Showing papers in "Tobacco Control in 1998"

Psychosocial factors related to adolescent smoking: a critical review of the literature

Abstract: OBJECTIVE To extend the analysis of psychosocial risk factors for smoking presented in the United States surgeon general’s 1994 report on smoking and health, and to propose a theoretical frame of reference for understanding the development of smoking. DATA SOURCES General Science Index, Medline, PsycLIT, Sociofile, Sociological Abstracts, and Smoking and Health. Holdings of the Addiction Research Foundation of Ontario Library as well as the authors’ personal files. STUDY SELECTION Reviewed literature focused on studies that examined the association of sociodemographic, environmental, behavioural, and personal variables with smoking. DATA SYNTHESIS Adolescent smoking was associated with age, ethnicity, family structure, parental socioeconomic status, personal income, parental smoking, parental attitudes, sibling smoking, peer smoking, peer attitudes and norms, family environment, attachment to family and friends, school factors, risk behaviours, lifestyle, stress, depression/distress, self-esteem, attitudes, and health concerns. It is unclear whether adolescent smoking is related to other psychosocial variables. CONCLUSIONS Attempts should be made to use common definitions of outcome and predictor variables. Analyses should include multivariate and bivariate models, with some attempt in the multivariate models to test specific hypotheses. Future research should be theory driven and consider the range of possible factors, such as social, personal, economic, environmental, biological, and physiological influences, that may influence smoking behaviour. The apparent inconsistencies in relationships between parental socioeconomic status and adolescent disposable income need to be resolved as does the underlying constructs for which socioeconomic status is a proxy.

Psychosocial, behavioural, and health determinants of successful smoking cessation: a longitudinal study of Danish adults

Abstract: OBJECTIVE—To examine the factors that determine whether or not smokers become long-term quitters, and to study whether determinants of successful cessation differ with levels of motivation to stop. DESIGN—In a cohort of men and women, aged 30-60 years at first examination in 1982/1984, smoking behaviour was evaluated from questionnaires at baseline and at follow up 10 years later. SETTING—County of Copenhagen, Denmark PARTICIPANTS—2554 subjects from the original sample of 4581 were successfully followed. This study deals with the 1365 subjects who were smokers at the first examination. MAIN OUTCOME MEASURE—Smoking status (abstinent for one year or more) at follow up. RESULTS—At follow up 15% of the baseline smokers had been abstinent for one year or more. In multivariate analysis, successful smoking cessation was associated with older age, high social status, low prior tobacco consumption, baseline motivation to stop smoking, and having a non-smoking spouse/cohabitant. The same result was obtained when the analyses were repeated separately for smokers with and without motivation to stop. CONCLUSIONS—Smokers motivated to stop are more likely to quit and remain abstinent than smokers with no such motivation. Age, social status, spouse/cohabitant's smoking behaviour, and the daily consumption of tobacco predict success in smoking cessation, irrespective of smokers' former motivation to stop. Keywords: smoking cessation predictors; Denmark

Filter ventilation and nicotine content of tobacco in cigarettes from Canada, the United Kingdom, and the United States

Abstract: OBJECTIVES The purpose was to determine filter ventilation and the nicotine content of tobacco and their contribution to machine-smoked yields of cigarettes from the United States, Canada, and the United Kingdom. METHODS Ninety-two brands of cigarettes (32 American, 23 Canadian, and 37 British brands) were purchased at retail outlets in State College, Pennsylvania, United States, Toronto, Canada, and London, United Kingdom. A FIDUS FDT filter ventilation tester measured the percentage air-dilution from filter vents. High-pressure, liquid chromatography was used to measure the nicotine content of tobacco. Regression techniques were used to examine the contributions of tobacco nicotine content and filter ventilation to machine-smoked yields of tar, nicotine, and carbon monoxide (CO). RESULTS Ninety-four per cent of the American brands, 91% of the Canadian brands, and 79% of British brands were ventilated. The total nicotine content of tobacco and percent nicotine (by weight of tobacco) averaged 10.2 mg (standard error of the mean (SEM) 0.25, range: 7.2 to 13.4) and 1.5% (SEM 0.03, range 1.2 to 2) in the United States, 13.5 mg (SEM 0.49, range: 8.0 to 18.3) and 1.8% (SEM 0.06, range: 1.0 to 2.4) in Canada, 12.5 mg (SEM 0.33, range: 9 to 17.5) and 1.7% (SEM 0.04, range: 1.3 to 2.4) in the United Kingdom. Multiple regression analyses showed that ventilation was by far the largest factor influencing machine-smoked yields of tar, nicotine, and CO. CONCLUSION Filter ventilation appears to be the predominant method for reducing machine-smoked yields of tar, nicotine, and CO in three countries. However, some brands contain about twice as much nicotine (total content or percent nicotine) as do others, indicating that tobacco types or blends and tobacco casings can be used to manipulate nicotine content and nicotine delivery of cigarettes.

Errors in using tobacco withdrawal scale

Abstract: Editor,— Several scientists and clinicians have used a tobacco withdrawal scale either received from us or based on our published work. We would like to make some suggestions about use of our scale to minimise misinterpretation. First, the name we prefer is the “Minnesota Nicotine Withdrawal Scale.” Second, total withdrawal scores are often reported; however, there is some variance in which symptoms are included and thus scores across studies are not comparable. Many researchers include drowsiness, fatigue, gastrointestinal complaints, headaches, and somatic complaints as scale items because we …

Cigarette smuggling in Europe: who really benefits?

