A systematic review of the effectiveness of policies and interventions to reduce socio-economic inequalities in smoking among youth.

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1







Centre for Population Health Sciences

University of Edinburgh



A systematic review of the
effectiveness
of
policies and
interventions to
reduce
socio
-
economic inequalities in smoking
among youth
.


Report
March 2013

Amanda Amos

Tamara Brown

Ste
ph
e
n

Platt


SILNE
-

Tackling socio
-
economic inequalities in

smoking: learning from natural
experiments by time trend
analyses and cross
-
national
comparisons








2


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


A
cknowledgements

The project team would like to thank members of the SILNE project and
members of the
Eur
opean
Network for Smoking and Tobacco Prevention
(
ENSP
)

who

help
ed in the

search for grey literature.



3


Table of Contents

EXECUTIVE SUMMARY
................................
................................
................................
................

4

1

INTRODUCTION

................................
................................
................................
.......................

6

1.1

Background

................................
................................
................................
................................
...........

6

1.2

Aims and objectives

................................
................................
................................
..............................

8

2

METHODS

................................
................................
................................
................................

10

2.1

Search
strategy

................................
................................
................................
................................
...

10

2.2

Study selection

................................
................................
................................
................................
....

11

2.2.1

Study selection process

................................
................................
................................
...................

11

2.2.2

Inclusion criteria

................................
................................
................................
..............................

11

2.2.3

Data extraction

................................
................................
................................
................................

13

2.2.4

Quality assessment

................................
................................
................................
..........................

13

2.2.
5

Data synthesis

................................
................................
................................
................................
..

14

3

RESULTS

................................
................................
................................
................................
..

16

3.1

Introduction

................................
................................
................................
................................
........

16

3.2

Impact o
f population
-
level policies and interventions on smoking inequalities in youth

....................

21

3.2.1 Smoking restrictions in cars, schools,
workplaces and other public places

................................
..........

21

3.2.1

Controls on advertising, promotion and marketing of tobacco
................................
.......................

29

3.2.2

Mass media campaigns

................................
................................
................................
....................

32

3.2.3

Increases in price/tax of tobacco products

................................
................................
......................

33

3.2.4

Controls on access to tobacco products

................................
................................
..........................

37

3.2.5

School
-
based prevention

................................
................................
................................
.................

43

3.2.6

Multiple policy interventions

................................
................................
................................
...........

48

3.3

Impact of individual level cessation services and support on smoking inequalities
in youth

...............

51

4

DISCUSSION

................................
................................
................................
............................

55

5

CONCLUSIONS

................................
................................
................................
........................

60

6

REFERENCES

................................
................................
................................
..........................

61

7

APPENDICES

................................
................................
................................
...........................

65

7.1

Appendix A
Search strategies: electronic searches, handsearching and searching for grey literature

.

65

7.2

Appendix B WHO European countries
and other stage 4 countries

................................
.....................

77

7.3

Appendix C Inclusion/exclusion form

................................
................................
................................
..

78

7.4

Appendix D Included studies
-
Youth

................................
................................
................................
....

80

7.5

Appendix E Excluded studies
-
Youth

................................
................................
................................
....

83

7.6

Appendix F
Data extraction
-

Youth

................................
................................
................................
....

86

7.7

Appendix G Quality assessment

................................
................................
................................
........

152

7.8

Appendix H Summary of equity impact of youth polices/interventions

................................
............

15
4

7.9

Appendix I Equity impact model of youth policies/interventions by SES measure

............................

161




4


EXECUTIVE SUMMARY



Smoking is the single most important preventable
cause

of premature mortality
in
Europe

and a
m
a
jor cause of inequalities in
health
.



While there is good evidence on what types of tobacco control policies are effective
in reducing smoking uptake in young people, little is known about what is effective
in reducing inequalities in smoking in young people.




The aim of this report was to un
dertake a systematic review of the effectiveness of
policies and interventions in reducing socioeconomic inequalities in smoking among
youth.



The

systematic review
included

primary
studies involving young people (aged 11
-
25)
,

published between January 1995

and January 2013
,

which assessed the impact of
smoking prevention policies and interventions, and smoking cessation support,

by
socioeconomic status.



Any type of tobacco control intervention, of any length of follow
-
up, with any type
of smoking
-
related o
utcome was included. A broad range of smoking related
outcomes
and s
ocioeconomic variables
was

included.



The equity impact(s) of each intervention/policy
on smoking
-
related outcome
s

was
assessed
as either being positive (reduced inequality), neutral (no difference by
socioeconomic status) or negative (increased inequality).



Very few studies
were found to
ha
ve

assessed the equity impact
of the
policy/intervention

and all were from
tobacco
control
.

Thirty
-
three

studies

were
included in the review, of which 31 were population level

tobacco
control
policies
/interventions and
two

were individual level cessation support interventions.
The

types of policies/intervention

included

were
: smoking restriction
s in cars,
schools, workplaces and other public places (9); controls on the advertising,
promotion and marketing of tobacco (3); mass media campaigns (1); increases in
price/tax of tobacco products (6); controls on access to tobacco products (5); school
-
ba
sed prevention programmes (5); multiple policy interventions (3) and individual
cessation support (2).
(One study was included in two types of policies/intervention
category).



Assessing

the overall equity impact of different types of interventions/policies was
complicated

by studies having different outcome measures and length of follow
-
up.
However,

overall there was no consistent equity effect for each type of tobacco
5


control policy/
int
ervention. Most interventions had, on balance, either a negative (11)
or neutral (15) equity impact. One had a mixed impact.



Only
six

of the 31 population level
prevention
studies showed the potential to
produce a positive equity impact. These included thr
ee US studies of increasing the
price/tax of tobacco products, two US studies on age
-
of
-
sales laws and one UK study
of a smoking prevention programme (ASSIST).
The two smoking cessation studies
both used text
-
messaging interventions. The New Zealand study
had a short
-
term
neutral equity impact and the US study had a short
-
term positive equity impact.



Very few studies have assessed the equity impact of policies and intervention
s on
smoking prevention or
cessation in youth
.

There is
therefore
little availabl
e evidence
to inform tobacco control policy and interventions that are aimed at reducing
socioeconomic inequalities in youth smoking. There is a need to strengthen the
evidence base for the equity impact of tobacco control interventions
which target

young
people
.



6


1

INTRODUCTION

1.1

Background

S
moking prevalence rates differ substantially
within European countries
according to
people’s

educational level, occupational class and income level
;

and smoking is the largest
single contributor to socioeconomic inequalities in mortality

in Northern Europe
.
The
patterning of smoking by socioeconomic status (SES) within a country reflects the stage of
the tobacco epidemic in that country. In general sm
oking is initially taken up by higher SES
groups, followed by
lower SES

groups
. H
igher SES

groups are
then
the first to show
declines in smoking, followed by
lower SES

groups
.
1

The tobacco epidemic is

also gendered
in that men first take up smoking, followed by women
.
2

Most countries in the
European
Union (
EU
)

are characte
rised as being in the fourth (last) stage of the epidemic. In these
countries l
ower
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
. T
his is reflected in the differential patterning of smoking by SES and gender,
where the clear relationship be
tween low SES and smoking
found
in men is only starting to
emerge in women.

