-report.
Weighted data
so that
sample representative of all
French adults in terms of
age,
gender,
education,
geographical area and size of
town of residence.
External validity
focused mainly on the
responses of smokers who
did not quit
Validity
of
author’s
conclusion
Valid but only tentative
conclusions due to study
design weaknesses – difficult
to assess equity impact as
focuses on smokers who did
not quit
Increases in price/tax of tobacco
products
Author , year
Peretti-Watel, 2012
Country
France
Design
Single, cross-sectional
Objective
(1) To build a typology of persistent
smokers’ reactions to increasing
cigarette prices (persistent smokers
were defined as smokers who did
not quit because of such increases)
and (2) to investigate which factors
were correlated with their reactions
(no reaction, trying to quit or
smoking less, reducing the cost of
smoking).
SES variables
Educational level: <below highschool graduation; high-school
completed; University degree
Financial
resources
of
the
household:
<1500D/month,
≥1500D/month
Study analyses
Logistic regressions
315
as questions about their sociodemographic background, personal
time
perspective,
smoking
behaviour and reasons for smoking.
Length of study
June-July 2008, retrospective to
2003
Outcomes
Quit attempt/smoking less,
Reduced smoking cost only,
No change in smoking behaviour
316
Details
Method
Results
Comments
General population
pregnant women only
Price elasticity
Full sample: -0.70
SES
Price elasticity
Education
Less than high school:: -0.30
High school: -0.49
Some college: -0.86
College: -3.39
Internal validity
large dataset from an annual
census of all
births
External validity
Underreporting of smoking status
may be more of a problem for data
from pregnant women compared
with the general population.
Generalisable to all pregnant
women in USA.
Validity of author’s conclusion
Increases in price/tax of tobacco products
Author, year
Ringel (2001)
Country
USA
Study design
Repeat cross-sectional -econometric
Objective
To estimate how changes in state
cigarette taxes affect the smoking
behaviour of pregnant women
SES variables
education (none, less than high
school, high school, some college,
college)
Analyses
probit model, using a within-group
estimator to account for state-specific
effects and factors that vary over time
Data sources
Natality Detail File, an annual census of births in
the US (1989 to 1995), self-reported data for if
mothers smoked during pregnancy and the
amount smoked. Monthly state excise tax data
from “The Tax Burden on Tobacco” adjusted to
real 1997 values by the Consumer Price Index.
Participant selection
Participant characteristics
N=20,025,000. 16.5% of mothers reported
smoking in pregnancy. 17.5% black, 67.1%
white, 11% Hispanic; 39.7% aged 24 or less;
21.1% less than high school education, 36.6%
high school, 40.2% college.
Intervention
Increase in cigarette tax
Length of study
1989 to 1995
Outcomes
smoking participation during pregnancy
Author’s conclusion of SES impact
Smoking participation rates varied widely
across demographic and socioeconomic
groups implying that responsiveness to
price changes would vary in a similar way.
The results indicate that highly educated
women are most responsive to changes
in cigarette taxes. All subgroups of
pregnant women had higher price
elasticities than the general population.
This is not surprising because as many
pregnant women try to quit smoking
interventions such as tax increases may
be more effective during pregnancy.
Valid
317
Details
Method
Increases in price/tax of tobacco products
Result
Comments
Author, year
Schaap, 2008
Country
18 European countries; Finland, Sweden,
Denmark, England, Ireland, Netherlands,
Belgium, Germany, France, Italy, Spain,
Portugal, Slovakia, Hungary, Czech Rep.,
Lithuania, Latvia, Estonia
Design
Cross-sectional
Objective
To examine the extent to which tobacco
control policies are correlated with
smoking cessation, especially among
lower education groups
SES variables
Education; relative index of inequality
(RII). The RII assesses the association
between quit ratios and the relative
position of each educational group, can
be interpreted as the risk of being a
former smoker at the very top of the
educational hierarchy compared to the
very lowest end of the educational
hierarchy
Analyses
Log-linear regression analyses to explore
the correlation between national quit
ratios and the national score on the
Tobacco Control Scale (TCS).
General population
Large variations in quit rate and RII
between countries.
Quit rates positively associated with
tobacco control scale score. Policies
related to cigarette price showed the
strongest association with quit ratios. A
comprehensive advertising ban showed
the next strongest associations with quit
ratios in most subgroups. Health
warnings negatively associated with quit
rates.
Regression coefficient 2.08 (-0.36 to
8.48) for men and 2.07 (-1.09 to 8.66) for
women for price.
Regression coefficient 1.33 (1.11 to 8.02)
for men and 1.59 (1.39 to 8.67) for
women for advertising bans.
Regression coefficient 0.94 (-2.43 to
5.89) for men and 0.41 (-3.84 to 5.26) for
women for public place bans.
Regression coefficient 0.54 (-3.05 to
6.17) for men and 0.54 (-3.52 to 6.41) for
women for campaign spending.
Regression coefficient -0.40 (-7.32 to
2.31) for men and -0.42 (-9.51 to 3.43) for
women for health warnings.
A ‘stripped’ analysis focusing on price,
health warnings and treatment (excluding
recent policy developments) supported
the main findings.
SES
Quit rates positively associated with
tobacco control scale score. More
educated smokers more likely to have
quit than lower educated, for men and
women. Larger absolute difference
between high and low educated for 25-39
year olds. However no consistent
Internal validity
Non-response percentages ranged from
about 15% in Italy and Spain up to 49%
in Slovakia, while percentages in most
other countries were between 20% and
35%.
Survey conducted before tobacco control
scale devised, and before some policies
enacted so may underestimate the
impact of recent policies.
Difficult to draw conclusions about
causality as study only examines the
association between ex-smokers and
presence of policies, rather than changes
in prevalence post-implementation.
Occasional smokers excluded from all
analyses.
External validity
Included data from Eastern Europe and
Baltic countries. Limited analyses to the
adult population aged 25–59 years.
Difficulty in drawing conclusions from
multiple nations with varying average
standards of education, definition of
‘highly educated’ likely to vary for some
nations.
Validity of author’s conclusion
Conclusion is consistent with the data
presented; however it’s difficult to draw
strong conclusions about the impact of
any
one
intervention
given
the
methodological limitations discussed
above.
Data sources
National
health
surveys.
100,893
respondents over 18 countries.
Participant selection
Selection process varies. Non-response
rate between 13.4 and 49% depending
on country.
Participant characteristics
Ireland has most developed tobacco
control policy, Latvia least.
Intervention
Joosens and Raw’s tobacco control scale
used as a proxy, with some analysis by
individual policies including:
Price, advertising bans, public place
bans, campaign spending, health
warnings
Length of study
Year 2000, except Germany and Portugal
= year 1998-9.
Outcomes
Quit ratios
318
differences were found between quit
ratios in high and low educated groups
and tobacco control scale score.
Policies related to cigarette price showed
the strongest association with quit ratios.
Significant positive association between
quit ratio and price for high SES aged 4059 years.
A
comprehensive
advertising
ban
showed the next strongest associations
with quit ratios in most subgroups (not
low SES aged 40-59 or low SES women
aged 25-39 years.
Health warnings negatively associated
with quit rates.
Author’s conclusion of SES impact
High and low educated groups seem to
benefit equally from nationwide tobacco
control policies. More developed tobacco
control policies are associated with
higher quit rates.
319
Details
Method
Result
Comments
General population
Between January 1991 and December
2006. Prevalence decreased from 28.2%
to 19.7%, and price increased from
$3.39 to $11.60. In the beginning of the
period, the age-adjusted prevalences in
the low-, medium-, and high-income
groups were 36.5%, 28%, and 21.5%,
respectively. At the end of the study
period, the prevalences had decreased
to
28.4%,
21.8%,
and
16.6%,
respectively.
real price and prevalence were
negatively associated (p<0.001)
SES
Price elasticity in lowest income groups
(<AU $18,000) of -0.32, but only -0.04
and -0.02 in medium and high income
groups.
One Australian dollar increase in price
was associated with a decline of 2.6%,
0.3%, and 0.2% in the prevalence of
smoking among low-, medium-, and
high-income groups, respectively.
There was a clear gradient in the effect
of income on prevalence that
diminished at higher levels of price.
Author’s conclusion of SES impact
Lowest income group are most
responsive to price increases.
Internal validity
No data on survey refusal rates.
Included controls for several other
policies enacted during the survey
period;
televised
antismoking
advertising, the availability of nicotine
patches by prescription, the availability
of nicotine replacement therapy by
over-the-counter sale, the availability of
buproprion
by
prescription,
the
introduction of six bold rotating health
warnings on cigarette packs, the ban of
most forms of tobacco sponsorship, and
addiction (both myopic and rational).
External validity
Survey covers 61% of adult population,
but only in metropolitan areas.
Generalisability to rural areas unknown.
Over the 4-year period during which
prices were monitored, the average
actual price of cigarettes sold across all
outlets was significantly lower than the
recommended prices, but the extent to
which it was lower remained constant
over the course of the study. Study
focuses on only 2 brands – 38% of the
market in 2003 – is this sufficient to
capture valid results?
Validity of author’s conclusion
Increases in price/tax of tobacco products
Author , year
Siahpush, 2009
Country
five largest cities of Australia; Sydney,
Melbourne, Brisbane, Perth, and
Adelaide
Design
Repeat cross-sectional - Econometric
Objective
To examine the effect of price on
cigarette smoking prevalence across
three income groups
SES variables
Income level of households highest
earner; <$18,000 (low); $18,000–
$49,000 (medium); >/=$49,000 (high).
Analyses
Poisson regression modelling
Data sources
Roy Morgan Single Source; weekly
omnibus survey, face-to-face interviews
by Roy Morgan Research, an Australian
market research company. Cigarette
price data were acquired from the retail
trade magazine Australian Retail
Tobacconist,
which
gave
the
recommended retail price for packs of
all brands in each state and territory
throughout the period of the study.
Price was adjusted for inflation to reflect
2006 dollars. The adjusted price is often
referred to as “real price.”
Participant selection
18+ years. random sample of Australian
residents in the five largest cities of
Australia
Participant characteristics
n=515866; 48% male, 21% 18-19 years,
41% 30-49 years. Approximately
18% and 58% of the sample had low and
medium
levels
of
education,
respectively. Approximately 23% and
45% had low and medium incomes,
respectively.
Intervention
Change in adjusted (‘real’) cost of packet
of cigarettes based on two leading
brands; two top selling Australian
brands, Peter Jackson 30s and Winfield
25s,
320
Length of study
1991 to 2006
Outcomes
Smoking prevalence, measured by
whether respondents currently smoked
manufactured cigarettes or had smoked
roll your own tobacco in the previous
month
321
Details
Method
Results
Controls on advertising, promotion and marketing of tobacco
Author , year
Data sources
Cantrell 2013
web-based experimental study
Country
Participant selection
USA
Recruited from two online research
Design
panels
(GfK
Group
[formerly
RCT (random numbers generator)
Knowledge
Networks]
Objective
KnowledgePanel® and Research
To evaluate the potential impact of Now – both had purposive recruiting
pictorial warning labels compared Participant characteristics
with text-only labels among U.S. N = 3,371, adult smokers, 1,665
adult
smokers
from
diverse subjects were randomized to the textracial/ethnic
and
socioeconomic only condition and 1,706 subjects
subgroups.
were randomized to the pictorial
SES variables
HWL condition.
income (<150% federal poverty
<150% FPL:26.3%
level [FPL]/150–300% FPL/300%+ 150–300% FPL:28.1%
FPL);
300%+ FPL:45.6%
education (high school or less/some Education HS or less:29.1%
college/college or more)
Some college:41.6%
Analyses
College+:29.3%
regression analyses adjusted for
race/ethnicity, education, and income
Intervention
Warning label policy. U.S. Family
Smoking Prevention and Tobacco
Control Act of 2009 requires updating
of the existing text only health
warning labels on tobacco packaging
with nine new warning statements
accompanied by pictorial images.
Participants viewed either the new
FDA approved pictorial warnings or
text-only warnings.
Comments
General population
Significantly stronger reactions for the
pictorial condition for each outcome:
salience (b = 0.62, p<.001); perceived
impact (b = 0.44, p<.001); credibility (OR =
1.41, 95% CI = 1.22-1.62), and intention to
quit (OR = 1.30, 95% CI = 1.10-1.53).
SES
Individuals with a high school education or
less compared with higher educated
individuals had stronger responses for
perceived impact and salience. There were
no significant differences in reactions
across income categories.
No significant results were found for
interactions
between
condition
and
race/ethnicity, education, or income. Which
suggest that the greater impact of the
pictorial HWLs compared to the text-only
HWL was consistent across these study
subpopulations. The only exception
concerned the intention to quit outcome,
where
the
condition-by-education
interaction was nearly significant (p =
0.057). Stronger effect for the pictorial
condition versus the text-only condition
among individuals with moderate education
compared with higher educated groups.
Author’s conclusion of SES impact
Findings suggest that the greater impact of
the pictorial warning label compared to the
text-only warning is consistent across
diverse racial/ethnic and socioeconomic
Internal validity
This paper reports wave 1 (of
3) of data analyses. Study
adequately powered. For the
KnowledgePanel®, the panel
recruitment rate was 14.3%
and the survey completion rate
50.4%; for the opt-in panel
(Research Now), the survey
completion rate for the opt-in
panel was 18.0%.
Compared to participants in the
experimental condition, those
in the control group included
slightly more individuals with
college education (i.e., 27.8%
versus
30.9%,),
fewer
individuals with some college
education (i.e., 39.5% versus
43.6%) and fewer individuals
who were ready to quit (21%
versus 24.2%). However, these
differences were relatively
small and only marginally
statistically significant.
Race/ethnicity, education and
income differed across the two
panels by design, due to
purposive recruiting of specific
subgroups
of
smokers
available in each panel.
Smoking behaviors also varied
between the two panels, with
most markers of addiction
322
2x9 factorial with two conditions (textonly and text+ pictorial images) and 9
HWL messages (e.g., ‘‘Cigarettes
cause cancer’’).
Participants assigned to the control
condition were exposed to one of
nine text-only HWLs, and participants
in the experimental condition were
exposed to one of 9 pictorial HWL
with the same text messages as in
the control condition. The HWL
stimuli included the 9 distinct textual
messages and the pictorial imagery
designed to accompany them. The
stimuli consisted of the front of a
plain package of cigarettes, which
was approximately 2 inches wide by
2.75 inches high on the computer
screen with the HWL text or HWL
text+pictorial covering the front and
top 50% of the package. The size,
color and font of the text were
equivalent in both the text only and
text+pictorial images.
Length of study
September 2011
Outcomes
Salience,
Perceived impact,
Credibility,
Intention to quit
populations. suggest that the FDAapproved pictorial HWLs can achieve their
desired
effect
without
exacerbating
inequalities
being somewhat higher among
the
KnowledgePanel®
respondents: for example,
KnowledgePanelH
subjects
smoked
significantly
more
cigarettes per day and had
lower
readiness
to
quit
compared with the opt-in panel.
Table 3 does not report data
for
highest
SES
groups
(income and education)
External validity
The text-only warnings in this
study are not equivalent in
placement, size or font to the
current text-only warnings in
the U.S., which are on the
sides of packs, in smaller font
and in colours that blend in
with the colour scheme of the
pack.
Study does not replicate real
life.
Validity
of
author’s
conclusion
Valid, authors hypothesised
that pictorial labels would be
more effective than text-only
labels amongst lower SES
323
Details
Method
Results
Controls on advertising, promotion and marketing of tobacco
Author , year
Data sources
Frick 2012
Field observations
Country
Participant selection
Columbus, Ohio, USA
Random sample
Design
Participant characteristics
Single cross-sectional
129 licensed tobacco retailers
Objective
Intervention
To assess retailer compliance with Tobacco Control Act and FDA
Food and Drug Administration (FDA) regulations on tobacco sales and
regulations on tobacco sales and advertising practices, including pointadvertising practices, including point- of-sale advertisements. Practices
of-sale advertisements, in two distinct considered out of compliance with
Columbus,
Ohio
neighbourhood FDA regulation were: sales of loose
groups by income.
cigarettes, offering free items with
cigarette or smokeless tobacco (ST)
SES variables
High
and
low
income purchase, and self-service access to
neighbourhoods,
defined
as cigarette or ST products.
proportion of families in poverty with Length of study
those above median designated as October to December 2010
low income and those below median Outcomes
as high income
Compliance with exterior and interior
Analyses
marketing and sales practices
Descriptive, t tests and Chi square
Comments
General population
No outlets were out of compliance by
selling loose cigarettes or offering free
items with cigarette purchase.
SES
Less than 10% of sampled outlets were out
of compliance by offering self-service
access to cigarettes, which did not differ by
neighbourhood income (P<0.05).
There were no significant differences in
compliance by income, but the mean
number of advertisements on the building
and self-service access to cigars was
significantly different by neighbourhood
income (TCA does not apply to cigar selfservice).
Author’s conclusion of SES impact
Highly prevalent advertising and marketing
and also high degree of compliance with
regulations. Some significant difference
between
high
and
low
income
neighbourhoods.
Internal validity
All tobacco retailers required
state licence and only 3
retailers currently in business
were not surveyed.
Single observer.
External validity
Specific to this urban region
and regions with similar
distributions of families in
poverty.
Validity
of
author’s
conclusion
Valid. Study doesn’t inform on
how advertising and sales
practice influence smoking
behaviour.
324
Details
Method
Results
Comments
General population impact
Comparisons on specific elements indicated that
warnings were perceived as more effective if they
were: full color (vs. black and white), featured real
people (vs. comic book style), contained graphic
images (vs. nongraphic), and included a
telephone “quitline” number or personal
information.
Among adults, younger respondents gave higher
effectiveness ratings.
Impact by SES variable
Association between index ratings scores and
both education and income were not significant.
Author’s conclusion of SES impact
The most effective ratings performed equally well
across SES groups.
Internal validity
Due to a technical flaw in the
program, the second set of
warnings assigned to respondents
was not assigned at random from
the remaining eight sets. For
example, for a respondent randomly
assigned to see Set 3 first (all sets
received an arbitrary number for the
purposes of programing), the
second set of warnings was
randomly assigned from sets 4
through 9 only, rather than Sets 1,
2, and 4 – 9. Therefore, the number
of participants who viewed each set
of warnings not balanced.
Internal consistency of the four
outcome measures was tested on a
subset of responses (the first
warning
labels
viewed
by
participants) and was demonstrated
to be very high (Cronbach’s α =
.93). Therefore, a single index of
warning label effectiveness was
created by calculating the mean
rating of the four measures.
External validity
Study sample likely to be more
educated and have a higher
socioeconomic profile than the
general population.
The study setting in which
participants rated a series of
warnings after viewing the warnings
for a brief amount of time does not
replicate the repeated exposures of
health warnings in “real life.”
Controls on advertising, promotion and marketing of tobacco
Author, year
Hammond 2013
Country
US
Study design
Quasi-randomised trial
Objective
To evaluate the efficacy of the 36 proposed
FDA warnings for each of the nine
“statements” or health effects specified in
the Act.
SES variables
Annual net household income (Low
<$30,000,Medium $30,000 – 59,999, High
≥ $60,000)
Education level (Low = high school or less,
Medium
=
technical/trade/community
college or some university, and High =
university degree or higher).
Study analysis
Linear mixed effects models were used to
test all pairwise differences between
individual warnings within each of the nine
health effect sets (separately for the adult
and youth samples), adjusting for multiple
comparisons using the Tukey correction.
Data sources
Web-based survey of US respondents
Participants were compensated with points
from the survey firm (equivalent to ~ $3
USD).
Participant selection
Recruited via email from a consumer panel
through Global Market Insite, Inc.
Participant characteristics
Adult smokers (n=783, aged 19 years or
older, mean age 47, and smoked at least
one cigarette in the last month) and youth
(n=510, aged 16 – 18, including both
smokers and non-smokers).
Adults: 25% low education, 45% medium
education and 30% high education. 24%
low income, 39% medium income, 35%
high income and 2% refused.
Intervention
Web-based survey to view and rate two
sets of 6-7 health warnings, each set
corresponding to one of nine health effect
statements required under the Tobacco
Control Act
Length of study
December 2010
Outcomes
Respondents rated each warning while the
image appeared on screen, one at a time
then ranked the warnings within a set on
325
Details
Method
Results
Comments
Controls on advertising, promotion and marketing of tobacco
overall effectiveness.
Youth not assessed by SES.
Validity of author’s conclusion
Not representative study sample
and results by SES only described
in text.
326
Details
Method
Controls on advertising, promotion and marketing of tobacco
Author , year
Data sources
Hitchman 2012
International Tobacco Control Policy
Country
Evaluation Project.
France, Germany, the Netherlands, Computer-assisted
telephone
UK
interviewing
(CATI).
In
the
Design
Netherlands, two different sampling
Cross-sectional
and survey modes were used: (i) a
Objective
CATI sample a computer-assisted
To examine the effectiveness of the web interviewing (CAWI) sample
text health warnings among daily
Participant selection
cigarette
smokers
in
France,
random digit dialling, CAWI sample
Germany, the Netherlands, UK
drawn from internet panel TNS
SES variables
NIPObase
Education, net household income
Participant characteristics
Analyses
Daily smokers (>/=18 years of age)
Linear and logistic regressions
from France (n = 1,532), Germany (n
= 1,305), the Netherlands (n = 1,788)
and the UK (n = 1,788).
Intervention
The European Commission requires
tobacco products sold in the
European
Union
to
display
standardized text health warnings
Length of study
Single survey wave in each of the 4
countries between 2007 and 2008
Outcomes
(i) smokers’ ratings of the health
warnings on warning salience,
thoughts of harm and quitting and
forgoing of cigarettes;
(ii) impact of the warnings using a
Labels Impact Index (LII), with higher
scores signifying greater impact;
Results
Comments
General population
Scores on the LII differed significantly
across countries. Scores were highest in
France, lower in the UK, and lowest in
Germany and the Netherlands. Impact
tended to be highest in countries with more
comprehensive
tobacco
control
programmes.
SES
Across all countries, scores were
significantly higher among low-income
smokers (i.e. rated warnings more
effective) F3,6142 = 5.44, P = 0.001, with no
significant interaction between country and
income. There was a main effect of
education, F2, 6142 = 5.46, P = 0.004, as
well as a country x education interaction,
F6,6142 = 4.62, P < 0.001. Although
scores on the LII tended to be higher
among smokers with low to moderate
education in France, Germany and the
Netherlands, the opposite trend was
observed in the UK.
Author’s conclusion of SES impact
The impact of the health warnings was
highest among smokers with lower
incomes and smokers with low to moderate
education (except the UK in the case of
education) suggests that health warnings
could be more effective among low SES
groups.
Internal validity
Survey cooperation rates were:
France (75.3%), Germany
(94.9%), the Netherlands CATI
(78.1%),
the
Netherlands
CAWI (78.1%) and the UK
(87.3%).
Stratified
geographically except France
and analyses weighted on sex
and age.
External validity
Comparison of data across 4
European countries.
Validity
of
author’s
conclusion
Valid although UK and France
now have pictorial warnings
327
Details
Method
Results
Comments
Controls on advertising, promotion and marketing of tobacco
(iii) differences on the LII by
demographic characteristics and
smoking behaviour.
328
Details
Method
Results
Comments
Controls on advertising, promotion and marketing of tobacco
Author, year
Kasza 2011
Country
United Kingdom, Canada, Australia, and
the United States
Design
prospective cohort survey
Objective
To examine the effectiveness of
advertising restrictions enacted in
different countries on exposure to
different forms of product marketing, and
differences in exposure across different
SES groups.
SES variables
annual household income and level of
education were combined to create a
three-category indicator of SES using the
following criteria: if both income and
education were low, then SES was
defined as low, if either income or
education was low, then SES was
defined as moderate, and if neither
income nor education were low, then
SES was defined as high.
Analyses
generalized
estimating
equations
multivariate regression analyses adjusted
for age, gender, minority group, and the
heaviness of smoking index
Data sources
International Tobacco Control Four
Country Survey (ITC-4)
Participant selection
Random digit dialling was initially used to
recruit current smokers within strata
defined by geographic region and
community size.
Participant characteristics
21,615 adult smokers (5251 in the UK,
5265 in Canada, 4806 in Australia, and
6293 in the US).
Intervention
35-minute telephone survey to evaluate
the psychosocial and behavioural impact
of various national-level tobacco control
policies on marketing regulations.
Length of study
6 years; waves 1 to 7 collected between
2002 to 2008
Outcomes
Awareness of tobacco marketing through
15 different channels.
General population
Since 2002, various tobacco marketing
regulations have been enacted in the United
Kingdom (UK), Canada, Australia and the
United States.
Tobacco
marketing
regulations,
once
implemented, were associated with significant
reductions in smokers’ reported awareness of
pro-smoking cues, and the observed reductions
were greatest immediately following the
enactment of regulations. While tobacco
marketing regulations have been effective in
reducing exposure to certain types of product
marketing there still remain gaps, especially with
regard to in-store marketing and price
promotions.
SES
Changes in reported awareness were generally
the same across different SES groups, although
some exceptions were noted: awareness of
billboard advertising and arts sponsorships in
the UK were reduced more sharply among
those in the high SES group relative to those in
the low SES group immediately following
enactment of Tobacco Advertising and
Promotion Act 2002.
In each of the four countries, the high SES
groups experienced greater reductions in the
total number of channels through which they
reported being aware of tobacco marketing
compared to the low SES groups. However, at
baseline, the high SES groups in each country
were exposed to more marketing channels than
were the low SES groups, leaving the high
groups more room to experience reduction
across the study period.
Author’s conclusion of SES impact
tobacco marketing regulations are associated
Internal validity
Respondents lost to attrition were
replenished at each wave. All
respondents who participated in at
least one of the seven survey
waves were included in the
present study.
External validity
Findings from each of the four
countries can be compared as
same survey used.
Validity of author’s conclusion
In the UK, national legislation
prohibiting smoking in worksites,
bars,
and
restaurants
was
implemented during this time might
have influenced awareness of
tobacco marketing.
329
with reduced exposure to pro-smoking cues
among all SES groups, evidence indicates that
certain channels are still being used by tobacco
companies to reach significant percentages of
smokers in each country.
330
Details
Method
Result
Comments
General population
Large variations in quit rate and RII
between countries.
Quit rates positively associated with
tobacco control scale score. Policies
related to cigarette price showed the
strongest association with quit ratios. A
comprehensive advertising ban showed
the next strongest associations with quit
ratios in most subgroups. Health
warnings negatively associated with quit
rates.
Regression coefficient 2.08 (-0.36 to
8.48) for men and 2.07 (-1.09 to 8.66) for
women for price.
Regression coefficient 1.33 (1.11 to 8.02)
for men and 1.59 (1.39 to 8.67) for
women for advertising bans.
Regression coefficient 0.94 (-2.43 to
5.89) for men and 0.41 (-3.84 to 5.26) for
women for public place bans.
Regression coefficient 0.54 (-3.05 to
6.17) for men and 0.54 (-3.52 to 6.41) for
women for campaign spending.
Regression coefficient -0.40 (-7.32 to
2.31) for men and -0.42 (-9.51 to 3.43) for
women for health warnings.
A ‘stripped’ analysis focusing on price,
health warnings and treatment (excluding
recent policy developments) supported
the main findings.
SES
Quit rates positively associated with
tobacco control scale score. More
educated smokers more likely to have
quit than lower educated, for men and
women. Larger absolute difference
between high and low educated for 25-39
year olds. However no consistent
Internal validity
Non-response percentages ranged from
about 15% in Italy and Spain up to 49%
in Slovakia, while percentages in most
other countries were between 20% and
35%.
Survey conducted before tobacco control
scale devised, and before some policies
enacted so may underestimate the
impact of recent policies.
Difficult to draw conclusions about
causality as study only examines the
association between ex-smokers and
presence of policies, rather than changes
in prevalence post-implementation.
Occasional smokers excluded from all
analyses.
External validity
Included data from Eastern Europe and
Baltic countries. Limited analyses to the
adult population aged 25–59 years.
Difficulty in drawing conclusions from
multiple nations with varying average
standards of education, definition of
‘highly educated’ likely to vary for some
nations.
Validity of author’s conclusion
Conclusion is consistent with the data
presented; however it’s difficult to draw
strong conclusions about the impact of
any
one
intervention
given
the
methodological limitations discussed
above.
Controls on advertising, promotion and marketing of tobacco
Author, year
Schaap, 2008
Country
18 European countries; Finland, Sweden,
Denmark, England, Ireland, Netherlands,
Belgium, Germany, France, Italy, Spain,
Portugal, Slovakia, Hungary, Czech Rep.,
Lithuania, Latvia, Estonia
Design
Cross-sectional
Objective
To examine the extent to which tobacco
control policies are correlated with
smoking cessation, especially among
lower education groups
SES variables
Education; relative index of inequality
(RII). The RII assesses the association
between quit ratios and the relative
position of each educational group, can
be interpreted as the risk of being a
former smoker at the very top of the
educational hierarchy compared to the
very lowest end of the educational
hierarchy
Analyses
Log-linear regression analyses to explore
the correlation between national quit
ratios and the national score on the
Tobacco Control Scale (TCS).
Data sources
National
health
surveys.
100,893
respondents over 18 countries.
Participant selection
Selection process varies. Non-response
rate between 13.4 and 49% depending
on country.
Participant characteristics
Ireland has most developed tobacco
control policy, Latvia least.
Intervention
Joosens and Raw’s tobacco control scale
used as a proxy, with some analysis by
individual policies including:
Price, advertising bans, public place
bans, campaign spending, health
warnings
Length of study
Year 2000, except Germany and Portugal
= year 1998-9.
Outcomes
Quit ratios
331
differences were found between quit
ratios in high and low educated groups
and tobacco control scale score.
Policies related to cigarette price showed
the strongest association with quit ratios.
Significant positive association between
quit ratio and price for high SES aged 4059 years.
A
comprehensive
advertising
ban
showed the next strongest associations
with quit ratios in most subgroups (not
low SES aged 40-59 or low SES women
aged 25-39 years.
Health warnings negatively associated
with quit rates.
Author’s conclusion of SES impact
High and low educated groups seem to
benefit equally from nationwide tobacco
control policies. More developed tobacco
control policies are associated with
higher quit rates.
332
Details
Method
Results
Comments
Controls on advertising, promotion and marketing of tobacco
Author, year
Willemsen 2005
Country
The Netherlands
Design
Cross-sectional
Objective
To examine the self-reported effect of the
health warnings on cigarette packets on
the attractiveness of cigarettes, on
smokers' motivation to quit and on
smoking behaviour, and to determine
whether these effects differed for
subgroups of smokers.
SES variables
education
Analyses
Univariate and multivariate logistic
regression
Data sources
Continuous Survey of Smoking Habits
(CSSH) carried out by TNS NIPO.
Participant selection
Internet survey in which each week 800
households are randomly selected from a
database of .50 000 households.
Participant characteristics
12,654 aged 15 years+, in original
sample; 3,937 of original sample were
smokers (31%), 3318 (84.3%) had
noticed change to health warnings and
were
asked
further
questions
Intervention
EU Directive as of 30 Sept 2002, the front
of cigarette packets in EU countries were
required to have one of two health
warnings, covering 30% of surface. The
back of the packet must contain one of
14 different health warnings, covering
40% of the surface. On 1 May 2002 the
new health warning labels came into
effect in The Netherlands.
Length of study
June 2002 to June 2003
Outcomes
noticing changes to warnings
smoking behaviour
motivation to quit
Preference for buying pack with / without
new warning
inclination to buy cigarette pack
with new warning
General population
Across the survey period, 3318 (84.3%) said
they had noticed changes to the health
warnings. This percentage was higher in the 3
months directly after the introduction (90%)
compared with the months April to June of 2003
(81% p<0.001).
