34


One

US

retrospective survey
31

examined trend
s in smoking initiation by cigarette prices and
tobacco industry marketing budget
;

results are reported in
section
3.2.1
.

Initiation rates were
highest among high school dropouts and lowest amongst those who eventually attended
college. The study highlights that cigarette prices and tobacco marketing budget increased
during this decade as did smoking initi
ation rates amongst

adolescents, and that
price
increases did not reduce smoking initiation.

One US
econometric
study
35

tested the assumption that policies targeting youth to reduce
smoking initiation will reduce lifetime smoking propensities.
Estimates of the effect of
current taxes (taxes in the year of interview) on current
adult

smoking measured in 1984
(age
d 19 to 28), 1992 (aged 27 to 35), and 1994 (aged 29 to 37)
revealed that
the age
coefficients were positive (measured in 1979)
showing that
there was
a positive secular trend
in youth smoking. Youth from higher income families were less likely to smoke, w
hereas the
results were inconsistent for level of education between different types of analyses (probit
marginal effects and linear regression fixed effects). Participation elasticities for the three tax
current tax variables (1984, 1992, and 1994) using p
robit marginal effects or linear
regression fixed effects were

0.1 and

0.09, respectively.

The study

estimated the effect of cigarette taxes at age 14 years

(in 1979) on future overall
smoking behaviour, quitting and initiation using prospective longitud
inal cohort data with
cross
-
sectional analyses. Cigarette t
ax at age 14 had
the most effect on low income people at
ages 19
-
28 for
current

smoking but not late initiation or quitting according to longitudinal
data.
The effect of cigarette tax at age 14 on
subsequent

smoking
(
at follow
-
up in 1992 and
1994
)

was not significant.

Elasticities declined over time for low income people indicating
that by age 39 the effect of taxes at age 14 had largely disappeared. Low income (< $12,000
median

in 1979) elasticity
was
-
0.65, p<0.10 (at age 14),
-
0.33 (at age 24),
-
0.01 (at age 34),
and 0.15 (at age 39).

Cigarette tax increases at age 14 reduced smoking and had a positive
equity effect

on young people in their 20’s.

I
t should be noted that i
n

some models

(i.e. effec
t of cigarette tax at age 14 on current
smoking)
, results presented

for
the
low income
subgroup
include
a
control for ‘current’ tax
(taxes in the year of interview)
,

whereas
o
ther models (i.e. effect of cigarette t
ax at age 14 on
late initiation, quitting
)

did not control for current tax in low
-
income subgroup.

It is difficult
to see how an effect of tax at age 14 could be determined if
there is no adjustment for
tax at
other subsequent time points.

35


A
US
econometric analysis
36

using repeated cross
-
sectional data, evaluated the impact of
prices
,

clean air regulations and youth access restrictions
on youth (13 to 18 years) smoking
in the 1990’s.

Price was the only
significant determinant of smokin
g.
Price was the most
important determinant of smoking by 16
-
18 year

old
s but not for younger teenagers.
Sensitivity to price suggested cross
-
elasticity between price and income: f
or
1
6 to 18 year

olds
: s
ensitivity

to prices increased

for teenagers with le
ss educated parents,
however
sensitivity to smoking intensity increased for those with more educated parents.

For 16 to 18
year

old
s, the elasti
city of participation was
-
4.39 (
p<0.05
)

for those whose parents were
high school dropouts or graduates and
-
0.24 for parents with some college education. For
smoking intensity this trend was reversed with elasticities of
-
0.40 for high school and
-
2.39
(
p<0.05
)

for college education. There was
no pattern for younger teenagers (<16 years),
although participation elasticity was positive and statistically significant for hig
h school
educated parents (2.72,
p<0.05
).

A survey
39

conducted between 2005 and 2006 on a random sample of 2455 university
students in South
-
Eastern France, investigated young smokers


(mean age 19.5 years)
retrospectiv
e reactions to an increase in cigarette prices. Daily smokers with low

educated
parents were less likely to
report
react
ing

to the price increase, daily smokers who had at
least one parent that completed high school were more prone to
report
react
ing

to hi
gher
cigarette price (OR 2.5; 95% CI: 1.6 to 4.0 for cheaper smoking versus no reaction; and OR
2.1; 95% CI: 1.4 to 3.3 for smoking less versus no reaction; in multivariate analysis, p <
0.001 and p< 0.01, respectively). Students who reported difficulties
in financing their
studies
were significantly more likely to purchase cheaper cigarettes (OR 1.9; 95% CI: 1.0 to 3.7; p<
0.1).

It should be noted that overall, 32%
said that they
did not react to price increase
, the
survey was regional rather than national

and the reactions to price increase are only relevant
to daily smokers who did not quit, all of which may which may limit study generalisability.

W
e can’t tell whether these reactions
to a price increase
impacted on quitting but
there
appeared

to be a negative equity impact on smoking less.

An Irish study
37

used retrospective cohort data
to investigate the role of tobacco taxes from
1960 to 1998, in starting and qu
itting smoking

and how this differed

by level of education.
The data was derived from a single cross
-
sectional survey on women’s knowledge,
understanding and awareness of lifetim
e health needs, but mainly focussed on hormone
replacement therapy as part of an unpublished MA thesis at the University College Dublin.
The sample consisted of just over 700 women
,

mean age
was
35 years and mean age started
36


smoking was 19 years.

The SES m
easure used wa
s education level
(‘primary cert’/’junior
cert’/’leaving cert’/’third level’
)
.

Higher
cigarette
tax levels were associated with later initiation

of smoking which
differed by
education level.
Taxes had the greatest positive effect in terms of
delaying smoking initiation
for women with intermediate level education

and weakest effect among
women
with the
lowest education. The results were tentative because of the potential for recall bias (goi
ng
back 40 years in some cases
) and the results
are sp
ecific to
a sample of
Irish
women aged 48

years or younger
.

The measure of education level used in this study may not be
generalisable across time and to other countries.
T
he SES
subgroups were relatively small,
and

during the study period
cigarette
tax was relatively low and there was increasing
awareness of the harms of smoking. Therefore study findings cannot be directly attributed to
the effects of
increasing cigarette
tax
.


It should be noted that whilst data has been extracted for this review on

smoking initiation
(because
this is the outcome of relevance for youth), the study also reported smoking
cessation and showed
inconsistent equity impact results for how tax effect differed by
education level, depending on the outcome measure (initiation a
nd cessation).

Cigarette
taxes had the greatest positive effect in terms of delaying smoking initiation for women with
intermediate level education and the weakest effect among women with the lowest
education.
However cigarette t
axes

had the strongest effe
ct on cessation among women with
the lowest education, and an equal impact on those with other levels of education.

Summary

The m
ajority of evidence is from
the
US,
and
suggest
s

there is variation in the
evidence of
the
equity impact of increases in cigarette tax or price on
youth
smoking behaviour

and
variation in smoking behaviour amongst youth of different ages

and different SES groups
.

Two retrospective surveys showed contrasting results; o
ne survey showed that low

i
ncome
teenagers were more likely than more affluent teens to cut costs by cutting down smoking or
(less often) by switching to cheaper brands but were not more likely than more affluent
teenagers to consider quitting. However, only 53% of the teenagers who

continued to smoke
denied having had any of the 3 potential reactions to
the
price increase.