SES is an important determinant of smoking uptake in young people. Parental smoking
status, which is related to SES,
is

a predictor of smoking uptake in young people
.
5;6

However, the relationship between SES and smoking uptake is generally less clear than that
for adult smoking, reflecting the difficulty of assessing SES among adolescents.
Commonly

used adult measures of SES such as educational attainment
,

occupation
and i
ncome
are not
relevant for adolescents. However, some surveys have developed measures of
youth
SES
,

including the Health Behaviour in School
-
aged Children survey (HBSC). The HBSC, which
is carried out in 39 countries, mostly
i
n Europe, uses a measure of ‘
family affluence’
(FAS)
to assess participants’ SES. The 2005/6 survey found that, as with adult smoking, the
relationship between youth smoking and SES varied between countries depending on their
stage of the tobacco epidemic and gender
.
7

Low family affluence was significantly
associated with weekly smoking among girl
s in nearly half the countries, but in only a few
countries among boys. This pattern was strongest for girls in countries in stage four of the
tobacco epidemic (North and Western Europe, Canada, USA). In Eastern and Southern
Europe (mostly Stage 3 countrie
s such as Ukraine, Estonia, Russia), family affluence was
generally not associated with smoking. Fifteen year old girls from low affluent families in
North Europe were also more likely to have started smoking earlier
i.e.

at age 13 or younger.

7


Since the 19
90s, many European countries have
implemented new and stronger

tobacco
control policies
including smokefree

legislation covering
smoking in public places,
bans on
tobacco
advertising and
promotion
,

and tax increases.
There is good evidence on what is
effective in reducing adult smoking amongst the general population. A review of the
international evidence by the World Bank in 2003
8

identified six cost
-
effective policies
which they concluded should be priorit
ised 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 ac
cess to medications


These priorities have been endorsed by
World Health Organisation (
WHO
)
9

and form the
basis of the Framework Convention on Tobacco Control (FCTC), the first international
public health treaty.
10


R
eviews on smoking prevention in young people have endorsed the importance of these
measures
for preventing smoking uptake,
though the evidence on effective youth cessation
support
is less strong than that for adults
.
5

The

recent
US
Surgeon General
’s

report on
Preventing Tobacco U
se Among Youth and Young Adults
6

stated

that the evidence is
sufficient to conclude that mass media campaigns, comprehensive community programmes,
comprehensive statewide tobacco control programmes and increases in
cigarette

prices
redu
ce
smoking
initiation and
prevalence

i
n youth (
and taxes
also
reduce prevalence among

young adults). They also concluded that certain types of school programmes can produce at
least short
-
term effects
in reducing youth smoking prevalence.



What is much l
ess certain is how ‘real world’ policies and interventions that reduce overall
smoking prevalence within the general population impact on socioeconomic inequalities in
smoking. Tackling these socioeconomic inequalities in smo
king is central to reducing the

health inequalities gap and is the fundamental underpin
ning aim of the “SILNE” project,
11

“Tackling socioeconomic in
equalities in smoking: learning from natural experiments by time
trend analyses and cross
-
national comparisons”. SILNE 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
8


Framework Programme; ‘Developing methodologies to reduce inequities in the determinants
of health’ programme (grant agreement no. 278273). The SILNE project involves twelve
European p
artners who will deliver the seven work packages which make up the project.
This systematic review is part of
W
ork
P
ackage 6 of the SILNE project.

There have been t
wo
previous
reviews
on

the equity impact of tobacco control
interventions.
12;13

In 2008 the Centre for Reviews and Dissemination (CRD) at the
University of York published a systematic review of the equity impact of tobacco control

on
young people and adults
,
12

focussing on population

level interventions
a

(not individual
-
level
smoking cessation interventions) publish
ed up to January 2006. In 2010 the Department of
Health’s Policy Research Programme, through the Public Health Research Consortium
(PHRC), funded a study of tobacco control and inequalities in health in England
.
13

This
study
included a review of the evidence on
the
effectiveness
of interventions
to reduce
adult
smoking amongst
socioeconomic
ally deprived populations,
which built on the CRD review
and includ
ed evidence published from January 2006 until September 2010.
It included both
population
-
level interventions and individual
-
level cessation support interventions.
The
PHRC review concluded that there was limited evidence
to inform tobacco control policy
and interventions that are aimed at reducing socioeconomic inequalities in smoking
behaviour.

While c
onsiderable progress has been made in tobacco control in many countries in the EU
in recent years, there is considerable variation in the strength and comp
rehensiveness of
tobacco control
policies

and their implementation
.
14

However
,

whil
e

overall
smoking
prevalence is reducing; the social gradient is not. A
ddressing inequalities in smoking is a key
public health
priority
, starting with improving our understanding of the equity impact o
f
existing policies and interventions.

1.2

Aims

and objectives

The overarching
aims of
W
ork
P
ackage 6 are
t
o undertake
a
systematic review of the
effectiveness of policies an
d interventions to reduce socio
economic 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
with
in the EU.




a

Population

level control interventions have
been defined as ‘those applied to populations, groups, areas, jurisdictions or
institutions with the aim of changing the social, physical, economic or legislative environments to make them less
conducive to smoking.




9


Th
is

report
focuses on the findings of the
systematic rev
iew of the effectiveness of policies
and interventions to reduce socio
-
economic inequalities in smoking among youth
. It h
as
two
objectives:

1.

To identify and review the
strengths and limitations of the
published evidence on the
effectiveness of policies (at

the population level) to prevent and/or
reduce
smoking
amongst socio
economically deprived populati
ons as compared to higher
socio
economic groups
,

and implications for European and other countries at stage 4
b

of the tobacco epidemic.

2.

T
o identify and review the strengths and limitations of the published evidence on
the effectiveness of tobacco control interventions (at the individual level) to prevent
and/or
reduce
smoking amongst socio
economically deprived populati
ons as
compared to hig
her socio
economic groups
,

and implications for European and other
countries at stage 4 of the tobacco epidemic.




b

The 4 stages of the tobacco epidem
ic are described: Stage 1, characteri
s
ed by low uptake of smoking and low cessation
rates; Stage 2, characteri
s
ed 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 prevalen
ce 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).


10


2

METHODS

2.1

Search strategy

A comprehensive search
strategy was
developed to encompass studies published from
January
1995 to May 2012.
The search
include
d

published papers identified through
searches of relevant
electronic
databases
,
and papers pending publication identified through
handsearching of key journals,

and contact
ing
key tobacco control e
xperts.
A database of
relevant references was prod
uced using Reference Manager 12 software package
.

D
etails of
the search strategies
,

including

hand

searching
and searching for grey literature,
can be
found

in Appendix A
.

The following databases
were
searched:



BIOSIS



CINAHL Plus



Cochrane Library

(Cochrane Database of Systematic Reviews; Database of Abstracts
of Reviews of Effects; Cochrane Central Register of Controlled Trials; Health
Technology Assessment Database)



EMBASE



ERIC



Conference Proceedings Citation Index



MEDLINE



PsycINFO



Science Citati
on Index Expanded



Social Science Citation Index
.