Of all smokers, 14% indicated they were less
inclined to purchase cigarettes as a result of the
new warnings; 31.8% said they prefer to buy
packets without the new warnings; and 10.3%
said they smoked less because of the new
warnings. A strong dose-response relationship
was observed, e.g. the higher the intention the
greater the impact of the warnings. 17.9%
reported that warnings made them more motivated to
quit; Multivariate analysis showed that those
Internal validity
Excluded proxy interviews and
excluded interviews in April and
May 2003 as smokers unable to
purchase packets containing new
warnings.
External validity
Unclear whether internet survey is
representative
Validity of author’s conclusion
Only surveys smoker participants
who had noticed the new health
warning labels who might be more
motivated to change smoking
behaviour
intending to quit smoking within 1 month had
higher change of reporting that they smoke less
because of new warnings (OR 7.89)
independent of other variables.
SES
Self-reported change in smoking behaviour
There were no significant differences in level of
education for respondents in reported change in
smoking behaviour.
Self-reported change in motivation to quit
More respondents with medium level of
education (19.4%) reported being more
motivated to quit than those of high (18.3%) or
low levels (15.8%) (p<0.001)
Preference for buying pack with/without new
warning
More respondents with a higher level of
education (35.5%) reported a preference for
buying packs without the new warning
compared to those of low (28%%) or medium
333
levels 31%.
Change in inclination to buy cigarette pack
with new warning
There was no significant difference between
education levels in inclination to buy the new
packs.
Author’s conclusion of SES impact
Results by SES not discussed outwith tables
334
Details
Method
Results
Comments
General population
The introduction of the new PHWs was
associated with a 24 absolute percentage point
between-wave increase in Quitline number
recognition (from 37% to 61%, p < .001).
Matched odds ratio of 3.31, 95% CI = 2.63 to
4.21.
SES
A majority of all five quintiles of socioeconomic
deprivation using a small area measure (range
58.0%–65.5%) recognized the Quitline number
in Wave 2. The increase between the waves
was lowest in the most deprived quintile (p <
.001), though this group had the highest level of
recognition
at
baseline.
For
individual
deprivation, the increase was highest in the
second to least deprived grouping and lowest in
the most deprived. For both types of deprivation,
the most deprived had the highest level of
recognition in Wave 1 and the lowest level of
recognition at Wave 2 (though in the latter, the
differences were not significantly different).
Recognition increased from a minority of
respondents to a majority for all deprivation
levels (using small area and individual
measures), and financial stress (two measures).
Author’s conclusion of SES impact
This study provides some evidence for the value
of clearly identifying quitline numbers on
tobacco packaging as part of PHWs and
appeared to benefit all sociodemographic
groups. It may also help equalize differences
that previously existed, for both measures of
deprivation.
Internal validity
Between-wave attrition of 32.9%
occurred.
External validity
The overall response rate for this
study was 32.6%. Weighting
process may not have fully adjusted
for nonresponse bias.
Validity of author’s conclusion
May not be generalisable to whole
of New Zealand due to sampling.
Controls on advertising, promotion and marketing of tobacco
Author, year
Wilson 2010a
Country
New Zealand
Design
Prospective cohort
Objective
To examine how recognition of a national
quitline number changed after new health
warnings were required on tobacco
packaging
SES variables
small area deprivation, individual
deprivation, and financial stress
Analyses
Paired matched odds ratio
Data sources
International Tobacco Control
Policy Evaluation Survey (ITC Project)
New Zealand arm
Participant selection
The NZ arm of the ITC Project survey
differs somewhat from other ITC samples
as the smokers involved are New
Zealand
Health
Survey
(NZHS)
participants. NZHS respondents were
selected by a complex sample design,
which included systematic boosted
sampling of the Māori, Pacific, and Asian
populations. Invited at end of NZHS to
participate in this study.
Participant characteristics
923/1376
Intervention
Wave 1 respondents were exposed to
text-based warnings with a quitline
number but no wording to indicate that it
was the “Quitline” number. Wave 2
respondents were exposed to pictorial
health warnings (PHWs) that included the
word “Quitline” beside the number as well
as a cessation message featuring the
Quitline number and repeating the word
“Quitline.”
Length of study
12 months (wave 1 between March 2007
and February 2008 and wave 2 between
March 2008 and February 2009.
Outcomes
Quitline number recognition
335
Details
Method
Controls on advertising, promotion and marketing of tobacco
Author , year
Data sources
Zacher 2012
3 observational audits
Country
Participant selection
Melbourne, Australia
Stores randomly selected using
Design
electronic white and/or yellow pages
Participant characteristics
Cohort of stores (before and after)
Objective
302 stores (milk bars, convenience
To
evaluate
compliance
with stores, newsagents, petrol station,
legislation which restricted cigarette supermarket)
displays in retail outlets, and to Intervention
assess prevalence of pro- and anti- Point of Sale cigarette display ban.
tobacco elements in stores pre- and Legislation which restricted cigarette
post-legislation.
displays in retail outlets.
SES variables
Experienced fieldworkers attended
Neighbourhood
SES:
Australian stores
and
observed
tobacco
Bureau of Statistics’ Socio-Economic displays, behaving like regular
Indexes for Areas (SEIFA) index of customers.
disadvantage. Low-SES includes Length of study
postcodes in the first two quintiles of October 2010 and December 2011
the
index,
mid-SES
includes Outcomes
postcodes in the third and fourth Anti-Tobacco Signage Index;
quintiles, and high-SES contains Pro-Tobacco Index
postcodes in the upper quintile.
Analyses
mixed model repeated measures
Results
Comments
General population
Of 290 stores, 94.1% observed the full ban
on cigarette package visibility, while new
restrictions on price board size and new
requirements for graphic health warnings
were followed in 85.9% and 67.2% of
stores, respectively. In Audit 3, 89.7% of
the remaining 281 stores complied with
price board restrictions, and 82.2% of
stores followed requirements for graphic
health warnings.
SES
Overall, the prevalence of anti-tobacco
signage
increased
and
pro-tobacco
features decreased between audits for
every store type and neighbourhood SES.
Mid-SES stores had consistently lower
scores than low- and high-SES stores for
non-mandated signage (i.e. removed
graphic health warning indicator) but not
mandated signage.
Author’s conclusion of SES impact
Anti-tobacco signage was observed more
frequently over time in all store types and
for all neighbourhood SES groups. The
large variation in the extent of pro-tobacco
features in different store types prior to the
legislation diminished substantially after the
legislation was introduced, leaving stores of
all types (and from all SES areas) with very
few pro-tobacco features.
Internal validity
Specialist tobacconists were
excluded, as they were exempt
from the legislation.
290/302 still sold tobacco at
second audit and 281/302 still
sold tobacco at third audit.
External validity
sample of stores located in the
Melbourne,
Victoria,
metropolitan area, results may
not be generalizable to all
tobacco retailers in the state of
Victoria, though Melbourne
accounts for 74% of Victoria’s
population
Validity
of
author’s
conclusion
Valid
336
Details
Method
Results
Comments
Data sources
Novosibirsk Quit & Win Campaign 1998
to 2004
Participant selection
n/a
Participant characteristics
18 years and older, smoked at least one
cigarette a day during one year and
wants to quit
Intervention
Interviewed registered participants of
international quit & win campaign one
year after each campaign. Conducted at
same time in each country, all
participants to abstain from 1st May to
29th May and end on International nonsmoking day 31st May. Participants who
did not smoke may take part in drawing
of the prize, abstinence biochemically
confirmed. International prize (10,000
US$) and 6 regional prizes (2,500 US$)
are raffled between winners from
participating countries.
Length of study
6 years; 1998 to 2004
Outcomes
1 month abstinence (cotinine)
1 year abstinence (cotinine)
Uptake of campaign by education level
General population
did not smoke during month of campaign:
1994=69.8% (n=1261)
1996=92% (n=455)
1998=88% (n=1358)
2000=82% (n=1228)
2002=90% (n=742)
did not smoke in following year:
1994=36.5% (n=1261)
1996=37.5% (n=455)
1998=40% (n=1358)
2000=40% (n=1228)
2002=40.6% (n=742)
90% did not smoke during month of campaign
and 40% did not smoke in following year.
Number of people willing to stop smoking
completely increased from year to year.
Participants intentions before the campaign:
Intention to quit completely:
1996=77%
1998=79%
2000=82%
2002=87%
Intention to quit for one month:
1996=11%
1998=10%
2000=8%
2002=2%
Intention to decrease smoking:
1996=12%
1998=11%
2000=10%
2002=11%
Internal validity
Only analyses uptake by education
level and not abstinence
External validity
there is no comparison with the
SES of smokers in the general
population
Validity of author’s conclusion
Cannot tell if there is an equity
effect.
Mass media - Quit & Win campaign
Author, year
Alekseeva 2007
Country
Novobirsk, Russia
Design
Repeat yearly cohorts
Objective
To study participants of the campaign
SES variables
education
Analyses
Registration card at baseline and followup questionnaire at one year follow-up
337
Details
Method
Results
Comments
Mass media - Quit & Win campaign
35% in 1998 and 92% in 2004.
SES
Higher education; 32% in 1998, 43% in 2000,
30% in 2002;
Secondary professional education; 28% in 1998,
27% in 2000, 27% in 2002;
Secondary school education; 15% in 1998, 16%
in 2000, 13% in 2002
Primary education; 10% in each campaign
Author’s conclusion of SES impact
Mass antismoking campaigns are effective.
338
Details
Method
Results
Comments
Data sources
Telephone survey
Participant selection
Comparison group selected by
random telephone survey from larger
4-county area
Participant characteristics
231 Quit & Win Challenge
participants from two of the four
Eastern Ontario counties (Frontenac,
Lennox & Addington). 1) Residents
of Eastern Ontario; 2) aged 18 or
older; 3) daily smokers, consuming a
minimum average of 10 cigarettes
per day; and 4) entered the Quit and
Win contest in January 1995.
Smokers selected by random
telephone survey (n = 385) came
from these regions as well as two
neighbouring counties (Hastings,
Prince Edward). 1) Residents of
Eastern Ontario; 2) aged 18 or older;
and 3) daily smokers, consuming a
minimum average of 10 cigarettes
per day.
4 counties in Eastern Ontario =
combined
population
of
approximately 306,000. About two
thirds of the population resided in an
urban area, and the first language of
92% of residents was English. The
General population
After one year, 19.5% of Quit & Win
participants reported that they were smokefree, whereas less than 1% of the random
comparison group had achieved cessation.
Participation rate of 0.83% combined with
the cessation rate means impact rate was
0.17% (extrapolates to 1 in 8 smokers led
to quit due to Quit & Win contest).
SES
Compared with the random survey group,
Quit and Win participants tended to be
more educated at baseline.
Intervention vs control:
Less than high school 1.8% vs 11.2%
Some high school 13.2% vs 22.9%
Completed high school 29.8% vs 34.0%
Some college/university 16.7% vs 14.0%
Completed college 38.6% vs 18.2%
P=0.001
Author’s conclusion of SES impact
No association between level of education
or occupation level and cessation at one
year. The intervention did not well
represent smokers with lower SES.
Internal validity
Response rates = 97.7% for
intervention group and 92.8%
for control group
Follow-up rate = 86.5%,
n=200) in intervention group
and 84.4% (n=325) in control
group
External validity
Specific to region of Eastern
Ontario.
87% Quit & Win participants
were actively trying to quit at
baseline (and were more likely
to successfully quit) so only
relevant to highly motivated
population. person's motivation
to quit, as indicated by
categorization according to the
Stages of Change model,
showed a strong (albeit not
statistically
significant)
association with one-year
cessation.
Validity
of
author’s
conclusion
Valid – less SES could be due
to differences in motivation
between SES groups or
differences in exposure to
advertising/methods
of
Mass media - Quit & Win campaign
Author, year
Bains 2000
Country
4 counties, Eastern Ontario, Canada
Design
Cohort with comparison cohort group
Objective
To evaluate the impact of an
intervention that was developed to
help daily smokers to quit smoking
completely.
SES variables
education
Analyses
Bivariate and multiple logistic
regression
339
Details
Method
Results
Comments
Mass media - Quit & Win campaign
median household income in 1991
was about $44,000, and the overall
rate of unemployment was 8.6%.
Intervention
Quit & Win challenge, incentivebased intervention plus Quit Kit. The
intervention was developed to help
daily smokers to quit smoking
completely.
Enrolled adult smokers who pledged
to quit smoking for a designated
period of time. In exchange, they
were entered into a lottery with a
cash prize of $1,000 and secondary
prizes of lesser values. The initiative
was promoted through the local print
and radio media, as well as through
the distribution of leaflets. A contest
winner, who was required to be
smoke-free in the month leading up
to the prize ceremony, was selected
by random draw approximately three
months after the contest was
initiated. As described in the contest
rules, the winner was asked to
provide the name of a "buddy" to be
contacted to verify his or her smokefree status. Those who enrolled in the
contest were also given the
educational
Quit
Kit,
which
contained a letter of encouragement,
advertising by SES groups.
340
Details
Method
Results
Comments
Mass media - Quit & Win campaign
information on cessation methods, a
list of local cessation programs,
helpful tips on maintaining a smokefree status and a refrigerator magnet
with the telephone number of a
health unit information line.
Length of study
1995 to 1996
Outcomes
Self-reported 6 months continuous
abstinence
341
Details
Method
Results
Comments
Data sources
2006 New York City Department of
Health and Mental Hygiene (DOHMH)
annual health surveys
Participant selection
random-digit–dialed health surveys of
approximately
Participant characteristics
10,000 adult New York City residents
Intervention
Extensive, television-based anti-tobacco
media campaign using graphic imagery
of the health effects of smoking; focused
on increasing smokers’ motivation to quit.
Advertisements included testimonials
from sick and dying smokers and graphic
images of the effects of smoking on the
lungs, arteries, and brains of smokers.
Advertisements
included
diverse
messages in both English and Spanish.
The television campaign broadcast for 23
of 40 weeks during January–October
2006, with 100–600 gross ratings points
(GRPs) per week, for a total of
approximately 6,500 GRPs.
New York State Department of Health
also aired a separate, simultaneous
statewide television-based anti-tobacco
media campaign that included New York
City.
The
campaign
included
advertisements featuring graphic images
of the effects of smoking and
emphasizing the effects of secondhand
smoke on children. The broadcasts
equated to approximately 4,400 GRPs in
New York City from January through
December 2006. Thus, in total, New York
General population
The smoking prevalence among New York City
residents decreased significantly from 21.5% in
2002 to 18.4% in 2004 (p<0.001). From 2004 to
2005, smoking prevalence did not change
significantly among New York City residents
overall. in 2006, the year during which television
advertisements were aired, smoking prevalence
did not change significantly among New York
City residents overall (17.5% in 2006 compared
with 18.9% in 2005, p=0.055). The total
decrease associated with New York City’s
comprehensive program from 2002 to 2006 was
19%, an average annual decrease of 5%.
SES
From 2002 to 2004 decreases were
demonstrated in all education subgroups. %
change in smoking prevalence from 2002 to
2006 among those with less than a college
education was higher than among those with
more education (p<0.001). From 2004 to 2005,
no significant changes occurred within
education subgroups.
Author’s conclusion of SES impact
Intensive, broad-based media campaign has
reduced smoking prevalence among certain
subgroups.
Internal validity
telephone survey excluded certain
populations
(e.g.,
military
personnel residing on bases,
institutionalized populations, and
persons
without
landline
telephones
External validity
This decrease in prevalence
occurred more quickly than those
documented
by
BRFSS
in
California (3%–4% annually during
1998–2005), Massachusetts (2%
annually during 1995–2005), or the
United States as a whole (2%
annually during 1965–2004 and
3% annually during 2002–2006) in
any period since data were first
collected in 1965.
Validity of author’s conclusion
Editor’s note: the New York City
data suggest that large-scale,
intensive
anti-tobacco
media
campaigns, when implemented in
the
context
of
existing
comprehensive
tobacco-control
components such as taxation and
smoke-free workplace legislation,
can have a contributory
effect on reducing smoking
prevalence
among
certain
subpopulations
Mass media
Author, year
CDC 2007
Country
New York City, USA
Design
Before and after study (different
participants)
Objective
To assess the effect of two mass media
campaigns on smoking prevalence
SES variables
education
Analyses
regression
342
Details
Method
Results
Comments
Mass media
City adult smokers were exposed to
nearly 11,000 GRPs during this 1-year
period, equating to the average viewer in
NYC
seeing
an
advertisement
approximately 110 times over the year.
Length of study
4 years, 2002 to 2006
Outcomes
Smoking prevalence
343
Details
Method
Results
Comments
Data sources
Anonymous survey in homes
Participant selection
Selected from the database of 1.124,711
individual radio and TV subscribers in the
Republic of Croatia. The selection was
geographically stratified, with a variable
fraction according to the density of the
population.
Participant characteristics
2,143 (1,026 men and 1,117 women) TV
viewers and radio listeners aged 15 and
older. The selected group of subjects
consisted of 700 individual radio and TV
subscribers and all members of their
households who were 15 years or older.
Intervention
First national ‘smoke out day’ media
campaign on first day of Lent as part of
the ‘Say yes to no smoking’ campaign.
The activity was connected with an event
of cultural and religious significance for
the majority of the Croatian people (88%
of the population are Roman Catholic)
and was also supported by other religious
communities, governmental, and nongovernmental
associations.
Various
strategies were used (intense media
campaign, round tables, stands, public
events at main town squares, activities in
nurseries, schools, and work places). The
aim of these simultaneous activities was
to reach the target population, ie
smokers, in the phase of contemplation
about quitting smoking regardless of age,
gender, or duration of smoking.
Length of study
General population
In the total analysed sample 1,822 (85.0%)
heard of the activity and 1,608 (75.0%) knew the
exact date of the “Smoke out day.” Among
smokers, 27% had given up smoking on that
day and 16% declared they would not smoke
during Lent.
SES
Among smokers, 141 (15%) subjects had
primary school education, 579 (64.1%)
secondary school education, 71 (7.9%) had
university education, and 112 (12.4%) were
students.
The analysis of abstainers according to the level
of education showed that the lowest response to
“Smokeout day” was among smokers with
university education. 20.4% primary school
educated abstained for one day, compared with
59.1% secondary school educated, 16.8%
university educated (3.7% were students).
Author’s conclusion of SES impact
Antismoking mass media activity can influence
smokers’ behavior especially if it is connected to
cultural and religious aspects. In the future,
efforts should be made to make activities and
messages more attractive to different subgroups
of smokers and evoke a better response.
Internal validity
Of 2,310 selected listeners and
viewers, 2,143 (92.7%) responded
and were interviewed.
External validity
members of the household who
were currently in institutions or in
other town were excluded from the
study.
The
study
is
only
generalisable to Croatia and
possibly other countries with
majority Roman Catholics.
Small numbers in group of
abstainers limits generalisability.
Validity of author’s conclusion
Abstaining for one day may not
lead to long-term abstinence.
Mass media
Author, year
Civljak 2005
Country
Croatia
Design
Cross-sectional
Objective
To evaluate the impact on smokers
behaviour of ‘smoke out day’ depending
on gender age and education level
SES variables
education
Analyses
344
Details
Method
Results
Comments
Mass media
One week (began the day after ‘smoke
out day’ 2003
Outcomes
Smoking behaviour
Attitudes to smoking
345
Details
Method
Mass media
Author , year
Dunlop 2012
Country
New
South Wales, Australia
Design
Repeat cross-sectional
Objective
To identify modifiable factors that
increase the efficiency of an
advertisement reaching the target
audience and of their recalling that
advertisement.
SES variables
The income and education variables
were combined into dummy variables
indicating low, middle or high SES.
Postcodes were used with the SocioEconomic Indices for Areas to
indicate
neighbourhood
SES
(quintiles 4–5=low SES, quintiles 1–
3=moderate–high SES).
Analyses
Multivariable logistic regression
Results
Data sources
The Cancer Institute NSW’s Tobacco
Tracking Survey (CITTS) telephone
survey with weekly interviews of adult
smokers and recent quitters
Participant selection
Households are recruited using
random digit dialling of landline
telephone numbers and a random
selection procedure is used to select
participants (selecting the nth oldest
eligible adult in the household).
Participant characteristics
Adutl smoekrs and recent quitters,
N=13,301, 42% low SES, 25%
moderate SES, 33% high SES
Intervention
Antismoking
advertising,
low
emotion; high emotion with graphic
imagery; high emotion with narrative
format
Length of study
April 2005 and December 2010
Outcomes
Unprompted recall,
Prompted recognition
Comments
General population
GRPs and broadcasting recency were
positively associated with advertisement
recall, such that advertisements broadcast
more at higher levels or in more recent
weeks were more likely to be recalled.
Advertisements were more likely to be
recalled in their launch phase than in
following
periods.
Controlling
for
broadcasting parameters, advertisements
higher in emotional intensity were more
likely to be recalled than those low in
emotion;
and
emotionally
intense
advertisements required fewer GRPs to
achieve high levels of recall than lower
emotion advertisements. There was some
evidence for a diminishing effect of
increased GRPs on recall.
SES
Unprompted recall:
Univariate associations: moderate and high
SES had increased OR for recall compared
to low SES. Neighbourhood SES not
significant.
Multivariate association: high SES but not
moderate SES had increased OR for recall
compared to low SES (OR 1.11,
95%CI:1.04 to 1.19)p=0.001.
Multivariate with interactions (between
advertisement type and broadcasting
parameters): high SES but not moderate
SES had increased OR for recall compared
to low SES.
Prompted recognition:
Internal validity
Tracked recall and recognition
while advertisements were
currently or recently on air.
External validity
Overall response rate of 40%
limits generalisability.
Validity
of
author’s
conclusion
Authors do not discuss SES
data in text, only reported in
tables.
Individual composite measure
of SES (income and education)
but
not
neighbourhood
measure of SES showed
significant associations with
recall
and
recognition.
Association
was
different
between
two
outcome
measures: high SES had
increased recall, moderate and
high SES had decreased
recognition in comparison with
low SES.
346
Univariate associations: moderate and high
SES had decreased OR for recognition
compared to low SES. Neighbourhood SES
not significant.
Multivariate association: high SES and
moderate SES had decreased OR for recall
compared to low SES (OR 0.91, 95%CI:
0.85 to 0.97, p=0.004; and OR 0.89 95%
CI: 0.83 to 0.96, p=0.002 respectively.
Multivariate with interactions (between
advertisement type and broadcasting
parameters): high SES and moderate SES
had decreased OR for recall compared to
low SES.
Author’s conclusion of SES impact
Not reported
347
Details
Mass media
Author, year
Durkin, 2009
Country
Massachusetts, USA
Design
Cohort
Objective
To assess which types of mass
media messages might reduce
disparities in smoking prevalence
among disadvantaged population
subgroups
SES variables
Cumulative measure. High school
education or lower and household
income of $50,000 or less = low
SES. More than $50,000 household
income and at least college
education = high SES. All others
medium.
Analyses
Multivariate
logistic
regression.
Exposure measured by Gross Rating
Points (GRP, estimated). 1 unit
increase in GRP equates to 10
exposures to an advert over the
study period.
Method
Results
Comments
Data sources
First 2 waves of UMass Tobacco
Study, a longitudinal survey of
Massachusetts adults designed to
investigate
responses
to
the
Massachusetts Tobacco Control
Program.
Participant selection
Probability sample of 6739, oversampling 18-30 year olds and recent
quitters. Response rate 46%, follow
up rate 56%. Excluded those not
smoking at baseline and not from
Massachusetts’s three main media
markets.
Participant characteristics
Average age 40, 55% women, 41%
ear under $50,000, 46% high school
education or lower. 87% live in
Boston. 83.9% non-Hispanic white.
Intervention
Television adverts of varying intensity
aired in the two years prior to data
collection.
20.2%
were
highly
evocative
personal
testimonials,
13.4% emotional but not testimonials,
11.2% testimonials but not highly
emotional, and 53.7% not highly
emotional or testimonials.
Length of study
24 months (baseline was January
2001 to June 2002, follow-up was
January 2003 to July 2004)
Outcomes
Smoking status (quit=one month
General population
On average, smokers were exposed to
more than 200 antismoking ads during the
2-year period, as estimated by televised
gross ratings points (GRPs). The odds of
having quit at follow-up increased by 11%
with each 10 additional potential ad
exposures (per 1000 points, OR=1.11; 95%
CI=1.00, 1.23; P<.05).
Greater exposure to ads that contained
highly emotional elements or personal
stories drove this effect (OR=1.14; 95% CI
1.02, 1.29; P<.05), which was greater
among respondents with low and mid
socioeconomic status than among high–
socioeconomic status groups. Comparison
ads show no significant effect (OR=0.93)
SES
Television-watching frequency varied, low
SES more likely to watch TV 0-3 days a
week or 7 days a week (no indication of
length of time viewing).But reports no
significant variation in exposure: Low 440.5
GRP, Mid 439.9, and High 434.8.
Likelihood of quitting for each 10
additional potential exposures to an
emotionally evocative or personal
testimonial ad, adjusting for all covariates:
Increased for respondents in the low-SES
group (approx. 13%), the mid-SES group
(highest increase, approx. 47%), and the
undetermined-SES group. By contrast,
smokers in the high-SES group showed a
decreased likelihood of quitting with each
Internal validity
One branch of adverts not
included in analysis due to lack
of data on exposure.
Unusual interpretation of socioeconomic status.
218 (14.6%) undetermined
socio-economic status due to
lack of data.
Tracking quit rates against
exposure pre-baseline. Miss
those who quit smoking during
the initial two year period, and
the effect of other interventions
during the subsequent two
years.
External validity
Population appear to have
similar characteristics as the
UK
population.
Unclear
whether English audiences
would react as strongly to
emotive adverts.
Validity
of
author’s
conclusion
Disagree about overall impact
of the advert exposure - raw
data shows middle and high
SES groups had a higher quit
rate than low SES despite
lower overall exposure. But
they report no significant
interaction
between
total
exposure and SES.
Greater impact on mid-SES
348
Details
Method
Results
Comments
abstinence)
10 additional potential exposures to these
types of ads.
Quit status at follow-up: 12.9% of low
SES ex-smokers at follow up, 18.2% of mid
and 19.2% of high SES. Middle and high
SES groups had a higher quit rate than low
SES despite no significant variation in
exposure between SES groups.
Effects of Potential Exposure
to 2 Types of Ads on Odds of Quitting
Smoking: Mid SES significantly more likely
to quit than low SES (OR=1.70, 1.02-2.83,
p<0.05) High SES slightly less significant
(OR=1.70,
0.95-3.03,
p<0.1).
Undetermined SES most likely to quit
(OR=2.11, 10.7-4.14, p<0.05).
Greater impact on mid-SES groups than
low.
Author’s conclusion of SES impact
Considered together, all adverts had an
equal effect on SES. Exposure to harder
hitting adverts (highly emotional and/or
personal testimonial) had a greater impact
on low and mid-SES groups. Likely to be
more effective among high-risk (low SES),
and high-proportions of smokers (midSES).
groups than low.
No
relationship
between
television watching and SES,
suggests that adverts could be
better targeted to have a
greater impact on SES.
Role of undetermined SES
group may be undermining the
significance of intervention’s
impact.
Mass media
349
Details
Mass media
Author , year
Farrelly 2012
Country
New York State, USA
Design
Repeat cross-sectional
Objective
To assess the impact of emotional
and/or graphic antismoking TV
advertisements on quit attempts in
the past 12 months among adult
smokers in New York State.
SES variables
Education (high-school degree or
less education and at least some
college education),
Household income (<$30,000 and
>/=$30,000)
Analyses
Regression
Method
Results
Comments
Data sources
New York Adult Tobacco Surveys
(NY-ATS)
Participant selection
random-digit-dial telephone survey
Participant characteristics
8780 current adult smokers (at least
100 lifetime cigarettes and smoking
every or some days at time of
interview) for GRP models and 5936
for confirmed recall models
Intervention
Mass
media
–
antismoking
advertisements, emotional and/or
graphic. Smokers saw an average of
three emotional and/or graphic
(defined as such by interrater
agreement 0.81 to 1.00) and three
comparison advertisements (defined
as not emotional and/or graphic) per
month across the study period. Of
the 142 study advertisements, 98
(69%) were comparison and 44
(31%)
were
emotional
and/or
graphic.
Length of study
Quarterly data from 2003 to 2010
Outcomes
Exposure (self-reported confirmed
and market level gross rating points
= annual number of GRPs for each of
the ten media markets in the state.
Past-year GRP variables were
divided by 5000 such that an OR
General population
Overall exposure
Both measures of exposure to antismoking
advertisements (all types) are positively
associated with increased odds of making
a quit attempt among all smokers. Current
smokers who recall recently seeing at least
one advertisement have an increased odds
of making a quit attempt in the past year of
31% (p<0.01). For every increase of 5000
GRPs annually, the odds of making a quit
attempt increase by 21% (p<0.01).
Education is not a predictor of quit attempts
by all types of exposure measured by
confirmed recall and past-year GRP
models. Income is marginally signifıcant in
the confırmed recall model.
Exposure by type
Exposure to emotional and/or graphic
advertisements is positively associated with
making quit attempts among smokers
overall. Exposure to advertisements
without strong negative emotions or
graphic images had no effect. Recalling at
least
one
emotional
or
graphic
advertisement recently is associated with a
29% increase in the odds of making a quit
attempt (p<0.05), whereas each additional
5000 GRPs of exposure to emotional
and/or graphic advertisements in the past
year is associated with a 38% increase in
the odds of making a quit attempt (p<0.01).
Education is not a predictor of quit
attempts, income is marginally signifıcant in
Internal validity
Data were weighted to reflect
the state population of adults,
adjusting
for
different
probabilities of selection and
survey nonresponse.
Controlled for market-level
cigarette prices and an annual
secular trend variable.
External validity
Specific to New York Ste
adults.
Validity
of
author’s
conclusion
As well as exposure by SES
measured through both recall
and GRP, this study provides
quit attempts by SES.
Results show equally effective
for all SES when measured by
GRP but most effective for high
SES for all types of adverts
and for low SES for emotional
and/or graphic adverts when
measured by recall.
350
Details
Method
Results
represents the change in odds for an
increase of 5000 GRPs).
Past year quit attempts
the confırmed recall model.
SES
GRP measure
Exposure to all types of advertisements
and
to
emotional
and/or
graphic
advertisements is positively associated with
making quit attempts by income, and
education.
Comments
Mass media
Recall measure
Smokers with incomes of >/=$30,000, and
smokers with some college education or
beyond were more likely to make a quit
attempt if they reported recall of
advertisements (all types).
Recall of emotional and/or graphic
advertisements was associated with
making a quit attempt for smokers with
incomes <$30,000 and those with a highschool degree or less (p<0.05).
Exposure
to
the
comparison
advertisements, as measured by past year
GRPs and confırmed recall, was not
associated with quitting for any group of
smokers.
Author’s conclusion of SES impact
The
emotional
and/or
graphic
advertisements were effective with lowincome and low education smokers.
351
Details
Mass media
Author , year
Graham, 2008
Country
Minnesota and New Jersey, USA
Design
Cohort
Objective
To examine the feasibility of online
advertising to increase demand for
cessation services.
SES variables
Education
Analyses
Univariate
Method
Results
Comments
Data sources
Healthways QuitNet database
Participant selection
Registered with QuitNet either
through traditional (n=23293) or
online
advertising
(n=8536,
total=9655 but 1119 registered for
phone only and data not available).
