of smoking. Dissertation Abstracts International Section A: Humanities and Social Sciences 73[4-A], 1295. 2012. Poulin CC. School smoking bans: do they help/do they harm? Drug & Alcohol Review 2007; 26(6):615-624. Does not report outcomes for high versus low group Schmitt CL. The effect of decision heuristics and ethnicity on cigarette sales to minor girls. Dissertation Abstracts International: Section B: The Sciences and Engineering 2002; .62(9-B). Not an intervention or policy to reduce adult smoking or to prevent youth starting to smoke Sims M, L, Gilmore A. England's legislation on smoking in indoor public places and work-places: Impact on the most exposed children. Addiction 2012;107(11): 2009-2016. Does not report outcomes for high versus low group - regression analyses adjust for SES Straub DM, Hills NK, Thompson PJ, Moscicki AB. Effects of pro- and anti-tobacco advertising on non-smoking adolescents' intentions to smoke. Journal of Adolescent Health 2003; 32(1):36-43. Does not report outcomes for high versus low group Tangari AH, Tangari AH, Burton S, Andrews JC, Netemeyer RG. How do anti-tobacco campaign advertising and smoking status affect beliefs and intentions? Some similarities and differences between adults and adolescents. Journal of Public Policy & Marketing 2007; .26(1):60-74. Does not report outcomes for high versus low group Veldwijk J, Hoving C, van Gelder BM, Feenstra TL. Potential reach of effective smoking prevention programmes in vocational schools: Determinants of school directors' intention to adopt these programmes. Public Health 2012; 126(4):338-342. Not an intervention or policy to reduce adult smoking or to prevent youth starting to smoke - about theoretical intention to adopt a schools programme Weinman ML, Weinman ML. A comparison of three groups of young fathers and program outcomes. School Social Work Journal 2007; .32(1):1-13. Does not report outcomes for high versus low group Wildey MB, Clapp EJ, Woodruff SI, Kenney EM. Retailer education to reduce the availability of single cigarettes. Journal of Health Education 1995; 26(5):297-302. Does not report outcomes for high versus low group
Details Method Results Comments Smoking restriction in cars, workplaces, schools and other public places Author, year Galan 2012 Age (years) 15-16 Setting 79 secondary schools, Madrid, Spain Study design Cross-sectional study Objective To evaluate the relationship of contextual factors with smoking on school premises SES variables used School-level: Socioeconomic status of the census tracts in which the school Data sources Surveillance System of Risk Factors associated with diseases targeting the adolescent population in the fourth year of compulsory secondary education in the Madrid region (15–16 years), Participant selection Two-stage cluster sampling with stratification in the selection of schools according to area and type (public or private). Overall General population impact smokers, 50.6% had smoked on school premises during the last thirty days with significant variability (0% to 100%) between schools Impact by SES variable with school-level and variables: a lower probability of smoking on school premises was found among adolescents whose fathers had a university education (OR Internal validity The questionnaire was filled out in the classroom in the presence of previously trained staff. Smoking variable previously validated but potential for response bias. Some subgroups are not sufficiently powered. SES measured by census tracts of the school rather than the location of the home of the student so may not be accurate.