This search
was
supplemented by hand
searching of four key journals
from January 2012 to
the end of Ju
l
y 2012
to identify articles ‘in press’ published on the journals’ websites:



Addiction




Nicotine and Tobac
co Research




Social Science and Medicine




Tobacco Control


11


Three key reviews were also search
ed for relevant primary studies:

the York review
,
12

the
PHRC review
,
13

and a report by the
US
Surgeon General on Preventing Tobacco Use
Among Youth

and Young Adults
6

which was published during the production of this review.

Bibliographies of included st
udies were also searched for further relevant studies.
Members
of SILNE
and members of the ENSP
were asked to identify any relevant studies not
identified by the extensive searching of the electronic databases and the handsearching.

Update search

The electronic search strategy was rerun in
the
three databases which yielded the majority of
the included studies
from the initial search (
EMBASE, MEDLINE and PsycINFO
)

to
identify studies published between May 2012 and end of January 2013.
In February 20
13,
t
he same four key journals were
hand
searched
to identify articles published on the journals’
websites

(but not yet listed in electronic databases)

for publication in journal issues up to
April 2013.

See appendix A for details.

2.2

Study selection

2.2.1

Study
selection process

Articles retrieved from the searches
were
screened by title and abstract, to
identify potentially
relevant studies
.
An initial screen of the first 200 references imported into Reference Manager
from MEDLINE were screened by title and abst
ract by two reviewers (AA
c

and TB
d
) 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 (SP
e
) was consulted.

2.2.2

Inclusion criteria

All primary study designs
based in a WHO European country or non
-
European country at
stage 4 of the tobacco epidemic
were eligible for inclusion
(see Appendix B for list of
included countries).

The inclu
sion ages for the youth review we
re
11
-
25
years
and
,

for the adult review
,

18
+
years
. Smoking uptake continues until around the age of 25 years
,

which is why this cut
-
off



c

AA=Amanda Amos

d

TB=
Tamara Brown

e

SP=Stephen Platt

12


was chosen

for the youth review
; it also enables comparisons to be made across studies set
within different countries where age of leavi
ng
secondary
education can vary considerably.

However, many adult

focused interventions target smokers aged 18 years and older. Thus 18
years and older was used to categorise adult interventions. In the rare cases where studies
straddled both age categorie
s they were included in both the youth and adult reviews.

When
the inclusion ages for
the youth
review were defined this was with a focus on
studies
relating to
smoking
initiation.
This inclusion
criterion

was later modified for studies
evaluating smokefre
e legislation in light of studies that included all ages of children.

In order to assess the equity impact of tobacco control measures in the general population,
we included
both population
-
level policies

and interventions,

and individual
-
level
interventio
ns
which aimed to reduce adult smoking or to prevent youth starting to smoke.
Studies of p
opulation
-
level policies
and interventions
cover
second
hand smoke
(SHS)
exposure by SES
,

the strength or reach
of

policy coverage by SES
, and
the impact by SES of
the

'voluntary' adoption/spread/strength of smokefree policies
,

i.e.
,

where countries do not
have comprehensive legislation.

In order to be included
in the reviews
an article must have assessed the
equity
impact of a
tobacco control intervention or policy, a
nd have presented results with a differentia
tion
between high and low socio
economic groups.
In other words, the review
only included
studies which reported differential smoking
-
related outcomes for at l
east two socio
economic
groups
.

Any type of
tobacco con
trol
intervention
,

of any length of follow
-
up
,

with any type of
smoking
-
related
outcome was included
.
A broad range of smoking related outcomes, either
self
-
reported or observed/validated,
was

included
:

initiation and cessation rates, quit
attempts, intent
ions to smoke/quit, prevalence, exposure to SHS, policy reach, social
norms/attitudes, use of quitting services and sources of smoking (i.e. vending machines).

Socio
economic variables included income, education, and occupational social class, area
-
level so
cio
-
economic deprivation

(including neighbourhood and school
-
level SES)
, housing
tenure, subjective
social status and

health insurance
. P
roxy measures for youth SES
were
also included,
such as free school meals, parental educational
, occupation

and income.

13


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 r
eported in the main body of
the text
even if the abstract did not report that SES was assessed. If grey literature, such as
reports not published as journal articles, was identified by experts as assessing equity impact
then this evidence could be included

even if
the abstract did not report that SES was
assessed.
In addition, such reports that were written in non
-
English
were included if
an

English synopsis

was provided (and otherwise met the inclusion criteria)
.
Only studies
published since 1995 in full
-
t
ext and in English language were included. No settings were
excluded. See Appendix C for inclusion/exclusion form.

T
he SILNE review excluded interventions targeted
exclusively at

one socio
economic group
and
also
excluded studies which reported socio
-
demog
rap
hic data only (without any
socio
economic 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 focus
ed

solely on
tobacco products other than
cigarettes (
e.g.

cigars, smokeless tobacco,
waterpipes
) or
toba
cco replacement products were

excluded,
unless
used as part of a smoking cessation programme. Interventions that focus
ed

solely on outcomes fo
r providers of a smokin
g cessation intervention were excluded unless
results we
re also reported for
high versus low socio
economic
participant
groups.
Papers
reporting study protocol and design

only without
reporting the impact of the intervention or
policy

were excluded
.

2.2.3

Data extraction

Data from the included studies
were

extracted
by one reviewer (TB) and independently
checked by another reviewer (AA).
Data relating to population characteristics, study design
and outcomes
were
extracted into data extraction forms. Data from studies presented in
multiple publications
were
extracted and reported as a single study with all other relevant
publications listed
in the report.

Data extraction from non
-
English reports (grey literature) w
as
limited because it was derived from an English synopsis provided by an expert; therefore the
synopsis is reported directly in the text (not in data extraction tables).

2.2.4

Quality assessment

All included studies were
assessed for methodological quality
by o
ne reviewer (TB) and
independently checked by another reviewer (SP).
The exception to this was non
-
English
14


language
reports (grey literature); where any reference to quality was derived from an
English synopsis and reported directly in the text.
Methodolog
ical quality was assessed by
adapting the
method used in the York review.
12

Each study was assesse
d on a scale of
quality of execution using the

six

item checklist of quality of execution adapted from the
criteria developed for the Effective Public Health Practice Project in Hamilton, Ontario.
15

Certa
in
items of quality are not applicable to all study designs, for example,
randomisation
and comparability are
not applicable to cross
-
sectional study designs.
We added
a new
criterion

of ‘generalisability’
(external validity)
and assessed
whether the
findings of each
study were

generalisable at a national, regional, or local level
.

2.2.5

Data
synthesis

Given the variations in study methodologies, intervention types and outcome measures
,

the
results
are
presented in the form of a narrative synthesis

and
accor
ding to
intervention type
(population

level policies
/interventions

and individual

level

cessation support interventions
).
In order to provide a simple basis for comparing the methodology of each study a typology
of study designs was devised (
Table
1
).