A regional survey of
French
u
niversity student smokers showed that students with a lower SES were less likely to
37


have reacted to the cigarette price increase whic
h included smoking less, however 32% of
students reported that they did not react to the price increase.


An Irish study

showed
that cigarette taxes were
associated with later s
moking initiation
in
women
with intermediate education but not for
women
with o
nly a primary education.
37

Two econometric studies showed contrasting results; one study showed t
hat cigarette tax at
age 14 had a statistically significant negative effect on current smoking for low income
people but by age 39 years, the effect of taxes at age 14 had largely disappeared. In the other
study, the equity impact varied according to the a
ge of the teenagers and there was no pattern
for younger teenagers. For older teenagers: sensitivity to prices increased for teenagers with
less

educated parents,
and
sensitivity to smoking intensity increased for those teenagers with
more

educated parents
.

It does not appear that low income youth are consistently more responsive to tax/price
increases than high income youth groups: youth of lower SES are not more likely to stop
smoking when cigarette prices/taxes increase.

3.2.4

Controls on access to tobacco
products

A total of five

studies assessed the socio
-
economic impact of controls
on access to tobacco
products.

Three

studies assessed the impact of legislation on age of sale of cigarettes. Two
single cross
-
sectional studies
40;41

examined the impact of age
-
of
-
sale

laws in the US on
retailer comp
liance and whether the impact differed by SES. One repeat cross
-
sectional
study
examined the impact of
UK
legislation
which increased the minimum age for the legal
purchase of cigarettes
,

and

was
set in secondary schools in England
.
42

A German study

used

observational field data
of new electronic locking devices on cigarette vending machines to
prevent underage purchasing of cigarettes in
Cologne
43
. A

prospective cohort study
based in
the US, examined whether youn
g, especially low SES females, are influenced by tobacco
control policies in terms of smoking initiation and transition.
44


An English study examined
whether there was
any differential impact of
UK
legislation
whic
h increased the minimum age for the legal purchase of cigarettes from 16 years to 18
years and which came into force in October 2007.
42

The SES variable employed was
eligibility for free school meals
(FSM)
which is assessed on the bas
is of parental
employment status and income levels.

Annual survey data was collected
before

and after the
38


legislation; from 2003 to 2008. There were b
aseline differences in age, gender and ethnicity
but
these differences were
controlled

for in analyses.


I
ncreasing the minimum age for purchase was associated with a significant reduction in
regular smoking
among youth
aged between 11 and 15 years
(adjusted OR 0.67; 95% CI
0.55 to 0.81
, p
=0.0005).
This effect was not significantly different in pupils eligible for FSM
compared with those
who
were not
eligible
(adjusted OR 1.29; 95% CI 0.95 to 1.76, p=0.10
for interaction term).
Regular smoking was not significantly different in pupils eligible for
FS
M compared with those that were not (adjusted OR 1.29; 95% CI 0.95 to 1.76, p=0.10).

The p
ercentage of regular

smokers who usually bought cigarettes from a vending machine
decreased significantly in the non
-
FSM but not in the FSM group.
The p
ercentage of
regular
smokers who usually bought cigarettes from friends and relatives or from other people
increased significantly in the non
-
FSM but not the FSM group after the introduction of age
res
triction.
Regular smokers eligible for FSM were

significantly more l
ikely to be given
cigarettes by their parents in 2006 (p<0.001) but this was no longer the case in 2008
(p=0.42).
The p
ercentage of pupils who stated that they found it difficult to buy cigarettes
from a shop did not increase in those eligible for FSM (25.
2% to 33.3%; p=0.21) but did
increase significantly in others (21.2% to 36.9%; p<0.01) between 2006 and 2008.
The
p
ercentage of regular smokers who were successful in buying cigarettes from a shop during
their latest attempt decreased significantly in the
non
-
FSM but not the FSM group between
2006 and 2008. No differences in ease of purchase were found between pupils eligible for
FSM and those not before or after the legislation (2006: p=0.34, 2008: p=0.55).

It should be noted that a
lthough the response rat
e for schools was only 58% in 2008, the
sampling frame ensured that schools participating in the survey closely reflect the
composition of schools in England generally.


However, the national
s
mokefree
legislation

and alcohol restrictions
were
also introdu
ced during this time which may confound these
results
.

The German Sources of Tobacco for Pupils (STOP) study
43

compared the number of
vending machines and other commercial sources before and after new legislation which
involved electronic

locking devices on vending machines to prevent underage (<16 years)
purchasing of cigarettes in Germany. Three geocoders made an inventory of commercial
cigarette sources in 2005
,

2007 and 2009 and mapped using Geographic Information System
to produce a d
ensity of sources before and after the legislation.

Cologne was selected as the
39


area of study because it had existing sociogeographical data
,

however the authors report data
to show that Cologne data appears comparable with Germany as a whole.

The number
of commercial sources declined by 12% from 2005 to 2009
,

resulting mainly
from
the
removal of 44% of outdoor cigarette vending machines (indoor machines decreased
by 5%). The lower the income
level in a district, the higher the availability of cigarettes
(
Pearson’s r = .595; p = .009).
Convenience cigarette sources reduced by only 0.9%,
and
supermarket and

drug stores increased by only
2.6%.
The study did not report whether the
decline
in
commercial source

by retail category (outdoor and indoor vending mach
ines,
convenience stores, supermarkets and drug stores) varied by the income level of districts.
The same occurred for the alternative indicators such as youth unemployment (Pearson’s r =
.548; p = .019), the percentage of

people receiving social welfare (
Pearson’s r = .485; p =
.041), and the percentage of pupils attending low
-
qualifying schools (Pearson’s r = .473; p =
.048).

In 2005 as well as in 2009, there were significantly fewer commercial cigarette sources in
districts with above

average SES than in

districts with below

average SES. This can be seen
in terms of absolute as well as relative numbers. The density of commercial cigarette sources
in 2005 in districts with above

average SES was 3.20 per 1,000 inhabitants and 4.84 per
1,000 inhabitants in t
he districts with below

average SES. In 2009, the numbers were 2.63
per 1,000 inhabitants and 4.44 per 1,000 inhabitants, respectively. The differences between
socially advantaged and disadvantaged districts appeared to be significant in both years
(2005:
t(15) = 9.017, p < .001 and 2009: t(17) = 6.915, p < .001).

This study showed that
electronic locking devices on vending machines to prevent underage (<16 years) purc
hasing
of cigarettes in Germany was
not associated with a decrease in inequalities of acce
ss to
cigarettes, for youth.

A US study
41

evaluated the relationship of point
-
of
-
sale tobacco advertising and
neighbourhood characteristics (including 150% below the poverty level) to
underage sales of
tobacco. Study authors used three data sources: observations of the advertising environment
in stores; records of
age
-
of
-
sale tobacco checks

where an undercover minor working with
law enforcement attempted to purchase tobacco; and demogra
phic data from the Year 2000
U.S. census. Analyses w
ere

conducted on 467 of 655 licensed tobacco vendors in Minnesota,
USA. Compliance failure was defined as the sale of tobacco to a youth, regardless of
whether the store clerk examined the minor’s ID.

40


The

study did not find a significant association between store advertising characteristics or
neighbourhood
poverty
level
and stores’ compliance check failure. Of a total of 467 stores,
48 failed the compliance check. Tobacco shops were most likely to fail co
mpliance checks
(44%) and supermarkets were least likely to fail (3%). The poverty
level
of stores ‘block
group’ was not associated with compliance failure. Stores in ‘block groups’ with a greater
percentage of people living in poverty were not more likel
y to fail the
compliance

check.