Participant characteristics
Predominantly female (59%), white
(84%), age 25-44 (57.3%), preparing
or contemplating quitting (86.1%)
Intervention
Online ads placed on national and
local websites and search engines
between Dec 1 2004 and October 31
2006 to promote QuitNet’s webbased cessation program and state
run telephone quitlines (Minnesota
and New Jersey). Invite user to click
to receive more information (3 diff
ways
to
quit).
Comparison:
Billboards, tv and radio ads, outdoor
ads (eg bus shelters), direct mail and
physician referrals.
Length of study
December 1, 2004 and October 31,
2006
Outcomes
Number of’ clicks’, demographic,
smoking
and
treatment
use
characteristics of those recruited, and
cost.
General population
106291 clicked on online advert, but only
9.1% registered for Intervention (6.8% for a
web-only intervention).
Online ads recruited more males, nonwhites, and 18-24 years, with high school
degree or less.
Significant, but relatively small, difference
in engagement with the intervention
between smokers recruited traditionally and
via the online ads.
SES
Online ads recruited more people with a
high school degree or less than traditional
media (24.6% v 23.2%, p<0.02). Humorous
online ads were significantly more likely to
recruit than traditional media (26.8%,
p<0.01).
Banner adverts, rather than actively
searching for cessation assistance, was a
source of significantly more smokers with
high
or
lower
school
education.
Engagement not analysed by SES.
Author’s conclusion of SES impact
More effective at recruiting smokers from
certain minority groups. Results suggest
that online advertising is promising.
Enrolment rate of 9.1% exceeds most
studies
of
traditional
recruitment
approaches.
Internal validity
Big drop off between those
who click on the ads and those
who register
External validity
Only likely to attract, and keep
engaged those who are fairly
regular internet users. Study
was a partnership between
Healthways Quitnet, ClearWay
Minnesota and New Jersey
Dept. of Health.
Validity
of
author’s
conclusion
Would fail to reach parts of the
population who are not internet
users, or infrequent users so
potential equity impact for the
lowest groups is limited.
Doesn’t entirely compare like
with like – humorous ads may
be
more
effective
than
traditional media as a whole
but may not be as effective as
a humorous traditional advert.
May still be inequitable as
doesn’t compare to SES and
smoking in the population
352
Details
Mass media
Author, year
Hawk 2006
Country
Erie and Niagara counties, Western
New York region, USA
Design
3 intervention groups with regional
control group
Objective
To compare baseline characteristics
and determine abstinence and
predictors of abstinence.
SES variables
Education;
Analyses
Multivariate logistic regression
Method
Results
Comments
Data sources
Telephone survey of the Quit & Win
and NRT giveaway, compared with
Erie-Niagara Tobacco Use Survey
(ENTUS)
Participant selection
Random sample of 341 Quit & Win
participants (40%) and 314 (46%)
NRT voucher and 230 (100%)
combination group. Follow-up rates
were 60-64%, n=204, 179, 143 for
Quit & Win, NRT, combination
groups respectively.
Participant characteristics
Quit & Win participants younger
than those signed up for NRT
voucher.
N=849 Quit & Win only;
N=690 NRT only;
N=230 combination group;
Intervention
Concurrent Quit & Win contest and
nicotine replacement therapy (NRT)
voucher giveaway. Smokers could
enrol in both or either programme
(combined group).
Daily smokers (at least 10 cigarettes
per day) offered opportunity to win
prizes including $1000 if they
stopped smoking for the month of
January 2003 with quit date of 1st
January. NRT voucher redeemable at
General population
At follow-up the self-reported quit rates
were similar across 3 intervention groups:
25 to 30%. Higher quit rate in younger
smokers in the combination group.
SES
‘more than high school education’
Quit & Win: 62%
NRT: 57%
Combined: 60%
Erie-Niagara Tobacco Use Survey: 51%
Compared with smokers in region – those
enrolled in the 3 interventions had more
years of formal education p<0.05.
Adjusted OR for 7-day point prevalence =
1.11 (95% CI: 0.72 vs 1.70) for ‘high
school or less’ vs ‘some college’
Author’s conclusion of SES impact
The results for recruitment of low educated
smokers were not positive.
Internal validity
Completers were older than
noncompleters (41 years vs 38
years). Quit & Win participants
had follow-up that was 2 weeks
earlier than other 2 groups.
External validity
We don’t know how
representative the regional
cohort of smokers was in the
ENTUS survey, authors’ state
‘relatively representative’.
Smokers in all 3 intervention
groups were heavier smokers
than in general population (2021 vs 17 cigarettes per day).
Validity of author’s
conclusion
don’t know how representative
the regional cohort of smokers
was in the ENTUS survey
which was used to measure
reach
353
Details
Method
Results
Comments
Mass media
pharmacies for a 2-week supply of
nicotine gum or patch.
Media coverage included press
conference, newspaper and television
coverage. $35,000 spent on radio
advertisments aired on 6 local radio
stations. Focus mainly on Quit &
Win contest – when phoned Ney
York State (NYS) quitline people
were informed of free NRT
giveaway.$22,500 newspaper
advertising of Quit & Win and NRT
then $22,500 only on Quit & Win.
Marketed to minority populations (A
frican American and Latino) using
newspaper, churches and community
sites.
Length of study
4 to 7 months from 1st January 2003,
median 5.5 months follow-up
Outcomes
Reach,
7-day point prevalence
354
Details
Mass media
Method
Result
Comments
Author, year
Levy, 2006
Country
USA
Design
Repeat cross-sectional
Objective
To
examine
association
between smoking and tobacco
control policies among women
of low SES.
SES variables
Not completed high school or
no high school degree or GED
Analyses
multivariate logistic models,
Data sources
Tobacco Use Supplement, four waves
between 1992 and 2002. Sample nationally
representative of non-institutionalised civilian
population over the age of 15.
Participant selection
Females grouped by education level (less
than high school, high school or higher,
bachelor’s degree). Low education males
included as a reference population. Sample
varies between 176,452 and 228,552.
Participant characteristics
Majority white, with increasing Hispanic
proportion in later surveys. Majority 25 year
olds or over. Over 40% from the South,
approx. 20% each from the Midwest,
Northeast and West.
Low educated female constitutes between
21.6 and 26.6% of each survey, mideducated 19.3-22.4%, high educated are 7.3
to 9.2%
Intervention
cigarette prices, clean air regulations, and
tobacco control media campaigns,
Clean air laws were represented by an index
of state level clean air regulations. States
with ‘‘no smoking allowed (100% smoke
free)’’ were counted as 100% of the effect,
with ‘‘no smoking allowed or designated
smoking areas allowed if separately
ventilated’’ as a 50% effect, and with
‘‘designated smoking areas required or
allowed’’ as a 25% effect. We used separate
indices by type of law, and settled on an
aggregate weighted index, with worksite laws
weighted by 50%, restaurant laws by 30%,
and laws for other public places by 20%.
Media campaign exposure measured at the
state level rather than individual, and youth
campaigns coded as half a media campaign.
General population impact
Smoking prevalence declining across all
categories.
SES
Price:
As price increased the OR of low-education
female smoking fell, but influence varies
over survey waves. Only lower than 1 in
1992-3 and 2001-02. Med-higher educated
groups less responsive.
Media:
In a state with a media campaign low
education women’s OR=0.86, medium
education = 0.89, high = 0.93 (non sig).
Low education men also significantly less
likely to smoke (0.92) Generally, the
association of the media variable and
smoking prevalence declines in the more
recent survey waves.
Smokefree legislation
Marginal effect on current smoking. Over
the period 1992–2002, current smoking
among low education women is inversely
related to the index of clean air laws with
an odds ratio of 0.91 (0.80, 1.03), but is
significant only in the medium education
female subpopulation, with an odds ratio of
0.88 (0.83, 0.94). However, only in the
2001/02 model do clean air laws seem to
play a part for the medium education
female sample, although the confidence
intervals around the estimates for each
survey wave overlap for this group.
Author’s conclusion of SES impact
Low
education
women
particularly
responsive to media and price increases
especially in comparison with high
education women. Tax increases can play
an important role. Tax increases and media
messages may reduce prevalence among
Internal validity
No before and after, simply tracks the
association between policy and prevalence.
Fail to adjust for confounding individual
characteristics.
Small sample sizes at some state levels.
External validity
Most of the developments in clean air
regulations at the state level occurred after
2001.
A number of tobacco control policies were
introduced during this period as well as
changing social norms and increasing
awareness, all of which may have influenced
the results. Data is now one, in some cases
nearly two, decades out of date. Covers a
substantial Hispanic population that wouldn’t
exist in the UK.
No description of the types of media
campaigns involved, and which were the most
effective (either the mode of intervention or
locations) in order to replicate the study.
Validity of author’s conclusion
No examination of individual level exposure, or
whether media campaigns were actively
influencing people to change their smoking
behaviour. Outcome may simply be the
consequence of changing social norms in
these populations.
355
Length of study
1992 to 2002
Outcomes
Individual use, attitudes towards smoking
and clean air laws, and smoking bans at
home or work.
women with low education. Health-SES
relationship not irreversible.
356
Details
Mass Media
Author , year
Nagelhout 2013
Country
The Netherlands
Design
Cohort
Objective
To examine age and educational
inequalities in smoking cessation due
to the implementation of a tobacco
tax increase, smoke-free legislation
and a cessation campaign.
SES variables
Education, low (primary education
and lower pre-vocational secondary
education), moderate (middle prevocational secondary education and
secondary vocational education) and
high [senior general secondary
education, (pre-) university education
and higher professional education].
Analyses
Univariate and multivariate logistic
regression. All analyses were
weighted by age and gender to be
representative of the adult smoker
population in the Netherlands.
Method
Results
Comments
Data sources
Three
survey waves
of
the
International Tobacco Control (ITC)
Netherlands Survey, 2008 (before)
and 2009 and 2010 (after)
Participant selection
Recruited from a probability-based
web database
Participant characteristics
N=1820/2331 (78.1%) in first survey,
1447 in second survey and 1275 in
third survey. Analyses restricted to
respondents who participated in all
three survey waves (n=1176). And
excluded 128 who had quit during
2008 and 2009 surveys, n=1048 and
then answered all questions, n=962.
Dutch smokers (having smoked at
least 100 cigarettes in their lifetime
and currently smoking at least once
per month) aged 15 years and older
Intervention
Tobacco tax increase, smoke-free
hospitality industry legislation and
mass media cessation campaign (all
at national level) implemented during
the same time period in the
Netherlands in 2008. The Dutch
cessation campaign focused on
smokers with low to moderate
educational levels.
Length of study
2008 – 2010
General population
Cessation:
281 out of 962 respondents (29.3%) had
tried to quit smoking between the 2009 and
2010 surveys. At the 2010 survey, 86 out
of
962
respondents
(8.9%)
had
successfully quit smoking. There were no
significant age inequalities in successful
smoking cessation. Smokers aged 15–39
years were more likely to attempt to quit
smoking.
Exposure:
In total, 82.4% reported having paid more
for their cigarettes in the 2009 survey than
in the 2008 survey, 65.6% reported having
visited a drinking establishment that had
some form of smoking restriction and
83.1% reported having experienced one or
more parts of the campaign. Smokers aged
15–24 years were more exposed to the
smoke-free legislation, whereas smokers
aged 25–39 years were more exposed to
the cessation campaign.
Exposure to the smoke-free legislation and
to the cessation campaign had a significant
positive association with attempting to quit
smoking in the univariate analyses, but not
with successful smoking cessation. In the
multivariate analyses, only the association
between exposure to the smoke-free
legislation with attempting to quit smoking
remained significant [odds ratio (OR)=1.11,
95% confidence interval (95% CI)=1.01–
1.22, P=0.029]. Exposure to the price
Internal validity
70% follow-up rate
External validity
Prices increased by only 8%.
Smokefree legislation was
weak, not well implemented
and issues with compliance.
Study authors report that
almost half of the sample was
either lost to follow-up or did
not answer all questions.
These
respondents
were
younger, less addicted and had
more intention to quit smoking.
Therefore, our results may not
be fully generalizable to the
broader population of Dutch
smokers.
Validity
of
author’s
conclusion
Smokefree, price, mass media
campaigns
were
not
associated with reduction in
prevalence of smoking.
357
Details
Method
Results
Outcomes
Exposure,
Quit attempts,
7-day point prevalence (successful
quitters)
increase only predicted successful smoking
cessation among young respondents.
SES
Exposure: Higher educated smokers were
more exposed to the price increase and the
smoke-free legislation.
Smokers from different educational levels
were reached equally by the mass media
campaign.
Cessation: There were no significant
educational inequalities in successful
smoking cessation.
Author’s conclusion of SES impact
There were no overall ages or educational
differences
in
successful
smoking
cessation after the implementation of the
three interventions.
Comments
Mass Media
358
Details
Mass media
Author , year
Niederdeppe, 2008
Country
Wisconsin, USA
Design
Before and after (same participants)
Objective
To examine whether impact of
televised smoking cessation ads
differed by education or income.
SES variables
Education, income
Analyses
Multivariate logistic regression
Method
Results
Comments
Data sources
Wisconsin Tobacco Survey 2003
(baseline, random digit dialling).
Wisconsin Behavioral Health Survey
2004 (follow up).
Participant selection
Participants in both health surveys
above. Smoked over 100 cigs in
lifetime and currently smoked
some/every day.
Participant characteristics
Education: 47% high school degree
or less, 33% some college, 20%
college degree.
Annual household income: <25k
(31%) 25-50k (36%) 50k+ (29%)
Unreported (4%)
Intervention
Televised smoking cessation ads in
Wisconsin Tobacco Control and
Prevention Programme. TV ads aired
most weeks between May 2002 and
Dec 03. Highlighted dangers of SHS
or keep trying to quit messages
(KTQ), and aimed to promote
Quitline calls.
SHS
ads
included
personal
testimonials, KTQ didn’t. Subset of
both ads targeted at low SES groups.
Length of study
2003 to 2004
Outcomes
Quit attempts, abstinence, ad recall
General population
42% had made a quit attempt, 13%
abstinent at one year.
SES
KTQ ads had higher recall among higher
educated groups (p<.05).
Positive relation between KTQ ad recall
and quit attempts for higher educated, but
negative relationship for lower educated.
No relationship between KTQ recall and
income.
KTQ ad recall showed some, nonsignificant, association with education (high
school or lower v college educated
OR=0.47, 0.16-1.33).
SHS ads showed no differential recall.
Low educated group who recalled SHS ad
were less likely to agree that SHS concerns
were over-stated.
SHS ads were also associated with low
income respondents being more likely to
believe that SHS is harmful.
Author’s conclusion of SES impact
Media messages may have a greater
impact on quit attempts among moreeducated populations, though there is no
indication of directionality (quit because
they saw the advert, or recall advert
because they were trying to quit?). SHS
ads may have lower chance of widening
health disparities.
Internal validity
Response rate = 51%, followup rate = 29%
Less loss to follow up among
older, women, non-Hispanic,
more educated, more nicotine
dependent, more quit attempts,
and advised by Doctor to quit.
Combined with small initial
sample size to give low overall
ability to detect influence of
adverts.
External validity
Doesn’t mention which form of
television the adverts were run
on. Funding considerably lower
than CDC recommended level.
Validity
of
author’s
conclusion
SHS ads only have lower
chance of widening health
disparities
because
they
appear to have little impact on
behaviour.
359
Details
Mass media
Author , year
Niederdeppe 2011
Country
New York, USA
Design
Repeat cross-sectional
Objective
To (1) examine SES variation in
response to different types of
cessation ads and (2) apply
predictions derived from studies
using the Stages of Change Model in
an attempt to understand why SES
differences may occur
SES variables
Education, (high school diploma,
some college, college degree,
graduate school)
Income
Analyses
Logistic and ordinary least squares
regressions
Method
Results
Comments
Data sources
New York Media Tracking Survey
Online a self-administered webbased survey
Participant selection
Adult
smokers
who
currently
participate in the Harris Poll Online
and reside in either New York or
media markets within New Jersey
where the New York Tobacco Control
Program purchased advertising time.
Participant characteristics
The Recall dataset consisted of 5004
unique adult smokers (62.1% female;
82.6% white, 5.3% African American,
6.0% Hispanic, 6.1% other/not
specified; mean age = 45.0, SD =
12.7). The Effectiveness dataset
consisted of 7060 unique adult
smokers (64.5% female; 83.3%
white, 5.3% African American, 5.6%
Hispanic, 5.7% other/not specified;
mean age = 45.1, SD = 12.7).
Intervention
Mass media antismoking advertising.
Exposed each participant to videos of
a random selection of specific ads via
online multimedia within the survey.
The exact number of ads viewed by
each respondent ranged from four to
six.
All ads were 30 seconds long and the
order in which ads were presented to
any
single
participant
was
General population
Participants recalled Why-Testimonial ads
at higher rates than ads using the other
three themes. Participants perceived WhyGraphic ads as more effective than all
three other ad themes.
SES
Recall:
Significant interaction between How ads
(vs. Why-Testimonial) and income.
Significant interactions between both WhyGraphic and How ads (vs. WhyTestimonial) and education.
The interactions between How ads and
income/education were not robust to the
inclusion of both interaction terms.
Stage of change did not interact with ad
theme: did not change the size or
significance of the coefficients for the
interaction between Why-Graphic ads or
How ads (vs. Why-Testimonial) and
education on aided ad recall.
Why-Testimonial ads had the highest and
How ads had the lowest ad recall across all
levels of education. This difference was
greatest at low levels of education. For
example, among those with 10 years of
education, the model predicts 71% recall of
Why-Testimonial ads vs. 33% recall of How
ads, a difference of 38 percentage points.
Among those with 20 years of education,
the model predicts 67% recall of WhyTestimonial ads vs. 40% recall of How ads,
Internal validity
A subset of participants (n =
834 in the Recall dataset; n =
1170 in Effectiveness dataset)
completed more than one wave
of the survey.
Two coders independently
categorized each ad (Cohen’s
k = 0.77).
Analyses
using
education
variable was restricted to
smokers aged 25 years and
higher.
External validity
The New York survey sample
is not representative of the
broader population of smokers
in New York, New Jersey or
elsewhere). The internet-based
sample was skewed toward
White, affluent and educated
smokers.
Validity
of
author’s
conclusion
Valid, thematic differences in
recall and response were more
pronounced among smokers
with the lowest levels of
education.
360
Details
Method
Results
randomized. participants showed a
number of ads from five main
categories: (1) Why-Graphic (n = 10
ads), (2) Why-Testimonial (n = 15
ads), (3) How (n = 7 ads, only one of
which used a personal testimonial),
(4) Anti-Industry (n = 4 ads), and (5)
Secondhand Smoke (n = 9 ads).SHS
ads excluded from analyses.
Length of study
Five waves over two years: spring
2007, summer 2007, spring 2008,
summer 2008, and spring 2009.
Outcomes
Aided ad recall,
Perceived ad effectiveness
a difference of 27 percentage points.
Effectiveness:
Significant interactions between How ads
(vs. Why-Graphic ads) and income, and
How ads (vs. Why-Graphic ads) and
education, respectively.
How ads (vs. Why-Graphic) and income
was not robust to the inclusion of
interactions with education. Significant
interaction between How ads and the
contemplation stage, although in the
opposite direction of what would be
expected based on the theory. The
inclusion of interactions between ad theme
and stage of change did not substantially
alter the size or significance of the
interaction between How ads and
education.
Why-Graphic ads had the highest level of
perceived effectiveness. This value was
higher than How ads across all levels of
education. Once again, however, the
difference was most pronounced at low
levels of education.
Author’s conclusion of SES impact
Smokers (particularly those with low
education) recalled ads focused on How
less often, and perceived them as less
effective, than ads using graphic imagery
or personal testimonials to convey why to
quit. Differences in readiness to quit
between higher and lower educated
populations did not explain why thematic
differences in recall and response were
Comments
Mass media
361
Details
Method
Results
Comments
Mass media
more pronounced among smokers with the
lowest levels of education.
362
Details
Method
Results
Comments
Data sources
cohort of 3,571 current smokers
drawn from eight U.S. Designated
Market Areas
Participant selection
Randomly selected, among baseline
respondents, 4,067 successfully
completed the follow-up survey,
resulting in a follow-up response rate
of 73% and an overall response rate
of 48% among known eligible
households.
Participant characteristics
3,571 current smokers; 88.6% were
current daily smokers and 11.5%
were current nondaily smokers. The
mean number of cigarettes smoked
per day was 17.6 among current
daily smokers and 6.4 among current
nondaily smokers at baseline. A
majority
of
respondents
were
seriously thinking of quitting at
baseline, with 15.6% expressing an
intention to quit within 30 days and
51.6% within six months.
The majority was non-Hispanic White
(79.9%), followed by non-Hispanic
Black (12.5%), and Hispanic (7.6%;
Table 1). The sample consisted of
slightly more females (55.3%) and
tended to fall in the target
demographic of 25–49 years of age
(84.5%). Almost half of the sample
reported earning either a high-school
General population
At the six-month follow-up, 46.5% had confirmed awareness of the EX campaign (EX
awareness). The mean value of the
cessation-related cognitions index at
baseline was 21.3 and stayed constant at
21.2 at follow-up. The percentage of
current smokers making a quit attempt was
44.6% at baseline and 42.2% at follow-up.
The greatest predictor of quit attempts at
follow-up was baseline quit attempts. This
estimate was 0.320 (SE = 0.02), indicating
that reporting a quit attempt at baseline
increased the likelihood of reporting a quit
attempt at follow-up by approximately 32%.
Lower levels of nicotine dependence at
baseline (i.e., longer time to first cigarette
in the morning) was also positively and
significantly related to quit attempts at
follow-up, with an effect estimate of 0.044
(SE = 0.01).
The direct effect of EX awareness on quit
attempts was 0.031 (SE = 0.01), which
indicates that EX awareness increases the
probability of reporting a quit attempt at
follow-up by approximately 3%. Although
small, the effect is statistically significant.
The indirect effect of EX awareness on quit
attempts (0.010, SE = 0.004) was
calculated by multiplying the estimate from
the independent effect of EX awareness on
cessation-related cognitions at follow-up
with the estimate from the independent
effect of cessation-related cognitions on
Internal validity
Other behavioural outcomes,
such as cigarette consumption
and utilization of smoking
cessation resources, were
considered but not analysed
due to lack of a statistically
significant association with EX
awareness.
A cessation-related cognitions
index measured at the followup survey was used as a
mediating variable in the
model. The index had a
Cronbach’s alpha of .79.
The sample for this analysis
excluded an additional 6.7% of
follow-up respondents who quit
successfully between baseline
and follow-up.
Uses
structural
equation
modeling to formally test a
mechanism by which confirmed
awareness of a nationally
televised smoking cessation
mass-media campaign affects
quit behaviour.
External validity
May only be generalisable to
adults considering quitting and
aged 25 to 49 years.
Validity
of
author’s
conclusion
Mass media – EX campaign
Author, year
Richardson 2011
Country
USA
Design
Longitudinal cohort
Objective
To examine whether changes in
cessation-related cognitions mediate
the relationship between awareness
of a national mass-media smoking
cessation
campaign,
the
EX
campaign, and quit attempts
SES variables
Education (less than high school,
high school, some college, and
college graduate or beyond).
Analyses
structural equation modeling
363
Details
Method
Results
Comments
diploma or GED. (43.6%), while
approximately one fifth reported
having less than a high-school
education (19.7%).
Intervention
EX national media campaign
Length of study
February 2008 to October 2008.
Outcomes
Confirmed awareness of campaign
Quit attempts
quit attempts at follow-up (0.408 × 0.025 =
0.010). The indirect effect of EX awareness
on quit attempts at follow-up, although
statistically significant, was smaller than the
direct effect. Altogether, the model
explained approximately 18% of the
variance in quit attempts at follow-up. Data
suggest that there are both a direct effect
of confirmed awareness of EX on quit
attempts as well as an indirect effect
mediated by positive changes in cessationrelated cognitions.
SES
only respondents with less than a highschool education showed a statistically
significant effect of EX awareness on quit
attempts, and this effect was both direct
(0.082, SE = 0.04) and indirect (0.017, SE
= 0.01).
Author’s conclusion of SES impact
Awareness of EX is significantly associated
with positive changes in cessation-related
cognitions and quit attempts in those with
less than a high-school education.
Authors hypothesis was that
EX awareness manifested in
changes in quit behaviour
through initial modification of
cessation-related
cognitions.
The data, however, do not fully
support this hypothesis. While
there
was
a
statistically
significant
effect
of
EX
awareness on quit attempts
mediated through cessationrelated cognitions, the larger
effect of EX awareness on quit
behaviour was not mediated
through
cessation
related
cognitions. Furthermore, the
mechanism underlying how EX
awareness
promotes
quit
attempts
differs
across
education subgroups.
Mass media – EX campaign
364
Details
Method
Results
Comments
Data sources
Longitudinal panel data set
Participant selection
Random digit-dial from 8 designated
markets areas
Participant characteristics
4067/5616 current smokers, 18 to 49
years,
mean
age
37
years
Intervention
Branded national smoking cessation
media
campaign
designed
to
promote cessation among lower
income and blue collar smokers of
diverse race/ethnicity, ages 25 to 49,
who are interested in quitting, based
on behaviour change theory. This
study focuses on impact of campaign
television advertising only
Length of study
6 months, August to October 2008
Outcomes
Cessation-related cognitions index
score and quit attempts
General population
n/a – only presented by race/ethnicity
SES
EX
campaign
awareness
differed
significantly by education, with higher
awareness observed among those with
higher educational attainment (41.0%
weighted estimate for college degree vs.
30.2% for less than high school diploma,
summary p value = .002).
EX was significantly related to a higher
cognitions index score at 6-month follow-up
only among respondents who had achieved
less than a high school education (OR =
2.6, p = .037). Baseline cognition index
score was consistently predictive of followup cognition index score for all educational
strata at the p < .000 level.
a statistically significant relationship
between confirmed awareness of EX and
having made a quit attempt at follow-up
was observed among those with less than
high school education (OR = 2.1, p = .016).
Among smokers with less than a high
school education, confirmed awareness of
the EX campaign more than doubled their
odds of having more favourable cognitions
about quitting smoking at 6-month followup, and doubled their odds of having made
a quit attempt during the study period.
Author’s conclusion of SES impact
EX campaign may be effective in promoting
cessation-related
cognitions
and
Internal validity
73% follow-up rate and overall
response rate of 48% among
known eligible households.
External validity
Results are limited to impact of
television advertising only and
may only be generalisable to
these 8 media markets.
Relatively low level of media
delivery—47% of the Centers
for Disease Control and
Prevention's media delivery
recommendation—its
effect
may not have been detectable
at the national level.
Validity
of
author’s
conclusion
valid
Mass Media – EX campaign
Author, year
Vallone 2011
Country
United States
Design
Before and after study (same
participants)
Objective
To assess effectiveness of largescale national smoking cessation
media campaign – EX – across
racial/ethnic
and
educational
subgroups
SES variables
education
Analyses
Multiple logistic and linear regression
analyses
365
Details
Method
Results
Comments
Mass Media – EX campaign
behaviours
among
disadvantaged smokers
minority
and
366
Details
Mass Media
Author , year
Van Osch, 2009
Country
The Netherlands
Design
Cohort with control
Objective
To
explore
determinants
of
successful quitting through a Quit
and Win contest.
SES variables
Education: low level of education =
primary or basic vocational school,
medium level education = secondary
vocational school or high school,
high level of education = higher
vocational school or university.
Analyses
Logistic regression
Method
Result
Data sources
Baseline questionnaires and follow
ups at 1 month and 1 year.
Participant selection
Four inclusion criteria: (i) a
minimum age of 18, (ii) living in The
Netherlands, (iii) having smoked for
at least 1 year and (iv) daily smoking.
Entrants who provided a valid email
address were contacted (2887 of
3694), 1551 (54%) consented to
participate in study.
Random sample of 7500 Dutch
smokers approached by email to act
as control group, 1147 agreed, 244
met selection criteria.
39% Quit & Win and 25% Control
lost to follow up at one month, 56%
Quit & Win and 49% Control at one
year.
Participant characteristics
Mean age 36.9, 60% females, 96%
Dutch, 29.7% less than high school
education, 44.5% high school, 25%
higher. Controls older and less
educated.
Intervention
The Dutch Quit and Win contest took
place in May 2005 and was
organized and coordinated by the
Dutch Cancer Society. The main
objective
was
to
encourage
General population
Abstinence rates at 1 and 12 months:
Control: 15.3% and 5.6%
Quit & Win: 57.7% and 27.1%
OR=7.83 and 3.03 (p<0.001 for both)
Abstinence rates at 1 and 12 months
including non-respondents as still
smoking:
Control: 10.9% and 2.9%
Quit & Win: 35.4% and 11.9%
OR=4.70 and 2.46, (p<0.001 for
both)
One-month
abstinence
was
significantly predicted by use of
buddy support and Quit and Win email messages. Quit and Win e-mail
messages
remained
significant
predictor for continuous abstinence at
12 months.
52.3% recruited by radio, 26.2% by
friends.
SES
Participants with a higher education
were more likely to maintain their
quit attempt for the entire contest
month.
Higher education was a slightly
significant predictor of cessation at
one month (OR = 1.199 (95%CI
1.032-1.393) p<0.05), but did not
predict continuous abstinence at 12
months (OR=1.109 (0.895-1.374).
Comments
Internal validity
Low participation rate.
High rate of loss to follow up, higher
in the experimental group than the
control.
Self-report measure of cessation
likely to over-estimate the impact of
the contest.
Differences
in
baseline
characteristics between intervention
and control sample; control sample
were older and less educated (all
analyses corrected for baseline
differences).
External validity
Not a representative study sample.
Validity of author’s conclusion
Quit & Win contestants more
educated than random control group.
Higher SES Quit & Win contestants
more likely to maintain abstinence at
one month but not at 12 months. No
analyses of various types of cessation
support by SES.
367
Details
Method
respondents to abstain from smoking
for at least 1 month. Recruitment of
participants was promoted on a
national as well as regional level.
Regionally, several municipal health
centres suspended campaign posters
and distributed brochures to the
public and placed advertisements in
regional newspapers. On a national
level, several radio stations and
newspapers drew attention to the
contest.
In total, five supportive e-mail
messages were sent to the
participants.
Participants were
offered the opportunity to receive
computer-tailored cessation advice,
support from a telephonic coach, and
they could enrol in an e-mail
counselling programme, all of which
were provided by the Dutch
Foundation on Smoking and Health
(STIVORO).
Participants were also asked to name
a buddy, whom they could call upon
for support during their cessation
attempt.
Other cessation support included
NRT and bupropion. After 1 month,
prize winners were randomly
selected from a pool of successful
quitters. Winners of prizes (first
prize: €1.000 and 11 regional prizes
Result
No analysis of recruitment method,
use of buddy system or other aids by
SES.
Author’s conclusion of SES impact
Not discussed.
Comments
368
Details
Method
Result
of €450) were obliged to undergo a
urine cotinine test to verify their
abstinence from smoking.
Length of study
One year
Outcomes
Abstinence at 1 and 12 months
Comments
369
Details
Mass media - Quitlines
Author, year
Burns, 2010
Country
Colorado, USA
Design
Quasi-experimental
(2group pre-post design)
Objective
To examine the effect of a
Spanish-language media
campaign on the reach and
outcomes of a statesponsored Quitline among
Latino smokers.
SES variables
Education,
insurance
status
Analyses
Logistic regression
Method
Result
Comments
Data sources
Service utilisation data from the
Quitline database during pre and postcampaign periods (Apr-Aug and SepNov 2007). Random selection of users
from pre and post groups was followed
up at 7 months.
Participant selection
All smokers calling the Quitline were
eligible if they provided data on
ethnicity.