Table
1

Typology of study designs

Code

Study design

1.0

Population
-
based observational

1.1

Cross
-
sectional

1.2

Repeat cross
-
sectional

1.3

Cohort longitudinal

1.4

Econometric analyses (cross
-
sectional data)

2.0

Intervention
-
based observational

2.1

Single intervention (before and after, same participants)

2.2

Single intervention with internal comparison

2.3

Comparison between different
types of intervention

3.0

Intervention
-
based experimental

3.1

Randomised control
led

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


15


The equity impact of each intervention/policy is summarised
by adapting a model used in

the
York review
16
:



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 n
eutral 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 leve
l 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
:
t
o what extent are results from interventions and
policies carried out in various countries transferable across Europe despite differences in
tobacco co
ntrol policies,
stage of the tobacco epidemic,
socioeconomic conditions, and other
factors?

We draw c
onclusions
about
the strengths and weaknesses of the current evidence of
the impact of tobacco control and other policy interventions on reducing socioeco
nomic
inequalities in smoking
in youths and adults
(equity impact)
and
identify
the most effective
and promising interventions.



16


3

RESULTS

3.1

Introduction

The
initial
electronic search produced 12,605 references after duplicates were removed. Two
hundred and
eighty
-
seven references were identified as potentially relevant to the review
s

and 286 references were successfully obtained as full
-
text journal articles.
Of t
hese 286 full
-
text articles,
171

were excluded
. Sixteen of the remaining 1
15

studies focused on
young
people and were included in the youth review.
In addition to these 16 studies
,

a further 10
studies (11 papers) were identified through handsearching, searching of key reviews and
contacting experts. Three of these 10 studies
17
-
19

were identified in one paper by Mercken et
al
20

which included secondary analyses of these three primary studie
s, and these four papers
are classed as three studies. An update of the searches was carried out in January 2013
which included both electronic searching, handsearching and contact with experts, which
identified a further seven relevant studies .

In summa
ry, a total of 33 studies were included in the youth review; of which 31 studies
were population

level polices/interventions and two studies were individual level cessation
support interventions.

Appendix D

contains bibliographic details for all the included youth
studies including details of source.

The details of studies that were excluded at the stage of
screening the full
-
text articles, for the initial electronic search (n=13) and for the updated
electro
nic search (n=7) are listed in Appendix E with reasons for exclusion.

The findings of these 33 included studies are presented by intervention type. A summary of
studies by design and type of intervention are summarised in
Table
2
. Population
-
level
interventions (which aimed

to change social norms, smoking behaviour and/or access to
tobacco
)

included
:

smoking restrictions in
cars,
schools, wor
kplaces and
other public places;

controls on advertising
, promotion and

marketing of tobacco; anti
-
tobacco
mass media
campaigns; increases in price/tax of tobacco products; controls on access to tobacco
products, school
-
based prevention programmes, and multi
ple

policy

interventions.
Individual
-
level cessation support interventions included two interventions using mobile
phone text messaging.


Data extraction tables and quality assessment, grouped by intervention type, can be found in
Appendices F and G
,

respectively. Textual and visual summaries of the data can be found in
Appendices H and I
,

respectively. It should be noted that whilst the equity impact graph
17


(Appendix I) is meant to provide a visual representation of the equity impact of the various
po
pulation
-
level policies/interventions; it should be interpreted in conjunction with the
narrative descriptions of the results.



18


Figure
1

Study selection flow chart



*9 papers assessed in more than 1 review
;
**
1 paper =
secondary analyses of 3 papers, so 4 papers
classed as 3 studies
;
***2 papers assessed in more than 1 review



Electronic search May 2012

Titles and abstracts screened


n = 12,605

excluded from title and
abstract

n = 12,318

Full papers ordered

n = 287

screened

n = 286

INCLUDED

N = 115

EXCLUDED (full text)

n = 171

(13 youth + 34 adult policy +
133 adult cessation)*

youth included

n = 16

youth

handsearching, reviews,
experts

n = 11

update
youth

n = 2

update youth

handsearch, experts

n = 5

total number youth studies

n = 33**

individual
-
level cessation
studies

n = 2

population
-
level studies

n = 31

update electronic search
January 2013

titles and abstracts

n = 1149

update full papers screened

n = 42

update included

n = 16

update excluded

n = 26

(7 youth + 13 adult policy +
8)***

19


Table
2

Summary of studies by design
and
intervention type*

Design c
ode

Intervention type

Smoking restrictions in cars,
schools, workplaces, and other public places

1
.2

Akhtar 2010

1
.1

Galan 2012

1.2

MacKay 2010

1.2

Millett 2013

1
.2

Moore 2011

1.2

Moore 2012

1.1

Nabi
-
Burza 2012

1
.1

Noach 2012

2
.1

Woodruff 2000

Controls on advertising, promotion and marketing of
tobacco

1
.1

Gilpin & Pierce 1997

3.1

Hammond 2011

1
.1

Pucci 1998

Mass media campaigns

1
.2

Vallone 2009

Increases in price/tax of tobacco products

1
.1

Bie
ner 1998

1
.1

Gilpin & Pierce 1997

1
.3

Glied 2002

1
.4

Gruber 2000

1.4

Madden 2007

1
.1

Perretti
-
Watel 2010

Controls on access to tobacco products

1
.3

Kim 2006

1.1

Lipperman
-
Kreda 2012

1
.2

Millett 2011

1
.2

Schneider 2011

1.1

Widome 2012

School
-
based prevention

programmes

3.1

Bacon 2001

3.1

Crone 2003
**

3.1

De Vries 2006
**

3.1

Campbell 2008
**

3.3

Menrath 2012

Multiple policy interventions***

1.2

Helakorpi 2008

1.3

Pabayo 2012

20


1.2

White 2008

Individual cessation support

3.1

Rodgers 2005

3.3

Ybarra 2013

*
Studies can be categorised in more than one intervention type;
**Study identified in Mercken 2012
; *
**Interventions that
have several elements and/or papers that try to assess the relative impact of several policy interventions over a period of
time



21


3.2

Impact of population
-
level policies and interventions on smoking
in
equalities in youth

3.2.1
Smoking restrictions in
cars,
schools, workplaces and other public
places

A total of
nine

studies assessed the socio
-
economic impact of smoking restrictions

in public
places
;
one intervention study
21

five repeat cross
-
sectional studies
22
-
26

and three

single cross
-
sectional studies.
27
-
29

T
hree

studies explored the impact of national comprehensive
smokefree legislation on
primary school children’s

exposure to secondhand smoke

(SHS)
,

one of w
hich was set in Scotland
22

one in Wales
25
and one study pooled data from Scotland,
Wales and Northern Ireland.
26

Two studies examined whether smokefree legislation was
associated with change in hospital admissions for childhood asthma in Scotland
23

and
England.
24

One study examined smoking behaviour in cars with children present, amongst
smoking parents in the US.
27

A further two studies explored

the impact of voluntary
compliance with smoking restrictions
on smoking behaviour
in
secondary school children,
one of which was set in Spain
29

and one in Israel.
28


An

interventio
n study assessed the
impact of an organisational
(workplace)
smokefree ban in 19 year old female US Navy
recruits
,

using a before and after experimental study design.
30

Only the two school
-
based studies of
comprehensive
smokefree legislation
22;25

scored the
maximum according to study design.
All the study samples except two
27;28

were
represe
ntative of the study population.