The study sample was representative and the results are generalisable at a regional level.
Only vendors with a current license can sell tobacco in state of Minnesota but this is not the
case across all US states.
Also

stor
es who repeatedly violate youth access laws have their
license rescinded. The study authors report that compliance checks may not be a very valid
measure of commercial tobacco accessibility for minors.

Another US study
40

examined contextual
,

community and retail characteri
stics associated
with youth access to tobacco through commercial sources. Data sources were access surveys
carried out by four buyers who were over 18 years of age (mean age 19 years) but who were
judged to appear younger by
an

independent panel.

Purchase
attempts were made at 997
tobacco outlets in 50 mid
-
sized California cities by a team of two buyers. At each outlet a
single buyer attempted to purchase a pack of

Marlboro or Newport cigarettes (
the most
popular cigarette brands among high school
-
aged stud
ents
)
. If asked about their
age

they
stated that they were over 18 years old, and if asked for an age ID they indicated they had
none. If a sale was refused, the buyers left without attempting to pressure the clerk.
The main
outcome measure was retailer
co
mpliance

with underage tobacco sales laws.

Overall
,

the
rate of retailer non
-
compliance with underage tobacco sales laws in the 997
selected outlets was 14.3%. Buyer’s actual age,
being
a male clerk and asking young buyers
about their age were
each positiv
ely associated with
successful cigarette purchases.
Buyer’s
actual age and minimum age signs increased

the likelihood that clerks

request
ed

identification (ID).

A

greater percentage of residents
(within each city)
with at least a college
degree was
associated with increased likelihood of non
-
compliance with underage tobacco
sales laws.

A
lower percentage of residents with at least a college degree was associated with
retailers asking for an ID.

H
igher cigarette prices of Marlboro but not Newport wer
e
associated with higher median household income.

41


Although the study authors state that t
here were no significant differences between the
sampled and the un
-
sampled cities in relation to population size, ethnic diversity, household
size and median househol
d incomes
, there wa
s no data
reported
to clarify the
representativeness of the study sample and therefore the generalisability of the study results
.

A
US
national longitudinal study of adolescent health (Add Health
)

was a school based
survey of the health
related behaviours of adolescents using follow
-
up in
-
home surveys.
44

‘Add Health’ used
state

level tobacco policy
on age of sale
scores developed by the US
National Cancer Institute, evaluating 9 items for each sta
te each year (statewide
enforcement, random inspections, graduated penalties, photo identification, free distribution,
minimum age, packaging, vending machines, and clerk intervention).

The analyses
were
restricted to female adolescents, and showed that s
tronger state

level
tobacco policies were associated with lower likelihood of smoking initiation and adverse
transition among low SES women, although the effect sizes were small. The positive policy
effects for initiation were strongest for low SES females
, whose odds ratio was 0.95 (0.98 for
middle SES, 1.00 for high SES). For initiation, school level smoking rates did not vary
substantially across low, middle, and high SES groups (OR=1.01, 0.99 and 1.00,
respectively. For statewide enforcement, the odds r
atios of initiation were significantly lower
for the low (0.89) and middle (0.91) SES female groups; on the other hand, the policy had no
effect on the high SES female group (OR=1.00). For random inspections the odds ratios of
initiation were significantly

lower for low (0.88) and middle (0.90) SES female groups.
Photo identification had a significant positive effect on the low SES female group
(OR=0.85), but not on the middle SES female group (OR=0.95, NS) and on high SES
females (OR=1.10, NS). Other polic
ies had a pattern similar to the significant ones.

It should be noted that this US cohort uses longitudinal data with a seven year gap in the data
used to assess transition from adolescence to young adulthood, and this gap may have
missed other important m
ediators.

Summary

Five

studies of controls on access to tobacco product
s

showed mixed results for equity
impact.
Although four of the five studies focussed on age of sale legislation, the German
study of vending machines was unique, and in addition, the range of outcomes reported with
the studies varied.

42


Increasing the minimum age for the purchase of tobacco in Engl
and was associated with a
significant reduction in
overall
youth smoking and
regular smoking was not significantly
different in pupils eligible for FSM compared with those that were not and so the legislation
was neu
tral with regard to
equity
. However smok
efree legislation also came into force
during the time of this study and could have contributed to the reduction in overall youth
smoking.

In addition there were significant differences in the percentages of adolescents
eligible for FSM compared to those n
ot eligible for FSM in terms of
higher rates of
accessing cigarettes from a variety of sources, which showed
negative
equity
impact
differences.

New legislation which involved electronic locking devices on vending machines to prevent
underage purchasing of

cigarettes in Germany has not been associated with a decrease in
inequalities of access to cigarettes, for youth.
The supply density of cigarette
vending
machines in Germany
was greater in socially
dis
advantaged areas, both before and after new
legislatio
n to prevent underage access; there were
also
greater decreases in the number of
vending machine sources in socially advantaged areas.


Two US studies reporting retailer compliance with age
-
of
-
sale laws showed inconsistent
results for SES.
A US study
41

evaluating the relationship of point
-
of
-
sale tobacco advertising
and neighbourhood characteristics to underage sales of tobacco did not find a significant
association between store advertising characteristics or poverty and stores’ compli
ance check
failure.

A study of compliance with underage tobacco sales laws in California
40

showed that
higher education was a significant predictor of underage tobacco sales and youth in
communities with higher educational levels may have easier access to cigarettes from
c
ommercial sources.

A US national longitudinal study of adolescent health showed that stronger state level
tobacco policies

on age of sale

were associated with lower likelihood of smoking initiation
and adverse transition among low SES adolesce
nt girls,
a
lthough the effect sizes were small.

It is difficult to ascertain how access to tobacco translates into smoking prevalence and how
stricter enforcement of access laws would help to reduce the gap between low and high SES
in terms of smoking prevalence. Inc
reasing age of sale and restricting youth access do not
appear to be widening the gap between high and low SES but the evidence is limited and
only two studies report smoking outcomes rather than supply outcomes.

43


3.2.5

School
-
based prevention

F
ive

RCTs
assessed
the socio
-
economic impact of school
-
based smok
ing prevention
programmes
.
Two interventions were drug prevention programmes which included elements
of smoking prevention.
45;46

One RCT examined the effects of a school
-
based drug prevention
programme

which included smoking prevention in school children

aged 11 years in Florida,
US
.
45

One quasi
-
randomised trial
46

in 53 public secondary schools in northern Germany
evaluated the effects of two validated lif
e skills programmes: ‘Fit and Strong for Life’ and
‘Lions Quest’.

Three intervention studies focused on smoking prevention.
One RCT investigated whether a
peer group pressure and social influence intervention reduced the percentage of adolescents
who star
t to smoke, in the Netherlands.
17

The European Smoking Prevention Framework
(ESFA) study
assessed the impact of a social influence school
-
based intervention with
parental and community involvement on smoking uptake amongst adolescents in six
European countri
es.
19

The ‘A Stop Smoking in Schools Trial’ (ASSIST)

assessed
the
effectiveness of a peer
-
led intervention that aimed to prevent smoking
uptake in secondary
schools in England and Wales.
18

Two

of the studies did not report socioeconomic impact on
initial
analyses;

however a paper

by Mercken et al.
20

was identified which performed
secondary

analyses of the socioeconomic impact of
these three intervention studies
17
-
19

using
the SES variables reported within the original primary studies.


