To provide the most reliable evidence as to the nature of the associations between smoking and cause-specific illness, as well as the expected benefits from quitting smoking, in studies conducted in Asia, where smoking remains popular among men.
Studies published between January 1966 and October 2008, identified in the Medline search strategy with medical subject headings, in addition to studies from the Asia Pacific Cohort Studies Collaboration.
Studies were considered to be relevant if they were prospective studies, in an Asian setting that reported on the association between smoking, quitting and cause-specific illness.
Two reviewers independently screened all identified articles for possible inclusion and extracted data.
The pooled relative risks (RRs) for incidence or mortality, comparing current to never smokers were always significantly higher than unity; the highest was for lung cancer: 3.54 (95% confidence interval 3.00 to 4.17). The pooled RRs for former smokers (compared to never smokers) were also always significantly higher than unity, and were lower than in current smokers, for coronary heart disease, stroke, lung and upper aero-digestive tract cancer. Only for respiratory disease was the RR for former smokers higher than that for current smokers.
This meta-analysis has shown that, despite the relative immaturity of the smoking epidemic in Asia, smoking is unquestionably a major contributor to ill health and death. However, the beneficial effects of quitting are not yet always apparent, most probably because quitting is a consequence of ill health and the relative unpopularity of smoking cessation in many Asian populations.
To investigate the relation between household passive smoking exposure and risk of ischaemic heart disease (IHD) among never-smoke female patients by a retrospective case-control analysis.
This study recruited 314 patients with IHD who had never smoked and 319 controls who were admitted for other reasons in the same hospital during the same period. Subjects were interviewed about their exposure to household passive smoking. The dose metrics of passive smoking exposure were evaluated by using "pack years" and "hour years", which indicated the cumulative amount and duration of exposure. The ORs and 95% CIs were computed by unconditional logistic regression, adjusted for other risk factors.
Subjects with passive smoking exposure were associated with higher risk of IHD (OR 1.51, 95% CI 1.01 to 2.27, p = 0.043) when compared to non-exposed subjects. Subjects exposed to an average of >=1 pack of cigarette per day had an OR of 1.69 (95% CI 1.07 to 2.68, p = 0.025). The OR was 1.52 for those exposed for >=5 years (95% CI 1.01 to 2.29, p = 0.043) and was 1.82 for those exposed >=4 h per day (95% CI 1.05 to 3.15, p = 0.032). Similarly, the risk of IHD increased with cumulative exposure duration, with an OR of 1.53 (95% CI 1.01 to 2.32, p = 0.043) at the exposure level >=5 pack years, and an OR of 1.61 (95% CI 1.03 to 2.52, p = 0.037) at the exposure level >=20 hour years. There was a significant dose-response association between the exposure measures and risk of IHD (p<0.01 for trend).
Our data suggested an increased risk of IHD from passive household smoking in female never-smoke subjects, and demonstrated a dose-response association.
To examine the impact of health warnings on smokers by comparing the short-term impact of new graphic (2006) Australian warnings with: (i) earlier (2003) United Kingdom larger text-based warnings; (ii) and Canadian graphic warnings (late 2000); and also to extend our understanding of warning wear-out.
The International Tobacco Control Policy Evaluation Survey (ITC Project) follows prospective cohorts (with replenishment) of adult smokers annually (five waves: 2002–2006), in Canada, United States, UK and Australia (around 2000 per country per wave; total n = 17 773). Measures were of pack warning salience (reading and noticing); cognitive responses (thoughts of harm and quitting); and two behavioural responses: forgoing cigarettes and avoiding the warnings.
All four indicators of impact increased markedly among Australian smokers following the introduction of graphic warnings. Controlling for date of introduction, they stimulated more cognitive responses than the UK (text-only) changes, and were avoided more, did not significantly increase forgoing cigarettes, but were read and noticed less. The findings also extend previous work showing partial wear-out of both graphic and text-only warnings, but the Canadian warnings have more sustained effects than UK ones.
Australia’s new health warnings increased reactions that are prospectively predictive of cessation activity. Warning size increases warning effectiveness and graphic warnings may be superior to text-based warnings. While there is partial wear-out in the initial impact associated with all warnings, stronger warnings tend to sustain their effects for longer. These findings support arguments for governments to exceed minimum FCTC requirements on warnings.
Developing countries are at high risk of epidemic increases in tobacco smoking, but the extent of this problem is not clearly defined because few collect detailed smoking data. We have surveyed tobacco smoking in the Ashanti region of Ghana, a rapidly developing African country with a long-established tobacco industry.
We took a random sample of 30 regional census enumeration areas, each comprising about 100 households, and a systematic sample of 20 households from each. These were visited, a complete listing of residents obtained and questionnaire interviews on current and past smoking, age at smoking uptake, sources of cigarettes and other variables carried out in all consenting residents aged 14 or over.