All

cross
-
sectional studies used credible data
collection methods,
and all
repeat cross
-
sectional studies had
a sufficient number of
participants included in analysis in each wave. The
US
intervention
study
30

had partially
validated
data collection instruments and an acceptable level of attrition for post
-
intervention
data but not at the 3
-
month follow
-
up.

It is reas
onably likely that the observed effects of
smokefree legislation in Scotland
,
Wales
and Northern Ireland;
and the s
mokefree workplace
ban
30

were attributable to the interventions under investigation
.

The comprehensive smokefree legislation studies including
two studies
of hospital
admissions

for asthma are all generalisable on a national level (all UK based).
The Spanish
study
29

results of voluntary compliance
are likely to be gen
eralisable at the regional level.
T
he study population in the Israeli study
28

of voluntary compliance,
was
heterogeneous; with
a broad range of ethnic, religious and socioeconomic subpopulations and is not generalisabl
e
to other WHO European or stage 4 countries.
It was unclear how generalisable the results
22


were from the study of smoking in cars amongst US parents.
27

The workplace study
population was specific to female young US Navy recruits o
nly
30
.

National smokefree policies

Thre
e studies from the changes in child exposure to environmental tobacco smoke (CHETS)
study

were included: CHETS Scotland,
22

CHETS Wales
25

and a CHETS UK study
.
26

Individual data from the Scottish
22

and Welsh
25

studies are described separately and are also
included i
n the pooled analyses of UK data along with data from Northern Ireland
.
26

The
Scottish, Welsh and Northern Irish
stu
dies applied repeat cross
-
sectional class
-
based

surveys
,

in order to explore the impact of smokefree legislation on 11 year old children’s
exposure to
SHS
;

using biochemical measures

(
salivary
cotinine levels)
.

The smokefree
legislation
in Scotland
22

was associated with a decline in cotinine levels
across all socio
-
economic groups.
T
he greatest absolute decline in cotinine levels was among
the lowest
self
-
reported family socioeconomic classification (SEC) and family affluence
scale (FAS)

groups
,

even after adjusting for parental smokers (e.g. 0.10ng/ml in SEC
1 v
s

0.28ng/ml in SEC4).
However
,

a linear regression model suggests that relative inequa
lity
between socio
-
economic groups ha
d

widened; the decline in
SHS exposure
among children
from low
er SES households

was
greater in absolute terms but small
er in relative terms
,

compared with
changes in SHS exposure
among children from higher SES households.

Cotinine levels remain
ed

the highest in children from the lowest SEC/FAS groups.


The likelihood of providing a sample containing an undetectable level of cotinine increased
significa
ntly a
fter
smokefree
legislation in Wales
25

among children from high
SES
households
[relative risk ratio (RRR) = 1.44, 95% CI = 1.04

2.00,

p=0.03] and medium SES
ho
useholds (RRR = 1.66, 95% CI = 1.20

2.30, p<0.01), while exposure among children
from lower SES households remained unchanged (RRR=0.93, 95% CI=0.62
-
1.40, p=0.72).
Parental smoking in the home, car
-
based SHS exposure, and perceived smoking prevalence
were
highest among children from low SES households. Parental smoking in the home and
children’s estimates of adult smoking prevalence declined only among children from higher
SES households.

Children’s estimates of people smoking in the streets outside buildin
gs
declined greatest and approached statistical significance amongst
children

from
h
igh
-
SES
households only
.
25

In
summary, in
Wales
25

post
-
legislation reductions in SHS exposure were limited to children
from higher SES households whose exposure was already significantly lower prior to

23


smokefree
legislation.

Children from lower SES households continued to have high l
evels of
exposure

(though

these had not increased)
, particularly in homes and cars, and to perceive
that smoking is the norm among adults. Therefore the smokefree legislation
was potentially
associated with
increased socioeconomic disparity in terms of SHS

exposure amongst
children.

Average cotinine concentrations among children in the Scottish study were
substantially higher than in the Welsh study, and children’s SHS exposure outside of the
home was perhaps greater in Scotland, with impacts of the smokefr
ee legislation therefore
g
reater overall in Scotland than
in Wales, and distributed a
mong all socio
-
economic groups.

O
ne
UK
study
26

pooled

data from the Scottish, Welsh and N
orthern Irish CH
E
TS studies
.
The pooled data were used
to examine socioeconomic patterning
(using the FAS)
in
children’s SHS exposure
,

and parental restrictions on smoking in private spaces

(cars,
home)
.
Participants were non
-
smokers (self
-
reported
non
-
smo
kers

providing saliva samples
containing

<
15
ng/ml

cotinine) in their final year at 304 primary schools in

Scotland (n
=

111), Wales (n
=

71) and N
orthern
I
reland
(n
=

122).

Multinomial regressions were used to
assess change in SHS exposure as measured by c
otinine levels; and change in home
-
smoking
restrictions. Binary logistic regression models examined car
-
based smoking. The pooled data
was adjusted for country and age, and clustering was accounted for.

The data set comprised
10,
867 children (5347

baselin
e/5520 follow
-
up), average age was 11.2 years. SES varied
significantly between survey years, with affluence being higher at follow
-
up survey.

Percentages of children with undetectable concentrations

of cotinine increased from 31.0%

(n
=

1715) to 41.0% (n
=

2251) following

legislation overall, and from 20.1
%

to 34.2
%
,
44.9
%

to 51.0
%

and 38.6
%

to 42.9% in Scotland, Wales and N
orthern
I
reland
, respectively.

26

Regression analysis indicated that the

relati
ve risk of children’s samples containing no
detectable

cotinine increased significantly following legislation
. However this was accounted
for by decreases in samples containing low levels of cotinine rather than decreases in
samples containing higher level
s of cotinine; and

this was the case

in all three countries and
after adjusting for parental smoking and smoking restriction levels in homes and cars.

26


Children of high SES were significantly more l
ikely to have no detectable cotinine and
significantly less likely to have high levels of cotinine following the
smokefree
legislation
compared to lower SES children
, and
this
remained significant following adjustment for
country, parental smoking and priv
ate smoking restrictions
. The study
26

author’s report that
the gap between low and high SES children appears to have widened following the
24


legislation, in terms of
children with
no detectable cotinine
levels
.
A trend towards widening
inequality was also seen within each individual country for no detectable cotinine levels.

Gradients for higher cotinine levels remain unchanged.

Two studies evaluated the impact of national smokefree legislation on
emergency hospital
admissions for asthma in children aged less than fifteen years: one set in Scotland
23

and one
set in England
.
24

Both study samples

were representative of the general population and
generalisable on a national scale. Both studies
used SES quintiles based on the
Index for
Multiple Deprivation

and both studies applied bi
nomial regression models

to assess hospital
admissions. T
he English study
24

also produced admission r
ate ratios,

which is the ratio of the
actual admission rate in relation to the rate projected by the underlying trend
.