The secondary analysis included a review to identify ‘high
-
quality European intervention
studies with clear overall effects that could be selected for secondary analyses
'
. Included
intervention studies had to be published in the international scientific literature in English
language, since 1995 and conducted in Europe since 1990. This procedure resulted in the
inclusion of three school
-
based intervention studies. The thre
e studies were reanalysed using
the definitions of variables as defined in the original studies. Multilevel modelling
techniques were used; models were estimated using the restricted iterative generalized least
squares (RIGLS) estimation procedure combined

with first
-
order penalized quasi
-
likelihood
within MLWin 2.10 beta. The multilevel model was tested separately for adolescents in each
of the categories of the included SES indicators.

It is unclear how representative all

five
study samples

were of the re
spective study
populations.
The groups in three of the studies
17
-
19

had comparable characteristics at
baseline.
Attriti
on rates were acceptable for three

studies
18;45;46

but relatively hi
gh for the
44


other two studies
17;19
.
The
ASSIST
study
was the only stud
y

to biochemically validate
measure
s of self
-
reported smoking, and
scored highest for quality.
18

It is likely that the
obse
rved effects of each of the five

interventions were attributable to
the interventions
.

Two

studies evaluated school
-
based programmes

which included
elements of
smoking
prevention
:
one

based in the US and one
in Germany
.
46

One RCT
examined the effects of a
school
-
based drug prevention programme

which included smoking prevention in school
children.
45

The study was published as a paper presented at the Annual Conference of the
American Educational Research Association and assesses the impact of a

school
-
based drug
prevention programme ‘Too Good for Drugs II’ (TGFD II) on student’s behaviours and risk
and protective factors. Students in six middle schools in Florida, US were randomised to 9
lesson units (40 minutes each) taught by a trained classro
om teacher or TGFD II instructor;
including social and emotional competencies, reducing risk factors and building protective
factors; emphasising cooperative learning activities, role
-
play and skills building methods.

Students were follow
ed
-
up 20 weeks aft
er the
9 week intervention.

The

school
-
based
curriculum also involved community partners and parents; and the theoretical basis included
Social Learning Theory, Problem Behaviour Theory and Social Development Theory.

At the end of the intervention, 8% (48
/588) of students in the intervention group indicated
greater likelihood of actual tobacco use compared with 12% (45/375) of students in
the
control

group
, and this difference was statistically significant. There was no statistically
significant
difference between the groups at 20 weeks follow
-
up.

The overall findings of the
comparison of
change

scores for
treatment

students indicated the programme was similarly
effective in impacting
on
students risk and protective factors regardless of economic
status
(perception of peer resistance skills; positive attitudes toward non
-
drug use, perceptions of
peer normative substance use, perceptions of peer disapproval of substance use, association
with prosocial peers, perceptions of locus of control self
-
effi
cacy).

A significant interaction effect for
treatment

students was seen between
level

of risk and
protective factor scores and SES (measured by free/reduced lunch status) at the end of
intervention and 20
-
week follow
-
up. Significant trends appeared betwee
n low and high SES
in the areas of ‘perceived peer norms’ and ‘perceived peer approval of substance use’ at the
end of the intervention and in addition with ‘association with prosocial peers’ at 20
-
week
follow
-
up. The
direction

of the effect by SES is not
reported.

45


One RCT investigated whether a peer group pressure and social influence intervention
reduced the percentage of adolescents who start to smoke, in 26 junior secondary education
schools in the Netherlands.
17

The intervention consisted of three lessons on knowledge,
attitudes, and social influence, followed by a class agreement not to start or to stop smoking
for five months and a class based competition.


At five months 9.6% of th
e
non
-
smokers

at baseline had started to smoke in the intervention
group, whereas 14.2% started to smoke in the control group (N = 1388, OR = 0.61, 95% CI
= 0.41

0.90). After 1
-
year follow
-
up, the effect was no longer significant.

At 5 months,
smoking beha
viour was significantly lower in adolescents who indicated that their parents
had mid to high completed education (OR = 0.35, 95% CI = 0.13

0.95). The intervention did
not result in smoking fewer cigarettes among adolescents who indicated that their parent
s
had lower education (OR = 0.80, 95% CI = 0.37

1.72). The additional analyses stratified by
gender and SES showed that the intervention was only effective at 5 months follow
-
up
among boys with higher parental educational levels (OR = 0.24, 95% CI = 0.07

0
.79). All
significant intervention effects disappeared at 12 months follow
-
up.
17

The ESFA study assessed the impact of a social influence school
-
based intervention with
parental and community involvement on smoking uptake amongst adolescents in six
European countries.
19

In Finland, Denmark, UK and Portugal schools or r
egions were
randomly assigned whereas i
n Spain and The Netherlands
the study design was quasi
-
randomised
.

Since the strong
est and significant long
-
term effects after 24 and

30 months
were found in the Portuguese sample, only data of the ESFA study in Portugal were
reanalysed on the impact by SES and so only results f
or Portugal are discussed within this
review.

The Portugues
e intervention consisted of l
essons on
the
effects of tobacco, reasons for (not)
smoking, social influence processes, refusal skills and decision makin
g and a smoke
-
free
competition.
Due to the fact that peer
-
led programmes were uncommon in

the ESFA
countr
ies, programmes w
ere teacher
-
led.

Teachers received 48 hours of training,
a
manual
and smoking cessation material
.
Schools received the ESFA no
-
smoking policy manual and
non
-
smoking posters.
For

the parents, information was offered on how to discuss non
-
sm
oking with their adolescents. Pharmacists furthermore offered cessation courses for 150
parents. At the community level, the Portuguese Health Minister and mayor of the
community introduced the ESFA study on the national
no smoking

day
.
19

46


At 30 months
,

41.8% of the never smokers
at baseline had
started to smoke in the
intervention group,
compared to
53.8% of the never smokers

at baseline

in

the control group
(N = 1304, OR = 0.62, 95% CI = 0.48

0.80)
.
The results were mixed depending on the SES
indicator used

(mother/father and full
-
time/not full
-
time jobs were no
t

included as a measure
of SES in our review)
.
The intervention was significant
in reducing smoking uptake among
adolescents who indicated hav
ing

no to only a low amount of spending money (OR = 0.62,
95% CI = 0.46

0.84
). This
statistically significant
effect was not seen among adolescents
reporting receiv
ing

mid to high amounts of spe
nding money (OR = 0.57, 95% CI = 0.32

1.03).
Although
the actual odds ratio is smaller for the ‘mid to high’ spending money
subgroup compared with the ‘none to low’ spending money subgroup, the
lack of
significance here is due to the wider confidence inter
vals
,

which are
explained by
the
relatively
small numbers in the subgroup
with ‘mid to high’ spending money
(n=182)
.

Additional analyses stratified by gender and SES showed that the intervention was mostly
effective among girls.
19

P
ocket money was used as a proxy measure and there may not be a
strong association between adolescents’ pocket money and household income.

As Mercken
et al
.
20

state; those adolescents with less pocket money may well have parents with higher
levels of education or income.