is located, estimated from an index based on aggregate data (unemployment, temporary workers, manual workers, and low educational level among the overall adult [age >15 years] and young adult [age 16–29 years] populations). Individual variables: Educational attainment of parents Employment status of parents Study analysis Multilevel logistic regression models of smoking response rate (schools and students) was 83.1%. Participant characteristics 15-16 year olds in fourth year of compulsory education, N=1179 Outcomes measured Probability of smoking in school Intervention details Survey of smoking behaviour and individual and school-level contextual variables 0.43, 95% CI: 0.19 to 0.96) or among those who did not know the level of studies of their father (OR 0.39, 95% CI: 0.16 to 0.94) compared with those with fathers who had a very low level educational attainment. Adolescents with low academic achievement showed an OR of 1.51 (95% CI: 1.00–2.29). Employment status of either parent or educational level of mother was not significant. SES of the census tracts External validity Should be representative and generalisable to secondary schools in Spain and other similar countries. However, presence or absence of smoking policy did not include an evaluation of whether policy was implemented which limits applicability of this study. Validity of author’s conclusion Agreed, census tract of school may
population (n=1,179=32.6% analyses on 1,116=94.7% of sample of smokers) of the school was not significant, nor was written reference to smoking control policy or educational activities about smoking prevention. A lower probability of smoking on school premises was found for state subsidized private schools (odds ratio [OR]: 0.20; 95% CI: 0.11–0.35) and nonsubsidized private schools (OR: 0.30; 95% CI: 0.14–0.62) when compared with that for public schools not be sensitive to school-level SES
Schools, Israel Study design study Objective To examine determinant of SHS exposure in Israeli adolescents SES variable Maternal and paternal education (<12 years, 12 years, College or University, other degree) Study analysis Participant selection Israel Ministry of Education provided list of approximately 1,000 schools from the educational system. Sample stratified by population group (Jewish, Arab + Bedouin, Druze), stream (state, state religious), school level (7–9, 10–12), and SES (defined by the Ministry of Education as related to the school, as low, high). For each school entertainment: 73.3%; other: 16.3%). Impact by SES variable Parental education is not a significant determinant of smoking in school Home: Teenagers whose fathers had less than 12 years of education (OR = 1.48; CI: 1.09, 1.99; p = .0111) were more exposed than were teenagers whose fathers had a degree from a university or college. Teenagers with assess nutritional status and so smoking question is basic yes/no. External validity Schools from the ultraorthodox Jewish, independent and private sectors were excluded, as were boarding schools. Israel is heterogeneous with broad range of ethnic, religious and socioeconomic populations and is not generalisable to other WHO European or stage 4 countries.
Logistic regression models chosen as a primary sampling unit, the grade level and then the class within each grade level were randomly selected. Response rates were high (school: 91.8%, child: 87.9%), with 6,274 participants. Participant characteristics Average age was 15 years (11–19 years). N=6,274 students: 55.7% girls, 44.3% boys; 70% Jews, 30% (18% Moslem Arab, mothers (OR = 1.39; CI: 1.02, 1.90; p = .0366) were more exposed than teenagers with mothers with degrees from a university or college. Author’s conclusion of SES impact The high levels of SHS exposure among Israeli adolescents were characterized by different patterns of exposure among different population groups Validity of author’s conclusion No comprehensive smokefree bans at time of survey so survey is not assessing impact of specific policy implementation but lending support to National Tobacco Control plan recently approved by Israeli government
Details Method Results Comments Controls on advertising, promotion and marketing of tobacco Author, year Gilpin & Pierce 1997 Age 14-21 in 1979 to 1989 Setting US Study design Cross-sectional study Objective To investigate the possible association between increased tobacco marketing and increased smoking initiation by adolescents Intervention Examines trends in smoking initiation by inflation-adjusted cigarette prices and tobacco industry budget for marketing SES variables used Education (less than 12 years, 12 years with no college education, more than 12 years with some college education as adults) Study analysis Data sources Combined data from 3 Current Population Surveys (September 1993, January 1993, May 1993) that contained special supplement on tobacco use. One quarter=in person interviews and ¾ = telephone interviews. Tobacco Institute for weighted average pack prices, US Federal Trade Commission for marketing expenditure; adjusted to 1989 dollars using Consumer Price Index Participant selection Civilian non-institutionalised population aged 15 years+, surveyed about 56,000 households per month Participant characteristics Analysis restricted to respondents 17-38(n=140,975) that would have been 14-21 in 1979 to 1989 Outcomes measured Initiation rates by education (rate