A

Scottish study
23

assessed the impact of
national
smokefree legislation on hospital
admissions for childhood asthma

by linking data from the Scottish Morbidity Record and
death
-
certificate data to
identify all hospital admissions and deaths before arrival at the
hospital that occurred
from January 2000 through October 2009. Before the legislation was
implemented, admis
sions for asthma were increasing at a mean rate of 5.2% per year (95%
confidence interval [CI], 3.9 to 6.6). After implementation of the legislation, there was a
reduction
of 18.2% (95% CI, 14.7 to 21.8; P<0.001)

in the annual rate of
asthma admissions,
re
sulting in a
net reduction in asthma admissions
of
13.0% per year (95% CI, 10.4 to 15.6).

The study accounted for asthma deaths and showed that the decrease in admissions was not
due to an increase in the incidence of deaths before arrival at the hospital.

There were no
significant interactions between hospital admissions for asthma and quintile of S
ES. All SES
subgroups
were
associated with significant reduction in admissions.

An

English
study
24

assessed the impact of national

smokefree legislation on hospital
admissions for childhood asthma, using Hospital Episode Statistics over 8.5 years (April
2002 to

November 2010).
Before the implementation of the legislation, there was a mean
increase in

the admission rate for asthma of 2.2%

per year (adjusted rate ratio 1.02; 95%
CI
:
1.02

1.03). After implementation of the legislation, there wa
s a significant immed
iate
reduction in the admission rate of
8.9% (adjusted rate ratio 0.91; 95% CI: 0.89

0.9
3) and a
reduction in time trend of
3.4% per year (adjusted rate ratio 0.97; 95% CI: 0.96

0.98).

Overall, the legislation was associated with a net 12.3% reduction of h
ospital admissions for
childhood asthma in the first year. This change was equivalent to 6802 fewer hospital
admissions in the first 3 years after implementation.

The results were very similar when

25


based on admissions

data

alone
,
as

there
were
few

recorded
deaths

prior to admission
.

Reductions in asthma admissions did not differ by SES.

Both studies
23;24

were
suffici
ently similar to enable comparison and show that both the
English and Scottish smokefree legislation were associated with significant reductions in
admissions for asthma across
all SES subgroups

i.e.

a neutral equity impact
.
The relative
rate of admission
s before the legislation was higher in Scotland compared to England, and
relative
reductions in hospital admissions
after the legislation
were higher in
Scotland
compared with England,
however the net overall reduction
in hospital admissions
was
similar in

both studies
(12
-
13%).

Neither study determined the extent to which the observed reduction in asthma was due to
reduced exposure to SHS by setting (public places, home, car) or reduction in smoking
among children. The impact on results of changes

in the
treatment of asthma and diagnostic
coding of asthma c
annot
be
rule
d

out
. However both studies assessed asthma which required
hospitalisation (i.e. severe asthma)
.


Smokefree car

policies

Pooled data from the CHETS
26

study showed that in the UK as a whole and also within
England, Northern Ireland and Wales,
as SES increased, the likelihood of partial or no home
smoking restrictions (rather than full smoking restrictions) decreased significantly, whilst

the
odds of smoking being allowed inside the family car also decreased significantly. These
trends remained after adjustment for parental smoking and there was no change in inequality
following legislation

i.e.

a neutral equity impact
.

A US study
27

determined the prevalence of parents smoking in their cars with children
present and how often paediatric health care providers advised parents to have smoke
-
free
cars. The study used baseline data from 10 control sites (in 8 US state
s) 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.

26


Parents who smoked were asked about smoking behaviours in their car and
receipt of smoke
-
free car advice at the visit. Parents were considered to have a “strictly enforced smoke
-
free
car policy” if they reported having a smoke
-
free car policy and nobody had smoked in their
car within the past 3 months. The measure of SES used
was level of education (high school
or less versus some college or college graduates). Analyses were limited to parents who
smoked and who reported having a car that they owned or travelled in frequently, it was
unclear how representative this study sample

was of the SES of the general population.

Twenty
-
nine percent of 795 parents reported a smokefree car policy and 48% reported that
smoking occurred with children present in the car. Fourteen percent of smoking parents
reported being asked if they had a sm
oke
-
free car, and 12% reported being advised to have a
smoke
-
free car policy by a paediatric health care provider. Of those who smoked with
children present in the car, only 5% were counselled about having a smoke
-
free car.

No significant association was
found between parents education level and having a strictly
enforced smokefree car policy. However, parents of children aged less than one year were
more likely to have strict smoke
-
free car policies if they were college educated (OR:2.42;
95% CI: 1.21 to
4.83, p = 0.013). Strict smoke
-
free car policies were more common when
parents were both light smokers (smoked 10 cigarettes or less per day) and college educated
(OR: 2.88; 95% CI: 1.24 to 6.66, p = 0.013).

V
oluntary compliance

with smoking restrictions
in schools

Two cross
-
sectional studies explored the impact of voluntary compliance with smoking
restrictions on smoking behaviour in secondary school children, one of which was set in
Spain
29

and one in Israel.
28

The smoking outcomes we
re not
biochemically

validated and
we
re based on self
-
report.


In Madrid s
moking has been banned in schools since August 2002 how
ever at the time of
this survey
29

a
mong smokers

aged 15 to 16 years
, 50.6% had smoked on school premises
during the last thirty days with significant variability (0% to 100%) between schools
. A
lower probability of smoking on school premises was found among adolescents whose
fathers had a university edu
cation (
OR 0.43;

95% CI: 0.19 to 0.96) or among those who did
not know the level of s
tudies of their father (OR 0.39;

95% CI: 0.16 to 0.94) compared with
those with fathers who
had a very low level of education
al attainment.
A lower probability of
smoking
on school premises was found for state subsidized private schools (OR 0.2
0; 95%
27


CI: 0.11 to 0.35) and non
-
subsidized private schools (OR 0.30; 95% CI: 0.14 to 0.62) when
compared with that for public schools.

Employment status of either parent, educational

level
of the mother, SES of the school census tract, written reference to a smoking control policy
and educational activities about smoking prevention were not significantly associated with
smoking on school premises
among student smokers
.

In Israel
28

there was no comprehensive smokefree ban at
the time of the survey and

most
Israeli adolescents (average age 15 years) were exposed to SHS (total: 85.6%; home: 40%;
school: 31.4%; entertainment: 73.3%; other: 16.3%). Parental education was not a significant
determinant of smoking in school

but corre
lates of exposure at school differed from those at
home
. Adolescents whose fathers had less than 12 years of education were more exposed
to
SHS
at home,
than were teenagers whose fathers had a degree from a university or college
(OR = 1.48
; CI: 1.09 to 1.9
9,

p =
0
.0111). Adolescents with less
-
educated mothers were
more exposed
to SHS
at home
than teenagers with mothers with degrees from a university
or
college (OR = 1.39; CI: 1.02 to 1.90,

p =
0
.0366). The high levels of SHS exposure among
Israeli adolescen
ts were characterized by different patterns of exposure among different
population
sub
groups.
Israel is a heterogeneous country;

with a broad range of ethnic,
religious and socioeconomic populations and the results are not generalisable to other WHO
Europe
an or stage 4 countries.