Abstract: Cigarette smuggling, now on the increase, is so widespread and well organised that it poses a serious threat to public health. This threat comes from two principal directions. First, smuggling makes cigarettes available cheaply, thereby increasing consumption. A third of annual global exports go to the contraband market, representing an enormous impact on consumption, and thus causing an increase in the burden of disease, especially in poorer countries. It is also costing government treasuries thousands of millions of dollars in lost tax revenue. Second, the tobacco industry uses smuggling politically, lobbying governments to lower tax, arguing that smuggling is caused by price differences. This paper shows that the claimed correlation between high prices and high levels of smuggling does not exist in western Europe. In fact, countries such as Norway and Sweden, with expensive cigarettes, do not have a large smuggling problem, whereas countries in the south of Europe do. Cigarette smuggling is not caused principally by "market forces". It is mainly caused by fraud, by the illegal evasion of import duty. The cigarettes involved are not the cheap brands from southern European countries, for which there is no international market. It is the well-known international brands such as Marlboro and Winston. We propose much tighter regulation of cigarette trade, including an international transport convention, and a total ban on transit trade-sale by the manufacturers to dealers, who sell on to smugglers.

Reducing children’s exposure to environmental tobacco smoke in homes: issues and strategies

Abstract: It is now well established that children's exposure to environmental tobacco smoke (ETS) results in substantial public health and economic impacts. Children are more likely than adults to suffer health effects from ETS exposure, and the home is the most important site of such exposure. Although the responsibility and authority of the community and health professionals to protect children from harm are entrenched in North American society, social, economic, legal, and political factors contribute to a lower level of support for ETS control measures in homes compared with workplaces and public places. It is now clear that ETS control in home environments must be a priority on the public health agenda. Programme and policy options and strategies for ETS control in home environments are outlined. We conclude that the current research base is inadequate to fully support programme and policy development in this area and priorities for research are identified. Keywords: environmental tobacco smoke; homes; children

Patterns of smoking in Russia.

Abstract: BACKGROUND Tobacco is a leading cause of avoidable death in Russia but there is, as yet, relatively little information in the public domain on who is smoking and how this is changing. This information is important for those seeking to develop effective policies to tackle this issue. OBJECTIVE To determine the prevalence of smoking in Russia and its association with sociodemographic factors. DESIGN Cross-sectional survey on patterns of tobacco consumption. SETTING Data were collected using the New Russia Barometer, a multi-stage stratified-sample survey of the population of the Russian Federation undertaken in the summer of 1996. PARTICIPANTS Data were available on 1587 individuals (response rate 65.7%). Respondents differed little from the overall Russian population in terms of age, sex, education, and voting intention. MAIN OUTCOME MEASURES Prevalence of current and past smoking. RESULTS Smoking is common among males of all ages and in all areas. Of those aged 18–24 years, 65% smoke, rising to 73% in those aged 25–34 and then falling steadily to reach 41% in those aged 65 and older. Among women, smoking is much more common among the young (27% in those aged 18–34) than among the middle-aged and elderly (5% in those aged 55 and older), and more common among those living in urban areas than in rural areas. Smoking is also more common among men and women suffering material deprivation but there is no independent association with education. Among men, but not women, church attendance is inversely associated with smoking. In both sexes, but especially women, heavy drinking and smoking are associated. CONCLUSIONS Tobacco poses a major threat to the health of future generations in Russia, especially among women. A robust policy response is required.

Seeing, wanting, owning: the relationship between receptivity to tobacco marketing and smoking susceptibility in young people

Abstract: OBJECTIVE—To assess the effect of the tobacco industry's marketing practices on adolescents by examining the relationship between their receptivity to these practices and their susceptibility to start smoking. DESIGN—Paper-and-pencil surveys measuring association with other smokers, exposure to tobacco industry marketing strategies, experience with smoking, and resolve not to smoke in the future. SETTING—25 randomly selected classrooms in five middle schools in San Jose, California. SUBJECTS—571 seventh graders with an average age of 13 years and 8 months; 57% were female. Forty-five per cent of the students were Asian, 38% were Hispanic, 12% were white, and 5% were black. MAIN OUTCOME MEASURES—Exposure to social influences, receptivity to marketing strategies, susceptibility to start smoking. RESULTS—About 70% of the participants indicated at least moderate receptivity to tobacco marketing materials. Children who are more receptive are also more susceptible to start smoking. In addition to demographics and social influences, receptivity to tobacco marketing materials was found to be strongly associated with susceptibility. CONCLUSIONS—Tobacco companies conduct marketing campaigns that effectively capture teenage attention and stimulate desire for their promotional items. These marketing strategies may function to move young teenagers from non-smoking status toward regular use of tobacco. Our results demonstrate that there is a clear association between tobacco marketing practices and youngsters' susceptibility to smoke. The findings, along with other research, provide compelling support for regulating the manner in which tobacco products are marketed, to protect young people from the tobacco industry's strategies to reach them. Keywords: adolescents; advertising; smoking initiation

Reducing the addictiveness of cigarettes. Council on Scientific Affairs, American Medical Association