The ASSIST
study
assessed
the effectiveness of a

peer
-
led intervention that aimed to prevent
smoking uptake in secondary schools in
S.W.
England and Wales.
18

Influential students were
trained
by external professionals
to act as peer supporters during informal interactions
outside the classroom to encourage peers not to smoke. During the 10
-
we
ek intervention
period, peer supporters undertook informal conversations about smoking with their peers
when travelling to and from school, in breaks, at lunchtime and after school in their free
time.

At 1
-
year follow
-
up, the

OR
of being a smoker in inter
vention compared

with control group
was 0∙77 (95% CI 0∙59

0∙99). At

2
-
year follow
-
up, the corresponding
OR
of 0∙85

(0∙72

1∙01) was not significant (p=0∙067)
. For the high
-
risk group

(occasional, experimental, or
ex
-
smokers at baseline)
, the OR

at 1
-
year
follow
-
up was

0∙75 (0∙56

0∙99) and at 2
-
year

follow
-
up was

0∙85 (0∙70

1∙02)
.
In a three
-
tier multi
-
level model u
sing data from all three
follow
-
ups the odds of

being a smoker in the intervention group compared with the control
grou
p was 0.78 (95% CI = 0.64

0.96)
.
18

The original primary study pap
er found no evidence
of a differential effect by FSM entitlement (0.99 (95% CI =0.65
-
1.51)).

47


The secondary data analysis
20

c
ombined data from the three follow
-
up p
eriods and
conducted a multi
-
level analysis using

three

measures of SES
:

FAS, FSM and
school located
in the Valleys (which are areas of deprivation). No significant main effect of the intervention
was found for FAS or FSM entitlement, though a trend was vi
sible for FSM. The
intervention was significant among schools located in the
valleys but

not in schools in other
locations. Additional analyses showed that in
Valley

schools the intervention was also
effective among those with low FAS score, and a gender a
nalysis showed that the
intervention was mostly effective among lower SES girls.

Summary

The overall findings from the f
ive

school
-
based studies are mixed in terms of the impact by
SES, the results also varied by the type of SES used to measure effect, and over time
(shorter
-
term benefit appeared to attenuate over time).

The
findings from a substance abuse prevention programm
e set in schools were

equally
effective for students regardless of SES,

however the study did not ask about current
smoking behaviour and the outcome was intention to smoke in the next 12 months rather
than actual
smoking behaviour.
45

The results of this prevention programme relate

to scores
for substance use which includes
(
but is not limited to
)

tobacco use and so this limits study
findings.

A German study
46

of two life skills programmes had a positive effect on smoking
prevention regardless of SES; with socially disadvantaged children b
enefitting equally

(neutral equity impact)
.

The
Netherlands study
had a significant effect among higher SES adolescents
only and in the
short
-
term only,
and appeared to widen inequalities

(negative equity impact)
.
17

The
ES
F
A
study showed mixed results
depending on th
e specific SES indicator used; w
hen using
spending money as a SES indicator, the intervention did appear to decrease inequalities in
smoking.
19

However, the amount of spending money which an adolescent has may not be
strongly associated with household income.

For example, in Scotland low SES adolescents
have
higher levels of disposable income than higher SES

adolescents
.
47

ES
F
A i
nterventions
differed between countries and Portugal received
the most intensive teacher training
;
so
results may only be generalisable to that type of intervention in that country.

Process
evaluation
of ES
F
A
included
self
-
report of exposure to each element of the intervention
and
showed
it
was
reasonably likely that the observed effects were attributable to the
school
-
based elements of the
intervention

rather than outside school elements.

48


The most promising findings in terms of equity impact were for
ASSIST
which used a social
network approach
in which adolescents delivered the intervention
. While this intervention

also showed mixed results
depending on the spec
ific SES indicator used
, it

was
effective at
one year and
most effective for adolescents in deprived area
s, particularly among low SES
g
irls

(positive equity impact)
. H
owever
,

the
beneficial effects of the intervention seemed to
attenuate over time.
18

3.2.6

Multiple

policy interventions

T
hree

studies assessed the socio
-
economic impact of multiple policy interventions: two
repeat cross
-
sectional studies
48;49

and a
prospective
cohort study.
50

One

repeat cross
-
sectional study
49

was set in Australia

and examined the im
pact of tobacco control policy on
smoking prevalence.

The other repeat cross
-
sectional study
48

assessed the impact of the
1976 Tobacco Control Act (TCA) on smoking initiation across socioeconomic groups

of
Finnish youth
.
A prospective cohort study described the

association between smoking
intolerance in schools, restaurants and corner shops near secondary schools, and the
initiation of smoking in a convenience sample of adolescents (mean age 13 years) in
Montreal, Canada.
50


T
he cohort study
50

used a convenience sample
and
it was unclear whether the study sample
was representative of the study population

or whet
her the study results are generalisable
. The
Australian study
49

reported changing
retention rates which meant that the characteristics of
the student sample in
school
years 11 and 12 were likely to differ systematically across the
survey years
,

which could have affected the prevalence rates (instead of
,

or as well as
,

tobacco control po
licy).
Both the Australian and Finnish studies were
large population
surveys
with results that
are
likely to be
generalisable at the national level.

An Australian national survey
49

examined whether SES was associated with changes in
smoking prevalence among adolescents during three phases of tobacco control activity: low
tobacco
-
contro
l funding (1992
-
1996)

and

high tobacco
-
control activity (1984
-
1991 and
1997
-
2005
)

which included smoking restrictions and increased tax.

Random samples of
students aged 12 to 17 years from each Australian state and territory and three main
education
sectors, completed anonymous surveys of cigarette use as part of a larger survey
assessing the use of alcohol and illicit drugs between 1987 and 2005.

There was a significant
and substantial reduction in the likelihood of smoking
among all SES groups for o
lder (16
-
17 years) and younger students (12
-
15 years) between 1987 and 2005.

Overall, for younger
49


students (12
-
15) the reductions differed by SES (interactions p <0.01), with reductions in all
smoking behaviours, greater for students from higher SES group
s. Among older students
(16
-
17), only the reductions in committed smoking
(
cigarette use on at least three of the
previous seven days)
differed across SES groups (interaction p < 0.01), and again reductions
were greater among students from higher SES group
s.


Between 1990 and 1996 the proportion of younger and older students involved with smoking
increased significantly. Among younger students, the increase in monthly and weekly
smoking was greater among lower SES students. Between 1996 and 2005 the preval
ence of
monthly and weekly smoking decreased significantly among both younger and older
students, and these decreases were consistent across SES groups. The magnitude of the
decreases in smoking prevalence between 1996 and 2005 did not differ significantly

between
SES groups for most indicators of
smoking behaviour
. For committed smoking, the
interaction between year and SES was of borderline significance for students from both age
groups, suggesting that the decrease may not be consistent across SES groups
. It should be
noted that co
-
operation rates of the schools declined over t
i
me from 85% in 1987 to 63% in
2005 and the changing prevalence estimates might be the result of different survey samples.

A Finnish

study
48

assessed the impact of the 1976 TCA on smoking initiation across
socioeconomic groups. The TCA prohibited smoking in most public places, including public
transport; and the sale of tobacco products

to those below 16 years of age;

and required
obligatory h
ealth warnings on packages.