Participant characteristics
See results column.
Intervention
Spanish-language
advertising
to
promote a state Quitline to Latino
smokers in Colorado, a population
historically under-represented among
users of the service. Adverts were
aired between Sep-Nov 2007 on
predominantly
Spanish-language
television and radio channels and in
movie theatres attended by Latino
populations.
Ads designed to deliver positive,
supportive, family-oriented messages
about cessation.
Quitline offered free NRT and 5
proactive coaching sessions. First 40%
of participants and heavy smokers
referencing the campaign received 8
weeks of NRT, others received 4
weeks.
Length of study
7 months; April to November 2007
Outcomes
General population
Estimated 79.8% of households exposed to
campaign messages an average of 12
times each. Call volume increased from 390
per month to 614 per month during the
intervention period. Service use was higher
and more sustained during the campaign.
QuitLine calls increased among Latinos
during the campaign by 57.6% (1169 vs
1842 in 3-month periods). Compared with
pre-campaign Latino study respondents,
Latino respondents during the campaign
were significantly younger (younger than 45
years), more often Spanish speaking,
uninsured, and less educated. Among
Latino enrolees, program completion and
nicotine replacement therapy use were
similar before and during the campaign.
Six-month abstinence among Latinos
increased significantly during the campaign,
(18.8% vs 9.6%; P<.05) and 7 day
abstinence increased marginally (41.0% vs
29.6%; P=.06). However abstinence rates
at both time periods were significantly lower
for non-Latinos during the campaign.
Suggest that this may be a consequence of
NRT protocol change that occurred partway
through the study that limited NRT to a 4week supply instead of an 8-week supply.
Impact by SES variable
Latino Respondents during the campaign
period were significantly more likely to be
less educated and uninsured. 42.5% of
callers during the intervention had less than
high school education, compared to 22.2%
pre-intervention.
56.0%
uninsured,
Internal validity
Potential for advertising campaign to
have
influenced
the
cessation
outcomes
among
pre-intervention
callers. Post-campaign group was
actual ‘during’ campaign, may have
missed the influence of final weeks of
the campaign.
No direct measure of campaign
exposure.
Response rates 44.1% and 50.4%
among pre and post-campaign Latinos,
and 54.3% and 52.7% among pre and
post-intervention
non-Latinos.
Individuals lost to follow up typically
younger and uninsured, less likely to
have completed the program, and less
likely to have requested a second NRT
shipment.
Used
complete
case
outcomes, rather than including nonresponse at follow up as a failed
cessation attempt which appears more
likely given the characteristics of nonrespondents presented.
External validity
Target ethnic group is not as
substantial in England, unclear if a
similarly targeted intervention would be
as effective among other minority
ethnic groups.
Validity of author’s conclusion
SES variations in quit rates are not
discussed, but is assumed that the rise
in low SES callers has led to a rise in
low SES service utilisation and quit
rates.
370
Characteristics of Quitline callers,
service utilisation, abstinence.
compared to 40.5% pre-intervention.
Author’s conclusion of SES impact
Increased reach among low SES Latinos,
while sustaining or improving service use
among the group. Negative impact among
non-Latino ethnic groups.
Appears that the media intervention is
having a positive impact on inequalities
in smoking behaviours, but the
changes in Quitline NRT-provision
have had a negative impact on overall
quit rates, potentially more significantly
among low SES service users.
371
Details
Method
Results
Comments
Data sources
Random telephone survey of adult
smokers in NYC (n=1000) conducted
in 2006. Survey conducted in English
or
Spanish
only.
Responses
weighted
Participant selection
Current smokers (10 cigarettes or
more) or those who had quit since
beginning of NPP (14% screening
response rate). 56% of eligible
smokers completed the survey
(n=602).
Participant characteristics
Hard to assess due to the use of
‘population
estimates’.
Appears
sample was dominated by Hispanics,
males, and mid-low income groups.
High school graduates the largest
group, followed by college educated,
then some college and <high school.
No
indication
of
the
representativeness of the sample.
Intervention
Media campaign to promote an NRT
giveaway. Nicotine patch giveaway
between May 3rd and June 6th 2006.
Smokers could enrol via free nonemergency Government information
line. Callers received 4 weeks of
patches.
Advertised via multimedia campaign
(TV/radio/print in English & Spanish)
General population
35,000 registered for the program. Program
awareness high (60% overall), with most
awareness coming from TV advertising
(62%) followed by word-of mouth
(19%) and radio advertisements (14%).
Interest among those who hadn’t heard of
the program fairly high (54%).
Internal validity
Response and co-operation
rates were low. Extrapolated
from a very small population to
make assertions about a huge,
diverse city. No assessment of
the representativeness of the
sample of either smokers or
NYC as a whole.
Likely to over-estimate the
number of people aware of the
programme, and also potential
users given the hypothetical
question on interest (those
reporting
interest
would
significantly
outweigh
the
number of actual users).
Doesn’t mention the type of TV
used:
free-to-air,
potential
demographics.
External validity
Likely to be less cost-effective
in less dense populations.
Unlikely to be representative of
most urban populations.
Program awareness estimates
may also be overestimates, as
the NPP was tied to a larger
social marketing campaign
around quitting smoking.
Validity
of
author’s
conclusion
Difficult to make serious
Mass media - NRT
Author , year
Czarnecki, 2010a
Country
New York City, USA
Design
Cross-sectional
Objective
To improve understanding of: (1)
awareness of the 2006 Nicotine
Patch Program (NPP) among New
York City (NYC) smokers; (2)
differences in sociodemographic
characteristics among those who
reported a desire to participate
compared to those who did not; (3)
perceived barriers and reasons for
not wanting to participate; and (4)
suggested outreach methods for
future
giveaways
and
media
campaigns.
SES variables
Income, education
Analyses
Differences between groups were
assessed using t-tests.
The most common reason for not calling
was not being ready to quit smoking
(25%). Most ‘barriers’ were a lack of
interest in quitting/aids.
SES
Populations with lower levels of income
and education expressed more interest in
the program compared to groups with
higher levels of income and education.
Compared to 37% of respondents with an
annual income of $75,000 or more, 56% of
respondents each earning less than
$25,000 (p=0.04) and $25,000 to less than
$50,000
(p=0.03)
reported
program
interest. Sixty-three percent of those with
less than a high school education (p=0.04)
and 67% of high school graduates
(p<0.001) reported program interest,
compared to 43% of college graduates.
No SES evaluation of the other research
questions (3) perceived barriers and
reasons for not wanting to participate; and
(4) suggested outreach methods for future
giveaways and media campaigns.
% reported awareness significantly lower
372
Details
Method
Results
Comments
from January to October 2006,
including testimonials from dying/sick
smokers, and graphic images of
smoking’s impact.
Length of study
January to October 2006
Outcomes
Program
awareness,
untapped
interest in programme, perceived
barriers (not by SES), future outreach
methods (not by SES)
for highest income group ($75,000 or more)
and for highest education (college
graduate) group.
% reported awareness (95%CI) N=602:
Income ($)
<$25,000 = 58.7 (49.2, 67.6) P=0.138
$25,000–<$50,000 (ref)=67.5 (60.1, 74.1)
$50,000–<$75,000=59.9(49.5,69.5)
P=0.2287
>/=$75,000=51.2 (43.4, 59.0) P=0.0025*
Education
Less than high school grad=57.3 (47.2,
66.8) P=0.2789
High school grad=61.5 (54.5, 68.0)
P=0.612
Some college (ref)=64.0 (56.7, 70.7)
College grad =51.6 (45.0, 58.1) P=0.0120*
Untapped interest: respondents who
would have participated in 2006 Nicotine
Patch Program (n=199)
Income ($)
<$75,000 = 56.1 (41.2, 70.0) P=0.0400*
$25,000–<$50,000=55.5(42.5,67.7)
P=0.0310*
$50,000–<$75,000=50.1(34.4,65.9)
P=0.1792
>/=$75,000=36.5 (25.9, 48.6) ref
Education
Less than high school grad=62.7 (45.3,
77.3) P=0.0413*
High school grad=67.3 (56.2, 76.8)
judgements given the concerns
over validity.
Mass media - NRT
373
Details
Method
Results
Comments
Mass media - NRT
P=0.0007*
Some college =47.4 (35.4, 59.8)p=0.5635
College grad =42.8 (33.6, 52.6) ref
Author’s conclusion of SES impact
Highest untapped interest in the lower SES
groups. Mass media effective for informing
smokers.
374
Details
Method
Results
Comments
Data sources
2008 Nicotine Patch and Gum
Program (NPGP), Population
estimates for current smokers are
based on the Community Health
Survey
Participant selection
Participant characteristics
18 years and over, resident in NYC
Intervention
2008 Nicotine Patch and Gum
Program, 16 days April to May 2008
conducted in collaboration with 3-1-1
NYC’s non-emergency information
line. Large-scale distribution of NRT
in NYC. All campaign messages
directed interested smokers to call 31-1 during the publicized dates.
Applicants were notified of program
eligibility via mail; eligible callers
received the appropriate NRT
package (determined by the number
of cigarettes smoked per day), while
ineligible callers received a letter
with a referral to other cessation
services. Recruitment was by TV and
radio commercials and recruitment
letters. Two days before the end of
the NPGP, the NYC Department Of
Health and Mental Hygiene issued a
press release announcing that there
General population
In 2006 the adult smoking prevalence in
NYC was 17.5%, representing 1,065,000
smokers. More than 32,000 smokers
applied for the 2008 NPGP and almost
30,000 (92.1%) were found eligible.
Almost all of the applicants and enrollees
(99.6%) had geocodable addresses. The
primary sources of referral reported by all
NPGP enrollees were TV commercials
(66.5%), followed by recruitment letters
(11.2%), word of mouth (9.5%), and radio
commercials (5.2%).
3% NYC smokers enrolled in the
programme.
SES
Low income adults had high enrolment
percentages of 3.3% (% of NYC current
smokers enrolled) compared to 2.5%
middle income neighbourhood and 2.6%
high income neighbourhood.
Adults with less than a high school
education had high enrolment (3.6%)
compared to 2.7% for high school
graduate; 2.7% for ‘some college’ and
1.2% for college graduate.
Neighbourhoods varied in percentage of
smokers enrolled, ranging from 1.2 to
5.1%, with the low and medium income
neighbourhoods having more enrollees
compared to high income neighbourhoods
Internal validity
Single cross-sectional study
External validity
Results are specific to NYC
neighbourhoods. GIS provided
near real-time assessment of
participation patterns and
impact of media and outreach
strategies.
Validity of author’s
conclusion
Valid. One of few studies to
assess reach of NRT
programme.
Mass media - NRT
Author, year
Czarnecki 2010b
Country
New York City, USA
Design
Cross-sectional
Objective
To use geographic information
system (GIS) analyses to monitor
large-scale distribution of nicotine
replacement therapy (NRT) in New
York City (NYC).
SES variables
Education, Neighborhood income is
measured as percent of residents that
are below 200% of the Federal
Poverty Level (FPL); Low
income=43–90% of residents are
below 200% FPL; Middle
income=30–42% of residents are
below 200% FPL; High income=12–
30% of residents are below 200%
FPL.
Analyses
The intake data were analysed in two
ways, as the percent of NYC current
smokers enrolled (through intake
reporting) and the geographic density
of enrolment (through mapping).
375
Details
Method
Results
was only 48 hours left to call for
NRT.
The complete intake data were
electronically passed from 3-1-1 to
the NYC DOHMH daily for analysis,
reporting, and mapping.
Length of study
16 days in 2008
Outcomes
Reach - % of NYC current
smokers enrolled
(data not shown).
Among neighbourhoods with high smoking
prevalence, lower income neighbourhoods
had higher enrolment compared to higher
income neighbourhoods.
Author’s conclusion of SES impact
NPGP data were collected at a finer
resolution than a ZIP code (a geocoded
address), differences were identified that
otherwise might not be apparent when
viewing data aggregated to the
neighbourhood level.
Comments
Mass media - NRT
376
Details
Mass media - quitline & NRT
Author, year
Deprey 2009
Country
Oregon, USA
Design
Before and after study – different
participants.
Objective
To determine whether an offer of
free NRT in the form of nicotine
patches could generate and sustain
incoming call volumes more
efficiently
than
paid
media
advertising.
SES variables
Insurance status, education
Analyses
A sample 6 months prior to the
launch was utilized as the
comparison group
Method
Results
Comments
Data sources
Oregon Tobacco Quit Line
Participant selection
The sample size consisted of 22
health plans and included health
maintenance organizations (both
Medicaid
and
non-Medicaid),
preferred provider organizations,
and indemnity-based plans. Of the
health plans contacted as potential
collaborators, 12 agreed to promote
the Free Patch Initiative (FPI).
Participant characteristics
920 before intervention and 6491
after launch
Intervention
Oregon Free Patch Initiative (FPI): for
2.5 months the Oregon Tobacco Quit
Line offered a free 2-week starter kit
of nicotine patches to all callers and
one counselling call with a tobacco
quit coach. Supplemented with NRT
that participants would obtain on
their own (either via their health
plan or by purchasing).
The promotional plan, utilizing
Roger’s Diffusion of Innovation
theory, targeted health plans, local
policy makers, media sources, and
referral sources, such as healthcare
General population
In 3 months, the FPI achieved free news
media coverage, generated a 12-fold
increase in calls to the ORQL, sustained a
two-fold increase in calls for 5 months
after the FPI, and reached 1.3 percent of
all Oregon smokers in 3 months.
Between October and December 2004, the
top two specific sources of hearing about
the ORQL identified were TV news (17.1%)
and family or friends (16.2%). In the
preinitiative sample, the two top sources
of hearing about the ORQL identified at
registration were TV/commercial (19.3%)
and a Medicaid letter (17.9%). In the first
week of the initiative launch, the number
of registrations with the ORQL increased
from 224 to 2 614. In all of October 2004, 4
810 callers registered for services (In
November 2004, 1 423 tobacco users
registered and in December 1 018 tobacco
users registered with the ORQL. Overall,
the high volume of registrations with the
ORQL continued well after the free patch
offer was discontinued. Utilizing the 2004
smoking rate of 19.9 percent in Oregon
adults the ORQL reached 1.3 percent of
the adult smokers in Oregon during the FPI
(3 months). If these volumes were
sustained, the annualized reach would be
Internal validity
A comparison sample used
during the same time period
12 months prior would have
controlled for seasonal call
volume differences that are
seen
from
October
to
December due to the Great
American Smoke Out and
other quitline promotions
leading up to New Year’s Day.
However, the ORQL was not
active from October to
December 2003 due to a
decision to close services
temporarily.
Another limitation to the study
results is that more than 10
percent of the data were
missing for certain variables in
the
prelaunch
sample:
ethnicity, cigarettes smoked
per day, time to first cigarette,
and previous quit attempts.
With this high percentage of
missing
data,
the
generalizability of the results is
reduced and limited.
External validity
Results mainly relate to
377
Details
Mass media - quitline & NRT
Method
Results
Comments
providers.
Word-of-mouth
advertising was also encouraged
using a free patch card, which could
be handed out to tobacco users. Six
weeks prior to the public launch,
information about the initiative was
disseminated by e-mailing and
sending letters to public and private
sector partners. The ORQL paid for
media (TV commercials) during the
preinitiative period, but not during
the initiative.
Length of study
6 months - March through May 2004
(preinitiative) and October through
December 2004 (postlaunch). Free
Patch Initiative launched October
2004 until December 2004
Outcomes
Calls to quitline
5.2 percent.
SES
The ratio of insured to uninsured callers
dramatically increased in October. In the 9
months preceding the FPI, the ratio of
insured to uninsured callers ranged from
1:6 (January and February) to 1:4 in all
other months. In October, the ratio
increased to 1:2.
Of the tobacco users reporting insurance
status, 30.5 percent of the FPI participants
reported being uninsured compared with
21.5 percent of the preinitiative group. At
the time of the FPI, the rate of uninsured
was 17 percent in Oregon. 56.2% ‘high
school or less education’ vs 54.2% after
launch; 36% ‘some college’ before and
35.3% after; ‘college graduate or more’
7.8% before and 10.5% after;
Author’s conclusion of SES impact
health plans’ and insurers’ promotional
activities of the initiative may have
increased the calls from insured smokers
to the quitline
insurance status which is
specific to USA and may not
generalise to other countries
Validity of author’s conclusion
Two plans waived the copay
for telephone counselling, and
two sent a voucher for 6
additional weeks of NRT. One
plan waived a required
doctor’s office visit for
additional NRT. Within 6
months of the FPI, 2 of the 22
health plans decided to add
tobacco
cessation
phone
counselling as a member
benefit. These Health Plan
system changes that occurred
during the initiative may have
influenced call rates.
378
Details
Methods
Results
Comments
Mass media - Quitlines
Author, year
Durkin 2011
Country
Victoria, Australia
Design
Cross-sectional
Objective
To examine the efficacy of
different types of mass media
advertisements in driving lower
SES smokers to utilise quitlines
SES variables
socioeconomic index for areas
(ranks postcodes)
Analyses
negative binomial regressions
examined relationship between
exposure to ads and calls to
quitline adjusting for covariates
Data sources
33,719 calls to Victorian quitline
Participant selection
N/A
Participant characteristics
target group=18 to 39 year old
smokers
Intervention
13 advertisements designed to
motivate smokers to quit, all
advertisements ended with quitline
number displayed
Length of study
2yrs (Dec 2006 to Dec 2008)
Outcomes
Calls to quitline
General population
8839 anti-smoking ad TARPS, or each person within target
population exposed 88.39 times, rates of exposure similar across ad
types. After all significant covariates were included, increases in
anti-smoking advertising TARPs were significantly associated with
the number of quitline calls (Rate Ratio = 1.070, 95% CI 1.020 to
1.122, P = 0.005). Higher emotion narrative ad exposure had the
strongest association with quitline calls, increasing call rates by 13%
for every additional ad exposure per week (per 100 points, rate ratio
= 1.132, P = 0.001).
SES
Victorian quitline received 6275 calls from low SES (18.61% of total
calls), 5458 calls from mid-low SES (16.19% of total calls), 9619
calls from mid-high SES (28.53% of total calls) and 12 367 calls
from high SES callers (36.68% of total calls).
Victorian quitline received a significantly higher rate of calls from
high SES (RR = 4.177, P < 0.001) and mid-high SES (RR = 1.804,
P < 0.001) smokers compared with those from the low SES group,
but call rates from mid low SES smokers (RR = 0.869, P < 0.001)
were significantly lower than those from the low SES smokers, there
was no interaction between TARPs and SES group P = 0.223).
Substantially, greater increases in calls to quitline from lower SES
groups were observed when higher emotion narrative ads were on
air compared with when other ad types were on air, and this
advantage was not as strong among higher SES groups.
Author’s conclusion of SES impact
although there was an over-representation of Quitline calls from the
high SES group over the study period, when the ads were on air,
Quitline calls increased by the same degree across each SES
group. This suggests that the overall effect of the advertising aired
over this period neither increased nor reduced SES disparities in
quitline calls. Airing higher emotion narrative anti-smoking ads may
contribute to reducing, but not eliminating, socio-economic
disparities in calls to the quitline through maximizing the responses
of the lower SES smokers.
Internal validity
External validity
introduction of smokefree
pubs and clubs legislation
was significant covariate
which was adjusted for in
model
Validity
of
author’s
conclusion
379
Details
Mass media – NRT
Author, year
Hawk 2006
Country
Erie and Niagara counties, Western
New York region, USA
Design
3 intervention groups with regional
control group
Objective
To compare baseline characteristics
and determine abstinence and
predictors of abstinence.
SES variables
Education;
Analyses
Multivariate logistic regression
Method
Results
Comments
Data sources
Telephone survey of the Quit & Win
and NRT giveaway, compared with
Erie-Niagara Tobacco Use Survey
(ENTUS)
Participant selection
Random sample of 341 Quit & Win
participants (40%) and 314 (46%)
NRT voucher and 230 (100%)
combination group. Follow-up rates
were 60-64%, n=204, 179, 143 for
Quit & Win, NRT, combination
groups respectively.
Participant characteristics
Quit & Win participants younger
than those signed up for NRT
voucher.
N=849 Quit & Win only;
N=690 NRT only;
N=230 combination group;
Intervention
Concurrent Quit & Win contest and
nicotine replacement therapy (NRT)
voucher giveaway. Smokers could
enrol in both or either programme
(combined group).
Daily smokers (at least 10 cigarettes
per day) offered opportunity to win
prizes including $1000 if they
stopped smoking for the month of
January 2003 with quit date of 1st
January. NRT voucher redeemable at
General population
At follow-up the self-reported quit rates
were similar across 3 intervention groups:
25 to 30%. Higher quit rate in younger
smokers in the combination group.
SES
‘more than high school education’
Quit & Win: 62%
NRT: 57%
Combined: 60%
Erie-Niagara Tobacco Use Survey: 51%
Compared with smokers in region – those
enrolled in the 3 interventions had more
years of formal education p<0.05.
Adjusted OR for 7-day point prevalence =
1.11 (95% CI: 0.72 vs 1.70) for ‘high
school or less’ vs ‘some college’
Author’s conclusion of SES impact
The results for recruitment of low educated
smokers were not positive.
Internal validity
Completers were older than
noncompleters (41 years vs 38
years). Quit & Win participants
had follow-up that was 2 weeks
earlier than other 2 groups.
External validity
We don’t know how
representative the regional
cohort of smokers was in the
ENTUS survey, authors’ state
‘relatively representative’.
Smokers in all 3 intervention
groups were heavier smokers
than in general population (2021 vs 17 cigarettes per day).
Validity of author’s
conclusion
don’t know how representative
the regional cohort of smokers
was in the ENTUS survey
which was used to measure
reach
380
Details
Method
Results
Comments
Mass media – NRT
pharmacies for a 2-week supply of
nicotine gum or patch.
Media coverage included press
conference, newspaper and television
coverage. $35,000 spent on radio
advertisments aired on 6 local radio
stations. Focus mainly on Quit &
Win contest – when phoned Ney
York State (NYS) quitline people
were informed of free NRT
giveaway.$22,500 newspaper
advertising of Quit & Win and NRT
then $22,500 only on Quit & Win.
Marketed to minority populations (A
frican American and Latino) using
newspaper, churches and community
sites.
Length of study
4 to 7 months from 1st January 2003,
median 5.5 months follow-up
Outcomes
Reach,
7-day point prevalence
381
Details
Method
Results
Comments
Data sources
In 2003, the New York City Department
of Health and Mental Hygiene (NYC
DOHMH), in collaboration with the New
York State Department of Health and the
Roswell Park Cancer Institute, undertook
a large-scale distribution programme of
free NRT. Comparison group from
Community Health Survey (cluster survey
design).
Participant selection
From April 2, to May 14, 2003, more than
38 000 callers were screened for
eligibility to receive free NRT patches. To
qualify for free treatment, smokers had to
be at least 18 years of age, a resident of
New York City, have no medical
contraindications to NRT patch use, not
be using other NRT or bupropion, agree
to attempt to quit in the week after the
screening call, have smoked ten or
more cigarettes per day for at least a
year, and agree to be contacted for
follow-up.
Participant characteristics
34 090 individuals
Intervention
large-scale programme that used existing
telephone helplines to screen smokers
for NRT eligibility and to post a full course
of free NRT patches directly to those who
were eligible.
On April 2, 2003, the NYC DOHMH
announced the availability of free 6-week
courses of NRT patches to the first 35
000 eligible smokers to call the New York
State Smokers’ Quitline. All major
General population
An estimated 5% of all adults in New York City
who smoked ten cigarettes or more daily
received NRT; most (64%) recipients were nonwhite, foreign-born, or resided in a low-income
neighbourhood. Of individuals contacted at 6
months, more NRT recipients than comparison
group members successfully quit smoking (33%
vs 6%, p<0·0001), and this difference remained
significant after adjustment for demographic
factors and amount smoked (odds ratio 8·8,
95% CI 4·4–17·8).NRT recipients who received
counselling calls were more likely to stop (246
[38%] vs 189 [29%], adjusted odds ratio 1·5;
95% CI, 1·1–1·9) than those who did not.
SES
Similar proportions of NYC heavy smokers and
NRT recipients
resided in low-income
neighbourhoods. Neighbourhood income level
and educational attainment were not associated
with quit success.
Author’s conclusion of SES impact
Easy access to cessation medication for diverse
populations could help many more smokers to
stop.
Internal validity
Random sample but exclusions. Of
the people in the random sample,
about 60% of NRT recipients
participated in the 6-month followup survey. 31% response rate for
non-random comparison group
(eligible callers who did not receive
NRT).
Comparison group more likely to
be
living
in
low-income
neighbourhoods
than
NRT
intervention group.
External validity
An estimated 5% of all NYC heavy
smokers (ten cigarettes per day or
more) and 15% of those smoking
more than one pack of 20
cigarettes per day received free
NRT throughout this programme.
New York City implemented this
programme at a time when new
smoke-free workplace legislation
and
increased
taxation
on
cigarettes focused public attention
on cessation.
Validity of author’s conclusion
Valid
Mass media - NRT
Author, year
Miller 2005
Country
New York, USA
Design
Quasi-experimental
At 6 months after treatment, we assessed
smoking status of 1305 randomly
sampled NRT recipients and a nonrandomly selected comparison group of
eligible smokers who, because of mailing
errors, did not receive the treatment. NRT
recipients were compared with local
survey-derived data for heavy smokers in
New York City
Objective
To assess the effectiveness of a
programme of free NRT to improve
smoking cessation
SES variables
Area-level deprivation - Zip code of
residence at the time of enrolment was
used to assign NRT recipients to specific
neighbourhoods,16 which were grouped
into three categories (<30%, 30–44%,
>/=45%) on the basis of the percentage
of people living in households with an
income less than 200% of the federal
poverty level.
Analyses
Logistic regression
382
Details
Method
Results
Comments
Mass media – NRT
metropolitan newspapers and television
and
radio
stations
reported
the
programme launch. Neighbourhoodspecific media and promotional efforts
were used to reach populations with the
highest prevalence of heavy smokers.
Kits contained a 2-week supply each of
generic 21 mg, 14 mg, and 7 mg patches;
instruction sheets in English and
Spanish; patient information from the
manufacturer; a self-help stop-smoking
guide; and a list of local services for
smoking cessation. Counselling calls,
averaging 3 min, were attempted to all
NRT recipients at 3 weeks and again at
about 14 weeks after the intake call.
Counselling included advice on patch
usage,
management
of
adverse
reactions, and encouragement to start or
continue a quit attempt. Telemarketing
staff, trained by NYC DOHMH, made the
calls using a computer-assisted script. Of
the NRT recipients, 15 212 (45%)
received at least one counselling call,
and 5128 (15%) received two calls.
Length of study
6 months
Outcomes
quit attempts, successful quits
383
Details
Method
Results
Comments
Data sources
recall surveys of callers to the helpline
carried out two months and one year
after their initial call
Participant selection
3019 of 18,873 log sheets were randomly
selected in proportion to total number of
calls each day between 26 December
and 31 March 1998. 905 of 6038
(participants who had left telephone
numbers to be contacted) were randomly
selected for 2-month recall survey. Only
473 (of 905) recontact interviews were
achieved at 11 months post-baseline.
Fresh sample (n = 951) was randomly
drawn from the 5133 baseline log sheets
with telephone numbers that had not
been used for the two month recall study.
This provided an additional 257
respondents. Thus a total of 730
respondents were interviewed one year
after their initial call to Quitline; 521 were
current smokers at baseline.
Participant characteristics
Compared with all smokers in general
population in England, callers were more
likely to be women, to be in the age
groups 25-34 or 35-44 years, to come
from households with children under the
age of 16 years, and to be heavy
smokers (smoke 20 or more cigarettes a
day).
Intervention
The helpline is staffed by trained
counsellors
who
offer
one-to-one
telephone information, advice, and
counselling. Callers can also receive an
General population
Currently Quitline receives around half a million
calls in the course of one year, 93% of whom
are phoning for themselves. This represents
4.2% of the total population of adult smokers in
England. At one year the social class profile of
callers to the helpline reflected the social class
profile of all adult smokers; 63% of the sample
were of manual occupations or unemployed
compared with 61% of the adult smoker
population.
Among smokers at baseline, 24% of those who
received the two month recall reported not
smoking at one year compared with 18% who
had not received the two month recall (X2 =
3.123, narrowly missed significance at p < 0.05).
At one year 22% (95% CI; 18.4% to 25.6%) of
smokers reported that they had stopped
smoking. Assuming that those who refuse to
take part in the one year follow up are
continuing smokers and a further 20% of
reported successes fail biochemical validation,
this yields an adjusted quit rate of 15.6% (95%
CI 12.7% to 18.9%) at one year.
Among ex-smokers, 41% (95% CI 34.3% to
47.7%) reported that they were still not smoking
at one year. The adjusted figure for ex-smokers
at one year is 29% (95% CI 23.3% to 34.8%). Of
those who resumed smoking 28% were smoking
less than they had been initially.
SES
Social classes ABC1 were associated with not
smoking at one year among ex-smokers.
25% (17.05 to 32.95) social classes ABC1
stopped smoking at one year.
21% (13.52 to 28.48) social class C2DE
stopped smoking at one year.
Internal validity
730 of 6038 were followed-up at
one year = 12%. Compared with
callers at baseline, women, those
aged 35 and over, and those with
moderate consumption levels (1019 cigarettes a day) were
overrepresented in the one year
recall sample. The one year recall
sample also included more long
term smokers.
Information on social class was not
available at baseline and so it is
not possible to assess any bias
attributable to this factor.
External validity
Small sample size
Validity of author’s conclusion
Valid but small sample size
Mass media - Quitlines
Author, year
Owen 2000
Country
England
Design
Cohort
Objective
To evaluate the impact of a telephone
helpline (Quitline) with additional support
(written information) on callers who use
the service during the HEA 3-month TV
and radio advertising campaign.
SES variables
Social
classes
ABC1
include
professional, managerial, clerical, and
administrative grades; C2DEs include
skilled manual and unskilled manual and
those on state benefits.
Analyses
Analysis of caller profiles from log sheets
completed by Quitline counsellors. The
second and third stages involved a series
of telephone recall interviews with a
sample of callers conducted two months
and one year after their initial call to the
helpline. The recall interviews were
carried out by Consumer Focus, an
independent research company.
384
Details
Method
Results
information pack through the post
containing information on a variety of
smoking related topics such as the risks
of smoking and advice on how to quit.
The advertising campaign comprised
television and radio advertisements and
was supported by advertorials (adverts
that look like editorial) in women's
magazines.
The
television
advertisements were targeted at young
smokers (aged 16-24 years) and aimed
to challenge their reasons for smoking
and provide them with reasons to quit. In
contrast to previous campaigns, the TV
adverts adopted a hard hitting testimonial
approach. The radio and magazine
adverts were aimed at a slightly wider
audience and were intended to provide
support and encouragement to those who
want to quit. All adverts included the
Freephone Quitline number.
Length of study
December 1997 to February 1999
Outcomes
Calls to helpline, smoking status at one
year
Author’s conclusion of SES impact
The social class distribution of callers to the
Quitline reflected the social class distribution of
smoking in the population, with nearly two thirds
of callers being in manual occupations or
unemployed. One fifth of the smokers who
called Quitline who were in manual occupations
or unemployed reported having stopped at one
year, it seems likely that such a service can
make a major contribution to achieving smoking
reductions among these priority groups.
Comments
Mass media - Quitlines
385
Details
Mass media - quitlines
Author, year
Siahpush, 2007
Country
Victoria, Australia
Design
Cross-sectional
Objective
To assess the socioeconomic
variations in call rates to the Quitline
(Victoria, Australia) and in the impact
of anti-tobacco television advertising
on call rates.