Abstract: OBJECTIVE—To assess the feasibility of reducing tobacco-caused disease by gradually removing nicotine from cigarettes until they would not be effective causes of nicotine addiction. DATA SOURCES—Issues posed by such an approach, and potential solutions, were identified from analysis of literature published by the US Food and Drug Administration (FDA) in its 1996 Tobacco Rule, comments of the tobacco industry and other institutions and individuals on the rule, review of the reference lists of relevant journal articles, other government publications, and presentations made at scientific conferences. DATA SYNTHESIS—The role of nicotine in causing and sustaining tobacco use was evaluated to project the impact of a nicotine reduction strategy on initiation and maintenance of, and relapse to, tobacco use. A range of potential concerns and barriers was addressed, including the technical feasibility of reducing cigarette nicotine content to non-addictive levels, the possibility that compensatory smoking would reduce potential health benefits, and whether such an approach would foster illicit ("black market") tobacco sales. Education, treatment, and research needs to enable a nicotine reduction strategy were also addressed. The Council on Scientific Affairs came to the following conclusions: (a) gradually eliminating nicotine from cigarettes is technically feasible; (b) a nicotine reduction strategy holds great promise in preventing adolescent tobacco addiction and assisting the millions of current cigarette smokers in their efforts to quit using tobacco products; (c) potential problems such as compensatory over-smoking of denicotinised cigarettes and black market sales could be minimised by providing alternate forms of nicotine delivery with less or little risk to health, as part of expanded access to treatment; and (d) such a strategy would need to be accompanied by relevant research and increased efforts to educate consumers and health professionals about tobacco and health. CONCLUSIONS—The council recommends the following: (a) that cessation of tobacco use should be the goal for all tobacco users; (b) that the American Medical Association continue to support FDA authority over tobacco products, and FDA classification of nicotine as a drug and tobacco products as drug-delivery devices; (c) that research be encouraged on cigarette modifications that may result in less addicting cigarettes; (d) that the FDA require that the addictiveness of cigarettes be reduced within 5-10 years; (e) expanded surveillance to monitor trends in the use of tobacco products and other nicotine-containing products; (f) expanded access to smoking cessation treatment, and strengthening of the treatment infrastructure; and (g) more accurate labelling of tobacco products, including a more meaningful and understandable indication of nicotine content. Keywords: American Medical Association; addiction; nicotine; smoking cessation

Training pharmacists and pharmacy assistants in the stage-of-change model of smoking cessation: a randomised controlled trial in Scotland

Abstract: OBJECTIVE To evaluate a training workshop for community pharmacy personnel to improve their counselling in smoking cessation based on the stage-of-change model. DESIGN A randomised controlled trial of community pharmacies and pharmacy customers. SETTING All 76 non-city community pharmacies registered in Grampian, Scotland, were invited to participate. Sixty-two pharmacies (82%) were recruited. SUBJECTS All the intervention pharmacy personnel were invited to attend the training; 40 pharmacists and 54 assistants attended. A total of 492 customers who smoked (224 intervention, 268 controls) were recruited during the 12-month recruitment period (overall recruitment rate 63%). MAIN OUTCOME MEASURES The perceptions of customers and pharmacy personnel of the pharmacy support and self-reported smoking cessation rates for the two groups of customers at one, four, and nine months. RESULTS The intervention customer respondents were significantly more likely to have discussed stopping smoking with pharmacy personnel, 85% (113) compared with 62% (99) of the controls (p CONCLUSIONS The intervention was associated with increased and more highly rated counselling, and a trend toward higher smoking cessation rates, indicating that community pharmacy personnel have the potential to make a significant contribution to national smoking cessation targets.

One-year predictors of smoking initiation and of continued smoking among elementary schoolchildren in multiethnic, low-income, inner-city neighbourhoods

Abstract: OBJECTIVE To identify one-year predictors of smoking initiation among never-smokers, and of continued smoking among ever-smokers. DESIGN Two sequential cohorts of grade 4 and 5 children. Data were collected as part of Coeur en sante St Louis du Parc, a non-randomised controlled trial to evaluate the impact of a school-based heart health promotion programme. SETTING 24 inner-city elementary schools located in multiethnic, low-income neighbourhoods in Montreal. SUBJECT 1824 schoolchildren aged 9–12 years with baseline and one-year follow-up data. MAIN OUTCOME MEASURES Changes in smoking behaviour over a year; the ability of baseline data to predict smoking initiation and continued smoking a year later was investigated in logistic regression analyses. RESULTS The prevalence of ever-smoking was 21.1% at baseline and 30.2% at one-year follow up. One in six never-smokers initiated smoking; one in three ever-smokers continued smoking. Predictors of initiation included age (odds ratio (OR) = 1.6, 95% confidence interval (CI) = 1.3 to 2.0), male gender (OR = 1.5 (95% CI = 1.1 to 2.0)), friends who smoke (OR = 2.3 (95% CI = 1.7 to 3.3)), sibling(s) who smoke (OR = 1.9 (95% CI = 1.2 to 3.1)), father/mother who smokes (OR = 2.2 (95% CI = 1.6 to 3.0)), and frequent high fat/“junk food” consumption (OR = 1.6 (95% CI = 1.1 to 2.1)). Age and friends who smoke were also independent predictors of continued smoking in both genders. In addition, in boys, current smokers at baseline were 2.6 times (95% CI = 1.4 to 5.0) more likely to continue smoking than past smokers. In girls, being overweight was associated with continued smoking (OR = 3.5 (95% CI = 1.6 to 7.6)). CONCLUSIONS Smoking prevention programmes should address parental and sibling influences on smoking, in addition to refusal skills training. Among girls, weight-related issues may also be important.

The return of scare tactics

Abstract: Can you scare people out of smoking? Since Janis and Feshbach’s influential research on the use of fear in dental hygiene education in the early 1950s,1 several generations of health educators have often uncritically accepted as near holy writ that you should not try to scare people into healthy practices, including smoking prevention and cessation.2 3 Given that survey evidence from ex-smokers has repeatedly affirmed that personalised concern about “scary” health consequences is the primary motivation ascribed to smoking cessation4-6 and is associated with predictors of cessation,7 interesting questions arise about whether this dogma is empirically grounded or whether it rather reflects a profession-wide neurosis intent on avoiding opprobrium from those who believe it is somehow not “nice” to deal in gory imagery in the name of persuasion.8 A mass media-led campaign launched in Australia in June 1997 has been seen by many as “the mother of all scare campaigns” (see the illustrations on the cover of this issue of Tobacco Control , the figure in this essay, the campaign-related material on the world wide web at , and the description of that web site on page 89). The television advertising campaign has been described repeatedly as “hard-hitting”, “gory”, and something smokers will “see once and never forget”. It has since been used by the state of Massachusetts tobacco control programme9 with dozens of other international enquiries also having been received. To some, the campaign might be seen as something of a health promotion profanity in the wake of recent so-called “positive” practice—for example, campaigns using every manner of non-smoking role model; general proselytising about “healthy lifestyles”, freshness, and so on). However, to others it represents the culmination of a painstaking formative research process undertaken in the context of a stalled decline …