calculated as number in an age group who reported starting smoking regularly in a year, divided by number of never-smokers at start of the year) General population impact 1979 to 1984 adolescent initiation rates decreased but increased thereafter Impact by SES variable Initiation rates highest among high school dropouts and lowest amongst those who eventually attended college. Only quadratic model significant for dropouts (p=0.035). Neither model was significant for graduates and both models were significant for ‘some college’ (p=0.081 linear, p=0.014 quadratic). In 1988 initiation rate was 9.9% for those who did not graduate from high school, 6.9% for high-school graduates reporting no college and 3.7% for those reporting at least some college. Author’s conclusion of SES impact Marketing expenditure may be associated with an increase in smoking initiation especially in young people with lower levels of education. Internal validity Respondents are asked about how old they were when they started smoking (retrospective so potential for recall bias and underreporting) External validity Initiation are for decade 1979 to 1989 so relatively older study which limits its generalisability to current youth Validity of author’s conclusion Tentative because study links overall initiation rates by marketing budget but doesn’t assess marketing budget impact on initiation rates by education level
Regression models were used to examine the effect of experimental condition for primary outcomes: pack ratings, smoker image ratings, and beliefs about smoking. For each outcome, regression models were conducted in two steps. In Step 1, the model included only the “condition” variable. In Step 2 of the model, the following variables were entered as covariates: age, education, income, ethnicity, smoking status, and weight concerns. In Step 3, all two-way interactions with the “condition” variable were tested by entering each interaction term into the model one at a time. a random order. Packages were displayed according to each of the four experimental conditions: ( 1) female-oriented packages (standard condition); ( 2) packages with brand imagery, including colours and graphics, but with descriptors (i.e., slims) removed; ( 3) female-oriented packages without brand imagery and descriptors (i.e., plain packages); and (4) popular U.S. brands of “ regular ” or non – female- oriented packages state their income ( OR = 2.17, 95% CI = 1.29 – 3.65). No significant differences in pack selection were observed for smoking status, age, income, education, ethnicity, or weight concerns Author’s conclusion of SES impact Not stated Details Method Results Comments Controls on advertising, promotion and marketing of tobacco Author , year 1998 Age (years) 5-14, 15-19 Setting Boston, US Data sources field survey using single observations in 1996. Six Boston neighbourhoods—two with the highest, two with middle, and two with the lowest median household incomes—were selected. July to August 1996, four observer teams (one adult and two to three youth), General population impact The greatest number of for any neighbourhood was 22 in Roxbury, with Mattapan (21) second and East Boston (16) third. These three neighbourhoods also shared the top three positions for number of units: Mattapan (169), Roxbury (124), and East Boston (113). Internal validity Uses actual observations of tobacco density and links to buffer zones. However study does not include advertising, advertising inside stores that is seen from the street, or advertising on taxis and buses.
Details Method Results Comments Increases in price/tax of tobacco products Author, year Gilpin & Pierce 1997 Age 14-21 in 1979 to 1989 Setting US design Cross-sectional study Objective To investigate the possible association between increased tobacco marketing and increased smoking initiation by adolescents Intervention Examines trends in smoking initiation by inflation-adjusted cigarette prices and tobacco industry budget for marketing SES variables used Education (less than 12 years, 12 years with no college education, more than 12 years with some college education as adults) analysis Data sources Combined data from 3 Current Population Surveys (September 1993, January 1993, May 1993) that contained special supplement on tobacco use. One quarter=in person interviews and ¾ telephone interviews. Tobacco Institute for weighted average pack prices, US Federal Trade Commission for marketing expenditure; adjusted to 1989 dollars using Consumer Price Index Participant selection Civilian non-institutionalised population aged 15 years+, surveyed about 56,000 households per month Participant characteristics Analysis restricted to respondents 17-38(n=140,975) that would have been 14-21 in 1979 to 1989 Outcomes measured Initiation rates by education (rate calculated as number in an age group who reported starting smoking regularly in a year, divided by number of never-smokers at start of the year) General population impact 1979 to 1984 adolescent initiation rates decreased but increased thereafter Impact by SES variable Initiation highest among high school dropouts and lowest amongst those who eventually attended college. Only quadratic model significant for dropouts (p=0.035). Neither model was significant for graduates nor both models were significant for ‘some college’ (p=0.081 linear, p=0.014 quadratic). In 1988 initiation rate was 9.9% for those who did not graduate from high school, 6.9% for high-school graduates reporting no college and 3.7% for those reporting at least some college. Author’s conclusion of SES impact Increase in cigarette taxes did not reduce smoking initiation rates. Internal validity Respondents are asked about how old they were when they started smoking (retrospective so potential for recall bias and underreporting) External validity Initiation rates are for decade 1979 to 1989 so relatively older study which limits its generalisability to current youth Validity of author’s conclusion Tentative because study links overall initiation rates by marketing budget but doesn’t assess marketing budget impact on initiation rates by education level