SES variables
Index
of
Socioeconomic
Disadvantage
Analyses
Negative binomial regression
Method
Result
Comments
Data sources
Quitline, Victoria
Participant selection
Callers requesting Quit Packs
Participant characteristics
Television viewers in Victoria who
responded to anti-smoking and NRT
adverts.
Intervention
Predominantly featured hard-hitting
advertisements on the health risks of
smoking, and promotion of a
telephone Quitline.
Adverts shown irregularly over 169
week period (88weeks = no ads,
42weeks=medium
volume,
39weeks= high volume).
Attempts made to tailor adverts to
low SES groups, including placement
and content. Message mostly
focused on health impacts of
smoking, one looked at tobacco
industry tactics.
Length of study
Quitline calls tracked between
January 2001 and March 2004
Outcomes
Number of calls to Victoria Quitline,
and the number of calls per 100,000
smokers in the quintile
General population
Higher weekly TARPs correspond
closely with a larger overall volume of
calls. Antismoking and NRT TARPs
were positively associated with call
rates. Week had a rate ratio smaller
than unity, indicating a decreasing
trend over time in rates of calls to the
Quitline. Likelihood ratio tests for the
interaction of antismoking TARPs
(p=0.934), NRT TARPs (p=0.995)
revealed no evidence of an
interaction.
SES
Exposure to TV adverts led to higher
Quitline call-rates across all 5 SES
quintiles. Call rates increased almost
universally by 2.5-2.7 times in all five
quintiles.
SES and call rates were positively
associated. SES and call rates were
inversely associated. Adjusted call
rate was 57% (95% CI 45% to 69%)
higher in the highest than the lowest
SES quintile. The call rates gradient
appears to be very similar across
SES groups.
The trend in calls appears to be very
similar across SES categories,
indicating no interaction between
TARPs and SES in their effect on the
volume of calls.
No evidence of an interaction if time
with SES (p=0.336), suggesting that
SES differentials in call rates were
stable in the study period.
Internal validity
No indication of how they know SES
of Quit Pack requesters represented
the SES of all callers, as area was
the SES indicator used.
Only those who own a TV set eligible
for recruitment.
Definitions of low-med-high exposure
used to generate equal groups, not
by any genuine perception of ‘high’
exposure.
Doesn’t mention which channels are
used, i.e. Free-to-air
External validity
Possible influence of indigenous
Australians’ engagement with the
campaign? Not explored as a
confounder. Applicability outside of
urban settings?
Validity of author’s conclusion
Valid - the exposure/call relationship
shows no variation.
386
Author’s conclusion of SES
impact
SES groups had similar levels of
responsiveness to television adverts
387
Details
Method
Results
Comments
Data sources
Helpline callers plus 2002 National
Behavioral Risk Factor Surveillance
Study (BRFSS) and the 1999-2001
National Health Interview Study
(NHIS)
Participant selection
Convenience sample, 890 of 899 eligible
adult smokers participated (98.9%)
mostly from the Midwestern and
Southern states
Participant characteristics
890 adult current smokers, new and
voluntary callers only
Intervention
Mass media advertising campaigns using
health consequences messages directed
homogeneously across all population
segments were used to boost helpline
usage.
Helpline provides assistance to callers
across the United States via a toll-free
number. The helpline offers live
counselling that is standardized and
based upon transtheoretic model of
behavioural change as applied to
smoking cessation, supplemented by the
principles of social cognitive theory, a
patient-centred counselling strategy, and
the latest recommendations by clinical
experts; all new callers are mailed a free
package
of
self-help
educational
materials.
Length of study
January 2003 to October 2005
Outcomes
General population
Based upon an independent survey report of
432 callers, billboards were noted to be the
most common method (49.6%) for the users to
learn about the helpline, followed by radio
(12.5%), television (10.6%), and word of mouth
(7.6%).
SES
There was significant overrepresentation of
poorer and less educated smokers. Smokers
who used this national reactive telephone
helpline, when compared with the general adult
population of smokers across the United States,
were significantly more likely to be women, at
least 45 years of age, black, non-Hispanic,
educated up to high school level, and urban
residents, and to earn an annual household
income of less than $35,000, more likely to be
heavy smokers (i.e., smoking >25 cigarettes
daily).
Author’s conclusion of SES impact
Reactive
telephone
helplines
may
be
preferentially used by disadvantaged smokers
who are in greatest need of assistance
Internal validity
The helpline callers were not
sampled by a stratified design
across the entire United States.
Further, all comparisons between
the two populations were based on
crude or unadjusted prevalence
rates. Does not take into account
the secular trends in smoking
behaviour during the period 1999
to 2005.
External validity
Participants were mostly from the
Midwestern and Southern states
so
results
may
not
be
generalisable across US.
Helpline callers were more likely to
represent the contemplation stage
of behavioural change than the
general population of smokers.
Validity of author’s conclusion
Given all the validity concerns the
equity impact of the campaign and
the helpline are unknown.
Mass media - Quitlines
Author, year
Sood 2008
Country
USA
Design
Cross-sectional with control comparison
Objective
To describe the characteristics of current
smokers calling a national reactive
telephone helpline
SES variables
Educational status, annual household
income
Analyses
characteristic in the study
population were compared with
the theoretic control population of
adult current smokers in the United
States.
388
Details
Method
Results
Comments
Mass media - Quitlines
Helpline callers
389
Details
Method
Results
Comments
Data sources
International Tobacco Control
Policy Evaluation Survey (ITC Project)
New Zealand arm
Participant selection
The NZ arm of the ITC Project survey
differs somewhat from other ITC samples
as the smokers involved are New
Zealand
Health
Survey
(NZHS)
participants. NZHS respondents were
selected by a complex sample design,
which included systematic boosted
sampling of the Māori, Pacific, and Asian
populations. Invited at end of NZHS to
participate in this study.
Participant characteristics
923/1376
Intervention
Wave 1 respondents were exposed to
text-based warnings with a quitline
number but no wording to indicate that it
was the “Quitline” number. Wave 2
respondents were exposed to pictorial
health warnings (PHWs) that included the
word “Quitline” beside the number as well
as a cessation message featuring the
Quitline number and repeating the word
“Quitline.”
Length of study
12 months (wave 1 between March 2007
and February 2008 and wave 2 between
March 2008 and February 2009.
Outcomes
Quitline number recognition
General population
The introduction of the new PHWs was
associated with a 24 absolute percentage point
between-wave increase in Quitline number
recognition (from 37% to 61%, p < .001).
Matched odds ratio of 3.31, 95% CI = 2.63 to
4.21.
SES
A majority of all five quintiles of socioeconomic
deprivation using a small area measure (range
58.0%–65.5%) recognized the Quitline number
in Wave 2. The increase between the waves
was lowest in the most deprived quintile (p <
.001), though this group had the highest level of
recognition
at
baseline.
For
individual
deprivation, the increase was highest in the
second to least deprived grouping and lowest in
the most deprived. For both types of deprivation,
the most deprived had the highest level of
recognition in Wave 1 and the lowest level of
recognition at Wave 2 (though in the latter, the
differences were not significantly different).
Recognition increased from a minority of
respondents to a majority for all deprivation
levels (using small area and individual
measures), and financial stress (two measures).
Author’s conclusion of SES impact
This study provides some evidence for the value
of clearly identifying quitline numbers on
tobacco packaging as part of PHWs and
appeared to benefit all sociodemographic
groups. It may also help equalize differences
that previously existed, for both measures of
deprivation.
Internal validity
Between-wave attrition of 32.9%
occurred.
External validity
The overall response rate for this
study was 32.6%. Weighting
process may not have fully adjusted
for nonresponse bias.
Validity of author’s conclusion
May not be generalisable to whole
of New Zealand due to sampling.
Mass media - quitlines
Author, year
Wilson 2010a
Country
New Zealand
Design
Prospective cohort
Objective
To examine how recognition of a national
quitline number changed after new health
warnings were required on tobacco
packaging
SES variables
small area deprivation, individual
deprivation, and financial stress
Analyses
Paired matched odds ratio
390
Details
Mass media – NRT
Author, year
Zawertailo 2012
Country
Ontario, Canada
Design
2 intervention cohorts with control
cohort
Objective
To determine the effectiveness of
free nicotine replacement therapy
(NRT), brief advice and self-help
materials on quit attempts and 6month quit rates in motivated
smokers.
SES variables
Education, income
Analyses
Regression analyses using logbinomial regression model. In these
analyses, the OTS cohort making up
the comparator arm was restricted to
smokers matching STOP inclusion
criteria and was re-weighted by age
and sex to match the STOP
intervention arm.
Method
Results
Comments
Data sources
STOP
(Smoking Treatment for Ontario
Patients) Study and population-based
estimates of smoker characteristics in
the Ontario Tobacco Survey (OTS)
study
Participant selection
6261 consented to follow-up from
13143 eligible participants = 48%;
Sub cohort of OTS used as
comparator which matched STOP
participants, n=780
Participant characteristics
Ontario residents 18 years of
age and older who smoked at least 10
cigarettes per
day and were willing to make a quit
attempt within
30 days.
nicotine
patch (n=10 000) or nicotine gum
(n=4000)
Intervention
Provision of free NRT by mail
following a brief telephone
intervention.
5 weeks of NRT (patches or gum)
plus self-help and community
resource materials, to the first 14 000
eligible smokers to call a toll-free
General population
percentage reporting abstinence after
6 months in the treatment cohort was
21.4%, relative to 11.6% in the nointervention cohort (rate ratio of 1.84;
95% CI 1.79 to 1.89), with the 30-day point
prevalence of 17.8% and 9.8% for the
intervention and nointervention cohorts,
respectively (rate ratio 1.81; CI 1.75 to
1.87).
SES
Compared with all adult Ontario smokers
(OTS cohort not restricted to STOP
eligibility criteria), STOP participants were
more likely to have less than high school
education.
Lowest income group associated with
lower percentage of self-reported quit at
time of interview (bivariate analyses). In
multivariate analyses neither education or
income was significantly related to selfreported at least one serious quit attempt
within 6 months; being quit at the time of
interview; 30-day quit point prevalence;
Author’s conclusion of SES impact
initial brief intervention plus 5 weeks of
free NRT to motivated smokers in Ontario
with completer follow-up data significantly
increased self-reported 6-month abstinence
rates compared with our no intervention
control arm who did not receive any free
Internal validity
Completer analyses only: 42%
had complete follow-up data.
Two methods were used to
address the possible impact of
loss to follow-up as a source of
bias in comparing cessation
rates between STOP and OTS.
Completers were older than
noncompleters. Completers had
lower incomes than
noncompleters but differences
were small.
External validity
Motivated smokers, heavier
smokers than in general
population. large populationwide smoking cessation
intervention provided across
urban, rural and remote
areas
Validity of author’s
conclusion
Valid, comparator cohort
conducted concurrently and
recruited subjects from the
same general population of
Ontario smokers.
391
Details
Mass media – NRT
Method
Results
quitline.
STOP launched in January 2006.
Region-specific media promotion
was used to increase the reach in
more remote regions of the province
with a high prevalence of smoking.
Length of study
5 weeks
Outcomes
self-reported at least one serious
quit attempt within 6 months;
being quit at the time of interview;
30-day quit point prevalence;
NRT, materials or advice to quit.
Type of smokers reached through this
programme tended to be older, female,
less-educated heavier smokers with high
prevalence of psychiatric co-morbidities.
Comments
392
Details
Multiple policies
Author, year
Frieden 2005
Country
New York City, USA
Design
Repeat cross-sectional
Objective
to determine the Impact of
comprehensive tobacco control
measures in New York City
SES variables
education
Analyses
Univariate and multivariate
Method
Results
Comments
Data sources
Annual New York State Behavioral
Risk Factor Surveillance System
(BRFSS), New York City Department
of Health and Mental Hygiene
(DOHMH) conducted a populationbased,
random-digit
dialed
telephone community health survey
Participant selection
randomly selected
Participant characteristics
adult New York City resident
Intervention
9. April and July 2002 state and
city tax increases raised the
cost of a pack of cigarettes
by approximately 32%, to a
retail price of approximately
$6.85
10. 2002 Smoke-Free Air Act
(SFAA) became effective in
March 2003 eliminated
existing exemptions to make
virtually
all
indoor
workplaces,
including
restaurants
and
bars,
smokefree.
11. April 2003 nicotine-patch
distribution program began
providing
free
6-week
General population
During the 10 years preceding the 2002
program, smoking prevalence did not
decline in New York City; within a year of
implementation of the new policies, a
large, statistically significant decrease
occurred. From 2002 to 2003, smoking
prevalence among New York City adults
decreased by 11% (from 21.6% to 19.2%,
(P=.0002) approximately 140000 fewer
smokers).
Increased taxation appeared to account
for the largest proportion of the decrease;
however, between 2002 and 2003 the
proportion of cigarettes purchased outside
New York City doubled, reducing the
effective price increase by a third.
SES
Smoking declined among all education
levels. The decrease was more pronounced
among low-income women (an 18.1%
decrease, from 21.6% to 17.8%; P=.OO9).
Significant decreases in smoking were
found among people with more than a
high school education (a 12.4% decrease,
from 19.3% to 16.9%; P=.O1). Declines
were also large among people with annual
family incomes of less than $25000 (a
12.6% decrease) or $75000 or more (a
13.4% decrease).
Internal validity
Response rates per wave
among contacted households
were 64%, 59%, and 64%
respectively for three waves of
data collection 2002 to 2003.
ORs significantly reduced for
smoking, only for people in
income <$25,000 and ‘some
college’ education.
External validity
Analyses of education level
were restricted to adults aged
25 years and older
Validity of author’s conclusion
Valid,
but
respondents'
attribution of the impact of
various control measures on
their smoking behaviour may
not be accurate.
393
Details
Multiple policies
Method
courses (coupled with brief
telephone counseling) to 34
000 of the city's heavy
smokers
12. Expansion of educational
efforts such as publications
and
advertisements
in
broadcast and print media,
emphasized the health risks
of environmental tobacco
smoke and the benefits of
quitting. There was also
extensive media coverage of
the debate regarding smokefree workplace legislation.
Length of study
May 2002 to November 2003; The
2002 community health survey was
considered to be the preintervention
sample, and the 2 surveys conducted
in 2003 were combined and treated
as the postintervention sample.
Outcomes
Smoking prevalence
OR for smoking
Response to tax increase
Response to workplace smoking ban
Results
Comments
In 2003, former smokers who had quit
within the past year were more likely to
have low incomes compared with former
smokers who had quit more than 1 year
previously (43.6% vs 32.0%, p=.0001).
Residents with low incomes (<$25000 per
year) or with less than a high school
education were more likely than those
with high incomes (>$75 000 per year) and
those with a high school education or
higher to report that the tax increase
reduced the number of cigarettes they
smoked (income: 26% [low] vs 13.0%
[high], P=.0002; educational attainment:
27.5% [lower] vs 19.3% [higher], P=.OO9).
High-income people were more likely than
low-income people to report that the SFAA
reduced
their exposure to ETS (53.3% vs 41.9%,
P<.0001).
Author’s conclusion of SES impact
Groups that experienced the largest
declines in smoking prevalence included
people in the lowest and highest income
brackets and people with higher
educational levels.
Our data suggest that people with lower
incomes may have been more heavily
affected
by the increase in taxation, whereas
394
Details
Multiple policies
Method
Results
Comments
people with higher incomes may have
been more affected by greater awareness
of the dangers of environmental tobacco
smoke and expansion of smoke-free
workplace legislation.
395
Details
Method
Results
Comments
Data sources
Dutch Continuous Survey of Smoking
Habits (DCSSH). The DCSSH is
conducted by market research company
TNS NIPO for the Dutch expert centre on
tobacco
control
(STIVORO).
Respondents for the DCSSH were
selected from TNS NIPObase, a
database containing more than 140,000
potential respondents who participate in
internet-based research on a regular
basis.
Participant selection
Stratified random sample
Participant characteristics
Approximately
18,000
respondents
15years+ participated in the survey each
year, totaling 144,733 respondents in the
period 2001 to 2008.
Intervention
several tobacco control policies were
implemented;
2002 text warning labels for cigarette
packages
2002 tobacco advertising ban
2003 youth access law
2004 smoke-free workplace legislation
which was extended in 2008 so as to
include the hospitality industry.
Tax increases were implemented in
2001, 2004, and 2008.
Intensive national mass media smoking
cessation campaigns ran in 2003, 2004,
and 2008.
Length of study
2001 to 2008
General population
Not reported
SES
Lower educated respondents were significantly
more likely to be smokers, smoked more
cigarettes per day, had higher initiation ratios,
and had lower quit ratios than higher educated
respondents. Income inequalities were smaller
than educational inequalities and were not all
significant, but were in the same direction as
educational inequalities. Among women,
educational inequalities widened significantly
between 2001 and 2008 for smoking
prevalence, smoking initiation, and smoking
cessation. Among low educated women,
smoking prevalence remained stable between
2001 and 2008 because both the initiation and
quit ratio increased significantly. Among
moderate and high educated women, smoking
prevalence decreased significantly because
initiation ratios remained constant, while quit
ratios increased significantly. Among men,
educational inequalities widened significantly
between 2001 and 2008 for smoking
consumption only.
Author’s conclusion of SES impact
While inequalities in smoking prevalence were
stable among Dutch men, they increased
among women, due to widening inequalities in
both smoking cessation and initiation.
Multiple policies
Author, year
Nagelhout 2012
Country
The Netherlands
Design
Repeat cross-sectional
Objective
To examine trends in socioeconomic
inequalities in smoking prevalence,
consumption, initiation, and cessation
between 2001 and 2008 in the
Netherlands.
SES variables
Education; low (primary education and
lower
prevocational
secondary
education),
moderate
(middle
prevocational secondary education and
secondary vocational education) and high
(senior general secondary education,
(pre-)university education and higher
professional education).
Gross yearly household income level was
also categorized into three equal sized
groups: low (less than 28,500 Euro=<
25,600 GBP), moderate (between 28,500
and 45,000 Euro= 25,600 - 40,430 GBP),
and high (more than 45,000 Euro
=>40,430 GBP).
Analyses
Logistic regression analyses
Internal validity
There
were
no
significant
differences in education level,
gender, and age group between
years. However, income level
differed
significantly
between
years (χ2 (14) = 669.19, p<0.001),
which was due to an increase in
respondents with higher incomes
over time.
External validity
Possible
lack
of
representativeness of the Internet
sampling frame used.
Validity of author’s conclusion
valid
396
Details
Method
Results
Comments
Multiple policies
Outcomes
Smoking prevalence
Smoking consumption
Initiation ratios = current + former
smokers/all respondents
Quit ratios = (former smokers/current +
former smokers)
397
Details
Method
Result
Data sources
National
health
surveys.
100,893
respondents over 18 countries.
Participant selection
Selection process varies. Non-response
rate between 13.4 and 49% depending
on country.
Participant characteristics
Ireland has most developed tobacco
control policy, Latvia least.
Intervention
Joosens and Raw’s tobacco control scale
used as a proxy, with some analysis by
individual policies including:
Price, advertising bans, public place
bans, campaign spending, health
warnings
Length of study
Year 2000, except Germany and Portugal
= year 1998-9.
Outcomes
Quit ratios
General population
Large variations in quit rate and RII
between countries.
Quit rates positively associated with
tobacco control scale score. Policies
related to cigarette price showed the
strongest association with quit ratios. A
comprehensive advertising ban showed
the next strongest associations with quit
ratios in most subgroups. Health
warnings negatively associated with quit
rates.
Regression coefficient 2.08 (-0.36 to
8.48) for men and 2.07 (-1.09 to 8.66) for
women for price.
Regression coefficient 1.33 (1.11 to 8.02)
for men and 1.59 (1.39 to 8.67) for
women for advertising bans.
Regression coefficient 0.94 (-2.43 to
5.89) for men and 0.41 (-3.84 to 5.26) for
women for public place bans.
Regression coefficient 0.54 (-3.05 to
6.17) for men and 0.54 (-3.52 to 6.41) for
women for campaign spending.
Regression coefficient -0.40 (-7.32 to
2.31) for men and -0.42 (-9.51 to 3.43) for
women for health warnings.
A ‘stripped’ analysis focusing on price,
health warnings and treatment (excluding
recent policy developments) supported
the main findings.
SES
Quit rates positively associated with
tobacco control scale score. More
educated smokers more likely to have
quit than lower educated, for men and
women. Larger absolute difference
between high and low educated for 25-39
year olds. However no consistent
Comments
Multiple policies
Author, year
Schaap, 2008
Country
18 European countries; Finland, Sweden,
Denmark, England, Ireland, Netherlands,
Belgium, Germany, France, Italy, Spain,
Portugal, Slovakia, Hungary, Czech Rep.,
Lithuania, Latvia, Estonia
Design
Cross-sectional
Objective
To examine the extent to which tobacco
control policies are correlated with
smoking cessation, especially among
lower education groups
SES variables
Education; relative index of inequality
(RII). The RII assesses the association
between quit ratios and the relative
position of each educational group, can
be interpreted as the risk of being a
former smoker at the very top of the
educational hierarchy compared to the
very lowest end of the educational
hierarchy
Analyses
Log-linear regression analyses to explore
the correlation between national quit
ratios and the national score on the
Tobacco Control Scale (TCS).
Internal validity
Non-response percentages ranged from
about 15% in Italy and Spain up to 49%
in Slovakia, while percentages in most
other countries were between 20% and
35%.
Survey conducted before tobacco control
scale devised, and before some policies
enacted so may underestimate the
impact of recent policies.
Difficult to draw conclusions about
causality as study only examines the
association between ex-smokers and
presence of policies, rather than changes
in prevalence post-implementation.
Occasional smokers excluded from all
analyses.
External validity
Included data from Eastern Europe and
Baltic countries. Limited analyses to the
adult population aged 25–59 years.
Difficulty in drawing conclusions from
multiple nations with varying average
standards of education, definition of
‘highly educated’ likely to vary for some
nations.
Validity of author’s conclusion
Conclusion is consistent with the data
presented; however it’s difficult to draw
strong conclusions about the impact of
any
one
intervention
given
the
methodological limitations discussed
above.
398
Details
Method
Result
Comments
differences were found between quit
ratios in high and low educated groups
and tobacco control scale score.
Policies related to cigarette price showed
the strongest association with quit ratios.
Significant positive association between
quit ratio and price for high SES aged 4059 years.
A
comprehensive
advertising
ban
showed the next strongest associations
with quit ratios in most subgroups (not
low SES aged 40-59 or low SES women
aged 25-39 years.
Health warnings negatively associated
with quit rates.
Author’s conclusion of SES impact
High and low educated groups seem to
benefit equally from nationwide tobacco
control policies. More developed tobacco
control policies are associated with
higher quit rates.
399
Details
Method
Results
Comments
Data sources
Dutch Continuous Survey of Smoking
Habits; each week, 200 respondents are
randomly selected from a database of
more
than
200,000
respondents’
representative for the Dutch population
aged 15 years and older. Sample is
weighted for region, urbanization, gender,
age, household composition, and level of
education.
The
subjects
were
approached by Internet to fill in a
questionnaire.
Participant selection
Selected all 32,014 respondents aged
16–65 years in 2003, 2004 and 2005.
With paid work (n = 27,150) and without
(n = 4,864) paid work.
Participant characteristics
32,014 respondents (27,150 with paid
work and 4,864 without paid work) aged
16–65 years.
There were significant (p < .001)
differences in gender, age, and level of
education when we compared the group
of the respondents with paid work with
that without paid work.
Intervention
Respondents with paid work were
exposed to the following interventions:
the workplace-smoking ban from January
1, 2004 to February 1, 2004 (n = 601),
the workplace-smoking ban and the first
tax increase from February 1, 2004 to
January 1, 2005 (n = 8,427), and the
workplace-smoking ban and the first and
second tax increase from January 1,
2005 to December 31, 2005 (n = 8,908).
General population
When controlling for the covariates (period after
New Year, number of working hours, and age)
the effects of the interventions on quit attempts
were not significant among those with or without
paid work. For respondents with paid work, the
combination of a smoking ban and 2 tax
increases led to a decrease in the number of
cigarettes per day and in the prevalence of daily
smoking. For respondents without paid work,
there was no significant effect on any of the
outcome parameters.
For paid workers, there was no significant
change (OR: 0.87) in the likelihood of daily
smoking among the respondents interviewed in
the one month (January 2004) in which the ban
without additional tax increases was in force,
although the OR was similar to the other
interventions. The effects of the first (OR: 0.86)
and second tax increase (OR: 0.85) after the
ban on daily smoking were significant and in the
expected direction.
Among those without paid work, the tax
increases had no significant effect on the
likelihood of daily smoking. However, in terms of
effect size, there was little difference between
those with and without paid work in the effect of
the first (OR: 0.86 vs. OR: 0.87) and second
(OR: 0.85 vs. OR: 0.94) tax increase.
SES
In both paid and unpaid groups, there was no
evidence that the effect of the measures on
smoking was moderated by the respondent’s
level of education.
The likelihood of daily smoking was lower
among the higher educated group compared
with the lower educated group (OR:0.59) with
paid work. Higher educated respondents were
Internal validity
the lack of significance for the
workplace-smoking ban may be
due to too low statistical power
External validity
Possible
lack
of
representativeness of the Internet
sampling frame used. In the
Netherlands, the proportion of
people with access to Internet in
2005 is relatively high (83%).
Among those without work,
Internet access is lower (66%)
than among those with paid work
(90%).
Validity of author’s conclusion
The influence of the workplacesmoking ban is likely to be
incorporated in the effects found
for the first and second tax
increase because ban only in force
without tax increase for one
month.
Multiple policies
Author, year
Verdonk-Kleinjan 2011
Country
The Netherlands
Design
Repeat cross-sectional
Objective
To explore how the combination of a
workplace smoking ban and two tax
increases
influences
the
smoking
behaviour of the general population.
SES variables
education
Analyses
linear and logistic regression
400
Details
Method
Result
Those without paid work were not
exposed to an intervention until February
2004 (n = 1,825); they were exposed to
the first tax increase from February 1,
2004 to January 1, 2005 (n = 1,521) and
to the first and second tax increases from
January 1, 2005 to December 31, 2005
(n = 1,518).
Length of study
3 years; 2003 to 2005
Outcomes
Intensity of smoking
Quit attempts
Smoking prevalence
less likely to be daily smokers (OR: 0.54)
without paid work.
Author’s conclusion of SES impact
There was no evidence that the effect of the
measures on smoking was moderated by the
respondent’s level of education.
Comments
401
Details
Method
Results
Comments
Data sources
survey
Participant selection
randomly selected
Participant characteristics
2,644 black smoking households in four
sites in the north-eastern and southeastern parts of the United States; A
sample of 520 smokers was randomly
drawn from the baseline cohort for the
six-month follow-up. For the twelvemonth follow-up a random sample of 490
smokers were selected from the original
cohort after excluding those individuals
who had participated in the six-month
follow-up. At the time of the eighteenmonth follow-up survey, there were 2096
remaining members of the original cohort
left with known addresses who could be
followed up.
Intervention
Community-based intervention centred
on the health belief and diffusion of
innovation
models.
The
active
intervention areas were the subject of
special area-based intervention activities,
while the community as a whole (both the
active and the passive areas) were
exposed to a mass media campaign
designed to promote readiness to quit
smoking.
Length of study
18 months; 1989 to 1990
Outcomes
point prevalence of non-smoking
Period prevalence of quit attempts in the
prior six months;
Number of smoke-free days in the
prior six months;
General population
18-month: among the 1344 baseline smokers
re-interviewed at eighteen months, in the active
intervention groups combined, the point
prevalence of non-smoking was 16.7 percent
while it was 11.8 percent in the passive groups
combined, for an absolute difference of 4.9
percent. In other words, there was a 41.5
percent greater point prevalence rate of nonsmoking in the active versus the passive
intervention areas among the smokers
interviewed, a difference which was statistically
significant at p = 0.012.
In this same survey, the period prevalence of
attempting to quit at least once in the prior six
months was 33.8 percent for the active
intervention groups combined and 26.2 percent
for the passive intervention groups combined.
This absolute difference of 7.6 percent was
statistically significantly at p = 0.003.
There was a statistically significant difference in
smoke-free days (p = 0.001) between the active
group with a mean of 28.1 and the passive
group with a mean of 19.4 for a difference of 8.7
percent. The number of smoke-free days was
31 percent higher in the active intervention
group.
Finally, there was a statistically significant
difference (p = 0.004), between the active and
passive intervention areas in the reduction in
numbers of cigarettes smoked at eighteen
months versus at baseline. There was a mean
decrease of 2.0 and 0.4 fewer cigarettes
smoked daily, respectively, in the active and
passive groups when non-smokers were
omitted, for an absolute difference of 1.6. This
represents a 400 percent greater reduction in
cigarettes smoked in the active intervention
group.
Internal validity
The initial research design strategy
was
to
select
four
Black
neighborhoods in each of the
selected cities: two middle-income
areas and two lower-income
areas. One middle-income and
one lower-income area in each city
were designated as passive
intervention
sites
while
the
remaining middle- and low-income
areas were the active intervention
sites. Subsequent to the baseline
survey the four areas of Springfield
were combined into a single active
intervention site while the four
areas of Hartford were designed a
single passive site.
The
cross-sectional
studies
contained different individuals (in
the case of the 6- and 12-month
surveys), and only some of the
individuals in the eighteen-month
group overlapped with those from
the six- and twelve-month surveys.
Such a difference in population
make-up can be a source of
selection bias which can result in
spurious differences in outcome
variables between surveys.
There are no specific outcomes by
income area and income areas are
not defined in any more detail.
External validity
Generalisable to black smokers in
North-eastern and south-eastern
parts of US
Validity of author’s conclusion
It is difficult to tell from the paper
Settings based interventions
Author, year
Darity 2006
Country
USA
Design
Quasi-experimental, 2-group pre-post
design, with repeat cross-sectional
samples and follow-up of longitudinal
cohort
Objective
to determine the most effective
educational interventions to reduce
smoking
among
African-American
smokers
SES variables
low income vs moderate income areas
Analyses
18-month analyses, cohort retrospective
analyses,
sequential
cross-sectional
analyses, process variable analysis
402
Number of cigarettes smoked daily at the
time of interview.
SES
18-month analyses: The moderate income
areas tended to show a smaller percentage
change in smoking outcomes in the intervened
versus non-intervened groups than did the lower
income areas, although the differences were not
significant. The exception to this is the greater
percentage reduction in the number of
cigarettes smoked. There was only a small nonsignificant increase in personal smoking
behavior in moderate income groups as
opposed to low income groups.
Education was not significantly related to
outcome variables
Author’s conclusion of SES impact
The moderate income areas tended to show a
smaller percentage change in smoking
outcomes in the intervened versus nonintervened groups than did the lower income
areas, although the differences were not
significant. The exception to this is the greater
percentage reduction in the number of
cigarettes smoked.
An analysis of process variables strongly
suggests that, within this African-American
Community, “hands on” or “face to face”
approaches along with mass media, mailings,
and other less personal approaches were more
effective in reducing personal smoking behavior
than media, mailings, and other impersonal
approaches
alone
addressed
to
large
audiences.
what the impact was by area SES.
403
Details
Method
Results
Comments
Data sources
40 in-patient treatment centres. The
tobacco control policy questionnaire was
anonymous and answered by the director
of each treatment centre.
Participant selection
30 smaller centres self-recruited and 11
of 31 centres with at least 50 beds were
recruited by invitation.
(92.5%) were
included in follow-up; 774 patients out of
1178 at baseline (65.7%). Patients
recruited consecutively in 6-month period
starting June 2005.