Mortality attributable to cigarette smoking in Taiwan: a 12-year follow-up study

Abstract: BACKGROUND Assessment of the impact of cigarette smoking on mortality helps to indicate the importance of tobacco control in a given country. OBJECTIVES To examine the relative risk of dying from various diseases for cigarette smoking and to estimate annual mortality attributable to cigarette smoking in Taiwan. DESIGN Prospective cohort study. SUBJECTS AND SETTING A cohort of 14 397 male and female residents aged 40 years or older recruited from 12 townships and precincts in Taiwan from 1982 to 1986. Information on cigarette smoking was collected from each subject at local health centres through a standardised personal interview based on a structured questionnaire. They were followed up regularly to determine their vital status until 1994. MAIN OUTCOME MEASURES Cox’s proportional hazards regression models were used to derive relative risks of cause-specific mortality for current cigarette smokers compared with never-smokers, and to examine dose-response relationships between mortality from various causes and several measures of cigarette smoking (daily consumption, duration, age of initiation, and cumulative smoking in pack-years). RESULTS A total of 2552 persons died during the study period. Among men, cigarette smoking was significantly associated with an increased risk of dying from all causes combined (relative risk (RR) = 1.3); cancer of all sites combined (RR = 1.5); cancers of the stomach (RR = 1.9), liver (RR = 2.2), and lung (RR = 3.7); ischaemic heart disease (RR = 1.8); other heart diseases (RR = 1.4); and chronic obstructive pulmonary disease (RR = 1.9). Among women, cigarette smoking was significantly associated with an increased risk of dying from all causes combined (RR = 1.8), cancer of the lung (RR = 3.6), and peptic ulcer (RR = 17.8). The estimated number of deaths attributable to cigarette smoking in Taiwan in 1994 was 8161 (13.9% of total deaths) for men and 1216 (3.3% of total deaths) for women. In the same year cigarette smoking caused 21.3% and 2.9% of cancer deaths in men and women, respectively, in Taiwan. CONCLUSIONS Cigarette smoking has a striking impact on overall mortality and deaths from various causes in the Taiwanese population. Tobacco control should be established as the top priority in public health programmes in Taiwan.

Green tobacco sickness

Abstract: OBJECTIVE—To describe the health impact of harvesting tobacco and to suggest prevention and risk reduction strategies to avoid contracting green tobacco sickness (GTS). DATA SOURCES—A literature search of Medline, Toxline, and Toxline65 with the terms "green", "tobacco", and "sickness" covering the years 1966-1998. STUDY SELECTION—All studies, reviews, and commentaries that provided information on the health effects of harvesting green tobacco and disease prevention strategies. DATA SYNTHESIS—GTS occurs when tobacco workers hand-harvest, cut, or load tobacco plants, usually in the early morning or after a rainfall when tobacco plants are covered with moisture. GTS occurs through skin exposure to dissolved nicotine from tobacco leaves. Symptoms of GTS include weakness, headache, nausea, vomiting, dizziness, abdominal cramps, breathing difficulty, abnormal temperature, pallor, diarrhoea, chills, fluctuations in blood pressure or heart rate, and increased perspiration and salivation. The onset of the illness is three to 17 hours after exposure and the duration of illness is one to three days. Initial treatment includes cessation of work, change of clothing, showering, fluid intake, and rest. In more extreme cases, intravenous rehydration, anti-emetics, and dimenhydrinate are administered. Protective, water-resistant clothing; chemical-resistant gloves, boots, and socks; working in dry conditions; and dimenhydrinate can reduce the likelihood of contracting GTS. CONCLUSIONS—It is important to provide education to tobacco workers and employers about GTS. An international public awareness campaign about GTS timed to coincide with the tobacco harvest, along with enforced worker safety regulations, should be undertaken to protect the health of individuals working in tobacco production.

Adolescents’ responses to cigarette advertisements: links between exposure, liking, and the appeal of smoking

Abstract: Objective—To evaluate adolescents’ responses to cigarette advertisements for diVerent brands. Design—Adolescents were shown one print advertisement for each of five cigarette brands (Camel, Marlboro, Kool, Benson & Hedges, and Lucky Strike). They indicated on a structured questionnaire how many times they had seen the advertisement (or one almost like it), how much they liked it, whether or not they thought it made smoking more appealing, and whether or not it made them want to smoke cigarettes of that brand. Setting—Middle school and high school classrooms, seven schools in four states in the United States (New York, Pennsylvania, Ohio, and Texas). The classrooms were selected randomly within each school. Participants—534 adolescents in grades 6‐12 (ages 11‐18 years) from seven schools in four states, 54% female, 76% white. Results—The advertisements for Camel and Marlboro were more likely than the advertisements for the other brands to be seen, to be liked, to be viewed as making smoking appealing, and to influence adolescents to want to smoke cigarettes of that brand. More than 95% of the adolescents had seen an advertisement featuring Joe Camel or the Marlboro Man at least once, and more than 50% had seen these advertisements six or more times. Nearly half believed that the Joe Camel advertisement makes smoking more appealing, and 40% believed that the Marlboro Man advertisement makes smoking more appealing. Adolescent smokers were more likely than nonsmokers to believe that the advertisements for Camel and Marlboro make smoking more appealing. Conclusions—The advertisements most popular among adolescents are for two of the brands they are most likely to smoke— Marlboro and Camel. The results of the study are consistent with the view that certain cigarette advertisements enhance the appeal of smoking to many adolescents. (Tobacco Control 1998;7:129‐133)