The study used annual cross
-
sectional postal survey
data from 1978 to 2002 to assess the impact of the TCA on smoking prevalence (defined as
ever smoked daily for at least a year). The study authors defined the
critical age rang
e for
smoking initiation
as 13 to 20
years. Most

of the analyses
were

focussed on the
three largest
socioeconomic groups (upper white collar workers, lower white collar workers, blue
collar
workers manual workers).

Amongst men the secular cohort trend show
ed a decline in smoking only in upper white
collar workers before the TCA

(stable for lower white collar and blue collar) and this trend
remained unchanged after the TCA, with no difference for the interaction between SES and
trend. Among women the secular

cohort trend was increasing in each SES group before the
TCA and was reversed after the TCA, evenly across SES groups. For women, the general
cohort trend after the TCA differed from the secular cohort trend before the TCA, and this
differed by SES.

In co
horts reaching the smoking initiation age

after the TCA, the
50


prevalence of ever smoking remained relatively

stable among white collar female workers
but tended to

decline among blue co
llar female workers (OR 0.88;

95% CI:

0.72 to 1.02), in
contrast to the
sharply

increasing trend in older cohorts.


In terms of study validity, t
he a
verage response rate
during 1978 to
2002 was 70% among
men and 79% among women

and the response rate
declined
during this period,
in both
genders and all
age groups. The decline
w
as
faster

among men than women, and in younger
than

older age groups, which may
have biased the

study
results
.

Other tobacco control
policies came into force during the study period which could have influenced the study
results and explain some of the variability in smoking initiation by SES:
the 1976 TCA

was
supplemented by a total tobacco advertising ban in 1978
, and the environmental tobacco
smoke amendment
(
of the TCA
)

in 1995.
In addition, t
obacco prices rose substantially (real
price increase 27%) in 1975

1976.

A

Canadian study
describe
d

the association between smoking intolerance (the extent to
which smoking

is socially unacceptable) in schools, restaurants and corner stores near
schools and the initiation of smoking in adolescents
.
‘The Natural History of Nico
tine
Dependence in Teens Study’
50

involved completion of

questionnaires administered in
the
classroom, every 3 months from 1999 to 2005
by students ave
rage
age

13

years
,
in seven
English and three

French la
nguage secondary public schools in Canada.
The study
used a
convenience sample which produced a 55% student response rate
.


Students in smoking
-
intolerant schools (access and restrictions) were less li
kely to initiate
smoking than students in smoking
-
tolerant schools (Hazard

ratio [HR] = 0.83; 95% CI: 0.68,
1.01).
Students attending schools located in neighbourhoods with smoking
-
intolerant
restaurants were less likely to initiate smoking

(HR
0.85
; 95%
CI:

0.68 to

1.07). There was
no association between corner store smoking intolerance and smoking initiation
. The
HR
’s

for cigarette use initiation for low SES school
s were not significant. However, there was a
25% loss to follow
-
up of students over the fiv
e years and these students were more likely to
attend a low SES school, which may have impacted on the results.

Summary

The Australian survey
49

showed that the magnitude of the decreases in smoking prevalence
between 1996 and 2005 did not differ significantly between SES groups for most indicators
of
smoking behaviour
, but there may be
differences between younger and older youth.
51


However, there appeared to be an association between level of tobacco control funding and
smoking prevalence. There was also some evidence that low tobacco control funding had a
negative equity effect on smoking

prevalence among 12
-
15 year olds but not older students.

The Finnish TCA
48

was associated with a reduction in smoking initiation across all SES
groups
.

Among men, the

1976 TCA appears to have had th
e greatest impact on male white
collar employees. Among wome
n, the apparent effect was very
pronounced in all
socioeconomic groups and among blue collar

female workers the cohort
trend tended to
decline.

A convenience sample of pupils in Canada
50

showed that cigarette use initiation
was
associated with levels of smoking intolerance in schools and communities but th
at this
did
not differ by SES
. B
ut there was evidence of response bias by SES which may have
impacted on the results.

3.3

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

There
were

only
two

individual cessation
suppor
t
intervention
s

identified for youth which
assessed
smoking outcomes by SES
, one set in New Zealand and one in USA: both of which
used text
-
messaging as the mode of intervention
.


The New Zealand study
51

aimed to determine the effectiveness of a mobile
phone text
messaging smoking cessation programme which provided advice
,

support and distraction for
smokers who owned a mobile phone

and who wanted to quit smoking. P
articipants
were
aged 16 years and over,
with a

mean age of

25 years. The intervention inc
luded five free
personalised text messages per day for one week prior to a negotiated quit date and for four
weeks after the quit date. The control participants received one free month of text messaging
if they participated until 26 weeks.
A total of
1
,
705

smokers were recruited from adverts on
websites, media, email and text messaging mailing lists
;

and posters at tertiary education
institutions.

The

RR of
not smoking in the past week was 2.20 (95% CI 1.79 to 2.70) at 6 weeks, 1.55
(95% CI 1.30 to 1.84) at

12 weeks and
1.07 (
95% CI
0.91 to 1.26) at 26 weeks

(w
hen all
pa
rticipants with missing status we
re assumed to be smoking
)
.

The
RR
of
not smoking (in
the past week)

at six weeks by income level was presented as a forest plot
and showed no
52


difference in ef
fect by income level; all income levels showed significant positive effects of
the intervention
.

Biochemically verified abstinence was only performed on a random selection of participants
and showed over
-
reporting of quit rates but this over reporting was

not different between the
intervention and control group.
The quit rate at 6 weeks was 28.1% in the intervention group
compared wi
th 12.8% in the control group. A
ssuming the rate of true quitters was the same
as in the sample assessed for cotinine levels,

then the quit rate at 6 weeks was 13.9% in the
intervention group compared

with 6.2% in the control group and

the

absolute difference in
quit rates at 6 weeks is reduced to 7.
7% from 15
.3%.

Only 74% (n=1265) of participants were followed
-
up at 26 weeks an
d the
attrition
rate
differed significantly

between the groups
at 12 weeks and at 26 weeks
(69% in intervention
group vs 79% in control group

at 26 weeks
). This meant there was some uncertainty about
between group differences at 26 weeks. In
addition

repor
ted quit rates
increased

amongst the
control group from 13% at 6 weeks to 24% at 26 weeks
,

however this would have led to an
underestimation of treatment effects and all methods of data analyses showed a significant
difference in quit rates in favour of th
e intervention.


The US study
52

targeted a di
verse sample of motivated daily smokers aged 18 to 25 years,
owning their own mobile phone and ‘seriously thinking about quitting in the next 30 days’.
Two hundred and eleven young adults were randomised from 585 eligible participants and
the final sample
included 164 participants: 101 in the intervention group and 63 in the
control group; mean age 22 years, 56% male, with 43% reporting an annual household
income of less than $15,000.

The 6
-
week text
-
messaging intervention was tailored to each young adult
smoker based on
their quitting stage. Intervention participants also had access to a ‘Text Buddy’ similar to
that used in the New Zealand study
51

and ‘Text Crave’ (immediate, on
-
demand messages
aimed at helping the participant through a craving); and a project website
(StopMySmoking.com). The control group received a similar number of text messages, but
message content was aimed at improving sleep

and exercise habits within the context of how
it would help the participant quit smoking. Control group messages were not tailored nor
were Text Buddy and Text Crave components available.