Age 19 (when started smoking) Country Ireland Design Single cross-sectional survey containing retrospective cohort data Objective To investigate the role of tobacco taxes in starting and quitting smoking and explores how tax effect differs by education SES variables Education (primary, junior (age 16), secondary (age 18), University) Analyses Duration analyses – various parametric duration models 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. 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. 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. Potential for recall bias, 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 period, unclear whether the relationship would continue with further increases from current levels of taxation. Potential quitters had less cessation support available. Only covers 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
Study analysis Inventory of commercial cigarette sources in 2005 and 2007 and 2009 and mapped using Geographic Information System significant in both years (2005: t(15) = 9.017, p < .001 and 2009: t(17) = 6.915, p < .001). Author’s conclusion of SES impact In districts with above-average SES, the supply density was lower than in districts with below-average SES, even at the beginning of the study. Decreases in the number of cigarette sources were reflected more sharply in regions of higher SES, which also emphasizes the social inequalities between these two areas. Details Method Results Comments Controls on access to tobacco products Author , year Widome 2012 Age Minors aged 15-18 used for compliance checks Setting Minnesota, US Study design Data sources (1) Observations of the advertising environment in establishments (2) a record of age-of-sale tobacco checks where an undercover minor working with law enforcement attempts to purchase tobacco (3) Demographic data from the Year 2000 U.S. census. Participant selection 655 licensed tobacco vendors, both interior and exterior assessments General population impact No association between tobacco marketing and compliance check failure. Of a total of 467 stores, 48 failed compliance check. Tobacco shops were most likely to fail compliance checks (44%). Supermarkets were least likely to fail (3%). Impact by SES variable Poverty of stores block group was not associated with compliance failure of stores. Stores in block groups with greater Internal validity Completion of a full store assessment was not significantly associated with whether stores passed their compliance check (p = .931). Each store assessed by one assessor. External validity Authors report that Minnesota has less racial/ethnic diversity
12.7 Setting Montreal, Canada Study design Prospective cohort study Objective To describe the association between smoking intolerance in schools, restaurants and corner stores near schools and the initiation of smoking in adolescents SES variable Parental education Schools classified as low/medium/high SES based on mean household income Study analysis Cox proportional hazards modelling, limited to n=868 never smokers at baseline 1999 to 2005 in 1, 293 grade 7, age 12-13, students in 10 secondary schools. 7 English and 3 French language secondary public schools, Participant selection Convenience sample, 54.5% student response Participant characteristics Mean age 12.7 (SD 0.5), 11-16; 51% male Outcomes Smoking initiation Intervention details Longitudinal cohort and direct observation 0.68, 1.01); attending schools located in neighbourhoods with smoking intolerant restaurants, HR=0.85 (0.68, 1.07). There was no association between corner store smoking intolerance and smoking initiation Impact by SES variable HR for cigarette use initiation for low SES school, in schools=1.11 (0.88, 1.36), p=0.40; in restaurants=1.04 (0.83,1.31)p=0.74; in corner stores=1.10 (0.88, 1.37) p=0.59 Author’s conclusion of SES impact Not stated attend a low SES school (OR 1.7, 95% CI 1.2, 2.4; p<0.01) External validity Convenience sample limits generalisability of this Validity of author’s conclusion Study did not aim to assess differential impact by SES. Details Method Results Comments Multiple policy interventions Author, year Data sources General population impact Internal validity