Of 7096 eligible individuals resident in the sampled households, 6258 (88%; median age 31 (range 14–105) years; 64% female) participated. The prevalence of self-reported current smoking (weighted for gender differences in response) was 3.8% (males 8.9%, females 0.3%) and of ever smoking 9.7% (males 22.0%, females 1.2%). Smoking was more common in older people, those of Traditionalist belief, those of low educational level, the unemployed and the less affluent. Smokers were more likely to drink alcohol and to have friends who smoke. About 10% of cigarettes were smuggled brands. About a third of smokers were highly or very highly dependent.
Despite rapid economic growth and a sustained tobacco industry presence, smoking prevalence in Ghana is low, particularly among younger people. This suggests that progression of an epidemic increase in smoking has to date been avoided.
To identify the impact of a smoking cessation programme on area-based social and ethnic inequalities in smoking rates through social and ethnic differences in enrolment and quitting.
Analysis of records of 11 325 patients who enrolled in an innovative smoking cessation programme in Christchurch, New Zealand between 2001 and 2006. We compare enrolment, follow-up, quitting and impact on population smoking rates in the most and least deprived neighbourhoods and the neighbourhoods with the lowest and highest proportions of Maori.
Enrolment as a proportion of the population was higher from the most deprived areas but as a proportion of neighbourhood smokers, it was lower. Enrolees from the least deprived quintile were 40% more likely to quit than those from the most deprived quintile. Smoking rates were 2.84 (2.75 to 2.93) times higher in the most deprived neighbourhoods. If the programme had not been available we estimate that this differential would have reduced to 2.81 (2.72 to 2.90). In neighbourhoods with the highest proportion of Maori, smoking rates were 2.33 (2.26 to 2.41) times higher and we estimate that without the programme smoking rates would be 2.30 (2.23 to 2.37) times higher.
Although enrolees were drawn from a wide variety of backgrounds, those most likely to quit tended to reside in affluent areas or areas with a low proportion of Maori. There was no evidence that this smoking cessation programme increased or decreased inequalities within the Christchurch population. For smoking cessation programmes to have an impact on health inequalities more effort is required in targeting hard-to-reach groups and in encouraging them to quit.
Tobacco tax increases reduce tobacco use, can provide funds for tobacco prevention and enjoy broad public support. Because of tobacco industry influence in legislatures, US public health advocates have shifted the venue for tobacco tax policymaking to direct popular vote 22 times since 1988.
We combined case studies of individual state campaigns with tobacco industry documents to identify strategies related to outcome.
The tobacco industry developed a voter segmentation model to determine which tobacco tax increases it could defeat. Two industry arguments arising from this model often were raised in losing campaigns—the tax increase did not dedicate enough to tobacco control and hospitals and health maintenance organisations would profit. The industry effectively influenced early voters. Success was associated with building a strong base of public support before the campaign, dedicating sufficient funds to tobacco control, avoiding proposals largely devoted to financing hospitals and other medical service providers, effectively engaging grassroots and framing the campaign with clear justifications for cigarette tax increases.
Tobacco tax ballot measures commonly allocated substantial funds to medical services; tobacco companies are becoming more successful in making this use of funds an issue. Proponents’ campaigns should be timed to account for the trend to voting well before election day. Ballot measures to increase tobacco taxes with a substantial fraction of the money devoted to tobacco control activities will probably fare better than ones that give priority to funding medical services.
While many studies report determinants of adolescent cigarette smoking, few identify risk factors for nicotine dependence (ND). This study distinguished between risk factors for three hallmarks of ND including cravings, withdrawal symptoms and tolerance.
A total of 319 novice smokers were followed every 3 months from first puff on a cigarette until the end of secondary school. Outcomes included time to first report of cravings, withdrawal symptoms and tolerance.
Female sex, inhalation, smoking a whole cigarette, weekly smoking, daily smoking and alcohol use each independently increased the incidence of the onset of cravings. Inhalation, weekly smoking, daily smoking and alcohol use predicted the onset of withdrawal symptoms. Withdrawal symptoms, smoking a whole cigarette, monthly smoking, daily smoking and friends and siblings smoking increased the incidence of the onset of tolerance. None of parental education, impulsivity, novelty seeking, self-esteem, depression, stress, parental smoking, physical activity, or participation in sports teams was associated with the outcomes.
The hallmarks of early ND are related to intensity and frequency of cigarette use. Avoidance of daily smoking may be particularly important in preventing the onset of ND symptoms and sustained smoking.
Smoking prevalence rates are declining in most industrialised countries, partly because of growing cessation rates. However, little is known on recent time-trends in smoking cessation by socioeconomic position. This study aims to estimate educational inequalities in smoking cessation trends in Italy between 1982 and 2002.
Data were derived from two national health interview surveys carried out in Italy in 1999–2000 (n = 34 789) and in 2004–2005 (n = 33 135). On the basis of respondents’ age at starting and age at quitting smoking, we computed age-standardised smoking cessation rates at ages 20–44 years for subjects who were current smokers between 1982 and 2002.
Smoking quit rates were approximately constant at a figure of about 2 per 100 person-years until the period 2000–2002, when they rapidly increased up to 3–4 per 100 person-years. Higher educated smokers constantly showed higher cessation rates than lower educated subjects (rate ratio 1.33; 95% CI 1.25 to 1.41 for men and 1.41; 95% CI 1.30 to 1.53 for women). The relative size of educational difference in smoking cessation did not significantly vary by period. However, in absolute terms, the increase in cessation rates in 2000–2002 was larger among higher educated smokers.