53


Intervention participants were significantly more likely to have qu
it at 4 weeks post quit
(39%) than those in the control group (21%;
adjusted odds ratio [aOR]
= 3.33, 95%
CI
:
1.48, 7.45); and this was also the case for 7
-
day point prevalence (44% vs. 27%;
aOR
= 2.55,
95%
CI
: 1.22, 5.30). However the impact was not susta
ined, and 40% of the intervention
participants had a quit status verified by a ‘significant other’ compared with 30% in the
control arm at 3 months post
-
quit, which was not statistically significant (
OR
= 1.62, 95%
CI
:0.82, 3.21). Cessation rates among int
ervention participants were stable between 4 weeks
and 12 weeks, but
increased
among control participants

The intervention appeared to be more effective in young adults not currently enrolled in
higher education settings (45% intervention vs. 26% control h
ad quit at 3 months,
p
= .07;

aOR of verified quit at 3 months
= 2.7, 95%
CI
: 1.0 to 7.4). The US study
52

was a feasibility
study with a relatively small sample size so it was not sufficiently powered particularly to
detect differences in subgroup results. Eight participants were manually assigned to

treatment groups (rather than randomly) due to an imbalance within study subgroups.


Summary

Two studies of text messaging smoking cessation interventions were included, one set in the
USA and one in New Zealand. Participants in both studies were mobile phone owners in
their
late teens to
early twenties, who were motivated to quit smoking.
The
New

Zealand
study control participants received a passive control (one month free text messaging) and US
control participants received a text
-
messaging service that was not tailored

(intervention
participants received a tailored text
-
messaging service).

The N
ew Zealand study showed personalised mobile phone text messaging support could
double quit rates at 6 weeks amongst young adult smokers who wanted to quit, irrespective
of income level. The effect was still significant at 12 weeks but not at 26 weeks, in a
ddition
there was an increase in quit rates amongst the control group and significant
ly

more
intervention participants
were
lost to follow
-
up at 26 weeks.

The US study of a tailored text
-
messaging intervention compared to a non
-
tailored text
-
messaging intervention, showed
a significant increase in q
uit rates in intervention group
participants compared with control group participants at 6 weeks that were not
sustained at

12 weeks. Quit rates increased in control group participants. However youth not enrolled in
higher education (i.e. lower SES) appeared to benefit from the tailored text messaging
54


intervention with significantly positive quit rates at 12 weeks
compared to youth enrolled in
higher education.

The New Zealand study showed a
short
-
term
neutral equity effect and the US study showed
a
short
-
term
positive equity effect.
Quit rates increased in the control groups in both studies.
It is unclear how repre
sentative either study samples were of each study population, however
both studies cut
across all settings and all locations.



55


4

DISCUSSION

Only one review, the CRD review, has previously assessed the equity impact of tobacco
control policies on youth smoki
ng.
No

intervention
,
including restrictions on smoking in
schools and restrictions on sales to minors, provided any evidence about possible differential
effects by parental income, occupation or educational level for the youth population.
The
review presen
ted in this report has systematically assessed the available evidence on the
impact of population
-

and individual
-
level tobacco control interventions on socioeconomic
inequalities in youth smoking.
It identified 31 studies which
have
evaluated the impact o
f
population level prevention

polic
ies/
interventions and two individual

level cessation support
interventions, on smoking in young people by SES
,

measured by income, occupation or
education.

Before presenting the main review findings it is important to
consider the
strengths and limitations of both the review and the available evidence.

4.1 Strengths and limitations of the review

C
onsiderable attempts were made to include published and ‘in press’ studies
. However
, it is
possible that some
relevant
studie
s might have been missed which had not been published in
the peer reviewed literature and/or which were not
published in English. It is also possible
that papers
which
undertook analyses by SES were not included because th
ese analyses

w
ere

not mentioned
i
n

the
ir

abstract. However, this review goes beyond the previous CRD review
in including all types of youth interventions (prevention and cessation, population and
individual level
s
) and also
searching

for non
-
tobacco control interventions and polices (eg
ed
ucation, social policy) which assessed any smoking
-
related equity impacts.
It also
included

in press


article
s

from four key journals and asked European tobacco control
experts to provide any other relevant peer reviewed articles (non
-
English language) or

grey
literature. We also developed a modified quality assessment tool which was designed to
enable us to
assess the
quality
of

the
diverse
range of types of interv
entions and study
designs encompassed in the included studies.

4.2 Strengths and
limitations of the available evidence

There are major limitations in the available evidence, most importantly the very small
number of studies which have considered the equity impact of tobacco control interventions

aimed at young people
.
In addition
,

ther
e was a lack of consistency on the reported outcome
measures and length of follow
-
up.
There was also considerable variation in the quality of the
studies
(
Section 7.6

Appendix G
). Several of the studies were pilot or feasibility studies
56


and/or involved sma
ll numbers of participants. Thus
,

their findings may not be replicable.
For several important areas of
youth
tobacco control
eg

social marketing
, multifaceted
community programmes
,
mass media approaches using social media,
combating
smuggling/reducing the
black

market, smokefree homes interventions and
most forms of
cessation support
, we found no evidence on equity impact.
Nearly half the studies were from
North America (US and Canada) and a third from the UK
,

which
raises concerns about their
generalisabil
ity

and potential transferability
to,
or relevance
for
,

countries in Europe which
have different social and cultural contexts and/or different levels of tobacco control.
Finally,
a range of indicators of SES
was

used in papers (
e.g.

education level, income,
area
deprivation,
and other

indicators
) which made comparisons
between

studies difficult.
M
ost
studies used education income level
as a measure of SES but levels of educational attainment
and income
vary between countries and gene
rations.

4.3 Main findings and conclusions

Relatively few intervention studies have assessed their impact on socioeconomic inequalities
in

youth

smoking

or
other
smoking
-
related outcomes (eg exposure to second
-
hand smoke
)
.
Out of
the

original
12, 605
identified papers
(which also included papers focusing on adults)
only
33 studies

met the inclusion criteria and were included in the review
and none were
from outwith tobacco control

(
Figure 1 and
Table 2). The literature was international, with
nearly ha
lf of the
studies being carried out in
N
orth

America
.
Studies also included the
UK,
the Netherlands, France, Spain, Finland, Israel, New Zealand and Australia.

Of the 33 studies included in the review 31 were population level tobacco control
policies/inte
rventions and 2 were individual level cessation support interventions. The types
of policies/intervention included were: smoking restrictions in cars, schools, workplaces and
other public places (9); controls on the advertising, promotion and marketing of
tobacco (3);
mass media campaigns (1); increases in price/tax of tobacco products (6); controls on access
to tobacco products (5); school
-
based prevention programmes (5); multiple policy
interventions (3) and individual cessation support (2).

(One study wa
s included in two types
of policies/intervention category)
.

4.3.1 Positive equity impact

Only six of the 31 population
-
level studies showed the potential to produce a positive equity
impact i.e. to reduce inequalities in youth smoking
. T
hese ‘positive’
studies included three
US studies of increasing the price/tax of tobacco products,
35;36;38

two US studies on age
-
of
-
57


sales laws,
40;44

and
UK
one sch
ool
-
based smoking prevention programme
.
18

Three US
studies of cigarette price/tax increases
35;36;38

demonstrated a positive effect on low SES
youth of increasing price/tax to reduce smoking. A US prospective cohort study
44

showed
that stronger state level tobacco policies on age of sale were associated with
a
lower
likelihood of smoking initiation and adverse transition among low SES adolescent girls,
although the effect sizes were small. A study of compliance with underage
tobacco sales
laws in California
40

showed that higher education was a significant predictor of underage
tobacco sales and youth in communities with higher educational levels may have easier
access to cigarettes from commercial sources. One school
-
based smoking prevention
study
(ASSIST), using a peer
-
delivered intervention through social networks, appeared to reduce
smoking inequalities in school
-
children in England and Wales. However, results were mixed
depending on the specific SES indicator used.