Workplace smokefree policies

One intervention study assessed the impact of an organisational
(workplace)
smokefree ban

(24
-
hours, 8
-
weeks)

in 19 year old female US Navy recruits, using a before and after
experimental study design.
30

Among the 4393 recruits who provided

entry

(
before
)

and
graduation

(
after
)

survey data, 41.4% (n = 1819) reported any smoking in the 30 days
before

entering compared with 25% that reported being a smoker at graduation

(after)
, which was a
significant reduction. Slightly over two
-
thirds (n =
724) of “smoke
rs” who responded to the
follow
-
up survey had resumed smoking three months
after

graduation, and 32% (n = 340)
reported not smoking. Among past month smokers at entry

(
before
)
, the relapse

rate at the
three month follow
-
up
after

graduation
wa
s 81%. Daily smokers at entry
(
before
)
had the
highest relapse rate (89%)

at the three month follow
-
up
after

graduation
. The study did not
aim to assess differential impact by SES but reported that education did not significantly
predict smoking relapse.

I
t wa
s not reported whether
there was a difference by SES in
change over time
.


28


A response bias is present in this study; there was a low response rate
(39%)
at the 3
-
month
follow
-
up,
and
non
-
respondents had a slightly higher past 30 day smoking rate at

baseline
than did respondents. In addition, the d
efinition of ‘smoker’ differed at graduation (po
st 8
weeks) from baseline and 3
-
month follow
-
up.
The g
roup of smokers assessed for relapse was
broadly defined and included daily smokers, occasional smokers,

experimenters, or former
smokers.

As well as these quality
-
related issues, the study
only included female recruits and
results may not be generalisable to a ci
vilian population or setting
.

Summary

The evidence relating to smokefree restrictions is limited

to
eight

cross
-
sectional studies and
an intervention study of a workplace 24
-
hour 8
-
week smoking ban.

National comprehensive smokefree restrictions are associated with declines in SHS exposure
in
primary
school childre
n but the
equity
effect may vary acc
ording to how exposure is
measured (absolute levels or relative levels)
,
on the pre
-
ban level of exposure and the
balance between sources of exposure i.e. public places versus home.

Prior to the CHETS
stud
ies
, scant attention has been paid to whether
adoption of private smoking restrictions
following smokefree legislation has been patterned by SES.

Pooled data from Scotland, Wal
es and Northern Ireland following

national smokefree
legislation showed that declines in exposure occurred predominantly among

children with
low exposure before legislation, and from more affluent families
,

leading to increased
socioeconomic disparity

(negative equity impact)
. Substantial socioeconomic gradients in
proportions of children with higher SHS exposure levels remained
unchanged.
Children from
lower SES households continued to perceive that smoking
is the norm among adults whereas
smoking as a perceived norm declined amongst high
-
SES children.

Pooled data from Scotland, Wal
es and Northern Ireland following

national smoke
free
legislation showed that
there was no change in inequality following legislation.
A
s SES
increased, the likelihood of partial or no home smoking restrictions (rather than full smoking
restrictions) decreased significantly, whilst the odds of smoking be
ing allowed inside the
family car also decreased significantly.
Only one US
study
was included,
of parental
smoking behaviour in cars it was found that parent’s education level interacted with a child’s
age and the number of cigarettes smoked per day, both

of which were significant predictors
of car smoking policy. Parents with higher SES that were light smokers were more likely to
29


have a strict no smoking car policy and higher SES parents with children less than one year
were also more likely to have a sm
okefree car policy.

English
and Scottish
national smokefree legislation was associated with a significant
reduction in childhood asthma admissions which did not differ by SES

(neutral equity
impact)
.

When reviewing whether students comply with smoking r
estrictions in secondary schools
where there is no enforced and comprehensive smokefree ban, it is apparent that
parental
education may influence smoking behaviour of adolescents and smoking behaviour amongst
adolescents is also influence
d

by the setting (
home/school). Two school
-
based studies in two
very different countries showed co
nflicting results. A

study in Israel
where there was no
comprehensive smokefree ban
showed
high levels of SHS exposure among Israeli
adolescents

which were characterized by different patterns of exposure among different
religious groups; however
parental education was not a significant determinant of smoking
in schools
.
Second
-
hand smoke
exposure
from
outside the home

and school settings was
sizea
ble and overall SHS exposure
and SHS exposure at home
was greater among

low
er SES
adolescents
.
In
a study in Spain
where there
were

school smoking bans but variable
enforcement; adolescents whose fathers had a lower level of educational attainment were
mor
e likely to smoke on school premises.

A 24
-
hour 8
-
week
workplace
ban
in the US Navy
did reduce the proportion of women
smoking
immediately

post
-
ban but
most had
relapse
d

by 3
-
month follow
-
up. Education did
not significantly predict smoking relapse however

the response rate to the follow
-
up was low
and non
-
respondents

were more likely to be smoking.

3.2.1

Controls on advertising, promotion and marketing of tobacco

Three very different
US
studies assessed the equity impact of controls on the advertising,
promotion

and marketing of tobacco products

including
;

a retrospective survey
31

of the
impact on smoking initiation of cigarette prices and tobacco industry marketing budgets
conducted in the US in 1993 of nearly 141,00 respondents aged 17 to 38 years that would
have been

aged between 14 and 21 years old between 1979 and 1989
, an RCT
32

of a short
online survey of brand appeal of cigarette packaging, and an observational field study of
advertising density with school ‘buffer zones’.
33

The RCT consisted of a convenience
internet sample and it was not clear if it was
representative of the study population
. In
addition there were
some significant differences among the women at baseline between
30


treatment groups whic
h may have affected the results: education varied by condition, with
the highest level of education in the standard
pack
condition, and number of cigarettes
smoked
per day was significantly higher in the plain
pack
condition compared with the
standard
pack

condition among current smokers.
A
ll
three
studies used credible data
collection methods. It is reasonably likely that the observed effects of
cigarette packaging
were attributable to the intervention under investigation

and that these results are likely

to be
generalisable at a national level
.
The observational field study of advertising density with
school buffer zones may only be generalisable at the local level as the study population were
limited to neighbourhoo
ds in Boston, Massachusetts, US and no

details of the 6 Boston
neighbourhoods were provided.

One retrospective survey
31

conducted in the US in 1993 of nearly 141,00 respondents aged
17 to 38 years that would have been aged between 14 and 21 years old between 1979 and
1989 examined trends in smokin
g initiation by cigarette prices and tobacco industry
marketing budget.
Adolescent initiation rates decreased from 1979 to 1984 but increased
thereafter.
Initiation rates were highest among high school dropouts and lowest amongst
those who eventually atten
ded college. In 1988
the
initiation rate was 9.9% for those who
did not graduate from high school, 6.9% for high
-
school graduates reporting no college and

3.7% for those reporting at least some college

education
. The
equity
results from the study
can only
be tentative because
the study does not directly assess the effect of changes in the
tobacco marketing budget or cigarette prices on smoking initiation rates by education level.
The study simply highlights that cigarette prices and tobacco marketing budget

increased
during this decade as did smoking initi
ation rates amongst adolescents, and that marketing
expenditure may be associated with an increase in smoking initiation especially in young
people with lower levels of education.