Educational inequalities in smoking cessation persisted in both relative and absolute terms. The increase in smoking cessation rates in 2000–2002 suggests that tobacco control policies may have reached more disadvantaged smokers, although smokers of higher socioeconomic groups seem to have benefited the most.
Motor vehicles represent important microenvironments for exposure to secondhand smoke (SHS). While some countries and cities have banned smoking in cars with children present, more data are needed to develop the evidence base on SHS exposure levels in motor vehicles to inform policy and education practices aimed at supporting smoke-free motor vehicles when passengers are present.
To assess exposure to secondhand tobacco smoke in motor vehicles using passive airborne nicotine samplers.
17 smokers and five non-smokers who commute to and from work in their own vehicle participated. Two passive airborne nicotine samplers were placed in each vehicle for a 24-hour period, one at the front passenger seat headrest and the other in the back seat behind the driver. At the end of the sampling period, airborne nicotine was analysed by gas chromatography.
Median (IQR) air nicotine concentrations in smokers’ vehicles were 9.6 µg/m3 (5.3–25.5) compared to non-detectable concentrations in non-smokers’ vehicles. After adjustment for vehicle size, window opening, air conditioning and sampling time, there was a 1.96-fold increase (95% CI 1.43 to 2.67) in air nicotine concentrations per cigarette smoked.
Air nicotine concentrations in motor vehicles were much higher than air nicotine concentrations generally measured in public or private indoor places, and even higher than concentrations measured in restaurants and bars. These high levels of exposure to SHS support the need for education measures and legislation that regulate smoking in motor vehicles when passengers, especially children, are present.
To examine the impact of smoke-free policies on revenue in Tasmanian bars.
Monthly sales turnover from January 2002 to March 2007, provided by the Australian Bureau of Statistics was analysed. There were two outcome measures: (1) the ratio of monthly bar sales turnover in Tasmania to monthly bar sales turnover in four other Australian states, and (2) the ratio of monthly bar turnover to monthly retail turnover in Tasmania. Linear regression was used to assess the impact of the smoke-free policy on expenditure.
The smoke-free policy had no effect on sales turnover.
The smoke-free policy protects hospitality workers and patrons from exposure to secondhand smoke and has had no adverse effect on sales turnover.
To examine change in home smoking restrictions one year after introduction of Scottish smoke-free legislation, and whether type of restriction impacts upon secondhand smoke (SHS) exposure among children.
Comparison of nationally representative, cross-sectional, class-based surveys carried out in the same schools before and after legislation.
2527 primary schoolchildren (aged around 11 years) surveyed in January 2006 and 2379 in January 2007.
Self-reported home smoking restrictions, salivary cotinine concentrations.
Children surveyed after implementation of legislation were more likely than those surveyed before its introduction to report complete home smoking restrictions as opposed to partial (relative risk ratio (partial vs complete) 0.75 (95% CI 0.63 to 0.89) or no restrictions (RR (no restrictions vs complete) 0.50 (0.40 to 0.63). Children living with smokers were less likely to have stringent restrictions in place compared with children living with non-smokers (for both vs neither parents smoke: RR (partial vs complete) 18.29 (13.26 to 25.22) and RR (no restrictions vs complete) 104.73 (70.61 to 155.33). Among smoking households, restriction type varied according to the number and gender of parents who smoke. In both smoking and non-smoking households, children’s SHS exposure was directly related to type of home smoking restriction, with lowest exposures among those reporting complete restrictions.
This study has shown an increase in the proportion of children reporting a complete ban on smoking in their household after the introduction of smoke-free legislation and supports growing evidence of the wider impact smoke-free legislation can have on smoker behaviour. However, quitting smoking combined with complete home smoking bans will still afford children the best protection from SHS exposure.
To clarify the extent of use of foreign (including duty free, foreign normal retail and smuggled) tobacco, and to estimate missed government tax revenue in a geographically isolated country.
Discarded cigarette packs were collected on the streets of four cities and six New Zealand towns/rural locations between November 2008 and January 2009.
Out of a total of 1310 packs collected, 42 foreign packs were identified (3.2%, 95% CI 2.4% to 4.3%). Overall, the distribution of packs by country and company was not suggestive of any clustering that might indicate smuggling. At 3.2% of packs being "foreign", the New Zealand government is losing around $36 million per year in tobacco-related tax relative to if all this tobacco was purchased in New Zealand. For various reasons (including that it was not possible to identify packs bought duty free within New Zealand, and other New Zealand survey data indicating duty free product use at 3.8% of packs), the figure reached is probably an underestimate of the true level.
The New Zealand government is missing out on revenue that could be used for improving the funding of tobacco control, and smokers are being exposed to cheaper tobacco thus increasing their risk of continuing to smoke. This government and other governments can and should act at the international and national levels to end the sales of duty free tobacco.