Implementing smoking bans in American hospitals: results of a national survey

Abstract: Objectives—To determine how well hospitals complied with the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) tobacco control standards, which required banning smoking in hospital buildings; to explore issues involved in developing and implementing smoking bans; and to ascertain the perceived success of the policies. Design—Postal survey conducted January through June 1994. Participants—Stratified random sample of American hospitals surveyed by JCAHO (n = 1055). Main outcome measures—Enacting smoking policies more restrictive than the JCAHO standard; the respondent’s judgment of the relative success of the hospital’s smoking policy. Results—More than 96% of hospitals complied with the smoking ban standard; 41.4% enacted policies that were more restrictive than required by JCAHO. Several characteristics were associated with exceeding JCAHO requirements: location in a “non-tobacco state”; having fewer than 100 beds; location in a metropolitan statistical area; having unionised employees; and having no psychiatric or substance abuse unit, favour having the same tobacco policy in psychiatry and substance abuse units as the rest of the hospital. More than 95% of respondents viewed their hospital’s policy as successful. The JCAHO requirements and concern for employees’ health were the major forces influencing hospitals to go smoke-free. Negative employee morale and lack of acceptance by visitors and patients were the most commonly cited barriers to overcome when implementing smoke-free policies. Conclusions—Smoking bans were successfully implemented in American hospitals, with many restricting smoking beyond the JCAHO standard. Other industries wishing to follow hospitals’ lead would be most likely to succeed in the context of a social norm favouring a smoking ban and regulation by an outside agency.

Association of environmental tobacco smoke exposure with socioeconomic status in a population of 7725 New Zealanders

Abstract: OBJECTIVE—To test the hypothesis that environmental tobacco smoke (ETS) exposure is inversely associated with socioeconomic status. DESIGN—Survey. SETTING—General community, New Zealand. PARTICIPANTS—7725 non-smoking adults (volunteer sample of a multi-industry workforce, n = 5564; and a random sample of urban electoral rolls, n = 2161), including 5408 males; mean age 45 years. MAIN OUTCOME MEASURES—ETS exposure was assessed as self-reported number of hours per week spent near someone who is smoking, and as prevalence of regular exposure to some ETS. Socioeconomic status was assessed as educational level, occupational status, and median neighbourhood household income. RESULTS—Both measures of ETS exposure were steeply and inversely associated with all three indicators of socioeconomic status (all p<0.0001). Geometric mean ETS exposure ranged from 16 minutes per week among university-educated participants to 59 minutes per week in the second lowest occupational quintile (95% confidence intervals: 14-18 minutes per week and 54-66 minutes per week). The associations with occupational status and educational level were steeper than those with neighbourhood income. The socioeconomic gradients of ETS exposure were steeper among participants aged less than 35 years than among participants aged over 50 years, among men than women, and among Maori than Europeans. CONCLUSIONS—In this study population, ETS exposure was inversely associated with socioeconomic status. Greater ETS exposure might therefore contribute to the higher risks of disease and death among low socioeconomic groups. These results provide a further rationale for targeting tobacco control measures to people in low socioeconomic groups. Keywords: environmental tobacco smoke; socioeconomic status; population survey

Worldwide survey of education on tobacco in medical schools

Abstract: OBJECTIVES To determine the extent of teaching about tobacco, tobacco-related diseases, and smoking cessation techniques in medical schools around the world; and to ascertain the problems of getting the teaching about tobacco onto the medical curriculum. DESIGN Cross-sectional survey. Questionnaires were sent to the 1353 medical schools in 143 countries around the world using the World Health Organization’s Directory of Medical Schools. The questionnaire was translated from English into French, Russian, Mandarin, and Japanese. SUBJECTS Deans of medical schools worldwide, or their nominees. MAIN OUTCOME MEASURES Extent and format of teaching about tobacco in the medical curriculum, objectives and content of the courses on tobacco, and problems encountered in introducing the topic of tobacco. RESULTS 493 medical schools responded, representing 64% of countries and 36% of schools. Only 12% of medical schools did not cover the topic of tobacco in the medical curriculum. 58% of medical schools taught about tobacco during the teaching of other subjects. 40% taught tobacco by systematically integrating teaching with other modules. 11% had a specific module on tobacco. The medical schools reported on the objectives and content of their courses on tobacco, which commonly included knowledge about tobacco-related diseases and pharmacological issues. Only a third taught about smoking cessation techniques. 22% had encountered problems in introducing the topic of tobacco, and respondents offered solutions to overcome these problems. CONCLUSIONS Medical schools need continued encouragement to include tobacco issues in their curricula, with particular emphasis on teaching about smoking cessation techniques.

State laws on youth access to tobacco in the United States: measuring their extensiveness with a new rating system

Abstract: OBJECTIVE To develop and implement a rating system evaluating the extensiveness of state laws restricting youth access to tobacco. DESIGN State laws on youth access to tobacco were analysed and assigned ratings on nine items. Six items addressed specific tobacco-control provisions, and three related to enforcement provisions. For each item, a target was specified reflecting public health objectives. Achieving the target resulted in a rating of +4 points; for three items, a rating of +5 was possible if the target was exceeded. Criteria for lower ratings were established for situations when the target was not met. SETTING United States . RESULTS State scores (sum of the ratings across all nine items) ranged from 0–18 in 1993, 2–21 in 1994, and 1–21 in 1995 and 1996, out of a possible total of 39. The average score across states was 7.2 in 1993, 7.9 in 1994, 8.2 in 1995, and 9.0 in 1996. The overall mean rating (per item) was 0.80 in 1993, 0.88 in 1994, 0.91 in 1995, and 1.00 in 1996, on a scale where 4.0 indicates that the target goals (per item) were met. From 1993 to 1996, scores increased for 20 states, decreased for one state, and remained unchanged for the others. The number of states for which state preemption of local tobacco regulation was a factor doubled from 10 states in 1993 to 20 states in 1996. CONCLUSIONS Although all states have laws addressing youth access to tobacco, this analysis reveals that, as of the end of 1996, the progress towards meeting health policy targets is slow, and state legislation that preempts local tobacco regulation is becoming more common.