4.3.2 Equity impact b
y type of tobacco control policy/intervention


Assessing the overall equity impact of different types of interventions/policies was
complicated by studies having different outcome measures and length of follow
-
up.
In some
studies differen
t outcomes var
ied

in equity impact or the same SES measure and outcome
var
ied

by gender or by setting.
For example,
o
ne school
-
based prevention programme
showed a positive effect only in high SES girls and had the potential to widen inequalities.
Which specific measure
s

of
SES
were

used appear
ed

to influence the results across all types
of policy interventions. The equity impact
could

also
vary depending on the timing of the
outcome measurement
. For example,
two of the school
-
based prevention programmes
found

that
the
effect

varie
d

across time points; with beneficial intervention effects attenuating over
time.
Similarly b
oth cessation interventions using text
-
messaging showed a significant
beneficial effect that was not sustained in the longer
-
term.

Thus
,

t
he summary of the equity
impact
of policies/interventions was
derived ‘on balance’

(Appendices H and I).


Overall there was no consistent equity effect for each type of tobacco control
policy/intervention. Most interventions had, on balance, either a negat
ive (11) or neutral (15)
equity impact. One had a mixed impact.

However, it should be borne in mind that studies of
policies associated with a neutral equity effect indicate that these policies have benefits for
youth across SES groups. For example,

both t
he English and Scottish
national
smokefree
legislation were associated with significant reductions in admissions for asthma across all
SES subgroups.

58




S
moking restrictions in cars, schools, workplaces and other public places
-

None of
the nine studies
showed

a positive equity impact
. Four had
a
negative equity impact
,
four had a neutral impact
,

and one had both negative and neutral impacts. T
h
e studies
indicate that th
e equity impact of comprehen
sive smoking
legislation

in public places
may differ depen
ding on the pre
-
ban level of exposure and the balance between
sources of exposure i.e. public places versus
the home.
While
c
omprehensive
smoking restrictions
can

reduce overall SHS exposure
across all SES groups of

children.
Changes in smoking restrictions in homes and cars following UK
smokefree legislation did not appear to be patterned by SES in pooled analyses,
however smoking in homes and cars remains more prevalent amongst children from
low SES families.
Evidence

shows t
hat there is signifi
cant variation by SES in levels
of exposure

prior to smokefree legislation with
higher levels of exposure in lower
SES. Whether exposure is measured in relative or absolute terms appears to influence
the equity impact results.

However,
there is some evidence that smokefree legislation
can
also have a neutral equity impact in terms of increasing voluntary smoking
restrictions in cars.
T
he evidence
also
suggests that where there are no
comprehensive smoking restrictions in schools or where

there is variable compliance
with voluntary bans; inequity in smoking will continue.



Controls on the advertising, promotion and marketing of tobacco
-

Two of the studies
had a negative equity impact and one had a neutral impact.
The three studies were
ver
y different
with

one indicat
ing

that t
obacco companies marketing expenditure may
be associated with an increase in smoking initiation especially in young people with
lower levels of education.
Another study found that d
espite
an

FDA buffer zone
policy to protect children from tobacco advertising, tobacco advertising
wa
s
specifically targeted at adolescents of low SES inside school buffer zones and
that
this has the potential to increase inequality in smoking amongst youth.
This w
ould
indicate that b
anning all tobacco advertising would
be
particularly

beneficial for

low
SES

children
.

There was also some tentative support from one study that introducing
plain packaging would have a similar impact across all SES groups.



M
ass media ca
mpaigns
-

only one study assessed the equity impact of a mass media
campaign, the Truth

campaign. The
overall
equity impact was difficult to assess

but
there was a
neutral equity impact

in terms of receptivity
.




Increases in price/tax of tobacco products
-

t
he majority of evidence on price/tax is
from the US, and suggests
that
there is variation in the equity impact of increases in
59


cigarette tax or price on youth smoking behaviour and variation in smoking
behaviour amongst youth of different ages and differe
nt SES groups. Low income
youth
were

not consistently more responsive to tax/price increases compared with
high income youth: youth of lower SES
were

not more likely to stop smoking when
cigarette prices/taxes increase
d
. The inconsistency within the
evidence could reflect a
true effect or measurement errors such as failure to capture youth behavioural
reactions

in retrospective recall studies
.



Control
s on access to tobacco products
-

Reducing access to cigarettes through
increasing the minimum age of
sale, including vending machines sales, may impact
on youth sales but
the inconsistent evidence from the UK and US studies make it
difficult to draw conclusions about whether they also

reduce
youth
smoking
inequalities.



School
-
based prevention programmes
-
o
nly one study (ASSIST)
had

promising
findings in terms of a positive equity impact. The other studies findings were
inconsistent
,

varied by type of SES measure used and attenuated over time.




Multiple policy interventions
-

these were three very different studies (two national
and one
at
community level) in

three different countries looking at different types of

policies which make
s

it
difficult

to draw any conclusions about the equity impact of
multiple policy interventions
.





I
ndividual cessation support
-

o
nly two studies were included which evaluated
individual

level smoking cessation support for youth. Both of these interventions
used

te
xt

messaging
. T
he US study
showed a
short
-
term (12 weeks) neutral

equity
impact and the

New Zealand study
showed a
short
-
term (12 weeks)
positive equity
impact

but this was not significant at 26 weeks
.
The
ir

equity impact
s

should be
viewed with caution given that the representativeness of both study samples were
unclear: both sample participants were motivated young adults who owned a mobile
phone. However text

messaging intervention
s have

the potential to reach large
numbe
rs of young smokers
.


60


5

C
ONCLUSIONS

Thirty
-
three studies were included which evaluated the effect of policies and interventions to
prevent or stop youth smoking by SES.
Only six of the
31
population

level studies showed
the potential to reduce inequalities i
n youth smoking
; including three
on

increasing the
price/tax of cigarettes,
enforcing
strong policies on age
-
of
-
sale,
and one
school
-
based
prevention stud
y (ASSIST)
.
There
were

only two individual

level cessation support
interventions identified for youth which assessed smoking outcomes by SES.
Both cessation
studies used text

messaging
. O
ne showed a neutral equity impact and
the other
showed a
positive equity impact.
There wa
s variation in
the
equi
ty impact

of each type of
tobacco
control
policy/intervention
.

The limited nature and extent of the evidence base considerably constrains what conclusions
can be drawn about which types of tobacco control
polices/
interventions are likely to reduce
inequali
ties in youth smoking.
Very few studies have assessed the equity impact of policies
and interventions on smoking prevention or
cessation in youth. There is therefore little
available evidence to inform tobacco control policy and interventions that are aim
ed at
reducing socioeconomic inequalities in youth smoking. There is a need to strengthen the
evidence base for the equity impact of tobacco control interventions aimed

at young people
.

The review provides very little evidence to suggest that
any

specific
policies would be able
to reduce inequalities in smoking initiation.



61


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