A recent RCT of a short on
line survey intervention
32

ex
amined brand appeal of cigarette
packaging amongst women aged 18 to 19 years in the

US. The convenience sample was

randomised to four experimental conditions which viewed eight
cigarette

packages one
at
a
time displayed in random order and according to the

four experimental conditions: (1)
female
-
oriented packages (standard condition); (2) female
-
oriented packages with brand
imagery, including colours and graphics, but with descriptors (
e.g.

slims) removed; (3)
female
-
oriented packages without brand imagery

and descriptors (i.e., plain packages); and
(4) popular U.S. brands of “ regular ” or non


female
-

oriented packages.


31


Women in the high income and high education categories endorsed a greater number of
positive smoker traits (female/male, glamorous/not
glamorous, cool/not cool, popular/not
popular, attractive/unattractive, slim/overweight, and sophisticated/not sophisticated) than
those in the low income and low education categories. High

income respondents were more
likely to endorse smoking and weight
control beliefs compared with respondents reporting
low (OR = 1.70, 95% CI = 1.12


2.60) and medium income
(OR

= 1.73, 95% CI = 1.09


2.73) and those who did not state their income
(OR

= 2.17, 95% CI = 1.29


3.65).
The
reactions to and perceptions of the different types of packs was the same by SES for nearly
all the measures.
No significant differences in pack selection were observed for smoking
status, age, income, education, ethnicity, or weight concerns.

An obser
vation field study
33

assessed
youth exposure to
stationary outdoor
tobacco
advertising density within FDA 1,000 foot buffer zones around
schools in

6 Boston
neigh
bourhoods

in the US. The overall advertising density for schools in all neighbourhoods
combined was higher for middle (10.1) and high schools (9.9) than for elementary schools
(6.3). The majority of outdoor tobacco advertising was in the neighbourhoods wit
h the
lowest median household incomes. The study

probably underestimated

advertising density
because it does not include point
-
of
-
purchase advertising, advertising inside stores that is
seen from the street, or a
dvertising on taxis and buses.

Summary

Thre
e very different US
-
based studies assessed the equity impact of controls on the
advertising, promotion and marketing of tobacco products.

One study showed that i
nitiation rates
of smoking
amongst adolescents varied

by level of
education
; initiation rates
were highest amongst high
-
school dropouts and lowest amongst
those who eventually attended college
.
Marketing expenditure may be associated with an
increase in smoking initiation especially in young people with lower levels of education.

Very tentatively,
controlling the promotion of cigarettes through plain packaging might have
a
positive effect on all
young
women and have a
neutral equity effect for
young
women

because reactions to/perceptions

of different types of packs were the same regardless of
SES
fo
r nearly all the measures
.


32


Despite the
FDA buffer zone

policy
,
one study showed that tobacco advertising is targeted at
adolescents of low SES inside school buffer zones, particularly middle and high school
adolescents, and this has the potential to incre
ase inequality in smoking behaviour amongst
youth.
Banning all outdoor tobacco advertising would reduce exposure particularly in
children of lower SES.

3.2.2

Mass media campaigns

One
telephone survey
34

evaluated the impact of the
US
truth® campaign on awareness and
receptivity among youth aged 12 to 17 years.
The truth® campaign is a branded counter
tobacco
marketing campaign designed to prevent smoking among at
-
risk youth, primarily
through edgy television advertisements with an anti
-
tobacco industry theme.
Seven waves of
Legacy Media Tracking Survey data were collected from September 2000 through to
January 2004.
It was unclear how representative the study sample was of the study
population because response rates declined over the se
ven waves of data collection, from
60% to 30
%
.

Youth who lived in zip codes in which the median household income was less than or equal
to US$ 35,000 had a lower level of confirmed awareness
of the campaign
than respondents
in each of the other income cate
gories (p< 0.05). There were no statistically significant
differences in confirmed awareness by median level of education, though there was a pattern
in which the proportion of confirmed awareness increased with education.
T
here were no
differences in rece
ptivity by median household income or median household education,
though there was a pattern of increasing receptivity with greater income and education
.

During the campaign there was a gradual shift towards cable TV ownership and e
ducation is
positively a
ss
ociated with cable TV ownership.

H
owever the authors report that SES
differences were concentrated in the early years of the campaign when
it was aired mainly
through network
TV.

The study controlled for year of survey
administration

and the effect of
th
e intervention over the seven waves of survey data
. It is not reported w
hether
the effect of
the intervention
differed by SES over time.

Summary

This one study

of a relatively large, lengthy and
well
-
funded
anti
-
tobacco mass media
campaign,

using repeat cross
-
sectional data
over four years
,

showed that
youth who lived in
zip codes in which the median household income was less than or equal to US$ 35,000 had a
lower level of confirmed awareness than respondents in each of the other income cat
egories.
33


Zip code level median household
education
was not associated with confirmed awareness
and there were no differences in receptivity by zip code level income or education.
The
equity impact of
the mass media campaign
is unclear
as the effect on camp
aign awareness
varied according to the SES variable that was measured (income/education) and the equity
impact in terms of receptivity appeared neutral.

3.2.3

Increases in price/tax of tobacco products

Six

studies evaluated

the equity impact of
increases
in the
price or tax of cigarettes
, the
majority of which we
re US
-
based studies using retrospective survey data.

Two studies
35;36

we
re econometric studies (report price elasticities),

one of which used both longitudinal and
cross
-
sectional data
.
35

One study used
retrospective cohort data
37

and the
remaining

three
studies were
single

cross
-
sectional studies.
31;38;39

Four of the study samples

were
representative of the study populations and for
two

studies
it was unclear if
the samples were
representative.
35;37

For three

studies it was unclear if credible methods of data collection had
been used, due to lack of reported information in one case
38

and unpublished data in the
other

two studies
.
37;39

Two studies
38;39

were likely to be generalisable

at the regional level
and two

studies
31;35;36

at a national level.


A retrospective survey
38

examined smokers aged 12 to 17 years perceptions of the impact of
statewide tobacco taxes in Mas
sachusetts, USA.
Teenage smokers from low

income
households were much more likely than more affluent teenagers to
report
cut
ting

the
costs of
their smoking (by cutting down the amount smoked or, less often, by switching to cheaper
brands) in response to
the price increase, rather than do nothing (OR 7.57; 95%CI: 1.55 to
36.98) or cut
ting

costs rather than consider quitting (OR 14.72; 95%CI: 2.55 to 84.95).
Household income was unrelated to the choice between considering quitting and doing
nothing (OR 0.51
; 95% CI: 0.13 to 2.77).

Young low

income smokers were not more likely
than wealthier teenagers to consider quitting.
There appeared to be a positive equity impact
on smoking less and a neutral equity impact on quitting behaviour of statewide tobacco tax
i
ncreases.
It should be noted that 53% of the teenagers who continued to smoke denied
having had any of the 3 potential reactions to price increase and so it is possible that the
study failed to measure an important variable.