Tobacco control advocates must demand high-quality media campaigns: the California experience

Abstract: OBJECTIVE—To document efforts on the part of public officials in California to soften the media campaign's attack on the tobacco industry and to analyse strategies to counter those efforts on the part of tobacco control advocates. METHODS—Data were gathered from interviews with programme participants, direct observation, written materials, and media stories. In addition, internal documents were released by the state's Department of Health Services in response to requests made under the California Public Records Act by Americans for Nonsmokers' Rights. Finally, a draft of the paper was circulated to 11 key players for their comments. RESULTS—In 1988 California voters enacted Proposition 99, an initiative that raised the tobacco tax by $0.25 and allocated 20% of the revenues to anti-tobacco education. A media campaign, which was part of the education programme, directly attacked the tobacco industry, exposing the media campaign to politically based efforts to shut it down or soften it. Through use of outsider strategies such as advertising, press conferences, and public meetings, programme advocates were able to counter the efforts to soften the campaign. CONCLUSION—Anti-tobacco media campaigns that expose industry manipulation are a key component of an effective tobacco control programme. The effectiveness of these campaigns, however, makes them a target for elimination by the tobacco industry. The experience from California demonstrates the need for continuing, aggressive intervention by non-governmental organisations in order to maintain the quality of anti-tobacco media campaigns. Keywords: media campaigns; anti-tobacco advocacy; California

Patterns of smoking in Bulgaria

Abstract: BACKGROUND—Although the rate of smoking-related deaths in Bulgaria is still relatively low, in international terms, it has been rising rapidly. This is likely to become worse in the future as Bulgaria faces growing pressure from transnational tobacco companies. There is, however, little information on patterns of smoking, which is necessary for development of effective policies to tackle tobacco consumption. OBJECTIVE—To describe the pattern of smoking in Bulgaria and its relationship with sociodemographic factors. DESIGN—Multivariate analysis of data on patterns of tobacco consumption from a multi-stage nationwide survey of 1550 adults. SETTING—Bulgaria, in 1997. MAIN OUTCOME MEASURE—Prevalence of current cigarette smoking. RESULTS—38.4% of men and 16.7% of women smoke. Smoking rates are strongly associated with age, with 58% of men and 30% of women aged 30-39 smoking whereas only 5% of men aged 70 years and older and almost no women of this age smoke. Smoking is more common in cities, among those who are widowed or divorced, or who do not own their home. There is no clear association with household income or, for men, with education, although there is a suggestion that smoking may be more common among more highly educated women. CONCLUSIONS—The observed pattern of smoking indicates the need for a robust policy to tackle smoking in Bulgaria, especially among the young in large cities, informed by a better understanding of why smoking rates vary among different groups. Keywords: smoking prevalence; Bulgaria

Patterns of smoking, risk factors for smoking, and smoking cessation among Vietnamese men in Massachusetts (United States).

Abstract: OBJECTIVES To measure the prevalence and patterns of, and risk factors for, smoking and other tobacco use among Vietnamese men in Massachusetts (United States). METHODS Data were obtained via a telephone interview of 774 Vietnamese men in 1994. DESIGN Cross-sectional survey administered via telephone in 1994. SETTING Massachusetts, United States. SUBJECTS Randomly selected Vietnamese men (n = 774). MAIN OUTCOME MEASURES Present and past use of tobacco products, knowledge and attitudes regarding tobacco, and risk factors for tobacco use. Results were compared with data from the Massachusetts general population. RESULTS Vietnamese men smoked at a rate 1.9 times that of the Massachusetts general men’s rate (43% vs 24%). The smoking rate did not decrease with increasing length of residence in the United States. In a logistic regression, risk factors for current smoking were: age in the thirties; history of parental smoking; lower educational level; higher depression score; low level of exercise; lack of health insurance; and geographical origin from the south coast of Vietnam. Smoking cessation declined with increasing depression score. Most smokers (76%) had no plans to quit smoking. CONCLUSIONS Vietnamese men smoke at much higher rates than the general population, and are much less likely to be planning cessation. High rates of depression and sociocultural barriers to smoking cessation must be addressed in efforts to reduce tobacco use among this high-risk population.

To what extent do parents strive to protect their children from environmental tobacco smoke in the Nordic countries? A population-based study

Abstract: Objective—To assess to what extent Nordic parents strive to protect their children from environmental tobacco smoke (ETS) at home. Design—A cross-sectional study using an anonymous questionnaire. Subjects and setting—A stratified, random sample of 5500 households containing a child born during 1992, including 1500 households in Denmark and 1000 households in each of the countries of Finland, Iceland, Norway, and Sweden. Main outcome measures—Smoking status of parents, prevalence and magnitude of weekly ETS exposure, rules regarding smoking in the home. Results—82% of current smokers reported having tried to change their smoking behaviour for the sake of their children. Of all parents who answered the questionnaire, 75% reported having introduced some rules to limit ETS in their home. In households where at least one parent smoked, 57% reported that children were exposed to ETS at home. Child exposure to ETS was most prevalent in single-parent households and in households in which parents had lower levels of education. However, these parents were not less likely than other smoking parents to report having tried to change their smoking behaviour for the sake of their children. Conclusion—Environmental tobacco smoke at home is still a problem for many children in the Nordic countries. However, most smoking parents reported having made eVorts to change their smoking behaviour for the sake of their children; and in approximately half of all households containing at least one daily smoker, parents reported protecting their children from ETS exposure in the home. Although actual exposure may be higher owing to possible under-reporting of ETS, our results indicate a general awareness in the Nordic countries of the potential negative eVects of ETS on children. (Tobacco Control 1998;7:56‐60)