Participant characteristics
774 alcohol addicted patients mean
number of beds =112 (SD=65), mean
number of employees =62 (SD=35). The
mean duration of treatment was 12.9
weeks (SD=4.1). The majority of the
centres were located in the western part
of Germany. One fourth of the recruited
patients were female, the mean age of
the patients was 42 years. The majority
of the patients were not employed and
had an education of less than 12 years.
The mean smoking prevalence of
patients at admission was 84% varying
between 65% and 100%.
Intervention
Institutional tobacco control policy, 7
elements
included
Restrictions,
Enforcement, Assessment of smokers,
Smoking cessation offers, Non-smoker
protection,
Activities,
Training
of
Employees,
Length of study
June 2005 to March 2006
General population
The strength of tobacco control policy lie in the
areas of assessment of smokers, enforcement
of smoking restrictions and restrictiveness of
smoking policy.
There was a small but significant effect of
centres’ tobacco control policy on patients’
smoking cessation. A total of 39 patients being
smokers at admission (N=774) were nonsmokers (7-day prevalence) at discharge. This
equals an abstinence rate of 3.3% (Intent-totreat-analysis) respectively 5.0% (exclusion of
drop outs). Abstinence rates vary between
centres within the range of 0.0% to 23.0%.
Lower tobacco dependency predicted nonsmoking status at discharge (OR=0.84, 95% CI=
0.71 to 0.99).
Comprehensiveness of smoking restrictions
(OR=1.03, 95% CI=1.00 to 1.07) and intensity of
smoking related training of the employees
(OR=1.02, 95%CI=1.00 to 1.03)are significant
predictors for the variance in quit rates between
the institutions.
SES
Significant individual predictors for quitting
include
educational
status
(OR=1.86,
95%CI=1.25 to 2.75).
Author’s conclusion of SES impact
Higher education predicted non-smoking status
at discharge. There were two predictive areas of
tobacco control policy (restrictions and
employee
training)
while
an
overall
effectiveness of the developed concept could
not be proven.
Settings based interventions
Author, year
Donath 2009
Country
Germany
Design
Multi-centre field study with pre–post
design as well as a parallel crosssectional assessment of tobacco control
policy at participating centres. Data are
part of an RCT before the intervention in
the experimental group started.
Objective
To explore the influence of tobacco
control policies in German in-patient
substance abuse treatment centres on
smoking status of alcohol-addicted
patients at discharge.
SES variables
education
Analyses
multiple regression
Internal validity
The questionnaire consisted of
scores up to an optimal 100, for
seven policy areas and was
developed
using
published
material and piloted. Retest
reliability was acceptable in 5 of 7
areas (r=0.61 to r=0.81) and in 2
areas the retest reliability was
≤0.5.
The tobacco control policy was
measured by ratings of a single
person.
External validity
Very
specific
population
of
smokers whose quit rates are
relatively low and effects of
tobacco control policy are small.
Compared with the general
German population the education
of the sample was lower and the
unemployment higher. The mean
smoking prevalence of patients at
admission was 84% varying
between 65% and 100%.
May be some selection bias as
sample was only one-fifth of all
German
in-patient
substance
abuse treatment centres.
Validity of author’s conclusion
Only some of the policy areas
were predictive of smoking status
and not the whole policy.
404
Outcomes
7-day
point
consumption
prevalence
tobacco
405
Details
Method
Results
Comments
Data sources
random-digit-dialed telephone surveys of
‘Breathe Easy’ study
Participant selection
One county in each state was adjacent to
the other. These were designated the
intervention counties, giving geographic
separation of mass media markets
between conditions.
Participant characteristics
In 1990, the total population of the
intervention counties, Windham County,
Vt, and Cheshire County, NH, was 111
709 (41 588 and 70 121), of whom 35382
(12904 and 22478) were women aged 18
to 64 years. The total population of the
comparison counties, Rutland County, Vt,
and Belknap County, NH, was 111 357
(62 141 and 49216), of whom 34480
(19473 and 15007) were women aged 18
to 64 years.
The overall sample sizes were 6379 and
6436, baseline and follow-up.
Intervention
Social
cognitive
theory,
the
transtheoretical model of behaviour
change, diffusion of innovation theory,
and communications theory guided the
intervention. Community organization
approaches to create coalitions and task
forces to develop and implement a
multicomponent intervention in 2 counties
in Vermont and New Hampshire, with a
special focus on providing support to help
women
quit
smoking.
community
coordinator formed a local planning
group, and the program was named
General population
In the intervention counties, compared with the
comparison counties, the odds of a woman
being a smoker after 4 years of program
activities were 0.88 (95% confidence interval =
0.78, 1.00)(P=0.02, 1-tailed); women smokers'
perceptions of community norms about women
smoking were significantly more negative
(P=0.002, 1-tailed); and the quit rate in the past
5 years was significantly greater (25,4% vs
21,4%; P=,02,1-tailed).
SES
Quit rates were significantly higher in the
intervention counties among women with
household annual incomes of $25 000 or less
(14.6±2.0) compared with control counties
(22.6±2.3), p<0.01. No significant difference in 5
year quit rates between intervention and control
with household income >$25,000.
Author’s conclusion of SES impact
Higher quit rates were seen among those
specially targeted by the interventions—younger
women and those with lower incomes.
Internal validity
Response rates of 79,1% for the
baseline survey and 89,9% for the
year
5
survey
of
eligible
households
External validity
Mass media campaign used in the
context of a comprehensive
community programme including
telephone counselling, support
groups, primary care interventions,
cessation
classes,
workplace
initiatives, health fairs and public
events – mass media was
relatively minor component of the
programme.
Validity of author’s conclusion
difficult to tease out independent
effects of any separate component
Settings based interventions
Author, year
Secker-Walker 2000
Country
Two counties in Vermont and 2 in New
Hampshire, USA
Design
2 pairs of demographically matched
counties assessed preintervention and
postintervention.
Objective
To reduce the prevalence of cigarette
smoking among women with special
emphasis on lower-income women of
childbearing age, among whom smoking
was most prevalent.
SES variables
Household income
Analyses
Preintervention and post-intervention
random digit-dialed telephone surveys in
the intervention counties and the 2
matched comparison counties
406
Details
Method
Results
Comments
Settings based interventions
"Breathe Easy." Each county's planning
group formed a coalition, and each
coalition recruited volunteers to serve on
5 working groups: support systems,
health
professionals,
educators,
worksites, and mass media.
Length of study
1989 to 1994
Outcomes
Quit rates
Perceptions of norm
407
Details
Method
Results
Comments
Data sources
WellWorks
study;
self-administered
surveys
Participant selection
Recruited worksites in Massachusetts
based on number of workers (250 to
2500), less than 20% turnover rate, less
than
20%
non-English
speaking
employees and use of known or
suspected
carcinogens
in
work
processes. Random sample of workers
selected at each work site at baseline
and follow-up to complete surveys. 61%
completed surveys at baseline, range by
worksite was 36 to 99%.
Participant characteristics
2386 workers in 24 predominantly
manufacturing worksites.
Intervention
Worksite cancer prevention initiative for
blue-collar workers targeting behavioural
risk factors and exposure to job-related
hazards. Three key intervention elements
targeted health behaviour change: (1)
joint worker management participation in
programme planning and implementation
(2) consultation with management on
work-site environmental change (3)
health education programmes.
Length of study
1989 to 1994
Outcomes
6-month self-reported abstinence
General population
No significant effects were observed for
smoking
cessation.
Six-month
smoking
abstinence rates were 15% in the intervention
worksites and 9% in control worksites controlling
for worksites (p=0.123). When work site
removed from the model, the OR for the
intervention effect was 1.83 (p=0.04).
SES
Only job category was significantly associated
with smoking. Intervention by job category was
not significant; 6-month abstinence rate for
skilled and unskilled workers was 17.9% in the
intervention sites and 9.0% in the control sites.
For office workers abstinence was 5.1% in
control sites vs 2.5% in intervention sites, for
professionals and managers abstinence was
18.6% in control and 14.2% in intervention sites
(abstinence rates higher in control).
Author’s conclusion of SES impact
Although the differences by job category were
not significant; smoking abstinence rates among
blue-collar workers were comparable to those
among professional and managerial workers.
Internal validity
62% completed survey at follow-up
(range=43 to 92%).
Compared with those responding
only at baseline; the cohort had
higher percentage of skilled and
unskilled labourers (49 vs 43%)
and lower smoking prevalence
(23% vs 26%). Members of the
cohort were less likely to have
college degrees (26% vs 30%) but
more likely to have some college
(37% vs 32%).
External validity
Limited sample size for baseline
smokers-number assessed not
reported.
Validity of author’s conclusion
Settings based interventions
Author, year
Sorensen 1998
Country
Eastern and central Massachusetts, USA
Design
RCT one worksite in each matched pair
was randomly assigned to intervention
and the other to control
Objective
To evaluate the effects of the intervention
on dietary habits and smoking and
whether intervention effects differed by
job category or exposure to occupational
hazards.
SES variables
3 occupation groups; ‘skilled and
unskilled’ ‘office work’ and ‘professional,
managerial and administrative work’
Analyses
Worksite was unit of analysis, repeat
measures linear modelling.
408
Details
Method
Results
Comments
Data sources
WellWorks-2 study
Participant selection
Eligibility criteria for worksites recruited to
the study included the following: (i)
employ between 4oo and 2ooo workers,
(2) probable use of chemical hazards,
and (3) turnover rate less than 20%.
Workers were eligible to participate in the
surveys if they were non-contractual
workers employed on a permanent basis
for 15 hours per week or more, and
worked onsite
Participant characteristics
Worksites ranged in size from 424
workers to 1585 workers (mean: 741 per
site).
Types of manufacturing conducted at the
recruited worksites included adhesives,
food, technology, jewellery, motor
controls, paper products, newspaper,
abrasives, automobile parts, and metal
fabrication.
5156 subjects responded to both the
baseline and final survey. Embedded
cohort of smokers at baseline who
responded to final survey: n = 880.
Intervention
Worksite cancer prevention intervention,
Worksite health promotion only (HP
Group; eight worksites); and (2) Worksite
health promotion integrated with an
occupational
health
and
safety
intervention (HP/OHS Group; seven
worksites).
Included interventions at the individual,
organizational, and environmental levels
General population
For all smokers the quit rates were somewhat
higher in the HP/OHS condition compared to the
HP group, but the difference was not statistically
significant; 11.3% vs 7.5% respectively, p=0.17.
SES
Smoking quit rates among hourly workers in the
HP/OHS condition more than doubled relative to
those in the HP condition (11.8% VS 5.9%;
p=0.04),
No differences in quit rates between groups for
salaried workers. Smoking quit rates among
salaried workers in the HP/OHS condition was
9.9% vs 12.7% in the HP condition p=0.63.
Author’s conclusion of SES impact
A programme integrating health promotion and
occupational health and safety efforts can
significantly improve smoking quit rates among
blue-collar workers compared to health
promotion alone.
Resulted in a quit rate among blue-collar
workers that was over double that observed
among blue-collar workers in the health
promotion only group.
Internal validity
The unit of randomization and
intervention was the worksite,
while the unit of measurement was
the employee.
Of 41 eligible worksites, 15 agreed
to participate = 37% response
rate. Response rate to the
baseline cross-sectional survey
was favorable at 8o%, the
response rate to the final survey
was 65%.
Unclear how many smokers at
baseline in the embedded cohort
did not respond to follow-up survey
– although this study was an RCT,
quit rates not assessed in all
smokers randomised to each
intervention.
Unclear which differences in
baseline characteristics between
groups were adjusted for in
analyses.
External validity
Participating worksites may not be
representative
of
general
population of worksites of this size
and type of business.
Measure of blue and white collar
workers may not transfer over to
other types of business.
Validity of author’s conclusion
Settings based interventions
Author, year
Sorensen 2003
Country
Massachusetts, USA
Design
RCT- Cross-sectional sample before and
after intervention and ‘embedded cohort’
Objective
To examine whether, in comparison to a
standard health promotion intervention,
an
intervention
integrating
health
promotion plus occupational health and
safety would result in significant and
meaningful
increases
in
smoking
cessation and consumption of fruits and
vegetables, both in all workers and
among blue-collar workers
SES variables
Blue collar workers measured as ‘hourly
wage earners’. White collar workers
classified as ‘paid on salary’
Analyses
Linear logistic regression for crosssectional data and repeated-measures
analysis of change for ‘embedded cohort’
data
409
Details
Method
Results
Comments
Settings based interventions
of influence.
Length of study
2 years from 1997 to 1999
Outcomes
Self-reported abstinence for six months
prior to the survey. Current smokers
defined as smoked at least 100 cigarettes
in their lives and defined themselves as
current smokers
410
Details
Method
Results
Comments
Data sources
In 2002, MORI/NOP undertook a survey
of 500 residents aged 16 years and over
in each of the 39 NDC areas.
Participant selection
No details
Participant characteristics
10,390 residents in New Deal for
Communities (NDC) areas and 977
residents in comparator areas in
England.
Intervention
New Deal for Communities (NDC) areabased initiative that aims to improve
conditions in some of the most deprived
neighbourhoods in England and reduce
the gap between them and the rest of the
country. There are 39 NDC areas, each
with a budget of approximately £50
million with which to address five specific
outcome areas (health, unemployment,
education, crime and the physical
environment) over 10 years.
Length of study
2 years from 2002 to 2004
Outcomes
Quitting smoking
General population
Small overall improvements were seen on all
domains in NDC areas but similar improvements
were also seen in comparator areas. More than
10% of residents quit smoking
SES
At baseline there were large differences by
education for smoking and these differences
widened over the two-year follow-up. In NDC
areas, higher educational groups were more
likely to stop smoking.
Author’s conclusion of SES impact
Evidence from two-year follow-up does not
support an NDC effect, either overall or for
particular population groups. Residents with
lower education experienced the least
favourable health profiles at baseline and the
smallest improvements. Investigation of the
reasons for the differential improvement by
educational group was beyond the scope of this
study. It is possible that lower educational
groups are simply slower to take up new
services and resources and that, over time, the
socioeconomic differences will diminish.
Internal validity
73% attrition rate. The comparator
areas had a slightly lower
proportion of residents with no
educational qualifications (33%
versus 39%), however, which may
indicate that the areas were
slightly less deprived than their
NDC counterparts.
External validity
There was considerable overlap of
area-based initiatives in NDC
areas and it is likely that
interventions were underway in
some of the similarly deprived
comparator areas.
Validity of author’s conclusion
valid
Settings based interventions
Author, year
Stafford 2008
Country
England
Design
Cohort with comparison group
Objective
To assess health improvement and
differential changes in health across
various sociodemographic groups in
neighbourhood renewal areas
SES variables
Index of multiple deprivation for NDC,
education for individual
Analyses
Multilevel regression
411
Details
Settings based interventions
Author, year
Wendell-Vos 2009
Country
Maastricht (in the south Netherlands) and
Doetinchem (in the middle of the
Netherlands on the east)
Design
Cohort with comparison group
Objective
To investigate the effect of a CVD
prevention program 5 years on
SES variables
Education (less than intermediate school,
intermediate or higher secondary, higher
vocational education or university)
Analyses
compared mean within-person change in
lifestyle factors between the intervention
group and the control group using linear
regression analyses, assuming a normal
distribution for the variables under study
Method
Data sources
Baseline questionnaires and physical
examination, and follow-up questionnaire 5
years on.
Participant selection
Populations
taken
from
previous
monitoring studies. Gender and age
stratified sample used from Maastricht
(experiment) and Doetinchem (control)
2356 participants in experimental area,
758 in control. Follow-up rate >80%
Participant characteristics
Aged 31-70, 24% male smokers, 27%
female. 25% and 22% in control region.
45% males and 61% females of Low
education, 43% and 61% for control.
Intervention
The Hartslag Limburg Intervention, 5
year community lifestyle intervention
program, encouraging people to reduce
their fat intake, be physically active, and
stop smoking.
Umbrella project with two strategies, one
at population level and the other targeted
at deprived communities. 790 interventions
were implemented (9 anti-smoking).
Almost 50% took place in deprived areas.
Examples of these major interventions are
nutrition parties; debt assistance (people
with debts are taught to cook a healthy
meal on a small budget); printed guides
showing walking and cycling routes; a daily
TV guided aerobics program, including
information about the health advantages of
exercising; and antismoking campaigns
using billboards, posters, and leaflets.
Length of study
January 1998 to January 2003
Outcomes
Result
General population
6.5% of men in the intervention group quit
smoking after 5 years, compared to 5.8% in
the control group. 5.8% and 5.9% respectively
for women.
Initiation was 3.2% and 2.3% for men, and
3.3% and 3.2% for women.
All changes were significant at p<0.05.
There were no significant differences between
intervention and control groups.
SES
Smoking quit rates by education:
Low (Control) , med/high (control)
6.2% (5.8%) and 6.1% (5.9%).
Smoking initiation by education: Low (Control),
med/high (control) 2.2% (2.0%), 4.3% (3.7%).
There were no significant between intervention
and control by educational level.
Author’s conclusion of SES impact
Prevented negative change in a number of
behavioural
traits
[but
not
smoking],
particularly among women and those of low
SES.
Comments
Internal validity
Low rate of drop-out. >80% of the
subjects completed both the
baseline
and
the
follow-up
measurement.
External validity
Population involved in previous
health monitoring study, and so
likely more health-conscious than
the general population.
Validity of author’s conclusion
No apparent impact of the
intervention over the five year
period, either overall or by
education.
412
Smoking status and frequency (smoker
defined as anyone who currently smokers,
regardless of quantity)
413
Details
Method
Population-level cessation support interventions - UK Smoking Cessation
Author , year
Data sources
Bauld 2003
NHS SSS quarterly monitoring forms
Country
for 2000-2001 and co-ordinator
76 Health Authorities, England
postal survey 2001
Design
Participant selection
Cross-sectional
None
Objective
Participant characteristics
To determine the extent to which UK
Smokers attending NHS SSS’s and
NHS SSS’s in England reach
setting a quit date in 76 Health
smokers and support them to quit at
Authorities in England
Intervention
four weeks
SES variables
NHS SSS
Length of study
Index of Multiple Deprivation (IMD),
Health Action Zone (HAZ)
One year – April 2000 to March 2001
Analyses
Outcomes
Ordinary least squares regression
Reach,
Self-report quits at 4-weeks,
Cessation rate (number of smokers
who reported quitting at four weeks
as a percentage of those setting a
quit date).
Results
Services
General population
N/a
SES
Cessation services based in HAZ reached
140% more smokers compared to other
more affluent areas, and the number of
people who reported quitting at four weeks
was 90% greater in HAZ areas. When the
service was operating at full capacity,
reach was diminished and the number of
people reporting quitting at four weeks was
larger. However, there was an inverse
relationship between reach and cessation
rates (the number of smokers who reported
quitting at four weeks as a percentage of
those setting a quit date). Cessation rates
were lower in deprived areas compared
with more advantaged areas. Services
operating in deprived areas were more
likely to lose clients between setting a quit
date and reporting outcomes at four weeks.
Author’s conclusion of SES impact
The strong inverse relation between reach
and cessation rate suggests that when
more effort went into attracting a large
number of smokers to the service, this
tended to be at the expense of cessation
rates. However, the overall pattern of
results suggests that high reach is
desirable if the primary objective is to
maximise the actual number of people who
stop smoking.
Comments
Internal validity
Limited by self-report data and
short-term (4 weeks).
External validity
Generalisable across UK but
unique to the UK. Study was
done when NHS SSS’s were
relatively new.
Validity of author’s
conclusion
Valid
414
Details
Method
Results
Population-level cessation support interventions - UK Smoking Cessation Services
Author , year
Data sources
General population
Bauld 2007
Office for National Statistics and DoH In total, almost 1.5 million smokers were
Country
annual statistical reports of NHS SSS treated in England during the period as a
Spearhead areas, England
for England
whole. Fifty-five per cent (832 678) of
Design
Participant selection
smokers accessing treatment services and
Participant characteristics
Repeat cross-sectional
setting a quit date self-reported that they
Objective
Intervention
had quit at short-term follow-up.
SES
To assess whether NHS Stop Length of study
Smoking
Services
(SSS)
are 2003-4 to 2005-6
Cessation rate was lower (52.6% overall) in
reducing inequalities in smoking Outcomes
the Spearhead Group areas than
prevalence
Self-report quits at 4-weeks;
elsewhere (57.9%) (p<0.001). On the other
SES variables
Estimated one-year quit rates hand, the proportion of all smokers treated
Index of Multiple Deprivation (IMD) (assuming an average relapse rate of was higher (16.7%) in the more
2004 Local Authority Summary 75% for both Spearhead and non- disadvantaged areas than in the remainder
average score
Spearhead areas);
of England (13.4%) (p<0.001 ). Overall, the
Analyses
proportion of all smokers who were
The
statistical
significance
of
estimated to have quit at four-week and 52differences between areas is shown
week follow up was higher in the
using Pearson's 2 test. Simple
Spearhead areas (8.8% and 2.2%) than
measures of health inequality are
elsewhere (7.8% and 1.9%) (p<0.001).
calculated in terms of absolute rate
Assuming 75% of 4-week quitters will
gaps and relative rate ratios (with
relapse (across all areas) the absolute rate
95% confidence intervals) between
gap between Spearhead and nonthe Spearhead Group on the one
Spearhead areas was reduced from 5.2 to
hand and non-Spearhead areas and
5.0 %, and the relative rate ratio from 1.215
England as a whole.
(CIs: 1.216 to 1.213) to 1.212 (CIs: 1.213 to
1.210), between 2003 and 2006.
Author’s conclusion of SES impact
Although disadvantaged groups had
proportionately lower success rates than
their more affluent neighbours, services
were treating many more clients in
disadvantaged
communities.
Overall,
therefore, the net effect of service
intervention was to achieve a greater
Comments
Internal validity
Assumes that each smoker
treated is a unique individual,
but some people will have
been treated more than once
and so overestimates impact of
the service.
Assumes 75% of short-term
quitters will relapse within less
than one year.
External validity
Generalisable across UK but
unique to the UK
Validity
of
author’s
conclusion
Valid, although quit rates are
lower
among
more
disadvantaged groups (lower
SES) this is offset by
substantial
positive
discrimination towards such
groups in the delivery of
services. The net effect of new
services is to achieve a modest
reduction in inequalities.
415
Details
Method
Results
Population-level cessation support interventions - UK Smoking Cessation Services
proportion of quitters among smokers living
in the most disadvantaged areas.
Comments
416
Details
Method
Results
Population-level cessation support interventions - UK Smoking Cessation Services
Author , year
Data sources
General population
Bauld 2012
Observational study of Roy Castle At 1 year, 8.2% self-reported quit. The COCountry
Lung Cancer Foundation (RCLCF) validated prolonged abstinence rate at 52
Liverpool, Knowsley, UK
Fag Ends NHS Stop Smoking weeks for smokers attending the groups
Design
Service in Liverpool and Knowsley, was 5.6%, compared with 30.7% at 4
Cohort
UK.
weeks (a relapse rate of 78.2%).
Objective
Participant selection
SES
To assess longer-term outcomes of a Drop-in
Reach
drop-in rolling-group model of Participant characteristics
The
sample
was
particularly
behavioural support for smoking 2585 clients, aged 16 or over, setting
disadvantaged: 68% resided in the most
cessation and the factors that a quit date
deprived decile of the English Index of
influence cessation outcomes.
Intervention
Multiple Deprivation. Fag Ends clients are
SES variables
State-reimbursed
clinical
stop- drawn from particularly disadvantaged
National Statistics Socio-Economic smoking
service
providing groups when compared to the general
Classification (NSSEC), entitlement behavioural support and medication. population: only 20% finished their
to free prescriptions, education ‘Fag Ends’ is an alternative education after age 16, whereas in England
assessed through school-leaving age intervention type with support centred 49% have qualifications obtained after age
(16 years or under compared with on drop-in rolling groups. Quit date is 16 in 2009; nearly two-thirds were eligible
over 16 years), housing tenure different for attendees and can be for free prescriptions, whereas 50% of the
(owner, other or unknown and renter) determined by the client; no waiting general population are eligible; and a third
and neighbourhood deprivation, as lists,
no
appointments;
no were long-term unemployed, whereas the
measured by the English Index of requirement to be referred by a third General Lifestyle Survey 2008 estimate for
Multiple Deprivation (IMD) 2007.
party, although referral systems are UK over-16s was 4.2%.
Preliminary analysis showed that the in place. Weekly sessions run Quitting
sample distribution was skewed continuously. Clients can attend as School leaving age was the only sociotowards the most disadvantaged many sessions as they wish and can economic indicator that was not related
decile (68% of the sample resided in continue to attend even if they significantly to quitting.
the most deprived decile), so IMD relapse. Advisers are trained in
In general, more affluent clients were more
deciles
were
recalculated
for providing behavioural support to
likely to be quitters at 12 months.
Liverpool postcode areas only and smokers and providing information
Nevertheless, the relationship between
the five more affluent deciles were about stop smoking medication.
SES and quitting was not straightforward:
compared to the five more deprived Although there is a developed
groups with the highest affluence (those
deciles.
service protocol, the approach taken
living in the most affluent decile of
Home
ownership;
managerial, by the service staff can be dependent neighbourhoods and those with managerial
Comments
Internal validity
Those clients self-reporting
abstinence were asked for
biochemical (CO) verification
either at a service location or at
home, and were offered a £30
shopping voucher to cover their
time and travel costs. 147 of
211 self-report quitters at 52
weeks
attended
for
CO
validation so only able to
validate biochemically the quit
status of approximately
two-thirds of clients
External validity
Liverpool and Knowsley region
has high economic and social
disadvantage. Liverpool is most
disadvantaged
England.
local
authority
in
Long-term success rates were
lower than are found typically
in clinical trials.
In 2009–10 in England a total
of 33 296 clients, 4% of those
who set a quit date, attended
drop-in
rolling
groups
compared with 79% who
received one-to-one structured
support, 11% who attended
drop-in clinics and 2% who
attended closed groups, and
these percentages remained
virtually
unchanged
in
417
Details
Method
Results
Population-level cessation support interventions - UK Smoking Cessation Services
professional
or
intermediate on the numbers of clients who attend and professional occupations) had lower
occupation and resident in the most or the adviser’s own particular quit rates than slightly less advantaged
affluent half of Liverpool postcode approach
or
experience
in groups. This could be the result of a
area neighbourhoods were significant addressing their needs. One-to-one selected group of the most affluent
predictors
of
quitting
in
the support in a less open forum is also enrolling, as only 4.7% of clients had
preliminary bivariate analysis and available.
managerial and professional occupations,
were assessed in multivariate Length of study
whereas General Lifestyle Survey 2008
analysis as composite indicator
26 January and 8 April 2009
data suggest that about a third of the UK
Outcomes
population can be classified as managerial
Analyses
Multivariate logistic regression
Self-report quits (smoked five or or professional.
fewer cigarettes between quit date Economically inactive groups had high
and 52-week follow-up);
rates of quitting.
Carbon monoxide (CO)-validated quit CO-validated quitters were more likely to
at 52-week follow-up (less than 10 be more affluent [1.33 (1.07–1.65) for each
parts per million)
extra indicator of high socio-economic
status
Author’s conclusion of SES impact
Higher socio-economic status within the
sample was a predictor of quitting. Group
interventions can go some way towards
equalizing outcomes, and thus have more
potential to reduce inequalities than one-toone support.
Comments
2010/2011.
Validity
of
author’s
conclusion
Valid. Highest SES group may
not use this type of drop-in
rolling group service.
418
Details
Method
Population-level cessation support interventions
Author , year
Data sources
Hiscock 2009
PEGS enrolment between 2001 and
Country
2006, routine data collection geoChristchurch, New Zealand
coded by neighbourhood.
Design
Pre-intervention city-wide smoking
Repeat cross-sectional
rate estimated from 1996 and 2006
Objective
census data.
To identify the impact of a smoking Participant selection
cessation programme on area-based N=11325, f/u=7778 (69%)
tobacco-use
inequalities, Participant characteristics
“Preparation
Christchurch residents at the time of
Education Giving up and Staying PEGS implementation.
Intervention
smoke free’’ (PEGS) programme
SES variables
PEGS is delivered by GPs.
Neighbourhood deprivation, Census educational
smoking
cessation
meshblocks were classified by area- intervention with different types of
level deprivation in 2001 measured counselling and literature based on
using the New Zealand Deprivation patients level of readiness to quit.
Index (NZDep) and dividing all
Most ready participants are also
neighbourhoods into quintiles.
offered NRT and to nominate a quit
Analyses
date. The delivery of the programme
Adapted a methodology devised for is not consistent across practices but
NHS SSS’s
face-to-face support tends to be
given when the patient collects the
NRT from the practice every one or
two weeks. The NRT is heavily
subsidised by the Ministry of Health
for up to three months. Enrolees are
followed up by their GP 6 months
after their enrolment.
Length of study
Six years
Outcomes
Enrolment,
Self-reported cessation at 6 month
follow up (assumed those lost to
Result
Comments
General population
Enrolment falling year on year.
SES
Little difference in utilisation between
highest and lowest deprivation areas
as proportion of the city’s smoking
population (22.0% for least deprived
quintile and 20.7% for most deprived
quintile)
Quit rate for least
deprived
neighbourhoods was 36.1% v 25.6%
for most deprived (25.2 v 17.5
assuming non-followed up failed to
quit)
Estimated actual gap between most
and least affluent neighbourhoods
was reduced by 0.2 percentage
points (15.6% to 15.4%), but relative
gap widened from 2.81 to 2.84 OR.
Author’s conclusion of SES
impact
Effect was small and non-significant,
coverage in deprived areas could be
further
improved.
Effective
at
reducing smoking prevalence, but no
evidence of impact on area
inequalities. Confidence intervals
overlap so we can conclude that
PEGS
neither
increased
nor
decreased
deprivation-related
inequalities in the smoking rate.
Internal validity
31% loss to follow up
Geographic
areas
not
perfect
measures of SES.
External validity
No indication of the intervention’s
likely impact in rural areas. Assumes
a further 37.5% relapse over one
year and excludes latent quitters
from estimation of PEGs impact on
population smoking rates
Validity of author’s conclusion
Likely to over-estimate impact on
deprived
communities
due
to
emphasis on ‘readiness’ for referral
to the programme?
Reach favoured more affluent
neighbourhoods, quit rate higher in
more affluent areas. Smoking rates in
the most deprived neighbourhoods
were nearly three times higher than
in the most affluent areas and the
PEGS cessation programme did not
change this.
419
follow-up were smokers),
Absolute and relative smoking rate
differences
420
Details
Method
Results
Comments
Population-level cessation support interventions - UK Smoking Cessation Services
Author, year
Simpson 2010
Country
UK
Design
Cross-sectional
Objective
To confirm the recent acceleration in
smoking reduction found using survey
data, and also describe the recording of
smoking status, provision of smoking
advice, and referral to specialist stopsmoking services in patients registered in
primary care in the UK. It also aimed to
investigate whether these trends differed
between sex, age, and deprivation
groups.
SES variables
Deprivation – Townsend score (UK 2001
census)
Analyses
Data sources
Anonymised aggregated health data from
2.7 million patients from 525 general
practices
contributing
to
the
QRESEARCH database
Participant selection
General practices are self-selected
Participant characteristics
Patients were included if they were
registered in primary care on 1 April each
year and were registered for the
preceding 12 months and aged 16 years
or over.
