Research paper
Impact of tobacco prices and smoke-free policy on smoking cessation, by gender and educational group: Spain, 1993–2012

https://doi.org/10.1016/j.drugpo.2015.05.011Get rights and content

Highlights

  • A relationship between tobacco prices and smoking cessation has not been observed.

  • Low education women were the exception: quit ratio a fell with the price increase.

  • The smoke-free legislation altered the quit-ratio in the short term in all groups.

  • In subsequent years the quit-ratio declined except in high education men.

Abstract

Background

To evaluate the effect of tobacco prices and the implementation of smoke-free legislation on smoking cessation in Spain, by educational level, across the period 1993–2012.

Methods

National Health Surveys data for the above two decades were used to calculate smoking cessation in people aged 25–64 years. The relationship between tobacco prices and smoking quit-ratio was estimated using multiple linear regression adjusted for time and the presence of smoke-free legislation. The immediate as well as the longer-term impact of the 2006 smoke-free law on quit-ratio was estimated using segmented linear regression analysis. The analyses were performed separately in men and women with high and low education, respectively.

Results

No relationship was observed between tobacco prices and smoking quit-ratio, except in women having a low educational level, among whom a rise in price was associated with a decrease in quit-ratio. The smoke-free law altered the smoking quit-ratio in the short term and altered also pre-existing trends. Smoking quit-ratio increased immediately after the ban – though this increase was significant only among women with a low educational level – and then decreased in subsequent years except among men with a high educational level.

Conclusion

A clear relationship between tobacco prices and smoking quit-ratio was not observed in a recent period. After the implementation of smoke-free legislation the trend in the quit ratio in most of the socio-economic groups was different from the trend observed before implementation, so existing inequalities in smoking quit-ratio were not widened or narrowed.

Introduction

Tobacco control policies, especially when implemented as part of a comprehensive programme, can significantly reduce tobacco use. Raising the price of tobacco by increasing taxes and introducing clean indoor air laws by prohibiting smoking in public places have been singled out as the most effective measures for reducing overall smoking rates (IARC, 2011).

In high-income countries, smoking is persistently associated with social disadvantage, with the result that reducing social inequalities in smoking has become a political priority in many places. There is, however, no guarantee that interventions known to reduce overall smoking behaviour will be equally effective across all socio-economic groups. Although there are sufficient data to show that an increase in price reduces tobacco consumption (Becker et al., 1994, Gallus et al., 2006), decreases the prevalence of adult tobacco use (Farrelly et al., 2001, Kinh et al., 2006) and increases the likelihood of smoking cessation (Chaloupka and Warner, 2000, Forster and Jones, 2001), existing evidence of a possibly different price effect on different socio-economic groups is less conclusive. Whereas most studies have found that tobacco use among lower-income populations and persons of low socio-economic position is more responsive to price (Brown et al., 2014, Hill et al., 2014, Thomas et al., 2008), some studies have failed to observe any differences (Franks et al., 2007, Wasserman et al., 1991) and other studies suggest that persons with a higher educational level may be more sensitive to tobacco prices either because they get a significant reduction in cigarette consumption (Lee, Hwang, Ye, & Chen, 2004) or because they are more motivated to quit smoking (Ringel & Evans, 2001).

Evidence of the effect of clean indoor air laws on smoking behaviour is less plentiful. A reduction in smoking behaviours has been observed among workers subject to restrictions in the workplace (Fichtenberg and Glantz, 2002, IARC, 2009). At a population level, the effect of clean indoor air regulations on smoking behaviour is similar in all studies, when it comes to short- term assessment (Brugha et al., 2009, Callinan et al., 2010, Lee et al., 2011, Regidor et al., 2011); in the long term, however, pre-existing trends in smoking are affected according to some studies (Brugha et al., 2009, Regidor et al., 2011) and remain unaltered according to others (Callinan et al., 2010, Lee et al., 2011). As regards inequalities in smoking, there is weak evidence to show that workplace smoking restrictions may be more effective for higher educational groups, but at a population level the effect of clean indoor air laws on smoking cessation does not vary with socio-economic position (Brown et al., 2014, Hill et al., 2014), though only a small number of studies have been undertaken.

With the aim of increasing the amount of empirical evidence, this study assessed the effect of both types of smoking-control measures in smoking cessation in different socio-economic groups in Spain. The first regulation in Spain that sought to control smoking through taxation was introduced in 1992, since when tobacco prices have risen considerably. In addition, Spain promulgated the 2006 Smoke-free Act, thus becoming one of the first European countries to implement this type of measure which banned smoking in workplaces, bars and restaurants. The impact of nationwide tobacco control policies on smoking behaviour should preferably be examined in a longitudinal study design, wherein information about smoking behaviour before and after the implementation of a policy is measured. Unfortunately, longitudinal data on smoking are rare. In most of the cases alternative approaches are used to obtain evidence on the potential impact of national policies on smoking. For example, the use of estimates on smoking behaviour based on cross-sectional studies of several years. A natural experiment was thus undertaken, using data on smoking drawn from a series of national interview surveys conducted over the course of the two decades since 1992. Specifically, the aim of this study was to evaluate the effect of tobacco prices and the implementation of smoke-free legislation on the smoking cessation, by educational level, across the period 1993–2012.

Section snippets

Methods

The data were drawn from eight Spanish National Health Surveys conducted over the course of the preceding twenty years, i.e., 1993, 1995, 1997, 2001, 2003–2004, 2006–2007, 2009–2010, and 2011–2012. Subjects were selected by means of a stratified multi-stage sampling strategy and information was collected through personal interviews at subjects’ homes. A more detailed outline of the methodology used in these surveys can be found elsewhere (MSSSI, 2015). The sampling framework was made up of the

Results

The trend in tobacco prices and the absence or presence of a smoke-free law in the study period can be seen in Table 1. From 1993 to 2003 tobacco price increased by 50% and in the two decades covered by this study, the price multiplied by 2.5. Table 1 also shows the sample size along with the quit ratio in men and women at each of the observation points. The trend in tobacco prices and that of the quit ratios in subjects having low and high educational levels are shown in Fig. 1.

The

Main findings

Prior to the introduction of the smoke-free law, the tobacco prices and the magnitude of the quit ratios showed an upward trend, but there was no evidence of relationship between tobacco prices and quit ratios in any of the groups studied after adjusting for time. Analysis of the entire study period showed similar results, and even a decrease in the percentage of smokers quitting among women with a low educational level. The smoke-free law not only altered the smoking pattern in the short term,

Conclusion

This study's findings do not support a clear relationship between tobacco prices and quit ratio in national populations in the study period. Moreover, we found that after the implementation of smoke-free legislation in Spain the trend in the quit ratio in most of the socio-economic groups studied was different from the trend observed before implementation. In view of the fact that there was a difference between the trends observed for men and women with a high educational level, the law's

Funding

This work was carried out by the project “Tackling socioeconomic inequalities in smoking: learning from natural experiments by time trend analyses and cross-national comparison (SILNE)”, which is funded by the European Commission, Directorate-General for Research and Innovation, under the FP7-Health-2011 program, with grant agreement 278273.

Competing interests

The authors declare that they have no conflicts of interest.

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