To determine the effectiveness of a mobile phone text messaging smoking cessation programme Intervention Regular personalised text messages providing smoking cessation advice, support, distraction SES variable Income Study analysis Logistic regression Self-reported smoking status Biochemically verified abstinence on random selection Intervention details Free five text messages per day for week prior to negotiated quit date and for four weeks after quit date. Control group received free month of text messaging if participated until 26 weeks. Author’s conclusion of SES impact Text messaging can double quit rates and this effect was consistent across major subgroups including income level underestimating of treatment effects); External validity Participants had to be in the contemplative stage of change to be included; participants could use other smoking cessation strategies and were informed of quitline and government subsidy for NRT at baseline; participants had to own a mobile phone Validity of author’s conclusion Details Method Results Comments Individual smoking cessation support Author, year Ybarra 2013 Age (years) 18-25 Setting National, USA design Pilot Quasi RCT Data sources RCT Participant selection Purposefully targeted a diversity of communities. Recruited nationally through online advertisements (e.g., Craigslist) between May 3, 2011 and August 4, 2011. Eligibility criteria included the following: between the ages of 18–25, able to read and write in English, owning cell phone, General population impact 40% of the participants in the intervention arm had a verified quit status compared with 30% in the control arm at 3 months post quit. The observed difference was not statistically significant (OR = 1.62, 95% CI:0.82, 3.21). Participants in the intervention were significantly more likely to have quit at 4 weeks post quit (39%) than those in the control group (21%; aOR = 3.33, 95% CI: 1.48, 7.45); this was true also for 7-day Internal validity Feasibility sample – small sample size so not sufficiently powered particularly for subgroup results. Imbalance in the minimum number of participants intended for each arm within each subgroup (e.g., male heavy smokers). As a result, allocation concealment was broken for the last eight
Moore 2011 11 Repeat cross-sectional Primary Wales FAS Smokefree national legislation SHS exposure Reductions limited to children from more affluent households, whose exposure was already significantly lower prior to legislation, leading to increased socioeconomic disparity Moore 2012 11.2 Repeat Primary Ireland, FAS Smokefree national legislation SHS exposure Smoking restrictions in the home and car Declines in exposure occurred predominantly among children with low exposure before legislation, and from more affluent families. Substantial socioeconomic gradients in proportions of children with higher SHS exposure levels remained unchanged. No change in inequality following legislation for home and car-based smoking restrictions (socioeconomic patterning remained stable). Nabi-Burza 2012 Single cross-sectional USA Parental education Voluntary smokefree car policy smoking behaviour in cars and home Parental education was not significantly associated with strictly enforced smokefree car
policy on its own, only significant in interaction with child age and amount smoked. College educated parents of children aged <1 year were more likely to have strict smoke-free car policies. Noach 2012 15 Cross-sectional Israel Parental education Voluntary compliance SHS exposure Parental education was a significant predictor of smoking in the home but not at school, exposure was significantly greater amongst adolescents whose parents had less education Woodruff 2000 19 Before and after experimental study US Navy centre, females only Education 8-week 24-hour smoking ban Smoking relapse Education did not predict smoking relapse Controls on advertising, promotion and marketing of tobacco Gilpin & Pierce 1997 in Cross-sectional US surveys Education Tobacco marketing Smoking initiation Level of education impacted on initiation rates with initiation rates highest among high school dropouts and lowest amongst
welfare, schools prevent underage (<16 years) purchasing cigarettes, significant difference both before and after locking devices Widome 2012 Cross-sectional tobacco US Below 150% poverty level Age-of-sale tobacco checks Compliance There was no association between store advertising characteristics or poverty and stores’ compliance check failure. School-based prevention Bacon 2001 11 Cluster RCT Middle Florida, US lunch status ‘Too Good for II’ Intentions, attitudes and perceptions towards tobacco use Programme was similarly effective in impacting students risk and protective factors regardless of SES Campbell 2008* RCT & Wales FAS, FSM Peer-led social network smoking uptake prevention Smoking in past week The results were mixed depending on the specific SES indicator used. The intervention was most effective for adolescents in the Valley schools, located in a deprived area, particularly low SES girls. 2003* 13 RCT Parental education Anti-smoking class-based intervention Experimenting with smoking or smoking daily or weekly The intervention had a significant effect among higher SES adolescents and
Rodgers 2005 25 RCT New any setting, any location Income level Text-messaging Smoking cessation Text messaging doubled quit rates and this effect was consistent across major subgroups including income level Ybarra 2013 22 RCT USA, national Enrolment in higher education Text-messaging Continuous abstinence, 7-day point prevalence Significant increase in quit rates in intervention group vs control group at were not sustained at 3 months. Tailored text messaging appeared to benefit youth not enrolled in higher education. *study identified in Mercken 2012