Intervention
April 2004, a quality-based General
Medical Services contract was introduced
into UK primary care – included financial
incentives to record smoking status and
provide smoking cessation support
Length of study
6 years – 2001 to 2007
Outcomes
Provision of smoking cessation advice
Referral to stop smoking service
General population
The proportion of people with smoking status
recorded increased by 32.9% (2001/2002:
46.6% to 2006/2007: 79.5%). A large overall
increase in the provision of smoking cessation
advice (2001/2002: 43.6% to 2006/2007: 84.0%)
and
referral
to
stop-smoking
services
(2001/2002: 1.0% to 2006/2007: 6.6%) was also
observed. The proportion of people who smoked
(with a recorded smoking status) reduced by
6.0% (2001/2002: 28.4% to 2006/2007: 22.4%).
SES
The decrease in the proportion of people who
smoked was greatest among patients in the
most deprived areas (7.2%) and the youngest
patients (16–25 years: 7.1%). In 2006/2007,
more than twice as many patients in deprived
areas smoked as those in affluent areas (most
deprived: 33.8%; most affluent: 14.1%).
In 2001/2002, patients in deprived areas (who
had been recorded as smokers in the last 12
months) received the most smoking cessation
advice (P<0.001). However, in 2006/2007,
similar proportions from the most affluent and
most deprived groups, were provided with
smoking cessation advice. In 2001/2002,
patients in deprived areas were more likely to be
referred to a specialist stop smoking service
(P<0.001). In 2006/2007, those living in the
most deprived areas were most likely to be
referred. Large increases in the number of
patients referred to a specialist stop-smoking
service were also found (P<0.001), most
particularly among those in the most deprived
areas
Author’s conclusion of SES impact
A significant and important reduction in the
number of UK smokers occurred between April
Internal validity
There were a larger number of
non-smokers being recorded over
time which could overestimate
decreases in proportion of people
found to smoke.
External validity
During time period of study there
were a range of smoking cessation
initiatives introduced which could
have influenced the results.
Multifaceted government policies
included
publicity
campaign;
increase in cigarette tax; reduction
in tobacco smuggling; NHS
smoking
cessation
service;
Tobacco
Advertising
and
Promotion Act 2002
Validity of author’s conclusion
Study authors do not attribute any
specific intervention to observed
effects.
421
Details
Method
Results
Comments
Population-level cessation support interventions - UK Smoking Cessation Services
2001 and April 2007. However, although this is
an improvement, comparatively high rates of
smoking remain among younger adults and
those who are the most socioeconomically
deprived.
422
Details
Method
Results
Population-level cessation support interventions - UK Smoking Cessation Services
Author , year
Data sources
General population
Taggar 2012
The Health Improvement Network Overall, a greater proportion of patients
Country
(THIN) database
had a record of smoking status and
Participant selection
UK
cessation advice in 2008 as compared to
Design
THIN database includes over six 2004, and in 2004 compared to 2002. A
Repeat cross-sectional (before and million patients’ records from 446 substantial acceleration in recording of both
after QOF)
practices throughout the UK
smoking status and cessation advice was
Objective
Participant characteristics
observed between 2003 and 2005,
To investigate the association Aged 15+, 1,998,631 participants although rates of increase plateaued after
between
smoking-related
QOF 2002, 2,053,840 and 2,149,026 2006. Similar trends were observed for
targets and recording of smoking participants in 2004 and 2008, patients with at least one QOF-defined
status and delivery of cessation respectively. The mean (SD) age of chronic condition, although the compliance
advice in patients’ medical records, patients in all analyses was 47.9 to QOF targets was greater at every time
factors which influence these clinical (19.0) years for patients with a record point compared to non-morbid patients.
activities
of smoking status and 44.6 (SD 16.1) In 2008, 70.4% of women and 58.6% of
SES variables
years for patients with a record of men had their smoking status recorded and
Townsend quintiles (quintile I
advice against smoking.
57.1% of female and 44.6% of male
Intervention
representing the least deprived and
smokers had a record of cessation advice.
quintile V the most deprived)
Quality and Outcomes Framework SES
Analyses
(QOF) incentivises the recording of There was a greater recording of smoking
Multivariate logistic regression
smoking status and delivery of status and cessation advice with advancing
cessation advice in patients’ medical Townsend score (greater deprivation); this
records
was most apparent in 2008, when 67.8%
Length of study
and 53.0% of patients had smoking status
2000 to 2008, April 2002 (before and cessation advice recorded in the most
QOF), April 2004 (at introduction of deprived quintile, respectively. Multivariate
QOF) and April 2008 (after QOF). analyses for 2008 showed that patients
Outcomes
with greater deprivation were 35% more
Record of smoking status within the likely to have smoking status recorded (OR
last 27 months;
1.35, 95% CI 1.21-1.49, p<0.001) and 20%
Cessation advice within the last 15 more likely to have cessation advice
months
recorded (OR 1.20, 95% CI 1.10-1.30,
p<0.001), than those least deprived.
Author’s conclusion of SES impact
Adults with greater social deprivation were
independently more likely to have both a
Comments
Internal validity
Large sample size.
External validity
Smokefree legislation introducd
around sme time which may
have confounded study results.
Validity
of
author’s
conclusion
Valid but outcomes are only
intermediate – do not inform
how intervention impacts on
smoking prevalence. Lower SES
smokers less likely to be
successful when they attempt
to quit smoking, even after
accessing support from a
smoking cessation service
423
Details
Method
Results
Population-level cessation support interventions - UK Smoking Cessation Services
record of smoking status and cessation
advice.
Comments
424
Details
Method
Population-level cessation support interventions - Quitlines
Author, year
Data sources
Wilson 2010b
New Zealand Health Survey (NZHS)
Country
as part of The International Tobacco
New Zealand
Control Policy Evaluation Survey
Design
(ITC Project).
Participant selection
Repeat cross-sectional survey
Objective
Complex sample design, which
To describe use of a national quitline included
systematic
boosted
service and the variation in its use by sampling of the Māori, Pacific, and
smoker characteristics.
Asian populations.
SES variables
Participant characteristics
NZ-specific deprivation index for 2,438 participants aged18 years and
small areas (quintiles, NZDep2006) over. Between-wave attrition of
and also an individual measure of 32.9% occurred, resulting in 923
deprivation (scores, NZiDep)
respondents in Wave 2.
Analyses
Intervention
multivariate logistic regression
national quitline service
Length of study
2007 to 2009
Outcomes
Results
Comments
General population
Quitline use in the last 12 months rose from
8.1% (95% CI = 6.3%–9.8%) in Wave 1 to
11.2% (95% CI = 8.4% to 14.0%) at Wave
2.
SES
There was higher usage with increasing
small area deprivation (p = .04 for trend)
and for higher ratings in one of the two
measures of financial stress. Deprivation
by two measures was not associated with
Quitline usage, but smokers with financial
stress were more likely to use the Quitline
with this being statistically significant for the
measure around “not spending on
household essentials” in one model (i.e.,
for Model 2: AOR =1.71, 95% CI = 1.00–
2.92).
Author’s conclusion of SES impact
National Quitline service is successfully
stimulating disproportionately more calls by
those
with
some
measures
of
disadvantage. It may therefore be
contributing to reducing health inequalities.
Internal validity
Overall response rate was
32.6%. Results were weighted
to adjust for complex design
and nonresponse.
External validity
Sample could have become
less representative of the
national population of smokers
(via nonresponse at various
stages). The weighting process
may not have fully adjusted for
nonresponse bias, potentially
affecting the generalizability of
the findings to all NZ smokers.
New pictorial health warnings
and a more clearly identifiable
Quitline number on packs and
related
mass
media
campaigns.
Validity
of
author’s
conclusion
Valid but not representative.
425
7.7 Appendix G Quality assessment
Generalisability+
Attributability to
intervention†††
Attrition rate††
Credibility of data
collection
instruments†
Comparability***
Quality of execution
Randomisation**
study
design+
Representativeness*
Study
Smoking restrictions in workplaces, enclosed public places, cars and homes
Arheart 2008
1.2
n/a
n/a
yes
yes
Barnett 2009
1.2
n/a
n/a
yes
yes
Cesaroni 2008
1.2
n/a
n/a
yes
yes
Delnevo 2004
1.1
n/a
n/a
Deverell 2006
1.2
yes
n/a
n/a
yes
yes
regional
Dinno 2009
1.4
yes
n/a
n/a
yes
n/a
national
Eadie 2008
4.2
n/a
yes
yes
yes
Ellis 2009
1.1
n/a
n/a
yes
n/a
yes
Farrelly 1999
1.2
yes
n/a
n/a
yes
yes
national
Federico 2012
1.2
yes
n/a
n/a
yes
yes
national
Ferketich 2010
1.1
n/a
n/a
yes
n/a
Fowkes 2008
1.3
n/a
n/a
yes
Frieden 2005
1.2
n/a
n/a
yes
yes
Guse 2004
1.2
n/a
n/a
yes
yes
Guzman 2012
1.2
n/a
n/a
yes
yes
Hackshaw 2010
1.2
n/a
n/a
yes
yes
Hawkins 2011
1.3
n/a
n/a
yes
Hawkins 2012
1.2
n/a
n/a
yes
yes
Hemsing 2012
4.1
n/a
n/a
yes
n/a
King 2011
1.3
yes
n/a
n/a
yes
yes
national
Levy 2006
1.2
yes
n/a
n/a
yes
yes
national
MacCalman 2012
1.3
n/a
n/a
yes
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
Moussa 2004
1.1
n/a
n/a
Nabi-Burza 2012
1.1
n/a
n/a
yes
n/a
Nagelhout 2011a
2.1
yes
n/a
n/a
yes
yes
yes
national
Nagelhout 2011b
1.2
yes
n/a
n/a
yes
yes
Nagelhout 2013
1.3
n/a
n/a
yes
Parry 2000
4.1
n/a
n/a
yes
yes
yes
n/a
yes
regional
yes
national
yes
yes
n/a
national
yes
n/a
yes
426
Patel 2011
1.1
Plescia 2005
1.2
Razavi 1997
Quality of execution
Comparability***
Credibility of data
collection
instruments†
Attrition rate††
n/a
n/a
yes
n/a
n/a
n/a
yes
yes
1.2
n/a
n/a
Ritchie 4.3
n/a
n/a
yes
yes
yes
Schaap 2008
1.1
n/a
n/a
yes
n/a
yes
Semple 2010
1.2
n/a
n/a
yes
yes
yes
Shavers 2006
1.2
yes
n/a
n/a
yes
yes
Shopland 2004
1.2
yes
n/a
n/a
yes
yes
yes
national
Sims 2012
1.2
yes
n/a
n/a
yes
yes
yes
national
Skeer 2004
1.1
n/a
n/a
yes
n/a
Stamatakis 2002
1.1
n/a
n/a
yes
n/a
Tang 2003
1.2
n/a
n/a
yes
yes
Tong 2009
1.1
n/a
n/a
yes
n/a
Verdonk-Klienjan 2009
1.2
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
Ritchie
2010b
2010a,
yes
Attributability to
intervention†††
Randomisation**
Generalisability+
study
design+
Representativeness*
Study
regional
n/a
national
yes
yes
Increases in price/tax of tobacco products
Azagba & Sharaf 2011
1.4
Biener 1998
1.1
Bush 2012
1.2
Choi 2012
1.3
yes
n/a
CDC 1998
1.4
yes
Colman 2008
1.4
DeCicca 2008
yes
yes
yes
n/a
regional
yes
yes
regional
n/a
yes
yes
regional
n/a
n/a
yes
yes
national
yes
n/a
n/a
yes
yes
national
1.4
yes
n/a
n/a
yes
yes
national
Dinno 2009
1.4
yes
n/a
n/a
yes
n/a
national
Dunlop 2011
1.2
n/a
n/a
yes
yes
Farrelly 2001
1.4
yes
n/a
n/a
yes
yes
national
Farrelly 2012
1.2
yes
n/a
n/a
yes
yes
regional
Franks 2007
1.4
yes
n/a
n/a
yes
yes
national
Frieden 2005
1.2
n/a
n/a
yes
yes
Gospodinov & Irvine 2009
1.4
n/a
n/a
yes
yes
Gruber 2003
1.4
n/a
n/a
yes
yes
Hawkins 2012
1.2
yes
n/a
n/a
yes
yes
national
Levy 2006
1.2
yes
n/a
n/a
yes
yes
national
yes
yes
national
427
n/a
n/a
Metzger 2005
1.3?
n/a
n/a
Mostashari 2005
1.1
n/a
n/a
Nagelhout 2013
1.3
n/a
n/a
yes
Peretti-Watel 2009
4.2
n/a
n/a
yes
Peretti-Watel 2009
1.3
n/a
n/a
yes
Peretti-Watel 2012
1.1
n/a
n/a
yes
n/a
Ringel 2001
1.4
n/a
n/a
yes
yes
Schaap 2008
1.1
n/a
n/a
yes
n/a
Siahpush 2009
1.4
n/a
n/a
yes
yes
yes
Generalisability+
1.4
Attributability to
intervention†††
Comparability***
Madden 2007
Attrition rate††
Randomisation**
Quality of execution
Credibility of data
collection
instruments†
study
design+
Representativeness*
Study
yes
yes
yes
n/a
yes
yes
national
yes
Controls on advertising, promotion and marketing of tobacco
Cantrell 2013
3.1
yes
yes
yes
yes
Frick 2012
1.1
yes
n/a
yes
Hammond 2013
3.2
yes
n/a
yes
Hitchman 2012
1.1
yes
n/a
n/a
yes
n/a
yes
Kasza 2011
1.3
yes
n/a
n/a
yes
Schaap 2008
1.1
n/a
n/a
yes
Willemsen 2005
1.2
n/a
n/a
Wilson 2010a
1.3
n/a
n/a
yes
Zacher 2012
1.3
n/a
n/a
yes
yes
yes
n/a
n/a
regional
national
national
n/a
yes
yes
yes
yes
yes
regional
Mass media campaigns
yes
Alekseeva 2007
1.3
n/a
n/a
yes
Bains 2000
1.3
n/a
n/a
yes
yes
CDC 2007
1.2
yes
n/a
n/a
yes
yes
Civljak 2005
1.1
yes
n/a
n/a
Dunlop 2012
1.2
n/a
n/a
yes
Durkin 2009
1.3
n/a
n/a
yes
Farrelly 2012
1.2
n/a
n/a
yes
Graham 2008
1.3
n/a
n/a
yes
yes
Hawk 2006
2.3
n/a
n/a
yes
yes
Levy 2006
1.2
n/a
n/a
yes
Nagelhout 2013
1.3
n/a
n/a
yes
yes
yes
yes
regional
n/a
yes
yes
yes
yes
yes
yes
national
regional
national
yes
428
n/a
n/a
yes
Niederdeppe 2011
1.2
n/a
n/a
yes
yes
Richardson 2011, Vallone 1.3
2011
n/a
n/a
yes
yes
Van Osch 2009
n/a
n/a
yes
yes
yes
1.3
Generalisability+
1.3
Attributability to
intervention†††
Comparability***
Niederdeppe 2008
Attrition rate††
Randomisation**
Quality of execution
Credibility of data
collection
instruments†
study
design+
Representativeness*
Study
yes
yes
Mass media campaigns - Quitlines, NRT
Burns 2010
3.2
n/a
n/a
yes
Czarnecki 2010a
1.1
n/a
n/a
yes
n/a
Czarnecki 2010b
1.1
n/a
n/a
yes
n/a
yes
Deprey 2009
1.2
n/a
n/a
yes
yes
yes
Durkin 2011
1.1
n/a
n/a
yes
n/a
yes
Hawk 2006
2.3?
n/a
n/a
yes
Miller 2005
3.2
Owen 2000
1.3
n/a
n/a
yes
Siahpush 2007
1.1
n/a
n/a
yes
n/a
Sood 2008
1.1
n/a
n/a
yes
n/a
Wilson 2010a
1.3
n/a
n/a
yes
yes
Zawertailo 2012
2.3
n/a
n/a
yes
yes
Frieden 2005
1.2
n/a
n/a
yes
yes
yes
Nagelhout 2012
1.2
n/a
n/a
yes
yes
yes
Schaap 2008
1.1
n/a
n/a
yes
n/a
yes
Verdonk-Kleinjan 2011
1.2
n/a
n/a
yes
yes
yes
yes
yes
yes
yes
yes
yes
yes
regional
yes
n/a
yes
region
yes
yes
Multiple policies
Settings based interventions
Darity 2006
3.2
Donath 2009
1.3
Secker-Walker 2000
1.2
Sorensen 1998
3.1
yes
yes
yes
Sorensen 2003
3.1
yes
yes
yes
Stafford 2008
1.3
n/a
Yes
yes
Wendell-Vos
1.3
yes
yes
yes
yes
n/a
yes
n/a
yes
yes
n/a
n/a
yes
n/a
yes
yes
regional
Population-level cessation support interventions
Bauld 2003
1.1
Yes
n/a
national
429
Bauld 2012
n/a
n/a
yes
yes
1.3
n/a
n/a
yes
yes
Hiscock 2009
1.2
n/a
n/a
yes
yes
Simpson 2010
1.2
yes
n/a
n/a
yes
yes
national
Taggar 2012
1.2
yes
n/a
n/a
yes
yes
national
Wilson 2010b
1.2
n/a
n/a
yes
yes
Generalisability+
yes
Attributability to
intervention†††
Attrition rate††
1.2
Credibility of data
collection
instruments†
Bauld 2007
Comparability***
Quality of execution
Randomisation**
study
design+
Representativeness*
Study
national
yes
430
# 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
Longitudinal
4.3
## 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
431
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? A study
cannot be generalisable if not representative or representativeness is unclear.
Randomisation is not applicable (N/A) for all study designs except trials coded 3.1. Attrition rate is
N/A to cross-sectional studies coded 1.1.
432
7.8
Appendix H Equity Impact
Author,
year
Study
design
Country
SES variable
Policy
Intervention
Outcome
Smoking restrictions in workplaces, enclosed public places, cars and homes
Arheart
1.2
USA
Occupation
Smokefree
SHS exposure
2008
workplace
(cotinine
policies
levels) in nonsmokers
not
exposed
to
SHS at home
Barnett
2009
1.2
Christchurc Neighbourhood
h
Public social
Hospital,
deprivation
New
Zealand
Cesaroni
2008
1.2
Rome, Italy
Small-area
index
deprivation
National
smokefree
legislation
National
of smokefree
legislation
Acute
Myocardial
Infarction
hospital
admissions
Acute
coronary
events
Equity impact
Summary
(negative, neutral,
positive, unclear,
mixed)
Disparities in SHS workforce exposure Positive
are diminishing with increased adoption
of clean indoor laws. All worker groups
had declining serum cotinine levels.
Most dramatic reductions occurred in
subgroups with the highest cotinine
levels before smokefree policies. Large
differences in cotinine levels in worker
subgroups persist; including those
employed in the construction sector, and
blue-collar workers who continue to have
the highest cotinine levels.
Overall association of AMI admissions Neutral
with smoking status and with deprivation
was not consistently significant.
Only among the 55 to 74 year age group
does the RR analysis give a hint that
admissions may be falling in less
deprived areas with quintile 2 being
statistically significant (RR 0.76; CI
0.59–0.97).
People aged 35 to 64 years living in low Neutral
socioeconomic census blocks appeared
to have the greatest reduction in acute
coronary events after the smoking ban
with significantly reduced ORs for SEP
3,4 and 5 but not 1 and 2 however there
433
Author,
year
Study
design
Country
SES variable
Policy
Intervention
Delnevo
2004
1.1
USA
Education,
income
Smokefree
workplace policy
Deverell
2006
1.2
Massachuset
ts, USA
Education,
Poverty level
Transition from
no
100%
smokefree
restaurant
regulations
to
statewide ban
Dinno
2009
1.4
USA
Education,
household
income
Strong
(100%
ban)
indoor
smokefree
policies
Eadie 2008
4.2
Scotland
Social grade
National
smokefree
Outcome
Equity impact
was no evidence of a statistically
significant interaction between SEP and
smokefree legislation.
Policy
The likelihood of being protected by a
coverage
smoke-free workplace policy was
significantly lower among workers who
earned less than $50,000 annually, or had
a high school education or less.
Local adoption The proportion of college graduates in
of smokefree Massachusetts protected from SHS in
regulations
restaurants in their own town was
consistently between 2 and 7 percentage
points greater than the proportion of
nongraduates who were protected. Just
prior to the statewide smoking ban 40%
of college graduates were protected
compared to 33% of nongraduates. There
was also substantial disparity in
protection from SHS by individual’s
poverty status (protection higher for
those living above poverty line).
Smoking
Indoor smokefree policies appeared to
participation,
benefit all SES groups equally in terms
consumption
of reducing smoking participation and
consumption. Established patterns of
education and income disparity in
smoking were largely unaffected by
smokefree policies in terms of both mean
effects and variance.
Compliance in Bars in deprived study communities
community
tended to show lower compliance and
Summary
(negative, neutral,
positive, unclear,
mixed)
Negative
Negative
Neutral
Negative
434
Author,
year
Study
design
Country
SES variable
Ellis 2009
1.1
USA
Education,
income
Farrelly
1999
1.2
USA
Education
Policy
Intervention
Outcome
legislation
bars
Equity impact
Summary
(negative, neutral,
positive, unclear,
mixed)
less support for the legislation compared
with the relatively affluent community,
but there were exceptions to this. Social
norms
were
related
to
social
disadvantage and this partially explained
variance in compliance between bars.
New York City Prevalence,
Smoking prevalence in NYC was lower Negative
comprehensive
SHS exposure than that found nationally (23.3% vs.
smokefree
(cotinine
29.7%, p < .05). Smoking prevalence in
workplace
levels) in non- NYC (and nationally) was higher in
legislation
smokers
those earning less than $20,000 per year.
In NYC the effect of education on
prevalence did not reach significance
(but was significant nationally).
A higher proportion of NYC nonsmokers had an elevated cotinine level
compared with non-smokers nationally
(56.7% vs.44.9%, p < .01). In NYC those
with less than high school education
were 64% more likely than those with a
high school education to have elevated
cotinine level.
Various types of Prevalence,
The percentage point declines in the Unclear
workplace
consumption
prevalence of smoking in response to a
smoking policies
in
indoor smokefree environment were fairly
workers
uniform across educational groups.
As a percentage of current rate of
smoking, the largest effects (percentage
decline) were for workers with a college
degree (28.4% decline) and the least for
high school dropouts (13.7% decline).
435
Author,
year
Study
design
Country
SES variable
Federico
2012
1.2
Italy
Education
Ferketich
2010
1.1
Appalachia,
USA
Education
Policy
Intervention
Outcome
Equity impact
Summary
(negative, neutral,
positive, unclear,
mixed)
However, the opposite was true for the
effects of the smoking ban on average
daily consumption.
National
Prevalence,
Among highly educated females, trends Negative
smokefree
Quit ratios
in smoking prevalence and cessation
legislation
were not altered by the ban. The
immediate effect of the policy was more
favourable among low-educated females
than among the higher educated, with a
4.5% increase in quit ratios among loweducated females, p < 0.001. Long-term
trends clearly favoured the higher
educated and educational differences in
quit ratios widened over time.
Among both low and high educated
males, prevalence and cessation were
reduced in the short-term but not in the
long-term. The absolute difference in
smoking prevalence between high and
low-educated males widened slightly
over the whole time-period.
Adoption of clean Policy
A positive relationship was shown Negative
air ordinances
coverage
between education and the presence of
(workplaces,
workplace and restaurant clean air
restaurants and policies in Appalachian communities
bars)
outside West Virginia. Adjusting for
state and county, a 1% increase in high
school completion rate was associated
with a 10% increase in both the odds of a
workplace policy and the odds of at least
1 policy (workplace or restaurant).
436
Author,
year
Study
design
Country
SES variable
Fowkes
2008
1.3
Scotland
Scottish Index
of
Multiple
Deprivation
(SMID) score
Frieden
2005
1.2
USA
Education,
Family income
Policy
Intervention
Outcome
National
Quit
smokefree
legislation,
clinical trial of
aspirin in people
at
moderately
increased risk of
cardiovascular
events
New York City Prevalence,
smokefree
SHS exposure
legislation
Equity impact
Summary
(negative, neutral,
positive, unclear,
mixed)
There was a significant negative
relationship between median income and
presence of a restaurant policy.
Communities with a higher education
level were more likely to have a strong
ordinance.
No association between area of residence Neutral
or SIMD with the probability of
attempting to quit, or feeling influenced
to quit. Smokers from more affluent
areas more likely to have a positive
perception of the legislation.
Smoking declined among all education Unclear
levels. Groups that experienced the
largest declines in smoking prevalence
included residents in the lowest and
highest income brackets and residents
with higher educational levels.
In 2003, former smokers who had quit
within the past year were more likely to
have low incomes compared with former
smokers who had quit more than 1 year
previously (43.6% vs 32.0%, p=.0001).
High-income residents were more likely
than low-income residents to report that
the smokefree legislation reduced their
exposure to ETS (53.3% vs 41.9%,
P<.0001).
437
Author,
year
Study
design
Country
SES variable
Policy
Intervention
Guse 2004
1.2
USA
Education,
Income,
Occupation
Statewide
smokefree
policies
Guzman
2012
1.2
USA
Education,
Family income
Statewide
smokefree
legislation
Hackshaw
2010
1.2
England
Occupational
class
National
smokefree
legislation
Outcome
Equity impact
Summary
(negative, neutral,
positive, unclear,
mixed)
Policy
Residents with less than a high school Negative
coverage,
education or with a high school diploma
Prevalence
as well as residents making less than
$15,000 were much more likely to work
in an environment where smoking was
permitted or unregulated.
Smoking prevalence was generally
higher among people in occupations with
a lower percentage of workers covered
by smokefree workplace policy.
SHS exposure Participant exposure to tobacco smoke Negative
(home, outside outside the home improved among both
home,
education groups, and all income groups
workplace),
but it was decreased further in the
Home smoking highest income group (family income
ban,
>$60,000 per year). Participants being
Prevalence
exposed to smoke at work significantly
reduced only for middle income group.
Participants being exposed to smoke at
home were significantly reduced only for
the highest income group and the higher
education group. Participants having a
strict ban in the home were significantly
increased only for the highest income
group and the higher education group.
Smokefree legislation not associated
with change in smoking prevalence but
analyses weakened by small sample size.
Quit attempts
No significant difference in quit attempts Neutral
by social grade.
438
Author,
year
Study
design
Country
Hawkins
2011
1.3
Hawkins
2012
Hemsing
2012
SES variable
Policy
Intervention
Outcome
England and Occupational
Scotland
class, household
income,
education
National
smokefree
legislation
in
Scotland (but not
in
comparison
country
which
was England)
Quit
rates,
smoking
uptake, home
smoking
among parents
of
children
aged 0 to 5
years
1.2
USA
Household
income,
Household
education
Smokefree
legislation
Household
tobacco use in
households
with children
aged 6 to 17
years
4.1
Canada
Family income
Smokefree
legislation
Disparities in
the effect of
policies,
management
of SHS
Equity impact
Summary
(negative, neutral,
positive, unclear,
mixed)
Higher rate of smoking cessation Mixed
between baseline and follow-up among
mothers in England who had higher Negative
for
household income, higher occupational uptake and home
class, or left school at an older age. No smoking.
significant relationship for these factors Negative
for
in Scotland. Lower SES associated with quitting
in
higher rates of maternal smoking uptake England.
and smoking in the home in both Positive
for
countries. Socio-economic gradient in quitting
in
quitting smoking in Scotland has Scotland
flattened
slightly
following
the
smokefree legislation.
In adjusted causal inference models there Unclear
was no effect of smokefree legislation on
household tobacco use. In adjusted crosssectional models, a higher smokefree
legislation total score was associated
with a lower prevalence of household
tobacco use. The interaction between
smokefree legislation and household
income was only significant for
households at the 100–199 % Federal
poverty level but not at 0–99 % Federal
poverty level or above 199% federal
poverty level.
Women and men living on a low income Negative
were more likely to live in more crowded
areas, with more smokers and less safe,
open spaces. These physical constraints
limited opportunities to avoid SHS
439
Author,
year
King 2011
Study
design
1.3
Country
Australia,
Canada,
UK, US
SES variable
Education,
household
income
(composite)
Policy
Intervention
Smokefree
policies
(worksites,
restaurants
Outcome
Policy
coverage
bars,
Equity impact
Summary
(negative, neutral,
positive, unclear,
mixed)
exposure in spite of increasing
restrictions. Smoking in low-income
areas may be normalized, smoking
restrictions less enforced, and individuals
experiencing
the
many
stresses
associated with living on a low income
may find it difficult to quit.
The physical, social, and economic
barriers low income women and men
encounter to reducing smoking and
smoke exposure may reinforce or
intensify health-related disparities.
No consistent association was observed Positive
between SES and the presence or
introduction of bans in worksites.
Current smokers with higher SES were
more likely to have a total smoking ban
in the workplace; however, the rate of
smokefree policy adoption in the
workplace was comparable by SES
group. Although smokefree workplaces
have previously been more common in
high SES occupations, this disparity
appears to have disappeared.
The impact of recent efforts to expand
the proliferation of smokefree policies in
bars and restaurants in these four
countries has been seemingly uniform
across
those
serving
different
socioeconomic groups. On balance, the
evidence indicates that smoke-free
440
Author,
year
Study
design
Country
SES variable
Policy
Intervention
Levy 2006
1.2
USA
Education
Smokefree
legislation
MacCalma
n
1.3
England,
Scotland
Education
National
smokefree
legislation
Moore
2011
1.2
Primary
schools,
Wales
FAS
National
smokefree
legislation
Outcome
Equity impact
Summary
(negative, neutral,
positive, unclear,
mixed)
policies in public places are not being
implemented differentially by the
socioeconomic status of smokers.
Smoking status Smokefree legislation was associated Unclear
in women
with a marginal effect on current
smoking. Over the period 1992–2002,
current smoking among low education
women was inversely related to the index
of clean air laws, with an odds ratio of
0.91 (0.80, 1.03), but was significant
only in the medium education female
subpopulation, with an odds ratio of 0.88
(0.83, 0.94).
Attitude,
For the majority of the questions bar Neutral
Respiratory
workers who were educated to degree
symptoms,
level and higher were significantly more
Sensory
positive towards the legislation than
symptoms in those who did not continue with
bar workers
education after school. Education did not
significantly effect change in symptoms
reported. All bar workers of all SES
likely to benefit from SFL in terms of
perceived health.
Parental
The smokefree legislation in Wales Negative
smoking in the benefitted only high-SES parents and
home and car
was potentially associated with increased
socioeconomic disparity in terms of
parental smoking in the home and in the
car. In terms of parental smoking in cars
this conclusion is tentative because the
441
Author,
year
Study
design
Country
SES variable
Policy
Intervention
Moore
2012
1.2
Primary
schools,
Scotland,
Northern
Ireland,
Wales
FAS
National
smokefree
legislation
Moussa
2004
1.1
Sweden
Occupation
Smokefree
workplace
policies
Paediatric
practices,
USA
Parental
education
Voluntary
smokefree
policy
Nabi-Burza 1.1
2012
Outcome
Equity impact
Summary
(negative, neutral,
positive, unclear,
mixed)
number of children reporting car-based
exposure at both timepoints was
relatively low, with changes in
percentage exposure based on small
changes.
Smoking
Following the smokefree legislation in Neutral
restrictions in the UK, smoking restrictions in the home
the home and and in the car increased. Post-legislation
car
changes were not patterned by SES. No
change
in
inequality
following
legislation for home and car-based
smoking restrictions (socioeconomic
patterning remained stable). The
smokefree legislation in Scotland, Wales
and Northern Ireland did not appear to
displace smoking into the home or the
car.