Smoking prevalence and risk factors for smoking in a population of United States Air Force basic trainees

Abstract: OBJECTIVE—To provide a comprehensive assessment of smoking prevalence and risks for smoking in an entire population of United States Air Force (USAF) military basic trainees (n = 32 144). DESIGN—Population-based survey with every individual entering the USAF enlisted force from August 1995 to August 1996. SETTING—USAF Basic Military Training (BMT) facility at Lackland Air Force Base, Texas. All trainees were assessed during the first week of BMT. MAIN OUTCOME MEASURES—A 53-item questionnaire was developed to assess four domains: demographics, smoking history, risk factors for smoking, and other health behaviours. RESULTS—Approximately 32% of the trainees smoked regularly before basic training and a small percentage of the trainees (7.6%) described themselves as ex-smokers. Men, Euro-Americans, and those from lower educational backgrounds were more likely to smoke than other trainees. On average, smokers had smoked for approximately four years and had low nicotine dependence scores. Individuals who had smoked before BMT were more likely to use other drugs (such as alcohol, binge drinking, smokeless tobacco), and were less physically active than never-smokers. These findings were particularly strong for those who smoked up to basic training but were also evident for ex-smokers. CONCLUSIONS—Smoking is a prevalent risk factor among individuals entering the USAF. Furthermore, smoking was related to other risk factors believed to lower military readiness, including alcohol use and decreased physical activity. Comprehensive tobacco control policies aimed at reducing smoking among military trainees are needed. Keywords: military trainees; smoking prevalence; United States

Tobacco use and the United States military: a longstanding problem

Abstract: Ties between the United States military and the tobacco industry trace back to the early parts of the 20th century. During the second world war, for example, cigarette advertisements praising service members were widespread on popular radio programmes and in periodicals.1 Some ads even featured cigarette-using doctors vouching for the great taste and mildness of particular brands. Cigarettes were also included as part of the K-rations and C-rations provided to soldiers and sailors during the second world war, and these cigarettes frequently became more valuable for trading or selling than the food items in the rations. During times of war and peace, many young people (predominantly men, as they have traditionally comprised the bulk of military personnel) started smoking after they joined the military. In fact, it has been widely acknowledged in military circles that many young soldiers and sailors first started smoking during their initial military “boot camp” training. Before 1987, when tobacco use was banned at most training commands across the military services, giving or denying “smoke breaks” was a common form of reward and punishment used by drill instructors and company commanders training new soldiers or sailors.2 If recruits did not already smoke when they entered the military, in boot camp they quickly learned that smoking to get a work break was a desirable thing to do. Even beyond recruit training, the military culture—at least until relatively recently—has traditionally fostered the stereotype of heavy-smoking, hard-drinking, and adventuresome service members. This image has had empirical support from several studies indicating that military rates of tobacco and alcohol use have been higher than those found in comparable civilian sectors.3-7 As of 1995, however, the military/civilian differences in tobacco use have narrowed.8 Considering all the services combined, the differences between the military and standardised civilian samples …

Roll-your-own smoke yields: theoretical and practical aspects

Abstract: OBJECTIVE—To identify the key parameters that influence smoke yields from roll-your-own (RYO) cigarettes and to compare smoke yields of cigarettes made under laboratory conditions with those made by habitual RYO consumers. DESIGN AND SETTING—One-way parametric variations in the laboratory-based production of RYO cigarettes complemented by a consumer survey conducted in a busy street at Romford, Essex, United Kingdom. SUBJECTS—26 habitual RYO consumers. MAIN OUTCOME MEASURES—Cigarette weights, puff numbers, and yields (carbon monoxide, nicotine, and tar). RESULTS—Smoke yields vary for specimen changes in weight of tobacco used, paper porosity, and the incorporation of a filter in the cigarette. Yields of cigarettes produced by 26 RYO smokers ranged from 9.9 to 21.0 mg tar per cigarette and from 0.9 to 1.8 mg nicotine per cigarette, and were generally lower than yields of laboratory-produced RYO cigarettes. CONCLUSIONS—Laboratory studies can provide useful information concerning the parameters that affect smoke yields of RYO cigarettes such as the incorporation of a filter to reduce yields. However, such studies must be complemented by surveys of cigarettes made by actual current RYO smokers. In one such investigation, it was found that the mean tar yields from cigarettes produced by 57% of the smokers were above the current maximum of 15 mg per cigarette for manufactured cigarettes. Currently 8% of manufactured cigarettes in the UK have a declared nicotine yield of greater than 1.1 mg per cigarette whereas 77% of RYO smokers produced cigarettes with a nicotine yield greater than this value. Keywords: roll-your-own cigarettes; smoke yield; carbon monoxide; tar; nicotine

Changes in cigarette smoking among adults in 35 populations in the mid-1980s

Abstract: Objective—To examine changes in the prevalence of cigarette smoking in 35 study populations of the World Health Organisation’s MONICA Project. Design—Data from two independent, community-based surveys conducted, on average,five years apart. Setting—Geographically defined populations in 21 countries mainly in eastern and western Europe. Subjects—Randomly selected men and women aged 25‐64 years. Numbers of participants in each study population ranged from 586 to 2817 in each survey. Main outcome measures—Changes in proportions of current smokers, exsmokers, and never-smokers by age and sex using data collected by standardised methods. Results—Among men, smoking prevalence decreased in most populations, by three to four percentage points over five years. In Beijing, however, it increased in all age groups—overall by 11 percentage points. Among women there were increases in smoking in about half the populations. The increases were mainly in the age group 35‐54 years and often in those populations where smoking prevalence among women has been relatively low. Conclusions—Smoking initiation by middle-aged women in parts of southern and eastern Europe and among men of all ages in Beijing is a matter of concern. The various public health measures that have helped to reduce smoking among men in developed countries should be vigorously extended to these other groups now at growing risk of smoking-related disease. (Tobacco Control 1998;7:14‐21)