SHS exposure SHS exposure at work was highest Negative
among men in skilled manual work and
women in unskilled manual work
adjusting for age, country of origin, and
smoking patterns.
Smoking
Parental education level was not Negative
car behaviour in significantly associated with strictly
cars and home enforced smokefree car policy on its
own, only significant in interaction with
child age and amount smoked. College
educated parents of children aged less
than one year old were more likely to
have strict smoke-free car policies.
442
Author,
year
Study
design
Country
SES variable
Policy
Intervention
Outcome
Equity impact
Nagelhout
2011a
2.1
Ireland,
France,
Germany,
Netherlands
Education
National
Predictors
smokefree
smoking
legislation (partial bars
and
comprehensive)
Nagelhout
2011b
1.2
Netherlands
Education
National
smokefree
legislation
workplace
extended
hospitality
industry
Prevalence,
quit attempts,
– successful quit
then attempts
to
Nagelhout
2013
1.3
Netherlands
Education
National
smokefree
legislation
Quit attempts,
7-day
point
prevalence
(successful
quits)
Parry 2000
4.1
Scotland
Occupation
Workplace
Quit
rates,
smoking ban with change
in
some exceptions
smoking
behaviour
of
in
Summary
(negative, neutral,
positive, unclear,
mixed)
Smokers with a low educational level Negative
were more likely than smokers with a
high educational level to smoke in bars
post-ban. Societal approval of smoking
was a stronger predictor of smoking in
bars among highly educated smokers.
Workplace ban led to more successful Negative
quit attempts among higher educated
smokers than medium or lower educated
smokers.
Hospitality industry ban had a larger
effect on quit attempts among frequent
bar visitors than on non-bar visitors more frequent bar visitors more likely to
be higher educated.
Higher educated smokers were more Neutral
exposed to the smokefree legislation.
There were no significant educational
inequalities in successful smoking
cessation.
Significant differences were found in Negative
quit rates between academic and related
staff and manual staff (16.0% vs. 4.2%)
and in increase in smoking between
academic and related staff and manual
staff (2.8% vs. 8.9%). Workplace
smoking
restrictions
were
more
beneficial for staff in higher occupational
grades and the ban contributed to and
sustained social inequalities among staff.
443
Author,
year
Study
design
Country
SES variable
Policy
Intervention
Outcome
Patel 2011
1.1
New
Zealand
Area-level
deprivation
Voluntary
smokefree
policy
Observed point
car prevalence of
smoking
in
vehicles
Plescia
2005
1.2
USA
Occupation
Regional
smokefree
workplace
policies
Policy
coverage
Razavi
1997
1.2
Belgium
Occupation
National decree to Implementatio
regulate smoking n
in the workplace
Ritchie
2010a,
4.3
Scotland
area SEP
National
smokefree
Changes
smoking
Equity impact
in
Summary
(negative, neutral,
positive, unclear,
mixed)
Adults and children from high Negative
deprivation areas were much more likely
to be exposed to SHS smoke. Although
prevalence of smoking within vehicles
appeared to have decreased over time
and this reduction over time was
relatively greater in lower SES areas than
higher SES areas; absolute smoking
prevalence and thus exposure to SHS
within vehicles remained higher in more
deprived areas and suggests the gap may
be widening.
Significant disparities existed in policy Negative
coverage; blue collar and service workers
were significantly less likely to report a
smokefree worksite compared to whitecollar workers
Companies with a high blue/white collar Negative
ratio were less likely to have
implemented
health
policy
recommendations.
The difference regarding a more strict
smoking policy between companies
employing mostly blue collar (12% total
non-smoking policy) and companies
employing mostly white collar (2% total
non-smoking policy)
which
was
significant in 1990 had disappeared in
1993.
Smokers’ narratives in the disadvantaged Unclear
localities described more decreases in
444
Author,
year
Study
design
Country
SES variable
2010b
Policy
Intervention
Outcome
legislation
behaviour,
changes
physical
spaces
Quit ratios
Schaap
2008
1.2
18 European Education;
Smokefree
countries
relative index of legislation
inequality
Semple
2010
1.2
England,
Scotland,
Wales
Area-level
deprivation
National
smokefree
legislation
Equity impact
Summary
(negative, neutral,
positive, unclear,
mixed)
consumption and successful quitting than
in those in the affluent localities.
Smokers in advantaged areas said that
they smoked less, or quicker, because
going outside interrupted social activity,
and because of concerns over the stigma
of being seen smoking.
There appears to have been a more
substantial change in deprived areas,
because the advantaged areas already had
reasonably comfortable accommodation
for smokers outside. But is a small nonrepresentaive sample.
National score on the tobacco control Neutral
scale was positively associated with quit
ratios in all age-sex groups.
No consistent differences were observed
between higher and lower educated
smokers regarding the association of quit
ratios with score on the TCS.
The regression coefficient for the
association between national quit ratios
and sub score for public place bans, on
TCS was 0.94 (-2.43 to 5.89) for men
and 0.41 (-3.84 to 5.26) for women.
Particulate
Bars located in more deprived postcodes Positive
matter levels in had higher PM2.5 levels prior to the
bars
legislation. Linear trend in the change in
PM2.5 by deprivation category, which
suggests
more
deprived
areas
445
Author,
year
Study
design
Country
SES variable
Shavers
2006
1.2
USA
Poverty level
Shopland
2004
1.2
USA
Occupation
Sims 2012
1.2
England
Household
Policy
Intervention
Outcome
Equity impact
Summary
(negative, neutral,
positive, unclear,
mixed)
experienced greater percentage reduction
in PM2.5 levels up to 12 months postimplementation when compared to more
affluent areas.
Workplace
and Policy
Employed women further from the Negative
home
smoking coverage,
poverty line were more likely to be
restrictions
Home smoking covered by restrictions on smoking in the
restrictions,
workplace and home. Home smoking
Quit attempts, policies
were
more
consistently
in women only associated with a lower prevalence of
current smoking irrespective of poverty
status than workplace policies.
Lower adjusted odds ratio for quit
attempts among those who permitted
smoking in the home for all poverty level
categories except for women who were
125%–149% of the poverty level. In
contrast, workplace smoking policies
were not associated with a quit attempt in
the past year for any of the poverty level
categories.
Smokefree
Policy
Blue collar and service workers showed Neutral
workplace
coverage
the largest percentage gains in smokefree
policies
policy coverage 1993 - 1999 but
continued to lag significantly behind
their white collar counterparts with
barely a majority reporting a smokefree
workplace policy in 1999 compared with
more than three-quarters of white collar
workers.
National
SHS exposure Significant beneficial impacts were Negative
446
Author,
year
Study
design
Country
SES variable
Policy
Intervention
Outcome
Equity impact
social class
smokefree
legislation
(salivary
cotinine)
observed only among those from social
classes I to III. No significant beneficial
impact was seen in social classes IV and
V.
Local smokefree restaurant regulations Negative
were significantly more likely to be
adopted by towns with a higher
proportion of college graduates and a
higher per capita income in bivariate but
not in multivariate models. Strength of
regulation was not significantly related to
household income or poverty level.
However ‘agreeing to create the
Massachusetts
Tobacco
Control
Program’ was significant in multivariate
model and this measure was highly
correlated with both education and per
capita income.
Exposure to SHS at work was higher Negative
among women with some high school
education (adjusted OR 2.8, 95% CI 1.5,
5.3) and high school graduates (adjusted
OR 3.1, 95% CI 1.9, 5.1) and marginally
so for those with some college (adjusted
OR 1.5, 95% CI 0.9, 2.5).
Respondents who approved of the law Negative
were more likely to be more highly
educated or have household income
≥$60,001. Patrons with higher income,
or educational attainment tended to
report they were “more likely” to visit
Skeer 2004
1.1
USA
Population with Local restaurant Policy
college degree,
smoking
coverage
Per
capita regulations
income,
Household
income,
Families living
below poverty
level
Stamatakis
2002
1.1
USA
Education
Smokefree
workplace
policies
Tang 2003
1.2
USA
Education,
income
California
Bar
patrons
smokefree bar law responses
SHS exposure
at home and at
work in nonsmoking
employed
women
Summary
(negative, neutral,
positive, unclear,
mixed)
447
Author,
year
Study
design
Country
SES variable
Tong 2009
1.1
USA
Education
VerdonkKlienjan
2009
1.2
The
Netherlands
Education
Increases in price/tax of tobacco products
Azagba & 1.4
Canada
Household
Sharaf
income,
2011
education
Policy
Intervention
Outcome
Smokefree indoor
work
policies,
home
smoking
restrictions
Policy
adoption and
enforcement in
AsianAmerican
women
National
SHS exposure
workplace partial in
nonsmoking
ban smoking
(excluded
workers
hospitality
industry)
Cigarette
increase
tax Tax elasticity
Equity impact
Summary
(negative, neutral,
positive, unclear,
mixed)
bars or to report “no change” in their
patronage. Patrons with an income
≥$60,000 were less likely to perceive
non-compliance.
Similar rates of smokefree policies at Negative
work and at home but disparity in
enforcement by educational status with
lower educated Asian-American women
reporting greater SHS exposure both at
work and at home.
Both before and after implementation of Negative
the ban, lower-educated non-smoking
workers were twice as likely to be
exposed as those with higher level of
education. Significant difference both for
differences
between
educational
subgroups and the decrease since ban; so
ban has not abolished inequalities in
exposure.
There was a differential response by
income and education. While the
participation tax elasticity of the high
income group (−0.202) was larger than
the low income group (−0.183), it was
not statistically significant. However, the
low educated group was more tax
sensitive than the high educated group;
less secondary (−0.555), secondary
(−0.218), some post-secondary (−0.018)
and post-secondary (−0.042).
Mixed,
Neutral
for
income, Positive
for education
448
Author,
year
Study
design
Country
SES variable
Biener
1998
1.1
USA
Household
income
Bush 2012
1.2
USA
Education
Choi 2012
1.3
USA
Household
income,
education
Policy
Intervention
Outcome
Equity impact
Summary
(negative, neutral,
positive, unclear,
mixed)
Tobacco
tax Smoking
46% who continued to smoke denied Positive
increase
behaviour
having had any of the 3 reactions to price
increase. Low income adults were 3
times more likely to cut costs and twice
as likely to consider quitting rather than
not react to a price increase. Household
income was not related to choice
between cutting costs and quitting. The
lower the household income the greater
the impact of price on the decision to
quit.
Federal cigarette Calls
to Calls to quitlines increased by 23.5% in Positive
excise
tax quitline
2009 and more smokers with less
increase
education called after (versus before) the
tax. Quit rates at seven months did not
differ from before tax increase, however
this was not reported by SES.
Federal tobacco Quit,
quit Overall 42% purchased cartons rather Negative
tax increase
attempts,
than cigarette packs. The middle-income
smoking
groups (annual household income
behaviour
between $25,000 and $75,000) were
more likely than the highest income
group to report buying cigarettes from
cheaper places, using coupons or
promotions, and buying cartons instead
of packs. Participants who reported
buying cartons instead of packs to save
money were less likely to attempt to quit
smoking in the following year.
Having some college education, having
an annual household income between
449
Author,
year
Study
design
Country
SES variable
CDC 1998
1.4
USA
Family income
Colman
2008
1.4
USA
Income
DeCicca
2008
1.4
USA
Income,
education
Policy
Intervention
Outcome
Equity impact
Summary
(negative, neutral,
positive, unclear,
mixed)
$25,000 and $75,000 were associated
with higher odds of using at least one
price-minimizing strategy; having less
than high school education, having
annual household income less than
$75,000, were associated with higher
number of strategies used.
Cigarette
price Price elasticity Total price elasticity was –0.29 for Positive
increase
lower-income persons compared with
–0.17 for higher income persons
Cigarette
tax Price elasticity, Total price elasticities were -0.37 for Positive
increase
smoking
low-income, -0.35 for middle-income,
prevalence
and -0.20 for high-income groups.
Increasing tobacco taxation had a small
narrowing effect on socio-economic
inequalities in smoking. It was estimated
that a $1 rise in the price of a packet of
cigarettes would lead to a 2.3 percentage
point (pp) decrease in smoking
prevalence in low-income smokers,
compared to 1.7pp and 0.8pp in the
middle and high income groups,
respectively.
22 cigarette tax Price elasticity, Price participation elasticities of -0.43 Positive
increases
smoking
(low education) and -0.12 (higher
prevalence
education). Price participation elasticities
of -0.39 (low income) and -0.09 (higher
income).There was a greater impact on
lower SES smokers aged 45-59 years,
whether measured by education or
income. A $1 increase in tax reduced the
450
Author,
year
Study
design
Country
Dinno
2009
1.4
USA
Dunlop
2011
1.2
Australia
SES variable
Policy
Intervention
Outcome
Equity impact
Summary
(negative, neutral,
positive, unclear,
mixed)
prevalence of smoking among lowincome (<$35,000) groups by 10%,
while reducing smoking among those
with higher incomes by only 2% (or by
10% and 3%, respectively, when
analysing the impact by education).
Education,
Cigarette
price Smoking
Cigarette price increases appeared to Neutral
household
increase
participation,
benefit all SES groups equally in terms
income
consumption,
of reducing smoking participation and
price elasticity consumption. Established patterns of
education and income disparity in
smoking were largely unaffected by
cigarette price in terms of both mean
effects and variance.
Income,
Cigarette
Smoking and Overall, 47.5% of smokers made Positive
education,
price/tax increase product related smoking-related changes and 11.4%
Socio-Economic
changes
made product-related changes without
Indices
for
making smoking-related changes. The
Areas
proportion of smokers making only
product-related changes decreased with
time, while smoking-related changes
increased with time.
Smokers with lower incomes, less
education or from lower SES
neighbourhoods were more likely to
report the price minimizing product or
purchasing changes. However, these
low-income, less-education smokers
were no more likely to engage in these
practices without also reporting some
positive changes in their smoking-related
451
Author,
year
Study
design
Country
SES variable
Policy
Intervention
Outcome
price Price elasticity
Equity impact
Summary
(negative, neutral,
positive, unclear,
mixed)
behaviours. Smokers with less education
or less income were more likely to have
tried to quit, cut down or thought about
quitting than those who were more
educated or wealthier.
Adults with income at or below the Positive
median were more than four times as
price-responsive as those with income
above the median
Percentage of income spent on cigarettes Neutral
did not significantly increase over time
for high income smokers but did for low
income smokers. Lower income smokers
in New York State have not had a greater
response to higher taxes than smokers
with higher incomes.
Farrelly
2001
1.4
USA
Family income
Cigarette
increases
Farrelly
2012
1.2
USA
Household
income
Franks
2007
1.4
USA
Income
New York State Smoking
cigarette excise prevalence,
tax increase
Daily cigarette
consumption,
Share
of
annual income
spent
on
cigarettes
Cigarette
tax Price elasticity, Although the pre-Master Settlement Neutral
increases
smoking
Agreement (MSA) association between
prevalence
cigarette pack price and smoking
revealed a larger elasticity in the lowerversus higher-income persons (-0.45 vs 0.22), the post-MSA association was not
statistically significant for either income
group.
No evidence that increased cigarette
prices reduced disparities in smoking
prevalence, with some indication of
increasing difference in prevalence
between the low income and high
income groups.
452
Author,
year
Frieden
2005
Study
design
1.2
Gospodino 1.4
v
and
Irvine 2009
Country
SES variable
Policy
Intervention
Outcome
USA
Education
Cigarette
increase
tax Smoking
prevalence,
consumption
Canada
Education
Cigarette
increases
price Price elasticity,
smoking
prevalence,
cigarette pack
choice
Equity impact
Summary
(negative, neutral,
positive, unclear,
mixed)
It appeared that the high income group
responded to prices reaching a threshold
(c.$2.50) and had no further price
responsiveness. So despite the widening
of inequality the absolute gap of
smoking probability narrowed as price
increased (between lowest income and
other income).
Smoking declined among all education Unclear
levels. Groups that experienced the
largest declines in smoking prevalence
included people in the lowest and highest
income brackets and people with higher
educational levels.
Residents with low incomes (<$25000
per year) or with less than a high school
education were more likely than those
with high incomes (>$75 000 per year)
and those with a high school education or
higher to report that the tax increase
reduced the number of cigarettes they
smoked.
There was no evidence of either a Neutral
declining elasticity value moving from a
low to high education group or a higher
elasticity value for the lower education
group. Education had a strictly declining
impact on smoking.
Whilst the higher education group has
seen little change in its choice of
453
Author,
year
Study
design
Country
SES variable
Policy
Intervention
Outcome
Gruber
2003
1.4
Canada
After-tax
Cigarette
income quartiles increases
and expenditure
quartiles
price
Hawkins
2012
1.2
USA
Household
income,
Household
education
Cigarette excise
tax increase
Levy 2006
1.2
USA
Education
Cigarette
increases
price
Madden
2007
1.4
Ireland
Education
Cigarette
changes
tax
Metzger
1.3
USA
Income (area)
State and city tax
Equity impact
cigarette, the lowest income group has;
continuing smokers are progressively
smoking stronger cigarettes.
Price elasticity Almost all of the response of
consumption to price changes occurred
through reductions in consumption and
not quitting smoking. The lowest income
group was much more price sensitive
than higher income groups.
Household
An increase in excise tax was associated
tobacco use
with an overall reduction in household
tobacco use, but this reduction was not
consistent across all income levels.
There was no significant reduction in
consumption in the poorest households
or in the least poor households.
Smoking
Declining trends in smoking over the
prevalence in period 1992–2002 appeared in all
women
education subgroups, but greater relative
declines occurred for low education
populations. Moreover, evidence showed
that compared with better educated
women, low education women responded
with greater positive effect to certain
policy measures, particularly price.
Smoking
Taxation was associated with earlier
cessation
in cessation among those with a primary
women
education, but had no differential impact
among those with other levels of
education.
Over
the Pharmacies in low income areas
Summary
(negative, neutral,
positive, unclear,
mixed)
Positive
Unclear
Positive
Positive
Positive
454
Author,
year
Study
design
Country
SES variable
2005
Policy
Intervention
increases
Outcome
Equity impact
Summary
(negative, neutral,
positive, unclear,
mixed)
counter sales
of
generic
nicotine patch
and
gum
products
Cigarette excise Cigarette
tax increase
consumption
Mostashari
2005
1.1
USA
Income
Nagelhout
2013
1.3
Netherlands
Education
PerettiWatel 2009
1.3
France
Education,
Cigarette
income support, increases
occupation
Cigarette
increase
generally had larger and more persistent
increases in sales of nicotine patch and
gum products in response to tax
increases than those in higher-income
areas.
Response to the state tax increase varied Positive
by income level; 27.2% of those with
low incomes (<$25,000) and 11.0% of
those with high incomes (>$50,000) (P <
.0001) reduced the number of cigarettes
they smoked.
price Exposure,
Higher educated smokers were more Neutral
Quit attempts, exposed to the price increase. Exposure
7-day
point to the price increase was not associated
prevalence
with significant increased odds of quit
(successful
attempts or successful smoking cessation
quits)
in any SES group.
price Smoking
Striking
differences
across
HIV Negative
prevalence
transmission groups regarding socioamong HIV- demographic background and smoking
infected
prevalence.
smokers
The Intravenous Drug Use (IDU) group
having
was characterised by a lower SES, a
antiretroviral
higher smoking prevalence and a smaller
therapy
decrease in this prevalence over the
period 1997-2007.
The homosexual group had a higher SES,
an intermediate smoking prevalence in
1997, and the highest rate of smoking
decrease. In the dynamic multivariate
analysis, smoking remained correlated
455
Author,
year
Study
design
Country
SES variable
Policy
Intervention
PerettiWatel 2009
4.2
France
Occupation,
Cigarette
subjective social increases
status
PerettiWatel 2012
1.1
France
Education,
Household
income
Cigarette
increase
Ringel
2001
1.4
USA
Education
Cigarette
increases
Outcome
Equity impact
Summary
(negative, neutral,
positive, unclear,
mixed)
with indicators of socioeconomic
disadvantage.
Smoking remained much more prevalent
among patients with a lower educational
level as well as those who were
unemployed or on income support during
follow-up. In multivariate analysis only,
smoking
was
significantly
more
prevalent among patients who never
worked, as well as among those with an
intermediate level of occupation.
price Smoking
Smokers in low occupational groups and Negative
prevalence,
of low-income were less likely to
reasons
for respond to cigarette price increases
smoking
price Changes
in Of smokers who did not quit: more Positive
smoking
educated smokers and wealthier smokers
behaviour:
more frequently reported no reaction at
Quit attempts, all to price increase.
consumption,
smoking costs
tax Price elasticity, Pregnant women at lower education Negative
smoking
levels (high school or less) had higher
prevalence in than average smoking rates but lowerpregnant
than-average responsiveness to tax
women
changes.
In nearly all cases, pregnant women were
found to be more responsive to higher
cigarette taxes than the general adult
population.
Implied price elasticity = ‘less than high
456
Author,
year
Study
design
Country
SES variable
Policy
Intervention
Schaap
2008
1.1
18 European Education
Cigarette
Countries
(relative index increases
of inequality)
Siahpush
2009
1.4
Australia
Income
Cigarette
increases
Outcome
Equity impact
Summary
(negative, neutral,
positive, unclear,
mixed)
school’ -0.30, ‘high school’ -0.49, ‘some
college’ -0.96, ‘college’ -3.39.
Change in smoking percentage with
$0.55 tax hike = ‘less than high school’ 2.6, ‘high school’ -3.1, ‘some college’ 3.1, ‘college’ -3.8.
price Quit ratios
National score on the tobacco control Neutral
scale (TCS) was positively associated
with quit ratios in all age-sex groups.
No consistent differences were observed
between higher and lower educated
smokers regarding the association of quit
ratios with score on TCS.
Of all tobacco control policies of which
the TCS is constructed, price policies
showed the strongest association with
quit ratios in both educational levels.
price Price elasticity, Rising inflation-adjusted cigarette price Positive
smoking
had the greatest impact on those in the
prevalence
lowest income category (<AU $18,000),
with a price elasticity of -0.32 compared
to -0.04 and -0.02 in the mid and higher
income groups, respectively.
There was a clear gradient in the effect
of income on prevalence that diminished
at higher levels of price.
Controls on advertising, promotion and marketing of tobacco
Cantrell
3.1
USA
Education,
Pictorial
health Salience,
2013
income
warning labels on perceived
cigarette packs
impact,
credibility,
Greater impact of the pictorial health Neutral
warning labels compared to the text-only
warning was consistent across SES
groups.
457
Author,
year
Study
design
Country
SES variable
Frick 2012
1.1
USA
Household
income
Hammond
2013
3.2
USA
Education,
annual
household
income
Hitchman
2012
1.1
Kasza
2011
1.3
Schaap
2008
1.2
France,
Germany,
the
Netherlands,
UK
Australia,
Canada,
UK, USA
Education
annual
household
income
net
and
net
Policy
Intervention
Outcome
Equity impact
intention
to
quit
FDA regulations Compliance
There were no significant differences in
on sales
and
compliance by income, but there were
advertising
significantly fewer advertisements on the
practice including
buildings in high income areas.
point-of-sale
advertisements
Pictorial
health Rated
and The most effective ratings performed
warnings labels ranked
equally well across SES groups.
on cigarette packs warnings
Association between index ratings scores
and both education and income were not
significant.
EU
text-only Impact of the The impact of the health warnings was
health
warning warnings using highest among smokers with lower
labels on cigarette a
Labels incomes and smokers with low to
packs
Impact Index
moderate education (except the UK in
the case of education).
Tobacco
Awareness
Overall, in general, tobacco marketing
marketing
regulations were associated with reduced
regulations
awareness of pro-smoking cues among
all SES groups.
annual
household
income
and
level
of
education were
combined
18 European Education;
Advertising bans, Quit ratios
countries
relative index of Health warnings,
inequality
Tobacco control
campaign
spending
Summary
(negative, neutral,
positive, unclear,
mixed)
Neutral
Neutral
Positive
Neutral
National score on the tobacco control Neutral
scale (TCS) was positively associated
with quit ratios in all age-sex groups.
No consistent differences were observed
between higher and lower educated
smokers regarding the association of quit
ratios with score on the TCS.
458
Author,
year
Study
design
Country
SES variable
Policy
Intervention
Willemsen
2005
1.2
The
Netherlands
Education
EU
text-only
health
warning
labels on cigarette
packs
Wilson
2010a
1.3
New
Zealand
Small-area
deprivation,
individual-level
deprivation,
financial stress
Pictorial
health
warning
labels
including quitline
number
Zacher
2012
1.3
Australia
Socio-Economic
Indexes
for
Areas (SEIFA)
index
of
disadvantage
Legislation which
restricted
cigarette displays
in retail outlets
including point-
Outcome
Equity impact
Summary
(negative, neutral,
positive, unclear,
mixed)
A comprehensive advertising ban
showed the next strongest associations
with quit ratios (after price) in most
subgroups (not low SES aged 40-59 or
low SES women aged 25-39 years). No
significant association between campaign
spending or health warnings sub scores
and national quit ratios.
Smoking
There were no significant differences in Neutral
behaviour,
level of education for respondents in
motivation to reported change in smoking behaviour
quit,
nor inclination to buy the new packs.
preference for
buying pack
with/without
new warning,
inclination to
buy cigarette
pack with new
warning
Recognition of Quitline number recognition included Positive
quitline
with new pictorial health warnings,
number
increased across all SES groups, and the
gap in quitline number recognition
between the least and most deprived
groups narrowed.
Compliance
Overall, the prevalence of anti-tobacco Neutral
signage increased and pro-tobacco
features decreased between audits for
every store type and neighbourhood SES.
459
Author,
year
Study
design
Country
SES variable
Policy
Intervention
Outcome
Equity impact
Summary
(negative, neutral,
positive, unclear,
mixed)
of-sale cigarette
display ban
Mass media- cessation campaigns
Alekseeva 1.3
Russia
2007
Education
Quit
&
Campaign
Win Uptake
Win Reach,
plus cessation
Bains 2000
1.3
Canada
Education,
Occupation
Quit
&
Campaign
‘Quit Kit’
CDC 2007
1.2
USA
Education
Television-based
Prevalence
anti-tobacco
media campaign
(graphic imagery)
Civljak
2005
1.1
Croatia
Education
Dunlop
1.2
Australia
Composite
First
national Uptake,
one
‘smoke out day’ day abstinence
multi-media
campaign on first
day of Lent as
part of ‘Say yes to
no
smoking’
campaign
Antismoking
Unprompted
Only reports uptake by SES, which Negative
appears stable across time, the higher the
education level the higher the
participation. Study did not report
abstinence by educational level nor make
any comparisons with the SES of
smokers in the general population.
Lower SES adult daily smokers not as Negative
well represented as randomly selected
control cohort. However SES was not
significantly associated with cessation at
1 year.
Percentage
change
in
smoking Neutral
prevalence from 2005 to 2006 did not
differ by educational subgroup. In 2006,
smoking prevalence among those with
less than a college education was higher
than among those with more education.
Largest group of abstainers (one day) Unclear
had secondary school education and
smallest group of abstainers were those
with university education. No analysis of
quit rate by SES group.
Individual composite measure of SES Unclear
460
Author,
year
Study
design
Country
2012
SES variable
Policy
Intervention
Outcome
measure
of
education and
income,
Neighbourhood
SES
television
recall,
advertisements:
prompted
low emotion; high recognition
emotion
with
graphic imagery;
high emotion with
narrative format
Durkin
2009
1.3
USA
Cumulative
Television-based
measure
of anti-tobacco
education and media campaign
income
(emotional and/or
testimonials)
Quit
rates
(abstinence for
one
month),
quit rates by
type
of
advertisement
Farrelly
2012
1.2
USA
Education,
income
Exposure
(recall
and
GRP),
quit attempts
Emotional and/or
graphic
antismoking
television
advertisements
Equity impact
Summary
(negative, neutral,
positive, unclear,
mixed)
(income and education) but not
neighbourhood measure of SES showed
significant associations with recall and
recognition. Association was different
between two outcome measures: high
SES had increased recall of TV antismoking advertisements, moderate and
high SES had decreased recognition of
TV anti-smoking advertisements in
comparison with low SES.
Middle and high SES groups had a Mixed
higher quit rate at follow-up than low
SES despite no significant variation in
exposure between SES groups. The
highly emotional or personal testimonial
advertisements were more effective with
the low, mid and undetermined SES
groups compared to the high SES groups
for increasing the likelihood of quitting
smoking.
Association between quit attempts and Mixed
exposure to all types of antismoking
media and to emotional and/or graphic
media was equally effective for all SES
groups when measured by GRP.
When measured by recall, association
between quit attempts and exposure to all
type of antismoking adverts was most
effective for high SES, and exposure to
emotional and/or graphic adverts was
most effective for low SES.
461
Author,
year
Study
design
Country
SES variable
Graham
2008
1.3
USA
Education
Hawk 2006
2.3
USA
Education
Levy 2006
1.2
USA
Education
Nagelhout
2013
1.3
Netherlands
Education
Policy
Intervention
Outcome
Equity impact
Summary
(negative, neutral,
positive, unclear,
mixed)
Online
Uptake
(by Online ads recruited more people with a Unclear
advertising
of clicking
on high school degree or less than
QuitNet’s web- advert),
traditional media (24.6% v 23.2%,
based cessation recruitment,
p<0.02), mostly through passive banner
program and state engagement
ads rather than using active searching
run
telephone
methods. Although engagement was
quitlines
slightly lower among online users.
Quit
&
Win
contest
and/or
free 2-week NRT
promotion. Media
coverage included
a
press
conference,
newspaper
and
TV coverage.
Tobacco control
paid
media
campaign
Reach,
Compared with smokers in region –
7-day
point those enrolled in the 3 interventions
prevalence
(Quit & Win, NRT, combination) had
more years of formal education p<0.05.
Adjusted OR for 7-day point prevalence
by level of education was not significant.
Negative overall
Negative
reach,
Neutral
prevalence
for
for
Smoking
prevalence
among women
Smoking prevalence declined more Positive
rapidly among low-education compared
to medium and high education women.
Moreover, evidence showed that
compared with higher educated women,
low education women responded with
greater positive effect to mass media.
Generally, the association of the media
variable and smoking prevalence
declined in the more recent survey
waves.
Mass
media Exposure,
Smokers from different educational Neutral
smoking cessation quit attempts,
levels were reached equally by the mass
campaign - ‘There 7-day
point media campaign.
462
Author,
year
Study
design
Country
SES variable
Niederdepp 1.3
e 2008
USA
Education,
income
Niederdepp 1.2
e 2011
USA
Education,
income
Policy
Intervention
Outcome
Equity impact
is a quitter in
every smoker’ ran
on
television,
radio, print and
internet.
Television-based
cessation adverts
as
part
of
Wisconsin
Tobacco Control
and
Prevention
Programme.
prevalence
(successful
quits)
There were no significant educational
inequalities in successful smoking
cessation.
Recall,
quit attempts,
abstinence at
one year
Overall, neither Keep-trying-to-quit Unclear
(KTQ) nor secondhand smoke ad recall
was associated with quit attempts or
smoking abstinence at one year.
KTQ ads were significantly more
effective in promoting quit attempts
among higher- versus lower-educated
populations. No relationship between
KTQ recall and income. No differences
were observed for SHS ads by the
smokers' education or income levels.
Why-Testimonial ads had the highest and Unclear
How ads had the lowest ad recall across
all levels of education. This difference
was greatest at low levels of education.
Why-Graphic ads had the highest level
of perceived effectiveness. This value
was higher than How ads across all
levels of education. Once again,
however, the difference was most
pronounced at low levels of education.
Differences in readiness to quit between
higher and lower educated populations
did not explain why thematic differences
in recall and response were more
pronounced among sm