Measuring support for tobacco control policy in selected areas of six countries

Abstract: OBJECTIVE To explore the validity, reliability, and applicability of using a short, psychometrically sound survey instrument to measure population attitudes toward tobacco control policies. DESIGN Surveys. SUBJECTS AND SETTING Student respondents attending university in Australia (n = 403), Hong Kong (n = 336), the Netherlands (n = 351), South Africa (n = 291), the United Kingdom (n = 164) and the United States (n = 241); total n = 1786. MAIN OUTCOME MEASURE The Smoking Policy Inventory (SPI), a 35-item scale. SPI scores were adjusted for age, income, gender, and smoking status. Estimates of internal consistency and tests of factorial invariance were conducted in each sample. RESULTS Across all six countries, the SPI was found to be highly reliable and to have a consistent factor structure, indicating that the SPI scale represents a higher order construct that assesses general attitudes about tobacco control policy with five dimensions. In general, the degree of endorsement of anti-tobacco policies as measured by the SPI reflected the extent and strength of tobacco control legislation in those countries. Dutch students were the least likely, and Australian and Hong Kong students the most likely, to support tobacco control policies. CONCLUSIONS It is possible to develop appropriate and meaningful measurement tools for assessing support of tobacco control policies. Strong evidence was found for internal reliability and structural invariance of the SPI. The SPI may be a useful mechanism for monitoring ongoing policy initiatives, making cross-cultural comparisons, and evaluating population receptiveness to proposed policy approaches.

Tobacco COntrol in California: Who's winning the war? An evaluation of the Tobacco Control Program, 1989-1996. Final Report. A report to the California Department of Health Services.

Abstract: Executive Summary PREFACE The California Department of Health Services contracted with the University of California, San Diego, to conduct a series of California Tobacco Surveys and to provide an independent and scientific assessment of the progress of the California Tobacco Control Program. Any interpretations of data or conclusions expressed in this report are those of the authors and may not represent the views of the State of California. A primary goal of the Tobacco Control Program is to reduce smoking among California adults and adolescents. Assessment of Program progress in meeting this goal involves an examination of trends in per capita cigarette consumption and smoking prevalence. Program effects must be distinguished from differences resulting from changes in the demographic profile of the California population. Standardized prevalence estimates were computed to adjust for demographic changes. An effective program would lead to a more rapid decline in smoking than existed previously or that occurred in the rest of the United States. Moreover, the effect should persist over time. The analysis considered two periods in the Tobacco Control Program, suggested by changes in per capita cigarette consumption trends, standardized adult smoking prevalence estimates from the California Tobacco Surveys, and the relative level of funding for the Program and what the tobacco industry spends to promote smoking. Before fiscal year 1992-1993, the ratio of spending was 5: 1 in favor of the tobacco industry and subsequently it was 10:1. The higher ratio resulted from reduced funding for the Tobacco Control Program and increased tobacco industry expenditures. The first part of this executive summary presents a brief overview of the main evaluative outcomes relative to the California Tobacco Control Program: smoking behavior and exposure to secondhand tobacco smoke. Following this brief overview, trends in smoking behavior are discussed in more detail. Finally, other important findings, including those relating to secondhand smoke, are summarized under the five main tobacco control strategies identified by the Tobacco Education, Research, and Oversight Committee (TEROC). OVERVIEW The trends in per capita cigarette consumption and adult smoking prevalence indicate that the introduction of the California Tobacco Control Program led to an acceleration of the rate of decline in smoking, but that this effect was not maintained between 1993 and 1996. Over the course of the Program, there has been a continued major decline in the level of exposure to secondhand tobacco smoke among Californians. BEHAVIOR In Period 1, from the start of the Program in January 1989 through June 1993, adult (18+years) smoking prevalence and per capita cigarette consumption declined over 50% faster than previously, and over 40% faster than in the rest of the United States. In Period 2, July 1993 through December 1996, the rate of decline in per capita cigarette consumption and adult prevalence slowed, consumption to only 34% of the rate of decline in Period 1, and prevalence to only 15% of the Period 1 rate. In Period 2, California no longer showed a greater rate of decline in prevalence than the rest of the United States. However, per capita cigarette consumption was constant in the rest of the United States. The 1996 California Tobacco Survey estimated that adult smoking prevalence was 18.1 %. Adolescent (12-17 years) smoking prevalence in California remained stable in Period 1, but it increased 26.3% during Period 2 to 12.0% in 1996? A detailed analysis of California data suggests that adolescent smoking prevalence will continue to increase through 1999. Between 1993 and 1996, California smokers made considerable progress towards future successful cessation by decreasing consumption levels and increasing their quitting activity. A strong motivational tobacco control program may produce another major reduction in smoking prevalence.

Results from the first annual survey on addressing tobacco in managed care.

Abstract: Managed care organisations (MCOs) enjoy a history of promoting health through preventive services and health maintenance activities. In this unique capacity as healthcare providers, these organisations can effect healthy lifestyle changes in their member populations. The single most important cause of premature death and preventable illness, in the United States today, is cigarette smoking.1 Most individuals who smoke express a desire to quit.2 Through the implementation of smoking cessation programmes, MCOs can play a major part in helping motivated individuals to join the ranks of quitters. As part of the Robert Wood Johnson Foundation initiative, Addressing Tobacco in Managed Care, an annual survey of all managed healthcare plans is being conducted each year from 1997 to 2000. These surveys have the following objectives. The results of the first annual survey are outlined here. The survey was a mailed …